Discussion Assignment

Clinical Pediatrics 2015, Vol. 54(5) 430 –438 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814553430 cpj.sagepub.com

Article

Defining sexual harassment can be challenging, since it is not only considered physical face-to-face interaction and touching, it can be psychological, environmental, and via Internet and text messaging.1 Since there is no universal definition and sexual harassment has com- monly been paired with bullying, widely variable rates of sexual harassment have occurred across studies. In a recent national survey done by telephone in the United States in 2011, the respondents of youths aged (10-13 years) and (14-17 years) had experienced sexual harass- ment in the past year at rates of 2.8% and 9.3% respec- tively.2 However, in studies directly surveying children and adolescents from fifth grade throughout high school, who were asked if they experienced some form of sexual harassment within the past 2 weeks or ever, the reported rates of sexual harassment varied anywhere from 15% to 81%.3-5

Some studies have shown females to be much more likely to experience sexual harassment, and other stud- ies have shown males and females to have an equal like- lihood of experiencing sexual harassment.2,5 Gender differences in how a student might experience sexual harassment have been noted. Females are likely to expe- rience belittlement and objectification because of their sex, whereas males experience vulgar and homophobic

comments.6,7 Youth with more advanced pubertal status are also more likely than their less advanced peers to be victims of harassment.7,8

Despite the frequency and awareness of sexual harassment, there is little research found in the pediatric literature concerning the longitudinal mental and physi- cal health effects on both male and females as they prog- ress through school. Goldstein et al8 reported that sexual harassment in eighth grade predicted increased prob- lems with substance use, lower self-esteem, and symp- toms of depression 3 years later. It has also been reported that sexual harassment can increase school absences, worsen academic performance, and create mental stress leading to mental health problems.9 In addition, sexual harassment can increase an adolescent’s preoccupation with appearance and thus increase the risk of developing eating disorders.10 Chiodo et al11 reported on multiple

553430CPJXXX10.1177/0009922814553430Clinical PediatricsEom et al research-article2014

1Eastern Virginia Medical School, Norfolk, VA, USA 2Children’s Hospital of The King’s Daughters, Norfolk, VA, USA

Corresponding Author: John W. Harrington, Department of Pediatrics, Children’s Hospital of The King’s Daughters, 601 Children’s Lane, Norfolk, VA 23507, USA. Email: [email protected]

Sexual Harassment in Middle and High School Children and Effects on Physical and Mental Health

Elizabeth Eom, MS1,2, Stephen Restaino, DO1,2, Amy M. Perkins, MS1,2, Nicole Neveln, MS1,2, and John W. Harrington, MD1,2

Abstract Sexual harassment can be physical interaction and touching, as well as, psychological, environmental, or via Internet and text messaging. An online survey in an urban clinic asked children, aged 12 to 18 years the following: demographic data, height and weight, chronic medical conditions, healthcare use, questions concerning sexual harassment— witnessed and exposure, and finally questions from the Pediatric Symptom Checklist (PSC-35). Overall, 124 of 210 (59%) of the 12- to 18-year-olds surveyed had experienced sexual harassment, with the predominance being female 69% (80/116) versus 48% (49/92) male. Participants who had experienced sexual harassment were significantly more likely to score positive for psychological impairment than those who had not experienced sexual harassment (chi-square test P < .001; odds ratio: 4.7 (95% confidence interval, 1.9-11.8). There was a borderline significant association between elevated body mass index and having experienced sexual harassment (2-sample t test P = .08). Sexual harassment has a direct correlation to psychological impairment in adolescents, especially females.

Keywords sexual harassment, adolescent, mental health

Eom et al 431

psychosomatic parameters in their longitudinal study utilizing 12 items from the depression and anxiety sub- scales of the Brief Symptom Inventory.12 Their study showed strong correlations with sexual harassment and emotional distress, self-harming behaviors, and suicidal ideation.

