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<p class="title-left"><span class="bold">COVID-19 and a Potential Rise in Bullying Behaviors</span></p>
<p class="byline-regular">Ahmed Saeed Yahya, MRCPsych<span class="superscript">a,</span><span class="asterisk">*</span>; Shakil Khawaja, MRCPsych<span class="superscript">a</span>; and Jude Chukwuma, MRCPsych<span class="superscript">b</span></p>
<p class="drop-cap-with-body-text"><span class="bold-14pt-for-cap"><span class="bold">C</span></span>ases of bullying have been well documented in the medical and wider health care profession.<span class="htm-cite"><a href="#ref1">1</a></span> Bullying takes multiple forms, which may be accentuated by the coronavirus disease 2019 (COVID-19) crisis within various settings including health care teams, households, social groups, and especially children and adolescents. Bullying is already a major public health problem, with vulnerable individuals particularly at risk.<span class="htm-cite"><a href="#ref2">2</a></span> A study<span class="htm-cite"><a href="#ref3">3</a></span> from 2019 reported that 13.6% of US internal medicine residents said that they had been bullied during their training. The nonprofit antibullying organization Ditch the Label found in their annual survey (November 1, 2018–February 28, 2019) that 1 in 5 young people in the United Kingdom aged 12–20 years have been victimized by bullying.<span class="htm-cite"><a href="#ref4">4</a></span></p>
<p class="body-text">During the COVID-19 pandemic, there may be less monitoring and identification of these harmful behaviors and reduced opportunity for victims to access necessary support. We predict that many could now be affected by cyberbullying, workplace bullying, or an exacerbation of existent bullying in familial relationships. The majority of people are working from home, and bullying may manifest through online meetings or communications with colleagues via digital platforms. Limited means are available for victims to escape these environments given the current climate and restricted service provisions. Bullying at work impacts staff morale and well-being and is a well-known problem within health care organizations.<span class="htm-cite"><a href="#ref5">5</a></span> At a time when resources are constrained and front-line staff are overworked, such bullying behaviors may exacerbate staff burnout.</p>
<p class="body-text">Bullying is a traumatic experience, which may cause significant psychological distress. It may precipitate various psychiatric conditions including anxiety, depression, and psychotic disorders.<span class="htm-cite"><a href="#ref6">6</a></span> There is an association with bullying, self-injurious behavior, and suicide.<span class="htm-cite"><a href="#ref7">7</a></span> Children may present to their primary care physician with nonspecific somatic complaints including gastrointestinal problems, headaches, poor sleep, or emotional problems.<span class="htm-cite"><a href="#ref8">8</a></span> Individuals may also present with unexplained injuries and demonstrate unusual behavior such as being guarded, withdrawn, anxious, or visibly scared when the physician explores further. If there are signs of physical injury, then a comprehensive clinical examination is warranted investigating for signs of acute and historical trauma.<span class="htm-cite"><a href="#ref9">9</a></span> The patient’s history and examination findings should be documented contemporaneously.</p>
<p class="body-text">The clinician should inquire directly about bullying when patients present with signs of mental illness, behavioral difficulties, or psychiatric risk. It is important to review records to establish if there is an existing chronic medical illness or disability, previous physical injury, or any social difficulties. Risk factors for bullying can include financial deprivation, previous bullying history, familial discord, domestic violence, problems with schooling in children and adolescents, and substance misuse. Those from sexual minority groups and young people struggling with their weight may also be at greater risk.<span class="htm-cite"><a href="#ref9">9</a></span></p>
<p class="body-text">The physician should screen for any previous psychiatric history and historic risk in the form of self-harm or suicidality in those for whom there is an index of suspicion regarding bullying. To obtain the relevant details, the clinician should focus on communication and demonstrate appropriate empathy, reflective listening, compassion, and curiosity to form a positive therapeutic alliance.</p>
<p class="body-text">An integrated and collaborative approach is required in the management of bullying. This may involve the primary care physician liaising with occupational health, specialist organizations, schools, and family members. Children and adolescents require the support of their family to overcome this challenge.<span class="htm-cite"><a href="#ref9">9</a></span> It is important to jointly develop an appropriate safety plan with the patient by listing the key professionals and their contact details. Victims should be empowered and encouraged to keep up their physical activity, maintain good sleep hygiene, and, importantly, balance their social media usage.<span class="htm-cite"><a href="#ref10">10</a></span></p>
