Antibullying.eu

Childhood Bullying Behavior and Later Psychiatric
Hospital and Psychopharmacologic Treatment
Findings From the Finnish 1981 Birth Cohort Study
Andre Sourander, MD, PhD; John Ronning, PhD; Anat Brunstein-Klomek, PhD; David Gyllenberg, MD;Kirsti Kumpulainen, MD; Solja Niemelä, MD, PhD; Hans Helenius, MSc; Lauri Sillanmäki, BA; Terja Ristkari, MNSc;Tuula Tamminen, MD; Irma Moilanen, MD, PhD; Jorma Piha, MD, PhD; Fredrik Almqvist, MD, PhD Context: No prospective population-based study exam-
independently predicted psychiatric hospital treatment ining predictive associations between childhood bully- and use of antipsychotic, antidepressant, and anxio- ing behavior and long-term mental health outcomes in lytic drugs. Among males, frequent bully-victim and bully-only statuses predicted use of antidepressant andanxiolytic drugs. Frequent bully-victim status among Objective: To study predictive associations between bul-
males also predicted psychiatric hospital treatment lying and victimization in childhood and later psychiat- and use of antipsychotics. However, when the analysis ric hospital and psychopharmacologic treatment.
was controlled with total psychopathology score at age Design: Nationwide birth cohort study from age 8 to
8 years, frequent bully, victim, or bully-victim status did not predict any psychiatric outcomes amongmales.
Participants: Five thousand thirty-eight Finnish chil-
dren born in 1981 with complete information about
Conclusions: Boys and girls who display frequent bul-
bullying and victimization at age 8 years from parents, lying behavior should be evaluated for possible psychi- atric problems, as bullying behaviors in concert with psy- Main Outcome Measures: National register–based life-
chiatric symptoms are early markers of risk of psychiatric time information about psychiatric hospital treatments outcome. Among females, frequent childhood victimiza- and psychopharmacologic medication prescriptions.
tion predicts later psychiatric problems irrespective of psy-chiatric problems at baseline.
Results: When controlled for psychopathology score,
frequent victim status at age 8 years among females
Arch Gen Psychiatry. 2009;66(9):1005-1012 BULLYINGISAMAJORCON- monthsandshowedthatproblembehav-
ior was a consequence rather than a cause of bullying experiences. Until recently, fol- years of age. Although former victims were repetition.1 Boys engage in a greater amount spects, they had lower self-esteem and de- physical compared with that of girls, who pression more often than their nonvictim- are more likely to be involved in relational ized peers. To the best of our knowledge, forms of aggression.2,3 Bullying and victim- the only large-scale population-based long- ization are associated with poorer family functioning,4 interparental violence,5 and show that children who are both bullies and victims are the most troubled in terms of investigate, in part, the relationship be- Author Affiliations are listed at
prospectively.7,8,10,11 Kim et al8 observed seventh- and eighth-grade students for 10 (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 66 (NO. 9), SEP 2009 2009 American Medical Association. All rights reserved.
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dicative of an antisocial tendency. However, because of parents returned them in a sealed envelope to the teacher. The the methodology (birth cohort of males was initially fol- children filled out a questionnaire in the classroom. The teach- lowed up at obligatory military call-up), follow-up in- ers then sent the parents’ questionnaires, the parents’ written formation about females was not available at that time, consent sheet, the teachers’ questionnaires, and the children’s and information about psychiatric outcome among boys self-reports to the researchers in sealed envelopes.
The question that assessed bullying had 3 answers from which was limited to military call-up health examinations.
thechildcouldchoose:(1)“Ibullyotherchildrenalmosteveryday,” There are no previous population-based studies that (2) “I bully sometimes,” and (3) “Usually I do not bully.” Victim- examined late adolescence or adulthood outcomes of ization was assessed by the following: “Other children” (1) “bully childhood bullying among both males and females. In the me almost every day,” (2) “bully me sometimes,” and (3) “usu- present study, we used 2 sources of psychiatric out- ally do not bully me.” The question pertained to the child’s behav- comes not included in our previous reports for our en- ior in the last 2 weeks. Similar questions focusing on bullying and tire birth cohort: (1) the nationwide hospital discharge victimization were included in the parent and teacher question- register containing information about all psychiatric hos- naires (for a 12-month period), with the probe and response items pital treatments; and (2) information about psycho- worded as follows: The child bullies/is bullied by other children: tropic medication from the Finnish Social Insurance In- (1) does not apply, (2) applies somewhat, and (3) certainly applies.