Although studies have focused on psychosomatic complaints related to sexual harassment, few have looked directly at physical complaints or ailments. It has been shown that students who are bullied, perhaps a proxy for sexual harassment, can be affected by poor physical health. This can be manifested by a variety of symptoms including headache, backache, abdominal pain, skin problems, sleeping problems, bed-wetting, and dizziness.13-17 Some schools consider sexual harass- ment as a form of bullying.18,19 Distinguishing between the 2 terms is important because they have different definitions and therefore may not have similar longitudi- nal outcomes.

Sexual harassment, for our purposes, will be defined as unwelcome conduct of a sexual nature which can include unwelcome sexual advances, requests for sexual favors, or other verbal, nonverbal, or physical conduct of a sexual nature.20,21 This study seeks to specifically look at sexual harassment in the teenager age population by (1) assessing the prevalence of sexual harassment amongst adolescents, who present for well and sick care at a General Academic Pediatric practice, in a predomi- nantly urban African American population and (2) deter- mining whether exposure to sexual harassment correlates with psychological impairment on the Pediatric Symptom Checklist-35–Youth Report (Y-PSC-35), and (3) if exposure to sexual harassment has any effect on overall body mass index (BMI), increased listing of chronic illnesses, or increased health care utilization.

Methods

This study applied a questionnaire to adolescents in the clinic setting to investigate their experiences with sexual harassment at school and outside of school.

Survey Population

Participants were patients between the ages of 12 and 18 years, scheduled for a well or sick visit in the General Academic Pediatrics practice located on the main floor of the Children’s Hospital of The King’s Daughters, in Norfolk, Virginia. The patient population is predomi- nantly African American (85%) with Medicaid or Medicaid managed care as their primary insurance. Participation required both—consent from parent or legal guardian and assent from the adolescent.

Development of the Survey

The online survey tool SurveyMonkey was used to create the questionnaire used in this study. We included ques- tions on demographic data (age, sex, grade, and ethnic- ity); height and weight; questions on chronic medical conditions and on the use of health care; questions about the frequency of sexual harassment witnessed; questions concerning exposure to sexual harassment from American Association of University Women,20 and 35 questions from the Y-PSC-35.22 A copy of the full survey is available on request. Psychological impairment was defined as any score ≥ 30 on the Y-PSC-35. Participants were defined as having experienced sexual harassment if they reported “rare”, “occasional”, “often”, or “very often” occurrences of at least 1 of the following: (1) I have been the target of sexual comments, jokes, teasing, gestures, or looks; (2) I have had my clothing pulled in a sexual way; (3) I have had sexual rumors spread about me; (4) I have had my way blocked in a sexual way; (5) I have been touched, grabbed, or pinched in a sexual way; or (6) I have been shown or given sexual pictures, photographs, illustrations, messages, or notes.

Survey Administration

We collected data over 2 time periods—from June 2012 through August 2012 and from April 2013 through June 2013. An additional question concerning how the par- ticipant handles exposure to sexual harassment via elec- tronic and social media was included in the second time period. Participants completed the survey in the clinic at the time of their medical appointment using an iPad pro- vided by the researcher. The research assistant reviewed all the patients scheduled for the day in the General Academic Pediatric outpatient area and identified ado- lescents that met the study inclusion criteria as they were being triaged. Once the patient was placed in a room, the research assistant entered and explained to the patient and parent/guardian that they are recruiting the adolescent for an anonymous survey that will ask ques- tions concerning their experiences with sexual harass- ment at school and outside of school. Once the parent/ guardian consented and the adolescent assented to the study, the survey software was explained and the survey was completed by the adolescent. A research team mem- ber was present to ensure software functionality and ensure that there was no parental input in answering the survey questions. After the final question was com- pleted, the participant alerted the assistant and the con- nection to SurveyMonkey was discontinued (generally this occurred automatically, but was confirmed by the assistant).

