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Importance: Both bullies and victims of bullying are at Results: Victims and bullies/victims had elevated rates
risk for psychiatric problems in childhood, but it is un- of young adult psychiatric disorders, but also elevated
clear if this elevated risk extends into early adulthood. rates of childhood psychiatric disorders and family hard-
ships. After controlling for childhood psychiatric prob-
Objective: To test whether bullying and/or being bul- lems or family hardships, we found that victims contin-
lied in childhood predicts psychiatric problems and sui- ued to have a higher prevalence of agoraphobia (odds ratio
cidality in young adulthood after accounting for child- [OR], 4.6 [95% CI, 1.7-12.5]; P.01), generalized anxi-
hood psychiatric problems and family hardships. ety (OR, 2.7 [95% CI, 1.1-6.3]; P .001), and panic dis-
order (OR, 3.1 [95% CI, 1.5-6.5]; P.01) and that bullies/
Design: Prospective, population-based study.
victims were at increased risk of young adult depression
(OR, 4.8 [95% CI, 1.2-19.4]; P.05), panic disorder (OR,
Setting: Community sample from 11 counties in West-
14.5 [95% CI, 5.7-36.6]; P .001), agoraphobia (fe-
ern North Carolina.
males only; OR, 26.7 [95% CI, 4.3-52.5]; P .001), and
Participants: A total of 1420 participants who had being
suicidality (males only; OR, 18.5 [95% CI, 6.2-55.1];
bullied and bullying assessed 4 to 6 times between the P .001). Bullies were at risk for antisocial personality
ages of 9 and 16 years. Participants were categorized as disorder only (OR, 4.1 [95% CI, 1.1-15.8]; P .04).
bullies only, victims only, bullies and victims (hereafter
referred to as bullies/victims), or neither. Conclusions and Relevance: The effects of being bul-
lied are direct, pleiotropic, and long-lasting, with the worst
Main Outcome Measure: Psychiatric outcomes, which effects for those who are both victims and bullies.
included depression, anxiety, antisocial personality disor-
der, substance use disorders, and suicidality (including re-
current thoughts of death, suicidal ideation, or a suicide JAMA Psychiatry. 2013;70(4):419-426.
attempt), were assessed in young adulthood (19, 21, and Published online February 20, 2013.
24-26 years) by use of structured diagnostic interviews. doi:10.1001/jamapsychiatry.2013.504
R
ESEARCH ON BULLYING CAN creased risk of suicide ideation and sui-
be traced to the 1960s; cide attempts,7 with some evidence that
however, back then, it was those who are both victims and bullies
called mobbing and was de- (hereafter referred to as bullies/victims)8
scribed as collective aggres- are at higher risk for suicidality.9 In con-
sion against others of the same species.1 trast, the major adverse outcome of being
Systematic intervention research started a bully in childhood has been reported to
Author Affiliations: when 3 young boys killed themselves in be offending.10,11 However, bullying is still Author Aff
Department of Psychiatry and Departmen
Behavioral Sciences, Center for
short succession in Norway, all leaving commonly viewed as just a harmless rite Behavioral
Developmental Epidemiology, notes that they had been bullied by their of passage or an inevitable part of grow- Developme
Duke University Medical peers.2 Since then, it has been repeatedly ing up.12 Duke Unive
Center, Durham, North reported that being a victim of bullying in- Longitudinal studies on bullying that Center, Dur
Carolina (Drs Copeland, creases the risk of adverse outcomes, in- involve the victims or the bullies/victims Carolina (D
Angold, and Costello); and cluding physical health problems,3 be- (hereafter referred to as bullying involve- Angold, an
Department of Psychology and Departmen
Division of Mental Health and
havior and emotional problems and ment) have tended to be short-term stud- Division of
Well-being, University of depression,4 psychotic symptoms,5 and ies, following children either for a few Well-being
Warwick, Coventry, England poor school achievement.6 Furthermore, months or for a few years into adoles- Warwick, C
(Dr Wolke). being bullied is associated with an in- cence.4 Thus, it is unclear whether the ef- (Dr Wolke)
a Participants were categorized as bullies only, victims only, bullies and victims (hereafter referred to as bullies/victims), or neither. The odds ratios (ORs) and
95% CIs in bold are significant at P .05.
disorder, alcohol abuse or dependence, and marijuana abuse the childs family met 5 or more of the following conditions:
or dependence. Psychosis was not included in the analyses inadequate parental supervision of childs free time; overin-
because it was very rare in the community. Suicidality was volvement of the parent in the childs activities in an age-
assessed as part of the criteria for major depressive episode.25 inappropriate manner; physical violence between parents; top
Suicidality involves either recurrent thoughts of wanting to 20% in terms of frequency of parental arguments; marital re-
die, recurrent suicidal ideation without a specific plan, sui- lationship characterized by absence of affection, apathy, or in-
cidal plans, or a suicide attempt. Too few participants difference; child is upset by or actively involved in arguments
attempted suicide (n = 5) for us to study this group sepa- between parents; mother scores in elevated range on depres-
rately from ideation. As such, the focus of this analysis was sion questionnaire; top 20% in terms of frequency of argu-
on the broader construct of suicidality rather than the indi- ments between parent and child; and most parental activities
vidual aspects of suicidality. are source of tension or worry for the child. Maltreatment was
assessed as positive if the child or parent reported that the child
ASSESSMENT OF CHILDHOOD STATUS had been physically abused (the participant was the victim of
intentional physical violence by family member), sexually abused
All childhood psychiatric and family hardship variables (ex- (the participant was involved in activities for purposes of per-
cept when indicated) were assessed by parent and child report petrators sexual gratification, including kissing, fondling, oral-
using the Child and Adolescent Psychiatric Assessment.20 The genital, oral-anal, genital, or anal intercourse), or neglected by
time frame for the Child and Adolescent Psychiatric Assess- parents (caregiver unable to meet childs need for food, cloth-
ment was the 3 months immediately preceding the interview. ing, housing, transportation, medical attention, or safety). Code-
Childhood psychiatric variables included the same anxiety books for all items are available at http://devepi.duhs.duke.edu
and depressive disorders as in adulthood, behavioral disor- /codebooks.html.
