literature review of bullying

• Research article
• Open access
• Published: 14 December 2021

Bullying at school and mental health problems among adolescents: a repeated cross-sectional study

• Håkan Källmén 1 &
• Mats Hallgren   ORCID: orcid.org/0000-0002-0599-2403 2  

Child and Adolescent Psychiatry and Mental Health volume  15 , Article number:  74 ( 2021 ) Cite this article

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To examine recent trends in bullying and mental health problems among adolescents and the association between them.

A questionnaire measuring mental health problems, bullying at school, socio-economic status, and the school environment was distributed to all secondary school students aged 15 (school-year 9) and 18 (school-year 11) in Stockholm during 2014, 2018, and 2020 (n = 32,722). Associations between bullying and mental health problems were assessed using logistic regression analyses adjusting for relevant demographic, socio-economic, and school-related factors.

The prevalence of bullying remained stable and was highest among girls in year 9; range = 4.9% to 16.9%. Mental health problems increased; range = + 1.2% (year 9 boys) to + 4.6% (year 11 girls) and were consistently higher among girls (17.2% in year 11, 2020). In adjusted models, having been bullied was detrimentally associated with mental health (OR = 2.57 [2.24–2.96]). Reports of mental health problems were four times higher among boys who had been bullied compared to those not bullied. The corresponding figure for girls was 2.4 times higher.

Conclusions

Exposure to bullying at school was associated with higher odds of mental health problems. Boys appear to be more vulnerable to the deleterious effects of bullying than girls.

Introduction

Bullying involves repeated hurtful actions between peers where an imbalance of power exists [ 1 ]. Arseneault et al. [ 2 ] conducted a review of the mental health consequences of bullying for children and adolescents and found that bullying is associated with severe symptoms of mental health problems, including self-harm and suicidality. Bullying was shown to have detrimental effects that persist into late adolescence and contribute independently to mental health problems. Updated reviews have presented evidence indicating that bullying is causative of mental illness in many adolescents [ 3 , 4 ].

There are indications that mental health problems are increasing among adolescents in some Nordic countries. Hagquist et al. [ 5 ] examined trends in mental health among Scandinavian adolescents (n = 116, 531) aged 11–15 years between 1993 and 2014. Mental health problems were operationalized as difficulty concentrating, sleep disorders, headache, stomach pain, feeling tense, sad and/or dizzy. The study revealed increasing rates of adolescent mental health problems in all four counties (Finland, Sweden, Norway, and Denmark), with Sweden experiencing the sharpest increase among older adolescents, particularly girls. Worsening adolescent mental health has also been reported in the United Kingdom. A study of 28,100 school-aged adolescents in England found that two out of five young people scored above thresholds for emotional problems, conduct problems or hyperactivity [ 6 ]. Female gender, deprivation, high needs status (educational/social), ethnic background, and older age were all associated with higher odds of experiencing mental health difficulties.

Bullying is shown to increase the risk of poor mental health and may partly explain these detrimental changes. Le et al. [ 7 ] reported an inverse association between bullying and mental health among 11–16-year-olds in Vietnam. They also found that poor mental health can make some children and adolescents more vulnerable to bullying at school. Bayer et al. [ 8 ] examined links between bullying at school and mental health among 8–9-year-old children in Australia. Those who experienced bullying more than once a week had poorer mental health than children who experienced bullying less frequently. Friendships moderated this association, such that children with more friends experienced fewer mental health problems (protective effect). Hysing et al. [ 9 ] investigated the association between experiences of bullying (as a victim or perpetrator) and mental health, sleep disorders, and school performance among 16–19 year olds from Norway (n = 10,200). Participants were categorized as victims, bullies, or bully-victims (that is, victims who also bullied others). All three categories were associated with worse mental health, school performance, and sleeping difficulties. Those who had been bullied also reported more emotional problems, while those who bullied others reported more conduct disorders [ 9 ].

As most adolescents spend a considerable amount of time at school, the school environment has been a major focus of mental health research [ 10 , 11 ]. In a recent review, Saminathen et al. [ 12 ] concluded that school is a potential protective factor against mental health problems, as it provides a socially supportive context and prepares students for higher education and employment. However, it may also be the primary setting for protracted bullying and stress [ 13 ]. Another factor associated with adolescent mental health is parental socio-economic status (SES) [ 14 ]. A systematic review indicated that lower parental SES is associated with poorer adolescent mental health [ 15 ]. However, no previous studies have examined whether SES modifies or attenuates the association between bullying and mental health. Similarly, it remains unclear whether school related factors, such as school grades and the school environment, influence the relationship between bullying and mental health. This information could help to identify those adolescents most at risk of harm from bullying.