For the purposes of the present study, alternatives 1 and 2 were stitution. Hospital treatment in Finland is usually an regarded as indicating no or only occasional bully or victim sta- indicator of a severe disturbance and is the most expen- tus, whereas alternative 3 indicated frequent bully or victim status.
sive treatment in psychiatry.14,15 Our study aimed to ex- We classified the sample into the following groups: (1) those amine the associations between bullying and victimiza- who never or only sometimes bullied and were not victimized tion at the age of 8 years and psychiatric hospital treatment according to parental, teacher, and self-reports; (2) those who and use of psychiatric medications from 13 to 24 years.
frequently bullied (but were not victimized) according to at least We studied the different outcomes of children who only 1 informant; (3) those who were frequently victimized (but did frequently bullied, those who were only frequently vic- not bully) according to at least 1 informant; and (4) those timized, and those who were frequently both bullies and who both frequently bullied and were victimized using pooled victims (bully-victims). Furthermore, our interest was to information from all 3 informants. For example, if a boy fre-quently bullied according to teachers and was frequently vic- examine whether frequent bullying or victimization cor- timized according to self-reports, he was classified as a bully- relate with psychiatric outcomes when controlled for the victim. Only subjects with complete information about bullying effect of psychopathology and whether these correla- and victimization from all 3 informants were included in the tions are different among males and females.
analysis. Combining the parent, teacher, and child reports ofinformation about bullying/victimization by using the “either/ or” rule is justified by the low interrater agreement (weighted SUBJECTS
MEASURES ON PSYCHIATRIC SYMPTOMS
AT 8 YEARS OF AGE
This investigation is part of the nationwide Finnish 1981 BirthCohort Study. The Joint Commission on Ethics of Turku Uni- In this study, we analyzed parental and teacher reports of the versity and Turku University Central Hospital approved the re- child’s psychiatric symptoms as possible confounding vari- search plan, and informed consent was obtained from the chil- ables. Parents and teachers completed a Rutter Scale,19,20 which dren’s parents at baseline. Combined information from was composed of 3 subscales (conduct, hyperactivity, and emo- questionnaires and registry data was analyzed in such a way tional scores). The Rutter questionnaires for screening chil- that the subject could not be identified.
dren’s emotional and behavioral problems are well- The methodology of the study has been previously re- established and well-studied behavioral screening instruments ported in more detail.16-18 The original representative study that have proved valid and reliable in many contexts.21 In the sample was drawn from the total population of Finnish chil- present study, cut-off points corresponding to the 85th per- dren born in 1981 (N = 60 007). The first assessment was con- centile (total score cut-off point of 13 on the parental scale and ducted in October and November 1989. Of the selected 6017 9 on the teacher scale) were used as indicators of possible psy- children, 5813 (96.6%) took part in the study in 1989. The per- chiatric disturbance. These cut-off points are widely used in sonal identification numbers of 5351 subjects could be linked child psychiatric epidemiology.16,21 In the present study, the child with the Finnish Population Register. Altogether, 462 identi- was considered screen-negative if he or she scored below the fication numbers had been either lost or inappropriately cut-off points in both the parent and teacher total Rutter scores.
documented. Complete information about bullying and vic- Children who scored above the cut-off points in either the par- timization from all 3 informants (parent, teacher, and child self- ent or teacher scales were defined as screen-positive.
report) at age 8 years and outcome data until age 24 years wasobtained in 5038 subjects (86.7% of those who participated inthe study in 1989).
PSYCHIATRIC OUTCOMES
FROM AGE 13 TO 24 YEARS
Psychiatric Hospital Treatment
ASSESSMENT OF BULLYING AND
Information about psychiatric hospital treatment according to VICTIMIZATION AT 8 YEARS OF AGE
the Finnish Hospital Discharge Register was collected from Janu-ary 1, 1994, to December 31, 2005. The National Research and Data collection at baseline was organized through teachers. The Development Centre for Welfare and Health in Finland has teacher sent questionnaires via the child to the parents, and the maintained the Finnish Hospital Discharge Register since 1969.22 (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 66 (NO. 9), SEP 2009 2009 American Medical Association. All rights reserved.
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The Finnish Hospital Discharge Register contains personal iden- time observation. The strength of the associations were quan- tification numbers (since 1969), hospital identification codes, tified using hazard ratios (HRs) with 95% confidence intervals and data on length of stay and primary diagnoses at discharge (CIs). Survival curves were estimated using the Kaplan-Meier (together with 3 possible subsidiary diagnoses). Diagnostic in- technique. Statistical computations were done using SAS, re- formation in the register is based on clinical diagnoses made lease 9.1 (SAS Institute Inc, Cary, North Carolina).
by the attending physician. It covers all mental and general hos-pitals as well as in-patient wards of local health centers, mili- tary wards, prison hospitals, and private hospitals. The diag-nostic validity of the register concerning psychiatric disordersis good compared with medical records.23,24 We identified the Altogether, 6.0% of 8-year-old boys were frequently bul- subjects in our cohort by linking their unique identification num- lies but not victims according to at least 1 informant, ber to information in the Finnish Hospital Discharge Register.