ders (conduct disorder, attention-deficit/hyperactivity disor-
der, and oppositional defiant disorder), and any substance abuse STATISTICAL ANALYSES
or dependence. Participants were assessed as positive for a di-
agnosis if they met full DSM-IV criteria for the disorder at any Multiple assessments were completed in childhood (9-16 years)
childhood assessment. Childhood suicidality was assessed as and young adulthood (19, 21, and 24-26 years). Status for all
it was during young adulthood. variables were aggregated across assessments within these pe-
Four types of family hardships were assessed: low socio- riods. Thus, if an individual reported suicidality at any young
economic status, unstable family structure, family dysfunc- adult assessment, they were assessed as positive for suicidality
tion, and maltreatment. A low socioeconomic status was as- in adulthood. All associations were tested using weighted lo-
sessed as positive if the childs family met 2 or more of the gistic regression models in a generalized estimating equations
following conditions: below the US federal poverty line based framework implemented by SAS PROC GENMOD (SAS Insti-
on family size and income, parental high school education only, tute Inc). Robust variance (sandwich-type) estimates were used
or low parental occupational prestige.26 Unstable family struc- to adjust the standard errors of the parameter estimates for the
ture was assessed as positive if the childs family met 2 or more sampling weights applied to observations. Bivariate analyses in
of the following conditions: single parent structure, steppar- Table 1 and Table 2 involved prediction of outcome vari-
ent in household, divorce, parental separation, or change in par- ables by dummy-coded variables comparing each bully-victim
ent structure. Family dysfunction was assessed as positive if group with the neither group. Multivariable analyses in
a Participants were categorized as bullies only, victims only, bullies and victims (hereafter referred to as bullies/victims), or neither. The odds ratios (ORs) and 95% CIs
in bold are significant at P .05.
personality disorder, with 9.4% meeting full criteria in tion with depressive disorders was attenuated and no lon-
young adulthood compared with 2.1% in the neither ger statistically significant. There were sex differences in
group. None of the groups had elevated levels of sub- victims risk for substance disorders, although the in-
stance use disorders compared with those who had not creased risk for female victims in both cases fell below
been bullied or bullied others. common statistical thresholds. Bullies/victims contin-
ued to be at significant risk for depressive disorders and
CHILDHOOD PSYCHIATRIC DISORDERS AND for panic disorder after the inclusion of covariates. There
FAMILY HARDSHIPS was also evidence of sex-specific risk, with male partici-
pants at 18.5 times the odds for suicidality and female
Table 2 shows the relationships between group status and participants at 26.7 times the odds for agoraphobia com-
childhood psychiatric diagnoses and family hardships. pared with the neither group. The risk for generalized
These factors may have occurred either before or after anxiety and overall anxiety disorders were no longer sig-
the child was first bullied or first bullied others. The find- nificant for bullies/victims. As in the unadjusted mod-
ings are consistent with previous research in suggesting els, bullies were not at increased risk for either anxiety
widespread psychiatric problems and social/family hard- or depressive disorders, but they continued to be at risk
ships for victims and bullies/victims.12 Bullies looked simi- for antisocial personality disorder. Across all adjusted
lar to bully/victims, with high levels of disruptive behav- models, childhood psychiatric variables and hardships
ior disorders and family hardships, but they were not were associated with later psychiatric problems.
significantly elevated for emotional disorders. Suicidal- The models in Table 3 were adjusted for childhood
ity was higher in childhood for all victim groups (ie, vic- psychiatric status and hardships at any point in child-
tims and bullies/victims). hood or adolescence. As such, these covariates could be
confounders of the association between bully-victim sta-
LONG-TERM OUTCOMES AFTER ADJUSTMENT tus and later psychiatric problems if they occurred prior
FOR CHILDHOOD FACTORS to being bullied or bullying others, or they could be po-
tential mediators if they occurred subsequent to being
We tested whether the adverse long-term psychiatric out- bullied or bullying others. To provide a robust test of con-
comes observed were direct effects or better accounted founding, all models in Table 3 were rerun, including only
for by childhood psychiatric and family hardships. All psychiatric disorder and family hardships that had oc-
models were also tested for differences by sex. curred prior to being bullied or bullying others. This re-
The results of the multivariable models are provided analysis did not change the pattern of finding from Table 3
in Table 3. Victims of bullying continued to be at risk in any way.
for all anxiety disorders in models adjusted for child- The repeated assessments of bullying involvement
hood psychiatric status and hardships, but the associa- across childhood and adolescence allowed us to address