To address these issues, we investigated the prevalence of bullying at school and mental health problems among Swedish adolescents aged 15–18 years between 2014 and 2020 using a population-based school survey. We also examined associations between bullying at school and mental health problems adjusting for relevant demographic, socioeconomic, and school-related factors. We hypothesized that: (1) bullying and adolescent mental health problems have increased over time; (2) There is an association between bullying victimization and mental health, so that mental health problems are more prevalent among those who have been victims of bullying; and (3) that school-related factors would attenuate the association between bullying and mental health.

Participants

The Stockholm school survey is completed every other year by students in lower secondary school (year 9—compulsory) and upper secondary school (year 11). The survey is mandatory for public schools, but voluntary for private schools. The purpose of the survey is to help inform decision making by local authorities that will ultimately improve students’ wellbeing. The questions relate to life circumstances, including SES, schoolwork, bullying, drug use, health, and crime. Non-completers are those who were absent from school when the survey was completed (< 5%). Response rates vary from year to year but are typically around 75%. For the current study data were available for 2014, 2018 and 2020. In 2014; 5235 boys and 5761 girls responded, in 2018; 5017 boys and 5211 girls responded, and in 2020; 5633 boys and 5865 girls responded (total n = 32,722). Data for the exposure variable, bullied at school, were missing for 4159 students, leaving 28,563 participants in the crude model. The fully adjusted model (described below) included 15,985 participants. The mean age in grade 9 was 15.3 years (SD = 0.51) and in grade 11, 17.3 years (SD = 0.61). As the data are completely anonymous, the study was exempt from ethical approval according to an earlier decision from the Ethical Review Board in Stockholm (2010-241 31-5). Details of the survey are available via a website [ 16 ], and are described in a previous paper [ 17 ].

Students completed the questionnaire during a school lesson, placed it in a sealed envelope and handed it to their teacher. Student were permitted the entire lesson (about 40 min) to complete the questionnaire and were informed that participation was voluntary (and that they were free to cancel their participation at any time without consequences). Students were also informed that the Origo Group was responsible for collection of the data on behalf of the City of Stockholm.

Study outcome

Mental health problems were assessed by using a modified version of the Psychosomatic Problem Scale [ 18 ] shown to be appropriate for children and adolescents and invariant across gender and years. The scale was later modified [ 19 ]. In the modified version, items about difficulty concentrating and feeling giddy were deleted and an item about ‘life being great to live’ was added. Seven different symptoms or problems, such as headaches, depression, feeling fear, stomach problems, difficulty sleeping, believing it’s great to live (coded negatively as seldom or rarely) and poor appetite were used. Students who responded (on a 5-point scale) that any of these problems typically occurs ‘at least once a week’ were considered as having indicators of a mental health problem. Cronbach alpha was 0.69 across the whole sample. Adding these problem areas, a total index was created from 0 to 7 mental health symptoms. Those who scored between 0 and 4 points on the total symptoms index were considered to have a low indication of mental health problems (coded as 0); those who scored between 5 and 7 symptoms were considered as likely having mental health problems (coded as 1).

Primary exposure

Experiences of bullying were measured by the following two questions: Have you felt bullied or harassed during the past school year? Have you been involved in bullying or harassing other students during this school year? Alternatives for the first question were: yes or no with several options describing how the bullying had taken place (if yes). Alternatives indicating emotional bullying were feelings of being mocked, ridiculed, socially excluded, or teased. Alternatives indicating physical bullying were being beaten, kicked, forced to do something against their will, robbed, or locked away somewhere. The response alternatives for the second question gave an estimation of how often the respondent had participated in bullying others (from once to several times a week). Combining the answers to these two questions, five different categories of bullying were identified: (1) never been bullied and never bully others; (2) victims of emotional (verbal) bullying who have never bullied others; (3) victims of physical bullying who have never bullied others; (4) victims of bullying who have also bullied others; and (5) perpetrators of bullying, but not victims. As the number of positive cases in the last three categories was low (range = 3–15 cases) bully categories 2–4 were combined into one primary exposure variable: ‘bullied at school’.

Assessment year was operationalized as the year when data was collected: 2014, 2018, and 2020. Age was operationalized as school grade 9 (15–16 years) or 11 (17–18 years). Gender was self-reported (boy or girl). The school situation To assess experiences of the school situation, students responded to 18 statements about well-being in school, participation in important school matters, perceptions of their teachers, and teaching quality. Responses were given on a four-point Likert scale ranging from ‘do not agree at all’ to ‘fully agree’. To reduce the 18-items down to their essential factors, we performed a principal axis factor analysis. Results showed that the 18 statements formed five factors which, according to the Kaiser criterion (eigen values > 1) explained 56% of the covariance in the student’s experience of the school situation. The five factors identified were: (1) Participation in school; (2) Interesting and meaningful work; (3) Feeling well at school; (4) Structured school lessons; and (5) Praise for achievements. For each factor, an index was created that was dichotomised (poor versus good circumstance) using the median-split and dummy coded with ‘good circumstance’ as reference. A description of the items included in each factor is available as Additional file 1 . Socio-economic status (SES) was assessed with three questions about the education level of the student’s mother and father (dichotomized as university degree versus not), and the amount of spending money the student typically received for entertainment each month (> SEK 1000 [approximately $120] versus less). Higher parental education and more spending money were used as reference categories. School grades in Swedish, English, and mathematics were measured separately on a 7-point scale and dichotomized as high (grades A, B, and C) versus low (grades D, E, and F). High school grades were used as the reference category.

