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Cyberbullying1.pdf
Cad. Saúde Pública, Rio de Janeiro, 31(3):463-475, mar, 2015
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Cyberbullying and adolescent mental health: systematic review
Cyberbullying e saúde mental dos adolescentes: revisão sistemática
Acoso cibernético y la salud mental de los adolescentes: revisión sistemática
1 Universidade Federal de São Paulo, São Paulo, Brasil. 2 Universidade de São Paulo, São Paulo, Brasil.
Correspondence S. M. B. Bottino Universidade Federal de São Paulo. Rua Cônego Eugênio Leite 933, cj. 93, São Paulo, SP 05414-012, Brasil. [email protected]
Sara Mota Borges Bottino 1
Cássio M. C. Bottino 2
Caroline Gomez Regina 1
Aline Villa Lobo Correia 1
Wagner Silva Ribeiro 1
Abstract
Cyberbullying is a new form of violence that is expressed through electronic media and has giv- en rise to concern for parents, educators and re- searchers. In this paper, an association between cyberbullying and adolescent mental health will be assessed through a systematic review of two databases: PubMed and Virtual Health Library (BVS). The prevalence of cyberbullying ranged from 6.5% to 35.4%. Previous or current expe- riences of traditional bullying were associated with victims and perpetrators of cyberbullying. Daily use of three or more hours of Internet, web camera, text messages, posting personal infor- mation and harassing others online were as- sociated with cyberbullying. Cybervictims and cyberbullies had more emotional and psycho- somatic problems, social difficulties and did not feel safe and cared for in school. Cyberbullying was associated with moderate to severe depres- sive symptoms, substance use, ideation and sui- cide attempts. Health professionals should be aware of the violent nature of interactions oc- curring in the virtual environment and its harm to the mental health of adolescents.
Bullying; Adolescent; Mental Health
REVISÃO REVIEW
Resumo
Cyberbullying, uma nova forma de violência ex- pressa por meio da mídia eletrônica, tem preo- cupado pais, educadores e pesquisadores. A asso- ciação entre cyberbullying e a saúde mental dos adolescentes será revisada. Revisão sistemática em duas bases de dados: PubMed e a Biblioteca Virtual em Saúde (BVS). A prevalência do cyber- bullying variou entre 6,5% a 35,4%. Bullying tradi- cional prévio ou atual estava associado às vítimas e agressores do cyberbullying. Uso diário de três ou mais horas de Internet, web câmera, mensagens de texto, postar informações pessoais e assediar ou- tros online estavam associados ao cyberbullying. “Cybervítimas” e cyberbullies tinham mais pro- blemas emocionais, psicossomáticos, dificulda- des sociais, e não se sentiam seguros e cuidados na escola. O cyberbullying estava associado à sintomatologia depressiva moderada e grave, uso de substâncias, ideação e tentativas de suicídio. Profissionais de saúde devem conhecer as intera- ções de natureza violenta que ocorrem no ambien- te virtual e de seus agravos para a saúde mental dos adolescentes.
Bullying; Adolescente; Saúde Mental
http://dx.doi.org/10.1590/0102-311X00036114
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Introduction
Access to the Internet and use of text messaging has influenced social interaction among teenag- ers in recent decades. Most teenagers have a per- sonal computer or mobile phone and communi- cate daily with several people at the same time, being exposed to the influences of instant con- tact and its repercussions, which in many cases can be harmful 1. More recently, cyberbullying, a new form of violence expressed through elec- tronic media, has concerned parents, educators and researchers due to its effects on adolescents’ mental health 2.
The term cyberbullying is derived from tra- ditional bullying behaviors, which are observed mainly among elementary-school students, such as verbal abuse, teasing, insults and threats, as well as physical aggression, such as hitting, kick- ing, punching and damaging the belongings of others. Such behaviors must occur repeatedly and systematically against an individual who fails or is unable to defend himself or herself, in order to be classified as bullying 3. Correlates of traditional bullying can be useful to understand youth internet harassment, because this field is much more established. Just over 15% of children and adolescents are bullied “sometimes” or more frequently with negative health and social chal- lenges consistently reported. Studies revealed that victims report significantly more concurrent health problems, emotional-adjustment prob- lems, school-adjustment problems, and poorer relationships with classmates when compared with non-bullying involved youth 4,5. According to Hawker & Boulton 6, being the target of bully- ing was most strongly related to depression, com- pared with all other outcomes, in a meta-analysis performed with studies from 23 countries.
