Print version ISSN 0021-7557
J. Pediatr. (Rio J.) vol.81 no.5 suppl.0 Porto Alegre Nov. 2005
Aramis A. Lopes Neto
Physician. Member of the Associação Brasileira Multiprofissional de Proteção à Infância e à Adolescência (ABRAPIA Brazilian Multiprofessional Association for Children and Adolescent protection). Coordinator of the Program for Reduction of Aggressive Behavior among Students.
To warn pediatricians about the high prevalence of bullying among students,
to raise their awareness about the importance of their action in the prevention,
diagnosis, and treatment of possible damage to children's health and development,
and about the necessity to instruct families and society on how to face the
most frequent form of youth violence.
SOURCE OF DATA: Bibliographic databases and relevant Internet sites were searched for recent articles and texts about the theme.
SUMMARY OF THE FINDINGS:Aggressive behavior among students is a universal problem, traditionally accepted as natural and usually disregarded or not given proper attention by adults. Studies carried out during the past two decades showed that bullying can have immediate and late negative outcomes for children and adolescents who are directly or indirectly involved. The adoption of continued preventive programs in grade schools and in junior high schools has demonstrated to be one of the most effective measures for the prevention of alcohol and drug consumption and for the reduction of social violence.
CONCLUSION: The prevention of bullying among students represents an essential public health measure that may allow for total children's development, qualifying them for a healthy and safe social coexistence.
Key words: School violence, juvenile violence
Violence is a major public health problem that increases all over the world, causing serious individual and social damages, 1-4 especially to young people, who according to statistics are the most seriously injured and who most commit murders.5
Currently, consensus is reached in that violence can be prevented, its impact minimized and factors that contribute to violent responses changed. According to Debarbieux & Blaya, 6 this is not wishful thinking, but an assertion based on evidence. There are many successful examples from different parts of the world, from individual and community work in a small scale, to national policies and legal initiatives.
One of the most visible forms of violence is the juvenile violence, so called for being perpetrated by youths between 10 and 21 years-old. 7,8 Groups in which violent behavior is detected before puberty tend to present aggressive behavior that increases with age and peak with damaging attitudes during adolescence, persisting up to the adult age. 4,7,9,10
As for the environment in which violence against children and adolescents takes place, the school appears as a space that has not been fully explored yet, especially in what concerns the aggressive behavior between students. Violence at school is a severe and complex social problem, and probably the most frequent and visible problem of juvenile violence. 9,11-13 The term "school violence" comprises all types of aggressive and anti-social behavior, including interpersonal conflicts, damage of property, criminal acts, etc.
Many of such situations depend on external factors and possible interventions may be beyond the capacity and responsibility of schools and its employees. However, a countless number of such violent acts could be resolved within the school environment.
The violent behavior, so feared and worrisome, results from the interaction between individual development and social contexts such as family, school and community. Unfortunately, the world outside school is reproduced within the school, transforming safe places that are usually modulated by discipline, friendship and cooperation 3 into violent places where there are suffering and fear.
Studies on the influence of the school environment and educational systems on the academic development of young people have already been carried out, but they must also be approached under the point of view of health care.
The school has an important meaning to children and adolescents. Those who do not enjoy it are more likely to show an unsatisfying performance , physical and emotional problems or unfulfilling feelings towards life. Positive interpersonal relationships and academic development are directly interconnected; students that realize such a relationship are more likely to reach a good learning level. 14 Therefore, acceptance by peers if fundamental for the development of children's and adolescent's health, it helps them to refine their social abilities and strengthen the capacity of reacting against tense situations. 15
Aggressiveness in schools is a universal problem. 3,9 Bullying and victimization represent different types of involvement in violent situations during childhood and adolescence. Bullying is a form of interpersonal power affirmation by means of aggression. By victimization is meant aggressive behavior performed towards a less powerful person by a more powerful one . Both bullying and victimization can have immediate and long term adverse outcomes on all involved individuals : aggressors, victims and observers. 16
Bullying comprises all types of intentional and repeated aggression with no evident reason, performed by one or more students against other(s), causing pain and distress; it happens in unequal power relationships. 3,11 Such an asymmetry may be resulting from differences in age, size, physical or emotional development or from the aggressor finding support of the majority of students. 3,11,17
Aggressive acts that take place in the school environment are traditionally admitted as natural , ignored or taken for granted both by teachers and parents.
