Students ’ health : an integrative review on family and bullying

Bullying is a public health problem and this integrative review’s aim was to assess the relationship between family context and the occurrence of such a phenomenon. Its original contribution is to broadly address this type of violence. The SPIDER strategy was used to develop the study, which was guided by the question: what is the role of the family in the development, perpetuation and prevention of bullying? The following databases were searched: PsycInfo and Lilacs, and the SciELO Virtual Library using the descriptors 1. bullying and family; 2. bullying and parents, and their correlates in Portuguese and Spanish. The studies’ methodological quality was assessed according to level of evidence. A total of 27 papers published between 2009 and 2013 and written either in English, Spanish or Portuguese were included; the evidence found in the papers mostly ranged from strong to moderate. The analysis revealed most studies had a cross-sectional design and did not report the theoretical framework used. Aspects of the family context, sociodemographic characteristics and domestic violence, were associated with the involvement of students with bullying. Bullying requires intersectorial interventions and further studies are recommended to focus not only on individual characteristics of students but also on their contexts.


Introduction
This study's objective was to assess evidence available in the literature concerning the relationship between the family context and the occurrence of bullying through an integrative review.Bullying is a complex phenomenon that occurs in different contexts, especially at school, which is the focus of this review.Bullying presents various nuances in investigations addressing its occurrence, actors, as well as its potential origins and determinants.Given the invasive characteristics of bullying and its adverse effects in the short and long run on the quality of life of people, studies in the health and education fields confirm that it constitutes a severe public health problem that requires even more studies and interventions to fight it [1][2][3] .
This phenomenon is defined as repetitive violent behavior that occurs over time in relationships characterized by an imbalance in power and that can be manifested in many different ways 1 .It is the systematic abuse among peers or a process of intentional and repetitive aggression, characterized by aggressive behavior that involves direct or indirect intimidation, insults, harassment, exclusion and/or discrimination [4][5][6] .
This problem has existed since before the emergence of schools, but only in the 1970s did it begin to be investigated.Briefly, the first studies on school bullying were conducted in Sweden, and because of the favorable results achieved by the interventions implemented in that country, attention has been given to other sociocultural contexts, raising the interest of researchers in the development of epidemiological studies and interventions addressing different aspects, such as: involvement, actors, programs, and impact on life and on the learning-teaching process, among others.The importance of this issue is currently revealed in the conception that it is repetitive violence perpetrated among peers, causing physical and/or psychological damage to all those concerned, while it is considered a worldwide phenomenon 5,7,8 .
The configuration of this phenomenon makes it a relational problem among schoolchildren, whose strategy to ensure their space and social place is aggressiveness.In this sense, bullying is seen as a precondition for negative internationalizations of social interactions, about oneself, or of potentialities to respond to the demands coming from the collective and groups.
The behaviors that characterize bullying (gossiping, calling names, hitting, pushing, provoking, socially isolating, spreading rumors, among others) are deliberate, intentional and repetitively promulgated by an individual or group of people and impinge on others considered weaker in their social position or who have little capacity to defend themselves from aggression, considering power differences among peers (symbolic domination) 9,10 .
In regard to the damage caused to the psychological and physical health of those involved, bullying is considered to be an indicator for the diagnosis of conduct disorder and for the development of antisocial behavior and criminality 11,12 .Damage to the victims includes anxiety, depression, relationship problems, and fragile self-esteem, in addition to other psychiatric disorders that may culminate in suicide.Bystanders, in turn, are subject to the same problems to which victims are subject and can also develop aggressive behaviors, as they perceive themselves to be vulnerable to social situations otherwise 3,5,12 .
Therefore, bullying occurs within an enlarged social context, the privileged setting of which, addressed in this study, is the school, even while its origins vary.There are individual components and components related to groups and families.These compose a mosaic and the complexities involved in this phenomenon.They do not explain the phenomenon by themselves but provide clues concerning how to intervene effectively.Systemically, the dynamics of bullying go beyond students (i.e., bullies, victims, and bystanders) including other peers, teachers, the school community, parents and families.Healthcare providers are also implicated to the extent they promote prevention and interventions within health promotion models, especially in the primary healthcare sphere and through the work of teams in the territory with the ability to implement intersectorial coping strategies.
It is crucial that studies consider the social contexts and the phenomenon's multi-causalities to support interventions and pedagogical, social and health practices.Additionally, the roles of parents and families should also be valued in investigations addressing how bullying comes to develop, is maintained and can be prevented [12][13][14] .Therefore, understanding family relations and how they contribute to the development of the behavior of bullies or victims broadens our perspective on the phenomenon.

