research report about bullying pdf

• 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

87k Accesses

13 Citations

30 Altmetric

Metrics details

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.

Olweus D. School bullying: development and some important challenges. Ann Rev Clin Psychol. 2013;9(9):751–80. https://doi.org/10.1146/annurev-clinpsy-050212-185516 .

Article   Google Scholar  

Arseneault L, Bowes L, Shakoor S. Bullying victimization in youths and mental health problems: “Much ado about nothing”? Psychol Med. 2010;40(5):717–29. https://doi.org/10.1017/S0033291709991383 .

Article   CAS   PubMed   Google Scholar  

Arseneault L. The long-term impact of bullying victimization on mental health. World Psychiatry. 2017;16(1):27–8. https://doi.org/10.1002/wps.20399 .

Article   PubMed   PubMed Central   Google Scholar  

Moore SE, Norman RE, Suetani S, Thomas HJ, Sly PD, Scott JG. Consequences of bullying victimization in childhood and adolescence: a systematic review and meta-analysis. World J Psychiatry. 2017;7(1):60–76. https://doi.org/10.5498/wjp.v7.i1.60 .

Hagquist C, Due P, Torsheim T, Valimaa R. Cross-country comparisons of trends in adolescent psychosomatic symptoms—a Rasch analysis of HBSC data from four Nordic countries. Health Qual Life Outcomes. 2019;17(1):27. https://doi.org/10.1186/s12955-019-1097-x .

Deighton J, Lereya ST, Casey P, Patalay P, Humphrey N, Wolpert M. Prevalence of mental health problems in schools: poverty and other risk factors among 28 000 adolescents in England. Br J Psychiatry. 2019;215(3):565–7. https://doi.org/10.1192/bjp.2019.19 .

Article   PubMed Central   Google Scholar  

Le HTH, Tran N, Campbell MA, Gatton ML, Nguyen HT, Dunne MP. Mental health problems both precede and follow bullying among adolescents and the effects differ by gender: a cross-lagged panel analysis of school-based longitudinal data in Vietnam. Int J Ment Health Syst. 2019. https://doi.org/10.1186/s13033-019-0291-x .

Bayer JK, Mundy L, Stokes I, Hearps S, Allen N, Patton G. Bullying, mental health and friendship in Australian primary school children. Child Adolesc Ment Health. 2018;23(4):334–40. https://doi.org/10.1111/camh.12261 .

Article   PubMed   Google Scholar  

Hysing M, Askeland KG, La Greca AM, Solberg ME, Breivik K, Sivertsen B. Bullying involvement in adolescence: implications for sleep, mental health, and academic outcomes. J Interpers Violence. 2019. https://doi.org/10.1177/0886260519853409 .

Hogberg B, Strandh M, Hagquist C. Gender and secular trends in adolescent mental health over 24 years—the role of school-related stress. Soc Sci Med. 2020. https://doi.org/10.1016/j.socscimed.2020.112890 .

Kidger J, Araya R, Donovan J, Gunnell D. The effect of the school environment on the emotional health of adolescents: a systematic review. Pediatrics. 2012;129(5):925–49. https://doi.org/10.1542/peds.2011-2248 .

Saminathen MG, Låftman SB, Modin B. En fungerande skola för alla: skolmiljön som skyddsfaktor för ungas psykiska välbefinnande. [A functioning school for all: the school environment as a protective factor for young people’s mental well-being]. Socialmedicinsk tidskrift [Soc Med]. 2020;97(5–6):804–16.

Google Scholar  

Bibou-Nakou I, Tsiantis J, Assimopoulos H, Chatzilambou P, Giannakopoulou D. School factors related to bullying: a qualitative study of early adolescent students. Soc Psychol Educ. 2012;15(2):125–45. https://doi.org/10.1007/s11218-012-9179-1 .

Vukojevic M, Zovko A, Talic I, Tanovic M, Resic B, Vrdoljak I, Splavski B. Parental socioeconomic status as a predictor of physical and mental health outcomes in children—literature review. Acta Clin Croat. 2017;56(4):742–8. https://doi.org/10.20471/acc.2017.56.04.23 .

Reiss F. Socioeconomic inequalities and mental health problems in children and adolescents: a systematic review. Soc Sci Med. 2013;90:24–31. https://doi.org/10.1016/j.socscimed.2013.04.026 .