whereas 6.4% of boys were frequently victims but not bul- The following psychiatric diagnostic codes of the register were lies. Among boys, 2.8% were frequently both bullies and chosen as outcomes: the 1994-1995 International Classifica- victims. Among girls, the rate of frequent victims was tion of Diseases, Ninth Revision, codes 290 to 319 and the 1996- 3.6%. However, the percentage of girls who frequently 2005 International Statistical Classification of Diseases, 10th Re- only bullied or were bully-victims was very low, 0.6% and vision, codes F00 to F99. Because of the rather limited number of cases with psychiatric discharge diagnoses, it was not sen-sible to further classify the diagnostic groups for the purposeof the present study. Of males and females, 6.2% and 4.1%, re- CHILDHOOD BULLYING/VICTIMIZATION
spectively, had undergone psychiatric hospital treatment from AND PSYCHIATRIC HOSPITAL
TREATMENT AT FOLLOW-UP
Psychopharmacologic Treatment
As shown in Table 1, 17% of the male bully-victim group
had undergone psychiatric hospital treatment during follow-
Information about psychotropic medication use from January 1, up, whereas 9% in the frequent bully–only group, 10% in 1994, to December 31, 2005, was collected from the nationwide the frequent victim–only group, and 5% in the reference Drug Prescription Register filed by the National Social Insur- group (not frequently a bully or victim) had undergone psy- ance Institution. This register tracks medication that has been pur- chiatric hospital treatment during follow-up. Among fe- chased from a pharmacy and is composed of data on 97% to 98% males, 12% of the frequent victim group had undergone a of all reimbursed prescriptions.25 In Finland, the cost of prescrip- psychiatric hospital treatment, while 4% in the reference tion-only medicines deemed necessary for the treatment of an ill-ness is reimbursed by the Health Insurance Institution. Drug pur- group had undergone a psychiatric hospital treatment. Fre- chases were recorded using the date of purchase, and drugs were quent victim status among both males and females and coded according to the 2000 Anatomic Therapeutic Chemical bully-victim status among males predicted psychiatric hos- (ATC) classification system.26,27 According to the ATC classifi- pital treatment. However, when the analyses were ad- cation system, the drugs were further classified into (1) antipsy- justed with the total psychopathology score at age 8 years chotics (ATC code N05A), (2) antidepressants (ATC code N06A), (sum score of symptoms using pooled information from and (3) benzodiazepine derivates (ATC code N05BA) (clonaz- parent and teacher ratings), only female frequent victim sta- epam was excluded, as it is mainly used to treat epilepsy). The tus predicted psychiatric hospital treatment same subject could have been classified as using medication frommore than 1 drug group. The global index of having any psycho- CHILDHOOD BULLYING/VICTIMIZATION
pharmacologic treatment also included mood stabilizers, anti-epileptics (ATC code N03), and dixyrazine, hydroxyzine, buspi- AND PSYCHOPHARMACOLOGIC
rone, disulfiram, lithium, and methylphenidate. From age 13 to TREATMENT AT FOLLOW-UP
24 years, 13.2% of males and 16.7% of females had undergonepsychopharmacologic treatment.
As shown in Table 1, 32% of males in the bully-victimgroup had psychopharmacologic treatment during follow- Psychiatric Hospital
up, whereas 18% in the frequent bully–only group, 15% or Psychopharmacologic Treatment
in the frequent victim–only group, and 12% in the ref-erence group had psychopharmacologic treatment dur- As a global index of psychiatric outcome, information about ing follow-up. Thirty-two percent of females in the fre- psychiatric hospital and pharmacologic treatment was pooled.
quent victim group and 16% of females in the reference From age 13 to 24 years, 16.6% of males and 17.8% of females group had undergone psychopharmacologic treatment.
In the total sample, sexϫbullying group interactions weresignificant only for use of anxiolytics (P Ͻ.05).
STATISTICAL ANALYSIS
Among males in the unadjusted analysis, frequent bully-victim and frequent bully–only statuses predicted Associations of frequent bullying/victimization and psychiat- use of any psychiatric medication, antidepressants, or anx- ric symptoms with incidence of mental hospital treatment from iolytics. Bully-victim status predicted use of antipsychot- age 13 to 24 years were analyzed using Cox proportional haz- ics. Frequent victim status did not predict later use of psy- ards regression analysis.28 The time from age 13 years to thefirst mental medication or hospital treatment before age 24 years chiatric medications. However, when the analyses were was the observed time for end-point event in the analysis. For adjusted with the total psychopathology score, frequent those who did not have any medication or hospital treatment bully and bully-victim statuses did not predict any out- before age 24 years, the time from age 13 years to age 24 years come among males (Table 1). In unadjusted and ad- was recorded as the event time and it was handled as censored justed analyses among females, frequent victim–only sta- (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 66 (NO. 9), SEP 2009 2009 American Medical Association. All rights reserved.
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Table 1. Association Between Frequent Bullying and Victimization at Age 8 Years and First Use of Psychiatric Hospital
and Medical Treatment From Age 13 to 24 Yearsa
Frequent Victim
Frequent Bully
Frequent Bully-Victim
Frequent
HR (95% CI)
HR (95% CI)
HR (95% CI)
Participants
Unadjusted
Adjusted
Unadjusted
Adjusted
Unadjusted
Adjusted
Males (n = 2541)
Females (n = 2497)
Abbreviations: CI, confidence interval; HR, hazard ratio; NA, not applicable because of low numbers.
a Analyses were conducted using Cox regression without and with adjustment for total psychopathology score at age 8 years.
tus predicted any psychiatric medication, use of quent victim, and bully-victim groups were further clas- antipsychotics, antidepressants, and anxiolytics (Table 1).
