Traditional Bullying and Cyberbullying among Swedish AdolescentsGender differences and associations with mental health

Linda Beckman

DISSERTATION | Karlstad University Studies | 2013:31

Public Health Science

Faculty of Health, Science and Technology

DISSERTATION | Karlstad University Studies | 2013:31

Traditional Bullying and Cyberbullying among Swedish AdolescentsGender differences and associations with mental health

Linda Beckman

Distribution:Karlstad UniversityFaculty of Arts and Social SciencesCentre for Research on Child and Adolescent Mental HealthSE-651 88 Karlstad, Sweden+46 54 700 10 00

© The author

ISBN 978-91-7063-509-0

Print: Universitetstryckeriet, Karlstad 2013

ISSN 1403-8099

Karlstad University Studies | 2013:31

DISSERTATION

Linda Beckman

Traditional Bullying and Cyberbullying among Swedish Adolescents - Gender differences and associations with mental health

WWW.KAU.SE

ABSTRACT

Background: Adolescents’ social relations are associated with the state of their mental

health, and while positive relations can protect against development of mental health prob-

lems, negative social relations, such as bullying, is considered a risk factor. In addition, the

preconditions for establishing and maintaining social relations have changed along with the

development of information and communication technology (ICT). In this new arena nega-

tive social interactions, such as bullying, can also gain a footing. Given previous research

showing some distinguishing features between cyberbullying vis-a-vis traditional bullying,

there may be other differences as well, some of which will be studied in the current thesis. In

order to plan new and develop already-existing intervention strategies for bullying in school,

it is important to clarify whether we can use previous knowledge from the field of traditional

bullying or if we need to rethink our strategies. Given the harmful consequences that it en-

tails, bullying must be considered a public health issue.

Aim: The overall aim of this thesis is to study the differences and similarities between tradi-

tional bullying and cyberbullying among adolescents, with a particular focus on gender, psy-

chosomatic problems, and disabilities. The aim is also to gain insight into school-health

staff’s experience with bullying among school students.

Method: This thesis is based on four studies. Study I, II and IV take a quantitative approach

based on a web-based questionnaire. The data were collected on three occasions between

2009 and 2010 in the county of Värmland. Altogether more than 3,800 adolescents in Grade

7-9 participated all aged between 13 to 15 years. Logistic regressions and linear regression

analyses were applied in order to analyse associations, with both bullying and mental health

constituting outcome measures in different studies. In Study III, data were collected via fo-

cus groups. There were four focus groups comprising 16 school social workers and school

nurses. The data were analysed using qualitative content analysis.

Results: Study I: The results showed discrepant gender patterns for traditional bullying and

cyberbullying behaviour or victimization. Firstly, while there were almost no gender differ-

ences among traditional victims were found, girls were more likely than boys to be cybervic-

tims when occasional cyberbullying was included. Secondly, whereas boys were more likely

to be traditional bullies, girls were equally as likely as boys to be cyberbullies. Also, boys were

more likely to be traditional bully-victims, that is being bully and victim, while girls were

more likely to be cyberbully-victims. Study II: The results indicated an association with psy-

chosomatic problems for victims, bullies and bully-victims. The strongest associations were

seen for bully-victims and psychosomatic problems. The results do not indicate that the as-

sociation between bullying and psychosomatic problems is stronger for cyberbullying than

for traditional bullying. Study III: Three main categories emerged from the analysis of school

social workers’ and school nurses’ experience of and work with bullying: 1) “Anti-bullying

team”, 2) “Working style” and 3) “Perspectives on bullying”. The first described the organi-

zational bullying prevention work in schools; the second indicated different roles the partici-

pants played in their schools’ prevention and anti-bullying work. The third included different

views on bullying and how to handle bullying. Working Styles and Perspectives on Bullying

each comprising two sub-categories: “Team member”, and “Single worker”; and “Contextual

perspective” and “Individual-oriented perspective”. Study IV showed that, regardless of gen-

der and grade, students with a disability were more likely to be bully-victims and, more par-

ticularly, bully-victims involved in both traditional bullying and cyberbullying. No differences

between disabled adolescents and others were found with respect to the association between

bullying and psychosomatic health.

Conclusions: Bullying is a complex phenomenon and it takes on different forms along with

the changes in society. In the wake of Internet’s rapid development, we are all challenged –

parents, schools and researchers alike – to keep up with a younger, digitally savvy generation.

Cyberbullying and traditional bullying may not be two separate phenomena, but rather two

sides of the same coin. The results show that some adolescents are more likely to experience

higher levels of psychosomatic health problems. They also show that some that some ado-

lescents are more likely to be involved in bullying than others, either as victims, bullies or

bully-victims. One particular group that was recognized in the current thesis is the bully-

victims. Cyberbullying challenges schools in new ways, and hopefully the current thesis may

encourage schools to discuss this issue and how school health staff can optimize their re-

sources in alliance. In order to combat bullying, both contextual and individual approaches

are necessary, meaning that we need to take into account the structure surrounding the stu-

dents as well as the single individual in this matter. Providing school children and adoles-

cents with a safe and caring school experience can strengthen the mental health capital and

lay the foundation for students’ development and perspective of the world. Hence, reducing

bullying is an important issue to deal with, wheatear it happens online or offline.

SAMMANFATTNING

Bakgrund: Ungdomars sociala relationer är relaterat till deras psykiska hälsa, och medan

positiva relationer kan skydda mot att utveckla psykisk ohälsa, kan dåliga relationer, såsom

mobbning utgöra en riskfaktor. Därtill har förutsättningarna för att etablera och vidmakt-

hålla sociala relationer förändrats i takt med utvecklingen av informations- och kommunikat-

ionsteknologin. På denna nya arena kan också de negativa sociala interaktionerna, såsom

mobbning, få fäste. Nätmobbning och traditionell mobbning skiljer sig åt i vissa avseenden

vilket kan betyda att det föreligger andra skillnader också, varvid några perspektiv kommer

att undersökas i denna avhandling. I arbetet med att planera nya och utveckla existerande

interventioner om sociala relationer och mobbning i skolan är det viktigt att ta reda på om vi

kan använda redan känd kunskap från det traditionella mobbningsfältet för att motverka

nätmobbning eller om vi behöver tänka nytt i våra strategier. De skadliga konsekvenser som

mobbning kan innebära gör att mobbning bör betraktas som ett folkhälsoproblem.

Syfte: Det övergripande syftet med föreliggande avhandling är att studera mobbning med

avseende på skillnader och likheter mellan traditionell mobbning och nätmobbning bland

ungdomar, med fokus på kön, psykosomatiska besvär och funktionshinder och vidare få

kunskap om skolkuratorers och skolsköterskors erfarenheter av mobbning bland skolelever.

Metod: Avhandlingen bygger på fyra delstudier. Studie I, II & IV har en kvantitativ ansats

som baseras på ett webbaserat frågeformulär. Data samlades in vid tre olika tillfällen under

2009 och 2010 i Värmlands län. Sammanlagt deltog över 3,800 ungdomar i årskurs 7-9 i åld-

rarna 13-15 år. För att analysera samband med både mobbning och psykisk hälsa som ut-

fallsmått, användes binära och multinominala logistiska regressioner samt linjära regressions-

analyser. I Studie III samlades data in med fokusgrupper med sammanlagt fyra grupper och

16 skolkuratorer och skolsköterskor. Data analyserades med kvalitativ innehållsanalys.

Resultat: Studie I visade att det fanns könsskillnader med avseende på traditionell mobbning

och nätmobbning. Medan det nästan inte fanns några könsskillnader alls bland traditionella

offer, var sannolikheten att flickor nätmobbas större än för pojkar när ett lägre gränsvärde

för mobbning användes (”enstaka gång eller mer”). För det andra, medan det var en större

sannolikhet att pojkar var traditionella mobbare jämfört med flickor, påvisades ingen skillnad

mellan pojkar och flickor med avseende på att nätmobba andra. Sannolikheten var större att

pojkar var traditionella bully-victims (både mobbare och offer) jämfört med flickor, medan

sannolikheten för flickor att vara nätbully-victims var större jämfört med pojkar. Studie II

visade att det fanns ett samband mellan mobbning och psykosomatiska besvär, oberoende av

typ av mobbning, det vill säga offer, mobbare eller bully-victim. Analyserna visade dock inte

några skillnader i psykosomatiska besvär mellan cybermobbning och traditionell mobbning,

varken för offer eller för mobbare. I Studie III framkom tre huvudkategorier: 1) “Anti-

mobbningsteam”, 2) “Arbetsstil” och 3) “Perspektiv på mobbning”. Den första kategorin

beskriver skolans organisatoriska arbete mot mobbning, och den andra indikerade olika rol-

ler i deltagarnas förebyggande och anti-mobbningsarbete. Den tredje kategorin inkluderade

olika perspektiv på mobbning och hur mobbning kan hanteras. Arbetsstil och Perspektiv på

mobbning bestod av två sub-kategorier: “Lagmedlem”, och “Ensamarbetare”, och vidare

“Kontextuellt perspektiv”, och “Individorienterat perspektiv”. Studie IV visade att sannolik-

heten att elever med funktionshinder var bully-victims var större jämfört med elever utan

funktionshinder, och särskilt framträdande var sambanden för kombinerade bully-victims

(bully-victims som använder både traditionell mobbning och nätmobbning) och funktions-

hinder. Analyserna visade inte några samband mellan funktionshinder och att vara en mob-

bare. Det var större sannolikhet att flickor med funktionshinder var offer för mobbning jäm-

fört med flickor utan funktionshinder. Analyserna visade inte att funktionshinder modifie-

rade sambandet mellan mobbning och pyskosomatiska besvär, det vill säga; elever som är

involverade i, eller exponerade för mobbning rapporterar inte mer psykosomatiska besvär

om de också har ett funktionshinder, jämfört med om de inte har ett funktionshinder.