Stockholm City. Stockholmsenkät (The Stockholm Student Survey). 2021. https://start.stockholm/aktuellt/nyheter/2020/09/presstraff-stockholmsenkaten-2020/ . Accessed 19 Nov 2021.

Zeebari Z, Lundin A, Dickman PW, Hallgren M. Are changes in alcohol consumption among swedish youth really occurring “in concert”? A new perspective using quantile regression. Alc Alcohol. 2017;52(4):487–95. https://doi.org/10.1093/alcalc/agx020 .

Hagquist C. Psychometric properties of the PsychoSomatic Problems Scale: a Rasch analysis on adolescent data. Social Indicat Res. 2008;86(3):511–23. https://doi.org/10.1007/s11205-007-9186-3 .

Hagquist C. Ungas psykiska hälsa i Sverige–komplexa trender och stora kunskapsluckor [Young people’s mental health in Sweden—complex trends and large knowledge gaps]. Socialmedicinsk tidskrift [Soc Med]. 2013;90(5):671–83.

Wu W, West SG. Detecting misspecification in mean structures for growth curve models: performance of pseudo R(2)s and concordance correlation coefficients. Struct Equ Model. 2013;20(3):455–78. https://doi.org/10.1080/10705511.2013.797829 .

Holt MK, Espelage DL. Perceived social support among bullies, victims, and bully-victims. J Youth Adolscence. 2007;36(8):984–94. https://doi.org/10.1007/s10964-006-9153-3 .

Mark L, Varnik A, Sisask M. Who suffers most from being involved in bullying-bully, victim, or bully-victim? J Sch Health. 2019;89(2):136–44. https://doi.org/10.1111/josh.12720 .

Tsaousis I. The relationship of self-esteem to bullying perpetration and peer victimization among schoolchildren and adolescents: a meta-analytic review. Aggress Violent Behav. 2016;31:186–99. https://doi.org/10.1016/j.avb.2016.09.005 .

Veldkamp SAM, Boomsma DI, de Zeeuw EL, van Beijsterveldt CEM, Bartels M, Dolan CV, van Bergen E. Genetic and environmental influences on different forms of bullying perpetration, bullying victimization, and their co-occurrence. Behav Genet. 2019;49(5):432–43. https://doi.org/10.1007/s10519-019-09968-5 .

Janssen I, Craig WM, Boyce WF, Pickett W. Associations between overweight and obesity with bullying behaviors in school-aged children. Pediatrics. 2004;113(5):1187–94. https://doi.org/10.1542/peds.113.5.1187 .

Kelly EV, Newton NC, Stapinski LA, Conrod PJ, Barrett EL, Champion KE, Teesson M. A novel approach to tackling bullying in schools: personality-targeted intervention for adolescent victims and bullies in Australia. J Am Acad Child Adolesc Psychiatry. 2020;59(4):508. https://doi.org/10.1016/j.jaac.2019.04.010 .

Gunnell D, Kidger J, Elvidge H. Adolescent mental health in crisis. BMJ. 2018. https://doi.org/10.1136/bmj.k2608 .

O’Reilly M, Dogra N, Whiteman N, Hughes J, Eruyar S, Reilly P. Is social media bad for mental health and wellbeing? Exploring the perspectives of adolescents. Clin Child Psychol Psychiatry. 2018;23:601–13.

Unnever JD, Cornell DG. Middle school victims of bullying: who reports being bullied? Aggr Behav. 2004;30(5):373–88. https://doi.org/10.1002/ab.20030 .

Download references

Acknowledgements

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

Open access funding provided by Karolinska Institute. None to declare.

Author information

Authors and affiliations.

Stockholm Prevents Alcohol and Drug Problems (STAD), Center for Addiction Research and Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden

Håkan Källmén

Epidemiology of Psychiatric Conditions, Substance Use and Social Environment (EPiCSS), Department of Global Public Health, Karolinska Institutet, Level 6, Solnavägen 1e, Solna, Sweden

Mats Hallgren

You can also search for this author in PubMed   Google Scholar

Contributions

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.

Corresponding author

Correspondence to Mats Hallgren .

Ethics declarations

Ethics approval and consent to participate.

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).

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1..