Statistical analyses

The prevalence of mental health problems and bullying at school are presented using descriptive statistics, stratified by survey year (2014, 2018, 2020), gender, and school year (9 versus 11). As noted, we reduced the 18-item questionnaire assessing school function down to five essential factors by conducting a principal axis factor analysis (see Additional file 1 ). We then calculated the association between bullying at school (defined above) and mental health problems using multivariable logistic regression. Results are presented as odds ratios (OR) with 95% confidence intervals (Cis). To assess the contribution of SES and school-related factors to this association, three models are presented: Crude, Model 1 adjusted for demographic factors: age, gender, and assessment year; Model 2 adjusted for Model 1 plus SES (parental education and student spending money), and Model 3 adjusted for Model 2 plus school-related factors (school grades and the five factors identified in the principal factor analysis). These covariates were entered into the regression models in three blocks, where the final model represents the fully adjusted analyses. In all models, the category ‘not bullied at school’ was used as the reference. Pseudo R-square was calculated to estimate what proportion of the variance in mental health problems was explained by each model. Unlike the R-square statistic derived from linear regression, the Pseudo R-square statistic derived from logistic regression gives an indicator of the explained variance, as opposed to an exact estimate, and is considered informative in identifying the relative contribution of each model to the outcome [ 20 ]. All analyses were performed using SPSS v. 26.0.

Prevalence of bullying at school and mental health problems

Estimates of the prevalence of bullying at school and mental health problems across the 12 strata of data (3 years × 2 school grades × 2 genders) are shown in Table 1 . The prevalence of bullying at school increased minimally (< 1%) between 2014 and 2020, except among girls in grade 11 (2.5% increase). Mental health problems increased between 2014 and 2020 (range = 1.2% [boys in year 11] to 4.6% [girls in year 11]); were three to four times more prevalent among girls (range = 11.6% to 17.2%) compared to boys (range = 2.6% to 4.9%); and were more prevalent among older adolescents compared to younger adolescents (range = 1% to 3.1% higher). Pooling all data, reports of mental health problems were four times more prevalent among boys who had been victims of bullying compared to those who reported no experiences with bullying. The corresponding figure for girls was two and a half times as prevalent.

Associations between bullying at school and mental health problems

Table 2 shows the association between bullying at school and mental health problems after adjustment for relevant covariates. Demographic factors, including female gender (OR = 3.87; CI 3.48–4.29), older age (OR = 1.38, CI 1.26–1.50), and more recent assessment year (OR = 1.18, CI 1.13–1.25) were associated with higher odds of mental health problems. In Model 2, none of the included SES variables (parental education and student spending money) were associated with mental health problems. In Model 3 (fully adjusted), the following school-related factors were associated with higher odds of mental health problems: lower grades in Swedish (OR = 1.42, CI 1.22–1.67); uninteresting or meaningless schoolwork (OR = 2.44, CI 2.13–2.78); feeling unwell at school (OR = 1.64, CI 1.34–1.85); unstructured school lessons (OR = 1.31, CI = 1.16–1.47); and no praise for achievements (OR = 1.19, CI 1.06–1.34). After adjustment for all covariates, being bullied at school remained associated with higher odds of mental health problems (OR = 2.57; CI 2.24–2.96). Demographic and school-related factors explained 12% and 6% of the variance in mental health problems, respectively (Pseudo R-Square). The inclusion of socioeconomic factors did not alter the variance explained.

Our findings indicate that mental health problems increased among Swedish adolescents between 2014 and 2020, while the prevalence of bullying at school remained stable (< 1% increase), except among girls in year 11, where the prevalence increased by 2.5%. As previously reported [ 5 , 6 ], mental health problems were more common among girls and older adolescents. These findings align with previous studies showing that adolescents who are bullied at school are more likely to experience mental health problems compared to those who are not bullied [ 3 , 4 , 9 ]. This detrimental relationship was observed after adjustment for school-related factors shown to be associated with adolescent mental health [ 10 ].