Slutsatser: Mobbning är ett komplext fenomen som ändrar form i takt med förändringar i

samhället. I vågen av internets snabba utveckling utmanas vi alla – föräldrar, skolan såväl

som forskare – i att hålla sig uppdaterade med den yngre, teknikkunniga generationen. Nät-

mobbning och traditionell mobbning är kanske inte att betraktas som separata fenomen utan

istället, i flera avseenden, två sidor av samma mynt. Resultaten visar att risken är högre för

vissa ungdomar än för andra att involveras i mobbning som offer, mobbare eller bully-

victims. Vidare visar resultaten att en del ungdomar i högre grad upplever högre nivåer av

psykosomatiska problem. Den grupp som särskilt utmärkte sig i denna avhandling var bully-

victims. Nätmobbning utmanar skolan på nya sätt och förhoppningen med denna avhand-

ling är att skolor uppmuntras till att diskutera kring detta problem och också hur skolan kan

optimera sina resurser i allians. För att motverka mobbning är både kontextuella och indivi-

duella angreppsätt nödvändiga, det vill säga vi behöver beakta den strukturella omgivningen

kring eleverna såväl som individens i detta avseende. Att ge elever en trygg och säker skol-

gång kan stärka deras psykiska hälsa och lägga grunden för deras utveckling och deras per-

spektiv på omvärlden. Mobbning är därför ett särskilt viktigt problem att arbeta med, oavsett

om det sker online eller offline.

CONTENT

LIST OF PAPERS ................................................................................................................................................ 1

ABBREVIATIONS AND DEFINITIONS .......................................................................................................... 2

1 INTRODUCTION ..................................................................................................... 3

1.1 Central concepts .............................................................................................................................................. 6

1.2 Bullying in a changing society ........................................................................................................................ 7

1.3 Bullying as a public health concern ................................................................................................................ 10

2 SOCIAL RELATIONS .............................................................................................. 12

3 MENTAL HEALTH ................................................................................................. 15

3.1 Health and mental health ............................................................................................................................... 15

3.2 Children’s and adolescents’ mental health ..................................................................................................... 17

3.3 Stress, mental health and social relations ....................................................................................................... 18

3.4 School, learning and mental health ............................................................................................................... 20

4 THE SCHOOL ARENA .......................................................................................... 22

4.1 The dynamic school ...................................................................................................................................... 22

4.2 The school health service .............................................................................................................................. 23

4.3 Bullying prevention in school ........................................................................................................................ 25

5 BULLYING ............................................................................................................... 27

5.1 Scrutinizing the bullying criteria ................................................................................................................... 27

5.2 Cyberbullying – definition and features ........................................................................................................ 28

5.3 Socio demographic factors ............................................................................................................................ 30

5.4 Gender differences in aggressive and bullying behaviour ............................................................................. 32

5.5 Reasons for bullying ...................................................................................................................................... 36

6 METHODOLOGICAL PROBLEMS IN BULLYING RESEARCH .................... 37

7 THE “PREVENTIVE SCHOOL” PROJECT ........................................................ 40

8 PROBLEM SPECIFICATION AND AIMS ............................................................ 43

9 METHOD ................................................................................................................. 45

9.1 Participants .................................................................................................................................................... 45

9.2 Data collection .............................................................................................................................................. 46

9.3 Items, questions and instruments ................................................................................................................. 49

9.4 Data analysis ................................................................................................................................................. 52

9.5 Ethical considerations ................................................................................................................................... 54

10 MAIN RESULTS .................................................................................................... 56

11 DISCUSSION .......................................................................................................... 59

12 CONCLUSIONS AND IMPLICATIONS ............................................................. 74

Acknowledgment ................................................................................................................................................ 77

1

LIST OF PAPERS

I. Beckman, L., Hagquist, C. & Hellström, L. (2013). Discrepant Gender Patterns

for Cyberbullying and Traditional bullying – an Analysis of Swedish Adolescent

Data. Computers in Human Behaviours, 29(5), 1896-1903.

II. Beckman, L., Hagquist, C. & Hellström, L. (2012). Does the Association with

Psychosomatic Health Problems differ between Cyberbullying and Traditional

bullying? Emotional and Behavioural Difficulties, 17(3-4), 421-434.

III. Beckman, L., Hagquist, C. Perspectives on Bullying: A Study among School nurs-

es and School social workers in Sweden (Submitted to Advances in School Mental

Health Promotion).

IV. Beckman, L., Stenbeck, M., Hagquist, C. Disability in Relation to Bullying and

Psychosomatic Problems (Submitted to International Journal of Public Health).

Reprints have been made with prior permission of the publishers.

2

ABBREVIATIONS AND DEFINITIONS

Adolescent: According to The World Health Organization, adolescents range from 10-19 years

of age.

Bully-victim: By bully-victim I here mean someone that has reported being both a victim and a

bully. There is no established term for bully-victim in Swedish.

BUF: Children and Youth Administration [Barn- och utbildningsförvaltningen].

CFBUPH: Centre for Research on Child and Adolescent Mental Health

ICT: Information and communication technology

SN: School nurse

PS project: Preventive School project

SSW: School social worker

SHS: School Health Service. In Swedish “Skolhälsovård”.

TSH: Team for Students’ Health. In Swedish “Elevhälsa”.

3

1 INTRODUCTION

The background to this thesis is the school based project “Preventive school” (PS), a com-

munity based project aiming at promoting good mental health among school children. In

cooperation with the municipal of Karlstad, our research group “Centre for Research on

Child and Adolescent Mental Health” (Centrum för Forskning om Barns och Ungdomars

Psykiska Hälsa [CFBUPH]) was commissioned to evaluate the PS project by studying school

students’ mental health and lifestyle habits, as well as their experiences with bullying and

school environment. In addition, school staff were asked to give their perspectives, through

interviews and questionnaires. A particular focus of the project was bullying, which also be-

came the focus of this thesis.

In recent decades, the Swedish school system has been widely criticized for its over-

emphasis on the individual, the decline in academic achievement among students and in-

creased segregation due to the mushrooming of independent schools. At the same time, the

media has given us alarming reports of deteriorating mental health among today’s youth.

Although the link between these phenomena is not clear, one important factor which has

been shown to be a strong determinant for mental health and school achievement is social

relations among the young.

A recent systematic review concluded that poor social relations with peers and teach-

ers have a negative impact on students’ mental health, while positive relations with peers and

teachers can guard against mental health problems (Gustafsson et al., 2010). In addition, the

conditions for social interactions have changed along with the development of Information

and communication technologies (ICT). In this new, extensive arena, negative social interac-

tions such as bullying are far from excluded. The Internet has been increasingly integrated

into people’s everyday lives, and children and adolescents interact and maintain their social

relations using ICT through blogging, micro-blogging, chatting and social networking sites

(Livingstone, Haddon, & Ólafsson, 2011).

Bullying has been described as a sub group of aggression carried out during longer

time intervals. The definition of bullying usually includes three criteria: bullying is repeated

acts over time; bullying includes an imbalance in power between bullies and victims which

4

can be psychological, physical or social; and the actions are intended to cause physical or

psychological harm (Olweus, 1993; Olweus, 1996a). Although other definitions of bullying

exist in the literature, Olweus’ criteria are generally accepted, although different formulations

in the literature exist (e.g., Pepler, Jiang, Craig, & Connolly, 2008; Rigby, 2002). Peer victimi-

sation, as well as bullying, can include all kinds of physical and psychological aggression and

social exclusion. A distinction is often made between direct and indirect forms of peer vic-

timisation, were direct aggression include acts of for example kicking and hitting, and verbal

aggression such as name-calling and insulting, and indirect aggression is the covert manipula-

tion of social relations, and includes behaviours such as rumour spreading and exclusion. It

is also named social or relational aggression, which is the manipulation or disrupting of rela-

tions (Smith, 2004).

Devastating media reports of suicides linked to bullying via new media technology

has shaken local communities, both at home and abroad. Meanwhile, presenting oneself over

the Internet in order to seek personal confirmation has become a societal norm. A recent

series of articles in the local news (Wallmander, 2-3 July, 2013) gave a sad picture of 10- to

12-year-old children participating in beauty contests managed by 13-year-old boys via Insta-

gram (a social network site for sharing photos. The girls interviewed, who had also won the

contest, said that they believed that those who had not won were either unaffected, not sad

or did not care. A recent well-publicized Swedish court case furthermore serves as an exam-

ple of the possible consequences a lack of empathy can have when combined with immaturi-

ty and new forms of social media. In December 2012, two teenage girls, aged 15 and 16,

were charged with spreading libel in text and images via an account on Instagram. They were

sentenced in Gothenburg District Court on charges of gross defamation in 3 July 2013. The

photos had resulted in a riot in Gothenburg in December 2012 which gathered nearly 500

young people. The photos contained images of young girls labelled with offensive com-

ments. The 15-year-old girl pleaded guilty, although she claimed that she had not been aware

of the consequences of her actions. The other girl pleaded not guilty (Linné, 2013, 28 June).