Principal factor analysis description.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 05 October 2021

Accepted : 23 November 2021

Published : 14 December 2021

DOI : https://doi.org/10.1186/s13034-021-00425-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Mental health
• Adolescents
• School-related factors
• Gender differences

Child and Adolescent Psychiatry and Mental Health

ISSN: 1753-2000

• Submission enquiries: [email protected]

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• BMJ Paediatr Open
• v.5(1); 2021

Bullying in children: impact on child health

Richard armitage.

Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK

Associated Data

Bullying in childhood is a major public health problem that increases the risk of poor health, social and educational outcomes in childhood and adolescence. These consequences are felt by all those involved in bullying (bullies, victims and bully–victims) and are now recognised to propagate deep into adulthood. Cyberbullying is a relatively new type of bullying in addition to the traditional forms of direct physical, direct verbal and indirect bullying. Children who are perceived as being ‘different’ in any way are at greater risk of victimisation, with physical appearance being the most frequent trigger of childhood bullying. Globally, one in three children have been bullied in the past 30 days, although there is substantial regional variation in the prevalence and type of bullying experienced. The consequences of childhood bullying can be categorised into three broad categories: educational consequences during childhood, health consequences during childhood and all consequences during adulthood. Many dose–response relationships exist between the frequency and intensity of bullying experienced and the severity of negative health consequence reported. The majority of victims of cyberbullying are also victims of traditional bullying, meaning cyberbullying creates very few additional victims. Overall, adverse mental health outcomes due to bullying in childhood most severely impact on bully–victims. Bullying prevention is vital for the achievement of the Sustainable Development Goals, with whole-school cooperative learning interventions having the strongest evidence base for successful outcomes. Clear management and referral pathways for health professionals dealing with childhood bullying are lacking in both primary and secondary care, although specialist services are available locally and online.

Key messages

• Bullying in childhood is a global public health problem that impacts on child, adolescent and adult health.
• Bullying exists in its traditional, sexual and cyber forms, all of which impact on the physical, mental and social health of victims, bullies and bully–victims.
• Children perceived as ‘different’ in any way are at greater risk of victimisation.
• Bullying is extremely prevalent: one in three children globally has been victimised in the preceding month.
• Existing bullying prevention interventions are rarely evidence-based and alternative approaches are urgently needed.

Introduction

Bullying in childhood has been classified by the WHO as a major public health problem 1 and for decades has been known to increase the risk of poor health, social and educational outcomes in childhood and adolescence. 2 Characterised by repeated victimisation within a power-imbalanced relationship, bullying encompasses a wide range of types, frequencies and aggression levels, ranging from teasing and name calling to physical, verbal and social abuse. 3 The dynamics within such relationships become consolidated with repeated and sustained episodes of bullying: bullies accrue compounding power while victims are stripped of their own and become progressively less able to defend themselves and increasingly vulnerable to psychological distress. 4

However, only in the last decade have prospective studies been published that reveal the far-reaching effects of childhood bullying that extend into adulthood. There is now substantial evidence that being bullied as a child or adolescent has a causal relationship to the development of mental health issues beyond the early years of life, including depression, anxiety and suicidality. 5 As such, addressing the global public health problem of bullying in childhood has received increasing international attention and is vital for the achievement of Sustainable Development Goal 4. 6 The impact of the COVID-19 pandemic on child health and education has focused further attention on bullying in its digital form, so-called ‘cyberbullying’, the prevalence of which is feared to be increasing. 7

Types of bullying

Participants in childhood bullying take up one of three roles: the victim, the bully (or perpetrator) or the bully–victim (who is both a perpetrator and a victim of bullying). 5 Victims and bullies either belong to the same peer group (peer bullying) or the same family unit (sibling bullying), 8 although bullying frequently occurs in multiple settings simultaneously, such as at school (peer bullying) and in the home (sibling bullying), representing a ubiquitous ecology of bullying that permeates the child’s life.

Three main types of bullying are observed, the typical characteristics of which are illustrated in table 1 .

