Bullying in Children and Adolescents (Peer and Sibling)

from – https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/children-and-young-people/sibling-and-peer-bullying

General Overview

• Bullying prevalence: Peer and sibling bullying are common in Australian children, with a significant proportion of children experiencing bullying in some form.
• Types of bullying: Physical, verbal, relational (social exclusion), and property damage. Cyberbullying is also recognized, particularly as it can reach a large audience even with a single act.
• Sibling bullying: Considered one of the most common forms of family-based violence. Children bullied at home often experience bullying at school, creating an environment without a “safe place.”
• Hidden issue: Both peer and sibling bullying often go unnoticed by parents, teachers, and healthcare professionals, leading to under-recognition of their harmful effects.

Clinical Practice Recommendations

1. Awareness: Healthcare providers should maintain vigilance for both peer and sibling bullying, as both can significantly impact physical and mental health.
2. Screening: Develop a brief, structured approach to asking about bullying in children, especially those at higher risk.

Definitions and Characteristics of Bullying

• Definition: Bullying involves unwanted, aggressive behaviors with an imbalance of power, repeated over time or likely to recur.
• Key elements: Intentional harm or distress, power imbalance, and repetitive actions.
• Types: Direct (physical/verbal) and indirect (social exclusion, rumor-spreading, psychological intimidation).

Sibling Bullying vs. Rivalry

• Sibling rivalry: Typical conflict between siblings, often mutual and temporary.
• Sibling bullying: Becomes classified as bullying when:
  • The aggression is one-sided.
  • It involves a repetitive, escalating pattern.
  • It results in psychological, emotional, or social harm.

Prevalence

• Peer bullying: Approximately 25.1% lifetime prevalence for victimization and 11.6% for perpetration among children in Australia.
• Sibling bullying: Estimates range from 15-50% for victimization and 10-40% for perpetration, with young children (ages 2-9) commonly involved.

Risk Factors

• Predictors: Aggressive behavior in preschool predicts later bullying; environmental factors, parenting quality, and family structure (e.g., birth order, number of siblings, and close sibling age).
• Parenting style: Harsh or poor-quality parenting can increase sibling bullying likelihood. Children who bully often show low empathy and may struggle with understanding others’ perspectives.

Table 10.1 Risk factors for peer and sibling bullying
	Risk factors	Bullying
		Peer	Reference	Sibling	Reference
Individual	Physical (eg overweight, disability, chronic illness)	Moderate association	65–68
	Social (eg poorer social cognition, theory of mind)	Moderate association	62, 64	Strong association	50
	Behavioural (eg externalising and disruptive behaviours(a) including aggression, learning disability)	Strong association	69, 70	Strong association	50
	Gender (eg LGBTQIA+)	Strong association	71	Moderate association	72
	Emotional dysregulation(b) (eg impulsivity)	Moderate association	73, 74	Moderate association	58
	Adverse childhood experiences(c)	Strong association	75–78	Strong association	79
Family	Structural family characteristics (eg first born, having an older brother, having step-siblings)			Strong association	50, 58
	Domestic violence	Moderate association	80	Strong association	36, 50, 81
	Financial difficulties	Moderate association	82	Moderate association	10, 50, 61
	Socio-economic status	Inconsistent association	83	Inconsistent association	61
	Negative family dynamics (eg conflicting partnerships, arguing, hostile communication), interparental conflict	Strong association	84	Strong association	50, 79
	Parenting quality (eg harsh discipline or failure to discipline, lack of parental warmth, neglect, inter-parental hostility and abuse)	Moderate association	85	Moderate–strong association	50, 58–60, 79, 86, 87

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Health and Psychological Impact

• Mental health: Bullying contributes to mental health burden, including anxiety, depression, and self-harm. Those bullied at both home and school show significantly higher risks for mental health issues.
• Behavioral risks: Bullying involvement at home and school can lead to antisocial behaviors, criminal involvement, and substance misuse.

