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Several studies have found links between bullying and violence or crime, particularly among men (Gibb et al., 2011; McGee et al., 2011; Sourander et al., 2007, 2011). After controlling for externalizing symptoms at baseline, Reijntjes and colleagues (2011) found that peer victimization—which included being the target of teasing, deliberate exclusion, and being the target of physical threats and malicious gossip—was associated over time with exhibiting externalizing problems such as aggression, truancy, and delinquency (r =.14, 95% CI [.09,.19]). This study also discovered that externalizing problems predicted changes in peer victimization over time (r =.13, 95% CI [.04,.21]) and concluded that peer victimization and externalizing problems have a bidirectional relationship.

Symptoms of Psychosis
Evidence from larger studies on childhood trauma and stress suggests that early adverse life experiences, such as child abuse, are linked to the development of psychotic symptoms later in life (Institute of Medicine and National Research Council, 2014b). Until recently, the relationship between bullying and psychotic symptoms had received little attention (van Dam et al., 2012). Two recent meta-analyses back up the link between bullying and the onset of psychotic symptoms later in life (Cunningham et al., 2015; van Dam et al., 2012). van Dam and colleagues (2012) conducted a meta-analysis of 14 studies to determine whether childhood bullying is associated with the development of psychotic (clinical or nonclinical) symptoms. (Nonclinical psychotic symptoms7 put people at risk of developing psychotic disorders (Cougnard et al., 2007).) The findings of six studies that examined the relationship between bullying and nonclinical symptoms were more conclusive (adjusted OR = 2.3; 95% CI [1.5, 3.4]), with stronger associations when there was an increase in the frequency, severity, and persistence of bullying (Cougnard et al., 2007). Although some studies have found this link, a recent longitudinal study from New Zealand discovered that the link between bullying and the development of psychosis later in life is likely not causal, but rather reflects the fact that individuals who exhibit disordered behaviors throughout childhood and adolescence are more likely to become bullying targets (Boden et al., 2016) An examination of studies that looked at the relationship between bullying and psychosis in clinical samples was inconclusive (van Dam et al., 2012).

Cunningham and colleagues (2015) conducted a recent meta-analysis of ten European prospective studies, four of which were from the Avon Longitudinal Study of Parents and Children. Individuals who were bullied were more than twice as likely as those who were not bullied to develop later psychotic symptoms (OR = 2.1, 95% CI [1.1, 4.0]). Except for one of the studies included in the meta-analysis, these findings were consistent. More long-term research is required to fully comprehend the mechanisms by which trauma, such as bullying, can lead to the development of psychotic symptoms (Cunningham et al., 2015; van Dam et al., 2012). Importantly, in order to truly identify the temporal priority, this research must be prospective and examine the development of bullying and psychotic symptoms. The inclusion criteria for the Cunningham and colleagues (2015) meta-analysis included the study being prospective, including a measure of psychosis, and bullying occurring before the age of 18. Although the authors stated that “bullying appears to cause later development of psychosis,” such a conclusion necessitates early and ongoing assessment of mental health functioning, as premorbid characteristics may make individuals targets for poor peer treatment (see Kochel et al., 2012; Vaillancourt et al., 2013b, regarding depression leading to peer victimization).

Consequences of Academic Performance
A growing body of research shows that targets of bullying have lower academic achievement, whether measured by grades or standardized test scores (Espelage et al., 2013; Nakamoto and Schwartz, 2010). Children who are bullied have a higher risk of poor academic achievement (Beran, 2009; Beran and Lupart, 2009; Beran et al., 2008; Glew et al., 2005; Neary and Joseph, 1994; see also meta-analysis by Nakamoto and Schwartz, 2010) and absenteeism (Juvonen et al., 2000; Kochenderfer and Ladd, 1996; Vaillancourt et al., 2013b).

Bullying has a negative relationship with academic achievement since kindergarten (Kochenderfer and Ladd, 1996) and continues into high school (Espinoza et al., 2013; Glew et al., 2008). Espinoza and colleagues (2013) found that on days when adolescents reported being bullied more than usual, they also reported more academic challenges, such as failing a quiz, test, or homework, and feeling less of a good student, in a 2-week daily diary study with ninth and tenth grade Latino students. Thus, even isolated incidents of bullying can impair a student’s ability to concentrate on any given day. Glew and colleagues (2008) discovered that for every 1-point increase in grade point average (GPA), the odds of being a bullied child (versus a bystander) decreased by 10% in a cross-sectional study of over 5,000 students in grades 7, 9, and 11. However, due to the cross-sectional nature of this study, this association does not establish whether lower academic achievement among bullied children was a result of bullying.

Several short-term (academic year) longitudinal studies show that being bullied predicts academic problems rather than academic problems predicting being bullied (Kochenderfer and Ladd, 1996; Schwartz et al., 2005). This is a reasonable inference given the impairments in brain architecture associated with self-regulation and memory in animal models and the currently limited imaging data in human subjects, though reverse causation is possible. Early childhood abuse and neglect, for example, impair these abilities, lower self-esteem, and make a person more likely to be bullied. Juvonen and colleagues (2011) examined the relationship between victimization8 and academic achievement across three years of middle school in one of the few longitudinal studies that extended beyond one year. Academic adjustment was assessed using both year-end grades and teacher engagement reports. These researchers discovered that higher self-reported victimization was associated with lower school achievement from sixth to eighth grade. GPA dropped by 0.3 point for every unit increase in victimization (on a scale of 1-4).

Similar findings were found in other short-term longitudinal studies. For example, Nansel and colleagues (2003) discovered that being bullied in a given year (grade 6 or 7) predicted poor academic outcomes the following year, even after controlling for prior school adjustment and whether or not they had previously been targets of bullying. Similarly, Schwartz and colleagues (2005) discovered a negative relationship between victimization9 and achievement 1 year later in third and fourth grade children. Furthermore, Baly and colleagues (2014) discovered that being bullied for three years, from sixth to eighth grade, had a negative impact on GPA and standardized test scores.

