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Article |

Bullying, Psychosocial Adjustment, and Academic Performance in Elementary School FREE

Gwen M. Glew, MD; Ming-Yu Fan, PhD; Wayne Katon, MD; Frederick P. Rivara, MD; Mary A. Kernic, PhD, MPH
[+] Author Affiliations

Author Affiliations: Departments of Psychiatry and Behavioral Sciences (Drs Glew, Fan, and Katon), Pediatrics (Drs Glew and Rivara), and Epidemiology (Drs Rivara and Kernic), University of Washington, and Harborview Injury Prevention and Research Center (Drs Rivara and Kernic), Seattle.


Arch Pediatr Adolesc Med. 2005;159(11):1026-1031. doi:10.1001/archpedi.159.11.1026.
Text Size: A A A
Published online

Background  Over the past decade, concerns about bullying and its role in school violence, depression, and health concerns have grown. However, no large studies in the United States have examined the prevalence of bullying during elementary school or its association with objective measures of school attendance and achievement.

Objective  To determine the prevalence of bullying during elementary school and its association with school attendance, academic achievement, disciplinary actions, and self-reported feelings of sadness, safety, and belonging.

Design  Cross-sectional study using 2001-2002 school data.

Setting  Urban, West Coast public school district.

Participants  Three thousand five hundred thirty (91.4%) third, fourth, and fifth grade students.

Main Outcome Measure  Self-reported involvement in bullying.

Results  Twenty-two percent of children surveyed were involved in bullying either as a victim, bully, or both. Victims and bully-victims were more likely to have low achievement than bystanders (odds ratios [ORs], 0.8 [95% confidence interval (CI), 0.7-0.9] and 0.8 [95% CI, 0.6-1.0], respectively). All 3 bullying-involved groups were significantly more likely than bystanders to feel unsafe at school (victims, OR, 2.1 [95% CI, 1.1-4.2]; bullies, OR, 2.5 [95% CI, 1.5-4.1]; bully-victims, OR, 5.0 [95% CI, 1.9-13.6]). Victims and bully-victims were more likely to report feeling that they don’t belong at school (ORs, 4.1 [95% CI, 2.6-6.5] and 3.1 [95% CI, 1.3-7.2], respectively). Bullies and victims were more likely than bystanders to feel sad most days (ORs 1.5 [95% CI, 1.2-1.9] and 1.8 [95% CI, 1.2-2.8], respectively). Bullies and bully-victims were more likely to be male (ORs, 1.5 [95% CI, 1.2-1.9] and 3.0 [95% CI, 1.3-7.0], respectively).

Conclusions  The prevalence of frequent bullying among elementary school children is substantial. Associations between bullying involvement and school problems indicate this is a serious issue for elementary schools. The research presented herein demonstrates the need for evidence-based antibullying curricula in the elementary grades.

Figures in this Article

Bullying is defined as any repeated negative activity or aggression intended to harm or bother someone who is perceived by peers as being less physically or psychologically powerful than the aggressor(s).1 Of particular concern is the frequent bullying of children because this may have an adverse impact on victims’ scholastic achievement, desire to attend school, and self-esteem.2

The first large-scale study of bullying in the United States was published by Nansel and colleagues3 in 2000. By surveying more than 15 000 students in grades 6 through 10, they found the prevalence of bullying involvement among American teens and preteens was approximately 30%. The authors also found a significant association between bullying involvement and lower self-perceived academic achievement and other measures of social maladjustment.

Although Nansel et al found important evidence regarding the potential detrimental effects of bullying on self-perceived academic achievement and school attendance, no objective measures of academic achievement or attendance were collected. Furthermore, the study did not include children in lower grades (prior to sixth grade). Authors from other countries have reported the highest prevalence of bullying is among elementary school–aged children.1,4 The current study examines the prevalence of bullying involvement among elementary school children and its association with school records of attendance, academic achievement test scores, suspension or expulsion, and self-reported measures of psychosocial adjustment.

A large, urban public school system in 1 West Coast US city agreed to participate in this study. The school district annually surveys students in their homeroom classes to determine how the school climate can be improved to better serve the students. The authors were asked to submit bullying questions for the 2001 survey because the district recognized bullying as a problem.

