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Moore, Sophie, Norman, Rosana, Sly, Peter, Whitehouse, Andrew,Zubrick, Steve, & Scott, James(2014)Adolescent peer aggression and its association with mental health andsubstance use in an Australian cohort.Journal of Adolescence, 37 (1), pp. 11-21.

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https://doi.org/10.1016/j.adolescence.2013.10.006

https://eprints.qut.edu.au/view/person/Pacella,_Rosana.html

https://eprints.qut.edu.au/80237/

https://doi.org/10.1016/j.adolescence.2013.10.006

1

Adolescent peer aggression and its association with mental health and substance use in an Australian cohort

Sophie E. Moore a, Rosana E. Norman a,b, Peter D. Sly a, Andrew J.O. Whitehouse c,d, Stephen R. Zubrick c, James Scott e, f,*

a Children’s Health and Environment Program, Queensland Children’s Medical Research Institute, University of Queensland, Royal

Children’s Hospital, Herston, QLD, 4029, Australia

b School of Population Health, University of Queensland, Herston, QLD, 4006, Australia

c Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Subiaco, WA, 6008,

Australia

d School of Psychology, University of Western Australia, Crawley, WA, 6009, Australia

e Metro North Mental Health, Royal Brisbane and Women’s Hospital, Herston, QLD, 4029, Australia

f The University of Queensland Centre for Clinical Research, Herston, QLD, 4029, Australia

2

Abstract

Prospective longitudinal birth cohort data was used to examine the association between

peer aggression at 14 years and mental health and substance use at 17 years. A sample

of 1590 participants from the Western Australian Pregnancy Cohort (Raine) study were

divided into mutually exclusive categories (victims, perpetrators, victim-perpetrators

and uninvolved). Involvement in any type of peer aggression as a victim (10.1%),

perpetrator (21.4%), or a victim-perpetrator (8.7%) was reported by 40.2% of

participants. After adjusting for confounding factors, those who were a victim of peer

aggression had increased odds of later depression and internalising symptoms whilst

perpetrators of peer aggression were found to be at increased risk of depression and

harmful alcohol use. Victim-perpetrators of peer aggression were more likely to have

externalising behaviours at 17 years. These results show an independent temporal

relationship between peer aggression and later mental health and substance use

problems in adolescence.

Keywords

Bullying; Peer aggression; adolescent; Raine Study; mental health; substance use.

Abbreviations

Western Australian Pregnancy Cohort (Raine) study, Child Behaviour Checklist

(CBCL), Beck Depression Inventory for Youth (BDI-Y), Youth Self Report (YSR),

Odds Ratio (OR), Confidence Interval (CI).

3

Introduction

Peer aggression is a common sub-type of aggression in children and adolescents

(Ybrandt & Armelius, 2010), most prevalent between the ages of 9 and 14 (Cross et al.,

2009; Due, Holstein, & Soc, 2008). There are three main groups of participants in peer

aggression; the victim, the perpetrator and a third group who are both the victim and the

perpetrator (victim-perpetrator) (Austin & Joseph, 1996; Haynie et al., 2001; Veenstra

et al., 2005). The estimated prevalence of peer aggression (victim or perpetrator) ranges

from 5% to 35% with lower prevalence (3% -13%) for those in the victim-perpetrator

group (Copeland, Wolke, Angold, & Costello, 2013; Craig et al., 2009; Cross et al.,

2009; Due et al., 2008; Jansen et al., 2012; Solberg & Olweus, 2003; Sourander, Jensen,

Rönning, et al., 2007b). The variation in prevalence has been linked to methodological

differences in definition and measurement (Griffin & Gross, 2004; Shaw, Dooley,

Cross, Zubrick, & Waters, 2013) with recent studies now incorporating cyber-

aggression. Irrespective of this, it is clear that a large number of children and

adolescents are involved in peer aggression.

Victims of peer aggression are more likely to have fewer close friends, and are

at increased risk of mental health problems, particularly internalising symptoms which

are characterised by an over control of emotion expressed through behaviours such as

excessive worrying and social withdrawal (Achenbach & Edelbrock, 1978; Arseneault

et al., 2006; Boulton & Underwood, 1992; Nansel et al., 2001; Zeman, Cassano, Perry-

Parrish, & Stegall, 2006). It has been further demonstrated that victims of peer

aggression are likely to display sub-assertive behaviour which may increase their

likelihood of becoming victims of peer aggression, as perpetrators of peer aggression

perceive them as easy targets that are less likely to retaliate (Fekkes, Pijpers, Fredriks,

4

Vogels, & Verloove-Vanhorick, 2006). Longitudinal studies have consistently found

strong links between victims of peer aggression as a child or adolescent and later mental

health problems including depression, anxiety, suicide ideation and suicide attempts

(Copeland et al., 2013; Heikkilä et al., 2013; Hemphill et al., 2011; Klomek et al., 2008;

