While culturally we have become more aware of the prevalence and consequences of bullying, it remains a significant problem and a frequent reason for presentation for psychiatric care. National surveys indicate that bullying affects up to 50% of students (Pergolizzi F et al, Int J Adolesc Med Health 2011;23(1):11–8).

Bullies and victims are more likely to have mental health problems—both direct consequences of the bullying such as depression, suicidality, and school refusal, and pre-existing problems such as learning and social difficulties. Bullies and victims do not differentiate by diagnosis, and many victims are also bullies (Wang J et al, J Adolesc Health 2009;45(4):368–375).

That said, psychiatrists may be called upon to weigh in on appropriate interventions and the task can seem insurmountable at times. Bullying interventions need to occur in four domains: the school system itself, the classroom, the family, and the individual, whether the child is a victim or a perpetrator.

In my own practice, which serves several different school districts, children who are bullied or bullying are likely to come from a few particular schools. I have spoken with the principal of one of the prime offenders, a middle school, and have been told that this bullying does not occur, and if it does occur, it is the natural consequence of having middle school students—it’s how children are socialized to cultural norms. In reality, bullying thrives in environments that permit it. Many states are looking to legislate some acknowledgement of this fact. After a high school student and victim of unrelenting cyberbullying committed suicide, the state of Massachusetts passed legislation mandating that all schools have anti-bullying plans in place (Phoebe’s Law).

Anti-Bullying Programs
There are several anti-bullying, school-wide programs that have been shown to be effective, and several that have not. What the effective programs seem to have in common are three basic assumptions: 1) the child’s environment can encourage or discourage bullying, so 2) multidisciplinary school-wide interventions are needed, and 3) both bullying and victimization are skill deficits.

The anti-bullying program recommended by the Federal Department of Education is called Positive Behavioral Intervention and Supports (PBIS), and it has several advantages, not the least of which is a whole lot of free resources and support for schools, as well as help with implementation (which you can find at www.pbis.org). Others include KiVa (Williford et al, J Abnorm Child Psychol 2011;Aug 6:online ahead of print), and Olweus Bullying Prevention Program (see www.olweus.org).

The aspects of environment and skill deficits are key to psychiatric treatment of bullying and victimization. Each child who presents with involvement in bullying (in any role) needs both an individual and an environmental work up. On the individual front, a full evaluation for any psychiatric disorders and learning disabilities should be undertaken, because it is clear that both bullies and victims are at higher risk for both kinds of disorders.

The second thing that helps is social skills training. Appropriate self-assertion, social problem solving, and perspective taking skills are often lacking and can be effectively addressed in psychotherapy or in social skills groups.

Third, the strength of friendships is a protective factor for victims (Wang et al, op cit), and can be an excellent focus for children and families. Fourth, many children who bully struggle to contain their anger, and a program to address self-regulation, such as collaborative problems solving, is useful. (For more on collaborative problem solving, see CCPR May 2010 or www.livesinthebalance.org.)

Evaluating the Environment
The environmental evaluation can be tricky. Ideally, one investigates all possible sources of modeled bullying behavior: at school, at home, in daycare, or in any other environment (from riding lessons to Boy Scouts to Grandma’s house) that the child is in regularly. This can be both fascinating and alarming. An Israeli study linked verbal and physical abuse by teachers with bullying and victimization among peers (Khoury-Kassabri M, Child Abuse Negl 2009;33(12):914–923). In my experience, I have directly observed children taunted by their teachers and shrieked at by their principals. In attending PBIS trainings with a local school district, the most frequent objection I heard was, “Why should we be nice to someone who isn’t being nice to others? Isn’t that just rewarding bad behavior? He should get a taste of his own medicine.”

It may require the psychiatrist to assume the role of advocate, both by explaining directly and by addressing the school or school district about the need for anti-bullying initiatives and expectations of staff, from the principal to the janitor. Teachers may also benefit from a concrete understanding of what the practicalities of a child’s diagnoses are, especially ADHD and Asperger’s. Although many people have a superficial understanding of both disorders, teachers don’t necessarily understand that what seems like rude or defiant behavior can have an entirely different meaning.

The family is another common source of modeled bullying behavior. In a school I worked with, there were two second grade girls who could not leave each other alone. Each took turns doing something dreadful to the other. Things came to a head, however, when the father of one of the girls cornered the mother of the other, pinned her against the wall, and screamed that she better make her daughter stop picking on his kid.

A Center for Disease Control analysis of the 2009 Massachusetts Youth Health Survey showed that victims of bullying are almost three times as likely to be physically hurt by a family member, bullies almost four and a half times, and children who are both bullies and victims five times more likely to be hurt (CDC, MMWR Morb Mortal Wkly Report 2011;60(15):465–471).

Parents don’t always realize that their own behavior is bullying and may need some help making the connection while saving face in front of their children and the professional. I speak of a social “diet” (the way I also speak of an aggression diet in other situations) and say that while some yelling and such may be fine in other circumstances—like when the person you are interacting with is fairly far away or very hard of hearing, for example—for this child’s particular circumstances, the parents need to make the most of any and all opportunities to show the child how to behave at school. Therefore parents need to model calm, problem solving behavior all the time. Of course, remember that parents who bully or are verbally abusive may not have alternative skills, so this is an easy time to go through more optimal parenting techniques under the guise of explaining what the child needs to know.

Resources for Clinicians and Families
In addition to the PBIS website, there are some other excellent online resources for parents, schools, and clinicians. The American Association of School Administrators has a nice one at www.education.com/topic/schoolbullying-teasing. This website has a wide variety of articles on everything from what parents can do if they witness bullying to readable summaries of the relevant research on bullying and its causes and treatments. Some articles are in Spanish.

A great resource, where you can find “webisodes,” short cartoons that show kids how the characters experience and then overcome bullying, is www.stopbullying.gov. There is also a link to one of my favorite initiatives, the It Gets Better Project, www.itgetsbetter.org. This is a series of videos encouraging GLBT youth who may be the victims of bullies. The videos are done by a huge variety of celebrities, and include original songs/music videos, brief interviews with celebrities about their own experiences with bullying (or coming out), and even a message from President Obama.