432 Clinical Pediatrics 54(5)

Statistical Analysis

The data were analyzed using SAS 9.3 (SAS Institute, Cary, NC) and SPSS 19 (IBM, Armonk, NY) software. Descriptive statistics were reported for the survey responses, and unknown or missing values were excluded from the analysis. P values less than .05 were considered statistically significant. Comparisons of means between groups were performed using 2-sample t tests. Proportions were compared using chi-square or Fisher’s exact tests, where appropriate. A logistic regression model for hav- ing experienced sexual harassment assessed the signifi- cance of the relationship with psychological impairment after adjusting for school level, gender, ethnicity, BMI, chronic illness, and health care utilization.

Results

Demographics and Medical Conditions

Of the 238 patients approached, 210 (88%) agreed to participate in this study. Data was not collected on the 27 patients who did not participate. Approximately 89% of the patients surveyed were African American or multiracial and most were currently in high school (Table 1). Asthma and allergies were the most common

medical conditions indicated by participants and the most common interval to visit a doctor was every 6 months (Table 2).

Psychological Impairment

Overall, 39 participants (18.6%) had psychological impairment as measured by the Y-PSC-35. After exclud- ing participants with ADHD (attention deficit hyperac- tivity disorder), 33 of the 191 participants without ADHD (17.3%) had psychological impairment (Table 3).

Sexual Harassment

In response to the question “How much do you think sexual harassment happens in your school?”, 57 (27.5%) said “It doesn’t happen,” 73 (35.3%) said “It happens to only a few people,” 38 (18.4%) said “It happens to a fair number of people,” and 39 (18.8%) said “It goes on all the time” (Table 4). One hundred five (50.5%) had

Table 1. Demographics (N = 210).

n %

Age (years), mean ±SD 14.6 1.8 Gender Male 92 43.8 Female 118 56.2 School level Middle school 81 38.5 High school 109 51.9 Graduated high school 18 8.6 Dropped out 2 1.0 Race/ethnicity African American 169 80.4 Caucasian 12 5.7 Latino/Hispanic 5 2.4 Native American 3 1.4 Asian 1 0.5 Multiracial 18 8.6 Other 2 1.0 Height (in.), mean ± SDa 64.2 3.6 Weight (lb), mean ± SDb 145.1 38.0 BMI (kg/m2) mean ± SDc 24.76 6.10

Abbreviations: SD, standard deviation; BMI, body mass index. aSeventeen participants did not respond. bTen participants did not respond. cData missing for 20 participants.

Table 2. Chronic Medical Conditions and Doctor Visits (N = 210).

n %

Long-term medical conditions Asthma 74 35.2 Eczema 25 11.9 Constipation 3 1.4 Attention deficit hyperactivity disorder

19 9.1

Allergies 69 32.9 Diabetes 0 0.0 Obesity 6 2.9 Headaches/migraines 21 10.0 Seizures 0 0.0 Acne 21 10.0 Abdominal pain 4 1.9 Sickle cell disease 0 0.0 Heart problems 5 2.4 Other 9 4.3 Frequency of seeing doctora

Today is the first time I remember seeing a doctor

3 1.4

About once every 2 years 7 3.4 About once a year 54 26.0 About once every 6 months 59 28.4 About once every 3 months 25 12.0 About once a month 18 8.7 About twice a month 7 3.4 Weekly 4 1.9 Not sure 31 14.9

aTwo participants did not respond.

Eom et al 433

Table 3. Pediatric Symptom Checklist—Youth Report (N = 210).

