From Medscape Education Clinical Briefs

Study Identifies Risk Factors of Bullied Children Likely to Self-Harm CME

News Author: Deborah Brauser CME Author: Laurie Barclay, MD

Clinical Context
In the United Kingdom, approximately one quarter of all children are bullied at some point while they are in school. Children who are bullied are more likely to have behavioral problems during adolescence. However, few studies have tested the hypothesis that being bullied is associated with an increased probability of self-harm. The goals of this study by Fisher and colleagues were to examine whether exposure to frequent bullying in childhood is associated with an increased probability of self-harm in early adolescence and to identify which bullied children are at highest risk for self-harm.

Study Synopsis and Perspective

Young adolescent victims of bullying are at a significant risk for self-harm, new research suggests. In a large cohort study of more than 1000 pairs of twins from England and Wales, those who reported being bullied frequently were significantly more likely to self-harm by the age of 12 years than those who had not been bullied. Factors that increased the risk of self-harm in the children who were bullied included comorbid behavioral and emotional problems, a family history of attempted/completed suicide or selfharm behaviors, and physical maltreatment by an adult. "That bullying is linked to negative outcomes for the victims will surprise very few people. But we were saddened to find that children as young as 12...are around 3 times more likely to hurt themselves than children who were not victimized," lead author Helen L. Fisher, PhD, DPsychol, from the MRC Social, Genetic, and Developmental Psychiatry Center at the Institute of Psychiatry at King's College London, United Kingdom (UK), told Medscape Medical News. Dr. Fisher noted that the results remained significant even after adjusting for risk factors such as comorbid mental health problems. The association between bullying and self-harm "also held" when 1 twin had been bullied and the other had not, "which rules out other influences, such as parents and home life, from explaining this link," she reported. The investigators add that more effort should be made to help children cope with emotional distress from bullying and that the effectiveness of these strategies should be investigated. "This will require schools and health professionals who come into contact with bullied children to assess these indicators of concern and also to ascertain whether the help a child has is sufficient," they write.

The study was published online April 26 in BMJ.

Unique Look at Bullying and Self-Harm

According to the researchers, almost 25% of the children in the UK have reported being bullied by peers. "Over the past few years, the media have focused public attention on instances of suicide and self-harm among adolescents who have been bullied, and a commensurate rise in anti-bullying policies and laws has occurred on both sides of the Atlantic," they write. However, "few studies" have examined whether bullying significantly increases the risk for self-harm by victims. For this analysis, the investigators evaluated data from the prospective Environmental Risk study, which is tracking the development of a nationally representative cohort of same-sex twins born in 1994 or 1995. "As we have access to a comprehensive dataset of over 2000 twins who have been followed through childhood, we felt it was important for us to determine whether we could find robust evidence of a direct link between being bullied and self-harming," reported Dr. Fisher. "We felt it was particularly important to explore which factors increased the risk of self-harm at an early age amongst bullied children in order to inform future intervention strategies," she added. Home visits were conducted when the children were aged 5 years (baseline), with follow-up visits occurring when the children were aged 7, 10, and 12 years. During the follow-up visits, mothers and children were interviewed separately about possible bullying. When the children were 12 years old, investigators also asked the mothers about any deliberate self-harm or attempted suicide episodes by their kids during the previous 6 months. "Examples of self harming behaviours included cutting and biting arms, pulling out clumps of hair, banging head against walls, and attempted suicides by strangulation," write the study authors.

Urgent Need for Help

Results showed that 62 of the 2141 study participants (2.9%) had had self-harming behaviors by the age of 12 years. Of these, 56% were victims of frequent bullying. Reports of frequent bullying by both mothers and children were significant predictors of selfharm (on the basis of bullying as reported by mothers: relative risk [RR], 3.53; 95% confidence interval [CI], 2.10 - 5.93; as reported by children: RR, 3.33; 95% CI, 1.91 - 5.82). After adjusting for exposure to physical maltreatment, comorbid mental health problems, and low IQ, the association between bullying and self-harm was still significant (as reported by mothers: adjusted RR, 1.92; 95% CI, 1.18 - 3.12; as reported by children: adjusted RR, 2.44; 95% CI, 1.36 - 4.40).

In addition, twins who were bullied were significantly more likely to self-harm compared with their nonvictimized twin siblings (as reported by mothers: RR, 4.3; 95% CI, 1.3 - 14.0; as reported by children: RR, 1.7; 95% CI, 0.71 - 4.1). Compared with children who were bullied but did not self-harm, those who were bullied and did self-harm were significantly more likely to have a family history of attempted/completed suicide (mothers' bullying report: odds ratio [OR], 22.06; children's report: OR, 6.03), have a history of physical maltreatment (mothers' report: OR, 11.0; children's report: OR, 4.71), or have symptoms of conduct disorder, borderline personality disorder, depression, or psychosis. "Clinicians should be on the lookout for bullied children who are showing these signs," said Dr. Fisher. "These children are at greatest risk of hurting themselves and need help most urgently to enable them to cope more effectively with the distress they are experiencing."