sified into screen-positives (above clinical cut-off pointon either the Rutter teacher or parental scale) and screen- PSYCHIATRIC HOSPITAL AND/OR MEDICATION
negatives (below clinical cut-off point on both teacher TREATMENT AS GLOBAL OUTCOME INDEX
and parental scale). As Table 2 shows, male bully-
victim status (victim and bully status co-occurring with
The Figure shows the survival estimates for having psy-
psychiatric symptoms at age 8 years, ie, screen-positive chiatric hospital treatment and/or using psychiatric medi- in parent or teacher ratings) predicted a psychiatric out- cation from the age of 13 and 24 years, which was used as come (psychiatric hospital treatment and/or psychiatric a global index for psychiatric outcome. Among males, fre- medication from the age of 13 to 24 years) when the ref- quent bully–only (HR, 1.6; 95% CI, 1.1-2.3), frequent vic- erence group was screen-negative boys who were not in- tim–only (HR, 1.6; 95% CI, 1.1-2.3), and frequent bully- volved in frequent bullying behavior. Of note, almost all victim (HR, 3.8; 95% CI, 2.6-5.6) statuses; and among bully-victims (97%) were screen-positive at baseline. If females, frequent victim–only (HR, 2.2; 95% CI, 1.5-3.2) the boy was a frequent bully only or frequent victim only and frequent bully–only (HR, 2.6; 95% CI, 1.1-6.3) sta- but screen-negative, he was not at increased risk of a tuses predicted this outcome. However, when adjusted with psychiatric disorder. In paired comparisons, screen- the total psychopathology score at age 8 years, only fre- positive bully-victims had a significantly higher risk of quent victim status in females independently predicted this psychiatric outcome than screen-positive boys without bullying or victimization (HR, 2.6; 95% CI, 1.6-4.5) andscreen-positive boys with bully-only status (HR, 2.4; 95% FREQUENT BULLYING/VICTIMIZATION
AND PSYCHIATRIC SYMPTOMS
Among females, screen-positive and screen-negative frequent victim-only and screen-positive bully-only sta- To identify the outcomes of bullying associated with psy- tuses predicted psychiatric outcomes at follow-up chiatric symptoms at baseline, the frequent bully, fre- (Table 2). Of 14 girls who were frequent bullies, 10 (71%) (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 66 (NO. 9), SEP 2009 2009 American Medical Association. All rights reserved.
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Frequent victim, 1.6 (1.1-2.3), P = .02 Frequent victim, 2.2 (1.5-3.2), P<.001 Frequent bully, 1.6 (1.1-2.3), P = .01 Frequent bully, 2.6 (1.1-6.3), P = .03 Frequent bully-victim, 3.8 (2.6-5.6), P<.001 Frequent bully-victim, 1.0 (0.1-7.1), P = .1 Figure. Estimated survival curves for time to psychiatric hospital or medical treatment. Statistics in the key are hazard ratios (95% confidence intervals) with P values.
Table 2. Associations of Frequent Bullying/Victimization and Dichotomized Psychiatric Symptom Screens With Psychiatric Hospital
or Medication Treatmenta
Males (n = 2528)
Females (n = 2460)
Psychiatric Medication
Psychiatric Medication
or Hospital Treatment,
or Hospital Treatment,
Characteristic
Participants
Participants
Frequently a bully only and screen-negative Frequently a bully only and screen-positive Frequently a victim only and screen-negative Frequently a victim only and screen-positive Abbreviations: CI, confidence interval; HR, hazard ratio; NA, not applicable.
a The reference group was not frequently a bully or victim and screen-negative. Because of pooling together information about bullying and psychopathology, the number of cases is smaller than in Table 1. The analysis was conducted using Cox regression.
were screen-positive. Half of those with combined fre- quent bully–only and screen-positive status had under-gone psychiatric hospital or medication treatment at fol- The present study has several findings that are of major low-up. In paired comparisons among females, no public health significance. First, boys and girls are dif- significant interactions were found.
ferent in respect to the prevalence and outcome of bul- (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 66 (NO. 9), SEP 2009 2009 American Medical Association. All rights reserved.
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lying behavior. Compared with boys, very few girls were toms at age 8 years, the results suggest that the primary frequent bullies or bully-victims. Previous studies have intervention focus should be regulating behavior at school not always accounted for gender in their analysis.7,29-31 and enhancing peer relationships. An approach to screen- Second, girls who are frequently victimized are at risk ing that relies first on identifying frequent bullies, vic- of long-term psychiatric outcome regardless of their psy- tims, or bully-victims and then conducts a psychiatric chiatric statuses at baseline. Third, it was male bully- screening could be a cost-effective alternative to univer- victims who were at greatest risk of a wide range of psy- sal screening for psychiatric problems. However, the chiatric outcomes. This finding adds to previous studies screening approach requires second-stage clinical evalu- that have indicated that the male bully-victim group is ations, effective child mental health services, and efforts to assist families in obtaining help.