Sourander, Jensen, Rönning, et al., 2007b; Ybrandt & Armelius, 2010). The association

between being a victim of peer aggression and later substance abuse problems is less

clear with some studies reporting that victims of peer aggression are less likely to drink

alcohol later in life (Nansel et al., 2001) whereas others suggest that being a victim of

peer aggression is associated with an increased risk of later harmful alcohol use

(Goebert, Else, Matsu, Chung-Do, & Chang, 2011; Tharp-Taylor, Haviland, &

D'Amico, 2009). Similarly some studies have shown an association between being a

victim of peer aggression and later illicit drug and tobacco use (Goebert et al., 2011;

Niemela et al., 2011; Tharp-Taylor et al., 2009), whereas others have found no

association at all (Copeland et al., 2013; Hemphill et al., 2011; Sourander, Jensen,

Rönning, et al., 2007b).

Perpetrators of peer aggression have been consistently found to be at increased

risk of mental health problems particularly externalising behaviours which are

characterised by an under control of emotions and are displayed through acts such as

impulsivity, defiance, swearing and aggression towards others (Achenbach &

Edelbrock, 1978; Kim, Leventhal, Koh, Hubbard, & Boyce, 2006; Sourander et al.,

2010; Van der Wal, De Wit, & Hirasing, 2003; Veenstra et al., 2005). Most longitudinal

studies show perpetrators of peer aggression in early adolescence to be at an increased

risk of later alcohol dependence and other substance abuse problems as well as

increased risk of later criminal and violent behaviour (Farrington & Ttofi, 2011;

5

Hemphill et al., 2011; Niemela et al., 2011; Sourander, Jensen, Ronning, et al., 2007a;

Sourander, Jensen, Rönning, et al., 2007b). Some studies suggest that being a

perpetrator of peer aggression in childhood or adolescence increases the risk of later

depression, however this is seen predominately in males (Kaltiala-Heino, Fröjd, &

Marttunen, 2010; Klomek et al., 2008). Furthermore longitudinal evidence suggests that

perpetrators of peer aggression are more likely at risk of anti-social personality disorder

(Copeland et al., 2013; Sourander, Jensen, Rönning, et al., 2007b).

Compared to studies of victims and perpetrators of peer aggression, there is less

research examining the concurrent and later mental health problems of victim-

perpetrators of peer aggression. This group are more likely to display externalising

behaviours similar to perpetrators of peer aggression, but also have internalising

behaviours similar to victims (Ivarsson, Broberg, Arvidsson, & Gillberg, 2005).

Victim-perpetrators of peer aggression have the highest risk of later psychiatric

problems (Copeland et al., 2013; Kumpulainen & Rasanen, 2000; Sourander, Jensen,

Rönning, et al., 2007b) and the poorest psychosocial functioning out of the three groups

(Haynie et al., 2001; Veenstra et al., 2005). They have an increased risk of wide ranging

adverse outcomes including anxiety, depression, suicidal ideation, substance use

disorders and criminal behaviour (Copeland et al., 2013; Kim, Koh, & Leventhal, 2005;

Klomek et al., 2008; Sourander, Jensen, Ronning, et al., 2007a; Sourander, Jensen,

Rönning, et al., 2007b; Winsper, Lereya, Zanarini, & Wolke, 2012).

General strain theory is a framework that explains the underlying process in

which peer aggression affects mental health and substance use (Agnew, 1992, 2001).

This argues that those who are exposed to strain or strenuous events (i.e. peer

aggression) often develop negative emotions as a result. These negative emotions such

6

as depression, anxiety, and anger can then lead to the individual trying to escape the

strain through acts such as substance use, self-harm or suicide (Hay, Meldrum, & Mann,

2010). Although this provides a rationale for why victims or victim-perpetrators of peer

aggression develop mental health and substance use problems it does not explain why

perpetrators of peer aggression are at increased risk of adverse outcomes. Keeping this

theoretical framework in mind it is possible that adolescents become perpetrators of

peer aggression to escape strain or a strenuous event in their life. However, perpetrating

peer aggression may alienate these adolescents from their peers and teachers, further

exacerbating existing strain, causing these perpetrators like victims, to be at increased

risk of mental health and substance use problems.

An alternative explanation for the increased risk of mental health and substance

use problems after involvement in peer aggression is that early adverse experiences (i.e.

peer aggression) that occur during vulnerable developmental periods can cause

neurobiological changes (Anda et al., 2006; Shonkoff, Boyce, & McEwen, 2009)

expressed as illnesses such as depression in later years (Shonkoff et al., 2009).