Short- and long-term impacts of peer and sibling bullying
		Peer bullying		Sibling bullying
Short-term impacts
		Impact	Reference	Impact	Reference
	Physical health	Injury	22	Injury	79
		Headaches	93	Most studies have not separated out sibling aggression/bullying from peer bullying
		Abdominal pain	93
		Repeated sore throats	94
		Recurrent colds and breathing problems	94
	Social health	Loneliness and isolation through a more limited ability to make friends	95, 96	Increased likelihood of being bullied at school	10, 11, 61, 97, 98
		Decline in school performance/functioning, absenteeism from school/ home, withdrawal/avoidance	16	Decline in school performance/functioning	99
	Mental health	Psychosomatic symptoms (eg bedwetting, sleeping problems, abdominal pain, difficulty concentrating, dizziness, poor appetite, and feelings of tension or tiredness)	94, 100	Mental health distress	101–103
Long-term impacts
	Mental health	Anxiety, depression, self-harm, increased suicide ideation and suicide	6, 8, 104, 105	Anxiety, depression, psychotic symptoms	36, 37, 39, 98, 106
		Eating disorders	22, 107
		Obesity	108, 109
		Smoking	110
		Drug and alcohol problems	111, 112	Substance abuse	38, 81
		Low self-esteem/withdrawal	95, 113	Dose–response association	10, 37, 101, 103, 114
	Behavioural problems	Aggressiveness and conduct problems(a)	115	Sibling bullying victims exhibit bullying behaviour at school	10, 116, 117
		Criminal activities	7	Criminal activities	38
		Perpetrating violence (eg dating, intimate partner abuse)	99	Dating violence	49, 118
		Anti-social behaviour	38	Anti-social behaviour	38, 4

Role of the GP in Addressing Bullying

• Importance of GP Awareness and Intervention
  • GPs play a key role as trusted sources of information and support, offering a neutral environment free from stigma.
  • Given high rates of GP visits by children (83% per year), there is a frequent opportunity to identify and address bullying.
• Exploratory and Family-Centered Approach
  • Addressing bullying requires sensitivity to family dynamics and rapport-building with parents and children.
  • GPs should use non-judgmental language to avoid defensive reactions from parents.
• Physical and Psychological Impact
  • Bullying is strongly linked to various health concerns commonly seen in general practice.
  • Children bullied by siblings often face bullying in other settings, and sibling bullying is a prevalent form of family violence.
• Risks of Poly-victimization
  • Children facing bullying at home are at higher risk of bullying outside the home.
  • Schools tend to focus on peer bullying, leaving family-based bullying primarily in the GP’s domain for identification and intervention.
• Long-Term Impact and Lifespan Perspective
  • Bullying behavior can evolve into other forms of abuse, making early intervention crucial to prevent a cycle of aggression.
  • Addressing bullying behavior early can help transform potentially negative outcomes into positive lifelong coping strategies.
• Avoiding Labels and Focusing on Behavior
  • GPs should focus on specific behaviors rather than labeling a child a “bully,” which may imply that the behavior is unchangeable and stigmatize the child.
  • Labels can overshadow underlying factors contributing to the behavior.
• Sibling Bullying as an Adverse Childhood Experience
  • Recognized as part of adverse childhood experiences, sibling bullying demands structured anti-bullying interventions, yet most focus on school settings rather than family.
• Understanding Sibling Conflict vs. Bullying
  • Sibling conflicts often stem from competition for resources like parental attention.
  • Family dynamics, age hierarchy, and forced proximity can intensify sibling conflicts, sometimes escalating into bullying.
• Parenting Influences on Sibling Bullying
  • Certain family dynamics, such as power imbalances, rigid gender roles, and differential treatment, increase the risk of bullying.
  • GPs can help parents become aware of sibling aggression and encourage them to recognize when behaviors go beyond normal sibling rivalry.
• Challenges in Identifying and Addressing Sibling Bullying
  • GPs face difficulty in identifying sibling bullying due to:
    • Parental normalization of sibling aggression.
    • Differing parental responses to aggression in siblings vs. peers.
    • Limited parental awareness of the psychological impact of sibling bullying.
• Normalization and Disclosure Challenges
  • Many children and parents view sibling aggression as a normal part of development, reducing the likelihood of disclosure.
  • Children often don’t report sibling bullying due to fear of retaliation, shame, or a perceived norm of aggressive behavior within the family.
• Reducing the Taboo Around Sibling Bullying
  • GPs can encourage parents to reflect on family dynamics and support interventions to foster healthy relationships.
  • Building greater societal and familial awareness of sibling bullying’s impact can help normalize open discussions and improve intervention outcomes.

