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ScienceDirect Comprehensive Psychiatry 55 (2014) 405 – 413 www.elsevier.com/locate/comppsych

Association between school bullying levels/types and mental health problems among Taiwanese adolescents Cheng-Fang Yen a, b, c , Pinchen Yang a, c , Peng-Wei Wang b, c,⁎, Huang-Chi Lin b, c , Tai-Ling Liu b , Yu-Yu Wu d, e , Tze-Chun Tang c a

Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung City 807, Kaohsiung, Taiwan b Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung City 807, Kaohsiung, Taiwan c Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, 100 Tzyou 1st Road, Kaohsiung City 807, Taiwan d Department of Child Psychiatry, Chang Gung Memorial Hospital- Linkou Medical Center, and College of Medicine, Chang Gung University, Taiwan e YuNing Psychiatric Clinic, Taiwan

Abstract Background: Few studies have compared the risks of mental health problems among the adolescents with different levels and different types of bullying involvement experiences. Method: Bullying involvement in 6,406 adolescents was determined through use of the Chinese version of the School Bullying Experience Questionnaire. Data were collected regarding the mental health problems, including depression, suicidality, insomnia, general anxiety, social phobia, alcohol abuse, inattention, and hyperactivity/impulsivity. The association between experiences of bullying involvement and mental health problems was examined. The risk of mental health problems was compared among those with different levels/types of bullying involvement. Results: The results found that being a victim of any type of bullying and being a perpetrator of passive bullying were significantly associated with all kinds of mental health problems, and being a perpetrator of active bullying was significantly associated with all kinds of mental health problems except for general anxiety. Victims or perpetrators of both passive and active bullying had a greater risk of some dimensions of mental health problems than those involved in only passive or active bullying. Differences in the risk of mental health problems were also found among adolescents involved in different types of bullying. Conclusions: This difference in comorbid mental health problems should be taken into consideration when assessing adolescents involved in different levels/types of bullying. © 2014 Elsevier Inc. All rights reserved.

1. Introduction One important reason to evaluate young people's experiences of bullying and being victimized by perpetrators is their significant association with a range of mental health problems [1]. Youths who are bullied have been found to have significant risk of depression [2–4], anxiety [2,5], suicidal ideation and attempts [6], and attention-deficit/

⁎ Corresponding author. Department of Psychiatry, Kaohsiung Medical University Hospital, No.100, Tzyou 1st Road, Kaohsiung 807, Taiwan. Tel.: +886 7 3121101x6822; fax: +886 7 3134761. E-mail address: [email protected] (P.-W. Wang). 0010-440X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.06.001

hyperactivity disorder (ADHD) [7]. Bullying has also been found to be associated with ADHD [7], alcohol use disorder [8], depression [4] and suicidal ideation and attempts [6]. It is important for mental health professionals, educators, and parents to increase their awareness of mental health problems in adolescents involved in school bullying. Bullying behaviors can involve physical acts, verbal utterances, social exclusion, property theft, or other behaviors [9]. The nature of bullying and victimization in adolescents is heterogeneous. Research has identified various classes of victim [10]. Meanwhile, bullying behavior may serve different social functions and, depending on these functions, perpetrators differ in their skills, status, and social behavior [11]. Age [12], sex [12], and residential

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background variations [13] have been identified among those suffering from different types of bullying. These results of previous studies raise important issues that need further examination: Does increased co-occurrence of bullying-involvement experiences cause greater risk for mental health problems? Also, do different types of bullyinginvolvement experiences have different associations with mental health problems? A previous study found that increased co-occurrence of victimization types put adolescents at greater risk for poorer physical and psychological outcomes, including more severe depression and more frequent medically-attended injuries and medicine use [10]. In addition, different types of bullying victimization could result in independent and cumulative effects on psychological trauma symptoms [12]. However, it is not known whether there are differences in the risk of mental health problems among adolescents who perpetrated different levels and types of bullying on peers. Another issue needing further examination is whether perpetrator-victims, who are individuals who are involved in bullying others and who also are victims of bullying, have a higher risk of comorbid mental health problems than pure victims and pure perpetrators. Some research considered perpetrator-victims, defined as individuals who bully others but also are bullied themselves, as a distinct group and the most troubled among all individuals involved with bullying [14]. Compared with pure perpetrators and victims, the perpetrator-victims were found to have the greatest risk of externalizing behavioral problems [15], psychological and psychosomatic symptoms [16], referrals to psychiatric services [17], suicidal ideation [3], school and interpersonal dysfunction [4,5], and alcohol use [4]. Thus, it has been proposed that perpetrator-victims could particularly benefit from early identification and intervention [18]. However, some researchers have found no differences between perpetrator-victims and pure perpetrators/pure victims. For example, a previous study showed that the perpetratorvictims' level of risk-taking behaviors do not significantly exceed those of the bullying group, and that their increased suicidal ideation is similar to that in the victim group [19]. Further study is needed to compare the risks of mental health problems among perpetrator-victims, pure perpetrators and pure victims. This study had three major aims. First, we examined the association of various school bullying involvement experiences with a range of mental health problems. Second, we compared the risk of mental health problems among adolescents with different levels of bullying or victimization (victim of both passive and active bullying vs. victim of only passive or active bullying, and perpetrator of both passive and active bullying vs. perpetrator of only passive or active bullying). Third, we compared the risk of mental health problems among adolescents with different types of bullying or victimization (victim of only passive bullying vs. victim of only active bullying, perpetrator of only passive bullying vs. perpetrator of only active bullying, perpetrator-victims