Other studies, however, have not found such associations. In their study of students assessed in the fall and spring of kindergarten, Kochenderfer and Ladd (1996) found no relationship between being bullied and subsequent academic achievement, as did Rueger and Jenkins (2014) in their study of seventh and eighth graders assessed in the fall and spring of one academic year. In their 5-year longitudinal study of youth ages 11-14, Feldman and colleagues (2014) found no link between being a target of bullying and academic achievement. Peer victimization can also be predicted by poor academic performance (Vaillancourt et al., 2013b). The authors discovered that poor third-grade writing performance predicted increased bullying behavior in fifth grade, which remained stable until the end of eighth grade.

The longitudinal associations between peer victimization and school attendance are also ambiguous, with some studies finding a statistically significant association and others not (Baly et al., 2014; Buhs et al., 2006; Gastic, 2008; Kochenderfer and Ladd, 1996; Smith et al., 2004). (Forero et al., 1999; Glew et al., 2008; Rueger et al., 2011; Vaillancourt et al., 2013b).

10

In summary, a number of cross-sectional and longitudinal studies have found support for a link between bullying and an increased risk of poor academic achievement. However, given the inconsistencies found in longitudinal studies, more research in this area is needed to better understand the relationship between bullying and academic achievement over time.

GO TO: CONSEQUENCES FOR BULLYING PERSONS
There is evidence to support the conclusion that people who bully others have contradictory characteristics (Institute of Medicine and National Research Council, 2014a; Vaillancourt et al., 2010b). According to research, some children and adolescents bully others because they are maladjusted (Olweus, 1993a) or, as mentioned in Chapter 3, are motivated by establishing their social network status (Faris and Ennett, 2012; Rodkin et al., 2015; Sijtsema et al., 2009; Vaillancourt et al., 2003). As a result, the relationship between bullying, being bullied, acceptance, and rejection is nuanced (Veenstra et al., 2010). This complication is also linked to a general public stereotype of bullies. This stereotype portrays bullied children and youth as having a high level of psychopathology, a low level of social skills, and few assets and competencies that the peer group values (Vaillancourt et al., 2010b). Although research supports the occurrence of this “stereotypical bully” or “classic bully” (Kumpulainen et al., 2001; Olweus, 1993a; Sourander et al., 2007), when researchers consider social status in relation to bullying behavior, a different profile emerges. According to these studies, most children and youth who bully others wield significant power within their peer network, and high-status perpetrators are perceived by peers as popular, socially skilled, and leaders (de Bruyn et al., 2010; Dijkstra et al., 2008; Peeters et al., 2010; Thunfors and Cornell, 2008; Vaillancourt et al., 2003). High-status bullies have also been found to rank high on assets and competencies that the peer group values, such as attractiveness and athletic ability (Farmer et al., 2003; Vaillancourt et al., 2003); they have also been found to rank low on psychopathology and to use aggression to achieve and maintain hegemony (for reviews, see Rodkin et al., 2015, and Vaillancourt et al., 2010b). Given these findings of contrasting characteristics of bullying perpetrators, it is understandable that research on the outcomes of perpetrating is mixed. Unfortunately, most research on the short- and long-term consequences of bullying behavior has not taken this heterogeneity into account when considering the impact on children and youth who have bullied their peers.

Psychosomatic Effects
Cross-sectional studies that reported data on bullied individuals revealed that these individuals are at risk of developing psychosomatic problems (Gini, 2008; Srabstein et al., 2006). Gini and Pozzoli (2009) conducted a meta-analysis to determine whether children who engage in bullying behavior in any capacity are at risk of developing psychosomatic problems. They included 11 studies (n = 11) that looked at the relationship between bullying involvement and psychosomatic complaints in children and adolescents aged 7 to 16. The meta-analysis included studies that used self-report questionnaires, reports from peers, parents, or teachers, and clinical interviews that resulted in a clinical rating of the subject’s behaviors and health problems. There was also enough information in the included studies to calculate effect sizes. An analysis of six studies that met the selection criteria revealed that children who bully had a higher risk of developing psychosomatic problems (OR = 1.65, 95% CI [1.34, 2.04]) than their uninvolved peers.

The inclusion of cross-sectional and observational studies in this meta-analysis limited its scope. Because such studies cannot draw firm conclusions about cause and effect, the relationship between bullying perpetration and psychosomatic problems may be difficult to interpret. Because bullies are hesitant to identify themselves as perpetrators of bullying behavior, the methodologies used in the studies make them susceptible to bias and misclassification. The various types of victimization included in the underlying studies were also not reported in this meta-analysis. More research is needed to investigate the involvement in bullying behavior and its short- and long-term psychosomatic consequences.

Psychotic Issues
Wolke and colleagues (2014) used a population-based cohort study to investigate whether bullying perpetration and being a target of bullying in elementary school predicted psychotic experiences11 in adolescence. The authors evaluated 4,720 people aged 8 to 11 who were involved in bullying as either perpetrators or targets. Semistructured interviews were used to assess suspected or definite psychotic experiences at the age of 18. The researchers discovered that both individuals who are bullied (child report at age 10: OR = 2.4, 95% CI [1.6, 3.4]; mother report: OR = 1.6, 95% CI [1.1, 2.3]) and individuals who bully others (child report at age 10: OR = 4.9, 95% CI [1.3, 17.7]; mother report: OR = 1.2, 95% CI [0.46, 3.1]) had a higher prevalence of psychotic experiences at age 18. “Involvement in any role in bullying may increase the risk of developing psychotic experiences in adolescence,” the authors concluded (Wolke et al., 2014, p. 2208).