A novel finding was that boys who had been bullied at school reported a four-times higher prevalence of mental health problems compared to non-bullied boys. The corresponding figure for girls was 2.5 times higher for those who were bullied compared to non-bullied girls, which could indicate that boys are more vulnerable to the deleterious effects of bullying than girls. Alternatively, it may indicate that boys are (on average) bullied more frequently or more intensely than girls, leading to worse mental health. Social support could also play a role; adolescent girls often have stronger social networks than boys and could be more inclined to voice concerns about bullying to significant others, who in turn may offer supports which are protective [ 21 ]. Related studies partly confirm this speculative explanation. An Estonian study involving 2048 children and adolescents aged 10–16 years found that, compared to girls, boys who had been bullied were more likely to report severe distress, measured by poor mental health and feelings of hopelessness [ 22 ].

Other studies suggest that heritable traits, such as the tendency to internalize problems and having low self-esteem are associated with being a bully-victim [ 23 ]. Genetics are understood to explain a large proportion of bullying-related behaviors among adolescents. A study from the Netherlands involving 8215 primary school children found that genetics explained approximately 65% of the risk of being a bully-victim [ 24 ]. This proportion was similar for boys and girls. Higher than average body mass index (BMI) is another recognized risk factor [ 25 ]. A recent Australian trial involving 13 schools and 1087 students (mean age = 13 years) targeted adolescents with high-risk personality traits (hopelessness, anxiety sensitivity, impulsivity, sensation seeking) to reduce bullying at school; both as victims and perpetrators [ 26 ]. There was no significant intervention effect for bullying victimization or perpetration in the total sample. In a secondary analysis, compared to the control schools, intervention school students showed greater reductions in victimization, suicidal ideation, and emotional symptoms. These findings potentially support targeting high-risk personality traits in bullying prevention [ 26 ].

The relative stability of bullying at school between 2014 and 2020 suggests that other factors may better explain the increase in mental health problems seen here. Many factors could be contributing to these changes, including the increasingly competitive labour market, higher demands for education, and the rapid expansion of social media [ 19 , 27 , 28 ]. A recent Swedish study involving 29,199 students aged between 11 and 16 years found that the effects of school stress on psychosomatic symptoms have become stronger over time (1993–2017) and have increased more among girls than among boys [ 10 ]. Research is needed examining possible gender differences in perceived school stress and how these differences moderate associations between bullying and mental health.

Strengths and limitations

Strengths of the current study include the large participant sample from diverse schools; public and private, theoretical and practical orientations. The survey included items measuring diverse aspects of the school environment; factors previously linked to adolescent mental health but rarely included as covariates in studies of bullying and mental health. Some limitations are also acknowledged. These data are cross-sectional which means that the direction of the associations cannot be determined. Moreover, all the variables measured were self-reported. Previous studies indicate that students tend to under-report bullying and mental health problems [ 29 ]; thus, our results may underestimate the prevalence of these behaviors.

In conclusion, consistent with our stated hypotheses, we observed an increase in self-reported mental health problems among Swedish adolescents, and a detrimental association between bullying at school and mental health problems. Although bullying at school does not appear to be the primary explanation for these changes, bullying was detrimentally associated with mental health after adjustment for relevant demographic, socio-economic, and school-related factors, confirming our third hypothesis. The finding that boys are potentially more vulnerable than girls to the deleterious effects of bullying should be replicated in future studies, and the mechanisms investigated. Future studies should examine the longitudinal association between bullying and mental health, including which factors mediate/moderate this relationship. Epigenetic studies are also required to better understand the complex interaction between environmental and biological risk factors for adolescent mental health [ 24 ].

Availability of data and materials

Data requests will be considered on a case-by-case basis; please email the corresponding author.

Code availability

Not applicable.

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Authors are grateful to the Department for Social Affairs, Stockholm, for permission to use data from the Stockholm School Survey.

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HK conceived the study and analyzed the data (with input from MH). HK and MH interpreted the data and jointly wrote the manuscript. All authors read and approved the final manuscript.

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Principal factor analysis description.

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Källmén, H., Hallgren, M. Bullying at school and mental health problems among adolescents: a repeated cross-sectional study. Child Adolesc Psychiatry Ment Health 15 , 74 (2021). https://doi.org/10.1186/s13034-021-00425-y

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Long-term effects of bullying

Dieter wolke.

1 Department of Psychology and Division of Mental Health and Wellbeing, University of Warwick, Coventry, UK

Suzet Tanya Lereya

2 Department of Psychology, University of Warwick, Coventry, UK

Bullying is the systematic abuse of power and is defined as aggressive behaviour or intentional harm-doing by peers that is carried out repeatedly and involves an imbalance of power. Being bullied is still often wrongly considered as a ‘normal rite of passage’. This review considers the importance of bullying as a major risk factor for poor physical and mental health and reduced adaptation to adult roles including forming lasting relationships, integrating into work and being economically independent. Bullying by peers has been mostly ignored by health professionals but should be considered as a significant risk factor and safeguarding issue.

