bullying and suicide. a review

©Freund Publishing House Ltd. Int J Adolesc Med Health 2008;20(2):133-154

Bullying and suicide. A review Young Shin Kim, MD, MS, MPH, PhD and Bennett Leventhal, MD

2.3

1Child Study Center, Yale University School of Medicine, New Haven, CT;

2Center

for Child Mental Health and Developmental Neuroscience Institute for Juvenile Research; and

3Institute for Juvenile Research, University of Illinois College of

Medicine, Chicago, IL; United States of America

Abstract: Being a victim or perpetrator of school bullying, the most common type of school violence,

has been frequently associated with a broad spectrum of behavioral, emotional, and social problems.

Suicide is third leading cause of mortality in children and adolescent in the United States of America

and around the world. This paper provides a systematic review of the previous 37 studies conducted

in children and adolescents from communities, as well as in special populations that examined the

association between bullying experiences and suicide, with an emphasis on the strengths and

limitations of the study designs. Despite methodological and other differences and limitations, it is

increasingly clear that any participation in bullying increases the risk of suicidal ideations and/or

behaviors in a broad spectrum of youth.

Keywords: Bullying, school, suicide

Correspondence: Assistant Professor Young Shin Kim, MD, PhD, Child Study Center, Yale University

School of Medicine, 230 S Frontage Rd, POBox 207900, New Haven, CT 06520-7900 United States. Tel:

203-785-2198; Fax: 203-785-7402; E-mail: [email protected]

Submitted: January 01, 2008. Revised: January 16, 2008. Accepted: January 17, 2008.

INTRODUCTION

Bullying is an aggressive behavior in which

individuals in a dominant position intend to

cause mental and/or physical suffering to

others (1). Bullying is a serious public health

problem, with the international prevalence

ranging from 9% to 54% (2-4). All

participants in bullying are reported to be at

substantially increased risk for significant

mental and/or physical sequelae of bullying.

Victimized children are reported to have a

myriad of clinical problems, including bed

wetting, sleep difficulties, anxiety, depres-

sion, school phobia, feelings of insecurity,

and unhappiness at school; they may also

have low self-esteem, loneliness, isolation,

and somatic symptoms (5-12). In contrast,

perpetrators of bullying are reported to have

more depression and are more likely than are

their peers to be involved with antisocial

behaviors and legal problems later in adult-

hood (10,13). Victim-perpetrators, (aggressive

victims) are considered a distinct subtype of

school bullying, experiencing more psycho-

pathology, as well as problematic family and

educational profiles that differ from the other

two school bullying subtypes (14).

Suicide, the third leading cause of

mortality for adolescents in the United

States of America (US) and around the

world, is one of the most serious symptoms

of psychopathology (15). For example, a

recent, large scale, epidemiologic study in

the US suggested that in the past year, 19%

of high school students had serious suicidal

ideation, 15% made a specific plan to

BULLYING AND SUICIDE 134

attempt suicide, 8.8% reported suicidal

attempts, and 2.6% made a suicide attempt

that was serious enough to require significant

medical attention (16). Similarly, a 2001

Korean study found that the rate of com-

pleted suicides for adolescents (from 11 to

19 years) was 15.5 per 100,000, making

suicide the third leading cause of death, after

car accidents and cancer (17). For children at

greater risk for suicide, perceived peer rejec-

tion, being bullied, and being perpetrators of

bullying were associated, directly and

indirectly, with major depression, substance

use, and antisocial behavior with severe

suicidal ideation (18-20).

The goals of this review paper were (1)

to provide a systematic review of previous

studies that examined the association

between bullying experiences and suicide,

with an emphasis on the strengths and

limitations of the study designs; and (2) to

shed light on directions for future research.