vs. pure victims, perpetrator-victims vs. pure perpetrators, and pure victims vs. pure perpetrators). We hypothesized that any type of bullying involvement experiences would be significantly associated with mental health problems. We also hypothesized that adolescents with increased cooccurrence of bullying or victimization would have increased risk of mental health problems, as well as that the risk of mental health problems among the adolescents with different types of bullying or victimization would vary. 2. Method 2.1. Participants The present study is based on data from the 2009 Project for the Health of Adolescents in Southern Taiwan, a mental health research program of adolescents in grades 7 through 12 recruited from three metropolitan areas and four counties in southern Taiwan [20]. In 2009, there were 202,883 students in 143 senior high/vocational schools and 254,130 students in 205 junior high schools in this area. On the basis of the definitions of rural and urban districts in the TaiwanFukien Demographic Fact Book [21] and on school and grade characteristics, a stratified random sampling strategy was used to ensure that there was proportional representation of districts, schools, and grades. Five junior high schools and four senior high/vocational schools were randomly selected from rural districts; similarly, five senior high/vocational schools and five junior high schools were randomly selected from urban districts. The classes in these schools were further stratified into three levels based on grade in primary, junior high, and senior high/vocational schools. Then, a total of 6,703 high school students were randomly selected based on the ratio of students in each grade. The Institutional Review Board of Kaohsiung Medical University agreed to the use of passive consent from parents and students for several reasons. First, the Project for the Health of Adolescents in Southern Taiwan is a routine survey of adolescent health conducted every two to three years, and the adolescents could themselves make the decision whether to complete the anonymous questionnaire. Second, the IRB agreed that the results of this study would be beneficial to adolescents. Before conducting the study, we prepared a leaflet explaining the purpose and procedures of the study. Students took the leaflets home to their parents or main caretakers, who could telephone the researchers, write in a communication book, or ask their children directly to refuse to join the study. The students also had the right to refuse to participate in this study by returning blank questionnaires along with those from other students. 2.2. Instruments 2.2.1. Chinese version of the School Bullying Experience Questionnaire (C-SBEQ) The self-reported C-SBEQ was used to evaluate participants' involvement in school bullying in the previous one

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year with 16 items answered on a Likert 4-point scale range with 0 indicating “never”, 1 indicating “just a little”, 2 indicating “often”, and 3 indicating “all the time” [22,23]. This scale was composed of four 4-item subscales evaluating being a victim of passive bullying (items 1 to 4, including social exclusion, being called a mean nickname, and being spoken ill of), being a victim of active bullying (items 5 to 8, including being beaten up, being forced to do work, and having money, school supplies, and snacks taken away), being a perpetrator of passive bullying (items 9 to 12), and being a perpetrator of active bullying (items 13 to 16). Participants who answered 2 or 3 on any item among items 1 to 4, items 5 to 8, items 9 to 12, and items 13 to 16 were identified as self-reported victims of passive bullying, victims of active bullying, perpetrators of passive bullying, and perpetrators of active bullying, respectively. The results of the previous study examining the psychometrics of the CSBEQ have been described elsewhere and supported that the C-SBEQ has good reliability and validity [23]. Four groups were also distinguished by type of bullying involvement: pure perpetrators, those who bullied others but were not bullied by others; pure victims, those who were bullied by others but did not bully others; perpetrator-victims, those who bullied others and were also bullied by others; and a neutral group, those who neither bullied others nor were bullied by others. 2.2.2. Mandarin Chinese version of the Center for Epidemiological Studies-Depression Scale (MC-CES-D) The MC-CES-D used in this study was a 20-item selfadministered questionnaire that used a 4-point evaluation scale to assess the frequency of depressive symptoms in the preceding week [24,25]. Higher total MC-CES-D scores indicated more severe depression. The Cronbach's alpha for the MC-CES-D in the present study was .920. 2.2.3. Athens Insomnia Scale (AIS-8) We used the Taiwanese version of the 8-item AIS-8 to assess the severity of subjective insomnia over the last month [26,27]. Higher total scores indicated more severe insomnia symptoms and subjective sleep-related distress. The psychometrics of Taiwanese version of the AIS-8 have been described elsewhere [26,28]. The Cronbach's alpha for the AIS-8 in the present study was .721. 2.2.4. General anxiety We used the Taiwanese version of the Multidimensional Anxiety Scale for Children (MASC-T) [29,30] to evaluate the participants' self-reported general anxiety symptoms. The MASC-T consisted of 39 items answered on a Likert 4point scale. A higher total score on the MASC-T represented a more severe level of general anxiety. The Cronbach's alpha for the MASC-T in the present study was .891. 2.2.5. Social Phobia Inventory (SPIN) The 17-item SPIN was a self-reported rating scale answered on a Likert 5-point scale [31,32]. Higher total

