288
research on risk assessment. MML and
CJR have provided expert witness testi-
mony. MBP, SC and SPS have no potential
conflicts of interest.
See Review by Allnutt et al., 2013,
47(8): 728–736
References
Allnutt SH, Ogloff JR, Adams J, et al. (2013)
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Douglas KS, Ogloff JR, Nicholls TL, et al. (1999)
Assessing risk for violence among psychiatric
Is bullying in children and
adolescents a modifiable
risk factor for mental
illness?
Kasia Kozlowska1,2,3 and
Earle Durheim1
1The Children’s Hospital at Westmead,
Westmead, Australia
2Brain Dynamics Centre at Westmead
Hospital, Westmead, Australia
3Disciplines of Psychiatry and of Paediatrics
and Child Health, University of Sydney
Medical School, Sydney, Australia
Corresponding author:
Kasia Kozlowska, Department of
Psychological Medicine, The Children’s
Hospital at Westmead, Westmead, NSW 2145,
Australia.
Email: kkoz6421@uni.sydney.edu.au
DOI: 10.1177/0004867413515529
Scott and colleagues (2014) discuss
the importance of bullying as a risk
factor for serious mental illness and
propose a public health intervention
to target bullying in Australian schools
at a population level. Their article is
timely: ‘bullying’ – the modern shape-
shifter – has transformed itself into a
cyber-entity that invades and lives in
the psyche of modern children and
adolescents.
Australian & New Zealand Journal of Psychiatry, 48(3)
patients: The HCR-20 violence risk assess-
ment scheme and the Psychopathy Checklist:
Screening Version. Journal of Consulting and
Clinical Psychology 67: 917–930.
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in discharged patients with schizophrenia and
other psychoses: A national case-control
study. Schizophrenia Research 123: 263–269.
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chiatry serve the interests of patients or the
public? No. BMJ 346: f857.
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the belief in dangerousness. Australian and New
Zealand Journal of Psychiatry 46: 1099–1100.
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Systematic review and meta-analysis of the
clinical factors associated with the suicide
of psychiatric in-patients. Acta Psychiatrica
Scandinavica 124: 18–29.
Large MM, Ryan CJ, Singh SP, et al. (2011b) The
predictive value of risk categorization in
Traditional bullying typically
involved a bully (usually a more pow-
erful individual) or bullies, who con-
fronted the victim face to face with
the intention of manipulation and
intimidation. Whether at school or in
the community, bullying occurred in a
time-limited fashion. Home remained
a place of sanctuary where the child/
adolescent might recover from the
challenges of the day. Modern bullying
has no boundaries. Cyber-bullying –
an increasing form – has no respect
for boundaries between home and
school, night and day, public and pri-
vate. It continues constantly and ubiq-
uitously through online applications
such as text messaging and social-net-
working. These are so diverse and
ever-changing that parents, often
cyber-naïve, have little chance of
keeping their children safe. Legal sys-
tems are likewise ill prepared. In July
2013 the American state of Florida
enacted a cyber-bullying law that is
likely to become a model for laws in
other states. The problem has yet to
be addressed in Australia, at either
the state or federal level, although
harassment or threats are covered by
the 2004 Commonwealth Crimes
Legislation Amendment ((Tele­
communications Offences and Other
Measures) Act (No.2)).
ANZJP Correspondence
schizophrenia. Harvard Review of Psychiatry
19: 25–33.
Ryan C, Nielssen O, Paton M, et al. (2010) Clinical
decisions in psychiatry should not be based
on risk assessment. Australasian Psychiatry 18:
398–403.
Ryan CJ and Large MM (2013) Suicide risk assess-
ment: Where are we now? Medical Journal of
Australia 198: 462–463.
Troquete NA, van den Brink RH, Beintema H, et al.
(2013) Risk assessment and shared care planning
in out-patient forensic psychiatry: Cluster ran-
domised controlled trial. British Journal of Psychiatry
202: 365–371.
Wand T (2012) Investigating the evidence for the
effectiveness of risk assessment in mental
health care. Issues in Mental Health Nursing
33: 2–7.
Wand T and Large MM (2013) Little evidence for
the usefulness of violence risk assessment.
British Journal of Psychiatry 202: 468.
Some perpetrators of cyber-bully-
ing are known to their victims; others
are ‘trolls’ specialising in sowing dis-
cord online; they may even be the
recipients themselves (a form of self-
harassment or self-harm). Efforts to
address bullying are complicated by
non-existent or nascent legal frame-
works for intervention and by the
logistical difficulties in tracking the
originators of anonymous messages.
The proliferation of photo-sharing
applications – allowing children and
adolescents to exchange pictures of
themselves, called ‘selfies’ – raises the
stakes by creating electronic, immedi-
ately and widely distributable images,
which, when sexually explicit, raise
questions about the production and
distribution of pornography.