METHODS

Identification of relevant literature

A literature search was carried out using six

databases, without date specification: Web

of Science, SCOPUS, EMBASE, PubMed,

PsychInfo, and Ovid Medline. The search

terminology included the following:

1. bullying included either bully*, peer

victimization, peer aggression,

relational aggression, peer relation,

school violence, school aggression,

social dominant*, social hierarchy* or

peer abuse; and

2. suicide included either suicide, suicide

attempt, suicide ideation, suicide

behavior, self-harm or self-injurious

behavior.

The subsequent literature search resulted in

867 papers, which was narrowed to 103

relevant papers by further review of the

abstracts. Among the 103 papers, 37 papers

that met our inclusion criteria (below) were

finally selected for this review paper.

Inclusion criteria

Studies were included in the review if they

met the following criteria:

1. the age of study participants is

younger than or equal to high school

students in the general population and

all age ranges in special populations,

including populations with develop-

mental disorders, behavioral disorders,

of homosexual and/or bi-sexual

orientation or at detention centers;

2. the statistical methods were described

so that the appropriateness of the

analyses could be evaluated;

3. quantitative research that provided

numerical data regarding bullying/

peer victimization exposure and suicidal

risks;

4. the measures for bullying or peer

victimization were described; and,

5. the measures of suicidal behaviors,

ideations or self-injurious behaviors

were described.

Exclusion criteria

Studies were excluded in the review when:

(1) no quantitative data were provided; or

(2) suicidal risks were not compared between

bullying and non-bullying groups.

Grouping of studies

The studies were grouped according to the

characteristics of the study population:

(1) children and adolescents of the general

population; and, (2) a special population,

including people with Asperger Disorder

(AD), Learning Disorders (LD), behavioral

disorders, homosexual and/or bisexual

orientation, or at detention centers. Within

each group, suicidal risks were categorized

by the types of suicidality: (1) suicidal

ideation including suicidal thoughts and

YS KIM AND B LEVENTHAL 135

suicidal plans; (2) suicidal attempts, including

suicidal behaviors and self-injurious/self-

harm behaviors; and, (3) a composite

variable of any suicidality.

Summary of findings

Because this review paper aims to provide a

systematic review of the previous studies

that investigated the association between

bullying experience and suicide risks rather

than to create a statistical summary of

suicidal risks in people with bullying

experience, the authors did not perform a

meta-analysis.

The authors selected odds ratios (ORs)

with 95% confidence intervals (CIs) for

presenting suicidal risks in the summary

tables because (1) ORs are the most

common risk ratios researchers used in their

original studies; (2) ORs are conceptually

intuitive to understand for most readers;

and, (3) Suicidal risks represented by ORs

can be easily translated into clinical practice

for the children and/or their families. In

those instances when ORs were not

available, the statistical method and findings

that were used in individual research were

noted in footnotes.

In examining the relations between

bullying and suicidality, adjustments must

be made for several confounding factors.

These factors include: (1) gender; (2)

psychopathology (depression, aggressive-

impulsive behaviors and disruptive

behaviors); (3) a history of suicide; (4)

parental divorce; and (5) sociodemographic

disadvantage. In this review, covariates that

were controlled in the analyses to examine

the relations between bullying experience

and suicide were examined and listed in the

summary tables.

RESULTS

The nature of the studies

The search strategy identified 37 studies as

eligible for inclusion in this review. Two

reports included separate results for either

subgroup of study sample (23) or same

sample (26,28). These two studies were

reviewed separately under the same author

list.

Researchers from 16 countries in 5

continents have conducted research on the

bullying and suicide. Approximately one

half of the studies were conducted in the

US, one third in Europe, and the rest in

Australia, South Korea, Japan, South

Africa, and Canada. Of the 17 US studies

(53%), 9 used data from the Youth Risk

Behavior Survey (YRBS). To monitor

priority health-risk behaviors among youth

and young adults, Center for Disease

Control (CDC) developed the Youth Risk

Behavior Surveillance System (YRBSS)

(21). YRBSS includes national, state, and

local school-based surveys of students in

grades 9–12 that have been conducted

biennially since 1991. YRBS is based on

data from these ongoing YRBSS surveys.