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scores on the SPIN indicated higher severity of social phobia. The Cronbach's alpha for the SPIN in the present study was .925. 2.2.6. Attention-Deficit/Hyperactivity Disorder Self-rated Scale (ADHDS) The 18-item, 4-point Likert-type self-reported ADHDS [32] was modified from the Vanderbilt ADHD Diagnostic Parent Rating Scale [33] and represented the 18 diagnostic symptoms for ADHD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) [34]. Higher total scores for items 1 to 9 and 10 to 18 indicated more severe inattention and hyperactivity/impulsivity symptoms, respectively. The Cronbach's alpha for Inattention and hyperactivity/impulsivity subscales in the present study was .820 and .827, respectively. 2.2.7. Suicidality The 5-item questionnaire from the epidemiological version of the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS-E) [35] was used to assess the occurrence of suicide attempts and of four forms of suicidal ideation in the preceding year [36]. Each question elicited a “yes” or “no” answer. In a previous study the Cohen's kappa coefficient of agreement (κ) between participants' selfreported suicide attempts and their parents' reports was 0.541 (P b 0.001) [36]. Those who had a “yes” answer to any of the five items were classified as having suicidal ideation or attempts. 2.2.8. CRAFFT alcohol abuse screening test (CRAFFT) The self-reported 5-item CRAFFT was developed to assess problematic alcohol use in adolescents [37,38]. The “yes” answer is scored as 1 and “no” as 0. Previous research [37] demonstrated that a cutoff score of 2 on the CRAFFT could be used to identify adolescents with an alcohol use disorder or with problematic alcohol use based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [39]. 2.3. Procedures and statistical analysis A total of 6,445 students (96.2%) agreed to join this study. Each student completed the research questionnaire anonymously under the direction of research assistants in each classroom during school hours. All students received a gift worth NT$33 (one US dollar) at the end of the assessment. A total of 6,406 students (99.4%) completed the questionnaire for sex, age and bullying involvement (C-SBEQ) without omission. Of them, 3369 (52.6%) were girls and 3037 (47.4%) were boys, and their mean age was 14.8 years (SD = 1.8 years, range: 11–19 years). The ratios of participants with different experiences of bullying involvement were calculated. The association of each experience of bullying involvement (independent variable) with depression, insomnia, general anxiety, social phobia, inattention and hyperactivity/impulsivity and with suicidality and alcohol abuse (dependent variables) was

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examined by using multiple regressive analyses and logistic regressive analyses models, respectively. The results of longitudinal studies suggest that involvement in bullying in children and adolescents is a risk factor for subsequent mental health problems [2,5,18,40–42]. Thus we selected the experiences of involvement in bullying as predictor variables for mental health problems. Meanwhile, previous studies have found that there are differences of sex and age in bullying involvement [43], depression [44], insomnia [27], general anxiety and social phobia [20], inattention and hyperactivity/impulsivity [45], suicidality [39], and alcohol abuse [46]. Thus we controlled the effects of sex and age in the multiple regressive analyses and logistic regressive analyses models. We also compared the risk of various mental health problems between those with different levels of bullying involvement, as well as between those with different types of bullying involvement. We also used the standard criteria [47] to examine whether the associations between the experiences of bullying involvement and mental health problems were different in terms of the participants' sex and age. According to the criteria, moderation occurred when the interaction term for the predictor (the experiences of bullying involvement) and the hypothesized moderator (sex and age) were significantly associated with the dependent variable (mental health problems) after controlling for the main effects of both the predictors and hypothesized moderator variables. In this study, if the experiences of bullying involvement and hypothesized moderators were significantly associated with mental health problems, the interactions (the experiences of bullying involvement x hypothesized moderators) were further selected into the regression analysis to examine the moderating effects. Because of multiple comparisons, a two-tailed P value of less than 0.01 was considered statistically significant.

Table 1 Characteristics of bullying involvement and mental health problems. n (%) Victims of bullying Passive bullying Active bullying Passive or active bullying Perpetrators of bullying Passive bullying Active bullying Passive or active bullying Types of bullying involvement Neutral Pure victims Pure perpetrators Perpetrator-victims Score on the C-SBEQ Victimization of passive bullying Victimization of active bullying Perpetration of passive bullying Perpetration of active bullying Depression on the MC-CES-D a Insomnia on the AIS-8 b General anxiety on the MASC-T c Social phobia on the SPIN d Inattention on the ADHDS e Hyperactivity/impulsivity on the ADHDS f Suicidalityg Alcohol abuse h

Mean (SD)

Range

2.1 (2.0) .7 (1.3) 2.2 (2.0) .5 (1.2) 15.7 (9.8) 6.2 (3.1) 38.3 (15.7) 19.6 (13.0) 19.4 (4.6) 14.9 (4.6)

0–12 0–12 0–12 0–12 0–58 0–24 0–100 0–68 0–56 0–36

1369 (21.4) 537 (8.4) 1604 (25.0) 1135 (17.7) 354 (5.5) 1254 (19.6) 4174 (65.2) 978 (15.3) 628 (9.8) 626 (9.8)

2060 (32.3) 840 (13.2)

ADHDS: Attention-Deficit/Hyperactivity Disorder Self-rated Scale; AIS-8: Athens Insomnia Scale; C-SBEQ: Chinese version of the School Bullying Experience Questionnaire; MASC-T: Taiwanese version of the Multidimensional Anxiety Scale for Children; MC-CES-D: Mandarin Chinese version of the Center for Epidemiological Studies-Depression Scale; SPIN: Social Phobia Inventory. a n = 5956. b n = 6320. c n = 5537. d n = 6059. e n = 6204. f n = 6281. g n = 6385. h n = 6377.

