Don’t overlook bullying: Here are ways to help pediatric patients in need

Recurring ED visits may mask a hidden problem

Two young men go on a shooting rampage in their Littleton, CO, high school, killing 13 students and themselves. A 15-year-old Santee, CA, boy kills two students and wounds 13. An eighth-grade girl shoots a classmate in Williamsport, PA. What do all of those scenarios have in common? All of the shooters were victims of bullying.

"This is a topic that is ignored by many health care professionals," according to Terri Richards, RN, MA, an ED nurse at Children’s Hospital in Columbus, OH, and a school nurse for Teays Valley Schools in Ashville, OH. As an ED nurse, you probably tend to focus on the presenting complaint or the acute problem that brought the child to the ED, she explains. "We are not always in tune with the social and emotional aspects of the patient’s life," she says. "We may see physical injuries from fights or attacks, and may even hear them tell us it was from a bully or someone who has been harassing them. But seldom do we have a clear picture of the whole story."

Always take a child’s claims seriously, and remember that bullying can lead to serious injuries and even murder, warns Richards. "When a 14-year-old boy was brought to us with 80%-90% body burns, he was conscious at first. He was able to tell us who it was that did this to him, and that they had been harassing him before," she says. "The boy died the next day."

Don’t ever underestimate the fear that a bullied child feels, says Pamela A. Sanborn, RN, MSN, PNP, CEN, an ED nurse at Mount Auburn Hospital in Cambridge, MA. "Some children are picked on because they are shy, sensitive, anxious, insecure, overweight, physically small, disabled, or belong to a different race or religious faith," she adds. The victim feels isolated from their peers, who often reject him or her out of fear that they too will become a target of bullies, she says. "These feelings of isolation can lead to suicide or eventual violent retaliation by victims," says Sanborn.

Here are effective strategies to take when you suspect a child is a victim of bullying:

• Have a high index of suspicion. If a child frequently comes to your ED with headaches, abdominal pain, or sleeping difficulties with no physical cause after a thorough physical examination, it may be a sign that bullying is occurring, says Richards. "I recall several incidents of parents saying that their child is frequently ill while at school, but there is no problem once they get to the ED," she says.

When a 9-year-old girl came to the ED several times because of breathing problems, it was discovered that the visits always occurred before gym class. "She eventually confided in her mom that the gym teacher chastised her for not running fast enough and would make the whole class watch her finish the required distance," says Richards. "The girl had begun forcing herself to wheeze or hyperventilate prior to gym class."

Research has linked health problems such as headaches with bullying, notes Sanborn.1 "Is it constipation, early appendicitis, urinary tract infection, gastroenteritis, or migraine?" she asks. "If all tests are negative and the child does not have any physical findings on examination, it may be time to think of bullying."

Kate Reeves, RN, MA, CHPN, former administrative director of the ED at St. Joseph Hospital in Orange, CA, says she has seen many children whose symptoms were psychosomatic because of school-related problems. The most common symptoms were chronic stomachache or headache, Reeves says. "Some of them got million-dollar work-ups’ before the real problem was uncovered," she says.

• Speak openly about the problem with the child. The key message to get across to the victim is: It is not your fault that you are being bullied, and you do not have to face this on your own, says Sanborn. "The next step is to teach the child prevention methods," she says. "The nurse must find time to do this. If not, a hospital social worker should be called immediately."

Richards advises talking openly with the child about ways to avoid being bullied. "Let the child know that intimidation is unacceptable," she says. "Encourage them to talk to a trusted adult such as a parent, teacher, school counselor, or nurse," she says. Children may be unaware of their own rights and resources available to them, stresses Richards. "School nurses are an excellent starting point to refer the child," she says.

• Involve the child’s parents. Begin by asking the parents if the child is having problems in school, says Richards. "Ask if they suspect their child is being bullied," she recommends. "Ask how often the child visits the school nurse or gets ill at school."

Reeves advises discussing the problem with the parents away from the child’s hearing. "We can’t solve all the problems of the world, but some parents are oblivious," she adds.

However, Richards cautions that you should make sure your actions aren’t mistaken for professional counseling. "Ask a social worker to interview the child or family," she suggests. "If a social worker is not available, referrals to a mental health worker should be part of the care given to the child."

• Contact school nurses. Bullying is one of the most underrated problems in schools today, and the negative effects can last a lifetime, according to Sanborn. "Teachers, students, parents, school administrators, and health care professionals must work together as a team to take action against bullying," she says.

ED nurses should be more proactive in contacting schools when there is evidence of bullying, argues Reeves. "This is not a break in confidentiality because specific names don’t need to be used," she says. She suggests using the following script: "Hi, I’m Sally Smith, the evening charge nurse at St. Elsewhere. We have just cared for a child from Jones Street Elementary who has told us he was injured because the big boys pushed him around on the playground. I thought you should know about this because it can become a major issue, especially if the parents press charges. This little boy is in second grade, and he tells us this happens all the time at your school."

You also can contact the school principal. Again, you can protect the child’s identity unless the parents give you specific permission to share it, says Reeves. "These type of contacts need to be made, because parents are often afraid to complain for fear of retaliation," she says.

Another approach is to ask for written consent from the parent so you can share specific information with the school, Richards suggests. "This can be more effective than a general statement about a bully situation, because the schools may not take the call as seriously without a name and specifics," she says.

Richards acknowledges that time restraints may make these interventions difficult, especially if you work the night shift. "In a perfect world, this would happen. But in our ED, where there are more than 200 patients a day, this is often impossible," she says. If time won’t permit you to make these calls yourself, Richards recommends strongly encouraging families to do so on their own. "Explain that the school nurse will be able to follow up and provide a continuity impossible in the ED," she says.

Reference

1. Williams K, Chambers M, Logan S, et al. Association of common health symptoms with bullying in primary school children. BMJ 1996; 313:17-19.

Sources

For more information about treating children who are victims of bullying, contact:

Kate Reeves, RN, MA, CHPN, 70990 Star Shadow Road, RC-163, Mountain Center, CA 92561. Telephone: (760) 349-3394. E-mail: kreeves@royal-carrizo.com.

Terri Richards, RN, MA, Emergency Department, Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205. Telephone: (614) 722-4300. E-mail: trichards@teays-valley.k12.oh.us.

Pamela A. Sanborn, MS, RN, CPNP, CEN, 143 Currier Road, Andover, NH 03216-9712.

Resources

A Centers for Disease Control and Prevention (CDC) report published Dec. 7, 2001, titled School Health Guidelines to Prevent Unintentional Injuries and Violence, addresses prevention of bullying. The complete report can be accessed free at the CDC web site (www.cdc.gov/mmwr/preview/mmwrhtml/rr5022a1.htm). Or to obtain a paper copy for $3.50, contact: Superintendent of Documents, U.S. Government Printing Office, P.O. Box 371954, Pittsburgh, PA 15250. Telephone: (202) 512-1800.

Handouts for parents and children are available, including "How can I tell if my child is being bullied?" and "Recognizing and reporting early warning signs." Up to three handouts can be ordered free of charge at www.keystosaferschools.com. (Click on "Free Services," and "Free Handouts.") For more information, contact: Keys to Safer Schools, P.O. Box 296, Bryant, AR 72089-0296. Telephone: (877) 978-7678 or (501) 847-5225. Fax: (501) 847-0148. E-mail: keys@keystosaferschools.com