Bullying Prevention and Intervention in General Practice

• Primary Prevention Programs
  • Typically population-based, including community engagement and home visits.
  • Parenting programs focus broadly on positive parenting but rarely address sibling aggression or bullying directly.
  • Evidence suggests only limited improvement in child behavior from general parenting programs in primary care settings.
• Screening and Early Detection
  • Health professionals often recommend GPs screen for bullying directly or as part of identifying child abuse, though evidence on effectiveness is mixed.
  • Australian health initiatives acknowledge bullying as a health issue but provide minimal guidance for healthcare worker roles in anti-bullying efforts.
  • Sibling aggression is potentially a stronger predictor of adult violence than witnessing parental violence.
• Brief and Early Interventions
  • Interventions can be general (parenting skills) or specific, targeting families with known risk factors.
  • When conducting interventions, GPs should recognize that abusive sibling behaviors are often unaddressed by parents.
  • Steps for a brief intervention on bullying:
    • Ask: Seek permission to discuss bullying and maintain suspicion if psychosomatic issues are present.
    • Assess: Determine the bullying’s nature, extent, severity, and understand actions taken by the child or parents.
    • Advise: Highlight bullying’s potential impacts, encourage parental involvement, provide resources for parental education, and offer school contact if peer bullying is involved.
• Indicators for Bullying in Children
  • Psychosocial
    • Evidence of mood changes (eg anxiety, depression, low self-esteem, withdrawal)
    • Psychosomatic symptoms (eg problems with sleep, eating, bedwetting, headaches, stomach aches)
    • Children with externalising behaviours (eg aggression, impulsivity)
  • Physical
    • Unexplained (+/– repeated) injuries
    • Chronic illness, marginalised groups (eg LGBTQIA+), physical or other disability (eg learning difficulty)
    • Repeated vague complaints
    • Recurrent colds and sore throats
  • Social
    • Difficulty and/or withdrawal in relating to siblings and friends
    • Fears of rejection
    • Being tense, tearful and unhappy before or after school
    • Shyness or awkwardness with others
  • School
    • Fear or loss of interest in going to school
    • Decline in school performance

• Asking about Bullying
  • Open discussions around bullying and emphasize parental support and role modeling in handling conflict.
  • For adolescents, utilize the HEEADSSS assessment (home, education, eating, activities, drug use, sexuality, safety, and depression).
  • For young children, it may be useful to speak to them alone, though parents often minimize bullying behaviors.
  • For very young children, rely on observations and parental reports.

Suggested Questions

• Use open-ended questions to gently inquire about social interactions, emotions, and physical health to identify potential bullying.