Currently there are some limitations to the existing studies examining the mental

health problems of children and adolescents involved in peer aggression. Initially many

studies were cross sectional (Fekkes, Pijpers, & Verloove-Vanhorick, 2004; Kaltiala-

Heino, Rimpela, Rantanen, & Rimpela, 2000; Nansel, Craig, Overpeck, Saluja, & Ruan,

2004; Nansel et al., 2001; Van der Wal et al., 2003) which prevents the determination of

the direction of causality (Reichenheim & Coutinho, 2010). The advantage of more

recent longitudinal studies is that they may permit the direction of causality between

peer aggression and mental health problems to be inferred. However, the majority of

longitudinal studies have only adjusted for mental health problems at the time peer

7

aggression was measured and not for pre-existing mental health problems prior to the

age that the peer aggression was measured (Heikkilä et al., 2013; Kaltiala-Heino et al.,

2010; Kim et al., 2006; Klomek et al., 2008; Sourander, Jensen, Rönning, et al., 2007b).

It has been previously shown that children exhibiting emotional and behavioural

problems including aggression from as early as 17 months are at an increased risk of

becoming a victim or perpetrator of peer aggression in later life (Barker et al., 2008;

Jansen, Veenstra, Ormel, Verhulst, & Reijneveld, 2011). This aggression in very young

children is not necessarily directed towards another child but may consist of behaviours

such as destroying toys or temper tantrums (Reebye, 2005).

Fisher et al. (2012) suggests that there are individual characteristics such as pre-

existing mental health problems that make certain children and adolescents more

vulnerable to becoming victims of peer aggression. Incorporating this into their

methodology, Fisher et al. (2012) found that after controlling for early internalising and

externalising problems at age 5 the association remained between being a victim of peer

aggression (at 7 and 10 years) and later self-harm (at 12 years). This current study

builds on this premise by additionally controlling for co-existing mental health

problems at the age peer aggression was measured and including a broader range of

outcomes. By adjusting for pre-existing and co-existing mental health problems, any

association between peer aggression and later mental health and substance use problems

provides strong evidence of a temporal relationship. The presence of a temporal

relationship is one of the required criteria to show that a relationship is causal (Hill,

1965).

The aim of the present study was to examine the association between peer

aggression (victim, perpetrator, victim-perpetrator) at 14 years and mental health and

8

substance use problems at 17 years using a large prospective longitudinal birth cohort

after adjusting for pre-existing mental health problems at 5 years of age, and co-existing

mental health and substance use problems at 14 years.

Methods

Study Population

This study utilised population based data from the Western Australian Pregnancy

Cohort (Raine) study, a prospective birth cohort study of 2868 children born in Western

Australia between September 1989 and April 1992. Initial recruitment was from the sole

tertiary maternity hospital in Perth, Western Australia and consisted of pregnant women

who were between 16-20 weeks gestation. These women were followed up at 24, 28

and 38 weeks (Newnham, Evans, Michael, Stanley, & Landau, 1993). Data used in this

study were collected when the participants were 5 (78.0% retention), 10 (71.4%

retention), 14 (64.9% retention) and 17 (61.2% retention) years of age. At 17 years,

1754 of the original cohort participated, of whom 1590 (90.6%) completed the peer

aggression questionnaire at 14 years. Ethical approval for this study was granted by the

Human Research Ethics Committees from the Princess Margaret Hospital for Children

and King Edward Memorial Hospital in Western Australia and consent was obtained at

each follow up stage from the participants’ guardians.

Measures and Procedure

Peer Aggression. This study categorised participants into four mutually

exclusive groups; victims of peer aggression, perpetrators of peer aggression, victim-

perpetrators of peer aggression and the reference group of participants who were

uninvolved in any type of peer aggression. At 14 years peer aggression was assessed

through a self-reported questionnaire designed for the Raine study. The questionnaire

9

begins with the following statement, “Bullying is when someone is picked on by

another person, or a group of people say nasty things to him or her. It is also when

someone is hit, kicked, threatened, sent nasty notes or when no one talks to them.”

Although the Raine questionnaire used the term ‘bullying’ to describe these behaviours,

‘peer aggression’ is a better term as the definition provided to the participants does not

refer to a power differential or repetition of the behaviour, two key components of

bullying (Olweus, 1993). ‘Victims of peer aggression’ were those participants who

endorsed having been bullied at school in the previous three months. ‘Perpetrators of

peer aggression’ were those participants who endorsed having bullied other children at

school. ‘Victim-perpetrators of peer aggression’ were those participants who endorsed

having been bullied in the past three months and also having bullied other children at

school.

Outcomes. Depression was assessed at 17 years using the Beck Depression

Inventory for Youth (BDI-Y). The BDI-Y is a reliable and valid self-reported scale

which assesses the intensity of depression in adolescents and has excellent test-retest

reliability (Beck, Beck, & Jolly, 2001). The BDI-Y includes 20 items that relate to

depressive symptoms and feelings that the participant may have experienced over the

past two weeks. Each item has four possible answers (never=0, sometimes=1, often=2,

always=3) and the participant’s final score can range from 0 to 60, with higher scores

indicating a greater degree of depression. In order to obtain a binary variable

participants were either categorised as not having depression (normal) or mild-severe

depression, these categories were based on clinical cut-offs (normal <13; mild-severe

depression >14) (Beck et al., 2001).