Method
This literature integrative review addresses the roles of parents and families in the development, perpetuation, and prevention of bullying.An integrative review is a methodology used to synthesize data and present conclusions concerning a given topic, a procedure to describe information available in the literature, based on the construction of an evidence-based theoretical review.Categorized and described data generate consistent and comprehensible perspectives on complex issues and concepts, theories or phenomena that are relevant to health 15 .
The SPIDER 16 strategy was used to establish the study question and to conduct the search.This strategy was based on an adaptation of the PICO technique and comprises the following elements: Sample; Phenomenon of Interest; Design; Evaluation; Research type.It permits gathering studies with different designs and studies that address certain behaviors, relationships between qualitative and quantitative variables, individual and collective experiences, and interventions with social meaning, which influence the robustness of the review 16 .
The studies were identified between January and February 2014 according to the following question: What is the role (E) of parents and families (S) in the development, perpetuation and prevention of school bullying (PI)?The following steps were included in the review: 1. Establishment of objective (PI); 2. Search or sampling of the literature (establishment of inclusion and exclusion criteria) (S/D/R); 3. Data collection (S); 4. Critical analysis of the studies selected (E); 5. Discussion of results (E); and 6.Presentation.
The following databases were consulted: Psycnfo and Lilacs (Latin-American and Caribbean Center on Health Sciences Information) and SciELO virtual library.Since these databases do not have a controlled vocabulary, the search was based on the crossing of the following terms: 1. bullying and family; and 2. bullying and parents.The equivalent in Portuguese and Spanish were combined in the Lilacs and SciELO.The selection was not restricted, that is, "all the fields" were considered in the search.
Inclusion criteria were: full-papers published in Portuguese, English or Spanish with data collected in any country between 2009 and 2013; studies, the methodology of which provided clear evidence on the topic (objective); clinical trials; experimental studies; qualitative studies; and papers indirectly reporting investigations on the role of the family and parents on bullying.Note that, given the characteristics of the guiding question, which was not related to the efficacy of an intervention, technique or experiment but to how comprehensive was the knowledge produced concerning the topic, all types of methodological designs were possible.
Papers were selected if their titles and abstracts revealed potentially relevant information for the review and if they met pre-established criteria.This selection followed a protocol specifically developed for this purpose because the papers should address school bullying and families, present and discuss the potential relationships among these topics and mention social determinants that would explain the phenomenon.
In the process of checking the eligibility of texts, the full texts were collected and a validated instrument was used 17 to assess them in accordance with the proposal of the review.The instrument items addressed in this study were: paper identification; hosting institution; type of publication; methodological characteristics; and methodological rigor assessment.The material was summarized into four synopses and, after reading the texts and considering their objectives, objects, and guiding questions, the final sample was composed of 27 papers.Figure 1 presents a flowchart synthesizing the development of the corpus of this review.
The level of evidence of papers was also assessed 17 .This assessment classified evidence into categories of strong, moderate, or weak according to well-established criteria in the literature, which concerned the studies methodological quality and low risk of bias 17,18 .Note that the SPIDER strategy enabled the identification and inclusion of studies with different designs and types of research.
The presentation and discussion of results enabled us to assess the applicability of this integrative review and assess evidence available in the literature concerning the relationship between family context and the occurrence of bullying.The study project was not submitted to an Institutional Review Board because it did not involve human subjects, though ethical principles concerning authorship and the citation of consulted references were complied with.

Results
The 27 papers that met the inclusion criteria were analyzed.Of these, 20 were originally published in English, five in Spanish and two in Portuguese.The greatest number of studies was published in 2012, while 2011 was the year with the least number of publications included in this review.Most studies were conducted in the United States.Seven studies were conducted in developing countries and six studies were classified as having a moderate level of scientific evidence, while one was considered weak.There were two multi-center studies developed in two countries each.The studies' general characteristics were organized according to their quality of scientific evidence and are presented in Table 1.
Among the six papers classified as having a strong level of evidence, two analyzed data collected from more than one source of informants and also presented a theoretical framework in the analysis of results.The samples of all the studies were considered large and able to support and accomplish the objectives proposed, espe-cially in regard to the samples statistical power.The cross-sectional design predominated as well as the use of questionnaires in the collection of data.Studies that combined more than one instrument also combined questionnaires with scales, inventories or interviews.The expressive number of papers (n = 17) that did not present the theoretical framework adopted in the analysis of data is noteworthy.