Question Number n %

Total Y-PSC-35 score, mean ± SD — 20.3 10.5 Total Y-PSC-35 score (excluding

ADHD) (N = 191), mean ± SD — 19.8 10.4

Y-PSC-35 score ≥30 — 39 18.6 Y-PSC-35 score ≥30 (excluding

ADHD) (N = 191) — 33 17.3

Ranked Y-PSC-35 questions for participants with score ≥30 (N = 39)

Distract easilya 9 38 100.0 Are irritable, angry 12 38 97.4 Worry a lota 22 36 94.7 Feel sad, unhappy 11 36 92.3 School grades dropping 18 36 92.3 Have trouble concentrating 14 35 89.7 Have trouble sleeping 21 35 89.7 Complain of aches or painsa 1 34 89.5 Tire easily, little energy 3 34 87.2 Feel that you are bad 24 34 87.2 Take unnecessary risks 25 34 87.2 Do not listen to rules 29 34 87.2 Seem to be having less funb 27 32 86.5 Spend more time alone 2 33 84.6 Daydream too much 8 33 84.6 Do no show feelings 30 33 84.6 Fidgety, unable to sit still 4 32 82.1 Have trouble with teacher 5 31 79.5 Less interested in school 6 31 79.5 Visit doctor with doctor finding

nothing wronga 20 30 78.9

Are afraid of new situations 10 30 76.9 Down on yourself 19 30 76.9 Absent from schoola 17 29 76.3 Get hurt frequently 26 29 74.4 Feel hopeless 13 26 66.7 Want to be with parent more

than before 23 26 66.7

Do not understand other people’s feelingsa

31 25 65.8

Fight with other children 16 25 64.1 Less interested in friends 15 24 61.5 Refuse to share 35 24 61.5 Blame others for your troublesa 33 23 60.5 Act as if driven by motor 7 23 59.0 Tease othersb 32 20 54.1 Act younger than children your

age 28 20 51.3

Take things that do not belong to youa

34 18 47.4

Abbreviations: Y-PSC-35, Pediatric Symptom Checklist–Youth Report; SD, standard deviation; ADHD, attention deficit hyper-activity disorder. aOne participant did not respond. bTwo participants did not respond.

witnessed or seen sexual harassment at their school; 68 (32.7%) said they had not, and 35 (16.8%) were not

sure. Overall, 19 (9.2%) had seen or heard of 1 instance of sexual harassment, 36 (17.5%) said 2 to 5 instances, 44 (21.4%) said 6 or more instances in the past year, and 107 (51.9%) said none/not applicable. One hundred twenty-four (59.6%) reported that they had experienced sexual harassment. More specifically, 44 of 92 males (47.8%) and 80 of 116 females (69.0%) had experienced sexual harassment. Females were statistically signifi- cantly more likely to have experienced sexual harass- ment than males (chi-square test P = .002; odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.4-4.3; Figure 1). There were no significant differences in hav- ing witnessed or experienced sexual harassment between African American and Caucasian participants (Fisher’s exact test, both P > .05).

Psychological Impairment and Sexual Harassment

Thirty-three of the 124 participants (26.6%) who had experienced sexual harassment scored positive for psy- chological impairment on the Y-PSC-35. Six of the 84 participants (7.1%) who had not experienced sexual harassment scored positive for psychological impair- ment. Participants who had experienced sexual harass- ment were statistically significantly more likely to score positive for psychological impairment than comparable participants who had not experienced sexual harassment (chi-square test P < .001; OR = 4.7; 95% CI = 1.9-11.8; Figure 2). A logistic regression model was used to deter- mine that this relationship remained significant after adjusting for school level, gender, ethnicity, BMI, chronic illness, and health care utilization (P = .048; OR = 2.9; 95% CI = 1.0-8.5; Table 5).

After excluding participants with ADHD, 30 of the 113 participants (26.6%) who had experienced sexual harassment scored positive for psychological impair- ment. Three of the 76 participants (4.0%) who had not experienced sexual harassment scored positive for psy- chological impairment. After excluding participants with ADHD, those who had experienced sexual harass- ment remained statistically significantly more likely to score positive for psychological impairment than were comparable participants who had not experienced sex- ual harassment (N = 189; chi-square test P < .001; OR = 8.8; 95% CI = 2.6-30.0). Conversely, the Y-PSC-35 symptoms were not made worse by the combination of ADHD with sexual harassment (Fisher’s exact test, all P > .05), but this negative finding is most likely because of a lack of power given the small number of subjects with ADHD (n = 19). This analysis compared the Y-PSC-35 responses (“never” vs “sometimes” or “often”) for par- ticipants with ADHD who had experienced sexual

434 Clinical Pediatrics 54(5)

harassment (n = 11) versus those with ADHD who had not experienced sexual harassment (n = 8).