In conclusion, several studies have focused on the consequences of bullying for individuals who are bullied, as well as more broadly on the consequences for perpetrators of aggressive behavior (see Gini and Pozzoli, 2009; Lereya et al., 2015; Reijntjes et al., 2010; Ttofi et al., 2011), but the consequences of bullying involvement for individuals who perpetrate bullying behavior have received little attention to date. That is, while there is a wealth of literature on aggressors and the consequences of aggression, there are few studies specifically examining bullying perpetration, taking into account the power imbalance, repetition, and intentionality that distinguishes aggression from bullying from other forms of peer aggression. As discussed in Chapter 2, the available research on the prevalence of bullying behavior focuses almost entirely on bullied children. More research, particularly longitudinal research, is needed to understand the short- and long-term physical health, psychosocial, and academic consequences of bullying involvement on individuals who have a pattern of bullying others, as opposed to children who engage in general aggressive behavior.

GO TO: CONSEQUENCES FOR THOSE WHO BULLY AND ARE BULLIED
Individuals who bully and are bullied face a unique set of consequences that children who are only perpetrators and children who are only targets do not, such as comorbidity of externalizing and internalizing problems, negative perception of self and others, poor social skills, and rejection by the peer group. However, the peers with whom they interact have a negative influence on this combination of roles in bullying (Cook et al., 2010). A nationally representative cohort study found that young children who were both perpetrators and targets of bullying tended to develop more pervasive and severe psychological and behavioral outcomes than individuals who were only bullied after controlling for adjustment problems that existed prior to incidents of bullying others or being bullied (Arseneault et al., 2006).

Adolescents who were involved in cyberbullying as both perpetrators and targets were found to be more at risk for negative mental and physical health consequences than those who were only perpetrators, targets, or witnesses to bullying (Kowalski and Limber, 2013; Nixon, 2014). For example, Kowalski and Limber (2013) found that students who were both perpetrators and targets had the most negative scores on most measures of psychological health, physical health, and academic performance when compared to those who were only targets.

Consequences for Physical Health
Wolke and colleagues (2001) investigated the relationship between direct and relational bullying experiences and common health problems and discovered that students aged 6 to 9 who bullied others and were bullied by others had more physical health symptoms than children who were only perpetrators or were not involved in bullying behavior. Hunter and colleagues (2014) investigated whether adolescents who were bullied had more sleep problems than adolescents who were not bullied. They examined surveys originally collected for the UK National Health Service and completed by adolescents aged 11 to 17. After controlling for gender, school stage, socioeconomic status, ethnicity, and other factors known to be associated with sleep difficulties—alcohol consumption, tea or coffee consumption, and illegal drug use—the authors discovered that individuals who were both perpetrators and targets in bullying incidents were nearly three times more likely (OR = 2.90, 95% CI [1.17, 4.92]) to experience these sleep difficulties. More research is needed to determine the mechanisms underlying the short- and long-term physical health outcomes of people who bully and are bullied.

Psychosocial Implications
Individuals who are both perpetrators and targets of bullying have the poorest psychosocial profile of anyone involved in bullying behavior; their psychosocial maladjustment, peer relationships, and health problems are similar to those who are only bullied, while their school bonding and substance use are similar to those who are only perpetrators (Graham et al., 2006; Nansel et al., 2001, 2004). Individuals who both bully and are bullied by others have a broader range of internalizing and externalizing symptoms than those who only bully or are bullied (Kim et al., 2006).

Internalizing Issues
Some meta-analyses examined the relationship between bullying involvement and internalizing problems in the school-age population and concluded that individuals who were both perpetrators and targets of bullying had a significantly higher risk for psychosomatic problems than individuals who were only perpetrators or targets (Gini and Pozzoli, 2009; Reijntjes et al., 2010). Gini and Pozzoli (2009) conducted a meta-analysis of studies that looked at the relationship between bullying and psychosomatic complaints in children and adolescents. A subset of studies (N = 5) that reported analyses for individuals who bully and are bullied by others revealed that these individuals have a significantly higher risk of psychosomatic problems than their uninvolved peers (OR = 2.22, 95% CI [1.77, 2.77]).

According to research, individuals who bully and are bullied by others are more likely to have suicidal thoughts and behaviors due to increased mental health problems (see Holt et al., 2015, and Box 4-1).

BOX 4-1 Suicidality: A Review of the Available Meta-Analyses.

Externalizing Issues
Individuals who bully and are bullied by others, like those who bully, frequently exhibit increased aggression when compared to non-involved peers. They are by far the most socially isolated by their peers, the most likely to exhibit conduct problems, and the least engaged in school when compared to those who are either perpetrators or targets; they also report elevated levels of depression and loneliness (Juvonen et al., 2003). Additional research is needed to investigate the unique consequences of children and youth labeled as “bully-victims,” as they are frequently lumped together with “pure victims” (those who are only bullied) in studies. School shootings are a violent externalizing behavior that has been associated in the popular media with the consequences of bullying behavior (see Box 4-2 for additional detail).

BOX 4-2: Bullying and School Shootings.

Symptoms of Psychosis
Several studies have examined the links between bullying involvement in adolescence and mental health problems in adulthood and discovered that individuals who have bullied others and have also been bullied had an increased risk of high levels of critical psychotic symptoms when compared to non-involved peers (Gini, 2008; Sigurdson et al., 2015). There has been little research in this area, and the subject merits further investigation.

GO TO: BULLYING CONSEQUENCES FOR BYSTANDERS
Bullying is not an isolated phenomenon; it is intertwined with the emerging peer ecology, which is made up of social processes that serve specific functions for the individual and the group (Rodkin, 2004). Bullying occurs frequently in the presence of children and adolescents who are bystanders or witnesses. According to research, bullying can have a significant negative impact on these bystanders (Polanin et al., 2012).