Typical characteristics of the main types of childhood bullying

While traditional bullying has been recognised and studied for many decades 9 and is often accepted as an inevitable aspect of a normal childhood, 3 cyberbullying represents a relatively new phenomenon in which childhood bullying now takes place through digital modalities. The widespread uptake of electronic devices has reached almost complete saturation among adolescents in high-income countries, with users checking their devices hundreds of times and for hours each day. 10 While providing beneficial access to information and social support, this large and growing online exposure of young people renders them vulnerable to exploitation, gambling, and grooming by criminals and sexual abusers, as well as cyberbullying. 11 Due to the increased potential for large audiences, anonymous attacks and the permanence of posted messages, coupled with lower levels of direct feedback, reduced time and space limits, and decreased adult supervision, it is feared that cyberbullying may pose a greater threat to child and adolescent health than traditional bullying modalities. 12

Factors that influence bullying

Two large-scale international surveys regularly conducted by the WHO—the Global School-based Student Health Survey (GSHS) 13 and the Health Behaviour in School-aged Children (HBSC) study 14 —provide data from 144 countries and territories in all regions of the world. These data identify specific factors that strongly influence the type, frequency and severity of bullying experienced by children and adolescents globally. These factors, which are briefly described in table 2 , suggest that children who are perceived as being ‘different’ in any way are at greater risk of victimisation.

Summary of factors that influence child and adolescent bullying 15

Prevalence of bullying

A 2019 report from the United Nations Educational, Scientific and Cultural Organisation (UNESCO) 15 examined the global prevalence of bullying in childhood and adolescence using data from the GSHS and HBSC studies along with addition data from the Progress in International Reading Literacy Study 16 and the Programme for International Students Assessment. 17 It found that almost one in three (32%) children globally has been the victim of bullying on one or more days in the preceding month, and that 1 in 13 (7.3%) has been bullied on six or more days over the same period. 15 However, there is substantial regional variation in the prevalence of bullying across the world, ranging from 22.8% of children being victimised in Central America, through 25.0% and 31.7% in Europe and North America, respectively, to 48.2% in sub-Saharan Africa. There is also significant geographical variation in the type of bullying reported, with direct physical and sexual bullying being dominant in low-income and middle-income countries, and indirect bullying being the most frequent type in high-income regions. Nevertheless, bullying is a sizeable public health problem of truly global importance.

Encouragingly, there has been a decrease in the prevalence of bullying in half (50.0%) of countries since 2002, while 31.4% have seen no significant change over this time frame. 15 However, 18.6% of countries have witnessed an increase in childhood bullying, primarily among members of one sex or the other, although in both girls and boys in North Africa, sub-Saharan Africa, Myanmar, the Philippines, and United Arab Emirates. 15

Since its appearance, cyberbullying has received substantial media attention claiming that the near-ubiquitous uptake of social media among adolescents has induced a tidal wave of online victimisation and triggered multiple high-profile suicides among adolescents after being bullied online. 18 19 However, a recent meta-analysis suggests that cyberbullying is far less prevalent than bullying in its traditional forms, with rates of online victimisation less than half of those offline. 20 The study also found relatively strong correlations between bullying in its traditional and cyber varieties, suggesting victims of online bullying are also likely to be bullied offline, and that that these different forms of victimisation reflect alternative methods of enacting the same perpetrator behaviour. Recent evidence from England also indicates a difference between sexes, with 1 in 20 adolescent girls and 1 in 50 adolescent boys reporting cyberbully victimisation over the previous 2 months. 21

Consequences of bullying

There is a vast range of possible consequences of bullying in childhood, determined by multiple factors including the frequency, severity and type of bullying, the role of the participant (victim, bully or bully–victim) and the timing at which the consequences are observed (during childhood, adolescence or adulthood). The consequences can be grouped into three broad categories: educational consequences during childhood and adolescence, health consequences during childhood and adolescence, and all consequences during adulthood. Each will now be discussed individually.

Educational consequences during childhood and adolescence

Children who are frequently bullied are more likely to feel like an outsider at school, 17 while indirect bullying specifically has been shown to have a negative effect on socialisation and feelings of acceptance among children in schools. 22 Accordingly, a child’s sense of belonging at school increases as bullying decreases. 22 In addition, being bullied can affect continued engagement in education. Compared with those who are not bullied, children who are frequently bullied are nearly twice as likely to regularly skip school and are more likely to want to leave school after finishing secondary education. 16 The effect of frequent bullying on these educational consequences is illustrated in table 3 .