Only one of the papers included in the analysis 19 did not present a definition or conceptualization of bullying.Twenty papers cited the studies by Olweus 1,11 when defining and exploring their conceptions.Dan Olweus (Norwegian) is considered the main researcher in the world studying the topic of school bullying, as he has researched this problem for more than four decades.Additionally, he is considered a pioneer in the extensive investigation of this phenomenon and its characteristics and has developed instru-  Records that appeared more than once in the databases -removed (n = 154)

Eligibility
ments and methods to identify and analyze it, as well as to intervene.
In regard to the field of knowledge of the journals in which papers were published, nine were published in the field of psychology and 10 in periodicals that focused on child and adolescent issues, such as health, development and learning.The remaining papers were published in journals in the field of health or focused on violence.
The main results related to the objective of this review were grouped into three categories.They comprise qualitative aspects of the family context associated with bullying, such as: climate, type of communication, type of attachment, conflicts, manifestation of affection, acceptance and/or rejection, feelings of protection, social support, relationships among siblings, the parents' mental health, ambivalent relationships, and dysfunctional ties.Additionally, the families' socioeconomic conditions, the parents' education levels, type of family arrangement, and experiences of violence in the family context, considering different types of manifestations, were also associated with the occurrence of bullying or involvement with it.This categorization was synthesized in Chart 1, according to the study and respective level of evidence.
Note that family composition was not significantly related to the involvement of children with bullying; that is, according to the studies included in this review, the presence of both father and mother or the absence of one of the parents did not contribute to or minimize the occurrence of the phenomenon.Only four studies 28,[30][31][32] verified that living with only one parental figure increased the chance of one becoming involved with bullying as either a victim or a bully.The authors concluded that living with both parental figures (father and mother) is a protective factor against bullying.
Specifically regarding the role of parents in the development of bullying, we verified that  Source: Developed by the authors the less affectionate and most authoritarian and abusive parents, i.e., those using corporal punishment and harsh methods to discipline children, led children to learn social interaction models based on violence and aggressiveness and to find these models to be acceptable responses to conflict, anxiety and distress 10,20,35,36 .Likewise, negative feelings of parents toward children, such as rejection and a perception of having poor social support, were identified as dysfunctional family characteristics with the potential to lead students to practice bullying 13,[37][38][39] .
Aspects of the maternal relationship can also contribute to the development of social functioning based on introspection and difficulty dealing with social relationships.In general, overly protective mothers, those with difficulty manifesting affection, or those who clearly manifest an imbalance of power between parents and children, in which children have greater power than mothers, may hinder the internalization of healthy and positive social relation models and make children more susceptible to victimization.The presence of a psychiatric maternal diagnosis such as depression may also favor victimization 20,22,40 .
Studies confirm that the relationship among siblings is closely linked to a positive or negative domestic climate, since their primary relationships are considered the first experiences of socialization among peers.These relationships contribute to the development of social responses not based on violence and aggressiveness 10,20 .
Communication established with parents is another facet reported by the studies as being significant for bullying.Being intimidated, for instance, was significantly associated with poor social support and difficulty communicating with parents 13 .Domestic violence was also reported as being a strong predictor for the manifestation and involvement with bullying.Family violence, exposure to inter-parental conflicts, and physical punishment are positively associated with the perpetration of this phenomenon.As previously mentioned, children learn from the examples of adults and, if they see their parents using physi-Chart 1. Distribution of papers according to categories and level of evidence.PyscoInfo, Lilacs, SciELO, 2014.
Source: Developed by the authors.
cal force and violence between each other or to dominate or discipline children, they start using the same methods toward their peers 19,21,[32][33][34] .
Other variables addressed by the papers include the parents' low level of education and socioeconomic status, which indicate an increased risk of becoming involved with bullying and becoming a victim.In general, students with a lower level of family income were more frequently victims of bullying, while bullies are more frequently associated with families with higher incomes 8,22,29 .Obviously these factors often coincide with other factors of variable risk, such as family stress, violent partners, conflicts, father/child interaction, and authoritative parental practices.In summary, the characteristics of parents (e.g., education and family income) are predictors of being involved with bullying and being a victim.