Given that bullying is a problem for many school-aged children and adolescents in

Sweden (Molcho et al., 2009; Sentenac, Gavin et al., 2012) and the harmful consequences

5

(Farrington, Losel, Ttofi, & Theodorakis, 2012), and cost for society that bullying may entail

(Farrington et al., 2012), bullying should be labelled a public health issue (Feder, 2007).

The resources allocated to help children and adolescents with mental health problems

has in Sweden recently come under scrutiny, OECD (2013) concluded that school health

services are only limping along and are not able to keep up with the growing numbers of

children and adolescents in need. Along with the new Swedish Education act of 2012 (SFS,

2010:800), school health services were reorganized into comprehensive teams where, among

other things, the role of school social workers was acknowledged. The effects of this legisla-

tive amendment are worth following, insofar as the amendments impact the lives of students

with mental health problems.

Bullying, both online and offline, form a central part of this thesis and the current ar-

ticles attempt to shed light on this issue from various perspectives as well as through a com-

parison of new arenas for social relations in cyberspace with traditional arenas. Elucidating

possible differences between the two forms of bullying becomes important for schools when

planning intervention strategies. A useful question to pose in this regard is, for example, can

we use old knowledge to combat cyberbullying, or do we need to tackle cyberbullying differ-

ently?

In the current thesis, Study I, II and IV take a quantitative approach where compari-

sons between traditional bullying and cyberbullying are made with regard to gender differ-

ences (I), psychosomatic problems (II), and disabilities (IV). Study III takes a qualitative ap-

proach using focus groups, in order to gain insight into schools’ experience with bullying.

This introduction provides a contextual framework for these studies and will discuss the im-

portance of social relations, mental health, the school arena, and different aspects of bully-

ing.

6

1.1 Central concepts

Traditional bullying is in this thesis defined by the three criteria: repetition, power imbalance

and intention (Olweus, 1993).

Cyberbullying is in the current thesis defined as traditional bullying “but involves bullying through,

for example, mobile phones (calls or text messages), photo/video clips, E-mail, Chat-rooms, Web-pages, In-

stant Messaging (i.e. MSN)”. (Smith et al., 2008).

Peer aggression: Definitions of human aggression often imply that the aggressor is a “perpetra-

tor” and that the aggression recipient is a “victim” (Ferguson & Beaver, 2009). In the current

thesis, aggression is put in the context of victims and perpetrators (bullies), implying a mali-

cious relation between the involved and the definition of Berkowitz (1993) may be close to

what is meant with aggression in this thesis: “Aggression is all behaviours intended to hurt or harm

others either physically or psychologically”. Brown (1996) adds that aggression can be reactive, i.e. a

defensive response to a perceived threat, or proactive, i.e. unprovoked, aversive behaviour

intended to harm, dominate, or coerce another person.

Peer victimisation: The bullying literature often acknowledges a confusion regarding the con-

cepts of “peer victimisation” and “bullying” and the terms are often used interchangeably.

The concept of peer victimisation can be seen as an umbrella term that includes both bully-

ing and peer aggression and can thus include all kinds of physical and psychological aggres-

sion and social exclusion. Peer victimisation has been defined as experiences among children

of being a target of the aggressive behaviour of other children, who are not siblings and not

necessarily age-mates (Hawker & Boulton, 2000).

Mental health is considered an integral part of the definition of health and has been defined by

WHO as: “A state of well-being in which the individual realizes his or her own abilities, can cope with the

normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her

community” (WHO, 2001).

7

Psychosomatic problems refer to physical conditions that are psychologically induced and may

occur as for example stomach ache, head ache, feeling giddy (Petersen, Brulin, & Bergström,

2006).

Disability is in the current thesis defined as: “… for example, impaired movement, dyslexia, impaired

vision or hearing, or any other similar condition which might make things hard for you, either in or outside of

school. It may also mean that you have ADHD, epilepsy or diabetes.” There are many definitions of

disability/chronic health condition/functional limitations in the literature, and there is no

clear consensus on how the terms should be defined (van der Lee, Mokkink, Grootenhuis,

Heymans, & Offringa, 2007). Commonly, definitions may include notions of duration, such

as three months, and that the disability has interfered with daily functioning during the last

year (Grøholt, Stigum, Nordhagen, & Köhler, 2003). In the current thesis, the term disability

also includes chronic health conditions or chronic illness, which are terms commonly seen in

the literature.

1.2 Bullying in a changing society

The word mobbing was first introduced into Swedish language by the Swedish physician Pe-

ter-Paul Heinemann (Heinemann & Entell, 1972). He used the term mobbing1 to refer to

group violence against a deviant individual that occurs suddenly and subsides just as sudden-

ly, i.e., it is connected to the sudden formation of a “mob”. Heinemann turned against socie-

ty’s acceptance of such behaviour and demanded that it be treated as unacceptable and be

counteracted on all fronts. His argument was the springboard for the national and interna-

tional discussion in school, public debate and research concerning bullying (Larsson, 2008).

At the same time as Heinemann, the Swedish psychologist Dan Olweus (1978) also started

studying the phenomenon from a psychological perspective and became a pioneer within the

research field of bullying. This raised awareness among the public and in schools, and be-

came an emotional and important topic.

1 Mobbing was later re-written as mobbning, which was considered to be more in line with Swedish spelling.

8

In 1985, the term “bullying” became interconnected with the Swedish legal term “in-

sulting treatment” [Sw. kränkande behandling] in the Swedish Education act, which requires

those working within the school system to counteract all forms of insulting treatment such

as bullying. In 2006, the Act Prohibiting Discriminatory and Other Degrading Treatment of

Children and Pupils (SFS, 2006:67) was introduced. School staff became legally responsible

for reporting bullying in Swedish schools (SNAE, 2009). In 2009, the act was replaced by the

Discrimination Act (SFS, 2008:567). Today, the new Swedish Education act (SFS, 2010:800)

demands that each school establish a stepwise plan for the prevention of, and strategies

against, insulting treatment and bullying in schools. Schools are obliged, under 10 §, chapter

6, to take action when students consider themselves being exposed to insulting treatment in

connection with the organization. This includes cyberbullying or cyber harassments, since situa-

tions that arise outside school involving students at the same school are equally the school’s

responsibility.

Bullying occurrence

Society’s view of bullying has also changed. Peer victimisation has probably always been part

of school life in one form or another. There are documents from the 1700s describing how

older students harassed younger students in order to maintain the pecking order. This was

called penalising, a form of socialization that was more or less accepted. It was not until the

1960s that such oppression of students was paid attention to via Heinemann (Frånberg &

Wrethander, 2011).

Trying to compare understandings and prevalence rates of “bullying” across countries

is not an easy task. Bullying may have a different meaning to people in different countries,

and some languages do not have the term or may assign the word a different meaning (Från-

berg & Wrethander, 2011). There is also a diversity of methodologies being used to opera-

tionalize, define and measure bullying. Prevalence rates of traditional bullying and cyberbul-

lying varies greatly between and within countries and studies (Craig et al., 2009; Due et al.,

2005; Molcho et al., 2009) and also between schools (Smith & Ananiadou, 2003). For exam-

ple, Patchin and Hinduja (2011) illustrated through international comparisons how cybervic-

9

timisation rates vary from 5% to above 72%, and cyberbullying rates from 3% to 44%. Mol-

cho et al. (2009) reported country differences in traditional victimisation and bullying and

found rates of occasional bullying varying from 10% to 50%. Swedish children and adoles-

cents report relatively low prevalence rates of traditional bullying compared to other coun-

tries, about 3% to 15% (Craig et al., 2009; FHI, 2011b). Similar prevalence rates are reported

for cyberbullying, although they are usually somewhat lower compared to traditional bullying

(Beckman, Hagquist, & Hellström, 2012; Slonje & Smith, 2008).

In addition, measurement methods for bullying may fail to capture the total mental

health burden of peer-victimisation. In a study by Hellström, Beckman and Hagquist (in pro-

cess) health outcomes of bullying victims and victims of peer aggression were compared,

showing that bullying victims as well as peer-aggression victims reported significantly more

psychosomatic problems compared to non-involved adolescents, and that there was no sig-

nificant difference between the two groups. This means that when taking into account both

bullying and peer aggression, a wider range of students at risk of poor mental health will be

identified. Hence there are arguments that peer-aggression victimisation, in addition to bully-

ing victimisation, should be taken into consideration when assessing peer-victimisation

among adolescents. Same authors (Hellström, Beckman, & Hagquist, 2013) also examined

the empirical overlapping of peer-aggression victimisation and bullying victimisation which

showed quite a number of students reported being repeatedly exposed to peer-aggression

behaviour, but not bullying. This indicate that when measuring peer victimisation, questions

about peer-aggression and bullying should be used simultaneously in order to capture the

magnitude of a multifaceted phenomenon like peer victimisation.