3. Results 3.1. Prevalence rates of bullying involvement Prevalence rates of various experiences of bullying involvement in the past one year among participants are shown in Table 1. A total of 1604 (25.0%) participants reported being the victims of bullying. Of them, 1369 (21.4%) reported being the victims of passive bullying and 537 (8.4%) reported being the victims of active bullying. A total of 1254 (19.6%) participants reported being the perpetrators of bullying. Of them, 1135 (17.7%) reported being the perpetrators of passive bullying and 354 (5.5%) reported being the perpetrators of active bullying. Regarding the types of bullying involvement, 4174 (65.2%) participants reported that they had never been involved in any type of bullying (the neutral group), 978 (15.3%) reported being pure victims, 628 (9.8%) reported being pure perpetrators, and 626 (9.8%) reported being perpetrator-victims.

3.2. The association of bullying involvement with mental health problems The results of examining the association between various experiences of bullying involvement and mental health problems are shown in Table 2 and Table 3. The results indicated that being a victim of passive bullying, being a victim of active bullying, and being a perpetrator of passive bullying were significantly associated with all kinds of mental health problems. Being a perpetrator of active bullying was significantly associated with depression, insomnia, social phobia, inattention, hyperactivity/impulsivity, suicidality, alcohol abuse; however, the perpetrator of active bullying reported less general anxiety than those who were not the perpetrator of active bullying. The all three independent variables (each type of experiences of bullying

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Table 2 The association of various experiences of bullying involvement with depression, insomnia, general anxiety, social anxiety, inattention and hyperactivity/ impulsivity: Multiple regression analyses. a Depression Beta t Victim of passive bullying (Reference: not victim of passive bullying) Victim of active bullying (Reference: not victim of active bullying) Perpetrator of passive bullying (Reference: not perpetrator of passive bullying) Perpetrator of active bullying (Reference: not perpetrator of active bullying)

Insomnia Beta t

General anxiety Beta t

Social phobia Beta t

Inattention Beta t

Hyperactivity/ impulsivity Beta t

.279 22.311*** .178 14.308***

.185 14.113*** .219 17.310*** .221 17.812*** .175 14.068***

.182 14.378*** .100

.134 10.259*** .159 12.508*** .142 11.395*** .167 13.478***

8.015***

.183 14.393*** .126 10.124*** .114

8.893*** .063

.077

5.850*** .118

9.232*** .199 16.020*** .233 19.012***

5.013*** −.011

−.832*** .023

1.796*** .091

7.213*** .184 14.901***

a

Controlling the effects of sex and age. ⁎⁎⁎ P b .001.

involvement, sex and age) could account for 0.4% to 9.0% of the variance in each multiple regression analysis model. We further examined the moderating effects of sex and age on the association between the experiences of bullying involvement and mental health problems. The results found that the association between victimization of passive bullying and depression was more significant in girls (Beta = .298, t = 17.160, P b .001) than that in boys (Beta = .261, t = 14.308, P b .001) (Table 2). The association between victimization of active bullying and depression was more significant in younger adolescents (Beta = .238, t = 12.837, P b .001) than that in older ones (Beta = .131, t = 7.522, P b .001) (Table 2). The association between perpetration of passive bullying and inattention was more significant in younger adolescents (Beta = .230, t = 12.652, P b .001) than that in older ones (Beta = .169, t = 9.817, P b .001) (Table 2). 3.3. Comparison of the risk of various mental health problems for different levels and types of bullying involvement The results of examining the risk of various mental health problems for different levels and types of bullying involvement are shown in Table 4 and Table 5. The results indicated that victims of both passive and active bullying reported more severe depression, social phobia, and inattention than victims of only passive or active bullying (Table 4). Victims of both passive and active bullying also reported more severe general anxiety and hyperactivity/ impulsivity than victims of only passive bullying (Table 4). Perpetrators of both passive and active bullying reported more severe depression and hyperactivity/impulsivity than perpetrators of only passive or active bullying (Table 4). Perpetrators of both passive and active bullying were more likely to abuse alcohol than perpetrators of only passive bullying (Table 5). However, perpetrators of both passive and active bullying reported less severe general anxiety than perpetrators of only passive bullying (Table 4). In addition, perpetrators of only active bullying reported less severe

general anxiety and social phobia than perpetrators of only passive bullying (Table 4). Perpetrator-victims reported more severe depression, inattention, and hyperactivity/impulsivity than pure perpetrators and pure victims (Table 4). Perpetrator-victims were also more likely to have suicidality and alcohol abuse than pure perpetrators and pure victims (Table 5). Perpetratorvictims also reported more severe insomnia, general anxiety, and social phobia than pure perpetrators (Table 4). Pure perpetrators reported less severe depression, insomnia, general anxiety, and social phobia than pure perpetrators but more severe hyperactivity/impulsivity than pure victims (Table 4).