All 37 studies were cross-sectional

surveys. Of these studies, 73% were

conducted in children and adolescents in

their communities; the rest were performed

in special populations, such as populations

with developmental disorders (AD and

LD), drug problems, legal problems, and

homosexual or bisexual orientations (see

table 1.)

Measurement of predictors: Bullying

Ninety-two percent of research measured

bullying using self-report: 5% (two studies)

(22, 23) used peer nomination to identify

bullying and another 3% (one study) of

research interviewed children with Kiddie-

Schedule for Affective Disorders and

Schizophrenia-Present and Lifetime (K-

SADS-PL) (24) to identify bullying

experience in the study populations (see

table 2.) The time-frame of the bullying


Table 1. Summary of the studies selected for the review (number of studies = 37)

Characteristics of Study Number Percentage

Countries of Study Participants

1. North America (n=18)

US

Canada

17

1

45.9

2.7

2. Europe (n=13)

England/Wales/Ireland

Finland

Netherlands

Norway

Sweden

Belgium

Italy

Germany

2

1

2

2

1

1

2

1

5.4

2.7

5.4

5.4

2.7

2.7

5.4

2.7

3. Australia (n=2) 2 5.4

4. Asia (n=4)

South Korea

Japan

2

2

5.4

5.4

5. Africa (n=1) South Africa 1 2.7

Study Design

1. Cross-sectional 37 100.0

Study Population

1. Children & Adolescents of General

Population (n=27)

27 73.0

2. Special Populations (n=10)

Asperger disorder

Learning disorders

Drug addict

Detention/Jail/Offender

s

Gay/Lesbian/Bisexual

1

1

1

2

5

2.7

2.7

2.7

5.4

13.5

Bullying Measures

1. Self Report 34 91.9

2. Peer nomination 2 5.4

3. Clinical Assessment/Interview 1 2.7

Suicide Measure

1. Self Report 36 97.3

2. Clinical Assessment/Interview 1 2.7

Measures of Suicidality+

1. Suicidal Ideation 20 54.1

2. Suicidal Behaviors/Self-Harm

Behaviors

20 54.1

3. Composite Variable of Suicidality 8 21.6


+: Sum of each item is greater than 100% because some studies measured multiple aspects of

suicidality including suicidal ideation, attempts and/or self-harm behaviors

Table 2 landscape

P 1


Table 2 landscap

P 3


experience inquired ranged from „ever in

the past‟, „for the last six months‟ to

„weekly experience.‟ The self-reports of

bullying can be further divided into three

categories:

Self-reports designed to identify

bullying experience with items de-

scribing specific bullying behaviors.

Items in these self-reports include

o Physical bullying such as pushing,

shoving, grabbing, kicking, biting

or hitting;

o Verbal bullying such as insulting,

threatening, calling names or

spreading rumors; and,

o Exclusion such as being ignored,

being rejected, or no talking.

The number of items included in this

category of self-reports varies across studies,

ranging from one (25) to 40 items (26).

This category is represented by 13 studies

(23,25-33).

Self-reports designed to identify a

broader range of behavioral aspects of

bullying and the experiences of

children and adolescents that resemble

bullying behaviors, peer abuse or peer

victimization. Examples of this type of

self-report of bullying include the use

of items from YRBS survey. Included

were YRBS survey items -

o How many days did you not go to

school because you felt you would

be unsafe at school or on your way

to or from school?;

o How many times has someone

threatened or injured you with a

weapon such as a gun, knife or

club on school property?;

o How many times has someone

stolen or deliberately damaged

your property such as your car,

clothing or books on school

property?;

o How often they had started a fight;

o Have you ever threatened to use a

weapon to get something from

someone; and,

o Have you ever used a weapon to

threaten or assault someone.

Sixteen studies used this type of self-report

to identify bullying experience (34-49).