The sex ϫbullying interactions were significant only Most of the very few girls with bully-only status had for use of anxiolytics. However, frequent victimization comorbid psychiatric symptoms at age 8 years and the among girls but not among boys predicted psychiatric low numbers prevent meaningful conclusions drawn from hospital treatment and use of psychopharmacologic medi- this group. Girls with both frequent bullying and psy- cation when controlled with the effect of baseline psy- chiatric problems at age 8 years appeared to be at great chopathology. Previous research findings indicate that risk of a psychiatric outcome. These findings should be the child’s gender is a key variable in both the exposure interpreted cautiously, given the small number of girls to types of victimization and its link to later psychiatric with frequent bullying. Despite the lower prevalence of problems. Our findings are consistent with previous cross- antisocial behavior among girls, studies of clinically re- sectional, longitudinal, and population-based studies ferred samples frequently report that girls show more se- showing that victimization is associated with psychopa- vere problems than boys,50 a pattern known as the gen- thology, particularly among girls.2,34-37 der paradox.51,52 This paradox has also been previously Young boys often experience more physical victim- described in the bullying literature,8,53,54 suggesting that ization, while girls are more prone to relational victim- while girls are less likely to be bullies, when they are bul- ization.36,38,39 Therefore, compared with the often direct lies they have a more severe impairment than their male and observable victimization among boys, girls’ victim- counterparts. One explanation for this could be that from ization is more often indirect and subtle. Exclusion and a young age, girls are expected to control their behavior gossip are especially frequent among girls.40,41 Biologi- better than boys. When a girl is incapable of doing so it cal factors may also explain the gender differences found probably reflects severe psychiatric problems much more in the present study. Stressful life events have been shown than among boys, in whom such behavior is more ac- to increase vulnerability for depression among individu- cepted as part of their everyday lives. Boys and girls who als with a functional variant in the serotonin trans- display frequent bullying behavior should be evaluated porter gene, and this risk has been found to be particu- for possible psychiatric problems, because bullying be- larly high in females.42,43 Thus, negative feelings associated haviors in concert with psychiatric symptoms are early with victimization might develop into intense physi- markers of risk of psychiatric outcomes.
ological reactions, leading to depression and other forms This is the first population-based study to report a pre- of psychopathology especially among females. Previous dictive association between bullying behavior as early as studies have indicated that the impact of being bullied age 8 years and psychiatric outcome in adolescence and on depression and loneliness is greater for relational vic- early adulthood in both males and females. Many previ- timization than for overt victimization.44,45 Future stud- ous studies on bullying have not studied boys and girls ies should address if the victimization to which girls are separately, which has influenced earlier findings. As such, exposed is more traumatic than that to which boys are our study has several strengths: a nationwide sample; a exposed. However, because the severity of the bullying low attrition rate; combined information about child- events was not reported, the present study cannot fully hood bullying behavior from parent, teacher, and child self-reports; and the use of national registers. However, Among boys, almost half of the bully-victims at age 8 several limitations should be considered when interpret- years had undergone either psychiatric hospital treat- ing the results. It is very likely that many simultaneous ment or psychiatric medication at follow-up. Our re- factors that could not be tested in the present study affect sults support previous findings that, among males, bully- the outcome. These factors include rearing practices, mal- victims are the most troubled group.8,46 Of note, almost treatment, and neglect, which are found to be related to all bully-victims were screen-positive at age 8 years, in- being a bully and being victimized55-57 and to both con- dicating a strong association between psychopathology current and future psychopathology. Unfortunately, in- and bully-victim status among boys. Very few girls were formation about other types of victimization, besides bul- given the status of bully-victims. A multitude of studies have uncovered significant gender differences in both im- The prevalence of frequent bullying was rather low.
pulsivity and aggression, especially direct aggression, with There is a great variation in the prevalence rates of chil- boys scoring significantly higher across cultures.47-49 dren’s involvement in bullying across countries. In a cross- Bully-only status among boys also predicted out- national study of approximately 113 000 students aged 11 come, though less so than bully-victim status. Our ad- to 15 years from 25 countries, involvement in bullying var- justed results also show that bullies with psychiatric symp- ied from 9% to 54%.46 These values include both occa- toms were at elevated risk of later psychiatric outcomes.
sional and frequent bullying behavior, and the age group If the frequent bully did not have a high level of symp- was older than in the present study. One could argue that (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 66 (NO. 9), SEP 2009 2009 American Medical Association. All rights reserved.
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the definition of bullying/victimization was rather strict in Department of Child Psychiatry, Helsinki University, Hel- the present study. However, previously we showed that par- sinki, Finland (Dr Gyllenberg); Department of Child Psy- ent, teacher, and child reports of frequent bullying inde- chiatry, Kuopio University Hospital, Kuopio, Finland (Dr pendently predicted later psychiatric disorder among males, Kumpulainen); Departments of Psychiatry (Dr Niemelä while informant reports about infrequent bullying showed and Ms Ristkari), Biostatistics (Mr Helenius), and Bio- at most a rather low risk of adverse outcomes.58 statistics (Ms Sillanmäki), Turku University, Turku; De- Furthermore, this study lacks specification of bully- partment of Child Psychiatry, Tampere University and ing and victimization and whether it was executed by boys University Hospital, Tampere, Finland (Dr Tamminen); or girls. Only bullying in general was asked about, and Department of Child Psychiatry, Oulu University Hos- different types of bullying were not specified (physical pital, Oulu, Finland (Dr Moilanen); and Department of aggression, physical bullying, verbal aggression, and so- Child Psychiatry, Helsinki University Hospital, Hel- cial exclusion). Information about bullying was gath- ered in 1989 at the time when the concept of bullying Correspondence: Andre Sourander, MD, PhD, Depart-
might have been focused more on a type of aggressive ment of Child Psychiatry, Turku University Hospital, victimization. However, in our 10-year time-trend study, 20520 Turku, Finland (andre.sourander@utu.fi).
the prevalence of bullying and victimization was rather Financial Disclosure: None reported.