The term bullying is universally accepted as it is difficult to translate it to other languages. During the Online International Conference School Bullying and Violence , from May to June 2005, there was an agreement that the wide concept of the term bullying makes it difficult to translate it to languages as German, French, Spanish, and Portuguese, among others. 18
Research on bullying is quite recent and has gained space from the 1990's on, especially with the works by Olweus, 1993; Smith and Sharp, 1994; Ross, 1996; and Rigby, 1996. 3 Studies indicate a prevalence of 8-46% for bullied children and 5-30% for regular active bullies. 3,19
Traditionally, the school is seen as a place to learn where the students' performance is assessed based on tests grades and accomplishment of academic tasks. Three legal documents form the basis for the understanding of children's and adolescent's development and education: the Brazilian Constitution, the Statute of the Child and Adolescent and the UN Convention on the Rights of the Child. These documents are about the right children and adolescents have to be respected and to be treated with dignity; education is understood as a mean to provide the individuals' full development and prepare them for the practice of citizenship.
We all want the school to be a safe and healthy place, where children and adolescents can develop their intellectual and social potential to the full. However, it is not admissible that they be submitted to violent behavior that causes them physical and/or psychological injury, that they witness such events and remain quiet for fear of reprisals, and that they end up thinking that bullying is banal , thus starting to show aggressive behaviors too, because adults omit themselves and tolerate such acts.
The Brazilian Multiprofessional Association for the Child's and Adolescent's protection (ABRAPIA) developed the Program on Reduction of Aggressive Behavior among Students, with the goal of investigating the characteristics of violent events among 5,500 students from the elementary school and designing intervention strategies that could prevent bullying.
Although the program took a little more than a year, from September 2002 to October 2003, it was possible to reduce aggressive behavior among students, enhancing the school environment, the learning level, the property conservation and, most importantly, the human relations (Table 1 and 2)
Bullying can be direct, when victims are directly approached, or indirect, when victims are not present. Direct bullying consists of calling names, physical aggression, threats, hurtful words or unpleasant faces and gestures that bother the victims. Boys are four times more engaged in direct bullying than girls. Indirect bullying involves ignoring, isolation, defamation or denial of wishes, girls are more likely to use indirect bullying. 3,11,19-21
A new type of bullying, known as cyberbullying, has been seen with increasing frequency in different parts of the world. According to Bill Belsey, information and communication technologies ( e-mails , cell phones, instant messaging, digital cameras, web sites and online actions that spread hurtful images) are used as a resource to adopt deliberate, repeated and hostile behavior from an individual or group in order to damage the other(s). 22 In a survey carried out with adolescents, 14 to 23% reported to send offensive, pornographic, abusive or threatening texts through cell phones. 23-25
Economic, social and cultural factors, innate temperament aspects and influence from family, friends, school, and community are risks for the manifestation of bullying and have an impact on children's and adolescent's health and development. 9,21
Bullying is most prevalent among students ranging from 11 to 13 years-old, and less frequent in nursery and secondary school children. 14,17,26 Among aggressors, male individuals predominate; in cases of victimization there are no large differences between genders: boys are bullied as often as girls . The fact that boys are most commonly involved in bullying does not mean that they are more aggressive, but that they are more likely to adopt this type of behavior. The difficulty in identifying bullying among girls may be related to the use of subtler forms of bullying. 3,14
As bullying usually takes place away from the scrutiny of adults and most victims do not react or report what is happening, 22 it is understandable why teachers and parents are not aware of bullying, underestimate its prevalence and are not able to reduce and interrupt bullying events. 19,27 A study by ABRAPIA revealed that 51.8% of bullies admitted they were not reprimanded. 3 Apparent acceptance by adults and the consequent feeling of impunity allow for the continuation of aggressions.
Reduction of risk factors may help avoid aggressive behavior among children and adolescents. Efforts must be made to decrease the exposure of children and adolescents to violence in the home, school, community, and through the media. 28
The different ways kids get involved
Children and adolescents can be identified as victims, aggressors or witnesses, according to their position in bullying situations. There is no evidence as for the position each student may assume, once it can change according to the circumstances.