10

Adolescent internalising and externalising problems were measured at 17 years

through the Youth Self Report (YSR/11-18) (Achenbach, 1991b). The YSR is

composed of 118 items and is an empirically validated and reliable measure of

emotional and behavioural problems in adolescents (Achenbach & McConaughy, 1997).

Responses to YSR are scored on a three point scale with statements either being, not

true (0); somewhat/sometimes true (1) or very true (2). The raw scores were converted

to standardised T-scores for internalising (withdrawn, somatic complaints,

anxious/depressed) and externalising problems (aggressive/delinquent). In order to

obtain a binary variable a cut-off (T-score ≥60) was used to indicate clinically

significant internalising and externalising problems (Achenbach, 1991b).

Harmful alcohol use was assessed at 17 years through a self-reported

questionnaire designed for the Raine study. Participants were asked, “Have you ever

drunk 6 or more alcoholic drinks at one time or drunk so much alcohol that you

vomited?” In order to obtain a binary variable those who endorsed this question by

responding “yes, more than once” were categorised as harmful alcohol users and those

who reported “never” or “only once” were categorised as non-harmful alcohol users.

Harmful cannabis use was assessed at 17 years through a self-reported

questionnaire designed for the Raine study. The participants were asked, “How often do

you use cannabis (marijuana) for non-medical purposes?” In order to obtain a binary

variable those participants who responded to using cannabis monthly, weekly or daily

were categorised as harmful users of cannabis and those participants who responded to

using cannabis less than monthly, once a year or never were categorised as non-harmful

users/abstainers. Congruent with previous studies which have shown an association

between monthly use of cannabis in adolescence and increased risk of depression,

11

suicide ideation and attempts and the use of other illicit drugs (Fergusson, Horwood, &

Ridder, 2005; Moore et al., 2007), this study classified monthly use of cannabis as

harmful.

Current cigarette smoking was assessed at 17 years through a self-report

questionnaire of their smoking habits in the past week. Those participants who reported

smoking more than one cigarette in the past week were categorised as current cigarette

smokers. Non- smokers were those either reported smoking one or less cigarettes in the

past week or never smoking.

Confounding Variables. Socioeconomic status was assessed by asking the

parent, “What is your total family income before tax per year?” This study divided the

income into low (<$25 000), middle and high (>$60 000) categories based on the

Australian Taxation Office cut offs in that time period. Family structure was assessed

by asking the child’s parent “Is the father/mother of your child living with you?” If the

answer was “No” the parent was asked, “Do you have another partner who lives with

you?” This study divided family structure into three categories: lives with biological

parents, lives with single parent or lives in a blended family. Maternal mental health

problems were assessed by asking the child’s mother, “Have you ever been treated for

an emotional or mental health problem?”

Pre-existing mental health problems were measured at 5 years through the use of

The Child Behaviour Check List (CBCL/4-18) (Achenbach, 1991a). The CBCL is a

parent report measure which has 118 items consistent with the YSR. The CBCL was

chosen to be used in the Raine study due to its extensive use in Australia and in various

other settings (Hensley, 1988; Sawyer et al., 2001; Verhulst et al., 2003). It has been

well validated and widely used in research in studies of childhood mental health

12

problems, with Australian studies finding an eight week test-retest reliability of the

parent CBCL to be 0.87 and six month test-retest reliability 0.75 (Garton, Zubrick, &

Silburn, 1995; Zubrick et al., 1997).

Co-existing mental health problems, at the same time involvement in peer

aggression was assessed (14 years), were measured through the YSR and BDI-Y. Prior

use of substances (alcohol, cigarettes, cannabis) was also measured at 14 years. The

same self-report questionnaires to assess substance use were used at 14 and 17 years of

age.

Statistical Analysis

Using STATA 12.0 (StataCorp., 2011) descriptive statistics were obtained for all

variables. Logistic regression models with binary outcomes were used to investigate the

association between exposure to peer aggression (victims, perpetrators, victim-

perpetrators) at 14 years and mental health (depression, internalising, externalising

behaviour) and substance use (alcohol, cigarettes. cannabis) problems at 17 years.

Firstly, univariate logistic regression was used to calculate the unadjusted odds ratios. If

peer aggression contributed significantly (p<0.05) to an outcome these associations

were then further investigated through multivariate logistic regression. Model 1

controlled for the effects of sex, family income, maternal mental health problems and

family structure. Model 2 included all variables in model 1 plus pre-existing substance

use problems at 14 years and model 3 included all variables in model 2 plus pre-existing

(5 years) and co-existing mental health problems (14 years).