Discussion
The development of anti-bullying intervention programs needs to take into account the dynamic of this phenomenon and its relationship with different contexts.This is the original contribution of this study, as it broadens perspective on the phenomenon and gathers investigations that report a close link between situations experienced within the family context and the development of aggressive behavior at school.Bullying can be understood as a relationship problem that emerges from primary relationships (in general, composed by the family) and is established as a behavior pattern during childhood and extends into adolescence and adult life.
In regard to this understanding, as the studies included in this review present clear definitions and conceptions of the phenomenon, as well as the theoretical frameworks used, they enable greater conceptual proximity, meaning greater precision and coherence among the results obtained by different researchers.They also contribute to the development of a solid and cohesive body of knowledge concerning the theme, which is only possible when employing a reasonably common definition of the phenomenon under study.
The small number of Brazilian studies addressing the themes investigated in this review is an aspect that draws attention.Many studies were from the fields of psychology, education and health; however, they were focused on the characterization of the phenomenon, identifi-cation of its conceptions of teachers, indirect approaches of the phenomenon, and proposal of interventions.Two master's theses addressing the topics considered in this review were identified 43,44 , but even though this type of document was not included in this study their data were considered in the analysis of the results.This shows the need to establish agendas of contextual studies addressing bullying and its multiple dimensions.
Specifically discussing the contribution of family relations in the development of bullying, we stress evidence that children who experience physical, severe or humiliating punishment may have their quality of life affected and, consequently, may more easily become involved with violence at school.For instance, it is known that students who face many problems at home are more aggressive than those experiencing positive family relationships 20,21,39 .These aspects are interpreted from a perspective of human development that considers the family to be an essential element in people's psychological and social development.
As noted, some family experiences lead children to develop personal problems, such as an anxious demeanor during conflicts (victims) or to perceive their families negatively in terms of affective involvement, as evidenced in the studies addressed here.In general, the assessments of students concerning contextual variables (family functioning, school environment and climate factors) can be associated with the involvement of students experiencing bullying and victimization 10,12,45 .In this context, risk factors include: lack of affection on the part of parents; aggressiveness is allowed among siblings, peers and even adults; rejection; overly protective parents; neglecting parents; difficult communication with parents; physical punishment and emotional outbursts on the part of parents when disciplining children 3,8,14 .
Results reported by studies conducted in Brazil are similar to these findings.A master's thesis presented associations concerning parental disciplinary practices and the manifestation of aggressive behavior at school 43 .One study addressing a sample of 247 students in Rio Grande do Sul identified that a greater frequency of punitive practices used by parents was significantly associated with the involvement of children in bullying situations 43 .Another master's thesis using data collected in four Brazilian cities reported that family variables such as corporal punishment, family conflict, negative communication, and negative marital climate, significantly interacted with aggression and victimization and were indicated as risk factors 44 .
It is discussed that, in general, aggressive children and adolescents have authoritarian parental models, and have experienced a high frequency of emotional and physical abuse in their lives.Ambivalent and less cohesive family relationships, marked by violence, encourage the involvement of students in bullying situations.Family violence is one of the risk factors for school bullying and should be taken into account when devising interventions intended to cope with it 46 .Additionally, such experiences prevent children and adolescents from becoming autonomous, independent individuals able to exercise tolerance in the face of social diversity.Rather, such experiences encourage the use of violence as a valid mechanism to resolve conflicts and social interaction.
In regard to the maintenance of bullying situations, note that the way children respond to social problems and conflict depends on the intervention of/relationship with adults.From another perspective, studies confirm that the adults' essential role is to protect children and adolescents, which includes recognizing and responding to intimidating incidents.The maintenance of violent behavior also reflects family experiences, as it implies there is an example at home of similar situations or situations associated with aggressiveness and violence.Students who intimidate others learn how to use power and aggressiveness to control distress and other feelings, which may be established as a style of social interaction 45,46 {-Castro-Morales, 2011, Acoso escolar}.
Other information related to the perpetuation of bullying is linked to the expectations of parents in regard to children's performance at school.There is a significant risk of an increase in aggressiveness among students whose parents and teachers hold low expectations regarding their school performance.Additionally, students who are mocked by family members and/ or teachers because of their appearance tend to more frequently become involved with bullying than those who have not had such experiences 20,36,39 .Therefore, the family support provided to children who experience intimidation helps them break the cycle of violence and abuse, empowering and helping them to develop coping mechanisms to deal with intimidation 10 .