The classification used in ABRAPIA have tried not to label students, thus avoiding they were stigmatized by the school community. Terms adopted were bully or bullying author (aggressor), bullying target (victim), bullying target/author (aggressor/victim) and bullying witness. 3,29
The target is the student exposed repeatedly and over time to negative actions on the part of one or more students. Negative actions can include physical, verbal or indirect actions that are intended to inflict injury or discomfort upon another person who, in general , does not count on resources, status or ability to react or stop bullying. In general , victims are not very sociable, and feel insecure and hopeless as to the possibility of fitting to a group. Their low self-esteem is worsened by criticisms from adults as to the child's life or behavior, thus making it even more difficult to help them. The bullying victim is passive, shy, and unhappy and suffers with shame, fear, depression and anxiety. Their low self-esteem may be so damaged that they believe they deserve the bad-treatment they receive. 3,9,11,14,22,27,30
Period and frequency of aggressions strongly contribute to the worsening of effects. Fear, tension and distress with self-image may impair the academic development, besides increasing anxiety, lack of confidence and negative concept of oneself. 8 The victim can avoid school and social life in an attempt to escape from bullies. In rare cases, self-destruction or suicide ideation may be present, or the victim feels compelled to use drastic measures, such as revenge, violent reactions, carrying a gun or committing suicide. 25,27,31
Some physical, behavioral or emotional characteristics may make the victim more vulnerable to the actions of bullies and affect his/her relation with the group. Rejection to differences is an important fact reported in the occurrence of bullying, however, bullies are more likely to choose and use possible differences as a justification for aggressions, even if these are not the real causes of their behavior. 26,29,32,33
Although there are not accurate studies on education methods that produce bullying victims, some can be identified as facilitators: over protection, which may prevent children from developing challenge-coping abilities; childish treatment, which may cause reduced psychic and emotional development, lower than that accepted by the group; and giving the children the role of the family's scapegoat, systematically criticizing and considered them responsible for the parent's frustrations.
Two thirds of the armed students that opened fire against classmates and teachers in schools said to be victims of bullying and used the guns to combat the power that overwhelmed them. Such an aggressive behavior did not have a specific target, which suggests they wanted to "kill the school", the place where everybody saw them suffering and did nothing to protect them. 3
Victims usually do not reveal that they are being bullied, either for feeling ashamed, for being afraid of reprisals, for doubting the school will support them, or for fearing possible criticisms. In the research performed by ABRAPIA, 41.6% of target students admitted they did not tell anybody about their distress. 3 Silence is broken when victims feel they will be heard, respected and praised. When children and adolescents are aware that bullying is not accepted or tolerated they can deal with the problem with more power, transparency and liberty. 11
Bullies or bullying authors
Some adverse familial conditions may favor the development of aggressive behavior in children, such as unstructured family, poor affective relationships, excess of tolerance or permissive behavior, physical punishment, and violent emotional outbursts as control methods. 3,8,21,26,27
Individual factors may also contribute to aggressive behavior: hyperactivity, impulsiveness, behavioral disturbances, attention deficit , low intelligence level and low school performance .
The typical bully tends to be popular and involved in a range of aggressive behaviors; he or she may be aggressive even with adults and see aggressiveness as one of his or her qualities. The bully is impulsive, has positive opinions about him/herself, and in general is stronger than his target. A bully feels pleasure and satisfaction with domination, with controlling, damaging and hurting the others; moreover, he may benefit from his behavior with social and material gains. 11,21,29,34 They are less satisfied with the school and family, prone to absenteeism and school missing; they have increased tendency to present risk behavior (tobacco, alcohol and other drugs consumption; carrying guns, fighting, etc). 3,8,35-37 Children and adolescents that show antisocial attitudes before puberty and for a long time are more likely to present such risks when adults. 9,27,37
The bully may count on a small group of followers who may help him or her to bully the others or are ordered to bully the victim. Thus, the bullying author divides the responsibility with others or transfers it to their followers. These students are identified as assistants or followers, and rarely have the initiative to start bullying others, they feel insecure and anxious, and get involved partly to protect themselves and partly to have the status of belonging to the dominant group. 11
The majority of students do not get directly involved in bullying acts and in general they are afraid of becoming the "next victim", remaining quiet, not knowing what to do and distrusting the school attitudes. This silence may be interpreted by the authors as certainty of their power and ends up hindering the prevalence of bullying, transmitting a false idea of tranquility to adults. 3,27
Most part of witnesses fell sympathy for the targets, and tend not to blame them guilty for what happened, they condemn bullies and would like teachers intervened more effectively. 38,39 About 80% of students do not approve bullying acts. 3
The way how bullying witnesses react allows to classify them as helpers (actively take part in the aggression), supporters (stimulate the author), observers (only observe or get out) or defenders (protect the target and call an adult to interrupt). 19
Many witnesses end up believing the use of aggressive behavior against classmates is the best way to reach popularity and power and became bullies too. 19 Others may present a learning deficit ; they are afraid of being associated with the target figure, loosing status and becoming targets too; or they adhere bullying for pressure from peers. 9
The witnesses' interference and attempts to stop bullying are usually effective in most of the cases. It is therefore important that the power of the group is fostered, so that bullies will realize they do not have the necessary social support. 3,8
Nearly 20% of bullies are also victims as much as they are bullies. A combination of low self-esteem and aggressive and provocative attitudes is an indication of a child with motivation to bully, which is likely to be due to abnormal psychopathology that requires further attention. They may be depressive, insecure and nasty, they try to humiliate their friends in order to hide their own limitations. Different from the typical targets, they are not popular and are highly rejected by their friends or by the whole class. 11,17,21 Depressive symptoms, suicidal ideation and psychiatric disorders are mostly frequent in this group. 40,41
Targets, authors and witnesses suffer both physical and emotional consequences at long or short term, 8 which may cause academic, social , emotional and legal problems. 12,17 Obviously not all children and adolescents are affected uniformly, but there is a direct relation with frequency, lasting period and severity of bullying acts. 14
Children who suffered with bullying are more likely to suffer with depression and low self-esteem in the adult age. The same way as, the younger the aggressive child the highest will be the risk of presenting problems associated to anti-social behavior in the adult life and of loosing opportunities, as job instability and short-lasting relationships. 14,22,35
Simply witnessing bullying acts is enough to make a child unhappy with the school and to affect his or her academic and social performance . 11
Financial and social damages caused by bullying also affect families, schools and society as a whole. Children and adolescents that are victims of bullying or bully the others may require care from multiple services as: mental health, child and adolescence justice, special education and social programs.