Innovative Study
"I thought this was a great contribution to the field," Michael P. Marshal, PhD, assistant professor of psychiatry and pediatrics at the University of Pittsburgh, in Pennsylvania, and a licensed clinical psychologist specializing in assessing suicidality at the Adolescent Medicine Clinic at Children's Hospital of Pittsburgh, told Medscape Medical News. "It was very innovative. I don't know of any other studies that examined self-harm in such a young group of kids and examined bullying as a predictor of self-harm. So I think it's a one-ofa-kind study, was very well done, and had multiple strengths," said Dr. Marshal, who was not involved with this research. Some of the strengths he noted included using early childhood measures of bullying and selfharm, having a nationally representative sample, having "twin controls to rule out shared family effects," controlling for multiple possible confounders, and having a longitudinal design. "The one thing I wish they had done a little differently was to consider measuring for gender nonconformity. There's rich literature now showing that gay and lesbian kids are at higher risk for self-harm and suicide. And gender nonconformity is one of those indicators that a child might be same-sex attracted or be a gay or lesbian youth," he said.

Gay Kids at Even Greater Risk

As reported recently by Medscape Medical News, Dr. Marshal and colleagues published a study in the Journal of Adolescent Health that showed that gay and lesbian teens are 3 times more likely to report a history of suicidality and twice as likely to report symptoms of depression than their heterosexual peers. He noted that he would not expect the children in the current study to necessarily endorse same-sex attraction, but gender nonconformity "seems to be one of those risk factors. These kids often end up being targets for bullying, especially boys." "So understanding what role that played in all this would be important for future studies," said Dr. Marshal.

"However, I want to go on record that I think the strengths of this study far outweigh the limitations. That the investigators found significant effects of bullying on the outcome variable above and beyond all their confounders is a testament to how strong the impact of bullying is on children's emotional distress." He added that, as mentioned in the study, more effective bullying prevention programs need to be designed, especially those that target younger children. "I think more public health research dollars need to be invested in programs that can reduce bullying behavior. And I think the implications from this study are that we need to start targeting kids in kindergarten. Very young kids need to really understand what bullying is and what they can do about it," he said. In addition to having prevention programs that focus on children and that train teachers, staff, and parents to identify possible victims and perpetrators, Dr. Marshal said that clinicians should speak with and coach parents about what to do to detect symptoms or behaviors of bullying. "They should also coach parents about getting involved in changing school policies to protect children," he said. Both Dr. Marshal and Dr. Fisher also highly recommended Bully, the recent documentary by the Bullying Project that has gained widespread attention and applause for raising awareness about the painful consequences of these actions for children. The study was supported by the Medical Research Council, the Economic and Social Research Council, the US National Institute of Child Health and Human Development, the US National Institute of Mental Health, the British Academy, the Nuffield Foundation, and the Jacobs Foundation. The study authors and Dr. Marshal have disclosed no relevant financial relationships. BMJ. Published online April 26, 2012. Abstract

Study Highlights
The nationally representative UK cohort for the Environmental Risk longitudinal study consisted of 1116 twin pairs (2232 children) born in England and Wales in 1994-1995. Children were evaluated at ages 5, 7, 10, and 12 years. The primary study endpoint was the RR for self-harming behavior in the 6 months preceding their 12th birthday. Self-harm data were available for 2141 children. Examples of self-harm included cutting and biting the arms, pulling out clumps of hair, banging the head against walls, and attempting suicide by strangulation. Examples of bullying behavior included frequently saying mean or hurtful comments; shunning or excluding the child; hitting, kicking, or shoving the child; and telling lies or spreading rumors about the child. Self-harming behavior by age 12 years was reported by 62 children (2.9%). More than half (56%; n = 35) of children with self-harming behavior were frequently bullied. Of 237 children who were exposed to frequent bullying, 18 (8%) of them self-harmed vs 44 (2%) of the 1904 children who had not been bullied. Even after adjustment for children's premorbid emotional and behavioral problems, low IQ, and family environmental risks, exposure to frequent bullying predicted higher rates of selfharm.

For bullying oppression as reported by the mother, the adjusted RR for self-harm was 1.92 (95% CI 1.18 - 3.12). For bullying oppression as reported by the child, the adjusted RR was 2.44 (95% CI, 1.36 4.40). Compared with their twin siblings who were not bullied, twins who were bullied were more likely to self-harm (as reported by mothers: 13/162 vs 3/162; RR, 4.3; 95% CI, 1.3 - 14.0; as reported by children: 12/144 vs 7/144; RR, 1.7; 95% CI, 0.71 - 4.1). Bullied children who self-harmed were more likely than bullied children who did not selfharm to have a family history of attempted or completed suicide, concurrent mental health problems, and a history of physical maltreatment by an adult. These concurrent mental health problems included conduct disorder, borderline personality characteristics, and depressive or psychotic symptoms. The likelihood of self-harm was slightly higher for girls who were bullied (1.6%), but the association was present in boys as well as in girls. On the basis of these findings, the investigators concluded that prevention of nonsuicidal self-injury in young adolescents should emphasize reducing bullying and helping bullied children to cope more appropriately with their distress. They also suggested that intervention programs should target children who have additional mental health problems, have a family history of attempted or completed suicide, or have been maltreated by an adult. Limitations of this study include small sample size, reliance on self-report, and possible lack of generalizability to singleton children.

Clinical Implications
A longitudinal cohort study of twin pairs showed that more than half of 12-year-old children with self-harming behavior were exposed to frequent bullying. The investigators suggest that prevention of nonsuicidal self-injury in young adolescents should emphasize reducing bullying and helping bullied children to cope more appropriately with their distress. Risk factors associated with self-harming behavior in children who are frequently bullied are additional mental health problems, a family history of attempted or completed suicide, and maltreatment by an adult. The investigators suggest that intervention programs should target children with these risk factors.