New platforms for bullying

In the wake of societal and technological changes, the forms and platforms for bullying have

changed. Today, Internet access and Internet use have been increasingly integrated with ado-

lescents’ everyday life and only a minor percentage of young people today lack access to

computers and mobile phones. Children and adolescents interact and maintain social rela-

tions via ICTs including blogging, micro-blogging, chatting and social networking sites. A

10

society’s norms are reflected in its media; and beauty and youth have become highly prized

in the mainstream media (Egbert & Belcher, 2012). The popularity that comes with increased

personal exposure online may bring about an even greater emphasis on appearance and in-

crease consciousness of one’s looks, especially among girls (Vandenbosch & Eggermont,

2012). For example, it has been shown that adolescent girls who spend more time using so-

cial networking sites (SNS) report higher levels of self-objectification, i.e., the internalization

of an observer’s view of one’s own body (Vandenbosch & Eggermont, 2012).There is never-

theless an association between high Internet consumption and peer victimisation (Living-

stone et al., 2011; The Swedish Media Council, 2010), and the constant accessibility, for ex-

ample via today’s smartphones eradicating the differences in functionality between the Inter-

net and mobile phones, may further increase the risk of harm (Livingstone et al., 2011).

Since Sweden is a country with very high Internet usage among all ages, it would be easy to

assume that the risk of being exposed or involved in cyberbullying behaviour is relatively

high. However, Livingstone et al. (2011) reported that cyberbullying appears to be influenced

by the pervasiveness of traditional bullying, rather than by the pervasiveness of Internet us-

age. This suggests that cyberbullying may not primarily be a consequence of new technolo-

gies but rather a new form of a long-established child and adolescent problem (Livingstone

et al., 2011). However, this assumption may apply when studying bullying, but when looking

at other similar aggressive phenomenon, such as commenting nasty and threating things on

others’ blogs or personal profiles, it may not account for the same phenomenon. Thus, im-

pulsive behaviour may be acted out to a greater extent and the digital device thus becomes a

potential weapon with the possibility to easily hurt someone.

1.3 Bullying as a public health concern

From a public health perspective, bullying is a serious issue as it concerns a large proportion

of children and adolescents. The association between bullying and mental ill health is well

established. While victims usually report higher levels of internalizing problems such as lone-

liness, depression, social anxiety (Juvonen, Graham, & Schuster, 2003) compared to bullies,

bullies more often engage in other forms of externalizing behaviour such as drinking and

smoking, compared to victims (Nansel, Craig, Overpeck, Saluja, & Ruan, 2004; Sourander et

11

al., 2011). The most vulnerable group, which has gained attention in recent years, is the bul-

ly-victims, which are the ones usually reporting the highest levels of both internalizing and

externalizing problems (Kaltiala-Heino, Rimpelä, Rantanen, & Rimpelä, 2000; Kumpulainen,

Räsänen, & Henttonen, 1999; Nansel et al., 2004; Schwartz, 2000). In addition, bullying oc-

curs frequently among already vulnerable individuals, such as among those reporting disabili-

ties or chronic health conditions (e.g., Hamiwka et al., 2009; Nordhagen, Nielsen, Stigum, &

Köhler, 2005; Pittet, Berchtold, Akré, Michaud, & Suris, 2010; Sentenac et al., 2012; Taylor,

Saylor, Twyman, & Macias, 2010).

Child and adolescent health has taken on a higher profile in Sweden in recent dec-

ades, as can be seen in the political agenda. Sweden was one of the first countries to ratify

the Convention on the Rights of the Child (U.N. General Assembly, 1989). The over-

arching aim of national public health policy is to create societal conditions that will ensure

good health, on equal terms, for the entire population. Public authorities at all levels are

guided by 11 health objectives.2 Objective No. 3 covers conditions during childhood and

adolescence. Since conditions in early years are crucial to an individual’s life-long health, the

Swedish Parliament’s proposed a revised public health policy (Prop. 2007/08:110) that rec-

ognizes children and adolescents as a priority group within public health care. Since children

cannot choose their environment and yet are sensitive to external influence, investments in

health promotion among the young pay off in terms of healthy life styles habits among the

adult population (Prop. 2007/08:110).

2 Public Health objectives: 1) Participation and influence in society; 2) Economic and social prerequisites; 3) Condi-

tions during childhood and adolescence; 4) Health in working life; 5) Environments and products; 6) Health-promoting health services; 7) Protection against communicable diseases; 8)Sexuality and reproductive health; 9)Physical activi-ty; 10) Eating habits and food; and finally 11) Tobacco, alcohol, illicit drugs, doping and gambling.

12

2 SOCIAL RELATIONS

One of the major determinants for people’s health is their social relations. Social relations is

included in the WHO’s strategy for improved public health (Dahlgren & Whitehead, 1991).

Children and adolescents’ social relations are mostly taking part in their school environment,

where they spend most days of the week. It is therefore specifically important that they have

a healthy school environment.

The importance of social relations for people’s health is well known and has been

discussed by theorists such as Émile Durkheim in terms of, for example, the importance of

solidarity and suicide rates in Europe (Berkman, Glass, Brissette, & Seeman, 2000). Over the

past few decades, there have been profound changes in social relations in Western society,

particularly in the structure of family. Family structure and household composition have

changed dramatically. Major trends include a decrease in the numbers of couples marrying

and nuclear-family households; and an increase in the numbers of adults living alone, lone

parents with children, cohabiting heterosexual couples and homosexual couples and families.

Altogether, these trends constitute a divergence from the nuclear family. The decrease in the

number of nuclear family households is especially striking in more developed countries;

Sweden, together with Denmark, has the greatest number of single-adult households. These

trends reflect ongoing economic and social changes in the wake of globalization. Increased

employer demands, the spread of individualism and shifting social norms have stimulated an

increase in divorce (Martin & Kats, 2003).

Another cause of change in our social relations is the Internet. Today, we use the In-

ternet to communicate and to schedule our daily lives, and according to Livingstone (2009),

these “altered time-space conditions” for everyday life reshape our social relations. The pre-

conditions for relational activities have changed, and games and meetings do not necessary

need to be physical, and we can create our own personalized home pages or promote our-

selves online in endless ways. Thus, the trend is towards individualisation, privatisation and

personalisation.

Social relations include both positive and negative dimensions. The positive aspects

include the process through which social relations promote health, i.e., social support, which

13

is the individual’s perception of social resources that are available or that are actually provid-

ed (Cohen, 2004). The negative aspects are the relative absence of social relations (social iso-

lation or exclusion), such as bullying or peer victimisation, which affects the individual’s

mental health (House, Landis, & Umberson, 1988; Umberson & Montez, 2010). Social isola-

tion or exclusion has been argued to be a particular damaging form of peer victimisation for

children’s’ and adolescents wellbeing (see 3.3). Hence, being socially excluded from different

groups on Internet may function the same way. Gross (2009) found that socially excluded

adolescents reported e.g., lower self-esteem, anger and shame, compared to those who were

included in the peer group.

Studies on adults in the 1980 showed that people with close social ties and relations

(marriage, contacts with close friends and relatives, church membership, informal and formal

group associations) lived longer compared to people lacking such ties (Berkman & Syme,

1979). For children, relations with peers and parents are crucial and represent critical links

for understanding mental and physical health across the life span. Families characterized by

conflict, aggression and by cold, unsupportive and neglectful relationships are considered a

risk for children’s psychosocial, mental, and physical functioning, and health behaviours

(Repetti, Taylor, & Seeman, 2002). When children enter school age, peers and teachers be-

come important for adolescents’ mental health and school achievement (Wentzel, 1998;

Wentzel, Baker, & Russell, 2012).

The perception of social support from peers and adults has also shown to protect

against bullying involvement. Holt and Espelage (2007) found that those not involved in bul-

lying perpetration and victimisation reported greater perceived social support compared to

those who were bullies or victims. It may however be difficult to determine the direction of

these associations since poor social ties can be a result of being victimised or being a bully.

However, there has been longitudinal studies indicating the protective effect of peer rela-

tions: Malcolm, Jensen-Campbell, Rex-Lear and Waldrip (2006) found that quality friendship

protected against being victimized, and Kendrick, Jutenberg and Stattin (2012) found that

adolescents experiencing higher level of support from friends reported lower levels of both

bullying and victimisation.

14

Although social relations are necessary for all human beings and people cannot live in

total isolation (Taylor, Grimen, Lindén, & Molander, 1995), the associations are complex

and increases in social interactions are not always health protective. Those with less friends

and family members may be exposed to fewer opportunities to get into interpersonal con-

flicts, compared to their more social counterparts (Cohen, 2004). For example, in a study by

Bergh, Hagquist and Starrin (2011), higher levels of peer activity among adolescents corre-

sponded to higher frequency of alcohol consumption.

Stigmatisation and labelling

Connected with negative relations, and closely related to bullying, are the sociological phe-

nomena of stigmatisation (Goffman, 1963) and labelling (Becker, 1963). A person is labelled

as different if he or she is considered to deviate from the normative standards of a social

group, culture or society. Stigmatisation is the result of being labelled different. It relies on,

according to Link and Pehlan (2001), the use of stereotypes. It leads to “us and them” think-

ing and discrimination, and leaves the labelled person to experience a loss of status. Accord-

ing to Thornberg (2011), research on bullying shows that stigma theory and labelling theory

help us to understand the social processes of bullying. The concept of stigma lies at the core

of understanding the consequences of labelling. Negative labelling can spell social isolation

for an individual, as relations with that individual are either avoided or terminated due to fear

of stigma through association (Goffman, 1963). Hence, even students who not bully do not

want to be around the victim because of social pressure (Hamarus & Kaikkonen, 2008).