Bystanders have reported feelings of anxiety and insecurity (Rigby and Slee, 1993), which stemmed in part from fears of retaliation (Musher-Eizenman et al., 2004) and frequently prevented bystanders from seeking assistance (Unnever and Cornell, 2003). Rivers and colleagues (2009) used a questionnaire that included measures of bullying at school, substance abuse, and mental health risk to survey 2,002 students, ages 12-16, attending 14 schools in the United Kingdom, to investigate the impact of bullying on the mental health of students who witness it. Even after controlling for the effect of being a perpetrator or victim, they discovered that witnessing bullying significantly predicted elevated mental health risks (range of =.07 to.15). They also discovered that being a witness to bullying predicted elevated levels of substance use (=.06). Rivers and Noret (2013) discovered that, when compared to students who were not bullied, those who witnessed bullying reported higher levels of interpersonal sensitivity (e.g., feelings of being hurt or inferior), helplessness, and suicidal ideation.

Finally, there is very little research on the consequences of witnessing bullying for children and youth who are bystanders. Bystander behavior studies have traditionally sought to understand their motivations for participating in bullying (Salmivalli, 2010), their roles (Lodge and Frydenberg, 2005; Salmivalli et al., 1996), their behavior (either reinforcing the bully or defending the victim) in bullying situations (Salmivalli et al., 2011), and why observers intervene or do not intervene (Thornberg et al., 2012 More research is required to fully comprehend these consequences.

GO TO: MULTIPLE VIOLENCE EXPOSURES

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Poly-victims are a subset of school-aged youth who may be more vulnerable to the negative short- and long-term outcomes associated with bullying victimization. Finkelhor and colleagues (2007) coined the terms “poly-victim” and “poly-victimization” to describe a subset of youth who have been subjected to multiple victimizations of various types—for example, exposure to (1) violent and property crimes (e.g., assault, sexual assault, theft, burglary), (2) child welfare violations (child abuse, family abduction), (3) the violence of warfare and civil disturbances, and (4) being targets of bullying behavior—and who exhibit high A poly-victim is defined not only by the frequency of victimization, but also by victimization across multiple contexts and perpetrators (Finkelhor et al., 2007, 2009).

Ford and colleagues (2010) discovered that poly-victims were two times more likely to report depressive symptoms, three times more likely to report posttraumatic stress disorder, up to five times more likely to use alcohol or drugs, and up to eight times more likely to have comorbid disorders than youth who did not meet the criteria for poly-victimization. Poly-victims frequently engaged in delinquent behavior, hung out with deviant peers, and were entangled in the juvenile justice system (Ford et al., 2010). (Ford et al., 2013). Students who were multiple victims in the juvenile justice system reported more traumatic symptoms (Finkelhor et al., 2005). However, it is currently unknown whether bullying plays a significant or minor role in poly-victimization.

Go to: BULLYING PSYCHOLOGICAL EFFECTS MECHANISMS
The committee describes five potential mechanisms for the psychological effects of bullying behavior for both children who are bullied and children who bully in the following sections. Self-blame, social cognition, emotional dysregulation, genetic predisposition to mental health outcomes and bullying, and telomere erosion are examples of these. 13

Self-Blame
One important mechanism for the psychological effects of bullying is how the targets of bullying interpret the cause of their predicament (Graham, 2006). A history of bullying, for example, and the perception of being singled out as a target may lead an individual to wonder, “Why me?” In the absence of contradictory evidence, some people may come to blame themselves for their peer relationship issues. Self-blame and negative affect can then lead to a variety of negative outcomes, such as low self-esteem, anxiety, and depression (Graham and Juvonen, 1998).

The adult rape literature (another type of victimization) identifies a link between rape and self-attributions that imply personal deservingness, dubbed characterological self-blame, because they may lead to the person believing they are chronic victims (Janoff-Bulman, 1979). Characterological self-blame is internal and thus reflects on the self; it is stable and thus leads to the expectation that harassment will be chronic; and it is uncontrollable, implying an inability to prevent future harassment. Attributing negative outcomes to internal, stable, and uncontrollable causes makes people feel helpless and hopeless (Weiner, 1986). Behavioral self-blame, on the other hand (e.g., “I was in the wrong place at the wrong time”) implies a cause that is both unstable (the harassment is not expected to reoccur) and controllable (there are responses in one’s repertoire to prevent future harassment). Several studies in the adult literature have found that people who make characterological self-blaming attributions for negative outcomes cope worse, feel worse about themselves, and are more depressed than people who blame their behavior (see Anderson et al., 1994). Early adolescent research also revealed that characterological self-blame for academic and social failure resulted in increased depression (Cole et al., 1996; Tilghman-Osborne et al., 2008).

Graham and Juvonen (1998) found that sixth grade students with reputations as targets made more characterological self-blaming attributions for harassment than behavioral self-blaming attributions in the first attribution study focused specifically on bullying. In turn, characterological self-blame mediated the relationship between victim status and psychological maladjustment as measured by depression and social anxiety. Many studies since then have found a link between being bullied, characterological self-blame, and maladjustment (Graham et al., 2006, 2009; Perren et al., 2012; Prinstein et al., 2005). Furthermore, bullied youth who endorsed characterological self-blame were more likely to develop negative future expectations, which may increase the risk of continued bullying. Schacter and colleagues (2014), for example, found that characterological self-blame endorsed in the fall of sixth grade predicted an increase in reports of bullying in the spring of sixth grade. Self-blame can then cause psychological distress as well as an increase in bullying experiences over time.

