Effects of Bullying on Adolescent Suicidality

Are teenagers who are bullied and harassed at greater risk for suicidality than those who are not? Many people hold the belief that childhood bullying is a normal and acceptable part of growing up and correlate this behavior with a rite of passage or character growth. However, bullying has been correlated in many studies with adolescent suicide, a “preventable tragedy which is the third leading cause of death in young people of ages 10-24” (Cooper et al., 2012, p. 275). This paper examines the literature and findings on bullying and adolescent suicide (death by bullying) and provides implications for nursing practice.

Relevance of Topic to the Nursing Field

Bullying and adolescent suicide are of particular concern to school nurses and psychiatric-mental health nurses. Bullying can cause both physical and mental health problems in the victims, which can, in turn, affect school performance, social relationships, and emotional coping skills. School nurses often have difficulties intervening when a student is being bullied. Specifically, a survey of school nurses identified common barriers to intervention including the bullying takes place when the nurse is not present, not having enough time to deal with these situations, and not being educated on how to intervene (Hendershot et al., 2006, p. 229). While the first two barriers can be prevented through effective staffing solutions, the issue of intervention education is more complicated. It is extremely important to “empower school nurses with current, evidence-based information regarding childhood bullying and examine empirical science and tools to effectively address the serious problem of adolescent suicide risk assessment and intervention” (Cooper et al, 2012, p. 275). While education on this issue prior to employment would be ideal, schools can provide effective training on noticing, assessing, and intervening when bullying in school is discovered. Additionally, the most effective method to reduce bullying is to create a school environment that discourages bullying (Hendershot et al, 2006, p. 229). By creating an environment where bullying has a zero-tolerance policy, schools can greatly improve the safety of the environment and eliminate a portion of bullying.

However, not all bullying occurs within a school setting. Cyberbullying is an emerging issue among adolescents and is “similar to traditional bullying in that it is hurtful, repetitive behavior involving a power imbalance, often causing psychosocial issues” (Williams & Godfrey, 2011, p. 36). Adolescents have wider access to technology than previous generations including cell phones and social media and are therefore at risk of being victimized through these avenues. While nurses cannot directly prevent cyberbullying, they can assist with providing valuable education to students, administrators, parents, and the community at large. Nurses are in a position to help educate children about resources to prevent or cope with cyberbullying in a way that creates an attitude of prevention and support within the school community.

As previously mentioned, suicide is the third leading cause of mortality for adolescents in the United States (Kim & Leventhal, 2008, p. 133). School nurses have access to children who are experiencing suicidal ideation as the result of bullying and are often the first line of defense for these children.

Definition of Key Terms

While the definition of suicide is simply to take one’s own life, the range of different warning signs and risk factors helps to more fully understand the act of suicide. Rudd et al. (2006) list behavioral and emotional warning signs of potential suicidality including: thoughts of suicide or self-harm, obsession about death, changes in eating or sleeping, feelings of guilt, hopelessness, decreased interest in activities, anger, increased substance use, anxiety, and mood changes (p. 256). These warning signs in conjunction with potential risk factors for suicidality such as mood disorders, mental illness, substance abuse, bullying, trauma, and major life changes, provide a more thorough framework for nurses to assess suicide risk.

Bullying is the act of verbal or physical abuse or harassment meant to assert power or domination in a situation defined by an imbalance of social or physical power. Physical bullying includes pushing, grabbing, kicking, hitting, etc. Verbal bullying includes insults, threats, name-calling, and rumors. Additionally, exclusion such as ignoring or rejection is a form of bullying (Kim & Leventhal, 2008, p. 140). However, teachers and students tend to have different definitions of what bullying entails. “Pupils are more likely to restrict their definitions to direct bullying (verbal and/or physical abuse) and are less likely to refer to social exclusion, a power imbalance in the bully's favor and the bully's intention to cause the target hurt or harm and to feel threatened” (Naylor et al., 2006, p. 553). Additionally, girls are more likely than boys to mention verbal and emotional attacks as components of bullying.

Cyberbullying is a specific form of bullying, defined as “willful and repeated harm inflicted through the use of computers, cell phones, and other electronic devices” (Hinduja & Patchin, 2010, p. 208). The authors state the importance of understanding that this is an intentional pattern of behavior that is perceived as harmful by the victim. In general, cyberbullying consists of harassing or threatening text messages, phone calls, or emails. It also includes posting derogatory comments about someone on a social networking site.

Lastly, the term bullycide was coined by anti-bullying activists and refers to suicide provoked by the depression that results from bullying and harassment (Wallace, 2011, p. 741). Ruedy (2008) adds that cyberbullying includes threats, rumors, and derogatory comments and can occur anywhere online including websites, chat rooms, electronic bulletin boards, instant messaging, and social media sites (p. 326). Cyberbullying has the potential to be even more harmful than other forms of bullying due to its public nature and ease of distribution and access.

Literature Review

For this section, nine different studies regarding bullying, depression, and suicidality in adolescents across various cultures are analyzed for similarities and differences of data.