Cyberbullying, on the other hand, involves the use of electronic media with the intention of causing harm, humiliation, suffering, fear and despair for the individual who is the target of aggression. These actions can be carried out via email, chat rooms, online voting booths, cell phones and instant messaging 7. Studies suggest that 20-40% of teenagers will have at least one cy- berbullying experience during their adolescence, and that the number of cybervictims is increas- ing 8. Nocentini et al. 9, using a list of behaviors, classified cyberbullying according to the nature of attacks in: (1) written-verbal, which include phone calls, text messages and emails; (2) visual, which involves sending embarrassing images and/or pictures; (3) representation, which refers to more sophisticated attacks, consists of using or stealing someone else’s identity to reveal per- sonal information, using his/her account and;
(4) exclusion, which consists of deliberately ex- cluding someone who is a member of the online group.
Cyberbullying may achieve a greater audi- ence than traditional bullying, since it occurs in the virtual space, where free expression is allowed without social control. Additionally, it is difficult to remove information from a website. Dehue et al. 10 suggest three conditions that must be met for a behavior be considered “cyberbullying”: the attack must be intentional, occur repeatedly and cause psychological distress. The main dam- age caused by cyberbullying is to harm the vic- tim’s reputation, with repercussions that may be even greater than those observed in traditional bullying. Victimization related to cyberbullying has been associated with social and behavioral problems 8. In this article we aimed to review and evaluate the associations between cyberbullying and adolescent mental health problems.
Methods
This review included studies on the prevalence of cyberbullying and its association with men- tal health problems among adolescents in the general population. Several cyberbullying defini- tions have been presented in the literature, de- scribing some aggressive, hostile, or harmful act that is perpetrated by a bully through an unspeci- fied type of electronic device. In this review, we used the following definition of cyberbullying, with the aim of unifying the concepts that appear in the literature: “an intentional act of aggression towards another person online”. Mental health problems refer to a recognizable set of emotional problems, symptoms or behaviors associated with considerable distress and substantial inter- ference with personal functions.
Information sources
We searched for studies published in English, Portuguese and Spanish (languages) in two elec- tronic databases: PubMed and Virtual Health Li- brary (Biblioteca Virtual em Saúde – BVS). The BVS includes data from the Latin American and Caribbean Centre on Health Sciences Informa- tion (LILACS), Spanish Bibliographic Index of Health Sciences (SBIHS), MEDLINE, The Co- chrane Library and SciELO. The Pan American Health Organization/World Health Organiza- tion (PAHO-WHO), together with BIREME (the Latin American and Caribbean Center on Health Sciences Information) provides open access to full-text health related publications from Latin America and the Caribbean. The PRISMA state-
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ment was used to build and elaborate this sys- tematic review and the Effective Public Health Practice Project Quality Assessment Tool (EPHPP) was applied to assess the methodological quality of the articles included 11,12.
Search strategy
The search strategy was performed on two occa- sions: in May and June 2013. We searched for the term “cyberbullying” in all fields, with no time lim- its. The search was conducted using the follow- ing keyword combinations: (cyberbullying OR bullying) AND adolescent AND (mental health OR health). Search details were: cyberbullying OR (bullying [Mesh terms] OR bullying [All fields] OR cyberbullying [All fields]) AND (adolescent [MESH terms] OR adolescent [all fields]) AND (Mental Health [MESH terms] OR (mental [All fields] AND Health [All fields]) OR (mental health [All fields]. Article references were screened for additional information.
Study selection
Articles were evaluated and selected according to the following eligibility criteria: (1) population- based representative samples of 6th to 12th grade students or youth from the ages of 10 to 17; (2) cross-sectional prevalence studies on cyberbul- lying and; (3) the use of standardized instruments to assess cyberbullying and mental health prob- lems. We excluded studies on specific adolescent populations, such as, adolescents at risk of psy- chosis, those with intellectual disabilities, devel- opmental issues or obesity, homosexuals or ado- lescents who were in jail.
Titles and abstracts were assessed indepen- dently by two evaluators. Whenever there was disagreement between the evaluators, another reviewer was called to give his opinion.
Data collection
Data collected: total number of patients, age, sex, study design, sample characteristics, cyberbul- lying assessment instruments, prevalence and risks factors of cyberbullying, measures and mental health problems related to cyberbullying.