Survey questions were linked to school data on standardized test scores, attendance records, school suspension and expulsion records, and demographic data. All data were subsequently provided to researchers without identifying information. The study was approved by the University of Washington (Seattle) institutional review board and by the research committee of the school district.

In this study, we sought to address 3 questions: (1) What factors are associated with bullying involvement among young children? (2) Is bullying associated with adverse academic achievement and attendance? (3) What are the behavioral and emotional problems associated with bullying?

MEASURES
Bullying

Four questions about bullying were accepted by the school district for use in the internal school climate survey, along with 33 other questions. These 4 questions (Figure) were taken from a larger, reliable, well-validated bullying survey and adapted for the age groups surveyed.5 If the first 2 key bullying questions were not answered but the rest of the survey was, the respondent was unable to be classified as a victim or bully and was classified as a nonresponder. Those 12.4% who fell into the nonresponder category were similar to responders on sex, ethnicity, age, grade, socioeconomic status, special education status, and suspension or expulsion status. However, they differed from responders in that they had lower attendance and achievement and were more likely to endorse gun carrying, stealing, and smoking. Because of these differences, they were analyzed separately.

Place holder to copy figure label and caption
Figure.

Survey questions.

Graphic Jump Location

Students were classified as only victims, only bullies, bully-victims (those who were both victimized by bullies and bullied other children), bystanders (children who did not bully others and were not bullied by others), or nonresponders (students who could not be classified) based on their answers to the survey questions. Bystanders served as the reference group in all analyses.

Cutoffs for bullying status were chosen to be consistent with prior literature.1,3 Children who said they were hurt, bothered, or made fun of always, as opposed to sometimes and never, were considered victims. Children who said they bullied others 2 to 3 times per month or more were classified as bullies. Children who fit criteria for both bullies and victims were removed from the “bullies only” and “victims only” categories and treated as a separate “bully-victim” group.

Academic Achievement, Attendance, and Disciplinary Actions

The Washington Assessment of Student Learning6 and the Iowa Test of Basic Skills,7 2 standardized measures of academic achievement, were administered in the spring of 2002. Each examination consisted of subtest scores for reading, math, and listening. A composite score was created for each child, which was used as a proxy for academic achievement.

School attendance was expressed as a percentage of days attended of days enrolled during the 2001-2002 school year. This was treated as a continuous variable.

Students were categorized as suspended or expelled if they experienced either of these during the 2001-2002 school year. This variable was then treated as a dichotomous variable (suspended or expelled vs neither suspended nor expelled).

Psychosocial Measures

Other survey questions used for this analysis included whether the students felt safe at school, whether they felt they belonged at their school, and whether they felt sad most days. In addition, students were queried about how wrong they felt it was to engage in specific high-risk behaviors: carrying a gun to school, beating up people who start a fight, smoking cigarettes, stealing, cheating, initiating fights, and attacking other students with the idea of seriously hurting them (Figure).

Socioeconomic Status

Receiving free lunch at school was used as a proxy for low-income status. Based on the National School Lunch Program for the 2001-2002 school year, a child was eligible for free lunch if his or her family income was lower than 130% of the poverty level.8

STATISTICAL METHODS

Descriptive statistics including means, standard deviations, and frequencies for demographic variables are provided along with unadjusted odds ratios and their 95% confidence intervals (Table 1). Similar statistics for psychosocial variables are presented in Table 2. Since the 3 achievement subtest scores for each student are highly correlated, the statistical significance of each of them considered together in the same model might be diminished because of colinearity. To address this issue and use all available achievement data, we performed a principal component analysis. The result suggested that a composite score using similar weights for the 3 subtest scores would explain 84% of the variance. Therefore, we created a composite achievement measure, which was defined as the average of the 3 subtest scores. The composite achievement score was treated as a continuous variable in all analyses. Mean achievement test scores for each group were reported in Table 2.