Self-report designed to identify

bullying experience with direct inquiry

about „bullying‟ experiences with or

without the provision of a definition of

bullying. The bullying survey in WHO

Youth Health Study is an example. In

this study, children and adolescents

were asked how frequently they had

bullied others/been bullied during the

current term and whether these actions

occurred many times per week, once

per week, less frequently, or not at all,

after the definition of bullying was

provided. Eight studies used this form

of bullying self-report (50-57).

The peer nomination method was used in

two studies. Kim et al (22) used Korean-

Peer Nomination Inventory to identify four

types of victims, and/or perpetrators, using

the 17 items. Rigby and Slee (23) also used

Peer Rating Measures, using the eight items

to identify victims and bullies.

In one study, a direct interview was

conducted using one item from K-SADS-

PL interview to identify bullying experience

in children and adolescents (24).


Measurement of outcomes: Suicide

Self-report and interviews were used to

measure suicidality in children and adoles-

cents. Three types of suicidality were

measured: suicidal ideation, suicidal behavior

including self-harm/self-injurious behaviors

and composite variable of any suicidality

(see table 2). Self-report of suicidality were

measured in following ways:

Suicidal Ideation: Suicidal ideations

that were measured in the selected studies

included: “tired of life/occasional thoughts

of suicide,” “for last 6 month, thought about

committing suicide,” “I have explicit plans

of suicide/preparations for suicide.” The

time-frame covered for suicidal ideations

included: “ever,” “past 12 months,” “past 6

months,” “past 2 months,” “past 2 weeks,”

and “current suicidal thoughts.” Suicidal

ideations were identified using suicide

inquiring questions that were created for the

surveys, including the YRBS and the EAT

(25-28,31,39,42,43,48,51,54), a part of the

existing questionnaires, or interview scales,

including Youth Self-Report (YSR), Beck

Depression Inventory, Goldberg Health

Questionnaire (22,23,50,53), or suicide

specific questionnaires, such as Suicidal

Ideation Questionnaire (49,56).

Suicidal behavior: Suicidal Attempts

included in this review paper were

measured by items such as, “Have you ever

on purpose tried to take your own life?” and

“Have you attempted suicide in the past 12

months that resulted in an injury requiring

medical attention?” Suicidal attempts were

identified using suicide inquiry questions

that were created for the particular survey,

including the YRBS survey (25,31,33,35,

37,39,40,43,45-48,51,53), or a part of

existing questionnaires or interview scales

including YSR, or Diagnostic Interview

Schedule for Children (22,56). Self-

harm/injurious behaviors were identified by

self-harm/injurious behavior questions that

were created for the survey (52), or a part of

existing interview scales such as K-SADS-

PL (57). Items assessing self-harm/injurious

behaviors that were identified in the

selected papers ranged from “Have you cut

your wrist and/or arm more than once?” to

“Have you deliberately taken an overdose

of medication or tried to harm yourself in

some other way?”

Composite score of any suicidality:

Eight studies created a single composite

score of suicidality based on the responses

to the multiple questions on suicidal

ideations and/or suicidal behaviors asked of

study participants. This composite variable

of suicidality became the outcome of interest

(29,30,32,34,36,38,41,44).

Interviews were performed in one study to

measure suicidal ideations and behaviors.

Mill et al (24) conducted interviews using

the 19-item Scale for Suicide Ideation to

measure current and past suicide ideations,

and 19-item Suicide Intent Scale to quantify

suicide intent and attempts. One study did

not describe how it measured suicidal

ideations and attempts (55).

Covariates adjusted in analyses examining

associations between bullying and suicide

Covariates that were adjusted in the

examination of the association between

bullying and suicide are summarized in

table 3 and 4. Among the studies conducted

in the general populations of children and

adolescents, 23 of 27 studies adjusted for

gender, whereas 5 out of 10 studies in

special populations controlled for gender in

the examination of the relation between

bullying and suicide. Eight studies

conducted in the general population, as well


as four studies of special population,

adjusted for other psychopathological risk

factors for suicide. These risk factors

included depression, substance abuse, or

emotional/psychological distress.