Results
We found 377 articles in the systematic search and two articles in the manual search. A total of 43 articles were selected. Literature reviews, theoretical essays and qualitative studies were excluded, resulting in 13 articles. Three articles
were excluded for the following reasons: (1) the sample was repeated; (2) the study did not inform the prevalence of cyberbullying; and (3) the re- sponse rate was below 60%. Figure 1 describes the selection process of the studies included in this review.
Samples were taken from the population of adolescents who were attending the 6th to 12th grades, or aged between 10 and 17 years. Preva- lence of cyberbullying varied between 6.8% to 35.4% 13,14,16,17,18,19,20,21,22. In one study, whose par- ticipants were recruited from a popular website, the prevalence was higher: 72% 15. The number of questions used to investigate cyberbullying varied across studies. However, the content of questions was similar and were related to having received or sent messages with the intention of humiliating or causing embarrassment, with threats or disclosure of personal information, photos or photo mon- tage through electronic media, such as internet or mobile phone 14,15,16,17,18,19,20,21,21,22. We used the follow abbreviation to describe those involved in cyberbullying: cybervictims: Cy-v; cyberbullies (perpetrators of cyberbullying): Cy-b, and those who reported experiences both as a cybervictim and as a cyberbully: Cy-v/Cy-b (Table 1).
Risk factors associated with cyberbullying varied across studies. Nevertheless, in most stud- ies, history of previous or current experiences of traditional bullying was related to cyberbullying 13,14,15,16,17,18,19. The following factors were associ- ated with cyberbullying: three hours or more of daily internet use 13,16,17, use of instant messaging 15,16,17, relationship problems 13,16,17, hyperactivi- ty-inattention problems 17, behavior problems 17, school-related problems 14,17,18, and risky behavior on the internet, such as posting personal informa- tion, using a web camera and harassment of others online 13,14,15,16 (Table 2).
Between-group comparisons (Cy-v vs. Cy-b vs. Cy-v/Cy-b) showed that a higher proportion of cybervictims came from monoparental fami- lies, had psychosomatic problems (headache, abdominal pain and sleep problems), presented higher levels of perceived difficulties, emotional problems, peer and social difficulties, as well as not feeling safe at school and not feeling properly looked after by teachers 17. The following factors were related to being a cyberbully: headache; high levels of perceived difficulties, not feeling safe in school and not feeling properly looked after by teachers; behavior problems; hyperactivity; smok- ing, frequent drunkenness; and reduced pro-social behavior ( Table 2). Finally, all risk factors above were related to being cyberbullies and cyber- victims at the same time 17.
In a multicenter study that assessed emo- tional impact of different forms of traditional
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bullying and cyberbullying, 68.5% of adolescents experienced some negative emotions such as anger, upset, worry, stress, fear and “depressive feelings”, while 24.5% of adolescents did not care about the incidents 22.
Cyberbullying has been associated with depressive symptomatology in several studies 13,14,18,19. In three studies 13,14,18, the likelihood of reporting harassment carried out through the internet was significantly higher among adoles- cents who presented a more severe depressive symptomatology, as compared to those who pre- sented a mild or absent depressive symptomatol- ogy (OR = 3.38 13, OR = 4.38 18) (Table 2).
Adolescents evaluated in the Youth Internet Safety Survey who had depressive symptoms and a history of cyberbullying presented higher scores of emotional distress, as compared to those who did not present depressive symptoms and were not victims of cyberbullying 13. Five years later, the Second Youth Internet Safety Survey found an increase of 50% in the prevalence of cyberbully- ing: 9% 16. Emotional distress was present in 38%
Figure 1
Identification of independent studies for inclusion in systematic review.
of the adolescents. The following types of cyber- bullying were significantly related to a three-fold increased risk of emotional distress: episodes in which the aggressor was an adult; publication of a picture of the child or adolescent; and episodes accompanied by aggressive contacts off-line, like receiving a telephone call or when the aggressor went to the victim’s house 16,17. Preadolescents were significantly more likely to report distress due to the experience of cyberbullying, as compared to adolescents. After adjusting for confounders, the probability of stress and suffering among pre- adolescents had a four-fold increase (OR = 3.1; p < 0.04) 16.
Besides depressive symptomatology from moderate to severe intensity 13,14,18,19, use of sub- stances 20, suicidal thoughts and suicide attempts were also associated with cyberbullying 18,20,21 (Table 2). Cyberbullying was a predictor of suicide attempts, especially among those who suffer cy- bervictimization: 1.9 times compared to 1.5 times among the cyberbullying perpetrators 21.
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Table 1
Characteristics of studies.