Results

Prevalence and sex differences in peer aggression

13

Involvement in any peer aggression was reported by 40.2% of the sample, with

10.1% (N=121) of the participants reporting that they had been victims of peer

aggression. Of the 121 participants that reported being victims of peer aggression,

44.6% (N=54) were male (OR and 95% CI: 0.91, 0.62-1.33). One in five adolescents

(21.4%, N=293) reported that they were perpetrators of peer aggression. Being male

was associated with a doubling of the odds of being a perpetrator of peer aggression

compared to females (OR and 95% CI: 2.20, 1.69 –2.89). Victim-perpetrators accounted

for 8.7% (N=102) of whom males were more prevalent (59.8%) than females (OR and

95% CI: 1.68, 1.11 –2.53). Two significant sex differences were observed between the

outcome variables reported. Females were twice as likely to report depression than

males (OR and 95% CI: 2.55, 1.94 –3.35) and were also more likely to report

externalising problems than males (OR and 95% CI: 1.47, 1.11 –1.95) (Table 1).

Peer aggression at 14 years and mental health problems at 17 years

After controlling for sociodemographic covariates, mental health problems at 5

and co-existing mental health and substance use problems at 14 years (Model 3), those

participants who were victims or perpetrators of peer aggression at 14 years were

significantly more likely to be depressed at 17 years (OR and 95% CI: 2.12, 1.22- 3.69

and 1.81, 1.19-2.76 respectively). Only those participants who were victims of peer

aggression had significantly increased odds of being in the clinical range for

internalising problems at 17 years (OR and 95% CI: 2.34, 1.25-4.37). With respect to

externalising problems, only those participants who were victim-perpetrator of peer

aggression at 14 years were significantly more likely to have externalising symptoms in

the clinical range at 17 years (OR and 95% CI: 2.23, 1.08- 4.64) (Table 2).

Peer aggression at 14 years and substance use problems at 17 years

14

Being a perpetrator of peer aggression at 14 years was associated with an

increased risk of harmful alcohol use at 17 years even after controlling for mental health

problems at 5 and co-existing mental health and substance use problems at 14 years

(OR and 95% CI: 1.76, 1.23-2.53). Those who were victims of peer aggression at 14

years were significantly less likely to drink alcohol at 17 years (OR and 95% CI: 0.48,

0.26-0.88). After adjusting for all confounding variables (Model 3), no significant

associations were observed between any types of peer aggression at 14 years and

harmful cannabis use or cigarette smoking at 17 years (Table 3).

Discussion

The prevalence of peer aggression at 14 years reported in this study was

consistent with previous research which reports perpetration is the most common form

of peer aggression followed by victimisation and then engaging in both (Cross et al.,

2009; Kim et al., 2006). Similarly, previous research shows males are more likely to be

the perpetrators and victim-perpetrators of peer aggression (Copeland et al., 2013; Craig

et al., 2009; Veenstra et al., 2005).

This study demonstrates that peer aggression at 14 years is associated with a

variety of mental health and substance use problems at 17 years. These outcomes of the

groups diverge with victims of peer aggression being at increased risk of future

internalising symptoms whilst victim-perpetrators of peer aggression were found to be

at increased risk of developing later externalising problems such as aggressive and

delinquent behaviours. Other studies report similar findings (Arseneault et al., 2006;

Kim et al., 2006; Kumpulainen et al., 1998; Veenstra et al., 2005; Ybrandt & Armelius,

2010). Those in the victim-perpetrator group are sometimes known as ‘aggressive

victims’ as they react to victimisation by either becoming perpetrators of peer

15

aggression themselves or developing other externalising problems including delinquent

and disruptive behaviours (Olweus, 1978; Pellegrini, Bartini, & Brooks, 1999;

Schwartz, Dodge, Pettit, & Bates, 1997).

In relation to future alcohol use, those who were victims of peer aggression were

less likely to engage in later harmful alcohol use, whilst perpetrators of peer aggression

were at an increased risk of later harmful alcohol use. This might be attributed to the

differences in social interaction between victims and perpetrators of peer aggression.

During adolescent years, alcohol is often consumed in group situations (Cooper, 1994).

Since research has shown that victims of peer aggression are often socially isolated

individuals (Nansel et al., 2001), they may avoid social pressures that lead to alcohol

misuse. Harmful drinking is associated with externalising behaviours in adolescents

(Laukkanen, Shemeikka, Notkola, Koivumaa-Honkanen, & Nissinen, 2002). The

increased risk of future harmful alcohol use by those who perpetrate peer aggression

may in part be due to their social networks but also part of the spectrum of externalising

problems in which they are more likely to engage.