similar among 8-year-old children born in 1981 and those Funding/Support: This study was supported by a grant
born in 1991.59 Previous findings60 suggest that at 8 years from the Finnish National Social Insurance Institution of age, children contrast aggressive and nonaggressive sce- and the Sigrid Juselius Foundation, Finland.
narios, but do not distinguish clearly between differentforms of aggression. Future prospective longitudinal re-search on bullying and victimization should thus in- clude measures of different forms of bullying, who is theaggressor, whether social support is available, and whether 1. Olweus D. Bullying/victim problems among schoolchildren: basic facts and ef- fects of a school-based intervention programme. In: Pepler D, Rubin K, eds. The the child sought such support. Previous studies suggest Development and Treatment of Childhood Aggression. Hillsdale, NJ: Erlbaum; that when girls are victimized by boys it is often related to sexual harassment.61,62 Future research addressing gen- 2. Klomek AB, Marrocco F, Kleinman M, Schonfeld IS, Gould MS. Peer victimiza- der-related mechanisms related to bullying behavior and tion, depression, and suicidality in adolescents. Suicide Life Threat Behav. 2008;38(2):166-180.
3. Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simons-Morton B, Scheidt P. Bul- Because of a low number of cases, it was not possible lying behaviors among US youth: prevalence and association with psychosocial to examine associations between bullying and specific psy- adjustment. JAMA. 2001;285(16):2094-2100.
chiatric discharge diagnosis groups. Furthermore, find- 4. Rigby K, Cox I, Black G. Cooperativeness and bully/victim problems among Aus- ings on service use have limitations, since a substantial tralian school children. J Soc Psychol. 1997;137(3):357-368.
5. Baldry AC. Bullying in schools and exposure to domestic violence. Child Abuse number of disorders are not treated and some treated cases 6. Shields A, Cicchetti D. Parental maltreatment and emotion dysregulation as risk Bullying behavior should be considered a marker of factors for bullying and victimization in middle childhood. J Clin Child Psychol.
the risk of a later psychiatric disorder, which if not treated 7. Kumpulainen K, Räsänen E. Children involved in bullying at elementary school promptly, might develop into a serious problem for those age: their psychiatric symptoms and deviance in adolescence: an epidemiologi- involved and for society as a whole. Among girls, fre- cal sample. Child Abuse Negl. 2000;24(12):1567-1577.
quent childhood victimization may predict later psychi- 8. Kim YS, Leventhal BL, Koh YJ, Hubbard A, Boyce AT. School bullying and youth atric problems regardless of psychiatric problems at base- violence: causes or consequences of psychopathologic behavior? Arch Gen line. Developing prevention systems requires a knowledge Psychiatry. 2006;63(9):1035-1041.
9. Sourander A, Jensen P, Rönning JA, Elonheimo H, Niemelä S, Helenius H, Kumpu- of the biological, psychological, and social mechanisms lainen K, Piha J, Tamminen T, Moilanen I, Almqvist F. Childhood bullies and vic- involved. As later psychological disorders have been found tims and their risk of criminality in late adolescence. Arch Pediatr Adolesc Med.
to be associated with individuals displaying childhood bullying behaviors, there is a need for the integration of 10. Kumpulainen K, Räsänen E, Henttonen I, Almqvist F, Kresanov K, Linna SL, Moilanen I, Piha J, Puura K, Tamminen T. Bullying and psychiatric symptoms among el- mental health services into the school context. It is im- ementary school-age children. Child Abuse Negl. 1998;22(7):705-717.
portant to inform policymakers, school professionals, and 11. Sourander A, Helstelä L, Helenius H, Piha J. Persistence of bullying from child- the public about the potential short-term and long-term hood to adolescence: a longitudinal 8-year follow-up study. Child Abuse Negl.
consequences of bullying and victimization.
12. Olweus D. Bullying at school: long term outcomes for the victims and an effec- tive school-based intervention program. In: Huesmann R, ed. Aggressive Be- Submitted for Publication: June 19, 2008; final revi-
haviour: Current Perspectives. Plenum Series in Social/Clinical Psychology. New sion received January 23, 2009; accepted February 19, 13. Sourander A, Jensen PS, Rönning JA, Niemelä S, Helenius H, Sillanmäki L, Kumpu- Author Affiliations: Regional Center of Child and Ado-
lainen K, Piha J, Tamminen T, Moilanen I, Almqvist F. What is the early adult-hood outcome of boys who bully or are bullied in childhood? the Finnish from a lescent Psychiatry (Dr Sourander) and Department of Pe- boy to a man study. Pediatrics. 2007;120(2):397-404.
diatrics (Dr Ronning), Institute of Clinical Medicine, 14. Ellilä HT, Sourander A, Välimäki M, Warne T, Kaivosoja M. The involuntary treat- Tromsö University, Tromsö, Norway; Department of ment of adolescent psychiatric inpatients: a nation-wide survey from Finland.
Child and Adolescent Psychiatry, Columbia University, J Adolesc. 2008;31(3):407-419.