Reference Country Study design Sample
characteristics
Participants Participation
rate
Cyberbullying measurements Quality
of studies
Ybarra 13 USA Cross-sectional
populational-
based.
Randomly
selected phone
numbers.
Telephone
survey
Regular
Internet urban
users (i.e., at
least six times
in the previous
six months).
One young
person and one
caregiver
N = 1,501.
Age: 10-17 years.
47% girls and
53% boys.
82% (1) Whether the respondent felt
worried or threatened because
of someone else bothering
or harassing him or her while
online (yes/no) and (2) whether
the respondent felt threatened
or embarrassed because
someone had posted or sent
a message about the young
person for other people to see
(yes/no)
Strong
Ybarra et al. 16 USA Cross-sectional
populational-
based.
Randomly
selected phone
numbers.
Telephone
survey
Regular
Internet urban
users (i.e., at
least six times
in the previous
six months).
One youth and
one caregiver
N = 1,500.
Age: 10-17 years.
51% girls and
49% boys
45% (1) In the past year did you
ever feel worried or threatened
because someone was
bothering or harassing you
on-line?
(2) In the past year did anyone
ever use the Internet to
threaten or embarrass you by
posting or sending messages
about you for other people
to see?
Strong
Juvonen &
Gross 15 USA Cross-sectional.
Anonymous
web-based
survey
Participants
from 55 states
recruited
through a
popular teen
web site
N = 1,454.
Age: 12-17 years.
75% girls and
25% boys
NI 9 questions about aggressive
behavior on the Internet
Weak
Hinduja &
Patchin 21 USA Cross-sectional,
randomized.
Self-reported
questionnaire
36 middle
schools from
the largest
school district
of USA.
Representative
sample
N = 1,963.
6th-8th grades.
48% girls and
52% boys
96% 14 questions: 9 questions
about cybervictimization and 5
question about cyberbullying
offending
Moderate
Sourander et
al. 17 Finland Cross-sectional
populational-
based.
Self-reported
questionnaire
Two cities in north
and south of
Finland.
All children
attending the
seventh and ninth
grade, except
for children
attending classes
for the physically or
mentally disabled
N = 2,215.
7th-9th grades.
50% girls and
50% boys
90.9% Two general questions about
cyberbullying, defined as:
“cyberbullying is when someone
repeatedly makes fun of another
person online or repeatedly
picks on another person through
e-mail or text messages or when
someone posts something online
about another person that they
don’t like”:
(1) During the past 6 months, how
often have you been cyberbullied?
(2) During the past 6 months, how
often have you cyberbullied others
Strong
(continues)
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Wang et al. 19 USA Cross-sectional
populational-
based.
Self reported
questionnaire
A U.S.
nationally-
representative
sample of
adolescents
N = 7,313.
6th-10th grades.
42.3% girls and
56.7% boys
NI Two questions about: (1) having
suffered bullying through
computer: messages or photos;
(2) having suffered bullying
through cellular
Strong
Ortega et
al. 22 Italy,
Spain,
England
Cross-sectional,
multicentric.
Self-reported
questionnaire
Urban students.
Representative
sample
N = 5,862.
Age: 12-16 years.
8th-, 10th and 12th
grades.
48.8% girls and
52.2% boys
NI 12 questions to cellular phone;
12 questions to internet;
DAPHNE questionnaire (Genta
et al. 33)
Moderate
Schneider et
al. 18 USA Census: (86%)
of Boston
metropolitan
area.
Self-reported
questionnaire
22 high school
urban students,
middle and
upper-middle
class families
N = 20,406.
9th to 12th grades.
50.4% girls and
49.6% boys
88.1% One question: “How many
times someone used
the internet, cellular or
other means of electronic
communication to intimidate,
provoke or threaten you?”
Strong
Litwiller &
Brausch 20 USA Cross-sectional,
randomized.
Self-reported
questionnaire
27 high schools
public students,
from seven-
county region.
Representative
sample.
Rural Midwest
region
N = 4,693.
9th-12th grades.
47% girls and
53% boys
65% Three questions about
cyberbullying: (1) someone
spread rumors about you
online in chats, website, by
emails or text messages?;
(2) someone posted
compromising or inappropriate
photos of you online?; (3)
someone sent you aggressive
messages or messages with
threats by e-mail or text
Strong
Chang et al. 14 Taiwan Cross-sectional,
randomized.
Self-reported
questionnaire
26 urban high
schools, two
cities.
Representative
sample
N = 2,992.
10th grade.
