Bullying during adolescence in Brazil : an overview

Bullying has been the subject of worldwide study for over four decades and is widely reported by social media. Despite this, the issue is a relatively new area of research in Brazil. This study analyzes academic literature addressing bullying produced in Brazil focusing on aspects that characterize this issue as a subtype of violence: gender differences, factors associated with bullying, consequences, and possible intervention and prevention approaches. The guiding question of this study was: what have Brazilian researchers produced regarding bullying among adolescents? The results show that over half of the studies used quantitative approaches, principally cross-sectional methods and questionnaires, and focused on determining the prevalence of and factors associated with bullying. The findings showed a high prevalence of bullying among Brazilian adolescents, an association between risk behavior and bullying, serious consequences for the mental health of young people, lack of awareness and understanding among adolescents about bullying and its consequences, and a lack of strategies to manage this type of aggression. There is a need for intervention studies, prevention and restorative practices that involve the community and can be applied to everyday life at school.


introduction
Adolescence is a time of intense physical, psychological and relational change.Healthy cognitive, emotional, sexual and psychological development during this period requires a comfortable environment that transmits security, support and protection to the adolescent 1 .Despite these assumptions, up to 20% of adolescents worldwide present mental and behavioral disorders, and half of these conditions manifest themselves before the age of 14 2 .Depression and suicide account for a significant portion of the increase in morbidity and mortality among adolescents 3 .
Bullying is unwanted, aggressive behavior among school aged children 1,4,5 .Although this term traverses cultural barriers and is used worldwide by researchers and in dictionaries as a proper noun to indicate actions that go beyond aggression or mistreatment, in Portuguese a word that adequately encapsulates its full meaning does not exist 4 .
In general terms, bullying is defined as a subcategory of violence and is constituted by aggressive repetitive acts and asymmetrical power relations between peers 4,[6][7][8] that have serious health consequences among adolescents who, apart from having to lead with intense emotional and physical change, seek acceptance among their peers 1,9 .Dan Olweus 7 does not regard bullying as aggression among peers who have similar physical and emotional characteristics.Although this type of violence occurs within the general community 8,9 , bullying is a health problem around the world and involves interaction between individuals in the same context or environment 4 , such as school, over a long period of time.
Researchers have systemized bullying into two forms: direct physical (hitting, kicking, pushing, sexual abuse, harassment, threatening gestures, stealing or damaging belongings) and verbal (name-calling, teasing, cursing) aggression; and indirect actions, such as social isolation or exclusion, and spreading rumors.Generally, bullying is barely noticeable to adults since it is subtle 7,10,11 .
Cyberbullying, peer violence in virtual settings, is another type of bullying that has been widely studied 12,13 .This form of bullying has no set location and is more difficult to resolve since it is generally anonymous, open access and spreads at great speed 12 .
It is believed that bullying is rooted in social, cultural, economic and historical problemas 4 .According to the Brazilian researcher Cléo Fan-te 14 , bullying perpetration is associated with exposure to domestic violence and maltreatment, a passive upbringing (without limits) and lack of example within the family when it comes respecting others.
An individual can be involved in bullying as a victim (target), bully (bully) or victim/bully (target/ bully).Victims generally do not react to aggression, are more insecure, fear rejection and have few friends.Those who do react are regarded as victims/bullies and generally have low self-esteem, a more provocative and aggressive attitude and are less popular than typical victims; while bullies tend to be group leaders, popular, are dissatisfied with school, are negative and provoke their classmates 4,6 .
Bullying has been the subject of worldwide study for over four decades and is widely reported by social media [15][16][17][18] .Despite this, the issue is a relatively new area of research in Brazil 9,14,[19][20][21] .
In Brazil, severe cases of bullying involving homicide and suicide have made the headlines and have been widely reported by the media.One such case was the Massacre de Realengo in 2011, attributed to an act of revenge for bullying, where an ex-pupil shot and killed 12 children at a school in Rio de Janeiro and then turned the gun on himself 22 .In 2010, a youth from Porto Alegre was victim of homicide involving a firearm in a supposed case of bullying 23 , while in 2009, in Guarulhos, a girl who was victim of constant bullying was beaten unconscious by another adolescent while others filmed and laughed 24 .In other cases of bullying involving legal action, the parents of the bullies have been required to compensate the victim 5 .
There is an urgent need to understand and intervene in social problems such as bullying that pose a threat to adolescent health 1 .
This integrative review analyzes academic literature addressing bullying produced in Brazil focusing on aspects that characterize this issue as a subtype of violence: gender differences, factors associated with bullying and its consequences, adolescents' perceptions of bullying, and interventions to provide support to help educators and adolescents deal with bullying in school.