Consistent Results across Studies

The most consistent finding across the studies reviewed is that there is a positive correlation between being involved in bullying—whether as a victim, perpetrator, or victim-perpetrator—and suicidal ideation and attempts. Four studies presented percentages of students involved being bullied or acting like bullies. Mills et al. (2005) discovered greatly increased depression, suicidal ideation, and suicidal intent (p. 112). Winsper et al. (2012) reported that children who are chronically bullied at school are at significant risk for suicide or self-harm (p. 271). Klomek et al. (2007) found that in 10th-grade students in the United States, 13% are bullies, 10.6% are victims of bullying, and 6.3% identify as both (p. 40). In a study of cyberbullying, Reudy (2008) discovered that 11% of middle school students had been targeted, 7% had been both bully and victim, and 4% had bullied others online (p. 329). Of the students that are engaged in physical, verbal, exclusion, or cyberbullying, each study in the review reported higher instances of depression, anxiety, and suicidal risk than in students not engaged in bullying in any way. Kim et al. (2005) studied Korean middle school students and found that 26.6% of those who bullied or were bullied expressed suicidal ideation (p. 359). Cyberbullying proved to produce greater suicidal behavior, with bullies and victims both being 1.5-2 times more likely to attempt suicide than students not associated with bullying (Hinduja & Patchin, 2010, p. 216).

Additionally, the studies showed similar symptomology in addition to suicidal ideation. Symptoms associated with being a victim include depression, anxiety, bed wetting, sleep problems, self-harm, school phobia, isolation, insecurity, somatic symptoms, (Kim & Leventhal, 2008, p. 133), low self-esteem, poor mental health, and loneliness (Hinduja & Patchin, 2010, p. 209). In addition to exhibiting suicidal ideation, depression, and anxiety, being a bully is associated with juvenile delinquency, substance abuse, violence, peer rejection, and difficulty expressing emotions at 8-10 years after bullying behaviors (Winsper et al., 2012, p. 218).

Another similarity in the findings involves cyberbullying. Wang, Nansel, & Ionnatti (2011) found that while depression is associated with all types of bullying, victims of cyberbullying display greater depression and suicidal ideation (p. 417). Possible reasons for this include the ubiquity and ease of access to the internet and other forms of technology, the permanence of computer-based messages, and the difficulty of identifying the perpetrator. Additionally, people are more likely to communicate harmful messages via the internet because they do not have to say the direction of the hurtful things to a person (Reudy, 2008, p. 329).

Major Discrepancies across Studies

The two major discrepancies found in the literature are the prevalence of suicidal ideation in victims versus perpetrators and gender differences towards suicidal ideation in males versus females.

Some studies report that bullies exhibit the highest suicidal ideation, some report that victims have the highest ideation, and some cite equal amounts. For instance, Winsper et al. (2012) studied over 6,000 adolescents and found that suicidal ideation is most common among chronic perpetrators (p. 217). In cyberbullying specifically, victims reported higher levels of depression and suicidal ideation than either bullies or bully-victims (Wang et al., 2011, p. 415). Both Kim et al. (2005) and Klomek et al. (2007) found that students who were both perpetrators and victims of bullying exhibited the highest levels of both depression and suicidal ideation.

The other main discrepancy has to do with gender and bullying. While Winsper et al. (2012) discovered that boys experience more depression as the result of being bullied or bullying others (p. 219), Kim et al. (2005) found a greater risk of suicidal ideation, depression, and anxiety for females more than males (p. 361). Additionally, Kim & Leventhal (2008) argue that all minority children including girls, learning disabled, and LGBTQ adolescent victims are at greater risk of suicidality (p. 149-150).

Lastly, Klomek et al. (2009) tie together both gender and victim-perpetrator statistics and discuss how among boys, bullying and victimization are both associated with later suicidality, while the only victimization is correlated with suicidality in girls (p. 254).

Implications for Advancing Practice

In addition to providing health care and referrals for students, school nurses have the ability to be a confidant for students. Children are often afraid to talk to school officials or teachers for fear that the bullying may become worse. Nurses can be someone children can turn to when they need help but are reticent to talk to their teachers (Puskar & Bernardo, 2007, p. 216). Because of the rapport, nurses can develop with adolescents, they are in a position to provide individual support, family education, and community referrals to students experiencing suicidal ideation as the result of bullying.

Gatekeeper training in schools has become the most widely used intervention strategy in the identification of at-risk students (Wyman et al, 2008, p. 104). This training aims to increase staff knowledge of risk factors and warning signs and teach strategies for questioning students about suicidal ideation. While school nurses regularly assess student mental health, not all school nurses feel confident identifying risk factors for suicide. With proper training, nurses can recognize warning signs and make appropriate referrals addressing mental health (Puskar & Bernardo, 2007, p. 215). Additionally, school professionals often have misguided opinions on bullying such as bullying is a normal part of development, assertive children will not get bullied, or children would not get bullied if they avoided mean children (Kochenderfer-Ladd & Pelletier, 2008, p. 431). Consequently, training should include education on the motives behind bullying behaviors and the high risk of suicide for victims of bullying. Wyman et al. (2008) also recommend providing school nurses with a full list of referrals for suicidal students (p. 104).

With appropriate education, awareness, and support, school nurses can provide effective intervention of bullying behaviors, support for students who are being bullied, and resources for students who express suicidal ideation as a result of being bullied.  

References

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Hendershot, C., Dake, J. A., Price, J. H., & Lartey, G. K. (2006). Elementary school nurses' perceptions of student bullying. The Journal of School Nursing, 22(4), 229.

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Williams, S., & Godfrey, A. (2011). What is cyberbullying and how can psychiatric-mental health nurses recognize it? Journal of Psychosocial Nursing and Mental Health Services, 49(10), 36-41.

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Wyman, P., Brown, C., Inman, J., Cross, W., Schmeelk-Cone, K., Guo, J., et al. (2008). Randomized trial of a gatekeeper program for suicide prevention: 1-year Impact on secondary school staff. Journal of Consulting and Clinical Psychology, 76(1), 104-115.