48% girls and
52% boys
80% 12 questions: six
cybervictimization (how often
has someone: posted rude
comments; embarrassing
photos; spread rumours;
threatening comments;
talked about sex online) and
six cyberbullying (how often
have you ever: posted rude
comments; sent embarrassing
photos; spread rumours; made
threatening comments; talked
about sex online)
Strong
NI: not informed.
Table 1 (continued)
Reference Country Study design Sample
characteristics
Participants Participation
rate
Cyberbullying measurements Quality
of studies
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Table 2
Cyberbullying prevalence and mental health problems.
Authors Prevalence of
cyberbullying
Risk factors related to cyberbullying Measures of mental health
problems
Mental health problems related
to cyberbullying
Ybarra 13 6.5% Male gender:
Depressive sintomatology (OR = 3.38;
CI: 1.78-6.45);
Daily use of the internet for three or
more hours (OR = 4.34; CI: 2.12-8.89);
Harasser of others online (OR = 4.19;
CI: 2.06-8.50);
Interpersonal victimization (OR = 3.07;
CI: 0.57-6.00).
Female gender:
Daily use of the internet for three or
more hours (OR = 3.67; CI: 1.53-8.8);
Daily use of internet for two hours a
day (OR = 2.34; CI: 1.16-4.73);
Using the Internet most frequently
for instant messaging (OR = 2.92; CI:
1.19-7.79) or e-mail (OR = 2.75; CI:
1.20-6.26);
Harasser of others online (OR = 2.82;
CI: 1.43-5.50)
Depressive symptoms of DSM-
IV 34 Symptoms of major depression
(OR = 3.38; CI: 1.78-6.45)
Ybarra et
al. 16 9% Harassing others online (OR = 3.6; CI:
2.3-5.7);
Using internet for instant messaging,
blogging, and chat room (OR = 3.4;
CI: 0.9-6.3);
Borderline/clinically significant social
problems (OR = 2.4; CI: 1.2-4.4);
Interpersonal victimization (OR = 1.5;
CI: 1.0-2.2)
Youth Self-Report of Child
Behavior Checklist
(Achenbach 35)
Emotional distress: 38% of the
harassed youth reported distress
associated;
Characteristics associated with
emotional distress among
targets of harassment incident:
preadolescence (OR = 0.5.5; CI: 1.5-
19.3), adult harasser (OR = 4.1; CI:
1.4-11.6);
Being asked to send a picture of
oneself (OR = 3.2; CI: 1.2-8.4);
Aggressive offline contact (OR = 3.9;
CI: 1.5-10.1)
Juvonen &
Gross 15 72% School bullying (OR = 6.87;
CI: 4.90-9.62);
Daily use of the internet for three
hours or more (OR = 1.45;
CI: 1.04-2.02);
Instant messaging (OR = 2.84;
CI: 1.08-7.49);
Webcam (OR = 1.50; CI: 1.04-2.14)
Social anxiety scale
with 5 items
(La Greca & Lopez 36)
Social anxiety (β = 0.31; p < 0.01)
Hinduja &
Patchin 21 Cy-v: 5.7-18.3%.
Cy-b: 9-23.1%
Not found Four items about suicide
attempt and suicide adapted
from American School Health
Associations 37
Suicidal ideation:
Cybervictim (OR = 1.94;
p < 0.001);
Cyberbully (OR = 1.49; p < 0.05)
(continues)
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Sourander
et al. 17 17.6%.
Cy-v: 4.8%.
Cy-b: 7.4%.
Cy-v/b: 5.4%
Cybervictimization: not living with
both biological parents; perceived
difficulties; emotional problems and
peer problems; headache, abdominal
pain, sleeping problems, not feeling
safe at school and uncared about by
teachers.
Traditional victimization and school
bullying.
Cyberbullies: high level of perceived
difficulties, hyperactivity, conduct
problems, and lowprosocial behavior.
Traditional bullying. Cybervictim and
cyberbully were associated with all
these risk factors above
Strengths and Difficulties
Questionnaire – SDQ (Goodman 38)
Cyberbully:
Hyperactivity problems (OR =
2.4; 95%CI: 1.4-3.9);
Behavior problems (OR = 2.6;
95%CI: 1.5-4.5);
Low prosocial behavior (OR =
2.3; 95%CI: 1.5-3.4);
Emotional problems (OR = 2.1;
95%CI: 1.1-3.6);
Peer problems (OR = 4.8;
95%CI: 2.9-7.7);
Cybervictim:
Behavior problem (OR = 2.6;
95%CI: 1.5-4.5);
Hyperactivity problems (OR =
2.4; 95%CI: 1.4-3.9);
Emotional problems (OR = 2.2;
95%CI: 1.2-3.9);
Peer problems (OR = 4.8;
95%CI: 2.9-7.7)
Wang et
al. 19 10.1% Male-gender.