Sample questions to ask children about bullying
Peer bullying	Sibling bullying
‘I’d like to ask you some questions about what school is like.’ – ‘Have you ever been teased (or picked on) at school?’ – ‘What kinds of things do children tease you about? Have you ever been teased because of your illness/handicap/disability? Do you have any nicknames?’ – ‘What do you do when others pick on you?’‘Have you ever told your teacher or other adult? What happened?’ – ‘Do you know of other children who have been teased?’ – ‘At recess, do you usually play with other children or by yourself?’	‘I’d like to ask you some questions about life at home with your brother(s) and/or sister(s). ’‘How do you get on with your brother(s) and/ or sister(s)?’” “Sometimes brothers and sisters hit, bite, or kick each other when they are feeling mad or frustrated. They might pick on you, call you names or exclude you from things. Does that happen to you with your brother(s) or sister(s)?’ If child answers in affirmative or says ‘sometimes’, ask follow-up questions to gather information about frequency, types of bullying, severity, how long has it been occurring and the impact: – How often that does happen? (help the child to quantify): – Does it happen every day? – Every week? Or just sometimes? ’‘How long has this been going on for?’ ‘What do you do to try to stop the bullying? Does it work? If not, what else can you do to stop the bullying?’ ‘Can you tell them to stop? Can you escape when this happens?’ ‘How do you feel when you are bullied?’ ‘Do you have anyone you can talk to about this?’ ‘Some kids say it’s scary when they fight with their brother(s)/sister(s). Do you feel like it is scary when you fight with your brother(s) or sister (s), like you might get hurt really bad?’ If child answers in the affirmative or sometimes, ask questions to gather additional information such as: – ‘Do you feel scared lots of times or just sometimes? Tell me about that.’

Questions for Children Suspected (or Identified) of Bullying Behavior

1. General Involvement in Bullying
   • “Have you been involved in bullying others at school, in sports, or in your neighborhood?”
2. Frequency and Duration
   • “How long have you been bullying?”
   • “How often do you bully?”
3. Locations of Bullying
   • “Are you involved in bullying just at school, or in other places, such as at home, on a sports team, or at a community center?”
4. Types of Bullying and Perceptions
   • “Can you tell me about the types of bullying that you have used? How do the kids you bully feel?”
5. Support to Stop Bullying
   • “Have any adults talked with you to help you stop bullying?”

Questions for Parents

1. Identifying the Type and Extent of Bullying
   • Determine if the child is bully only, victim only, or bully–victim.
   • Inquire about the child’s social skills, such as making eye contact, listening, taking turns, and recognizing emotions in self and others.

For Parents of Victims of Bullying

1. Concerns About Child’s Social Experiences
   • “Are you concerned that your child is having problems with other children at school?”
   • “Has your child’s teacher ever mentioned that your child is often by themselves at school?”
2. Health and Physical Signs
   • “Does your child visit the school nurse frequently or have they come home with unexplained injuries?”
3. Suspicions of Bullying
   • “Has your child ever said that other children were bothering them?”
   • “Do you suspect that your child is being harassed or bullied at school for any reason? If so, why?”

For Parents of a Child Who is Bullying

1. Interactions with Others
   • “How does your child get along with other children/their siblings?”
   • “When conflict arises, how does your child typically approach it? Do you think your child is a bully?”
2. Understanding Child’s Behavior and Parental Response
   • “What do you think is going on with your child? Do you think it is affecting them emotionally?”
   • “Do you have any ideas of what may be contributing to your child’s behavior?”
   • “What have you done to try and deal with or address this behavior?”
3. Perceptions of Child’s Behavior (may provoke negative reactions; clarify these questions are exploratory)
   • “Do you think your child is mean or cruel to other children?”
   • “Do you think your child is trustworthy?”
   • “Do you think your child is manipulative?”
   • “Do you believe that your child lacks guilt?”

Questions for Sibling Bullying

1. General Parental Concerns
   • “Is this an issue for you?”
2. Understanding Sibling Interactions
   • “Can you tell me what happens?”
   • “Do you have any ideas about why they fight or argue?”
   • “What strategies, if any, do you use to stop this behavior?”
   • “How well do your children get on with each other?”
3. Observing Potential Bullying Behavior
   • “Do you think there is a lot of teasing and pushing/shoving between them?”
   • “Do you think this goes both ways (like sibling rivalry), or is it more one-sided?”
   • “Do you have any concerns that one child may be more often on the receiving end?”