The victim's parent's behavior may vary from distrust or indifference to rage or intolerance towards themselves and school. Feelings of guilt and incapacity to rule out bullying against their kids become their major concerns in their life, and depressive symptoms may arise, affecting their performance at work and their personal relationships. Denial or indifference from principals and teachers may cause discouragement and may raise the sensation that the student's security is of no concern. 42
Familial relationships may also be severely damaged. Victims may feel betrayed, in case their parents do not believe them or effective measures are not taken. 43.
The role of the pediatrician
Bullying effects are rarely evident, it is not very likely that the children or adolescents look for a pediatrician with a clear understanding about whether they are bullying victims or authors. On the other hand, it is possible to identify risk patients, to advise families and to look for possible psychiatric alterations, fostering the implementation of anti-bullying programs at schools. 17
Being a bullying victim can be an important predisposing factor for the installation and persistence of clinical signals and symptoms (Table 3). Identifying some of these complaints may indicate that individuals are being bad-treated by friends and shows how the attention by health professionals is necessary. 3,17,19,24,28
It is not clear yet whether health problems precede bullying or bullying acts affect the victim's health. Distress caused by victimization can lead to the development of pathologies, but children and adolescents with problems as depression or anxiety may become bullying targets. A few studies have investigated this relation, but both hypothesis are strongly supported. 19 Early intervention, both concerning targets and authors, can reduce the risks of late emotional problems. 29,43
In suspect cases, risk factors must be always investigated and managed, such as: personal characteristics, familial and community influences and school problems. 21,40
There are no diagnostic methods to indicate the presence of aggressive behavior as a predisposing factor to some behavioral or psychosomatic change. It is the pediatrician's responsibility to look for information on the process of school performance of his or her patients, not only assessing their ability to learn, but also their development of abilities related to social life. It is therefore important to ask the child or adolescent if they feel comfortable in the school environment, if they have friends, if they witness or are targets and/or authors of physical or moral aggressions. 17,27
A psychiatric and/or psychological evaluation may be necessary and may be provided in cases where children and adolescents show personality alterations, intense aggression, behavioral disorders or if they remain for a long time as targets, authors or target/authors of bullying. 11,17,22,29,44
Orientations as to adopt protective measures may prevent future incidents: ignoring nicknames, having non-aggressive classmates, avoiding risky places and informing teachers and school staff about bullying. 17,27
Among authors, changes in behavior, risk behavior and alcohol and drugs consumption are most frequently seen. 17 Other factors that contribute to aggressiveness and bad behavior are posttraumatic brain injuries, bad-treatment, genetic vulnerability, school failure, traumatic experiences, etc. 41
The treatment indicated to bullies must involve irritability control, adequate expression of anger and frustration, responsibility for his/her acts and acceptance of consequences from his/her acts. Therefore, patients that report situations in which they are protagonists of aggressive actions against their classmates deserve attention as much as those they attack. 40
Those identified as targets/authors show a higher probability of developing mental diseases, so they must be considered as those with higher risk. Manifestations as hyperactivity, attention deficit , behavior disorder, depression, learning difficulties, aggressiveness, beyond others that were already mentioned can be found. 17,39
Both bullies and victims families must be aided to understand the problem; they must be aware of all possible consequences resulting from bullying. Parents must be advised to count on the school as a partner, talking to principals or teachers that seem to be more sensitive towards the problem.