6-8 grade
Depression:
Six items: sadness; irritation, bad
mood; hopelessness; changes
in appetite; sleep; concentration
problems in the past 30 days
(Dahlberg et al. 39)
Depression, medically
attended injuries, medicine
use for sleeping problems and
nervousness *
Ortega et
al. 22 England: 2.0%
mobile phone, 2.6%
Internet;
Italy: 2.2% mobile
phone; 1.9%
Internet;
Spain: 0.5% mobile
phone 1.3% Internet
NI DAPHNE questionnaire
(Genta et al. 33)
Mobile phone cyberbullying:
angry – 35.8%; not bothered –
25.4%;worried – 19.5%; upset
– 18.3%; stressed – 13.3%; afraid
– 13.3%; depressed – 10.7%
Internet cyberbullying: not
bothered – 35.7%; angry –
33.7%; upset – 19.5%; worried
– 15.5%; afraid – 12.8%;
depressed – 10.3%
Schneider et
al. 18 15.8% Female gender; non-white/mixed
race; non heterosexuality identified;
lower school performance; lower
school attachment
Centers for Disease Control and
Prevention 40;
Health and Risk Behaviors of
Massachusetts Youth 41
Distress:
Depressive symptoms (OR=
4.38; 99%CI: 3.76-5.10);
Self-injury (OR = 4.79; 99%CI:
4.06-5.65);
Suicidal ideation (OR = 3.35;
99%CI: 2.71-4.13);
Suicide attempt (OR = 5.04;
99%CI: 3.88-6.55);
Suicide attempt that required
medical treatment (OR = 5.42;
99%CI: 3.56-8.26)
Table 2 (continued)
Authors Prevalence of
cyberbullying
Risk factors related to cyberbullying Measures of mental health
problems
Mental health problems
related to cyberbullying
(continues)
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Table 2 (continued)
Authors Prevalence of
cyberbullying
Risk factors related to cyberbullying Measures of mental health
problems
Mental health problems
related to cyberbullying
Litwiller &
Brausch 20 23% Not founded Suicidal behavior:
Center for Disease and
Control 40;
Substance use:
17 items from Monitoring the
Future Survey (Johnston 42);
Violent behavior: 4 items from
Center for Disease and Control,
2008 40;
Sexual behavior: 5 items from
Center for Disease and
Control 40
Substance use (estimate = 0.33;
95%CI: 0.28-0.35);
Violent behavior (estimate =
0.16; 95%CI: 0.14-0.19);
Non safe sex behavior
(estimate = 0.005; 95%CI: 0.00-
0.15);
Suicidal behavior R2adj = 0.67
Chang et
al. 14 35.4%.
Cy-v: 18.4%;
Cy-b: 5.4%;
Cy-v/Cy-b: 11.2%
Male (OR = 1.57; 95%CI: 1.15-2.16);
Lower academic performance
(OR = 1.69; 95%CI: 1.34-2.15).
Internet risks behaviors:
Posting personal information photos
and using a webcam to chat with
strangers:
Cy-b (OR = 1.87; 95%CI: 1.28-2.73);
Cy-v (OR = 1.58; 95%CI: 1.28-1.96);
Cy-v/Cy-b (OR = 4.28; 95%CI: 3.00-
6.10)
Rosenberg Self-esteem Scale
(Rosenberg 43);
Depression CES-D (Radloff 44)
Low self-esteem scores and high
depression scores *:
Cy-v: low self-esteem scores and
high depression scores;
Cy-b: high depression scores;
Cy-b/Cy-v: low self-esteem and
high depression scores
Cy-v: cybervictims; Cy-b: cyberbullies; Cy-b/Cy-v: cybervictims/cyberbullies; NI: not informed; R2: coefficient of multiple correlation.
* Odds ratio for mental health problems was not informed.
Adolescents who were victims of cyberbul- lying and traditional school bullying reported more depressive symptoms and higher scores on the suicidal ideation and suicidal behavior scale (OR = 1.5), as well as more suicide attempts that demanded medical treatment (OR = 2.1) 21. Hin- duja & Patching’s 21 study showed that the likeli- hood of attempting suicide was up to twice as high among victims and aggressors, as compared to those not involved in cyberbullying (OR = 1.5; OR = 2.1, respectively). In this review, all types of traditional bullying and cyberbullying were as- sociated with increased suicidal thoughts among victims and offenders 18,20,21 (Table 2).