Health Status

The mean BMI and standard deviation (± SD) was 25.22 ± 6.46 kg/m2 for participants who had experienced sex- ual harassment and 23.74 ± 4.99 kg/m2 for participants

Table 4. Responses to Sexual Harassment Questions (N = 210).

n %

How much do you think sexual harassment happens in your school?a

It doesn’t happen 57 27.5 It happens to only a

few people 73 35.3

It happens to a fair number of people

38 18.4

It goes on all the time 39 18.8 Have you witnessed or seen sexual harassment at your

school?b

No 68 32.7 Yes 105 50.5 Not sure 35 16.8 How many instances have your seen or heard of in the past

year?c

1 19 9.2 2-5 36 17.5 6+ 44 21.4 Not applicable 107 51.9 Experienced sexual

harassmentd 124 59.6

I have been the target of sexual comments, jokes, teasing, gestures, or looksb

Very often 4 1.9 Often 13 6.3 Occasionally 19 9.1 Rarely 58 27.9 Never 114 54.8 I have had my clothing pulled in a sexual wayb

Very often 3 1.4 Often 2 1.0 Occasionally 14 6.7 Rarely 15 7.2 Never 174 83.7 I have had sexual rumors spread about mec

Very often 4 1.9 Often 3 1.5 Occasionally 9 4.4 Rarely 24 11.7 Never 166 80.6 I have had my way blocked in a sexual wayb

Very often 2 1.0 Often 5 2.4 Occasionally 7 3.4 Rarely 17 8.2 Never 177 85.1 I have been touched, grabbed, or pinched in a sexual waya

Very often 7 3.4 Often 7 3.4 Occasionally 21 10.1

n %

Rarely 37 17.9 Never 135 65.2 I have been shown or given sexual pictures, photographs,

illustrations, messages, or notesc

Very often 10 4.9 Often 6 2.9 Occasionally 17 8.3 Rarely 22 10.7 Never 151 73.3 I have been physically intimidated by another student or

personb

Very often 6 2.9 Often 3 1.4 Occasionally 17 8.2 Rarely 19 9.1 Never 163 78.4 I have stayed home, cut class, or missed work because I felt

intimidatedb

Very often 1 0.5 Often 3 1.4 Occasionally 6 2.9 Rarely 8 3.9 Never 190 91.4 I have felt unsafe in school or outside homec

Very often 5 2.4 Often 6 2.9 Occasionally 4 1.9 Rarely 22 10.7 Never 169 82.0 I have been punished, threatened, or harassed more

as a result of complaining about or reporting sexual harassmente

Very often 2 1.0 Often 8 3.9 Occasionally 6 2.9 Rarely 7 3.4 Never 182 88.8

aThree participants did not respond. bTwo participants did not respond. cFour participants did not respond. dData missing for 2 participants. eFive participants did not respond.

(continued)

Table 4. (continued)

Eom et al 435

Figure 2. Student psychological impairment on the Y-PSC-35 stratified by whether they had experienced sexual harassment (N = 208). The result remained significant after excluding students with attention deficit hyper activity disorder (P < .001, N = 189). Abbreviation: Y-PSC-35, Pediatric Symptom Checklist—Youth Report.

who had not experienced sexual harassment. There was a borderline statistically significant association between BMI and having experienced sexual harassment (2-sam- ple t test P = .08). Ninety of 143 participants (62.9%) with a chronic disease had experienced sexual harass- ment, and 34 of 65 participants (52.3%) without a chronic disease had experienced sexual harassment. There was, however, no association between having a chronic illness (or each individual illness) and having experienced sexual harassment (chi-square or Fisher’s exact test, all P >.05). In addition, there was no associa- tion between health care utilization and having experi- enced sexual harassment (chi-square test P =.37).