Pediatricians may act as advisors in schools, in public security departments or community associations, advising about the impact that bullying may have on children, adolescents and schools, highlighting how important it is to create environments where friendship, solidarity and respect to differences are given proper value.
Assessing the performance of students through their grades and homework accomplishment is not enough. Realizing and monitoring abilities or possible difficulties that youths may have in their social life with friends is a compulsory responsibility of those who undertook the responsibility of educating, and caring for health and security of students, patients and kids.
All anti-bullying programs must see schools as dynamic and complex systems, which can not be all treated in the same way. In each school, strategies must always take into account social , economic and cultural characteristics of their population.
The involvement of teachers, workers, parents and students is basic for the implementation of bullying reduction projects. The participation of all aims at setting rules, guidelines and coherent actions. Actions must prioritize general awareness, support to victims so that they feel protected, bullies awareness about the incorrectness of their acts, and the warranty of a safe and secure school environment.
The bullying phenomenon is complex and difficult to solve, therefore, a continued work is required. Actions are quite simple and low-cost, 1,3 they can easily be included in the daily life of schools in the form of transversal topics along the school routine.
Students must be fostered to actively take part in the supervision and intervention of bullying, because when witnesses face the situation, the bullies are shown that they will not have the support from the whole group. Training using drama can be useful to practice the ability to deal with aggression. Another strategy is the formation of support groups that protect targets and help solving bullying situations. 19
Teachers must manage and resolve bullying events effectively, while schools must refine their techniques of intervention and look for the cooperation from other institutions, as health care centers, community councils and social support networks. 19
Bullies must be provided with the conditions to develop friendlier and healthier behavior, thus avoiding that only punishment measures are taken, which end up marginalizing them.
According to the World Health Organization, the programs that focus on social capacities and acquisition of competences seem to be among the most effective strategies for the prevention of juvenile violence, and they are more effective in primary and nursery schools. A program of social development that uses behavioral techniques in the classroom avoids bullying. 45
The Bullying Prevention Program by Dan Olweus is considered the most well-documented and effective in reducing bullying, significantly decreasing antisocial behavior and providing important improvements in the social life of children and adolescents, who adopt positive social relationships and increase their participation in school activities. 14,19,21
In schools where students actively participated in decisions and organization, a reduction in the levels of vandalism and discipline problems, and higher satisfaction of students and teachers with the school were seen. 15 In the ABRAPIA project, 63.5% of students actively participated in the project development. 3
Best results were obtained with early interventions comprising parents, students and educators. Dialogue, peer relation pacts, support and establishment of confidence and information links are effective instruments, and no violent actions should be admitted, under no circumstances. 4,13,15,46
Bullying consequences are so severe that North-American children aged between 8 and 15 consider it as a problem worst than racism and pressure to have sexual relations or drinking alcohol or taking drugs. 47
The lack of public policies that prioritize preventive actions against bullying in schools, which aim at assuring health care and education quality, makes evident that a number of child and adolescents are exposed to the risk of regular abuse from peers and that the most aggressive ones are not receiving the necessary support to be advised to get out of behavior that can damage their whole life.
Reducing the prevalence of bullying in schools can be a highly effective public health measure for the 21 st century. Its prevalence and severity compel researchers to investigate risks and protection factors in initiation, maintenance and interruption of this kind of aggressive behavior. Knowledge resulting from these studies must be used as a base that will help to guide the formulation of public policies and to outline multidisciplinary intervention techniques that would effectively reduce the problem.
In Brazil , a country where fostering the education quality improvement is an instrument for socialization and development and the majority of the social policies are turned towards school inclusion, schools became the adequate place for collective and permanent construction of favorable conditions for the full citizenship development.
Health and education institutions, as well as their staff , must acknowledge the extension and impact of bullying among students, and must develop practices to reduce it quickly. As to health professionals, especially pediatricians, they should be able to advice, investigate, diagnose and adopt adequate practices in violent situations that involve children and adolescents, either as bullies, targets or witnesses. Even when we assume that aggressive attitudes derive from social and affective influences, which are historically constructed and justified by familial and/or community issues, it is possible to consider the endless possibility of people finding more productive, happier and safer ways of life.
Children and adolescents have, individually and collectively, a human prerogative of changing, transforming and reconstructing things, even in very adverse conditions, so that their life can be based on peace, possible safety and happiness.
This is not a simple challenge and, in general , it depends on a firm and competent interdisciplinary intervention, especially by professionals from education and health areas.
Bullying can be understood as a parameter for the evaluation of the level of violence that can be tolerated. Therefore, while the society is not ready to cope with bullying, chances of reducing other types of aggressive and destructive behavior are minimal too.
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