Discussion
Cyberbullying occurs at a lower prevalence than other traditional or school bullying. However, cyberbullying affects a significant portion of adolescents (10 to 20%), being related to emo- tional stress and negative emotions such as an- ger, fear, stress depression 13,16,17,22. Cyberbullies and cybervictims reported more experiences
with school bullying, suggesting continuity and overlapping between traditional bullying and cy- berbullying 17,18. Considering the importance of virtual spaces for interaction and for the psycho- social development of adolescents, the results suggest that negative interactions in a virtual environment could mediate the broad range of disturbances associated with bullying and cyber- bullying: academic and psychosocial problems, depression, low self-esteem, and externalized hostility, among others.
Studies included in this review identified several psychosocial risk factors and mental health problems associated with cyberbullying among victims, offenders, and those who are, at the same time, victims and offenders. Cyberbul- lying is associated with emotional stress 13,16,17, social anxiety 15, substance use 20, depressive symptoms 13,14,18,19, suicidal ideation and sui- cide attempts 18,20,21.
Emotional responses of adolescents exposed to cyberbullying vary in intensity and quality. In a multicenter study, that assessed the emotional impact of different forms of traditional bullying and cyberbullying, 68.5% of adolescents expe-
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rienced some negative emotions such as anger, upset, worry, stress, fear and “depressive feel- ings”, while 24.5% of adolescents did not care about the incidents 22. The emotional impact is harmful to most victims, however adaptive resil- ience and a positive appraisal of a stressful situa- tion or developmental strengths like self-esteem and self-efficacy could minimize the emotional damage to some victims. Further research should investigate which resilience factors could buffer the impact of negative experiences such as cy- berbullying and bullying among adolescents 23.
Anger was the most common reported emo- tion among adolescents in the study cited previ- ously 22. Situations like “posted things about me that I do not want anyone to know” harm the victims’ reputation, publicly humiliate them or damage their friendships and social status in a stage of life in which the social group has an im- portant role in shaping identity 1. Anger has been considered a reaction to violations of autonomy and serves to facilitate a vigorous response to ad- dress the danger when an action has a negative impact on the “self” 24. Therefore, in this context, angry reactions, could be considered a “healthy response” to cyberbullying.
Cybervictims may suffer verbal and visual anonymous attacks (photomontage) and ano- nymity can increase the feeling of fear and inse- curity among the victims. When the perpetrator was an adult or an unknown person or group of persons, the victims also reported fear for their personal safety 9,15. Online aggressions can oc- cur at any time, in the victim’s own house, a safe environment. Most teens do not report the inci- dent to adults, and the main reason reported by them has been that “they need to learn to deal with their own problems” (50%), and also be- cause they fear their parents would restrict their access to the Internet (31%), leading to social isolation 14,25,26.
Adolescents who reported experiences of cy- berbullying, particularly those who suffered fre- quent attacks (two or more times a month), had more severe depressive symptoms when com- pared with adolescents exposed to other forms of bullying 18. The feelings of helplessness and powerlessness to defend themselves from inci- dents of cyberbullying can increase the sense of fear and emotional distress, contributing to the emergence of depressive symptoms. The associa- tion between bullying, cyberbullying and depres- sive symptoms found in several studies 13,14,18,19 suggests that these phenomena occur in a bidi- rectional way (i.e., they can be either the cause or the consequence of each other). Cognitive impairment and depressive mood can change the perception of victims and the lack of social
cues in online communication, such as volume and tone, can result in negative interpretations of ordinary situations, which can be perceived as threatening.
Cyberbulliyng may have even more harmful outcomes to adolescents’ mental health, includ- ing substance abuse, increased suicidal ideation and suicide attempts 20,21. The Hinduja & Patch- ing 21 study showed that the likelihood of com- mitting suicide attempts is up to twice as high among victims and aggressors, as compared to those not involved in cyberbullying. Having ex- perienced cyberbullying alone does not induce suicide. Nevertheless, adolescents who have suffered cyberbullying may experience negative psychological states and abuse of alcohol and other drugs as a way to deal with negative feel- ings related to the aggression. This explanation is in agreement with the drug abuse etiology in adolescence. The use of psychoactive substances may also help adolescents to habituate to the physical pain and anxiety associated with auto- mutilation. Using substances can also encour- age adolescents with suicidal ideation, increas- ing auto-mutilation behaviors, lessening the inhibition and aggravating negative pre-existing moods 27,28,29.