Relationship between being frequently bullied and educational consequences 20

Children who are bullied score lower in tests than those who are not. For example, in 15 Latin American countries, the test scores of bullied children were 2.1% lower in mathematics and 2.5% lower in reading than non-bullied children. 22 Compared with children never or almost never bullied, average learning achievement scores were 2.7% lower in children bullied monthly, and 7.5% lower in children bullied weekly, indicating a dose–response relationship. These findings are globally consistent across both low-income and high-income countries. 17

Health consequences during childhood and adolescence

Numerous meta-analyses, 2 23–26 longitudinal studies 5 27 28 and cross-sectional studies 29–31 have demonstrated strong relationships between childhood bullying and physical, mental and social health outcomes in victims, bullies and bully–victims. Some of these consequences are illustrated in table 4 . Reported physical health outcomes are mostly psychosomatic in nature. Most studies focused on the impacts on victims, although adverse effects on bullies and bully–victims are also recognised. Many studies identified a dose–response relationship between the frequency and intensity of bullying experienced and the severity of negative health consequence reported.

Summary of childhood health consequences of bullying during childhood

While there is significant regional variation, the association between childhood bullying and suicidal ideation and behaviour are recognised globally. 32 Alarmingly, childhood bully victimisation is associated with a risk of mental health problems similar to that experienced by children in public or substitute care. 33 Victimisation in sibling bullying is associated with substantial emotional problems in childhood, including low self-esteem, depression and self-harm, 8 and increases the risk of further victimisation through peer bullying. Overall, adverse mental health outcomes due to bullying in childhood appear to most severely impact on bully–victims, followed by victims and bullies. 34

Nine out of 10 adolescents who report victimisation by cyberbullying are also victims of bullying in its traditional forms, 35 meaning cyberbullying creates very few additional victims, 36 but is another weapon in the bully’s arsenal and has not replaced traditional methods. 37 Cyberbullying victimisation appears to be an independent risk factor for mental health problems only in girls and is not associated with suicidal ideation in either sex. 38 As such, traditional bullying is still the major type of bullying associated with poor mental health outcomes in children and adolescents. 21

Consequences during adulthood

A recent meta-analysis 39 and numerous other prospective longitudinal studies 40 41 that used large, population-based, community samples analysed through quantitative methods suggest that childhood bullying can lead to three main negative outcomes in adulthood for victims, bullies and bully–victims: psychopathology, suicidality and criminality. Some of these consequences are illustrated in table 5 .

Summary of adulthood consequences of bullying during childhood

A strong dose–response relationship exists between frequency of peer victimisation in childhood and adolescence and the risk of adulthood adversities. 39 For example, frequently bullied adolescents are twice as likely to develop depression in early adulthood compared with non-victimised peers, and is seen in both men and women. 41 Startlingly, the effects of this dose–response relationship seems to persist until at least 50 years of age. 33

The impact of childhood bully victimisation on adulthood mental health outcomes is staggering. Approximately 29% of the adulthood depression burden could be attributed to victimisation by peers in adolescence, 41 and bully victimisation by peers is thought to have a greater impact on adult mental health than maltreatment by adults, including sexual and physical abuse. 42 Finally, these consequences reach beyond the realm of health, as childhood bullying victimisation is associated with a lack of social relationships, economic hardship and poor perceived quality of life at age 50. 33

Bullying prevention

Until not long ago, being bullied was considered a normal rite of passage through which children must simply persevere. 3 However, the size and scale of its impact on child health, and later on adulthood health, are now clearly understood and render it a significant public health problem warranting urgent attention. 1 While parental and peer support are known to be protective against victimisation, regardless of global location, cultural norms or socioeconomic status, 43 structured programmes have been deployed at scale to prevent victimisation and its associated problems.

School-based interventions have been shown to significantly reduce bullying behaviour in children and adolescents. Whole-school approaches incorporating multiple disciplines and high levels of staff engagement provide the greatest potential for successful outcomes, while curriculum-based and targeted social skills training are less effective methods that may even worsen victimisation. 44 The most widely adopted approach is the Olweus Bullying Prevention Programme (OBPP), a comprehensive, school-wide programme designed to reduce bullying and achieve better peer relations among school-aged children. 9 However, despite its broad global uptake, meta-analyses of studies examining the effectiveness of the OBPP have shown mixed results across different cultures. 45–47