4. Discussion This study found that 25.0% and 19.6% of the participants reported being the victims of bullying and the perpetrators of bullying, respectively. A nationally representative survey of Table 3 The association of various experiences of bullying involvement with suicidality and alcohol abuse: Logistic regression analyses. a Suicidality OR (95% CI) Victim of passive bullying (Reference: not victim of passive bullying) Victim of active bullying (Reference: not victim of active bullying) Perpetrator of passive bullying (Reference: not perpetrator of passive bullying) Perpetrator of active bullying (Reference: not perpetrator of active bullying)

Alcohol abuse OR (95% CI)

2.316 (2.042–2.626) 1.599 (1.354–1.889)

1.981 (1.653–2.375) 1.738 (1.384–2.183)

2.072 (1.813–2.369) 1.753 (1.477–2.080)

1.673 (1.340–2.088) 3.029 (2.372–3.867)

OR: Odds ratio. CI: Confidence interval. a Controlling the effects of sex and age.

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Table 4 The risk of depression, insomnia, general anxiety, social anxiety, inattention and hyperactivity/impulsivity compared between those with different types and levels of bullying involvement: Multiple regression analyses. a Depression Beta t

Insomnia Beta t

Victim of bullying Only active type (Reference: −.035 −1.217 −.015 −.528 only passive type) Both passive and active types .148 5.310*** .019 .706 (Reference: only passive type) Both passive and active types .199 4.296*** .039 .863 (Reference: only active type) Perpetrator of bullying Only active type (Reference: −.066 −2.051* −.024 −.778 only passive type) Both passive and active types .137 4.443*** .014 .475 (Reference: only passive type) Both passive and active types .268 4.830*** .048 .905 (Reference: only active type) Perpetrator-victims (Reference: .094 3.644*** .021 .839 pure victims) Perpetrator-victims .238 8.245*** .087 3.040** (Reference: perpetrators) Pure perpetrators (Reference: −.137 −5.261*** −.072 −2.845** pure victims)

General anxiety Beta t

Social phobia Beta t

.008

.280

.002

.076

.099

3.385**

.128

4.559***

.122

2.493*

.157

3.349**

−.096 −2.912**

−.104 −3.255**

−.097 −3.032**

−.036 −1.164

.028

.460

.117

−.018

−.669

−.005

.181

6.019***

.161

Inattention Beta t

−.026

Hyperactivity/ impulsivity Beta t

−.938

.065 2.350*

.091

3.284**

.142 5.249***

.129

2.843**

.075 1.660

−.081 −2.549*

−.008 −.257

.030

.965

.219 7.389***

2.077*

.138

2.517*

.230 4.349***

−.174

.111

4.370***

.212 8.656***

5.517***

.136

4.697***

.150 5.229***

−.190 −7.124*** −.165 −6.366*** −.029 −1.136

.069 2.698**

a

Controlling the effects of sex and age. ⁎ P b .05. ⁎⁎ P b .01. ⁎⁎⁎ P b .001.

the United States children in 6–10th grades found that 31.2% of students reported the experience of bully victimization and 37.3% reported the experience of bully perpetration [48]. A study on Korean middle school students found that 40% of all students participated in school bullying; of them, 17% were perpetrators, 14% were victims, and 9% were both perpetrators and victims [49]. Although the difference in the definition and measurement of bullying involvement among this and previous studies limits the possibility to compare the prevalence rates of bullying involvement among adolescents of different countries, the results of this study indicates that bullying involvement is prevalent among adolescents in Taiwan. This study also found that being a victim of any type of bullying and being a perpetrator of passive bullying were significantly associated with all kinds of mental health problems, and being a perpetrator of active bullying was significantly associated with all kinds of mental health problems except for general anxiety. The results further support the necessity of surveying the extent of involvement in bullying of adolescents. If mental health and education professionals focus their attention on only the bullied adolescents, they may neglect the mental health problems of adolescents who perpetrate bullying. Meanwhile, all eight mental health indicators examined in this study are important to adolescents. It is necessary to survey the existence of these mental health problems among adolescents involved any type of bullying experiences. We also found that sex and age

were the moderators of the association between some dimensions of bullying involvement and depression and inattention. Because sex and age can influencing youths' behaviors with peers and psychological reaction to stresses, it is necessary for mental health professionals to take sex and age into consideration when developing prevention and intervention strategies for adolescent bullying. One of the major aims of this study was to compare the risk of various mental health problems among adolescents with different levels of bullying or victimization. We found that victims of both passive and active bullying had higher risks of several dimensions of mental health problems than victims of only passive or active bullying. These results were in line with the results of previous studies that demonstrated the cumulative effect of experiencing multiple forms of peer victimization on the existence of psychological distress [10,11]. On the other hand, because of the cross-sectional design of this study, the possibility that the adolescents with these mental health problems were more likely to be the victims of both passive and active bullying than those without these mental health problems could not be ruled out. Regardless of the causal relationship between being a victim of bullying and mental health problems, victims of both passive and active bullying need the greatest focus in surveying and intervention programs for these mental health problems. It is noteworthy that perpetrators of both passive and active bullying have more severe depression and hyperactivity/