Similar to another Australian study (Hemphill et al., 2011), there was no

association between any type of peer aggression and later cannabis use. Other studies

however have shown that perpetrators of peer aggression are at increased risk of later

cannabis use (Farhat, Simons-Morton, & Luk, 2011; Kim, Catalano, Haggerty, &

Abbott, 2011). The lack of association between perpetrators of peer aggression and

cannabis use in this study may be due to inadequate power. Consistent with other

studies, there was no association between victims of peer aggression and later cannabis

use (Farhat et al., 2011; Hemphill et al., 2011). Similar to alcohol use, as these

individuals are less socially connected (Nansel et al., 2001) this in turn may limit their

16

access to cannabis. Bond et al. (2007) found that good social connectedness at school

increased the risk of cannabis use in adolescence. Further research is needed to better

establish the reasons for the presence or absence of associations between involvement in

various aspects of peer aggression and later substance use. Unlike a previous study

(Niemela et al. 2011), this study found no association between cigarette smoking and

peer aggression after adjusting for mental health. It is likely that any association

between peer aggression and smoking is mediated by pre-existing and co-existing

mental health problems.

This study extends current knowledge of the outcomes associated with peer

aggression. Previous longitudinal studies have either adjusted for co-existing mental

health problems at the same age as when the peer aggression was measured (Kaltiala-

Heino et al., 2010; Kim et al., 2006; Klomek et al., 2008; Sourander, Jensen, Rönning,

et al., 2007b) or controlled for early childhood mental health problems that preceded the

peer aggression (Fisher et al., 2012). To the best of our knowledge this is the first study

to control for both pre-existing and co-existing mental health problems. These results

provide strong evidence of a temporal relationship between peer aggression and later

mental health problems suggesting that this outcome is not simply a continuation of pre-

existing psychopathology. This study shows that whilst some forms of peer aggression

are associated with later outcomes independent of pre-existing emotional and

behavioural problems (e.g. victims of peer aggression at 14 years and internalising

symptoms at 17 years), other outcomes are no longer significant (e.g. perpetrators of

peer aggression at 14 years and externalising behaviours at 17 years).

Strengths of this study include the prospective longitudinal methodology and the

use of well validated measures for depression (BDI-Y) and internalising and

17

externalising problems (CBCL/YSR). However, like all research, this study has

limitations. The measures used to assess peer aggression and substance use were

questionnaires designed specifically for the Raine study and therefore not widely used

measures. Additionally, the questionnaire did not collect information about the severity

or type of peer aggression (Shaw et al., 2013; Griffin & Gross, 2004) or the different

roles of adolescents in this behaviour such as reinforcing the victim or perpetrator or

bystanding (Gini, Albiero, Benelli, & Altoè, 2008; Salmivalli, Lagerspetz, Björkqvist,

Österman, & Kaukiainen, 1996). Although the study asked participants if they had been

victims of aggression in the previous three months, there was no measurement of when

the perpetration of aggression took place. Therefore, some of the participants who

endorsed that they had perpetrated aggression may have only engaged in that behaviour

when they were much younger.

Another limitation is that this study did not assess cyber aggression

independently of traditional forms of peer aggression. Little is known about the

differences between cyber aggression and traditional peer aggression in terms of long-

term impacts although several studies have linked cyber aggression (victim and

perpetrator) to mental health problems and suicidal behaviour (Dooley, Pyżalski, &

Cross, 2009; Hinduja & Patchin, 2010; Schneider, O'Donnell, Stueve, & Coulter, 2012).

However, it has been suggested that individuals may be engaged in both forms

of peer aggression. Therefore some of the consequences associated with traditional

forms of peer aggression observed in this analysis may be the result of an overlap with

unmeasured cyber forms of aggression. In addition, some participants reporting no

involvement in traditional forms of peer aggression may have engaged in cyber

aggression. A recent study has shown cyber aggression (victim or perpetrator) to be a

18

unique predictor of depressive symptoms and suicidal ideation after controlling for sex

and traditional peer aggression (Bonanno & Hymel, 2013). It is therefore important that

future peer aggression instruments measure involvement in cyber aggression along with

traditional forms of peer aggression, to enable comparisons and assess independent and

combined effects. Given the increasing accessibility to, and reliance on, technology,

cyber aggression should be addressed as a unique risk factor both in terms of

interventions and research (Bonanno & Hymel, 2013).

Although this study used clinical cut-offs, dichotomization of emotional and

behavioural problems that were measured on a continuum may have resulted in a loss of

information about individual differences and reduced the effect size and power of

statistical tests (MacCallum, Zhang, Preacher, & Rucker, 2002). Furthermore the

absence of an association between the victim-perpetrators and alcohol or cannabis use is

likely a result of lack of power due to the relatively small number of participants in this

group. A study with greater power may well have yielded a significant association.

Additionally the externalising subscale of the YSR has one item (of 28) that asks about

‘use alcohol and drugs for non-medical purposes.’ A decision was made to retain this

item in the YSR even though other outcomes measured alcohol and cannabis use.

Retention of this item enables the well validated clinical cut offs to be used in the study.