Methods
The study used the integrative review method, which consists of summarizing and organizing the results of empirical or theoretical literature to obtain a wide and deep understanding of a given topic in order to derive insights that may provide the basis for further research 25,26 .This literature review was conducted in the following stages: problem identification and formulation of the guiding question; data collection; classification; analysis and independent interpretation by two researchers to improve reading comprehension and reduce the possibility of misunderstanding during results presentation and knowledge synthesis.
Given the incipient nature of research related to bullying among adolescents, the guiding question of this study was: what have Brazilian researchers produced regarding bullying among adolescents?
The literature search was conducted in August 2014 using the following data bases: the Latin American and Caribbean Health Sciences Literature database (Literatura Latino-Americana e do Caribe em Ciências da Saúde -LILACS); the Scientific Electronic Library Online (SciELO); the Medical Literature Analysis Retrieval System Online (Medline); the Sociological Abstracts database (that indexes the international literature in sociology and behavioral sciences), focusing on the archives of the University of São Paulo; CINAHL Plus with Full Text; Web of Science; and Scopus.The descriptors were selected using the DeCS Health Sciences Descriptors, a structured and trilingual thesaurus.The synonym for bullying was assédio escolar (school harassment), while the synonyms for adolescente (adolescent) were adolescência (adolescence), jovem (youth) and juventude (youth).The English terms were used for the CINAHL, Web of Science and Scopus data bases.
The following descriptors were used for the respective data bases separated by the Boolean operators and or or: bullying and adolescent (Lilacs, Medline and CINAHL); bullying (SciELO and the Sociological Abstract); bullying and the word adolescence (Web of Science); bullying and adolescent or adolescence and Brazil (Scopus).These descriptors were used to refine or widen the search according to the search result.A time frame was not set in order to obtain unrestricted access to the literature.
A reading of the titles and abstracts of the articles obtained from the searches resulted in a total of 69 preselected articles (Table 1), of which 25 (six in English) were selected for comprehensive reading using the following inclusion criteria: full publications in national or international journals (with Brazilian authors affiliated to Brazilian universities) in Portuguese and English; and empirical or theoretical studies (original or revised).The following exclusion criteria were also used: repeated studies; and studies that did not address the central topic "bullying among adolescents".

results and discussion
The 25 articles analyzed by this study are presented in chronological order in Chart 1, which shows the title, type of study (as defined by the authors), sample and objective of each study.Two articles were produced in 2005, one in 2006, two in 2008,  one in 2009, five in 2010, one in 2011, six in 2012  and 2013, and one in 2014.Graph 1 shows the number of articles by type of study.Fourteen studies are quantitative (11 cross-sectional, with only three citing the use of questionnaires); three are qualitative (two use interviews and one uses participant observation and focus groups); two are quanti-qualitative (both use questionnaires, while one uses free word association and the other uses notes kept in a field journal, interviews and focus groups); four are bibliographical studies (one of which is a systematic literature review); and two are theoretical studies consisting of a critical analysis of the topic.The main focus of over half of the articles were correlations and factors associated with bullying, and the investigation and determination of prevalence of bullying.
There was a lack of research adopting strategic intervention, prevention and restorative approaches to aggression among adolescents and/ or qualitative studies that aim to understand the victims'/bullies' perspectives of bullying and their experiences in school, family, and community settings, perceptions of peer conflict and the motives and/or causes of involvement in given roles.
After vertical in-depth reading, the 25 articles were organized into the following topics: prevalence and types of bullying, gender differences, factors associated with bullying, consequences, adolescents' feelings, and possible interventions.