C.-F. Yen et al. / Comprehensive Psychiatry 55 (2014) 405–413 Table 5 The risk of suicidality and alcohol abuse compared between those with different types and levels of bullying involvement: Logistic regression analyses. a Suicidality OR (95% CI) Victim of bullying Only active type (Reference: only passive type) Both passive and active types (Reference: only passive type) Both passive and active types (Reference: only active type) Perpetrator of bullying Only active type (Reference: only passive type) Both passive and active types (Reference: only passive type) Both passive and active types (Reference: only active type) Perpetrator-victims (Reference: pure victims) Perpetrator-victims (Reference: pure perpetrators) Pure perpetrators (Reference: pure victims)

Alcohol abuse OR (95% CI)

.882 (.659–1.181)

1.106 (.763–1.604)

1.080 (.947–1.231)

1.159 (.985–1.365)

1.251 (.872–1.794)

1.214 (.776–1.900)

.595 (.462–.766)

1.697 (1.069–2.694)

1.033 (.891–1.198)

1.624 (1.374–1.919)

1.617 (1.014–2.578) 1.517 (.913–2.521)

1.147 (1.035–1.272) 1.362 (1.195–1.553) 1.498 (1.191–1.886) 1.608 (1.207–2.143)

.840 (.680–1.038)

1.121 (.841–1.495)

OR: Odds ratio. CI: Confidence interval. a Controlling the effects of sex and age.

impulsivity than perpetrators of only passive or only active type of bullying. Perpetrators of both passive and active bullying were also more likely to abuse alcohol than perpetrators of only passive bullying. Because of the negative influences of bullying behaviors on peers, perpetrators of bullying are often considered to be morally evil and are rejected by the their classmates. However, the results of this study indicated that perpetrators of both passive and active bullying had higher risks of mental health problems than perpetrators of only passive or active bullying. The results suggest that the mental health problems of adolescents perpetrating multiple forms of bullying need comprehensive survey and intervention. Another major aim of this study was to compare the risks of mental health problems among the adolescents with different types of involvement in bullying. The results of this study did not find significant difference in the risks of mental health problems between the victims of only passive bullying and the victims of only active bullying. The results raised the possibility that being a victim of passive bullying may have negative effects on mental health similar to those resulting from being a victim of active bullying. The comparison of the risks of mental health problems between the perpetrators of only passive bullying and the perpetrators of only active bullying told a different story.

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Perpetrators of only active bullying reported less severe general anxiety and social phobia than perpetrators of only passive bullying. It is possible that adolescents who had different levels of general anxiety and social phobia may apply different methods of bullying to manipulate interpersonal relationships. This study confirmed the need to differentiate between being a perpetrator of passive and active bullying instead of assuming that perpetrators are a homogeneous group. The results of this study indicated that perpetrator-victims had greater risks of several dimensions of mental health problems than pure victims and pure perpetrators. The results further support the results of the previous study that the perpetrator-victims were the most vulnerable group for developing multiple psychopathological deviances when compared with other types of bullying behaviors [40]. Previous research also suggested that perpetrator-victims, in particular, could benefit from early identification and intervention [12]. It is interesting that no difference was found in the risk of insomnia, general anxiety, and social phobia between perpetrator-victims and pure victims. This finding is in accordance with the results of a previous followup study showing that pure victims and perpetrator-victims were similar in some ways with regard to their behavior and emotional problems [12]. Our findings raise the possibility that bullying has harmful consequences for its victims with regards to symptoms of insomnia, general anxiety, and social phobia, whether or not the victims also bully others. However, this possibility cannot be confirmed without further study. This study is one of the first studies that examined the risk of a series of mental health problems compared among the adolescents with different levels and types of bullying involvement experience. However, there were several limitations in this study. First, the cross-sectional research design limited our ability to draw conclusions regarding the causal relationships between involvement in bullying and mental health problems. Longitudinal studies are needed to examine the temporal sequence of different levels and types of involvement in bullying and mental health problems. Meanwhile, why certain types of mental health problems are more prevalent in different levels/types of bullying involvement needs further study. Second, the data were provided by the adolescents themselves. Whether the information of involvement in bullying and mental health problems was under-reported needs further study. It also needs further study to examine whether the association between involvement in bullying and mental health problems changes when other sources of information is used. Third, the experiences of bullying involvement and mental health problems were measured in different periods. For example, while participants' experiences of bullying involvement were inquired in the period of past one year, depression was just measured by symptoms of the last week. Those who had ever been depressed but were not in a current depressive episode might be missed.

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5. Conclusion The results of this study indicate that adolescents who are involved in multiple types of bullying have the greatest risk of mental health problems and need the greatest attention in surveying and intervention programs. Mental health professionals must take this difference in comorbid mental health problems into consideration when assessing adolescents who are involved in different types of bullying instead of assuming that victims and perpetrators are a homogeneous group.