Interventions and follow-up

1. Initial Interventions

Assessment and Documentation

• Document the bullying history comprehensively, including types, duration, and impact on the child’s physical and mental health.
• Assess physical and psychological symptoms such as injuries, sleep disturbances, anxiety, depression, or school avoidance.
• Consider mental health screening tools (e.g., Strengths and Difficulties Questionnaire) to gauge social, emotional, and behavioral concerns.

Supportive Counseling

• Provide initial emotional support for the child and family, validating their experiences and concerns.
• Empower assertiveness and social resilience in children who are bullied by teaching self-advocacy and helping parents support confidence-building.
• Teach emotional regulation to children involved in bullying others, guiding them in identifying triggers and managing emotional responses.

Family and Parenting Guidance

• Encourage open family communication and stress the importance of parents being non-judgmental and supportive.
• Teach conflict resolution techniques for parents (like the IDEAL model) and discourage punitive measures that may worsen behavior.
• Promote healthy sibling relationships by addressing sibling bullying dynamics with strategies to encourage cooperation and reduce rivalry.

Referral to Support Services

• Psychological Services: Consider a Mental Health Treatment Plan (MHTP) for referral to a psychologist under Medicare if the child requires counseling or behavioral therapy.
• Community Support Programs: Refer to local community programs (e.g., Headspace for adolescents) for peer support or group therapy, and Parentline for parenting advice.
• School and Educational Support: Collaborate with school counselors or welfare officers to develop an anti-bullying plan, as Australian schools are often highly engaged in anti-bullying strategies.

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2. Tailored Interventions for Specific Roles

For Victims of Bullying:

• Empowerment Programs: Refer the child to social skills or resilience-building programs often run through schools or community centers.
• Parental Education: Guide parents to resources for managing bullying, such as the Bullying No Way website, which provides Australian-specific anti-bullying advice.
• Develop a School Action Plan: Encourage parents to work with the school to establish specific anti-bullying steps (e.g., monitoring, reporting) and follow up on progress.

For Children Who Bully Others:

• Behavioral Therapy Referral: Consider a referral for cognitive-behavioral therapy (CBT) if the child exhibits persistent aggressive behavior or difficulty with empathy.
• Emotional Regulation Training: Refer the child to counseling or programs focused on emotion management (available through community organizations or private practices).
• Assess for Underlying Issues: Screen for developmental or behavioral disorders (e.g., ADHD, conduct disorder) that may require specialized intervention.

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3. GP-Led Follow-Up and Monitoring

Scheduled Follow-Ups:

• Regular Review Appointments: Arrange follow-ups every 4-6 weeks initially to monitor the child’s emotional well-being, physical health, and school attendance.
• Update on School Involvement: Review school feedback on bullying incidents, and discuss progress on any school-initiated intervention plans.
• Track Parental and Family Impact: Address any stress or anxiety in parents, offering resources or referrals as needed.

Use of Health Plans and Medicare Services

• Mental Health Treatment Plan (MHTP): For children needing prolonged support, initiate or continue an MHTP, which provides access to Medicare-subsidized sessions with a psychologist.
• Chronic Disease Management Plan: For children with ongoing issues related to mental health or developmental disorders, a Chronic Disease Management Plan can cover additional allied health services if required.

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4. Community and School-Based Collaboration

School Partnerships:

• Encourage school-based mental health programs, like KidsMatter or MindMatters, which help promote student well-being and anti-bullying measures.
• Work with school staff and psychologists to ensure regular feedback on the child’s adjustment, interactions, and progress.

Community Resources for Parents and Children:

• Headspace (for youth aged 12-25) and Kids Helpline offer accessible support and counseling.
• Parentline provides counseling and parenting support, especially helpful for managing family dynamics around sibling bullying.

Parent Education on Online Safety:

• Educate parents on cyberbullying, advising on safe online behaviors and privacy settings, and provide resources like eSafety Commissioner guidelines for protecting children from online bullying.