Definition and epidemiology

Bullying is the systematic abuse of power and is defined as aggressive behaviour or intentional harm-doing by peers that is carried out repeatedly and involves an imbalance of power , either actual or perceived, between the victim and the bully. 1 Bullying can take the form of direct bullying, which includes physical and verbal acts of aggression such as hitting, stealing or name calling, or indirect bullying, which is characterised by social exclusion (eg, you cannot play with us, you are not invited, etc) and rumour spreading. 2–4 Children can be involved in bullying as victims and bullies, and also as bully/victims, a subgroup of victims who also display bullying behaviour. 5 6 Recently there has been much interest in cyberbullying, which can be broadly defined as any bullying which is performed via electronic means, such as mobile phones or the internet. One in three children report having been bullied at some point in their lives, and 10–14% experience chronic bullying lasting for more than 6 months. 7 8 Between 2% and 5% are bullies and a similar number are bully/victims in childhood/adolescence. 9 Rates of cyberbullying are substantially lower at around 4.5% for victims and 2.8% for perpetrators (bullies and bully/victims), with up to 90% of the cyber-bullying victims also being traditionally (face to face) bullied. 10 Being bullied by peers is the most frequent form of abuse encountered by children, much higher than abuse by parents or other adult perpetrators 11 ( box 1 ).

Bullying screener

• Are threatened or blackmailed or have their things stolen
• Are insulted or get called nasty names
• Have nasty tricks played on them/are subject to ridicule
• Are hit, shoved around or beaten up
• Get deliberately left out of get-togethers, parties, trips or groups
• Have others ignore them, not wanting to be their friend anymore, or not wanting them around in their group
• Have nasty lies, rumours or stories told about them
• Have their private email, instant mail or text messages forwarded to someone else or have them posted where others can see them
• Have rumours spread about them online
• Get threatening or aggressive emails, instant messages or text messages
• Have embarrassing pictures posted online without their permission

(Answered for A, B, and C separately on this 4-point scale)

• Not much (1–3 times)
• Quite a lot (more than 4 times)
• A lot (at least once a week)

Victims : Happened to them: quite a lot/a lot; did to others: never/not much

Bully/victims : Happened to them: quite a lot/a lot; did to others: quite a lot/a lot

Bullies : Happened to them: never/not much; did to others: quite a lot/a lot

Adapted from refs 3 8 12 13

Bullying is not conduct disorder

Bullying is found in all societies, including modern hunter-gatherer societies and ancient civilisations. It is considered an evolutionary adaptation, the purpose of which is to gain high status and dominance, 14 get access to resources, secure survival, reduce stress and allow for more mating opportunities. 15 Bullies are often bi-strategic, employing both bullying and also acts of aggressive ‘prosocial’ behaviour to enhance their own position by acting in public and making the recipient dependent as they cannot reciprocate. 16 Thus, pure bullies (but not bully/victims or victims) have been found to be strong, highly popular and to have good social and emotional understanding. 17 Hence, bullies most likely do not have a conduct disorder. Moreover, unlike conduct disorder, bullies are found in all socioeconomic 18 and ethnic groups. 12 In contrast, victims have been described as withdrawn, unassertive, easily emotionally upset, and as having poor emotional or social understanding, 17 19 while bully/victims tend to be aggressive, easily angered, low on popularity, frequently bullied by their siblings 20 and come from families with lower socioeconomic status (SES), 18 similar to children with conduct disorder.

How bullies operate

Bullying occurs in settings where individuals do not have a say concerning the group they want to be in. This is the situation for children in school classrooms or at home with siblings, and has been compared to being ‘caged’ with others. In an effort to establish a social network or hierarchy, bullies will try to exert their power with all children. Those who have an emotional reaction (eg, cry, run away, are upset) and have nobody or few to stand up for them, are the repeated targets of bullies. Bullies may get others to join in (laugh, tease, hit, spread rumours) as bystanders or even as henchmen (bully/victims). It has been shown that conditions that foster higher density and greater hierarchies in classrooms (inegalitarian conditions), 21 at home 22 or even in nations, 23 increase bullying 24 and the stability of bullying victimisation over time. 25

Adverse consequences of being bullied

Until fairly recently, most studies on the effects of bullying were cross-sectional or just included brief follow-up periods, making it impossible to identify whether bullying is the cause or consequence of health problems. Thus, this review focuses mostly on prospective studies that were able to control for pre-existing health conditions, family situation and other exposures to violence (eg, family violence) in investigating the effects of being involved in bullying on subsequent health, self-harm and suicide, schooling, employment and social relationships.