Table Graphic Jump LocationTable 1. Demographic Unadjusted Bivariate Associations of Students Surveyed Using Column Percentages
Table Graphic Jump LocationTable 2. School and Psychosocial Outcomes: Unadjusted Bivariate Associations Using Column Percentages*

Multiple logistic regression was performed with bullying status as the response variable, and each of the groups was compared separately to the bystander group. All analyses were adjusted for race and ethnicity, sex, age, and socioeconomic status as potential confounders. Each independent variable of interest was tested individually for significant association with bullying status using logistic regression adjusting for age, sex, ethnicity, and socioeconomic status. All significant independent variables from these regressions were then entered into the final model to determine which factors remained significantly associated with bullying status after adjustment for age, sex, race, ethnicity, and socioeconomic status. All variables included in each of the 4 final models, whether significant or not, are presented with their associated odds ratios and 95% confidence intervals in Table 3. Since 1 percentage difference in achievement score (range, 0-100) might not be considered clinically significant, we changed the unit of achievement score to 10 percentage points and the odds ratios for achievement score were interpreted accordingly.

Table Graphic Jump LocationTable 3. Multiple Logistic Regressions

The population of students sampled included all children in grades 3, 4, and 5 who attended 1 of the 27 schools where the survey was conducted. Of the 3861 students enrolled in these schools, 3530 (91.4%) participated in the survey.

Overall, 194 children (6%) surveyed reported being bullied “always” but did not bully others, 431 (14%) said they bullied others but were not seriously bullied themselves, and 51 children (2%) reported both bullying others and being bullied by others. Four hundred thirty-six (12.4%) did not respond to key bullying questions. The remaining 2416 (78%) reported that they were not involved in bullying. In this study, only 42% of students defined as victims and 44% of those defined as bully-victims said that they had reported their victimization to someone.

The playground was the most likely site (71%) for victimization followed by classrooms (46%), gym classes (40%), lunchrooms (39%), halls and stairs (33%), and buses (28%) among the 245 students who answered this question.

Forty-nine percent of the students were aged 8 to 9 years, and 50% were aged 10 to 11 years. Only 1% were aged 12 to 13 years. The mean (SD) age of the students was 9.6 (1.0) years. Fifty percent of students were female. Approximately one third of the students were from each of the 3 grades (third, fourth, and fifth grades). Sixty-four percent were from ethnic minority groups (27%, African American; 11%, Hispanic; 2%, Native American; and 24%, Asian). Forty-eight percent of students received free lunches.

Table 1 and Table 2 show bivariate associations between bullying status and school and psychosocial outcomes. Mean achievement scores (in percentages) for all bullying-involved groups were significantly lower than the scores of bystanders. Bully-victims had the highest percentage of boys. Bullies and bully-victims were generally older. More victims received free lunch than the other groups. All of the groups involved in bullying were significantly more likely to be suspended or expelled; to feel unsafe, sad, and like they didn’t belong at school; and to endorse cheating if they could get away with it compared with bystanders. Bullies and nonresponders were more likely than bystanders to endorse carrying guns to school, beating up someone who started a fight, and smoking cigarettes. Nonresponders were not more likely to say they felt sad, unsafe, or that they did not belong. No bullying-involved group had lower attendance compared with bystanders.

Multiple logistic regression analyses (Table 3) yielded the following results after controlling for age, sex, race and ethnicity, and socioeconomic background variables.

VICTIMS

Lower achievement, feeling unsafe, feeling as if one does not belong at school, and feeling sad were all positively associated with being a victim as opposed to a bystander. A student with a 10% higher achievement score had 20% lower odds of being a victim. Among those who felt unsafe at school, their odds of being a victim were 2.1 times as high as those who felt safe. Feeling as though one did not belong at school was most strongly associated with being a victim; the odds of members of this group being a victim were 4.1 times higher than those who felt they belonged at school. For students who felt sad most days, their odds of being a victim were 1.8 times higher than the odds of being a victim among those who did not feel sad most days.

BULLIES

Students who felt unsafe and sad most days had 2.5 and 1.5 times the odds of being a bully compared with a bystander. Students who endorsed beating someone up who started a fight had twice the odds of being a bully. Being male, 10 to 11 years of age (in the older half of the group), African American, and Native American were also associated with greater odds of being a bully.