These findings have implications for interventions aimed at bullied children. The goal would be to alter the targets’ maladaptive beliefs about the causes of their predicament. For example, instead of characterological self-blame, one could seek more adaptive attributions. Change efforts may, in some cases, target behavioral explanations for bullying (e.g., “I was in the wrong place at the wrong time”). In such cases, the goal would be to assist targeted youth in realizing that they have responses in their arsenal to avoid future encounters with harassing peers—that is, the cause is unstable and controllable (Graham and Bellmore, 2007). External attributions can also be adaptive in that they protect self-esteem (Weiner, 1986). Knowing that others are victims, or that some aggressive youth randomly target unsuspecting targets, can help reduce the tendency to blame oneself (Graham and Bellmore, 2007; Nishina and Juvonen, 2005). This approach of changing dysfunctional thoughts about oneself to affect and behavior change has resulted in a large empirical literature on attribution therapy in educational and clinical settings (see Wilson et al., 2002). The research’s guiding assumption can be applied to alleviate the plight of bullying victims.

Cognition in Social Situations
The most frequently cited models of social cognitive processes frequently reference Bandura’s (1973) work, as well as more recent conceptualizations by Crick and Dodge (1994). These models have been used to understand aggressive behavior, but there has been less research using these models to specifically understand bullying behavior. Anderson and Bushman’s (2002) general aggression model research provides a more focused understanding of the thoughts, feelings, and behaviors that contribute to the development of the negative outcome. This framework defines the inputs, routes, proximal processes, and outcomes associated with aggressive behavior and being targeted by or perpetrating bullying behavior (Kowalski and Limber, 2013; Vannucci et al., 2012). Although these theories apply to aggressive behavior more broadly, given that most researchers consider bullying to be a subset of aggressive behavior, these broader theories may also improve understanding of the etiology and development of bullying. According to research on hostile attribution bias, aggressive youth are especially sensitive to ambiguous and potentially hostile peer behaviors. Youth who bully are likely to have a similar hypersensitivity to threat.

Another aspect of social cognitive processes associated with aggressive behavior is normative beliefs about aggressive retaliation (Crick and Dodge, 1994; Huesmann and Guerra, 1997). In the context of provocation, such beliefs include the belief that aggressive retaliation is normative, acceptable, or justified. There has been research into the relationship between these beliefs and both reactive and proactive aggression. There has, however, been relatively little research specifically focusing on bullying behavior. However, the available literature suggests that, while targets of bullying may appear to support aggressive retaliation, it is the perpetrators of bullying, including those who are involved in bullying as both a perpetrator and a target, who are most likely to support such attitudes (Bradshaw et al., 2009, 2013; O’Brennan et al., 2009).

Dysregulation of Emotions
Attempts to identify mechanisms linking bullying to negative outcomes have largely focused on the social-cognitive processes described above (Dodge et al., 1990). Researchers have recently begun to investigate emotion dysregulation as an additional mechanism explaining associations between peer victimization and negative outcomes. People use emotion regulation strategies to “increase, maintain, or decrease one or more components of an emotional response” (Gross, 2001, p. 215). The strategies one chooses affect not only how strongly one responds to a stressor, but also how quickly one recovers from a stressful experience. Several studies have found that difficulties with emotion regulation, also known as emotion dysregulation, increase youths’ exposure to peer victimization and bullying (Hanish et al., 200414). (Mahady Wilton et al., 2000). However, it is critical to determine whether peer victimization causes difficulties with emotion regulation, which in turn predicts the negative outcomes associated with peer victimization (e.g., depression, aggressive behaviors).

Several lines of evidence support the hypothesis that emotion dysregulation may explain the link between peer victimization and negative outcomes in adolescents. First, peer victimization constructs such as social exclusion (Baumeister et al., 2005) and stigma (Inzlicht et al., 2006) impair self-regulation. Second, chronic stress during childhood and adolescence causes emotional regulation deficits (Repetti et al., 2002). Bullying has been conceptualized as a chronic stressor for children who are both perpetrators and targets, which may disrupt emotion regulation processes (Swearer and Hymel, 2015). Third, laboratory-based research has found that peer victimization is associated with emotion dysregulation (e.g., self-directed negative emotion, emotional arousal, and reactivity) in the context of a novel peer interaction (Rudolph et al., 2009) and in a manipulated play-group procedure (Schwartz et al., 1993). The effort required to manage the increased arousal and negative affect associated with peer victimization15 may eventually deplete individuals’ coping resources, and thus their ability to understand and manage their emotions adaptively, leaving them more vulnerable to negative outcomes (McLaughlin et al., 2009).

Several studies have found empirical support for emotion dysregulation as a mediator of the relationship between peer victimization and negative outcomes in adolescents. McLaughlin and colleagues (2009) used data from a large, prospective study of adolescents (ages 11-14) to show that peer victimization at baseline predicted increases in emotion dysregulation four months later, controlling for initial levels of emotion dysregulation. Emotion dysregulation, in turn, predicted subsequent psychological distress (depressive and anxious symptoms), mediating the prospective relationship between peer victimization (relational and reputational forms) and internalizing symptoms (McLaughlin et al., 2009). Following research on the same sample of adolescents revealed that emotion dysregulation mediated the prospective relationship between peer victimization and subsequent aggressive behavior (Herts et al., 2012).

There is also new evidence that emotion regulation mediates the links between bullying and negative outcomes. Cosma et al. (2012) examined associations between bullying and several emotion regulation strategies, including rumination, catastrophizing, and other-blaming, in a sample of adolescents in one example of this work. Although bullying was a predictor of all of these emotion regulation strategies, only one (catastrophizing) mediated the relationship between being bullied and subsequent emotional problems. While more research is needed, existing evidence suggests that both social-cognitive and emotion regulation processes may be important targets for preventive interventions among youths who have been victimized or bullied by their peers.