New York, New York (Drs Sourander and Brunstein- 15. Sourander A, Ellilä H, Välimäki M, Aronen ET. Psychopharmacological treat- ment of child and adolescent psychiatric inpatients in Finland. J Child Adolesc Klomek); Department of Child Psychiatry, Turku Uni- Psychopharmacol. 2002;12(2):147-155.
versity Hospital, Turku, Finland (Drs Sourander and Piha); 16. Almqvist F, Ikäheimo K, Kumpulainen K, Tuompo-Johansson E, Linna SL, Puura (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 66 (NO. 9), SEP 2009 2009 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ on 01/25/2013
K, Moilanen I, Räsänen E, Tamminen T, Piha J. Design and subjects of a Finnish 41. Owens L, Shute R, Slee P. “Guess what I just heard!” indirect aggression among epidemiological study on psychiatric disorders in childhood. Eur Child Adolesc teenage girls in Australia. Aggress Behav. 2000;26(1):67-83.
Psychiatry. 1999;8(suppl 4):3-6.
42. Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H, McClay J, Mill 17. Sourander A, Multimäki P, Nikolakaros G, Haavisto A, Ristkari T, Helenius H, Park- J, Martin J, Braithwaite A, Poulton R. Influence of life stress on depression: mod- kola K, Piha J, Tamminen T, Moilanen I, Kumpulainen K, Almqvist F. Childhood eration by a polymorphism in the 5-HTT gene. Science. 2003;301(5631):386- predictors of psychiatric disorders among boys: a prospective community- based follow-up study from age 8 years to early adulthood. J Am Acad Child Ado- 43. Kendler KS, Kuhn JW, Vittum J, Prescott CA, Riley B. The Interaction of stress- lesc Psychiatry. 2005;44(8):756-767.
ful life events and a serotonin transporter polymorphism in the prediction of epi- 18. Sourander A, Elonheimo H, Niemela S, Nuutila AM, Helenius H, Sillanmaki L, Piha sodes of major depression: a replication. Arch Gen Psychiatry. 2005;62(5): J, Tamminen T, Kumpulainen K, Moilenen I, Almqvist F. Childhood predictors of male criminality: a prospective population-based follow-up study from age 8 to 44. Crick NR, Grotpeter JK. Children’s treatment by peers: victims of relational and late adolescence. J Am Acad Child Adolesc Psychiatry. 2006;45(5):578-586.
overt aggression. Dev Psychopathol. 1996;8(2):367-380.
19. Rutter M. A children’s behaviour questionnaire for completion by teachers: pre- 45. van der Wal MF, de Wit CA, Hirasing RA. Psychosocial health among young vic- liminary findings. J Child Psychol Psychiatry. 1967;8(1):1-11.
tims and offenders of direct and indirect bullying. Pediatrics. 2003;111(6, pt 1): 20. Rutter M, Tizard J, Whitmore K. Education, Health and Behaviour. London, En- 46. Nansel TR, Craig W, Overpeck MD, Saluja G, Ruan WJ; Health Behaviour in School- 21. Elander J, Rutter M. Use and development of the Rutter parents’ and teachers’ aged Children Bullying Analyses Working Group. Cross-national consistency in scales. Int J Methods Psychiatr Res. 1996;6(2):63-78.
the relationship between bullying behaviors and psychosocial adjustment. Arch 22. Gissler M, Haukka J. Finnish health and social welfare registers in epidemiologi- Pediatr Adolesc Med. 2004;158(8):730-736.
cal research. Norsk Epidemiologi. 2004;14(1):113-120.
47. Archer J. Sex differences in aggression in real-world settings: a meta-analytic 23. Keskimäki I, Aro S. Accuracy of data on diagnoses, procedures and accidents in review. Rev Gen Psychol. 2004;8(4):291-322.
the Finnish Hospital Discharge Register. Int J Health Sci. 1991;2:15-21.
48. Caspi A, Moffitt TE, Silva PA, Stouthamer-Loeber M, Krueger RF, Schmutte PS.
24. Perälä J, Suvisaari J, Saarni SI, Kuoppasalmi K, Isometsä E, Pirkola S, Partonen Are some people crime-prone? replication of the personality-crime relationship T, Tuulio-Henriksson A, Hintikka J, Kieseppä T, Härkänen T, Koskinen S, Lönn- across countries, genders, races and methods. Criminology. 1994;32(2):163- qvist J. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry. 2007;64(1):19-28.
49. Cjˆte´ S, Tremblay RE, Nagin D, Zoccolillo M, Vitaro F. The development of impul- 25. National Social Insurance Institution. Statistical Yearbook of the Social Insur- sivity, fearfulness, and helpfulness during childhood: patterns of consistency and ance Institution. http://www.kela.fi/it/kelasto/kelasto.nsf/alias/Vk_06_pdf/. Ac- change in the trajectories of boys and girls. J Child Psychol Psychiatry. 2002; 26. Pahor M, Chrischilles EA, Guralnik JM, Brown SL, Wallace RB, Carbonin P.
50. Silverthorn P, Frick PJ. Developmental pathways to antisocial behaviour: the de- Drug data coding and analysis in epidemiologic studies. Eur J Epidemiol. 1994; layed-onset pathway in girls. Dev Psychopathol. 1999;11(1):101-126.
51. Loeber R, Keenan K. Interaction between conduct disorder and its comorbid con- 27. World Health Organization guidelines for ATC classification for DDD assignment.
ditions: effects of age and gender. Clin Psychol Rev. 1994;14(6):497-523.