Cooperative learning, in which teachers increase opportunities for positive peer interaction through carefully structured, group-based learning activities in schools, is an alternative approach to bullying prevention that has recently gained traction and been shown to significantly reduce bullying and its associated emotional problems while enhancing student engagement and educational achievement. 48 Also housed within the educational environment, school-based health centres became popular in the USA in the 1990s and provided medical, mental health, behavioural, dental and vision care for children directly in schools, and have had some positive impacts on mitigating the prevalence and impact of bullying. 49 In the UK, school nurses act as liaisons between primary care and education systems, and are often the first to identify victims of bullying, although their numbers in the UK fell by 30% between 2010 and 2019. 50

Due to the link between sibling and peer bullying, there have been calls for bullying prevention interventions to be developed and made available to start in the home, and for general practitioners and paediatricians to routinely enquire about sibling bullying. 8

While countless cyberbullying prevention programmes, both offline and online, are marketed to educational institutions, only a small proportion have been rigorously evaluated. 51 Furthermore, as cyberbullying rarely induces negative impacts on child health independently, interventions to tackle these effects must also target traditional forms of bullying to have meaningful impact.

Addressing the global public health problem of bullying in childhood and adolescence is vital for the achievement of the Sustainable Development Goals. In recognition of this, UNESCO recently launched its first International Day Against Violence and Bullying at School, an annual event which aims to build global awareness about the problem’s scale, severity and need for collaborative action. 52 Meaningful progress on this problem is urgently needed to increase mental well-being and reduce the burden of mental illness in both children and adults globally. Suggestions for immediate action are briefly described in box 1 .

Actions needed to improve child health through the prevention of bullying

• Promote the importance of parental and peer support in the prevention of bully victimisation across families and schools.
• Educate health professionals about the consequences of childhood bullying and provide training and resources to allow identification, appropriate management and timely referral of such cases (see further).
• Develop and make widely available bullying prevention interventions that tackle sibling bullying in the home.
• Create and deploy whole-school cooperative learning approaches to reduce bullying within educational institutions.
• Address cyberbullying with evidence-based interventions that also tackle traditional forms of bullying.
• Increase awareness of the presentation and impacts of bullying on child health among primary care professionals.

What to do if you suspect childhood bullying

GPs should be prepared to consider bullying as a potential contributory factor in presentations of non-specific physical and mental health complaints from children. While GPs recognise their responsibility to deal with disclosures of childhood bullying and its associated health consequences, they often feel unable to adequately do so due to the constraints of time-pressured primary care consultations, and uncertainty around the specialist services to which such children can be appropriately referred. 53

Clear management and referral pathways for health professionals dealing with childhood bullying are lacking in both primary and secondary care. Local, national and online antibullying organisations, such as Ditch the Label 54 and the Anti-Bullying Alliance, 55 provide free advice for children affected by bullying, and their parents, teachers and health professionals, along with free online certified CPD training for anyone working with children. School nurses continue to act as liaisons between primary care and education systems 56 and should be central to the multidisciplinary management of childhood bullying. Finally, if bullying is considered to be contributory to childhood depression, child and adolescent mental health services, along with primary care practitioners and educational professionals, should work collaboratively to foster effective antibullying approaches. 57

Supplementary Material

Contributors: RA was the sole contributor to the work.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: No, there are no competing interests.

Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Patient consent for publication: Not required.

Provenance and peer review: Commissioned; externally peer reviewed.

Data availability statement: Data sharing is not applicable as no datasets have been generated and/or analysed for this study.

This website uses Google Tag Manager. Please enable JavaScript to take full advantage of the features.

Work and mental health

On this page, mentally healthy work and why it matters, what influences mental health at work, building a mentally healthy workplace, your mental health at work, supporting someone at work, rights and obligations.

• Protect against risks to mental health. Mentally healthy work prevents harm to your mental health. Among other things, this means fair workloads. Fair work practices. And a safe environment.
• Promote wellbeing and the positive aspects of work . Mentally healthy work means things such as fairness, inclusion, and employee development. Good culture thrives from good work.
• Support people with poor mental health. In a mentally healthy workplace, your mental health is prioritised. Awareness, capability, commitment, and meaningful support exist. To help workers feel better, earlier.

Key facts - mental health at work

• Nearly 1 in 5 people experience poor mental health each year. Nearly half of us will experience poor mental health during our lives.
• Many people spend a third of their lives at work.
• Poor mental health costs the Australian economy from $12.2 to 22.5 billion each year (according to the Australian Government Productivity Commission).
• Work is a key setting to improve and support mental health.
• improves productivity
• improves commercial outcomes
• helps attract and retain staff.