BULLY-VICTIMS

Feeling unsafe, feeling that they did not belong at school, and lower achievement at school were associated with higher odds of being a bully-victim than a bystander. Those children who felt unsafe at school had 5 times the odds of being a bully-victim. Compared with those who felt they belonged at school, students who felt a lack of belonging had 3.1 times higher odds of being a bully-victim. A 10% higher achievement score was associated with 20% lower odds of being a bully-victim.

NONRESPONDERS

Students who said they did not belong at their school had 2.1 times the odds of being nonresponders than bystanders. Compared with white students, Hispanic students had lower odds of being nonresponders.

To summarize the results of this study, students who said they did not feel safe and that they did not belong at school were more likely to be involved in bullying. Children who said they were sad most days had higher odds of being bullies and victims. Lower achievement scores were associated with being a victim or bully-victim. Boys were more likely to be bullies and bully-victims. Children who said it was okay to beat up people who start a fight had higher odds of being bullies. Lower attendance, being suspended or expelled more, and being from low socioeconomic backgrounds were not associated with involvement in bullying in any way. All of these findings were obtained after adjustment for age, sex, race and ethnicity, and socioeconomic status. The take-home message is that elementary school–aged children who are psychologically distressed are more likely to be involved in some form of bullying, and children who struggle academically are more likely to be victims and bully-victims.

Whether the low academic achievement among victims and bully-victims preceded or was a consequence of victimization from bullying cannot be determined from this cross-sectional study. However, previous literature supports the hypothesis that bullying impairs concentration and subsequent academic achievement in victims.3,911 One study from Great Britain concluded that 11% of 723 elementary, middle, and high school children studied were “extremely stressed” by being bullied. One third of the bullied children in this study reported having impaired concentration and feeling nervous or panicked.10 A study of 204 Midwestern American middle and high school students found that 90% said they had a drop in grades, an increase in anxiety, and a loss of friends or social life as a result of bullying.11 One small study conducted in elementary schools in Los Angeles, Calif, used Stanford Achievement Test scores and grades as a measure of academic achievement and found a significant association between low scores and being a victim of bullying. However, this study did not examine bullies or bully-victims.9 A large US national survey of middle and high school students found that those who perceive themselves as having below-average academic achievement are more likely to be bullies or bully-victims.3

The longtime argument is that achievement test scores, despite their widespread use, validity, and reliability, are not necessarily a measure of success in school or overall school performance. The limitation is that while these scores are a marker of what is learned, they are not a perfect measure of a number of important things learned in school such as social skills, ability to collaborate, ability to accept criticism and learn from it, helping others, persistence when facing problems, ability to pay attention, and a host of other skills. We do not know whether bullying others or being bullied affects the ability to learn these other important skills. Achievement test scores are a marker, but an imperfect one, of school success.

Anecdotal and other evidence suggests that children who are bullied skip school to avoid being bullied.2,10,12,13 The Sharp study10 concluded that 20% of 723 British elementary, middle, and high school children surveyed said they would skip school as a strategy to avoid being bullied. The nationwide 1995 Youth Risk Behavior Surveillance study found that 4.5% of the students surveyed in grades 9 through 12 reported that they had missed at least 1 day of school during the 30 preceding days because they had felt unsafe at school or when traveling to or from school.13 These children were much older than the students in the present study. We include it herein because of the serious lack of information available on this topic in the age group of interest, elementary school students. Along with 1 British study, the present study, focusing on the younger age group and using objective measurement of attendance, did not find that children involved in bullying were associated with lower attendance after adjusting for multiple factors.14

The symptom of frequent sadness is known to have high sensitivity and specificity for the diagnosis of major depression.15 Scales for depression in childhood universally include a question about frequent sadness, which means that sadness is a depressive symptom.16 Both victims and bullies in this study admitted to feeling sad most days compared with children who were bystanders. This suggests that being a bully or a victim of bullying is associated with a key depressive symptom as early as elementary school. This finding adds to the previous literature, which supports a connection between the depressive symptom, sadness, and being involved in bullying among older children.1724

The primary limitation of this study is that it was cross-sectional so causality cannot be inferred. Another potential limitation is that the study was conducted in 1 school district in the United States, which calls into question whether the results can be generalized to other populations. A third limitation is that determination of whether a child was a victim, a bully, or a bully-victim was determined solely by self-report. However, with the intention of minimizing any potential misclassification of victims based on self-report, only the most severely affected children were defined as bullies and victims for this analysis. It would seem unlikely, because of the negative social stigma attached to being a victim, that a child would say they are always bullied if they truly are not. However, for bullies, there is some evidence to suggest that their social status can be above average.25 Because of this, students might be inclined to call themselves bullies even if they truly are not.