Acknowledgment This study was partially supported by grants NSC 982410-H-037-005-MY3 and 99-2314-B-037-028-MY2 awarded by the National Science Council, Taiwan (ROC) and the grant KMUH 100-0R48 awarded by Kaohsiung Medical University Hospital.

References [1] Pivak H, Prothrow-Stith D. The need to address bullying—an important component of violence prevention. J Am Med Assoc 2001;285:2131-2. [2] Bond L, Carlin JB, Thomas L, Rubin K, Patton G. Does bullying cause emotional problems? A prospective study of young teenagers. BMJ 2001;323:480-4. [3] Kaltiala-Heino R, Rimpelä M, Marttunen M, Rimpelä A, Ratenen P. Bullying, depression and suicidal ideation in Finnish adolescents: school survey. BMJ 1999;319:348-50. [4] Nansel TR, Craig W, Overpeck MD, Saluja G, Ruan WJ. Health Behaviour in School-aged Children Bullying Analyses Working Group. Cross-national consistency in the relationship between bullying behaviors and psychosocial adjustment. Arch Pediatr Adolesc Med 2004;158:730-6. [5] Sourander A, Jensen P, Rönning JA, Niemelä S, Helenius H, Sillanmäki L, et al. What is the early adulthood outcome of boys who bully or are bullied in childhood? The Finnish “From a Boy to a Man” study. Pediatrics 2007;120:397-404. [6] Kim YS, Leventhal B. Bullying and suicide. A review. Int J Adolesc Med Health 2008;20:133-54. [7] Holmberg K, Hjern A. Bullying and attention-deficit/hyperactivity disorder in 10-year-olds in a Swedish community. Dev Med Child Neurol 2008;50:134-8. [8] Ferrett HL, Cuzen NL, Thomas KG, Carey PD, Stein DJ, Finn PR, et al. Characterization of South African adolescents with alcohol use disorders but without psychiatric or polysubstance comorbidity. Alcohol Clin Exp Res 2011;35:1705-15. [9] Wolke D, Woods S, Bloomfield L, Karstadt L. The association between direct and relational bullying and behaviour problems among primary school children. J Child Psychol Psychiatry 2000;41: 989-1002. [10] Wang J, Iannotti RJ, Luk JW, Nansel TR. Co-occurrence of victimization from five subtypes of bullying: physical, verbal, social exclusion, spreading rumors, and cyber. J Pediatr Psychol 2010;35: 1103-12. [11] Peeters M, Cillessen AH, Scholte RH. Clueless or powerful? Identifying subtypes of bullies in adolescence. J Youth Adolesc 2010;39:1041-52.

[12] Turner HA, Finkelhor D, Hamby SL, Shattuck A, Ormrod RK. Specifying type and location of peer victimization in a national sample of children and youth. J Youth Adolesc 2011;40:1052-67. [13] Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simons-Morton B, Scheidt P. Bullying behaviors among US youth: Prevalence and association with psychosocial adjustment. JAMA 2001;285:2094-100. [14] Woods S, White E. The association between bullying behaviour, arousal levels and behaviour problems. J Adolesc 2005;28:381-95. [15] Kokkinos CM, Panayiotou G. Predicting bullying and victimization among early adolescents: Associations with disruptive behavior disorders. Aggress Behav 2004;30:520-33. [16] Fekkes M, Pijpers FIM, Verloove-Vanhorick SP. Bullying behavior and associations with psychosomatic complaints and depression in victims. J Pediatr 2004;144:17-22. [17] Kumpulainen K, Rasanen E, Henttonen I. Children involved in bullying: Psychological disturbance and the persistence of the involvement. Child Abuse Negl 1999;23:1253-62. [18] Arseneault L, Walsh E, Trzesniewski K, Newcombe R, Caspi A, Moffitt TE. Bullying victimization uniquely contributes to adjustment problems in young children: a nationally representative cohort study. Pediatrics 2006;118:130-8. [19] Liang H, Flisher AJ, Lombard CJ. Bullying, violence, and risk behavior in South African school students. Child Abuse Negl 2007;31: 161-71. [20] Yen CF, Ko CH, Wu YY, Yen JY, Hsu FC, Yang P. Normative data on anxiety symptoms on the Multidimensional Anxiety Scale for children in Taiwanese children and adolescents: Differences in sex, age, and residence and comparison with an American sample. Child Psychiatry Hum Dev 2010;41:614-23. [21] Ministry of the Interior. 2001 Taiwan-Fukien demographic fact book. Taipei, Taiwan: Republic of China: Executive Yuan; 2002 [in Chinese]. [22] Kim YS, Koh YJ, Noh J. Development of Korean-Peer Nomination Inventory (K-PNI): An inventory to evaluate school bullying. J Korean Neuropsychiatry Assoc 2001;40:867-75. [23] Yen CF, Kim YS, Tang TC, Wu YY, Cheng CP. Factor structure, reliability, and validity of the Chinese version of the School Bullying Experience Questionnaire. Kaohsiung J Med Sci 2012;28:500-5. [24] Chien CP, Cheng TA. Depression in Taiwan: Epidemiological survey utilizing MC-CES-D. Seishin Shinkeigaku Zasshi 1985;87:335-8. [25] Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas 1977:385-401. [26] Soldatos CR, Dikeos DG, Paparrigopoulos TJ. Athens Insomnia Scale: validation of an instrument based on ICD-10 criteria. J Psychosom Res 2000;48:555-60. [27] Yen CF, King BH, Chang YP. Factor structure of the Athens Insomnia Scale and its associations with demographic characteristics and depression in adolescents. J Sleep Res 2010;19:12-8. [28] Yen CF, Ko CH, Yen JY, Cheng CP. The multidimensional correlates associated with short nocturnal sleep duration and subjective insomnia among Taiwanese adolescents. Sleep 2008;31:1515-25. [29] March JS. Multidimensional Anxiety Scale for Children. North Tonawanda, NY: Multi-Health Systems Inc; 1997. [30] Yen CF, Yang P, Wu YY, Hsu FC, Cheng CP. Factor structure, reliability and validity of the Taiwanese version of the Multidimensional Anxiety Scale for children. Child Psychiatry Hum Dev 2010;41:342-52. [31] Connor KM, Davidson JRT, Churchill LE, Sherwood A, Foa E, Weislerm RH. Psychometric Properties of the Social Phobia Inventory (SPIN). New self-rating scale. Br J Psychiatry 2000;176:379-86. [32] Yen JY, Ko CH, Yen CF, Wu HY, Yang MJ. The comorbid psychiatric symptoms of Internet addiction: attention deficit and hyperactivity disorder (ADHD), depression, social phobia, and hostility. J Adolesc Health 2007;41:93-8. [33] Wolraich ML, Lambert W, Doffing MA, Bickman L, Simmons T, Worley K. Psychometric properties of the Vanderbilt ADHD Diagnostic Parent Rating Scale in a referred population. J Pediatr Psychol 2003;28:559-67.