In preparing this commentary, we
carried out an audit of 30 consecutive
presentations to our Emergency
Department in 2013 and found that
50% of cases involved technology as
part of the presenting history. To give
a flavour of the problem, we offer a
clinical vignette, a typical case that
presents to our emergency depart-
ment on a daily basis:
Ellen, a 13-year-old girl in year 8, lived
with her mother and younger brother.
Ellen’s parents were separated; she felt
ANZJP Correspondence
rejected by her father and was sensitive
to rejection by others. Primary school
was a refuge for Ellen, but life in high
school was more complicated. Her two
closest friends started smoking and
acting ‘cool’ and were angered by
Ellen’s refusal to follow suit. Ellen’s
mother attempted to monitor Ellen’s
social-networking account (as Ellen’s
‘friend’),but much of the communication
– e.g. ‘YABYABYAB’ ‘FOC’ ‘WTF?’
(see www.urbandictionary.com/) –
occurred via social steganography, a
coded language used to keep out
outsiders (Boyd and Marwick, 2011). In
addition, Ellen had set up dual accounts,
resulting in two parallel worlds, one
using language her mother didn’t
understand, and the other which her
mother didn’t know existed. The break
up of Ellen’s friendships was played out
in the first of these two cyber-worlds.
Day and night, Ellen was subjected to
venomous texts, though she gave as
good as she got. Ellen’s health
deteriorated: her sleep was disturbed,
she ruminated constantly, she was
overwhelmed with feelings of rejection,
and daily on the way to school she
experienced panic attacks and felt she
wanted to die. So Ellen retreated into
her other cyber-world, where she
talked to a 16-year-old boy named Sam,
whom she had never met. Ellen didn’t
question his veracity; it was enough
that they ‘connected’. Sam said that he,
like Ellen, had been rejected by his
father and felt depressed. He told Ellen
about cutting and sent her pictures of
his cuts. Ellen began to cut too, wearing
long sleeves so her mother would not
see. Over time the ‘selfies’ became
increasingly sexualised. Sam circulated
them amongst his friends. Ellen then
began to receive daily anonymous
communications that she was a slut,
bitch, cow, and f***ster, that she was no
good and should kill herself. Ellen’s
mother noticed that Ellen was moody
and withdrawn and tried, unsuccessfully,
to woo her out of her bedroom. Was
all Ellen’s adolescence going to be like
this? The situation came into focus
when Ellen posted that she would end
her life, took an overdose, and, after a
friend contacted Ellen’s mother, was
brought into the Emergency
Department.
Ellen’s story, an amalgam of repeated
tales told in our Emergency Depart­
ment, highlights the complexity of
bullying today. Cyber-bullying violates
many social norms and potentially
includes criminal behaviour, such as
harassment, stalking, pornography,
and incitement of individuals to harm
or kill themselves. As highlighted by
Scott and colleagues, a national anti-
bullying intervention focused on
measuring the prevalence of bulling
via available infrastructure – the
National Assessment Program for
Literacy and Numeracy (NAPLAN)
– could function to increase aware-
ness and galvanize students who are
aware of bullying to intervene by
bringing it to the attention of parents
and school staff. Making the presence
of bullying explicit, rather than secret,
is a powerful intervention in its own
right. However, school-based inter-
ventions are no more than a first
step. They would need to be sup-
ported by public awareness cam-
paigns delivered by the Australian
government and by collaborations
with therapeutic organisations such
as headspace. In addition, the increas-
ingly multi-dimensional and diverse
forms of bullying require legislative
action and close collaboration with
child protection agencies, the police
and the judicial system.
Scott and colleagues build upon the
long-standing ‘standard’ conception of
Australian & New Zealand Journal of Psychiatry, 48(3)
289
bullying as something like a physical
act that can be easily defined, identi-
fied and then reported (e.g., by
another student, in the school setting).
However, the continuing evolution of
cyber-bullying will raise ongoing ques-
tions concerning definition and identi-
fication. Since the information and
messages involved in cyber-bullying
may be shared within existing social
networks, members of those net-
works who report cyber-bullying may
find themselves the next victims. The
cost of reporting may be very high
indeed. It remains an open question
whether the intervention suggested
by Scott and colleagues will serve as a
useful foundation for addressing the
new world of bullying, but it is surely a
good start.
Funding
This research received no specific
grant from any funding agency in the
public, commercial or not-for-profit
sectors.
Declaration of interest
The authors report no conflicts of
interest. The authors alone are respon-
sible for the content and writing of the
paper.
See Viewpoint by Scott et al., 2014,
48(3): 209–212
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