Discussion

Our study demonstrates that females in middle and high school are more likely to be sexually harassed than males. Although recent studies have shown equal sexual harassment in males and females,11our study mirrors many of the findings in Goldstein et al8 and Nadeem et al,23 where African American females were more likely to be harassed and more likely to have negative psycho- logical outcomes from exposure. This current study also suggests that there may be differences in the pattern of sexual harassment based on a child’s ethnicity and socioeconomic class.

Our study reinforces the fact that exposure to sexual harassment can affect the emotional well-being of a child. The data clearly show a correlation for adoles- cents who experienced sexual harassment to be more likely to have a positive score on the Y-PSC-35. Although the Y-PSC-35 is not a screen that can provide an avenue to a specific diagnosis, data from previous studies show that 67% of children or adolescents with a positive score will have a moderate to severe impair- ment in psychosocial functioning with the other 33% with a positive score having at least a mild impairment, and all would likely benefit from more specific mental health testing.24,25

Although the mean BMI had SD that overlapped for those who had experienced sexual harassment (25.22 ± 6.46) and those who had not experienced sexual harass- ment (23.74 ± 4.99), there was a borderline statistically sig- nificant association with the 2-sample t test yielding a P value of .08. This may be related to the possibility that females who are heavier may have started their pubertal growth spurts earlier and this may have made them targets for harassment, or perhaps after being harassed they may have been more likely to eat for comfort from being emo- tionally distraught. There does not appear to be any correla- tion with sexual harassment and any chronic underlying

Figure 1. Student responses to whether they had experienced sexual harassment stratified by gender (N = 208).

436 Clinical Pediatrics 54(5)

illnesses such as ADHD, diabetes, or asthma. There also did not appear to be an increased use of health care via more primary care visits, emergency department, or sub- specialty visits. Interestingly, the question added in our sec- ond wave of data collection concerning, “what action taken after you were harassed?” approximately two thirds of the

respondents answered “nothing” and only 25% spoke with a parent, teacher, or counselor (Table 6).

Limitations

There is no preassessment data prior to middle school to determine if symptoms verified by the Y-PSC-35 existed prior to middle school. Correlation does not always mean causation, and children who are harassed may be preyed upon because of existing psychological disor- ders. Our data may not be generalizable because it is only from one primary care office but does provide intriguing data that could be replicated in a larger study. Unfortunately, our health indicators and health care uti- lization were by report and could not accurately be cross-referenced to the personal medical records in the study. There was 88% participation; however data was not collected on the 28 patients who did not participate. It is impossible to predict if they did not participate because they were concerned about talking about previ- ous harassment or if they would have been less likely to have been victims of sexual harassment. Obviously there is overlap between bullying, physical intimidation, and sexual harassment. We did not collect data on spe- cific antibullying campaigns within the schools that the participants’ attended and this may have affected overall prevalence and recall, since some data was collected during the school year and some was collected during

Table 5. Multiple Logistic Regression Model for Psychological Impairment Using SAS PROC LOGISTIC.a

Variable Coefficient (β) SE Wald χ2 P Value OR 95% CI

Intercept −7.3 1.8 15.6 <.001 NA NA School level Middle vs senior 0.2 0.5 0.2 .62 1.3 0.5-3.4 Gender Female vs male 0.1 0.5 0.1 .79 1.1 0.4-3.0 Ethnicity African American vs other 1.8 1.1 2.8 .10 6.0 0.7-50.3 Caucasian vs other 1.7 1.3 1.8 .18 5.6 0.5-69.0 BMI 0.1 0.0 2.9 .09 1.1 1.0-1.2 Chronic illness Yes vs no 1.1 0.6 3.1 .08 3.0 0.9-10.4 Health care utilization ≥5 visits/year vs ≤1 visit/year 1.2 0.7 2.7 .10 3.4 0.8-14.6 2-4 visits/year vs ≤1 visit/year 0.9 0.6 2.2 .14 2.5 0.8-8.3 Experienced sexual harassment Yes vs nob 1.1 0.5 3.9 .048 2.9 1.0-8.5