Table 3 landscape

P 1


Table 3 landscape

P 2


Only a single study of the total 37

studies considered past suicide history as a

covariate in its analysis (54). Seven studies

using a general population adjusted for

parental divorce or family structure as a

proxy for parental divorce in their analyses,

whereas none of the studies of special

populations did so. Additionally, 21 studies

of the general population, as well as 6

studies of special populations, controlled

for socioeconomic disadvantages, including

SES, poverty, exposure to violence, social

capital/social support, and demographic

information, such as age and race.

Suicide risks in children and adolescents

with bullying experience

Risks of suicidal ideations, suicidal attempts,

and composite risks of any suicidality that

were associated with bullying experience are

summarized in two tables: Table 3 summa-

rizes 27 studies in a general population of

children and adolescents and table 4 sum-

marizes 10 studies in special populations.

Using 15 samples from the general

population, studies examined the risks of

suicidal ideations in the victims of school

bullying. Whereas 3 studies reported no

association, 12 reported increased risks of

suicidal ideations in the victims of bullying,

with ORs ranging from 1.4 to 5.6. One

study reported a statistically significant

interaction with gender: female victims

were at a greater risk of suicidal ideations

than male victims (22). Additionally, three

studies reported dose-response-relations:

frequent victimization was associated with

higher risks for suicidal ideations than less-

frequent victimizations (26,50,56). Eight of

10 studies that examined the risks of

suicidal ideations in the bullying perpetrators

from the general population reported

increased suicidal risks, with ORs ranging

from 1.4 to 9.0. One study (22) reported

significantly higher risks of suicidal

ideations in female perpetrators than in

male perpetrators, and three studies (26,50,

56) reported dose-response-relations for

frequency of perpetrating behaviors and

suicidal risks. All five studies that

examined risks of suicidal ideations in the

victim-perpetrators (VPs) of school bullying

in the general population reported increased

risks, with ORs ranging from 1.9 to 10.0.

The suicidal risks in VPs were highest

among all the groups involved with

bullying in four studies (22,53,55,56), and

one study reported higher suicidal risk in

female VPs compared with male VPs (22).

Thirteen studies examined risks of

suicidal attempts, including self-injurious

behaviors, in the victims of bullying in

general population and twelve studies

reported increased risks, with ORs ranging

from 1.5 to 5.4. One study reported signifi-

cant interactions between suicidal risks and

female gender (25), and one showed dose-

response-relations (56). Two studies (53,56)

of the four that examined risks of suicidal

attempts in the perpetrators of bullying in

the general population reported increased

suicidal risks, with ORs ranging from 2.3 to

9.9. One study also reported dose-response-

relations between perpetrating behaviors

and suicidal risks (56). All five studies that

examined the composite risks of any

suicidality in victims of bullying in the

general population reported increased risks

of suicidality, with ORs ranging from 1.7 to

2.5. Two studies also examined the risks of

composite suicidality in perpetrators and

reported increased risks with ORs ranging

from 1.3-1.4.

Five studies examined risks of suicidal


ideations in victims of bullying in special

populations, and four studies reported

increased risks in juvenile offenders,

persons with LD, and lesbian/gay/bisexual

(LGB) sexual orientation, with ORs ranging

from 1.7 to 2.1. One study that examined

the risks of suicidal ideations in perpe-

trators of bullying among juvenile offenders

reported lowered risks compared with the

ones not involved with bullying (31).

Seven studies investigated the risks of

suicidal attempts and self-injurious behaviors

in the victims of bullying in special

populations, and six reported increased

risks, with ORs ranging from 1.4 to 4.6.

The special populations with increased

suicidal risks included individuals with LD,

drug abuse, juvenile delinquency, and of

LGB sexual orientation. Additionally, one

study reported increased risk of suicidal

attempts in the perpetrators of the children

and adolescents with LD with OR 2.7 (37).

Additionally, one study examined the

composite risks of any suicidality in

persons with LGB sexual orientation and

reported that bullying had a mediating role

between gender role conformity and

suicidal risk (32).