Bullying and Genetic Predisposition to Mental Health Outcomes
According to long-term research, being a victim or perpetrator of bullying does not result in the same pathological or nonpathological outcomes in everyone (McDougall and Vaillancourt, 2015). Many factors influence how a person responds to being victimized, with very strong links already established with life experiences, as discussed above. Most studies investigating heterogeneity in bullying outcomes have focused on environmental factors such as individual, family, and school-level characteristics to explain why some individuals fare better or worse when involved in bullying (Vaillancourt et al., in press). For example, the family’s moderating role has been investigated, with findings indicating that bullied children and youth with better home environments fare better than those living in more complicated families (Flouri and Buchanan, 2003; also see Chapter 3 of this report). There have been far fewer studies that have looked into the role of potential genetic influences as mediators between life experiences like bullying and mental health outcomes. Identifying potential genetic influences is critical for improving understanding of the vast amounts of behavioral and epidemiological data that have already been collected. At the moment, there is very little evidence-based understanding of physiology and neuroscience, and insufficient data has been gathered to produce informed hypothesis testing.

A growing body of literature investigates the relative role of genes’ interaction with the environment in relation to traumatic experiences. However, there have been fewer studies that investigate potential links between genes and being the target or perpetrator of bullying. These studies may appear to suggest that a person’s involvement with bullying is predetermined based on his or her genetic profile at first glance. However, it is important to remember that heritable factors are also associated with specific environments, making it difficult to distinguish between genetic and environmental effects. This is a phenomenon known as gene-environment correlations (rGE) (Brendgen, 2012; Plomin et al., 1977; Scarr and McCartney, 1983). Aggression, for example, which is highly heritable (Niv et al., 2013), can be linked to environment selection in a variety of ways (for review, see Brendgen, 2012). Aggressive children may choose friends who share their genetically influenced aggressive behavioral trait, and this type of selection influences the characteristics of their peer group (Brendgen, 2012, p. 420). This is an illustration of selective rGE. A child’s genetically influenced aggressiveness can also elicit a negative reaction from others, such as dislike. This environmental variable of rejection is now “correlated with the aggressive genotype” (Brendgen, 2012, p. 421). This is an example of rGE that is evocative. Another method for correlating a person’s genetic predisposition with their environment is through a more passive process known as passive rGE (Brendgen, 2012). Aggressive parents, for example, may be more likely to live in high-crime neighborhoods, which influences the likelihood that their child will associate with antisocial peers. Despite these important rGE processes and interaction confounds, it is worth noting that research on the genetics of being a target or perpetrator of bullying is still in its early stages, and caution is advised when evaluating the results, as replication is desperately needed in this area. Before delving into these studies, the committee will go over the concept of how genetic differences influence behavior, as it is critical to clarify new concepts in this burgeoning field of science (see Box 4-3).

BOX 4-3 is a box icon.
How Do Genes Impact Behavior?

With this in mind, the committee concentrated on twin studies of familial (family environment) versus genetic influence, gene by environment interaction, and a newer area of investigation, epigenetics: the study of cellular and physiological phenotypic trait variations caused by external or environmental factors.

Twin Research
Twin studies are commonly used to investigate the relative influence of genetics and environment on a specific phenomenon, such as being the target or perpetrator of bullying. The causes of phenotypic variation (for example, being a target or perpetrator of bullying) are divided into three components in these studies: (1) the additive genetic component or the heritable factor; (2) the shared environment component or the aspect of the environment that twins share, such as poor family functioning; and (3) the nonshared environment component or the aspect of the environment that is unique to each twin, such as the classroom if twins a

Two studies that deconstruct the unique effects of the environment and genetics on bullying behavior are best illustrated. Ball and colleagues (2008) examined children’s involvement in bullying and the genetic versus environmental contributions associated with their involvement using data from the Environmental Risk (E-Risk) Longitudinal Twin Study, a study of high-risk16 British twins reared together and apart. The twins in this study were assessed on their experiences with bullying using teacher and parent reports at the ages of 7 and 10. Genetic factors accounted for 73 percent of the variation in being the target of bullying and 61 percent of the variation in bullying perpetration, according to the findings. Brendgen and colleagues (2008) discovered that genetic factors accounted for 60% of the variation in aggression in girls and 66 percent of the variation in boys in another study of Canadian twins reared together and assessed at age 7, using teacher and peer reports to assess peer victimization and aggression. The Canadian study discovered that genetics did not play a role in the prediction of being targeted by peers. In fact, environmental factors accounted for nearly all of the variance in peer victimization—29 percent of the variance in peer victimization was from the shared environment and 71 percent from the nonshared environment. “Genetic modeling revealed that peer victimization is an environmentally driven variable that is unrelated to children’s genetic disposition,” the authors concluded (Brendgen et al., 2008, p. 455).

These two studies address the role that genetics may play in the expression of aggressive behavior, but they disagree on the heritability of bullying. Most studies on the heritability of externalizing problems, including those on aggression and bullying, report high heritability estimates. In fact, a recent meta-analysis discovered that aggression and rule-breaking were heavily influenced by genetics, with the heritability rate estimated at 41%. Furthermore, studies have found that heritability estimates for more serious forms of antisocial behavior tend to be higher. The heritability of psychopathy, for example, was reported to be 81% in 7-year-old British twin children reared together and apart and studied in the Twins Early Development Study. Estimates of the heritability of peer victimization, however, vary across studies, as evidenced by the above results from Ball and colleagues (2008) compared to those from Brendgen and colleagues (2008), and even within studies.