Abbreviations: CI, confidence interval; OR, odds ratio; SE, standard error; NA, not applicable; BMI, body mass index. aOdds ratio—controlling for other variables in the model, for example, the odds of psychological impairment for a participant who has experienced sexual harassment compared with an otherwise similar participant who has not experienced sexual harassment increase by 2.9. Model evaluation: Likelihood ratio test χ2 = 21.7, df = 9, P = .01; score test χ2 = 18.0, df = 9, P = .03; Hosmer-Lemeshow goodness-of-fit test χ2 = 7.0, df = 8, P = .54. bHaving experienced sexual harassment is a significant independent predictor of psychological impairment.

Table 6. Action Taken After Experiencing Sexual Harassment in Some Way (N = 93).

n %

Does not apply to me 31 33.3 Action(s) takena,b 62 66.7 Nothing 41 66.1 Talked with a friend about it 11 17.7 Talked with a parent about it 9 14.5 Talked with a relative about it 7 11.3 Talked to the person who sent the

message or picture 6 9.7

Talked with a teacher about it 4 6.5 Talked with a school counselor about it 3 4.8 Talked with someone in my church

including priest/reverend/clergy/ parishioner

2 3.2

Other 2 3.2 Brought a complaint to the police 1 1.6

aMultiple selections permitted. bQuestion was only included during the second time period.

Eom et al 437

the summer. However, the effectiveness of school-based antibullying programs have only shown small to moder- ate effects on victimization.26

Conclusions

Sexual harassment appears to have a direct correlation to psychological impairment in adolescents, especially females. Although it did not reach statistical signifi- cance, there was an elevated BMI in children who had been sexually harassed; however, no other chronic dis- ease or health care utilization appears to be effected in our cohort. The plausible relationship between elevated BMI and sexual harassment should be studied further. In addition, children who were harassed were not likely to do or say anything about that harassment. Pediatricians therefore should ask specific questions about sexual harassment during their adolescent health care visits commonly known as the HEADDSS (Home, Education/ Employment, Activities, Diet, Drugs, Sexuality, and Suicide/Depression) assessment.27 If questions concern- ing sexual harassment are affirmative, then the physi- cian should consider further screening for mental health and/or psychosomatic concerns.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

1. Ybarra M, Espelage D, Mitchell KJ. The co-occurrence of Internet harassment and unwanted sexual solicita- tion victimization and perpetration: associations with psychosocial indicators. J Adolesc Health. 2007;41 (6 suppl 1):S31-S41.

2. Finkelhor D, Turner HA, Shattuck A, Hamby SL. Violence, crime, and abuse exposure in a national sam- ple of children and youth: an update. JAMA Pediatr. 2013;167:614-621.

3. Walsh M, Duffy J, Gallagher-Duffy J. A more accurate approach to measuring the prevalence of sexual harass- ment among high school students. Can J Behav Sci. 2007;39:110-118.

4. Petersen JL, Hyde JS. A longitudinal investigation of peer sexual harassment victimization in adolescence. J Adolesc. 2009;32:1173-1188.

5. American Association of University Women Educational Foundation. Hostile Hallways: Bullying, Teasing, and

Sexual Harassment in School. New York, NY: Harris/ Scholastic Research; 2001.

6. Lindberg SM, Grabe S, Hyde JS. Gender, pubertal development, and peer sexual harassment predict objec- tified body consciousness in early adolescence. J Res Adolescence. 2007;17:723-742.

7. McMaster LE, Connolly J, Pepler D, Craig WM. Peer to peer sexual harassment in early adolescence: a develop- mental perspective. Dev Psychopathol. 2002;14:91-105.