The questions used for this survey were based on the Olweus Bullying Questionnaire,5 considered the gold standard for bullying questions. This survey was validated and determined reliable when used in a Scandinavian population. However, the precise wording of the questions was simplified greatly for this study to make the survey appropriate for the young children being studied. There is a definite need for reliability and validity information on both the English version of the Olweus survey and the simplified version of the questions used in this study.

In 2000, the US Secret Service reported that in two thirds of all school shootings that have occurred in the last decade, the attacker felt “bullied, attacked, threatened, or persecuted prior to the incident.”26(p7) Schools across the nation are working to implement antibullying interventions. There are antibullying interventions that do have good evidence to support them, although randomized controlled trials are lacking.1,27 The information presented herein provides additional evidence of the need for elementary school personnel to implement bullying prevention programs, not only to prevent school shootings but also to prevent potential barriers to providing education: student feelings of lack of safety, belonging, and sadness.28 Bullying may be a barrier that impedes effectiveness of teaching, the primary mission of school personnel, yet 1 recent study found that evidence-based, whole-school approaches to bullying are rarely implemented in elementary schools.29 Implementing antibullying interventions in the elementary years, before bullying becomes a part of school culture, might improve schools’ ability to carry out their educational mission by improving students’ ability to focus on learning and establishing an atmosphere of respect early on.

Correspondence: Gwen M. Glew, MD, Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195-6560 (gwenglew@hotmail.com).

Accepted for Publication: May 6, 2005.

Funding/Support: This study was supported by a National Research Scientist Award Fellowship (grants MH20021-06 and MH 20021-07) from the National Institute of Mental Health, Bethesda, Md.

Acknowledgment: Special thanks to Alison Sattler, BA, and Pam Collins, BA, for administrative support.