Corrigan and Watson (2002) discuss two types of stigma: public stigma and self-

stigma. Public stigma comprises reactions of the general public towards a group based on the

stigma associated with that group. Self-stigma is the prejudice which people with mental ill-

ness turn against themselves. It can result in for example failing to pursue work and housing

opportunities (Corrigan & Watson, 2002). Public stigma can have a severe impact on many

people’s everyday lives, including one’s social life and self-esteem, especially if it leads to self-

stigma (Rüsch, Angermeyer, & Corrigan, 2005).

15

3 MENTAL HEALTH

3.1 Health and mental health ”Mental health” has come to be a common term in the public heath debate, and the opposite

of mental health, i.e., mental disorder and mental illness, have been highlighted as a public

health problem by the WHO (2013). It is hard to find reliable data on prevalence, but ac-

cording to Gustavsson et al. (2011), in any one year, over a third of the total EU population

suffers from mental disorder. Historically, mental disorders and mental health problems have

been a taboo subject in society, connected with stigmatisation and shame. However, in line

with the increased proportion of self-reported mental illness in the wake of societal changes

such as the economic crisis of the 1990’s (Hagquist, 1997) and the increased prescribing of

antidepressant treatment (SSRI, “selective serotonin re-uptake inhibitors”), it seems to have

become more socially acceptable in the past two decades to seek help for anxiety and de-

pression. As Svenaeus (2009) argue, these conditions have undergone a process of “de-

stigmatisation”, and there is now less shame in talking about mental health problems.

Mental health is considered an integral part of The World Health Organization’s

(WHO, 1948) definition of health from 1948: “a state of complete physical, mental, and social well-

being and not merely the absence of disease or infirmity”. Although it has been subject to critique (see

Larson, 1999), it is still the most commonly used definition. In 1986, WHO made additional-

ly allowances within the context of health promotion and it was furthered emphasized that

health is not just a state, but also “a resource for everyday life, not the objective of living. Health is a

positive concept emphasizing social and personal resources, as well as physical capacities”. Mental health is

more than the absence of mental illness, and closely connected with physical health and be-

haviour. WHO’s definition of mental health follows: “A state of well-being in which the individual

realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully,

and is able to make a contribution to his or her community” (WHO, 2001). However, the concept of

health is broad and linked with individuals’ cultural and social situations, meaning that health

can have different meanings for different people (Ewles & Simnett, 1985; Naidoo & Wills,

2000).

16

Mental health, mental illness and mental disorder differ per definition. WHO’s defini-

tion of mental disorder (neuropsychiatric conditions) in ICD -103 includes e.g. unipolar depres-

sions, bipolar diagnoses, schizophrenia, epilepsy, alcohol- and drug misuse, Alzheimer’s and

other dementia related diseases, post-traumatic stress, compulsory behaviour, panic attacks,

neurotic, stress-related and somatoform disorders, and insomnia. These disorders are a great

suffering for the individual and the related family, and beyond this there is also a high and

indirect cost for the society (Gustavsson et al., 2011).

“Mental illness” is sometimes used interchangeably with “mental disorder” in the lit-

erature, but I shall use “mental illness” here to refer to when an individual’s state of mind is

harder to define than “mental disorder”. Mental illness can be explained as the experience of,

or the lack of sufficient ability to meet the challenges in everyday life and it is based on the

individual’s own experience of mental wellbeing. The delineation between normal and ab-

normal condition is not obvious and has varied between different time epochs and cultures

(SOU, 2006a). Here, more diffuse problems such as headache, worrying, anxiety, tiredness,

stress, sleeping problems, impaired mental wellbeing, suicidal thoughts and suicidal attempts

can be included.

Milder forms of mental illness symptoms can include psychosomatic symptoms or

problems, which refer to physical conditions that are psychologically induced. Psychosomat-

ic problems from two or more parts of the body, such as the stomach, head, leg, chest and

back, often co-exist (Petersen et al., 2006). Psychosomatic problems may lead to school ab-

senteeism and can be an early indicator of later mental health problems (Alfvén, 1997).

Stress is a generally accepted cause of psychosomatic problems. Long-standing acute stress

can be transformed into chronic negative stress, which can lead to mental health problems

such as psychosomatic problems (Alfven, Östberg, & Hjern, 2008). Acute stress and chronic

stress do in many ways use the same neurological mechanisms, but the body adapts to

chronic negative stress with negative outcomes such as sleep difficulties, pain and other psy-

chosomatic and somatic symptoms (Alfvén, 2003). Children and adolescents with disabilities

and chronic health conditions have been shown to suffer an elevated risk of poor mental

3 International Statistical Classification of Diseases and Related Health Problems, 10

th Revision

17

health including anxiety, low emotional well-being, lower quality of life, and lower self-

esteem (Bosk, 2011; Edwards, Patrick, & Topolski, 2003; Pinquart & Teubert, 2012; Pin-

quart, 2012).

In the current thesis, no distinction is made between mental illness and mental health

problems.

3.2 Children’s and adolescents’ mental health

Since the 1980s, there has been alarming reports in media concerning the mental health

among children and adolescents hence their life and well-being has taken a more pro-

nounced role on the political agenda (SOU, 2006a). However, despite the rapid stream pro-

posing a deteriorating mental health, there is still a lack of studies supporting such arguments

fully (Beckman & Hagquist, 2010). The question regarding trends in children and adoles-

cents mental health was raised by the Health Committee at The Royal Swedish Academy of

Sciences and in 2010, at a State of the Science Conference, an extended literature review

conducted by an expert group were presented (Petersen et al., 2010). The authors (Petersen

et al., 2010) concluded that considering indications of declining trends in mental health

among children and adolescents, the few existing studies suffer quality deficiencies.

Looking at studies conducted in Sweden there are indications of an increase in self-

reported mental health problems, especially among adolescent girls (Hagquist, 2009b; Pe-

tersen et al., 2010), and young women (SCB, 2008; Socialstyrelsen, 2009). International stud-

ies are, in accordance to the Swedish and Nordic, also scarce and show discrepant results.

Based upon the whole picture of trend studies, the authors to the literature review (Petersen

et al., 2010) concluded that the results were not consistent and that difference in time per-

spectives, informants, age groups, and measurements make it hard to compare studies and

draw any conclusions. A more recent study from the UK (Collishaw, Maughan, Natarajan, &

Pickles, 2010) based on youth and parent-reports showed that twice as many young people

reported frequent feelings of depression or anxiety in 2006 as in 1986.

The consequences of increased mental illness among children and adolescents can

aggravate among youths entering the labour market. The presence of mental disorders and

18

mental illness during childhood can be devastating for school achievement and does weaken

the chance of labour market participation. Hence, if the mental illness is left untreated, these

factors will be, as described by OECD, a constraint to the welfare of society more generally

and future supply and economic growth in particular (OECD, 2013; NBHW, 2013).

3.3 Stress, mental health and social relations

Stress has become a common term in todays’ society. Long lasting stress is believed to be the

onset of illness such as heart disease, musculoskeletal disorders and mental illness. The psy-

chological interpretation of stress focuses on the individual’s response to stress, that is; the

individual feels overwhelmed regarding the capacity to manage the situation (Lazarus &

Folkman, 1984). Pearlin et al. (Pearlin, Menaghan, Lieberman, & Mullan, 1981; Pearlin, 1989)

discuss the stress process from a social structural context, meaning that the sources of stress

arise from peoples’ various structural surroundings, such as different stratifications including

e.g. social economic class or ethnicity, statuses and roles such as family- or occupational

roles. Hence, the societies and cultures are fundamental for the stress process.

Hundreds of studies have shown that social relations and social support benefits

mental and physical health. The effect of social support may indirectly benefit mental health

by reducing the impact of stress (Cohen, 2004; Thoits, 1995). Cohen, Gottlieb and Under-

wood (Cohen & Wills, 1985; Cohen, 2004) describe two models that identify the conditions

under which social support influence mental health. According to the models, support is re-

lated to well-being either directly (e.g., social influence or information affect the individual’s

health behaviour and thus health outcome) or function stress-buffering (e.g., a stressful

event can be experienced as less severe dependent on perceived availability of social re-

sources). Despite the positive effects that social relations may bring (Mirowsky & Ross,

2003), social relations can also be extremely stressful (Walen & Lachman, 2000) and contrib-

ute to poor health habits in childhood, adolescence, and adulthood (Kassel, Stroud, & Paro-

nis, 2003).

The effect of computer and Internet usage on social relations among youth has been

debated since the 90s, and in the early reports the use of Internet was considered damaging

19

for adolescents’ health and well-being. An early often-cited longitudinal study by Kraut and

his colleagues (1998) studied the direction of the relationship between Internet use and social

involvement and psychological well-being during a 12–18 months period. Opposite to the

authors’ hypothesis that use of Internet would increase users’ social networks and the

amount of social support, they found that heavy Internet users, including use of communica-

tion, became less socially involved and lonelier than light users and reported an increase in

depressive symptoms. However, a 3-year follow-up of 208 of these respondents found that

the negative effects had diminished (Kraut et al., 2002). One major problem with the early

studies on Internet is that many researchers have treated the independent variable of Inter-

net use as one-dimensional, while the individual in reality use it for a range of different mo-

tives (Valkenburg, Peter, & Schouten, 2006). Valkenburg, Peter and Schouten (2006) assume

that well-being is more likely to be affected when Internet is used for communication than

information seeking. Today, studies on the associations with well-being show both positive,

deliberative aspects and negative, as regards to the possibilities of abusing the new kinds of

communication (Valkenburg & Peter, 2009). For example, Valkenburg and colleagues (2006)

found that positive feedback given on adolescents’ friend network profiles enhanced their

social self-esteem and well-being, whereas negative feedback decreased their self-esteem and

well-being.