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5. Additional Resources and Helplines

• Kids Helpline (1800 55 1800): Free, confidential counseling for children.
• eSafety Commissioner: Provides resources and reporting for online bullying or harassment.
• Bullying No Way: Offers guidance for parents and children on handling school bullying.
• Parentline (1300 30 1300): Support service for parents seeking advice on managing family issues, including bullying.

Case Studies

David

• Early Life and Family Dynamics
  • Experienced significant abuse from father and older brother: physical and emotional.
  • Beaten with objects like a belt buckle and a bamboo cane with nails.
  • Felt unworthy and unloved; believed no one liked him.
  • Mother and older sister were intimidated but never intervened.
  • David’s older sister recalls him as bright and humorous despite the abuse.
• School Years
  • Initially performed well in school but faced attention and focus issues in grade four.
  • Shy and withdrawn; struggled with making friends.
  • Limited social skills and a passive response to bullying at school.
• Adult Life and Relationships
  • Entered a relationship where his partner verbally demeaned him and had affairs.
  • Estranged from his partner in his 50s, leaving him with few possessions despite financial contributions.
  • Limited contact with older sister until reconnecting after a heart attack.
  • Estranged from parents following an abusive incident with his child.
• Health Issues
  • History of substance abuse, including heavy marijuana and alcohol use, starting in his 30s.
  • Became overweight and developed type 2 diabetes in his 40s; initially non-adherent to lifestyle and medication.
  • Experienced severe depression and attempted suicide; admitted for psychiatric care.
• Cardiac Health
  • Suffered a major myocardial infarction in his early 50s.
  • Ignored symptoms for hours; required a three-vessel coronary artery bypass.
  • Became fully adherent to treatment and lifestyle recommendations after the surgery.
  • Moved frequently between GPs, rarely discussing his family bullying history.
• Final Years and Death
  • Last saw his son, who found him deceased at home after an arrhythmia related to a heart attack.
  • Coroner’s investigation found he died days before being found, with no suspicious circumstances.
  • In the last months, David expressed feeling content, enjoying art, and isolation.
• Reflections
  • GP reflects on David’s lifelong experiences of abuse and the significant impact of unaddressed familial bullying.
  • Speculates that earlier intervention might have improved his life.
  • Emphasizes a newfound commitment to routinely ask children about bullying, both within and outside of family settings.

Case Study Summary: Addressing Sibling Bullying

• Background and Initial Observations
  • Stephen (10 years) and John (7 years) are brothers, with Stephen being physically bigger and stronger.
  • When visiting their aunt Kate and uncle Charlie, John appeared withdrawn, distressed, and difficult to engage—behavior out of character for him.
  • John’s father mentioned a decline in John’s grades and truancy, suspecting possible school bullying, though John denied it.
• Incident Awareness
  • During a visit, Kate noticed subtle instances of Stephen disrupting John’s activities and physical roughness, like using a judo move on John.
  • Kate observed Stephen’s actions and became increasingly concerned but was hesitant to speak to the boys’ recently separated parents.
• GP Consultation and Suggested Intervention
  • Kate consulted her GP, who identified Stephen’s behavior as sibling bullying.
  • The GP recommended a structured reward and penalty system:
    • Points system for cooperative behavior with a reward goal (a shared treat, like a quad bike ride).
    • Point deductions for rough or uncooperative behavior.
  • Both boys agreed to the goal of a quad bike ride; Kate and Charlie set a points target and communicated the system clearly.
• Outcome and Changes Over Time
  • During the two-week stay, the frequency of bullying behavior decreased, with a noticeable reduction in conflict.
  • As teens, the boys developed a positive relationship; John’s growth spurt led to a physical equalization, and school bullying he experienced also ceased.
  • John later expressed appreciation for Kate’s intervention, which had boosted his confidence and provided a safe environment.
  • Kate shared with her GP that the approach had positive, lasting effects and that her intervention provided John with much-needed emotional support.