Prevalence and types of bullying
In article 11, a study conducted with 60,973 pupils in 26 state capitals and in the Federal District, 5.4% of pupils reported that they had been continually bullied, 25.4% reported rarely being bullied, and 69.2% had never been victims of bullying 27 .Article 21 revealed that 67.4% of 237 pupils had witnessed bullying or been bullied, and 48.5% said they had been bullied 28 .This prevalence rate is similar to the findings of article 24, which showed that 67.5% of a sample of 465 pupils were victims of bullying 29 .A study conducted with 5,500 pupils, showed that 40.5% of the sample were involved in acts of bullying, of which 16.9% were targets of bullying, 12.7% bullies and 10.9% targets/bullies 19 , corroborating the findings of article 12 which showed that 17.6% of a sample of 1,075 pupils had been bullied 30 .The findings of article 22 that studied a sample of 1,230 pupils showed that 10.2% were victims and 7.1% were bullies 31 .
The different methods of data collectiontype of questionnaires used, different sample characteristics (number, age, gender, etc.), period, frequency and types of bullying considered (verbal, physical, psychological, sexual, material and virtual) 32 -may account for the variation in prevalence of victims, bullies and witnesses throughout these studies.
The lowest prevalence of bullying was reported by article 11.According to the authors, this was due to the time frame adopted for the occurrence of bullying (one month), which was chosen to reduce the risk of bias.Furthermore, the use of a self-applied questionnaire with the question "in the last thirty days, how often did one of your classmates abuse, mock, insult, intimidate or taunt you to the point that you felt hurt/annoyed/upset?" did not clearly include sexual bullying, spreading rumors, exclusion or isolation, and therefore may not have provided an accurate picture of the amount of pupils who had been bullied 27 .On the other hand, the high percentage of victims (48.5%) reported by article 22 28 may have been influenced by the questionnaire used by the Portuguese pupils, which encompasses a greater range of types of bullying including physical threats (pushing, hitting), sexual bullying (unwanted touching), isolation (being excluded from the group), and damaging personal belongings 33 .The high proportion of victims (67.5%) reported by article 10 is accounted for by a greater understanding of the concept of bullying among adolescents over the years, and the launching of the electronic game "Bully" (Rockstar Games) in 2006, which deals with bullying and may have influenced understanding.The game allows players to be bullies or victims and choose to attack or defend monitors, teachers and classmates in a school setting.Although its sale is prohibited Brazil, the game is still sold in the United States and in some shops in the United Kingdom 34 .
Article 5 showed that a surprising 100% of adolescents in correctional facilities (eight serving in a semi-open regime and eight on probation) were involved in bullying, both as targets and bullies.Bullying was more frequent among boys who had been involved in more serious crimes.However, the study suggests that further research is necessary to understand whether bullying is a precursor or consequence of the offences committed by the adolescents 43 .
The findings of these studies on bullying in Brazil are similar to those of international studies.A cross-sectional study carried out with 1,756 Korean pupils from the seventh and eighth grades, showed that 40% were involved in bullying; 14% were victims, 17% bullies, and 9% victims/bullies 55  bal: name-calling, insults, and "making fun" 29 .These findings corroborate the results of article 21, which showed that the most common types of bullying suffered by victims were name-calling and gossiping, while the most common type of bullying practiced by bullies was name-calling 28 .
Article 12 shows that the most prevalent forms of intimidation are verbal and physical, followed by psychological, ethnic and sexual aggression 30 .On the other hand, articles 9 and 22 show that physical aggression is most prevalent, followed by verbal abuse 31,43 .Article 8 draws attention to the fact that verbal provocation evolves into physical aggression (fighting, hitting, hair-pulling and kicking) and often starts within school and ends outside the school gates 45 .Verbal insults, exclusion, physical bullying and forcing someone to do something they do not want to do are among the most common types of bullying observed by an international study, with prevalence rates of 22, 23, 16 and 20%, respectively 55 .
Peer aggression tends to take place mainly outside the classroom 28 ; however, article 22 shows that after the playground, incidents take place mainly in the classroom 31 .