Being victimised may be seen as a form of stressful relationship and hence be experi-

enced as a stressful event. It has been argued that different form of bullying is more harmful

to mental health than others. Socially excluding someone is suggested to affect mental health

more negatively than more direct acts (Baldry, 2004; Hawker & Boulton, 2001; Rigby, 1999).

According to Hawker and Boulton (2001) this could be explained by humans historically in-

herited basic needs when social exclusion from a group were associated with a serious threat

to survival. There is however a risk that overlapping of subtypes diminishes the effect from

specific subtypes of bullying (Hawker & Boulton, 2001).

There are some aspects of differences between traditional bullying and cyberbullying

implying that cyberbullying may have a more severe impact on mental health compared to

traditional bullying (Campbell, 2005; Kiriakidis & Kavoura, 2010; Kowalski & Limber, 2007;

20

Perren, Dooley, Shaw, & Cross, 2010; Slonje & Smith, 2008; Wang, Nansel, & Iannotti,

2010). It has also been discussed that the different types of media have different impact on

mental health. Smith and colleagues (Slonje & Smith, 2008; Smith et al., 2008) found that

bullying through picture/video clip was considered worse than face-to-face bullying among

adolescents, while the impact of mobile phone calls and MSN bullying (Smith et al., 2008) or

of text messages and e-mail bullying were not considered as severe (Slonje & Smith, 2008).

Turner, Finkelhor and Ormrod (2006) discuss how other forms of life adversity are

likely to co-exist with victimisation experiences and often occur against a background of

chronic family adversity, often together with other events such as parental mental illness,

poverty, unemployment, parental alcohol or drug problems, and marital problems. Conse-

quently, the researchers (Turner et al., 2006) advocate the importance of the removal of such

stressful context from the specific effects of child victimisation. Most researchers share the

idea of a cumulative effect of victimisation and frequent exposure and that several types of

victimisation may contribute to increased mental illness (Klomek et al., 2009). Multiple stress

events may be regulated by structural factors and children living as racial and ethnic minori-

ties, in a low socio economic status with low parental education and with single parents of-

ten experience more types of victimisation and more of other form of adversity compared to

higher status children (Turner et al., 2006). Adolescents’ different preconditions and earlier

experiences and how they respond to victimisation vary depending on their interpretation of

the situation and their coping skills. Hence, even occasional harassment incidents can func-

tion as a trigger and lead to adjustment problems (Ladd, Ladd, & Juvonen, 2001).

3.4 School, learning and mental health

When children enter school age, peer and teacher relations become important for adoles-

cents’ mental health and school achievement (Wentzel, 1998; Wentzel et al., 2012). The rela-

tionship between mental health and academic achievement was discussed in 2010 at the State

of the Science Conference initiated by The Health Committee at The Royal Swedish Acade-

my of Sciences. A panel statement (Gustafsson et al., 2010) concluded that the association

between academic achievement and mental health is reciprocally related, which may lead to a

bad spiral of poor mental health and poor academic achievement. Social relations with peers

21

and teachers are involved in establishing the negative effects of school failure on mental

health, while positive relations with peers and teachers can work as protection against devel-

opment of mental health problems. A poor or bad schooling may follow the child through

transmission to adulthood. Thus, school has a great significance for children’s mental health

(Gustafsson et al., 2010).

The perception of social support from peers and adults has also shown to protect

against bullying involvement. Holt and Espelage (2007) found that those not involved in bul-

lying perpetration and victimisation reported greater perceived social support. It may howev-

er be difficult to determine the causality of these associations since poor social ties can be a

result of being victimised or being a bully. However, there has been longitudinal studies indi-

cating the protective effect of peer relations: Malcolm, Jensen-Campbell, Rex-Lear and

Waldrip (2006) found that quality friendship protected against being victimized, and

Kendrick, Jutenberg and Stattin (2012) found that adolescents experiencing higher level of

support from friends reported lower levels of both bullying and victimisation.

“School climate” is a frequently used term in order to describe different contexts in

schools that include peers, teachers and school, and are known as an important influence on

student adjustment (Bergh, 2011). There is no established definition of school climate but is

usually related to the schools’ quality and character of social interactions, sometimes called

the schools’ ethos (Svanström, 2002). The National School Climate Council defines school

climate: “School climate is based on patterns of people’s experiences of school life and reflects norms, goals,

values, interpersonal relationships, teaching and learning practices, and organizational structures” (Cohen

& Geier, 2010, p.1). A positive and supportive school climate has been shown to correspond

to more success in bullying prevention (Eliot, Cornell, Gregory, & Fan, 2010), and less vio-

lence in school (Steffgen, Recchia, & Viechtbauer, 2012). A recent review of school climate

by Thapa, Cohen, Guffey and Ann Higgins-D'Alessandro (2013) showed that school climate

has a profound impact on students’ mental and physical health, and that it may have a posi-

tive effect on externalized behaviour.

22

4 THE SCHOOL ARENA

4.1 The dynamic school

The Swedish school system has undergone big changes since the 1980s regarding govern-

ance and responsibility. Until the 1980s, there were independent and the responsibility for

schools’ organization was not linked to the municipality and local politicians. Schools were

financed by government subsidies and local politics had no impact on schools’ organization.

During late ’70s through to the 1990s, schools underwent a process of decentralization in-

tended to increase community influence and effectiveness in schools, as school organization

had become too complex to be managed by the State. In 1992, governance was handed over

to the municipalities and the overall system for Swedish schools was changed. The State was

no longer to determine the organization of schools, but only to specify the outcomes to be

achieved. In the mid-nineties, a new curriculum was introduced to serve the new outcome-

oriented organization. A parallel development included increased freedom in choice of

school, meaning that parents could place their children in any school they wished, which re-

sulted in a mushrooming of independent schools funded by the government. Today,

schools’ organizations vary between, as well as within, municipalities (SOU, 2007). In order

to reflect these developments, the Education act was revised in 2010. Amendments to the

act simplified and clarified the new school system and the responsibilities of the state and

municipality. In addition, each school’s health-care team was reorganized into a uniform

structure, which is described later in this thesis (SFS, 2010:800).

Current debate in Sweden has highlighted free choice of school and the proliferation

of independent schools. Free choice of school is widely seen as contributing to increased

segregation, due to the fact that parents from a higher socio-economic background, or with

more drive, use free choice of school to deselect schools with a higher number of students

with less scholastic ability or from lower socio-economic backgrounds (Schneider, Elacqua,

& Buckley, 2006). Likewise, independent schools may attract a more motivated group. Ac-

cording to the “peer-effect” theory, a student’s achievement in school is affected by the

achievement level of his or her peers (e.g., Hoxby, 2000; Sund, 2009). It has been argued that

increased segregation leads to more bullying, with the argument running along the lines of

23

“majority- minority status”: segregation creates an imbalance in power among students; and

minority students are left more vulnerable. Greater diversity in a school or in a classroom

may reduce such a power imbalance and hence reduce victimization (Graham & Juvonen,

2001; Graham, Taylor, & Ho, 2009). However, those who argued against increased freedom

to choose school say that the former state-run school system actually led to greater diversity

within a given individual school.

4.2 The school health service

The school arena has for long been acknowledged as important in terms of enhancing and

laying a foundation for good health because it reaches a large population gathered at the

same place during many years. Schools include many aspects that can affect health, such as

policies and practices, the school ethos, the curriculum and specific programs to promote

healthy lifestyles and mental health (Svanström, 2002). In addition to the WHO’s strategy

including supportive environments at the Ottawa Charter Conference in 1986 (WHO, 1986),

schools were identified to be one important setting for population based health promotion,

i.e., “Health Promoting School”. 4

The development of the School Health Service (SHS) is one example of a key setting

conducive to preventive work and good health (Naidoo & Wills, 2000). The SHS is estab-

lished as one of six components in schools’ health promoting strategies. 5 In Sweden, the

objectives of the SHS are “to follow, maintain and recover the pupils’ physical, mental and social

health”. Their primary work includes prevention and promoting health among school chil-

dren, and to support the students fulfilling the goals stated in the school law. All school chil-

4 In Sweden, however, the Health Promoting School concept is now called “health promoting school development”

(HPSD) [Sw: hälsofrämjande skolutveckling], a concept that implies a process and change (Nilsson & Norgren,

2003). In 1991, the WHO initiated an international network, “Schools for Health in Europe network” (SHE) aiming at

encouraging members to develop and implement national policies regarding school health promotion based on coun-

try specific, European and global experiences. Sweden is one of 43 country national members (Buijs, 2009). A health

promotion school takes on a whole school approach and thus include all organizational levels, not only the pedagogi-

cal (Weare & Markham, 2005), it is integrated in more than only the curriculum, school environment or the community

(Stewart-Brown, 2006; Wells, Barlow, & Stewart-Brown, 2003) and takes a holistic salutogenic perspective (An-

tonovsky, 1996). 5 Together with “healthy school policies”; “schools’ physical environment”; “schools’ social environment”; “individual

health skills and action competencies”; and “community links”.

24

dren are entitled to SHS and their health dialogues and immunizations during their entire

time in school (SFS, 2010:800).