The final limitation of this current study was the attrition rate which varied

across follow-up periods and among measured variables. Attrition is expected amongst

large cohort studies and this attrition rate is similar to other large Australian birth cohort

studies (Najman et al., 2005). Multiple imputation could not be used in this study to

address the attrition rate. Only baseline information is available for a large proportion of

those lost-to-follow-up with no early measurement of our main variables of interest

19

(peer aggression - victim, perpetrator, and victim-perpetrator and mental health and

substance use problems) for these participants. The variables available at baseline are

not strong predictors of the missing process and therefore imputing based on these

baseline variables would not give our study a more accurate result (Enders, 2010; Spratt

et al., 2010).

It is possible however that the selective attrition among socially disadvantaged

families may have impacted on the current results as previous studies have shown that

children or adolescents who come from socially disadvantaged families are at an

increased risk of involvement in peer aggression as either the victim or perpetrator

(Jansen et al., 2011; Kim et al., 2006). Selective attrition among social disadvantaged

families has been consistently reported in studies utilising Raine cohort data

(Whitehouse et al., 2010). The loss of participants from socially disadvantaged families

may have led to an underestimation of the prevalence of peer aggression in this sample

and therefore an attenuation of the associations between peer aggression and the

outcome. Selective attrition in a similar longitudinal study, however, did not invalidate

regression models used to predict behavioural outcomes (Wolke et al., 2009). While the

loss of these participants may have affected the results of this study, the original cohort

over-represented socially-disadvantaged women (Li et al., 2008), and therefore this

pattern of attrition may have increased the extent to which the findings can be

generalised.

This study provides strong evidence that peer aggression is independently

associated with adverse mental health and alcohol problems and that there is a temporal

relationship with the peer aggression preceding later mental health and alcohol

problems. Mental health problems continue to rank highly as causes of global morbidity

20

(Murray et al., 2012). There is robust evidence strongly supported by this current study

that peer aggression is associated with both co-existing and future mental health

problems. The causes of mental health problems are complex and many aetiological

factors such as genetic disposition, poverty and child maltreatment are difficult to

modify (Norman et al., 2012; Scott, Varghese, & McGrath, 2010). Peer aggression is

considered a modifiable risk factor for mental health problems (Scott, Moore, Sly, &

Norman et al. 2013) with school wide interventions that involve the entire school

community (i.e. both staff and students) found to be effective in reducing the prevalence

of peer aggression (Vreeman & Carroll, 2007). With an urgent need to address the

persistently high prevalence of mental health problems in adolescents, this study

highlights the need for implementation of effective interventions to reduce the high

prevalence of children and adolescents engaging in peer aggression.

21

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Table 1.

Prevalence and sex differences in peer aggression at 14 years and characteristics of

participants included in the study at 21 years

Peer Aggression and Bullying

No#

n (%)

Yes

n (%)

Model 1

OR (95% CI) N=1590

Victims 1074 (89.9%) 121 (10.1%)

Females 569 (53.0%) 67 (55.4%) Reference

Males 505 (47.0%) 54 (44.6%) 0.91 (0.62- 1.33)

Perpetrators 1074 (78.6%) 293 (21.4%)


Males 505 (47.0%) 194 (66.2%) 2.20 (1.69- 2.89)**

Victim-Perpetrators 1074 (91.3%) 102 (8.7%)


Males 505 (47.0%) 61 (59.8%) 1.68 (1.11- 2.53)*

No longer in the study at 21 years

No

n (%)

Yes

n (%)

Model 1

OR (95% CI)

Sex (N=2868)


Males 324 (22.3%) 1131 (77.7%) 1.35 (1.14- 1.60)**

Internalising Behaviours

2 yrs. (N=1990)

No 508 (49.0%) 109 (55.1%) Reference

Yes 529 (51.0%) 89 (44.9%) 1.25 (0.88- 1.79)

Internalising Behaviours

5 yrs. (N=2170)

No 477 (48.1%) 140 (57.6%) Reference

Yes 515 (51.9%) 103 (42.4%) 1.32 (1.04- 1.69)^

Externalising Behaviours

2 yrs. (N=1990)

No 380 (50.3%) 237 (50.8%) Reference

Yes 376 (49.7%) 230 (49.2%) 1.40 (1.04- 1.88)^

Externalising Behaviours

5 yrs. (N=2170)

No 563 (51.2%) 49 (42.6%) Reference

Yes 537 (48.8%) 66 (57.4%) 1.61 (1.27- 2.05)**

Family Income (N=1236)

Low

34

Middle 508 (49.3%) 113 (54.9%) 1.25 (0.92- 1.69)

High 522 (50.7%) 93 (45.1%) Reference

OR = Odds Ratio; CI = 95% Confidence Interval; ^ p< 0.05; * p< 0.01; ** p< 0.001

Model 1= unadjusted OR’s

Note: Number of participants varies due to different response rate

# Participants who were uninvolved in any type of bullying behaviour (comparison group)

35


Model 1= adjusted for sex, family income, mothers mental health, family structure; Model 2= adjusted for sex, family income,

mothers mental health, family structure, substance use at 14; Model 2= adjusted for sex, family income, mothers mental health,

family structure, substance use at 14 years, pre-existing mental health at 5 and 14 years.