Brendgen and colleagues have since revised their assessment of the role of genetics in the prediction of bullying victimization. Following the same children highlighted in the 2008 paper (Brendgen et al., 2008) across three assessment periods (kindergarten, grade 1, and grade 4), Boivin and colleagues (2013) reported that genetic factors accounted for a significant percentage of the variance in children’s difficulties with peers at each grade, among twins reared together and apart. Peer difficulties were evaluated as a latent factor based on self-, teacher-, and peer-reported peer victimization17 and rejection. Genetic factors account for 73 percent of the variance in peer rejection and victimization in kindergarten and grade 1, and 94 percent of the variance in peer rejection and victimization in grade 4.

Discrepancies between and within studies of the genetic contribution to bullying behavior can be attributed to a variety of factors. One reason is the way peer victimization is measured. Parent-, teacher-, peer-, and self-reports of bullying victimization have been shown to differ significantly across reporters (Ostrov and Kamper, 2015; Patton et al., 2015; Shakoor et al., 2011); thus, the method used to assess bullying involvement may result in different results. Another reason for the disparities could be development. The environment’s influence on children is expected to shift as they grow older. Young children are especially sensitive to family influences, whereas peer influence becomes more important during adolescence. Furthermore, the type of environment a person is exposed to (harsh or nurturing) interacts with genes to produce a brain that is tailored to the specific demands of that environment.

The genetic studies reviewed collectively suggest that aggression, which characterizes the perpetrator role in bullying (Vaillancourt et al., 2008), may have heritable components, but the findings on being the target of bullying or other aggressive behavior are mixed. Thus, more empirical research is needed before drawing conclusions about the role of genetic influences in both perpetrating and being a victim of bullying.

Interactions between genes and their environments
Researchers also wonder whether specific vulnerability genotypic markers (e.g., candidate genes) influence developmental outcomes in the face of adversity (i.e., environment). Importantly, there is some evidence that genetics influences the mental health issues associated with bullying, such as depression and heightened aggression. In gene-environment studies, for example, candidate genes have been investigated as moderators of exposure to a toxic stressor such as child maltreatment and health outcomes such as depression. When the body is subjected to repeated bouts of stress that do not resolve quickly, the increased vigilance and preparedness depletes its resources, and the stress hormone cortisol begins to produce negative effects. Prolonged stress, in particular, disrupts brain functions, resulting in impaired decision making, faulty cognitive assessment, impaired learning and memory, and a heightened sense of threat that alters behavior (Lupien et al., 2005; McEwen, 2014). There is evidence that changes in cortisol (either too high or too low) on learning may contribute to bullied children’s decline in academic performance, overeating/metabolic disorder, or emotional dysregulation (Vaillancourt et al., 2011), but this research is relatively new and needs to be explicitly explored within the context of bullying (McEwen, 2014).

Caspi and colleagues (2003) conducted a paradigmatic study in which the moderating role of a functional polymorphism in the promoter region of the serotonin transporter gene 5-HTTLPR was investigated in relation to childhood maltreatment and depression in adulthood. Depression rates were significantly higher among abused people who had two copies of the short allele. 18 Depression rates were lower in people who had the long allele, indicating that the long allele was protective, whereas the short allele was a risk factor for depression in the face of adversity. Although the precise role of this serotonin-related gene has been debated, a meta-analysis concluded that the findings are consistent across studies (Karg et al., 2011). Nonetheless, there is still skepticism and controversy surrounding studies of gene-environment interactions (Dick et al., 2015; Duncan, 2013; Duncan and Keller, 2011; Duncan et al., 2014). This important debate notwithstanding, there is evidence that variations in genotype might moderate the relation between exposure to being bullied and health outcomes. For example, Sugden and colleagues (2010) found that bullied children who carried two short versions of the 5-HTTLPR gene were more likely to develop emotional problems than bullied children who carried the long allele. Importantly, this moderating effect was present even when pre-victimization emotional problems were accounted for statistically. In addition to this study, three other studies have demonstrated the moderating effect of the 5-HTTLPR gene in the bullying-health link (Banny et al., 2013; Benjet et al., 2010; Iyer et al., 2013), with depression being worse for carriers of the short/short genotype (both alleles are the short version) than carriers of the short/long and long/long genotypes.

Although the evidence suggests that genotypes moderate the relation between being a target of bullying and poorer mental health functioning like depression, it is important to acknowledge that this relation is more complex. Indeed, some individuals may be particularly biologically sensitive to negative environmental influences such as being bullied, but this genetic vulnerability can also be linked to better outcomes in the context of a more supportive and enriched environment (see Vaillancourt et al., in press) (see Vaillancourt et al., in press). This phenomenon is termed differential susceptibility (Belsky and Pluess, 2009; Boyce and Ellis, 2005). (Belsky and Pluess, 2009; Boyce and Ellis, 2005). For example, in their study of 5 and 6-year old children, Obradovic and colleagues (2010) found that high stress reactivity as measured using respiratory sinus arrhythmia and salivary cortisol was linked to poorer socioemotional behavior in the context of being in an environment that was high in family adversity. In a context characterized by lower adversity, high stress-reactive children had more adaptive outcomes.

To the committee’s knowledge, there are no studies that have examined bullying perpetration in relation to serotonin transporter polymorphisms, although there are studies that have examined this polymorphism in aggressive and non-aggressive children. For example, Beitchman et al. (2006) examined 5-HTTLPR in clinically referred children between the ages of 5 and 15 and found a positive association between the short/short genotype and aggression. In other studies, the short allele has been associated with problems with impulse control that includes the use of aggression (Retz et al., 2004). (Retz et al., 2004).