C.-F. Yen et al. / Comprehensive Psychiatry 55 (2014) 405–413 [34] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text Revision. Washington DC: American Psychiatric Association; 2000. [35] Puig-Antich J, Chambers W. The Schedule for Affective Disorders and Schizophrenia for School Age Children (Kiddie-SADS). New York: New York State Psychiatric Institute; 1978. [36] Tang TC, Ko CH, Yen JY, Lin HC, Liu SC, Huang CF, et al. Suicide and its association with individual, family, peer and school factors in a population of 10,233 adolescents in southern Taiwan. Suicide Life Threat Behav 2009;39:91-102. [37] Knight JR, Sherritt L, Harris SK, Gates EC, Chang G. Validity of brief alcohol screening tests among adolescents: A comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res 2003; 27:67-73. [38] Ko CH, Yen JY, Yen CF, Chen CS, Weng CC, Chen CC. The association between Internet addiction and problematic alcohol use in adolescents: the problem behavior model. Cyberpsychol Behav 2008;11:571-6. [39] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC: American Psychiatric Association; 1994. [40] Kim YS, Leventhal BL, Koh YJ, Hubbard A, Boyce AT. School bullying and youth violence: causes or consequences of psychopathology? Arch Gen Psychiatry 2006;63:1035-41. [41] Kumpulainen K, Räsänen E. Children involved in bullying at elementary school age: their psychiatric symptoms and deviance in adolescence. An epidemiological sample. Child Abuse Negl 2000;24: 1567-77.

413

[42] Sourander A, Jensen P, Rönning JA, Elonheimo H, Niemelä S, Helenius H, et al. Childhood bullies and victims and their risk of criminality in late adolescence: the Finnish From a Boy to a Man study. Arch Pediatr Adolesc Med 2007;161:546-52. [43] Yen CF, Kim YS, Wang PW, Lin HC, Tang TC, Wu YY. Sociodemographic correlates of involvement in school bullying among adolescents in southern Taiwan. Taiwanese J Psychiatry (Taipei) 2012; 26:197-206. [44] Lin HC, Tang TC, Yen JY, Ko CH, Huang CF, Liu SC, et al. Depression and its association with self-esteem, family, peer and school factors in a population of 9,586 adolescents in southern Taiwan. Psychiatry Clin Neurosci 2008;62:412-20. [45] Liu TL, Yang P, Ko CH, Yen JY, Yen CF. Association between attention-deficit/hyperactivity disorder symptoms and anxiety symptoms in Taiwanese adolescents. J Atten Disord, in press. [46] Gau SSF, Chong MY, Yang P, Yen CF, Liang KY, Cheng ATA. A longitudinal study on psychiatric and psychosocial predictors for substance use disorders among adolescents. Br J Psychiatry 2007;190: 42-8. [47] Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51:1173-82. [48] Shetgiri R, Lin H, Flores G. Identifying children at risk for being bullies in the United States. Acad Pediatr 2012;12:509-22. [49] Kim YS, Koh YJ, Leventhal BL. Prevalence of school bullying in Korean middle school students. Arch Pediatr Adolesc Med 2004;158: 737-41.