Olweus  D What we know about bullying. Dunn  Jed.Bullying at School. Malden, Mass Blackwell Publishers Inc1993;9
Rigby  K Does bullying really do children any harm? Available at:http://www.education.unisa.edu.au/bullying/harm.htmlAccessed February 19, 2004
Nansel  TOverpeck  MPilla  RRuan  WSimons-Morton  BScheidt  P Bullying behaviors among US youth. JAMA 2001;2852094- 2100
PubMed Link to Article
Whitney  ISmith  P A survey of the nature and extent of bullying in junior/middle and secondary schools. Educ Res 1993;353- 25
Link to Article
Olweus  D The Revised Olweus Bully/Victim Questionnaire.  Bergen, Norway University of Bergen1996;
 WASL reliability and validity statement. Office of the Superintendent of Public Instruction,Dr Terry Bergeson Web site. Available at:http://www.k12.wa.us/assessment/default.aspxAccessed January 26, 2004
 Iowa Test of Basic Skills (ITBS) reliability and validity. Available at:http://seamonkey.ed.asu.edu/~alex/teaching/assessment/ITBS.htmlAccessed May 28, 2004
 School meals: National School Lunch Program. USDA Food and Nutrition Service Web site. Available at:www.fns.usda.gov/cndAccessed May, 2004
Schwartz  DGorman  A Community violence exposure and children’s academic functioning. J Educ Psychol 2003;95163- 173
Link to Article
Sharp  S How much does bullying hurt? Educ Child Psychology 1995;1281- 88
Hazler  RHoover  JOliver  R What kids say about bullying. Exec Educator 1992;1420- 22
Byrne  B Bullies and victims in a school setting with reference to some Dublin schools. Ir J Psychol Med 1994;15574- 586
Link to Article
Kann  LWarren  CWHarris  WA  et al.  Youth Risk Behavior Surveillance—United States, 1995 [CDC Web site]. Available athttp://www.cdc.gov/mmwr/preview/mmwrhtml/00043812.htmAccessed March 5, 2004
Wolke  DWoods  SBloomfield  LKarstadt  L Bullying involvement in primary school and common health problems. Arch Dis Child 2001;85197- 201
PubMed Link to Article
Kroenke  KSpitzer  RLWilliams  JB The patient health questionnaire-2: validity of a two-item depression screener. Med Care 2003;411284- 1292
PubMed Link to Article
Miller  LSKamboukos  D Symptom-specific measures for disorders usually diagnosed in infancy, childhood, or adolescence: Children's Depression Inventory. American Psychiatric Association,ed.Handbook of Psychiatric Measures Washington, DC American Psychiatric Association2000;299325- 326344- 350
Boulton  MUnderwood  K Bully/victim problems among middle school children. Br J Educ Psychol 1992;6273- 87
PubMed Link to Article
Snyder  JBrooker  MPatrick  MSnyder  ASchrepferman  LStoolmiller  M Observed peer victimization during early elementary school: continuity, growth, and relation to risk for child antisocial and depressive behavior. Child Dev 2003;741881- 1898
PubMed Link to Article
Juvonen  JGraham  SSchuster  M Bullying among young adolescents: the strong, the weak, and the troubled. Pediatrics 2003;1121231- 1237
PubMed Link to Article
Williams  KChambers  MLogan  SRobinson  D Association of common health symptoms with bullying in primary school children. BMJ 1996;31317- 19
PubMed Link to Article
Kaltiala-Heino  RRimpela  MRantanen  PRimpela  A Bullying at school—an indicator of adolescents at risk for mental disorders. J Adolesc 2000;23661- 674
PubMed Link to Article
Bond  LCarlin  JThomas  LRubin  KPatton  G Does bullying cause emotional problems? a prospective study of young teenagers. BMJ 2001;323480- 484
PubMed Link to Article
Salmon  GJames  ASmith  D Bullying in schools. BMJ 1998;317924- 925
PubMed Link to Article
Hawker  DBoulton  M Twenty years’ research on peer victimization and psychosocial maladjustment. J Child Psychol Psychiatry 2000;41441- 455
PubMed Link to Article
Farmer  TWEstell  DBBishop  JL Rejected bullies or popular leaders? Dev Psychol 2003;39992- 1004
PubMed Link to Article
Vossekuil  BReddy  MFein  RBorum  RModzeleski  W U.S.S.S. Safe School Initiative: An Interim Report on the Prevention of Targeted Violence in Schools.  Washington, DC US Secret Service, National Threat Assessment Center2000;
Frey  KHirschstein  MKSnell  JLVan Schoiack Edstrom  LMacKenzie  EPBroderick  CJ Reducing playground bullying and supporting beliefs: an experimental trial of the steps to respect program. Dev Psychol 2005;41479- 490
PubMed Link to Article
Adelman  HSTaylor  L Addressing barriers to learning: beyond school-linked services and full-service schools. Am J Orthopsychiatry 1997;67408- 421
PubMed Link to Article
Dake  JAPrice  JHTelljohann  SKFunk  J Principals’ perceptions and practices of school bullying prevention activities. Health Educ Behav 2004;31372- 387
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure.

Survey questions.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Demographic Unadjusted Bivariate Associations of Students Surveyed Using Column Percentages
Table Graphic Jump LocationTable 2. School and Psychosocial Outcomes: Unadjusted Bivariate Associations Using Column Percentages*
Table Graphic Jump LocationTable 3. Multiple Logistic Regressions