Gender differences
According to articles 11, 12 and 22, boys are more likely to be bullied or involved in bullying than girls 27,30,31 .Also, bullying among boys tends to involve physical aggression, isolation from the group and coercion, while in girls it is more likely to involve gossip and teasing, which is less noticeable 44 .Furthermore, boys are twice as likely to be bullies 31 , which does not necessarily mean that they are more aggressive, but rather more likely to be involved in bullying 29 .
Developmental differences between boys and girls may account for such behavior.Boys tend to be more aggressive than girls, which is reinforced by a male-dominated society that encourages them to have a hostile attitude towards their peers 57 .In addition, a free word association test showed that boys and girls have different perceptions of violence.Girls perceive aggression using the words "harassment, disrespect, rudeness, pain and animosity", while boys use the words "steal, kill, swear, hitting and fooling around" 46 .
According to article 7, among girls self-esteem is greatest among bullies and lowest in victims/bullies, while in boys it is greatest among witnesses and lowest in victims 41 .Interactions between girls tend to be most influenced by af-fection, bonds of friendship, emotions and feelings, while in boys it is affected by competition and achieving goals 28,41 .

Factors associated with bullying
Articles 7, 17 and 21 showed that bullying is associated with self-esteem and affects boys and girls differently according to their role in bullying (victim, bully or victim/bully) 28,41,[48][49][50][51] .There is also a relationship between body image dissatisfaction (but not with excess weight) and the likelihood of be bullied or bullying 31 .Findings show adolescents may associate physical differences with motives for psychological bullying 45 , and that bullies of both sexes are more likely to sexually harass classmates 36 .These findings demonstrate a certain psychological weakness among these adolescents when it comes to accepting or acknowledging their own physical characteristics and dealing with differences, emphasizing the urgent need to create prevention and restorative strategies that develop adolescents' personal and social skills in order to maintain a healthy school environment 1,4 .
Article 24 cites a possible relationship between being bullied and post-traumatic stress disorder symptoms 53 , hyperactivity and difficulty relating to classmates, but suggests that further research is necessary to ascertain whether bullying precedes and intensifies this type of behavior, or if adolescents with hyperactivity and behavioral problems tend to be more susceptible to being bullied 30 .
With regards to cyberbullying, article 27 shows that the longer adolescents spend on the internet and cell phone, the more vulnerable they are to bullying 48 , and that effective parental supervision of internet and cell phone reduces exposure and ensures more healthy use of social media.Both bullies and targets of cyberbullying tend to have lower self-esteem than non victims.Using electronic devices such as computers, video games and television for extended periods of times is associated with bullying 31 .It is evident therefore that the excessive use of technology and social media has a significant effect on adolescents' emotional health and requires parental and school control and supervision and restorative strategies to reduce the risk of mental health problems among this group 12 .
Alcohol consumption, illicit drug use and suffering physical aggression is also associated with all types of bullying except name-calling.There is a strong association between threaten-ing behavior, theft, physical abuse and teasing and risk behaviors, such as being involved in physical fights, accidents and carrying a weapon.Furthermore, other authors affirm that bullying is an independent variable associated with an increase in physical violence among peers 47 and that there is a general association between bullying and truancy and/or skipping classes 39,44 .Comparative studies cite various adolescent health risk behaviors that are strongly associated with bullying, thus showing that this type of violence must not be ignored and that urgent measures are needed to manage this problem 47 .With regard to family-specific aspects associated with bullying, article 8 observed a positive association between bullying and family environments characterized by violence and/or lack of affection 42 .Adolescents who grow up in a violent and/or nonaffectionate family environment are more likely to be violent at school, while those who are brought up within a loving family are likely to have less aggressive attitudes.Adolescents that received support from their family after having been bullied at school demonstrated less aggressive attitudes when they returned to school.Overly punitive, lenient (without setting limits) or negligent parenting, exposure to violence (games, films, music) and a social environment in which the adolescent experiences a long process marginalization (humiliation, abandonment, isolation) are associated with violent events, such as school shootings perpetrated by adolescents involving subsequent shooter suicide 40 .There is no association between bullying and level of maternal education 31 .To strengthen resilience to bullying, other authors emphasized the importance of health promotion that involves supporting victims' families and preparing them to cope with the emotional demands of their children and keep a watchful eye on the places their children frequent (school, community, family environment) 58 .