<p class="body-text">The familial response to the disclosure of bullying should be monitored closely and more so if there is concern about potential bullying in the household. Prompt identification and management is paramount to prevent further harm. Any psychiatric risk or signs of mental illness should be managed appropriately with consideration of referral to specialist psychiatric services. Victims should have regular medical follow-up and be referred to antibullying resources provided by third-sector organizations (<span class="callout">Box 1</span>).</p>
<div id="box1">
    <p class="subheads_subhead-1">Box 1. Online Antibullying Resources</p>
    <div>
      <p class="body-text"><span class="semibold">Online Resources in the United Kingdom</span></p>
      <ul>
        <li class="graphic-styles_table-text-bullet">Ditch the Label: <a href="http://www.ditchthelabel.org" target="_blank"><span class="hyperlink">www.ditchthelabel.org</span></a></li>
        <li class="graphic-styles_table-text-bullet">BullyingUK: <a href="https://www.bullying.co.uk/" target="_blank"><span class="hyperlink">https://www.bullying.co.uk/</span></a></li>
        <li class="graphic-styles_table-text-bullet">Anti-Bullying Alliance: <a href="https://www.anti-bullyingalliance.org.uk/" target="_blank"><span class="hyperlink">https://www.anti-bullyingalliance.org.uk/</span></a></li>
        <li class="graphic-styles_table-text-bullet">National Bullying Helpline:
          <a href="https://www.nationalbullyinghelpline.co.uk/about.html" target="_blank"><span class="hyperlink">https://www.nationalbullyinghelpline.co.uk/about.html</span></a></li>
      </ul>
      <p class="body-text"><span class="semibold">Online Resources in the United States</span></p>
      <ul>
        <li class="graphic-styles_table-text-bullet">Ditch the Label: <a href="https://us.ditchthelabel.org/" target="_blank"><span class="hyperlink">https://us.ditchthelabel.org/</span></a></li>
        <li class="graphic-styles_table-text-bullet">Stomp Out Bullying: <a href="https://www.stompoutbullying.org/" target="_blank"><span class="hyperlink">https://www.stompoutbullying.org/</span></a></li>
        <li class="graphic-styles_table-text-bullet">National PTA Connect for Respect:
          <a href="https://www.pta.org/home/programs/Connect-for-RespectBullying" target="_blank"><span class="hyperlink">https://www.pta.org/homeprograms/Connect-for-RespectBullying</span></a></li>
      </ul>
    </div>
  </div>
<p class="body-text">Should there be concerns about child or adolescent safety, then the clinician may need to alert social services. Should the victim or family object to information being forwarded to mandatory external agencies, then the physician will need to review the legislative framework in their area. Ensuring the safety of the victim and the environment to which they will return is critical. The COVID-19 pandemic has dramatically affected service provision. It is vital that clinicians take responsibility to ensure that a comprehensive management plan is in place once bullying is identified.</p>

<p class="end-matter"><span class="bold-italic">Received:</span> April 22, 2020.</p>
<p class="end-matter"><span class="bold-italic">Published online:</span> May 28, 2020.</p>
<p class="end-matter"><span class="bold-italic">Potential conflicts of interest:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Funding/support:</span> None.</p>
<p class="references_references-heading"><span class="bold">REFERENCES</span></p>
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<p class="front-matter-rule"><span class="superscript">a</span>Waltham Forest Mental Health Team, North East London Foundation Trust, Red Oak Lodge, London, England</p>
<p class="front-matter"><span class="superscript">b</span>Barnet, Enfield and Haringey Mental Health NHS Trust, London, England</p>
<p class="front-matter"><span class="asterisk">*</span><span class="italic">Corresponding author:</span> Ahmed Saeed Yahya, MRCPsych, Waltham Forest Mental Health Team, North East London Foundation Trust, Red Oak Lodge, London, England E11 4HU <span class="hyperlink">(<a href="mailto:a.yahya@nhs.net">a.yahya@nhs.net</a>)</span>. </p>
<p class="front-matter"><span class="italic">Prim Care Companion CNS Disord 2020;22(3):20com02642</span></p>
<p class="front-matter-rule"><span class="bold-italic">To cite:</span> Yahya AS, Khawaja S, Chukwuma J. COVID-19 and a potential rise in bullying behaviors. <span class="italic">Prim Care Companion CNS Disord</span>. 2020;22(3):20com02642.</p>
<p class="doi-line"><span class="bold-italic">To share:</span> https://doi.org/<span class="doi">10.4088/PCC.20com02642</span></p>
<p class="front-matter"><span class="italic">© Copyright 2020 Physicians Postgraduate Press, Inc.</span></p>

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