References

Olweus  D What we know about bullying. Dunn  Jed.Bullying at School. Malden, Mass Blackwell Publishers Inc1993;9
Rigby  K Does bullying really do children any harm? Available at:http://www.education.unisa.edu.au/bullying/harm.htmlAccessed February 19, 2004
Nansel  TOverpeck  MPilla  RRuan  WSimons-Morton  BScheidt  P Bullying behaviors among US youth. JAMA 2001;2852094- 2100
PubMed Link to Article
Whitney  ISmith  P A survey of the nature and extent of bullying in junior/middle and secondary schools. Educ Res 1993;353- 25
Link to Article
Olweus  D The Revised Olweus Bully/Victim Questionnaire.  Bergen, Norway University of Bergen1996;
 WASL reliability and validity statement. Office of the Superintendent of Public Instruction,Dr Terry Bergeson Web site. Available at:http://www.k12.wa.us/assessment/default.aspxAccessed January 26, 2004
 Iowa Test of Basic Skills (ITBS) reliability and validity. Available at:http://seamonkey.ed.asu.edu/~alex/teaching/assessment/ITBS.htmlAccessed May 28, 2004
 School meals: National School Lunch Program. USDA Food and Nutrition Service Web site. Available at:www.fns.usda.gov/cndAccessed May, 2004
Schwartz  DGorman  A Community violence exposure and children’s academic functioning. J Educ Psychol 2003;95163- 173
Link to Article
Sharp  S How much does bullying hurt? Educ Child Psychology 1995;1281- 88
Hazler  RHoover  JOliver  R What kids say about bullying. Exec Educator 1992;1420- 22
Byrne  B Bullies and victims in a school setting with reference to some Dublin schools. Ir J Psychol Med 1994;15574- 586
Link to Article
Kann  LWarren  CWHarris  WA  et al.  Youth Risk Behavior Surveillance—United States, 1995 [CDC Web site]. Available athttp://www.cdc.gov/mmwr/preview/mmwrhtml/00043812.htmAccessed March 5, 2004
Wolke  DWoods  SBloomfield  LKarstadt  L Bullying involvement in primary school and common health problems. Arch Dis Child 2001;85197- 201
PubMed Link to Article
Kroenke  KSpitzer  RLWilliams  JB The patient health questionnaire-2: validity of a two-item depression screener. Med Care 2003;411284- 1292
PubMed Link to Article
Miller  LSKamboukos  D Symptom-specific measures for disorders usually diagnosed in infancy, childhood, or adolescence: Children's Depression Inventory. American Psychiatric Association,ed.Handbook of Psychiatric Measures Washington, DC American Psychiatric Association2000;299325- 326344- 350
Boulton  MUnderwood  K Bully/victim problems among middle school children. Br J Educ Psychol 1992;6273- 87
PubMed Link to Article
Snyder  JBrooker  MPatrick  MSnyder  ASchrepferman  LStoolmiller  M Observed peer victimization during early elementary school: continuity, growth, and relation to risk for child antisocial and depressive behavior. Child Dev 2003;741881- 1898
PubMed Link to Article
Juvonen  JGraham  SSchuster  M Bullying among young adolescents: the strong, the weak, and the troubled. Pediatrics 2003;1121231- 1237
PubMed Link to Article
Williams  KChambers  MLogan  SRobinson  D Association of common health symptoms with bullying in primary school children. BMJ 1996;31317- 19
PubMed Link to Article
Kaltiala-Heino  RRimpela  MRantanen  PRimpela  A Bullying at school—an indicator of adolescents at risk for mental disorders. J Adolesc 2000;23661- 674
PubMed Link to Article
Bond  LCarlin  JThomas  LRubin  KPatton  G Does bullying cause emotional problems? a prospective study of young teenagers. BMJ 2001;323480- 484
PubMed Link to Article
Salmon  GJames  ASmith  D Bullying in schools. BMJ 1998;317924- 925
PubMed Link to Article
Hawker  DBoulton  M Twenty years’ research on peer victimization and psychosocial maladjustment. J Child Psychol Psychiatry 2000;41441- 455
PubMed Link to Article
Farmer  TWEstell  DBBishop  JL Rejected bullies or popular leaders? Dev Psychol 2003;39992- 1004
PubMed Link to Article
Vossekuil  BReddy  MFein  RBorum  RModzeleski  W U.S.S.S. Safe School Initiative: An Interim Report on the Prevention of Targeted Violence in Schools.  Washington, DC US Secret Service, National Threat Assessment Center2000;
Frey  KHirschstein  MKSnell  JLVan Schoiack Edstrom  LMacKenzie  EPBroderick  CJ Reducing playground bullying and supporting beliefs: an experimental trial of the steps to respect program. Dev Psychol 2005;41479- 490
PubMed Link to Article
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