The moderating role of different candidate genes has also been examined in relation to exposure to childhood adversity and poorer developmental outcomes (see review by Vaillancourt et al., in press) (see review by Vaillancourt et al., in press). With respect to bullying, only a few studies have examined gene-environment interactions. In one study by Whelan and colleagues (2014), harsh parenting was associated with increased peer victimization and perpetration, but this effect was not moderated by the Monoamine Oxidase A (MAOA) genotype. 19 In another longitudinal study, Kretschmer and colleagues (2013) found that carriers of the 4-repeat homozygous variant of the dopamine receptor D4 gene were more susceptible to the effects of peer victimization20 on delinquency later in adolescence than noncarriers of this allele. Finally, in a large sample of post-institutionalized children from 25 countries, VanZomeren-Dohm and colleagues (2015) examined the moderating role of FKBP5 rs136078021 in the relation between peer victimization22 and depression symptoms. In this study, gender was also found to be a moderator. Specifically, girls who had the minor genotype (TT or CT) were more depressed at higher levels of peer victimization, but less depressed at lower level of peer victimization than girls who had CC genotype. For boys, the CC genotype was associated with more symptoms of depression than girls with the same CC genotype who had been bullied.

It is clear that genetics influences how experiences contribute to mental and physical well-being, although the specifics of these gene-environment interactions are complex and not completely understood. Even though genes appear to modulate humans’ response to being a target or a perpetrator of bullying behavior, it is still unclear what aspects of these experiences are interacting with genes and which genes are implicated to produce the variability in outcomes. Human genes and environment interact in a very complex manner: what biological events a particular gene influences can change at different stages of development. That gene therefore interacts with the environment in unique ways across the development timeline. These gene-environment interactions can be subtle and are under constant flux (Lake and Chan, 2015). (Lake and Chan, 2015). Knowing both the genes involved and the specific environment conditions is critically important to understanding these interactions; a simplistic view of either the genetic or environmental component, especially when considered in isolation from the behavioral literature, is unlikely to be productive.

Epigenetic Consequences
It is clear from the research reviewed here that there are a variety of pathways leading to adaptive and maladaptive endpoints and that these pathways can also vary within the “system” along with other conditions and attributes (McDougall and Vaillancourt, 2015, p. 300), including a person’s genetic susceptibility. In this section, the committee focuses on studies examining how genetic susceptibility can make certain individuals more sensitive to negative environmental influences.

Although a person’s DNA is fixed at conception (i.e., nonmalleable), environment can have a strong effect on how some genes are used at each of the stages of development. One way such changes in gene use and expression can occur is through an epigenetic effect, in which environmental events alter the portions of the genome that control when gene replication is turned on or off and what parts of a gene get transcribed (McGowan et al., 2009; Roth, 2014). (McGowan et al., 2009; Roth, 2014). That is, while an individual’s genetic information is critically important, the environment can help to increase or decrease how some genetic information is used by indirectly turning on or off some genes based on input received by somatic cells from the environment. Such epigenetic alterations have been empirically validated in several animal studies. For example, in one line of epigenetic studies, infant rat pups are raised with either low- or high-nurturing mothers or with mothers that treated the pups harshly. The researchers found that the type of maternal care received in infancy had a notable effect on the rats’ subsequent ability to deal with stress (McGowan et al., 2011; Roth and Sweatt, 2011; Weaver et al., 2004). (McGowan et al., 2011; Roth and Sweatt, 2011; Weaver et al., 2004). The behavioral effects were correlated with changes in DNA methylation. 23 Epigenetic changes associated with gene-environment interactions is a new and exciting research area that provide a direct link between how our genes are read and is thought to enable us to pass our experiences to the next generations. It is helpful to think of genes as books in a library and epigenetics as placing a barrier in front of a book to decrease the chances it is read or providing easy access to the book. Thus far, research has found that certain epigenetic mechanisms are strongly correlated with different neurobehavioral developmental trajectories, including changes in vulnerability and resilience to psychopathology. How epigenetics relates to individual responses to being a target or perpetrator of bullying is not clear, but the research in related areas of behavior highlights an important emerging area for investigation.

Various epigenetic processes appear to interact with many changes in the brain produced by early life experiences, including not only the number and shape of brain cells but also how these cells connect to one another at synapses (Hanson et al., 2015). (Hanson et al., 2015).

Regarding bullying, the committee identified only one study that has examined epigenetic changes. Specifically, Ouellet-Morin and colleagues (2013) found an increase in DNA methylation of the serotonin transporter gene for children who had been bullied by their peers but not in children who had not been bullied. These researchers also found that children with higher serotonin DNA methylation had a blunted cortisol response to stress, which they had previously shown changes as a consequence of poor treatment by peers (Ouellet-Morin et al., 2011). (Ouellet-Morin et al., 2011). That is, their 2011 study of twin children assessed at ages 5 and 10 found that being bullied was correlated with a change in how the body responds to stress. Bullied children displayed a blunted cortisol response to a psychosocial stress test. Because the design of the study involved an examination of identical twins who were discordant with respect to their experiences of being bullied (one twin was bullied while the other one was not), Ouellet-Morin and colleagues (2011) concluded that the effect could not be attributed to “variations in either genetic makeup, family environment, or other concomitant factors, nor could they be attributed to the twins’ perceptions of the degree of stress experienced during the task” (Vaillancourt et al., 2013a, p. 243). (Vaillancourt et al., 2013a, p. 243).

In summary, it is important to note that there is no gene for being a perpetrator or a target of bullying behavior. Based on current knowledge of the genetics of complex social behavior, such as bullying, the genetic component of individual response is likely to involve multiple genes that interact with the environment in a complex manner. The current understanding of genetics and complex behaviors is that genes do not cause a behavior; gene-by-environment studies do not use the word “environment” the same way it is used in everyday language or even in traditional social psychology (as in Chapter 3). (as in Chapter 3). Rather, it is a construct used in a model to estimate how much variability exists in a given environment. This means that the same gene placed in different environments would yield very different percentages for gene-environment interactions. It is unclear how this information would inform our understanding of bullying.
QUESTION
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Examplee of instability or bullying that you have witnessed or heard about.Givee a suggestion or an example of how to improve it.