8. Goldstein SE, Malanchuk O, Davis-Kean PE, Eccles JS. Risk factors of sexual harassment by peer: a longi- tudinal investigation of African American and European American adolescents. J Res Adolescence. 2007;17:285- 300.

9. Houle JN, Staff J, Mortimer JT, Uggen C, Blackstone A. The impact of sexual harassment on depressive symp- toms during the early occupational career. Soc Ment Health. 2011;1:89-105

10. Peterson JL, Hyde JS. Peer sexual harassment and disordered eating in early adolescence. Dev Psychol. 2013;49:184-195.

11. Chiodo D, Wolfe DA, Crooks C, Hughes R, Jaffe P. Impact of sexual harassment victimization by peers on subsequent adolescent victimization and adjustment: a longitudinal study. J Adolesc Health. 2009;45:246-252.

12. Derogatis LR. Brief Symptom Inventory (BSI)-18. Administration, Scoring and Procedures Manual. Minneapolis, MN: NCS Pearson; 2001.

13. Fekkes M, Pijpers FI, Verloove-Vanhorick SP. Bullying behavior and associations with psychosomatic complaints and depression in victims. J Pediatr. 2004;144:17-22.

14. Forero R, McLellan L, Rissel C, Bauman A. Bullying behaviour and psychosocial health among school students in New South Wales, Australia: cross sectional survey. BMJ. 1999;319(7206):344-348.

15. Berntsson LT, Köhler L, Gustafsson JE. Psychosomatic complaints in schoolchildren: a Nordic comparison. Scand J Public Health. 2001;29:44-54.

16. Gini G. Associations between bullying behaviour, psy- chosomatic complaints, emotional and behavioural prob- lems. J Paediatr Child Health. 2008;44:492-497.

17. Rigby K. Peer victimisation at school and the health of secondary school students. Br J Educ Psychol. 1999;69 (pt 1):95-104.

18. Ashbaugh L, Cornell D. Sexual harassment and bullying behaviors in sixth graders. J Sch Violence. 2008;7:21-38.

19. Brown LM. Chesney-Lind M, Stein N. Patriarchy matters: toward a gendered theory of teen violence and victimiza- tion. Violence Against Women. 2007;13:1249-1273.

20. American Association of University Women. 2011 Survey on sexual harassment: Harassment-free hallways: How to stop sexual harassment in America’s schools. Washington, DC. http://www.aauw.org/files/2013/02/ Crossing-the-Line-Sexual-Harassment-at-School.pdf

21. Mitchell KJ, Ybarra ML, Korchmaros JD. Sexual harass- ment among adolescents of different sexual orientations and gender identities. Child Abuse Negl. 2014;38:280-295.

438 Clinical Pediatrics 54(5)

22. Youth Pediatric Symptom Checklist 35. Massachusetts General Hospital Psychiatry Web site. http://www. massgeneral.org/psychiatry/services/psc_forms.aspx. Accessed September 16, 2014.

23. Nadeem E, Graham S. Early puberty, peer victimization, and internalizing symptoms in ethnic minority adoles- cents. J Early Adolescence. 2005;25:197-222.

24. Jellinek MS, Murphy JM, Little M, Pagano ME, Comer DM, Kelleher KJ. Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study. Arch Pediatr Adolesc Med. 1999;153:254-260.

25. Little M, Murphy JM, Jellinek MS, Bishop SJ. Screening 4- and 5-year-old children for psychosocial dysfunction: a preliminary study with the Pediatric Symptom Checklist. J Dev Behav Pediatr. 1994;15:191-197.

26. Lee S, Kim CJ, Kim DH. A meta-analysis of the effect of school-based anti-bullying programs [pub- lished online October 3, 2013]. J Child Health Care. doi:10.1177/1367493513503581.

27. Cohen E, Mackenzie RG, Yates GL. HEADSS, a psy- chosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth. J Adolesc Health. 1991;12:539-544.