Before the new Swedish Education act (SFS, 2010:800) came into force in year 2011,

the schools’ health care organization consisted of two parallel tracks; on the one hand the

SHS (school nurses and school physicians) and on the other hand remedial teachers, school

social workers and school psychologists. In 2000, a Swedish Government Official Report

(SOU, 2000:29) concerning students’ health services’ organizational structure suggested an

integrated organization including these two tracks, i.e. “Team for Students’ Health” (TSH).

It was advocated that this new organization primarily should work preventive and health

promoting aiming at supporting students’ fulfilment of the educational goals (SOU,

2000:19). This promoting perspective came to permeate the proposition (Prop.,

2009/10:165) leading to the new Education act; i.e., the TSH should not focus strictly on

health or medical interventions but work preventive and promoting health interventions in a

broader perspective, including create environments promoting students’ learning, develop-

ment and health (SFS, 2010:800). The new organization was constituted in 2011 and the

SHS became part of an obligatory comprehensive team including the requirement of access

to a school physician, school nurse, school psychologist, school social worker, and personnel

with remedial competence (SFS, 2010:800). In addition, in the period covering 2012-2015,

the Swedish government will invest 650 million Swedish kronor (about 69 million Euros) in

student health services, which would allow expansion of the TSHs and more professional

development training, as well as provide funds for information campaigns on nutritious

school food (press release from the Ministry of Education, Nov 1st 2011).

The TSH is an important agency in the detecting of mental illness among students.

However, in a recent report by OECD (2013) it was concluded that Swedish school health

service did not have enough resources to meet the challenging increase of mental illness

among adolescents. They stated that it was imperative to increase resources at school to en-

sure rapid access to psychologists, and to provide systematic guidelines to school social

workers and school nurses regarding identification of mental health problems and how to

respond to students’ needs.

25

4.3 Bullying prevention in school

In the 1980s, Sweden and Norway were pioneers regarding bullying prevention in schools.

The first wide-spread bullying prevention program (Olweus’s Bullying Prevention Program

[OBPP]), developed by Dan Olweus, came to highlight bullying as an important problem

both national and internationally. Several OBPPs were evaluated and showed good effects

regarding reducing bullying and victimisation in schools (Olweus, 1993). During the 1990s, a

range of bullying prevention programs were introduced in Sweden and the issue of bullying

began to be encompassed in official reports, curricula and legal acts in terms of “insulting

treatment”.

However, the effectiveness of school based bullying prevention programs have been

questioned over time, and single studies show contradictious results. Ttofi and Farrington

(2011) conducted a meta-analysis including 44 school based programs in order to study pro-

gram components in these programs. Experimental studies evaluating the effects were in-

cluded in the meta- analysis. The results showed that overall, school-based bullying preven-

tion programs were effective with a decrease of bullying by 20–23% and victimisation by 17–

20%. Successful program elements and intervention components being associated with a

decrease in bullying were programs including parent meetings, firm disciplinary methods,

and improved playground supervision. In contrast to an earlier study by Ttofi and Farrington

(2009) work with peers was associated with an increase in reported victimisation. The inten-

sity of the program was also shown to improve the results.

A Swedish evaluation of anti-bullying programs was conducted in 2009 (SNAE). The

main findings comprised how effectively work against bullying should be conducted – and

not about the programs against bullying works best. Some crucial components of a success-

ful work were highlighted: systematic work, whole-school approach with both preventive

and remedial action is at the core of successful work. Interventions against bullying should

be clearly connected to each other and there need to be a clear role and responsibility among

the school staff.

Regarding cyberbullying prevention programs, research is still in its infancy, but as

with early development in intervention programs for traditional bullying, programs have

26

started to mushroom. A relatively recent study (Mishna, Cook, Saini, Wu, & MacFadden,

2011) reviewed the effectiveness of cyber-abuse interventions in increasing knowledge about

Internet safety and decreasing risky online behaviour. The types of interventions included in

the review targeted both children and adolescents and parents:

(a) technological and software initiatives used with children and adolescents to block or filter access to inap-

propriate online content; (b) online and off-line cyber abuse preventive interventions for children and youth de-

livered through any medium (including face-to-face presentations, video games, interactive software, etc.); (c)

online and off-line cyber abuse preventive interventions for parents to protect children from cyber abuse; and

(d) therapeutic interventions for children and youth who have experienced cyber abuse. (Mishna et al. 2011,

p.6)

Altogether, three programs were found that meet the researchers’ criteria. The results indi-

cated that participation in cyber abuse prevention and intervention strategies were associated

with an increase in knowledge about Internet safety. However, the authors highlight that

such participation in cyber abuse prevention interventions is not necessarily related to risky

Internet attitudes and behaviour. As with other public-health problems, awareness of cyber

abuse may not always lead to behaviour change. Although the authors identified a tendency

towards positive change reported in the treatment group regarding Internet behaviour, the

results were not significant. Two of the studies (US and Canada) focused on Internet-safety

knowledge and online risky behaviour, and the third program (US) had employed an anti-

bullying strategy in schools to address traditional face-to face bullying, as well as cyberbully-

ing. Interestingly, participation in a school-based anti-bullying strategy was not significantly

related to change in the number of incidents of cyberbullying experienced by students. Only

one of the programs targeted the parents by providing them with a guidebook (Mishna et al.,

2011).

In Sweden, although most schools seem to have included the use of mobile phones,

Internet, etc., in their description of bullying forms, there are no particular disciplinary

measures against cyberbullying per se. Instead, the same kinds of interventions are usually

used as for traditional bullying. For example, a report from Gothenburg showed that schools

that have used the Olweus preventions program also reduced the number of cyberbullying

incidents by half over two years (Englund, 2011).

27

In order to address problems like bullying in Swedish schools today, common ap-

proaches include forms of social and emotional learning (SEL). Compared to selective pre-

vention programs, programs like SEL are argued to address underlying causes of problem

behaviour while supporting academic achievement. According to Elias et al. (1997) SEL is a

process which enables people to manage emotions, set up and achieve goals, develop and

maintain positive relationships, make good decisions, behave ethically and responsibly, and

avoid negative behaviours. Positive effects from SEL on pro-social behaviours, conduct- and

internalizing problems, and academic performance on achievement tests and grades among

children and adolescents has been shown in a meta-analysis by Durlak and colleagues (2011).

On a general level, school based health education models and health interventions

take different approaches and operate at different levels. Interventions concerning students’

health are usually divided into three levels distinguishing the characteristics of the interven-

tion; (1) universal prevention i.e., interventions that do not distinguish between high- and

low risk groups. No individual or group is singled out; (2) selective prevention includes pre-

ventive work aiming at groups being exposed to one or more risk factors (3) and the indicat-

ed intervention, i.e., rectification or treatment when students are in acute need, individuals

with already identified problem or risk factors (Horowitz & Garber, 2006).

5 BULLYING

5.1 Scrutinizing the bullying criteria

The bullying definition has during the years been rather criticized. Although the purpose

with establishing the three criteria of bullying (repetition, intent and power imbalance) prob-

ably was supposed to show that all acts of peer aggression are not of equal severity, it is still

a problem of how to capture the criteria in measurements, especially power imbalance and

intentionality of the three criteria. The criterion of repeated behaviour finds most evidence

in literature (e.g., Brunstein Klomek, Marrocco, Kleinman, Schonfeld, & Gould, 2007;

Turner et al., 2006). Hunter, Boyle and Warden (2007) argue that if the repeated acts are in-

cluded, power imbalance and intent to harm may obviously follow, and then bullying is just

28

simply a different name for peer victimisation. The evidence of the effect of intention and

power imbalance is scarce. Hunter et al. (2007) conducted one study were they examined

whether bullied pupils and those experiencing peer aggression (peer aggression does not

necessary include power imbalance) differed in their levels of depressive symptomatology.

The result supported the hypothesis that aggression combined with power imbalance was

more damaging to the mental health.

As regards power imbalance, Finkelhor, Turner and Hamby (2012) question the

problem of defining what it really is. The common description includes someone bigger,

stronger or more popular, but such features are not always in alignment. According to the

authors; “it is a hypothesis that peer aggression episodes characterized by repetition and power imbalance

have special seriousness and commonality that deem them worthy of special attention” (Finkelhor, Turner

& Hamby, 2012, p. 272). Tam and Taki (2007) argue that power imbalance do not sufficient-

ly separate bullying from violence because in any violent situation, the perpetrators attack

when they think the victims is weaker than they are, meaning that power imbalance usually

exists in any violent situation and not only in bullying.

Further, Finkelhor, Turner and Hamby (2012) argue that Olweus’ definition excludes

trivial conflicts6 but at the same time excludes more serious peer aggression attacks. In con-

clusion, the authors (Finkelhor et al., 2012) propose to abound the bullying concept and in-

stead call the domain of interest peer victimisation or peer aggression.

5.2 Cyberbullying – definition and features

The concept of bullying was initially synonymous to traditional “face- to face” bullying, usu-

ally occurring in the school setting. However, following the variety of new easily available

technologies another form of bullying, here called cyberbullying, has emerged among adoles-

cents. Cyberbullying is characterized by bullying using different types of media such as e-

6 Olweus’ whole definition is stated as follows: “We say a student is being bullied when another student or several other students say mean and hurtful things or make fun of him or her or call him or her mean and hurtful names; completely ignore or exclude him or her from their group of friends or leave him or her out of things on purpose; hit, kick, push, shove around, or threaten him or her; tell lies or spread false rumors about him or her or send mean notes and try to make other students dislike him or her and do other hurtful things like that. These things may take place frequently, and it is difficult for the student being bullied to defend him or herself. It is also bullying when a student is teased repeatedly in a mean and hurtful way. But we don’t call it bullying when the teasing is done in a friendly and playful way. Also, it is not bullying when two students of about the same strength or power argue or fight.”