The adapted model showed in Figure 2 il- lustrates how drug use and violent behavior can mediate the relationship between cyberbully- ing, physical bulling and suicidal conduct in adolescents.
It is unlikely that experiences of cyberbully- ing alone lead to youth suicide. Rather, they may exacerbate an adolescent’s instability and hope- lessness at a time when they are already strug- gling with stressful life circumstances. Future research should identify the nature of this stress inducing experience. Studies regarding the dif- ferences found between adolescents facing cy- berbullying, such as those who “do not care” and those “strongly impaired”, may bring important contributions to strategies of prevention and in- tervention. Prevention strategies have to be im- plemented in order to avoid risk behaviors and aid adolescents to find effective ways of handling cyberbullying incidents and to avoid risk be- haviors, such as exposing personal information, photos and webcam use with strangers, which can raise cyberbullying incidents and mental health damage 30,31,32.
Limitations
Cyberbullying is a new concept in the literature and the methodology applied to investigate it is still a subject of discussion. A variety of terms
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are used including “online bullying”, “electronic bullying”, “internet harassment” and “cyberbul- lying”. For this reason the search of articles was carried out using a comprehensive methodology. However, articles from two relevant databases such as PsycINFO and Social Science Citation In- dex were not considered for this review.
Most of the studies developed specific ques- tions and evaluated the frequency of cyberbully- ing in different ways, depending on the research- ers’ objectives. Differences in definitions and, consequently, in the forms of measurement may impact on the estimates of prevalence of cyber- bullying and of its impact on mental health.
Evaluating violent behaviors, which are not socially accepted may have influenced the ad- olescents answers and biased the cyberbulling prevalences and their association with mental health problems. Finally the causal direction of the association between cyberbullying and men- tal health problems cannot be determined by transversal studies included in this review.
Conclusions
Online communication has become a center- piece in the life of adolescents, offering many opportunities for psychosocial development and construction of intimate relationships. However, in this context, violent interactions such as cy- berbullying may occur.
Cyberbullying is associated with emotional stress, social anxiety, substance use, depressive symptoms, suicidal ideation and suicide at- tempts. Parents and educators ought to know the risks of on-line communication and need to promote dialogue about the topic, aiding ado- lescents to find effective ways to deal with such incidents. Health professionals must be aware of the occurrence of cyberbulling and its associa- tion with mental health problems.
Resumen
Se revisa la asociación entre el acoso cibernético y la sa- lud mental de los adolescentes. Se realiza una revisión sistemática de dos bases de datos: PubMed y la Bibliote- ca Virtual en Salud (BVS). La prevalencia de ciberacoso varió de un 6,5% a un 35,4%. Los acosos cibernéticos tradicionales -pasados o actuales- se asociaron con las víctimas y los acosadores cibernéticos. El uso diario de tres o más horas de Internet, cámara web, mensajes de texto, la publicación de información personal y acosar a los demás se asociaron con el acoso cibernético. Ciber- víctimas y acosadores cibernéticos tenían más proble- mas emocionales, psicosomáticos, dificultades sociales y no se sentían seguros y cuidados en la escuela. El ci- beracoso se asoció con síntomas de moderados a graves de depresión, abuso de sustancias, ideación suicida e intentos de suicidio. Los profesionales de salud deben conocer la naturaleza violenta de las interacciones que se producen en el entorno virtual y sus peligros para la salud mental de los adolescentes.
Acoso; Adolescente; Salud Mental
Contributors
S. M. B. Bottino conceived the initial idea for the article, carried out the search, analyzed the results and wro- te the article. C. M. C. Bottino supported in the article write-up, revision and answers to partners. C. G. C. Re- gina collaborated with the initial selection of articles, applied the eligibility criteria, and supported the revi- sion and analysis of results. A. V. L. Correia contributed towards the results analysis and revision of the final text of the article. W. S. Ribeiro collaborated with the metho- dology, revision and application of eligibility criteria, and carried out the revision and correction of the final version of the article.
Acknowledgments
We wish to acknowledge the support of the Department of Psychiatry at the Federal University of São Paulo and Academic League for Violence Prevention and Interven- tion (LAPIV ).
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Submitted on 10/Mar/2014 Final version resubmitted on 15/Oct/2014 Approved on 17/Nov/2014
