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TRADITIONAL FOCUS ON SCHOOL SETTINGS

In the past decade, 49 states have instituted anti-bullying laws, according to Vessey. Research on the problem has grown substantially, as has the number of anti-bullying programs in schools. But as Vessey sees it, there is little improvement to show for all the effort.

The focus of state and local government efforts has been to define and outlaw behavior associated with bullying, mandate anti-bullying school programs, and create specific criminal statutes with punishment ranging from school suspension to jail time. The drawback, Vessey says, is that most school programs are group oriented and designed to encourage empathy; they have had little effect on the prevalence of bullying, which produces high rates of absenteeism and diminished academic performance.

Even the most effective anti-bullying school programs don鈥檛 offer practical solutions. 鈥淵ou can build awareness but you don鈥檛 necessarily teach kids strategy: what to do when bullying is happening in front of their face.鈥� Even when students can听turn to a school nurse (or a school psychiatrist in some wealthier schools and systems), Vessey says, 鈥淜ids don鈥檛 feel there is privacy.鈥� They fear that word will get around or they will be seen reporting to school administrators.

But while schools and legislatures have actively targeted the problem, organized health care, particularly nursing, has done little, according to Vessey. Indeed, while exploring the topic for Nursing Outlook, Vessey says she found scant attention paid to bullying in pediatric nursing. Her 2013 study pointed to a critical need for health care providers to take as active and systematic a role in screening for youth bullying as they do for other health concerns. Stepped-up efforts by health care providers are essential to identifying high-risk youths, detecting victims earlier, and curbing bullying鈥檚 cascading ill effects.

鈥淎ddressing bullying within a health context across health care settings is a nursing imperative,鈥� Vessey鈥檚 article concluded.

DETECTION THROUGH PRIMARY CARD PROVIDERS

The fact that 90 percent of adolescents visit their primary care provider at least once a year recommends the clinical setting as the best venue to administer screening questions about bullying, Vessey says. 鈥淎dolescents are more willing to confide in their primary care provider or nurse practitioner,鈥� she adds. Some primary care providers say they are already screening for bullying by simply asking, 鈥淎re you being bullied?鈥� But Vessey says that the nature of bullying leads young patients to give overly subjective answers, under- or overreporting incidents.

Hence the need for a screening tool aimed at finding the kids who most likely are being bullied and most likely to suffer consequences, so health care providers can flag the right patients and refer them for fuller assessment.

Good tools exist for detecting signs of domestic violence and alcoholism, and the success of those instruments fuels hope for greater bullying detection. However, Vessey is mindful that screening for these and other public health imperatives鈥攆rom prevalence of sexual activity to tobacco, alcohol, and drug use to depression to immunizations鈥攊s crowding the very brief time allotted to most routine clinical visits.

鈥淭he volume has just increased exponentially, and the time for the visits has been cut shorter and shorter,鈥� Vessey says. 鈥淭o tell any provider that you have to听screen for one more thing is enough to make you go cross-eyed.鈥� Any screening tool devised to detect bullying must be developed with that reality in mind. 鈥淚f we want uptake by primary care providers it needs to be done in such a way that it is reliable, simple to administer, free, doesn鈥檛 take much time, and is acceptable to providers, parents, and kids,鈥� she says.

Vessey wants to be sure that the CABS screen will be effective across cultural and socioeconomic groups. That鈥檚 why the study includes a range of adolescent participants from diverse cultural and socioeconomic backgrounds. Data is being collected throughout the Boston metropolitan area, Portland, and rural Maine.

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IMPROVING INTERVENTION AND PREVENTION

Vessey is principal investigator of the CABS scale, which is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The three-part mixed methodological study focuses on groups of young participants, asking what it means to be bullied and how they would feel if their primary care provider questioned them about it. The most illuminating responses will be vetted by an interdisciplinary group of clinical experts, principals, and counselors, then analyzed and winnowed further. The remaining questions will be put to 300 to 400 youths in a written questionnaire. Those results will be further analyzed and boiled down to four questions that can be quickly and easily incorporated in a doctor or nurse practitioner visit.

The goal of the screening questions is to identify youths involved in bullying earlier鈥攅ven before the physical signs are clear鈥攁nd intervene with medical and mental health treatment to curb harmful effects. Vessey鈥檚 aim is to reach victims as early as possible, at the annual trip to the doctor or in an emergency room visit, possibly sparing millions of adolescents further suffering.

鈥淚 want to focus on the middle group that is probably being bullied at school some, but hasn鈥檛 shared it with anyone yet.鈥� Missing an opportunity to help them means a critical lag in identifying and intervening before negative effects develop. Vessey says, 鈥淲e know that the earlier you come upon a problem, the easier it is to have success.鈥