consequences
The signs of bullying among children and adolescents include headaches, abdominal pains, insomnia, nocturnal enuresis (bedwetting), depression, anxiety, missing school, lower academic performance, self-aggression, thoughts of suicide and attempted suicide, missing belongings, bodily injury, torn or dirty clothing and aggressiveness.They may also constantly ask for money and be hungry after school, which suggests that other adolescents take their money during break 4,35 .
Victims and victims/bullies generally experience higher levels of anxiety than pupils who are not involved in bullying 50 .
Involvement in cyberbullying can lead to an increase in emotional disorders, such as symptoms of depression, anxiety, a decrease in empathic capacity and suicidal ideation 48 .Article 13 presents accounts of pupils who repeated the school year and changed classes after being repeatedly subjected to name calling 45 .Witnesses are also affected in their academic performance and their social environment by experiencing a violent environment 35 .Furthermore, being bullied is also associated with depressive, apathetic, cyclothymic and volatile tendencies, sadness, low self-esteem, reduced ability to focus, self-discipline (control), and capacity to confront and solve problems (coping), and greater emotional fragility in adult life 51 .
It can therefore be deduced that discrimination, intolerance and physical aggression among peers -aspects that constitute of this subtype of violence -have harmful effects on the mental health and academic life of pupils, therefore affecting their intellectual development, and may have repercussions on the family environment 4,45 .