Research has shown that investment in mental health has a positive return on investment. This can range from an average of $2.30 upwards for each dollar invested. Learn more about this research on the Mentally Healthy Workpla  ces website

• clarity on what you’re doing
• the effort required (job demands)
• fair treatment
• good support
• how work is recognised and rewarded
• your environment
• your relationships and dealings with people (including clients or the public)
• having the training, skills and tools to perform your work
• communication and change at work
• exposure to traumatic events or information.

Good work design

Practical tools to improve mental health at work, the key to change.

• commitment from leadership
• participation for everyone
• ongoing communication.

Practical tools to stay well at work

Check your mental health.

In Australia, there are protections and responsibilities relating to mental health in discrimination, privacy, and work health and safety laws.

Work health and safety

Workplace health and safety (WHS) laws require work to be reasonably safe for all. This includes measuring and managing risks to mental health. Learn more about WHS and mental health on the SafeWork Australia website . You can find links to your local Work Health and Safety Regulator at the bottom of this page.

Discrimination

Disability discrimination laws make it unlawful to discriminate against people with disabilities, including mental health conditions. Discrimination includes both direct and indirect actions. So not making reasonable adjustments to support your needs can be a type of discrimination. Find information about the Disability Discrimination Act on the Australian Human Right Commission website . Learn about reasonable adjustments. The Fair Work Act prohibits an employer from taking action against a worker for discriminatory reasons. Learn more about protection from discrimination at work on the Fair Work Ombudsman website . ​

Under Australian privacy law, a worker’s personal information is generally protected and can only be shared in certain circumstances. This includes information about your mental health. Find information about workplace privacy on the Fair Work Ombudsman website

Further resources

Staying well at work.

• Mindspot – for free online personalised mental health care.
• Headgear – a free smartphone app by Black Dog Institute which guides you through a 30–day mental fitness challenge.
• Smiling Mind – providing free and accessible tools to support healthy minds.

Building mentally healthy work

• The National Workplace Initiative: Mentally Healthy Workplaces
• SafeWork Australia – information on mental health
• People at Work – a free and validated Australian Psychosocial Risk Assessment Survey.
• Thrive at work – designing work that helps people, organisations and industry to thrive.
• Black Dog Institute: Workplace mental health and wellbeing

Work health and safety regulators

• Australian Commonwealth
• Australian Capital Territory
• New South Wales
• Northern Territory
• South Australia
• Western Australia

Subscribe to receive info about mental health, keeping well and stories from our community.

Help | Advanced Search

Computer Science > Computation and Language

Title: realm: reference resolution as language modeling.

Abstract: Reference resolution is an important problem, one that is essential to understand and successfully handle context of different kinds. This context includes both previous turns and context that pertains to non-conversational entities, such as entities on the user's screen or those running in the background. While LLMs have been shown to be extremely powerful for a variety of tasks, their use in reference resolution, particularly for non-conversational entities, remains underutilized. This paper demonstrates how LLMs can be used to create an extremely effective system to resolve references of various types, by showing how reference resolution can be converted into a language modeling problem, despite involving forms of entities like those on screen that are not traditionally conducive to being reduced to a text-only modality. We demonstrate large improvements over an existing system with similar functionality across different types of references, with our smallest model obtaining absolute gains of over 5% for on-screen references. We also benchmark against GPT-3.5 and GPT-4, with our smallest model achieving performance comparable to that of GPT-4, and our larger models substantially outperforming it.

Submission history

Access paper:.

• HTML (experimental)
• Other Formats

References & Citations

• Google Scholar
• Semantic Scholar

BibTeX formatted citation

Bibliographic and Citation Tools

Code, data and media associated with this article, recommenders and search tools.

• Institution

arXivLabs: experimental projects with community collaborators

arXivLabs is a framework that allows collaborators to develop and share new arXiv features directly on our website.

Both individuals and organizations that work with arXivLabs have embraced and accepted our values of openness, community, excellence, and user data privacy. arXiv is committed to these values and only works with partners that adhere to them.

Have an idea for a project that will add value for arXiv's community? Learn more about arXivLabs .