Childhood and adolescence (6–17 years)

A fully referenced summary of the consequences of bullying during childhood and adolescence on prospectively studied outcomes up to the age of 17 years is shown in table 1 . Children who were victims of bullying have been consistently found to be at higher risk for common somatic problems such as colds, or psychosomatic problems such as headaches, stomach aches or sleeping problems, and are more likely to take up smoking. 39 40 Victims have also been reported to more often develop internalising problems and anxiety disorder or depression disorder. 31 Genetically sensitive designs allowed comparison of monozygotic twins who are genetically identical and live in the same households but were discordant for experiences of bullying. Internalising problems was found to have increased over time only in those who were bullied, 32 providing strong evidence that bullying rather than other factors explains increases in internalising problems. Furthermore, victims of bullying are at significantly increased risk of self-harm or thinking about suicide in adolescence. 43 44 Furthermore, being bullied in primary school has been found to both predict borderline personality symptoms 30 and psychotic experiences, such as hallucinations or delusions, by adolescence. 37 Where investigated, those who were either exposed to several forms of bullying or were bullied over long periods of time (chronic bullying) tended to show more adverse effects. 31 37 In contrast to the consistently moderate to strong relationships with somatic and mental health outcomes, the association between being bullied and poor academic functioning has not been as strong as expected. 51 A meta-analysis only indicated a small negative effect of victimisation on mostly concurrent academic performance and the effects differed whether bullying was self-reported or by peers or teachers. 47 Those studies that distinguished between victims and bully/victims usually reported that bully/victims had a slightly higher risk for somatic and mental health problems than pure victims. 41 52 Furthermore, most studies considered bullies and bully/victims together; however, as outlined above, the two roles are quite different with bullies often highly competent manipulators and ringleaders, while bully/victims are described as impulsive and poor in regulating their emotions. 53 We know little about the mental health outcomes of bullies in childhood, but there are some suggestions that they may also be at slightly increased risk of depression or self-harm, 33 45 however, less so than victims. Similarly, the relationship between being a bully and somatic health is weaker than in bully/victims, 39 or bullies have even been found to be healthier and stronger than children not involved in bullying. 41 Bullying perpetration has been found to increase the risk of offending in adolescence; 54 however, the analysis did not distinguish between bullies and bully/victims and did not include information about poly-victimisation (eg, being maltreated by parents). Bullies were also more likely to display delinquent behaviour and perpetrate dating violence by eighth grade. 50

Table 1

Consequences of involvement in bullying behaviour in childhood and adolescence on outcomes assessed up to 17 years of age

Childhood to adulthood (18–50 years)

Children who were victims of bullying have been consistently found to be at higher risk for internalising problems, in particular diagnoses of anxiety disorder 55 and depression 9 in young adulthood and middle adulthood (18–50 years of age) ( table 2 ). 56 Furthermore, victims were at increased risk for displaying psychotic experiences at age 18 8 and having suicidal ideation, attempts and completed suicides. 56 Victims were also reported to have poor general health, 65 including more bodily pain, headaches and slower recovery from illnesses. 57 Moreover, victimised children were found to have lower educational qualifications, be worse at financial management 57 and to earn less than their peers even at age 50. 56 69 Victims were also reported to have more trouble making or keeping friends and to be less likely to live with a partner and have social support. No association between substance use, anti-social behaviour and victimisation was found. The studies that distinguished between victims and bully/victims showed that usually bully/victims had a slightly higher risk for anxiety, depression, psychotic experiences, suicide attempts and poor general health than pure victims. 9 They also had even lower educational qualifications and trouble keeping a job and honouring financial obligations. 57 65 In contrast to pure victims, bully/victims were at increased risk for displaying anti-social behaviour and were more likely to become a young parent. 62 70 71 Again, we know less about pure bullies, but where studied, they were not found to be at increased risk for any mental or general health problems. Indeed, they were healthier than their peers, emotionally and physically. 9 57 However, pure bullies may be more deviant and more likely to be less educated and to be unemployed. 65 They have also been reported to be more likely to display anti-social behaviour, and be charged with serious crime, burglary or illegal drug use. 58 59 66 However, many of these effects on delinquency may disappear when other adverse family circumstances are controlled for. 57

Table 2

Consequences of involvement in bullying behaviour in childhood/adolescence on outcomes in young adulthood and adulthood (18–50 years)

The findings from prospective child, adolescent and adult outcome studies are summarised in figure 1 .

The impact of being bullied on functioning in teenagers and adulthood.