Note: Number of participants varies due to different response rates

Table 2.

Associations between peer aggression at age 14 and mental health outcomes at age 17

Depression as measured by the BDI

N = 1103 No

n (%)

Yes

n (%)

Model 1

OR (95% CI)

Model 2

OR (95% CI)

Model 3

OR (95% CI)

Victims

No 612 (92.6%) 149 (81.4%) Reference Reference Reference

Yes 49 (7.4%) 34 (18.6%) 2.70 (1.61-4.52)** 2.63 (1.55-4.46)** 2.12 (1.22-3.69)*

Perpetrators


Yes 138 (18.4%) 57 (27.7%) 2.13 (1.43-3.18)** 2.05 (1.38-3.08)** 1.81 (1.19-2.76)*

Victim-Perpetrators


Yes 42 (6.4%) 79 (12.9%) 2.84 (1.55-5.20)** 2.51 (1.34-4.70)** 1.71 (0.87-3.36)

N=1114 Internalising Behaviours as

measured by the YSR

Victims


Yes 58 (7.9%) 25 (21.5%) 2.92 (1.69-5.05)** 2.96 (1.68-5.19)* 2.34 (1.25-4.37)*

Perpetrators


Yes 159 (19.0%) 38 (29.5%) 1.82 (1.16-2.84)* 1.87 (1.19-2.92)* 1.53 (0.93-2.52)

Victim-Perpetrators


Yes 41 (5.7%) 22 (19.5%) 3.85 (2.09-7.08)** 3.16 (1.67-6.01)** 1.78 (0.84-3.78)

N=1114 Externalising Behaviours as

measured by the YSR

Victims


Yes 67 (9.3%) 16 (12.2%) 1.28 (0.69-2.36) 1.27 (0.69-2.36) 1.10 (0.56-2.19)

Perpetrators


Yes 142 (17.8%) 55 (32.3%) 2.36 (1.57-3.53)** 2.27 (1.51-3.41)** 1.12 (0.68-1.84)

Victim-Perpetrators


Yes 33 (4.8%) 30 (20.7%) 6.41 (3.60-11.4)** 5.57 (3.08-10.09)** 2.23 (1.08-4.64)^

36


Model 1= adjusted for sex, family income, mothers mental health, family structure; Model 2= adjusted for sex, family income,

mothers mental health, family structure, substance use at 14; Model 2= adjusted for sex, family income, mothers mental health,

family structure, substance use at 14 years, pre-existing mental health at 5 and 14 years.

Note: Number of participants varies due to different response rates

Table 3.

Associations between peer aggression at age 14 and substance use at age 17

Harmful Alcohol Use

N=1101 No

n (%)

Yes

n (%)

Model 1

OR (95% CI)

Model 2

OR (95% CI)

Model 3

OR (95% CI)

Victims


Yes 61 (11.4%) 22 (7.1%) 0.57 (0.34-0.98)^ 0.52 (0.30-0.91)^ 0.48 (0.26-0.88)^

Perpetrators


Yes 93 (16.4%) 102 (26.2%) 1.87 (1.34-2.63)** 1.80 (1.28-2.54)** 1.76 (1.23-2.53)*

Victim-Perpetrators


Yes 43 (8.3%) 19 (6.2%) 0.64 (0.35-1.17) 0.66 (0.36-1.22) 0.54 (0.27-1.06)

N=1094 Harmful Cannabis Use

Victims

No 699 (90.3%) 59 (89.4%) Reference

Yes 75 (7.9%) 7 (10.6%) 0.81 (0.33-1.99)

Perpetrators

No 699 (81.2%) 59 (67.1%) Reference

Yes 162 (18.8%) 29 (32.9%) 1.61 (0.96-2.70)

Victim-Perpetrators

No 699 (92.8%) 88 (86.8%) Reference

Yes 54 (7.2%) 9 (13.2%) 1.55 (0.69-3.50)

N=1113 Cigarette Smoking

Victims


Yes 66 (9.1%) 45 (14.2%) 1.65 (0.94-2.89) 1.36 (0.74-2.50) 1.45 (0.78-2.72)

Perpetrators


Yes 152 (18.7%) 45 (29.2%) 1.79 (1.21-2.65)* 1.69 (1.10-2.60)^ 1.14 (0.70-1.86)

Victim-Perpetrators


Yes 48 (6.8%) 15 (12.1%) 1.89 (1.02-3.50)^ 1.70 (0.85-3.38) 1.11 (0.51-2.39)

c consult author(s) regarding copyright matters license · 2020. 4. 5. · niemela et al., 2011;...

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