In regard to the socioeconomic status and composition of families, as well as the parents' level of education and the correlation of these with bullying, we verify that the analysis of these variables is complex.In this sense, one recent study, conducted in Brazil with a sample of 109,104 students attending the 9 th grade, verified that a report of victimization was associated with mothers' low education, while the mothers of those who self-reported being bullies presented higher educational levels 2,47 .The study also addressed other family aspects explored by the studies included in this review, such as supervision by parents, students missing classes without telling their parents, and being subject to physical aggression at home, which were associated with bullying involvement 2,47 .
These findings should be more deeply analyzed in other studies, especially in Brazil, because poverty has a harmful impact on the lives of people and is a result of the social inequalities that mark Brazilian society, while at the same time there are diverse family arrangements and new forms of coexistence emerging.These variables are directly related to bullying and represent risk factors; however, they need to be considered within a macro structural dimension rather than in a cause-and-effect relationship.The way families are organized is not to blame nor is our intention to reinforce discourses that strictly link violence to the poorest population groups or those with the lowest educational levels.This review's findings indicate that exclusively focusing on the school context may not be the best approach to decrease violent behavior among students.The prevention of bullying requires proposals that reach all the dimensions of this complex and multi-faceted social phenomenon.Among these dimensions, the family needs to be considered essential to the construction of a non-violent culture, as it starts within home and is then extended to the community and social life.The family needs to be included in coping interventions within dialogical conceptions that are able to recognize and intervene in a health problem.In terms of practical implications, we verify that family relations need to be strengthened through public policies and programmatic actions that promote the strengthening of bonds, positive communication between parents and children, the construction of social support networks, and the valorization of affection and social learning to establish peaceful relationships in the face of adversity, which can be encouraged by the actions of multidisciplinary teams working in primary health care.
The information contained in this review promotes reflection on and discussion of inter-ventions to cope with bullying in the health field, as it assumes that coping actions are based on the acknowledgment of how important family relations are within this context.Health education or health promotion interventions gathering professionals from both the health and education fields are effective intersectorial practices to prevent, maintain, or reorient behavior, and to structure integral care practices.
Interventions should also consider the inclusion of strategies intended to improve family communication to help children and adolescents to socialize positively in other spaces, such as the school 41 .Additionally, family bonds and the relationship with the community can be enhanced by public policies and territorial base programs.
As a multi-faceted phenomenon and public health problem, bullying requires the adoption of contextual and intersectorial models to enable the inclusion of a debate on sociodemographic factors, as well as family and social factors, which are often neglected by individualizing and/or technocratic approaches.This is a proposition of interventions with a focus broadened beyond the school, directing attention to the attitudes that originate in the family and parents, in addition to congregating different types of knowledge, such as that found in education, psychology, and health, among other fields.

Final considerations
There is evidence that the family context and relationships are associated with the involvement of students with bullying.The analysis of data presented here indicates there is a cultural transmission of violence from within the families.This relationship pattern perpetuates other violent manifestations in society, as positive social skills weaken and coping strategies based on a perception that society is violent emerge, consequently demanding the same type of so-cial response.These results reinforce the role of families in the development of children and adolescents; that is, the family can either promote healthy or impaired development of children and adolescents.The impaired development of children may be reflected in their involvement with violent situations at school.This study has some limitations.First, most of the studies were based on cross-sectional studies, while some were based on the analysis of secondary data.For this reason, the associations presented here are not completely understood in such a way that they can help to construct models that explain the occurrence of bullying at school.Second, that there are only a small number of Brazilian studies focusing on the relationship between the family context and involvement with bullying hinders comparisons between results reported in the Brazilian context and global results.Consequently, the results presented here should be viewed with caution, considering the limitations of generalization.
In conclusion, this review integrated various strong points that aid in understanding the context and multi-level nature of bullying, both of which interfere in the health of school-aged children and adolescents.This review provides a theoretical framework that can encourage and support the construction of intersectorial and dialogical evidence-based interventions.Further studies, using different designs, are needed to test the relationships among these variables, especially in Brazil, to address the complex process of family dynamics and the increased number of reports of bullying observed in recent decades.
Finally, we stress that this study does not condemn family or parental relationships or those occurring in institutions; rather we note that the expression of violence at school is influenced by multiple factors and the promotion of positive family relationships can help to construct a culture of non-violence in defense of the life and health of schoolchildren.

Figure 1 .
Figure 1.PRISMA Flowchart of the process of construction of the revised corpus.PyscoInfo, Lilacs, SciELO, 2014.Source: Developed by the authors.