The carefully controlled prospective studies reviewed here provide a converging picture of the long-term effects of being bullied in childhood. First, the effects of being bullied extend beyond the consequences of other childhood adversity and adult abuse. 9 In fact, when compared to the experience of having been placed into care in childhood, the effects of frequent bullying were as detrimental 40 years later 56 ! Second, there is a dose–effect relationship between being victimised by peers and outcomes in adolescence and adulthood. Those who were bullied more frequently, 56 more severely (ie, directly and indirectly) 31 or more chronically (ie, over a longer period of time 8 ) have worse outcomes. Third, even those who stopped being bullied during school age showed some lingering effects on their health, self-worth and quality of life years later compared to those never bullied 72 but significantly less than those who remained victims for years (chronic victims). Fourth, where victims and bully/victims have been considered separately, bully/victims seem to show the poorest outcomes concerning mental health, economic adaptation, social relationships and early parenthood. 8 9 62 70 Lastly, studies that distinguished between bullies and bully/victims found few adverse effects of being a pure bully on adult outcomes. This is consistent with a view that bullies are highly sophisticated social manipulators who are callous and show little empathy. 73

There are a variety of potential routes by which being victimised may affect later life outcomes. Being bullied may alter physiological responses to stress, 74 interact with a genetic vulnerability such as variation in the serotonin transporter (5-HTT) gene, 75 or affect telomere length (ageing) or the epigenome. 76 Altered HPA-axis activity and altered cortisol responses may increase the risk for developing mental health problems 77 and also increase susceptibility to illness by interfering with immune responses. 78 In contrast, bullying may also differentially affect normal chronic inflammation and associated health problems that can persist into adulthood. 64 Chronically raised C-reactive protein (CRP) levels, a marker of low-grade systemic inflammation in the body, increase the risk of cardiovascular diseases, metabolic disorders and mental health problems such as depression. 79 Blood tests revealed that CRP levels in the blood of bullied children increased with the number of times they were bullied. Additional blood tests carried out on the children after they had reached 19 and 21 years of age revealed that those who were bullied as children had CRP levels more than twice as high as bullies, while bullies had CRP levels lower than those who were neither bullies nor victims ( figure 2 ). Thus, bullying others appears to have a protective effect consistent with studies showing lower inflammation for individuals with higher socioeconomic status 80 and studies with non-human primates showing health benefits for those higher in the social hierarchy. 81 The clear implication of these findings is that both ends of the continuum of social status in peer relationships are important for inflammation levels and health status.

Adjusted mean young adult C-reactive protein (CRP) levels (mg/L) based on childhood/adolescent bullying status. These values are adjusted for baseline CRP levels as well as other CRP-related covariates. All analyses used robust SEs to account for repeated observations (reproduced from Copeland et al 64 ).

Furthermore, experiences of threat by peers may alter cognitive responses to threatening situations. 82 Both altered stress responses and altered social cognition (eg, being hypervigilant to hostile cues 38 ) and neurocircuitry 83 related to bullying exposure may affect social relationships with parents, friends and co-workers. Finally, victimisation, in particular of bully/victims, affects schooling and has been found to be associated with school absenteeism. In the UK alone, over 16 000 young people aged 11–15 are estimated to be absent from state school with bullying as the main reason, and 78 000 are absent where bullying is one of the reasons given for absence. 84 The risk of failure to complete high school or college in chronic victims or bully/victims increases the risk of poorer income and job performance. 57

Summary and implications

Childhood bullying has serious effects on health, resulting in substantial costs for individuals, their families and society at large. In the USA, it has been estimated that preventing high school bullying results in lifetime cost benefits of over $1.4 million per individual. 85 In the UK alone, over 16 000 young people aged 11–15 are estimated to be absent from state school with bullying as the main reason, and 78 000 are absent where bullying is one of the reasons given for absence. 86 Many bullied children suffer in silence, and are reluctant to tell their parents or teachers about their experiences, for fear of reprisals or because of shame. 87 Up to 50% of children say they would rarely, or never, tell their parents, while between 35% and 60% would not tell their teacher. 11

Considering this evidence of the ill effects of being bullied and the fact that children will have spent much more time with their peers than their parents by the time they reach 18 years of age, it is more than surprising that childhood bullying is not at the forefront as a major public health concern. 88 Children are hardly ever asked about their peer relationships by health professionals. This may be because health professionals are poorly educated about bullying and find it difficult to raise the subject or deal with it. 89 However, it is important considering that many children abstain from school due to bullying and related health problems and being bullied throws a long shadow over their lives. To prevent violence against the self (eg, self-harm) and reduce mental and somatic health problems, it is imperative for health practitioners to address bullying.

Contributors: DW conceived the review, produced the first draft and revised it critically; STL contributed to the literature research and writing, and critically reviewed and approved the final version of the manuscript.

Funding: This review was partly supported by the Economic and Social Research Council (ESRC) grant ES/K003593/1.

Competing interests: None.

Provenance and peer review: Commissioned; externally peer reviewed.