adolescents' feelings
Five of the 25 articles showed that adolescents underestimate the seriousness and gravity of bullying, perhaps due to lack of guidance regarding the repercussions of such aggression 29,35,43,45,52 .
In a study conducted with 28 pupils using participant observation and focus groups, adolescents reported "having to tolerate so-called distasteful joking".Bullying is repeatedly tolerated by the victim in name of friendship and the emotional protection involved with belonging to a group 52 .Another study with 16 adolescents in conflict with the law draws attention to the fact that verbal aggression is viewed as a "joke", even when it evolves into physical aggression.The authors of this study explain that adolescents exhibit aggressive behavior as a way of gaining status and respect, which could account for the high prevalence of bullying, which they view as "normal" 43 .Article 1 shows that 69.3% of adolescents did not understand why bullying occurs and that many interpret it as a "joke" 35 .
Some adolescents tend to retaliate to name-calling with name-calling, which often evolves into physical aggression, thus reinforcing the cycle of aggression 45 .The majority of bullies think that it is funny to bully their peers 29 , and many mention that dominating their classmates generates a feeling of well-being or satisfaction, prestige and leadership, and view this attitude as a positive quality 27,35 .The lack of awareness among adolescents about bullying and its consequences seems to be a contributing factor to bullying and should be addressed by bullying prevention policies 6 .
Article 14 shows that the majority of targets of bullying become angry and either defend themselves or ignore the aggression, while only 13.3% sought help from an adult 29 .This raises the possibility that the victims that react belong to the victim/bully group, given that victims normally have a weaker character than victims/bullies and are less likely to react 35 .The witnesses did not do anything to help the victims, which suggests fear of retaliation from the bullies 29 , which is corroborated by article 23, which emphasizes that the majority of witnesses feel compassion for the victim and do not like to watch scenes of bullying, but do not defend the victims for fear of becoming victims themselves 52 .Some bullied adolescents mentioned feeling outraged, citing that one day bullies could feel the pain of discrimination 37 .Other studies revealed worrying data related to adolescents' feelings towards school.Article 14, involving 177 adolescents with an average age of 14 years, showed that 57.8% of the sample felt insecure at school 46 ; while the PENSE study, which sampled 60,973 schools in Brazil, revealed that 5.5% of pupils missed school because they felt insecure 27 .
For some pupils, bullying can contribute markedly to turning school into an uncomfortable and confrontational environment.Adult intervention in peer conflict, to set limits and show the importance of treating others with respect, is of fundamental importance for ensuring a healthy school environment 59,60 .
The adoption of a participatory and multidisciplinary approach to continuing health educa-tion targeting young people delivered by Family Health Teams has the potential to promote significant improvements in child and adolescent behavior 61 .Programs that address gender differences in bullying are also suggested, given that boys and girls experience different types of bullying behaviors 41,47 .Articles also recommend research into other factors associated with bullying, such as parenting styles, family violence, performance at school, relationships with parents and teachers, and other daily life issues, in order to obtain a clearer understanding of this type of violence 28,43 .
An analysis of the effectiveness of bullying intervention programs based on 165 articles showed that 33.9 and 23.6% of the articles were from Spain and the United States, respectively; only 3.6% of the publications were from Brazil, suggesting a lack of research in this country addressing intervention programs 54 .The present study found only two articles that used collaborative or interventional tools.Article 1 indicates signs and symptoms of bullying (described in the section on consequences above) to aid pediatricians, other health professionals and family members in general to identify bullying; while study 18, involving focus groups of pupils and teachers, made a positive evaluation of restorative circles (conversation circles held under the guidance of a skilled facilitator) as a tool to stimulate dialogue, support pupils and educators, and resolve conflicts, particularly those involving violence 49 .
Studies conducted by the United Nations Children's Fund (UNICEF) corroborate these findings, confirming that programs that promote psychosocial support combined with an intersectoral approach are an effective way of promoting health and well-being among young people 1 .An example is a study involving 307 fifth and sixth year pupils in Lisbon, Portugal conducted by a nurse, which aimed to reduce school violence through adopting the following strategies: multidisciplinary teamwork; changes in school policy to promote a reduction in violence through the implementation of an educational project; meetings between teachers and family members to develop violence prevention strategies; interventions with classes using techniques that reinforce positive behavior in the face of violence situations; and direct intervention with pupils involved in aggressive situations identified with the help of teachers and school psychologists.The results of this intervention, which enabled the mobilization of a multidisciplinary team, showed a decrease in the rate of bullying and highlight the important role played by nurses in such interventions in schools and in research 62 .With regard to cyberbullying, schools should regulate and promote parental control of the use of devices such as laptops and smartphones 12,48 .
Although article 4 did not suggest any interventions, it promotes reflection on the approach to managing bullying in schools, suggesting that this type of violence is rooted in prejudice.Prevention and control of bullying can therefore only be effective if actions address the issue of violence itself (barbarism) and the stereotypes imposed by society, suggesting that stereotypes generate intolerance, which in turn shape and drive prejudice and bullying 38 .

conclusion
The present study shows that over half of the studies carried out in Brazil used quantitative approaches, principally cross-sectional methods, and that the central focus of these studies was to determine the factors associated with bullying.The studies showed a high prevalence of bullying among Brazilian adolescents and gender differences, whereby boys are more likely to be bullied.The studies also highlighted a strong association between bullying and risk behavior, including use of alcohol, illicit drug use, fighting, skipping classes, and showed that the emotional and psychological consequences of bullying arise during adolescence and extend throughout adult life.The findings also suggest that bullying is seen by adolescents as a "joke", thus highlighting the need for guidance regarding this type of violence and its consequences.
Although these studies provide a general overview of the diverse aspects of bullying in Brazil, they also show that there is a lack of intervention studies and a gap in research addressing bullying prevention and restorative practices and the impacts of intervention programs.Apart from filling this research gap, there is an important need for intervention and/or qualitative studies that investigate and describe the experiences and perceptions of the subjects involved in bullying and evaluate intersectoral intervention programs that encompass schools, health services and other sectors of the community.

collaborations
PL Pigozi participated in study conception, data analysis and interpretation, drafting of this article and the approval of the final version the manuscript for publication.AL Machado participated in data analysis and interpretation, and in the approval of the final version the manuscript for publication.

acknowledgements
We are grateful to the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -CAPES) for granting a scholarship.

table 1 .
Number of articles obtained from each data base.
. Another study chart 1. Presentation of articles by Title, Year, Type of Study, Sample and Objectives.São Paulo, 2014.Number of articles by type of study.São Paulo, 2014.