DISCUSSION

Suicidality, the third leading cause of

mortality for adolescents (16), has been

examined in relation to bullying in 37

studies conducted in various countries.

Most of these studies reported positive

associations between all bullying types and

suicidal risks, with strongest risks in

Victim-Perpetrators, both in general popu-

lations of children and adolescents and in

populations with specials needs (behavioral

problems or of LGB sexual orientation.) In

addition, a few studies found that suicidal

risks differed based on gender, as well as

with regard to dose-response-relations. The

ORs for suicidal risks associated with

bullying experience ranged from 1.4 to

10.0. Nevertheless, these prior findings

must be interpreted with caution because of

three important, methodological problems:

1. When examining the relation between

bullying and suicidality, most studies

failed to control for other well-

established suicide risk factors,

including gender, psychopathology

(depression, aggressive-impulsive

behaviors and disruptive behaviors),

and a history of suicide (58). Twenty

eight of the thirty-seven studies

controlled for gender. Twelve studies

also controlled for psychopathological

risk factors for suicide, including

depression, substance abuse, or

emotional/psychological distress. Only

a single study controlled for gender,

depression, and prior suicidal history;

this paper reported a negative associ-

ation between bullying and suicide

(54). Taken together, the interpretation

of the observed positive associations

between bullying and suicide in these

studies is seriously limited because

uncontrolled risk factors may have

confounded the relation between

bullying and suicide.

2. The interpretation of these findings is

complicated by the shared method

variance caused by the use of the same

informants to identify both bullying

status and suicidal behaviors/ideations

(59-60). In those instances, self-reports

of bullying are based on the

individuals‟ own perception of the

social circumstances, a situation in

which it is possible that the psycho-

pathological characteristics of the

reporter can lead to the misinterpreta-

tion of otherwise normal social events.

This can result in a confounded

relation between suicide and bullying.

Two of the thirty-seven studies used


peer nomination to identify indepen-

dently bullying type and self-reports

for delineating suicidal thoughts/

behaviors; both studies reported an

increased risk of suicide in students

with bullying experience (22-23).

3. All 37 studies were cross-sectional,

making it impossible to make causal

inferences or conclusions that experi-

encing bullying increases suicide

risks.

Future studies should address these

major methodological limitations to establish

causal relations between bullying and risks

of suicide. Ideally, future studies should be

long-term, prospective in large community

samples of children and adolescents, as well

as in special populations, and with multiple

informants to identify predictors and out-

comes. The analyses should be planned and

conducted carefully to control for con-

founding effects of other well-established

suicidal risk factors. Findings should be

replicated by independent researchers in

independent study populations.

In the meantime, this systematic review

of 37 prior studies that were conducted in

various countries suggests that bullying is a

serious problem for our youth and our

communities. Not only does bullying inter-

fere with normal developmental and educa-

tional processes but also places adolescents

at an unnecessary and additional risk for

suicidal thoughts and actions. It seems clear

that these adolescents are at increased risk

for suicidal behaviors/ideations and deserve

our particular care and attention. Additionally,

the inclusion of screening and monitoring

of suicidal signs and symptoms in victims,

perpetrators, or victim-perpetrators in the

anti-bullying programs may be an effective

way to reduce suicidality in the children

and adolescents with bullying experience.

Finally, careful clinical evaluation for

suicidality in children with bullying

experience should be a standard practice

that is part of routine primary care visits.

Although many adolescents may experi-

ence bullying, either as participants or

observers, the observation that it is common

does not imply that it is „normal‟ and,

hence, an acceptable part of „normal devel-

opment‟. Indeed, the evidence from this

review suggests that exposure to bullying,

especially for participants, is harmful.

Therefore, it is imperative that there now be

a common goal to intervene actively to

reduce bullying in all communities and to

seek out both victims and perpetrators to

protect them from suicidality and other

potential lethal adverse consequences of

this serious public health problem.

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