Assessment of Bullying in Autism Spectrum Disorder: Systematic Review of Methodologies and Participant Characteristics

• Review Paper
• Published: 06 January 2021
• Volume 8 , pages 482–497, ( 2021 )

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• Hannah E. Morton   ORCID: orcid.org/0000-0002-5487-5182 1  

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The growing body of literature on bullying in autism spectrum disorder (ASD) suggests individuals with ASD are bullied more frequently than their non-ASD peers. However, there is no gold standard assessment tool for bullying in ASD, and the use of differing methodologies generates varying prevalence estimates. This systematic review evaluates the assessment methods for bullying in ASD and summarizes the participant characteristics in this literature. None of the identified measures meet literature recommendations for bullying assessment in ASD. Additionally, there is a need for increased sample diversity regarding the gender, race, and cognitive ability of ASD participants. Recommendations for researchers and practitioners are discussed, including the need for a gold standard assessment tool and consistency in the operationalization of bullying.

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Morton, H.E. Assessment of Bullying in Autism Spectrum Disorder: Systematic Review of Methodologies and Participant Characteristics. Rev J Autism Dev Disord 8 , 482–497 (2021). https://doi.org/10.1007/s40489-020-00232-9

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Literature Review on Bullying

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Although the bully-victim conflict is an age-old scenario, researchers only began studying it in school settings 45 years ago. The most agreed upon definition of bullying includes three criteria: 1) intentionality (desire or goal of inflicting harm, intimidation, and/or humiliation), 2) some repetitiveness, and most importantly, 3) a power imbalance between the socially or physically more prominent bully and the more vulnerable victim. The power differential can manifest among a variety of factors, such as physical dominance, self- confidence, peer group status, etc. Conversely, conflict between equals is not considered bullying, but rather, general aggression. Another, more recent concept that has emerged in the field of bullying research is the category of “bully-victims,” a smaller subset of youth who both perpetrate and experience bullying. The forms bullying can take include: direct aggression (e.g., name calling, hitting, belittling someone in front of others) or indirect, relational aggression (e.g., spreading rumors, exclusion from the group, hurting another’s reputation). Often occurring in school contexts, which has expanded in recent years to include cyberbullying in the virtual worlds of digital and social media, bullying takes place throughout the school years, from elementary to high school and has likewise been studied across the grades. And since bullying is a familiar, if not intimate, school experience for most people, it is sometimes easy or tempting to accept it as a rite of passage or a typical childhood experience, rather than a problem that needs to be addressed. As Olweus (2013) explains, “being bullied by peers represents a serious violation of the fundamental rights of the child or youth exposed” (p. 770). It is with this understanding of bullying – as a violation of basic human rights – that this two-part brief explores the phenomenon (history, prevalence, risk factors, and consequences) in Part I and reviews research- based interventions in Part II.

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Model Programs Guide Literature Review: Bullying and Cyberbullying

Based on a literature review, this web resource first distinguishes bullying from other types of aggression or violence and then presents sections on the following bullying-related topics: 1) scope of the problem; 2) theoretical foundation; 3) risk and protective factors; 4) consequences of bullying; 5) moderators and interactive protective factors; 6) bystanders; and outcome evidence for anti-bullying programs.

Bullying involving children and youth has become a topic of national conversation over the past few decades and is a major focus for schools across the United States and internationally (Gladden et al., 2014; Ybarra et al., 2019). Bullying can cause substantial harm to the children and youth who are victimized, to those who engage in bullying behaviors, and to the bystanders who witness bullying (Evans et al., 2018; Gladden et al., 2014; Zych, Farrington, and Ttofi, 2019). To address this problem, numerous antibullying interventions have been developed and implemented (Gaffney, Ttofi, and Farrington, 2019; Polanin et al., 2021). Along with these efforts, there has been a growing field of research on bullying, which strives to understand the causes, effects, and ways of effectively intervening and preventing bullying (National Academies of Sciences, Engineering, and Medicine, 2016). While multiple definitions of bullying are used in research (Eriksen, 2018; Gladden et al., 2014; Liu and Graves, 2011; Smith et al., 2002; Polanin, 2012; Younan, 2018), bullying is generally considered to be unwanted aggressive behavior(s) by another youth or group of youth (who are not current dating partners or siblings) that involves a power imbalance and is repeated multiple times or is highly likely to be repeated (Gladden et al., 2014). Although attention to bullying has increased noticeably among researchers since the late 1990s, and many studies have been published, bullying research is still considered "underdeveloped and uneven" (National Academies of Sciences, Engineering, and Medicine, 2016, p. 31). This literature review focuses on bullying that involves children and youth in elementary, middle, and high schools. The review summarizes research related to the scope of bullying in the United States; different types of bullying; theoretical foundations; predictors, risk factors, protective factors, and consequences of bullying; and interventions focused on prevention and/or reduction. Challenges and gaps in the literature are also identified. 

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