WHO Collaboration Centre for Drug Statistics Methodology. http://www.whocc 52. Tiet QQ, Wasserman GA, Loeber R, McReynolds LS, Miller LS. Developmental .no/atcddd/indexdatabase. Accessed June 2, 2008.
and sex differences in types of conduct problems. J Child Fam Stud. 2001; 28. Hoshmer DW, Lemenshow S. Applied Survival Analysis, Regression Modeling of Time to Event Data. New York, NY: John Wiley & Sons, Inc; 1999.
53. Brunstein Klomek A, Marrocco F, Kleinman M, Schonfeld IS, Gould MS. Bully- 29. Camodeca M, Goossens FA. Aggression, social cognitions, anger and sadness ing, depression, and suicidality in adolescents. J Am Acad Child Adolesc Psychiatry.
in bullies and victims. J Child Psychol Psychiatry. 2005;46(2):186-197.
30. Fekkes M, Pijpers FI, Verloove-Vanhorick SP. Bullying behavior and associa- 54. Prinstein MJ, Boergers J, Vernberg EM. Overt and relational aggression in ado- tions with psychosomatic complaints and depression in victims. J Pediatr. 2004; lescents: social-psychological adjustment of aggressors and victims. J Clin Child 31. Juvonen J, Graham S, Schuster MA. Bullying among young adolescents: the strong, 55. Ladd GW, Ladd BK. Parenting behaviors and parent-child relationships: corre- the weak, and the troubled. Pediatrics. 2003;112(6, pt 1):1231-1237.
lates of peer victimization in kindergarten? Dev Psychol. 1998;34(6):1450- 32. Austin S, Joseph S. Assessment of bully/victim problems in 8- to 11-year-olds.
Br J Educ Psychol. 1996;66(pt 4):447-456.
56. Bowers L, Smith PK, Binney V. Perceived family relationships of bullies, victims 33. Kaltiala-Heino R, Rimpelä M, Marttunen M, Rimpelä A, Rantanen P. Bullying, de- and bully/victims in middle childhood. J Soc Pers Relat. 1994;11(2):215-232.
pression, and suicidal ideation in Finnish adolescents: school survey. BMJ. 1999; 57. Carney AG, Merrell KW. Bullying in schools: perspectives on understanding and preventing an international problem. Sch Psychol Int. 2001;22(3):364-382.
34. Arseneault L, Walsh E, Trzesniewski K, Newcombe R, Caspi A, Moffitt TE. Bul- 58. Rønning JA, Sourander A, Kumpulainen K, Tamminen T, Niemelä S, Moilanen I, lying victimization uniquely contributes to adjustment problems in young chil- Helenius H, Piha J, Almqvist F. Cross-informant agreement about bullying and dren: a nationally representative cohort study. Pediatrics. 2006;118(1):130- victimization among eight-year-olds: whose information best predicts psychiat- ric caseness 10-15 years later? Soc Psychiatry Psychiatr Epidemiol. 2009; 35. Bond L, Carlin JB, Thomas L, Rubin K, Patton G. Does bullying cause emotional problems? a prospective study of young teenagers. BMJ. 2001;323(7311): 59. Santalahti P, Sourander A, Aromaa M, Helenius H, Ikäheimo K, Piha J. Victim- ization and bullying among 8-year-old Finnish children: a 10-year comparison 36. Crick NR, Bigbee MA. Relational and overt forms of peer victimization: a multi- of rates. Eur Child Adolesc Psychiatry. 2008;17(8):463-472.
informant approach. J Consult Clin Psychol. 1998;66(2):337-347.
60. Smith PK, Cowie H, Olafsson RF, Liefooghe APD, Almeida A, Araki H, del Barrio 37. Kim YS, Koh YJ, Leventhal B. School bullying and suicidal risk in Korean middle C, Costabile A, Dekleva B, Houndoumadi A, Kim K, Olafsson RP, Ortega R, Pain school students. Pediatrics. 2005;115(2):357-363.
J, Pateraki L, Schafer M, Singer M, Smorti A, Toda Y, Tomasson H, Wenxin Z.
38. Cullerton-Sen C, Crick NR. Understanding the effects of physical and relational Definitions of bullying: a comparison of terms used, and age and gender differ- victimization: the utility of multiple perspectives in predicting social-emotional ences, in a fourteen-country international comparison. Child Dev. 2002;73 adjustment. School Psych Rev. 2005;34(2):147-160.
39. Schäfer M, Werner NE, Crick NR. A comparison of two approaches to the study 61. Felix ED, McMahon SD. Gender and multiple forms of peer victimization: how of negative peer treatment: general victimization and bully/victim problems among do they influence adolescent psychosocial adjustment? Violence Vict. 2006; German school children. Br J Dev Psychol. 2002;20(2):281-306.
40. Crick NR, Casas JF, Nelson DA. Toward a more comprehensive understanding 62. McMaster LE, Connolly J, Pepler D, Craig WM. Peer to peer sexual harassment of peer maltreatment: studies of relational victimization. Curr Dir Psychol Sci.
in early adolescence: a developmental perspective. Dev Psychopathol. 2002; (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 66 (NO. 9), SEP 2009 2009 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ on 01/25/2013

Source: http://www.antibullying.eu/sites/default/files/childhood_bullying_behavior_and_later_psychiatric_hospital_and_psychopharmacologic_treatment.pdf