29

mail, Instant Messaging (IM, MSN), chat-room, web pages, picture/video clip, phone call

and text message (SMS). A study from the UK (Smith et al., 2008) reported bullying via mo-

bile phones (calls and text message) as most prevalent, followed by MSN. In line with the

increasing use of so called “smart phones”, the border between mobile phones and Internet

are today more or less erased.

It has been debated whether traditional bullying and cyberbullying are two different

phenomena or if they are part of the same expression (Menesini, 2012). This is an important

aspect when planning interventions and understanding the consequences of the problem.

In comparison to traditional bullying, there is yet no concurrent definition of cyber-

bullying and there is still an ongoing debate if cyberbullying should be defined differently

from traditional bullying (Kiriakidis & Kavoura, 2010; Menesini et al., 2012; Tokunaga,

2010). Most cyberbullying definitions are based on the traditional definition. Smith et al.

(2008), for example, defines cyberbullying as follows: “Cyberbullying is reported as an aggressive,

intentional act carried out by a group or individual, using electronic forms of contact, repeatedly and over time

against a victim who cannot easily defend him or herself”. Arguments that cyberbullying should be

defined using other criteria than traditional bullying is based on the assumptions that; 1)

power imbalance in cyberbullying is less evident than in traditional bullying, because of the

opportunity to stay hidden behind the screen. However, such arguments may apply to indi-

rect types of traditional bullying as well, such as gossiping and rumours. 2) The repetition

criterion, which may be the strongest argument for separate definitions (Dooley, Pyżalski, &

Cross, 2009). Bullies and victims can perceive the number of incidences differently as it is

harder to separate single and repeated incidents in cyberbullying. It may be an easy task to

count the number of sent text messages, but it is almost impossible to count every view on a

webpage containing a humiliating photo (Slonje & Smith, 2008). This perspective may how-

ever be applicable to traditional bullying as well, for instance writing something mean about

another person on a wall. 3) Intent is difficult to determine, and hidden behind a computer

screen, it may be even more difficult. A message can be misinterpreted as being hostile when

it was meant as an attempt at a joke (Bauman, Underwood, & Card, 2013).

30

In addition, research has shown two new possible criteria: anonymity and publicity,

which are more specific to virtual domains. These criteria were not considered prerequisites

necessary to labelling an action as cyberbullying, but they can connote the context (the sever-

ity and nature of the attacks, the relationship between actor and victim and the victim’s reac-

tions) (Nocentini et al., 2010). These findings were confirmed in a study including adoles-

cents in six European countries (Menesini et al., 2012).

It has been suggested that because of these claimed anomalies between traditional

bullying and cyberbullying, and the fact that cyberbullying is often labeled as a variant of

“bullying”, the concept of “cyberaggression” would be a more suitable topic of study, in

which case power imbalance, intent and repetition would not be necessary attributes and

room would be left for further exploration of the cyber phenomenon (Bauman et al., 2013).

5.3 Socio demographic factors

Some socio-demographic factors have been arguably associated with bullying behaviour, in-

cluding age, socio-economics, ethnicity, and family structure. Such factors should thus be, on

a theoretical basis, adjusted for. Bullying behaviour tends to increase during childhood, peak

during early adolescence, and decline slightly during the late adolescent years (Nansel et al.,

2001). Physical bullying usually decreases with rising age (Brame, Nagin, & Tremblay, 2001),

while other types of bullying, such as more covert forms, generally increases between the

ages of 11 and 15 (Eslea & Rees, 2001; Pellegrini & Long, 2002).

As regards cyberbullying research, the effect of age seems to vary between studies.

Ortega, Calamaestra and Mora-Merchán (2008) found that the effect of age was dependent

on which kind of device was being used. While younger students were more likely to be In-

ternet-victimized, older students were more likely to cyber-bully others; yet, when looking at

mobile-phone bullying, no age difference appeared. This could be due to the fact that older

students, as compared to their younger counterparts, have greater access to computers and

mobile phones, and also that cyberbullying may require verbal and technical skills, i.e., there

is a maturation effect at play.

Varying results regarding socio-economic status (SES) and bullying behaviour have

been reported. Some report no significant association between victimisation and SES of the

31

family (Baldry & Farrington, 2005), or weak associations (Wolke, Woods, Stanford, &

Schulz, 2001). However, a large body of research reports significant associations between

low SES and victimisation and bullying behaviour (Due et al., 2009; Due, Damsgaard, Lund,

& Holstein, 2009; Jansen, Veenstra, Ormel, Verhulst, & Reijneveld, 2011). It has been dis-

cussed that these differences is due to differences in social resources, such as more adoles-

cents from low socio-economic backgrounds growing up in single-parent homes, which may

lead to other difficulties such as economic or social problems (Due et al., 2009).

A Swedish study by Carlerby, Viitasara, Knutsson and Gådin (2012) found evidence

to suggest that Swedish adolescents with a foreign background are more likely to be involved

or exposed to bullying. Compared to boys of mixed or Swedish background, foreign back-

ground was associated with being a bully. Among girls of foreign background, significantly

higher frequencies of bullying involvement as victims, bullies, and bully-victims were report-

ed compared to girls of mixed or Swedish background. Theoretically, ethnicity may imply a

lower SES, hence less access to technical devices, and thus lower cyberbullying rates among

immigrants. However, today almost all adolescents have their own mobile phone regardless

of SES. In addition, Gådin et al., (2012) found that foreign girls were more likely to be vic-

tims, bullies and bully-victims; this can also indicate that foreign girls may be more exposed

or involved in cyberbullying behaviour as well.

Although varying results, most studies finds associations between bullying behaviour

and family structure, i.e., children and adolescent living in single parent family are in in-

creased risk of being victims, bullies and bully-victims (Jablonska & Lindberg, 2007; Jansen

et al., 2011; Nordhagen et al., 2005; Spriggs, Iannotti, Nansel, & Haynie, 2007). It is im-

portant to highlight that it may not be the family disruption per se that is the cause of the

bullying behaviour or other maladjustment, but rather factors including household finances,

parenting style, parents’ psychological well-being, marital conflict, and lack of involvement in

the child’s schooling. Single parents may be forced to work more to compensate for lost in-

come and may not have enough time to spend with their child (Ram & Hou, 2003). From a

cyberbullying perspective, children and adolescents spending lots of time home alone, with

32

no adult present, may be at particular risk of using the Internet for non- appropriate activi-

ties, or be exposed to cyber incidents.

5.4 Gender differences in aggressive and bullying behaviour

Gender patterns in traditional bullying have been evident over time. Boys are more likely

than girls to engage in bullying, particularly direct physical bullying (Björkqvist, Lagerspetz,

& Kaukiainen, 1992; Crick et al., 2001; Wang, Iannotti, & Nansel, 2009), either as bullies or

as bully-victims (Perren et al., 2010; Solberg, Olweus, & Endresen, 2007). Some studies re-

port that boys are more likely than girls to be traditional victims (Olweus, 1993; Solberg &

Olweus, 2003), whereas many do not report any gender differences at all (Kaltiala-Heino et

al., 2000; Perren et al., 2010; Ranta, Kaltiala-Heino, Pelkonen, & Marttunen, 2009; Solberg et

al., 2007). Verbal bullying, on the other hand, seems to be just as common among girls as

boys, and girls have been reported to more frequently engage in indirect/relational/social

bullying than boys (Björkqvist et al., 1992; Crick et al., 2001; Wang et al., 2009). However,

the idea that girls would be more indirectly aggressive than boys has been criticized and stud-

ies have shown contradictory results (Olweus, 2009). In the late 1990s, Galen and Under-

wood (1997) reported that adolescent girls in elementary and middle school were not more

socially aggressive. It was only the older girls (Grade 10) who reported significant, higher

levels of social aggression than boys. Salmivalli and Kaukainen (2004) used a similar ap-

proach and found that boys were, in general, both directly and indirectly more aggressive

than girls, but that there was a group of highly aggressive girls who predominantly used indi-

rect aggression. The gender differences were largest in the physical aggression group and

smallest in the indirect and non-aggressive groups.

In contrast to traditional bullying, cyberbullying research has shown inconsistent re-

sults regarding gender differences. Some studies report boys as overrepresented as cyberbul-

lies (Calvete, Orue, Estévez, Villardón, & Padilla, 2010; Smith et al., 2008), while some re-

port girls as more often exposed to cybervictimisation (Slonje & Smith, 2008; Smith et al.,

2008) and being bully-victims (Kowalski & Limber, 2007). However, many studies do not

report any gender differences at all (Mishna, Cook, Gadalla, Daciuk, & Solomon, 2010;

Patchin & Hinduja, 2006).

33

Biological aspects

The early theories of gender differences in deviant or aggressive behaviour suggest a biologi-

cal perspective. Maccoby and Jacklin (1980) argued that gender differences in aggression

have a biological origin because aggression is related to sex hormones, as seen in other pri-

mates, and appears early in life and is found across cultures. Although these arguments have

been criticized on several bases (Tieger, 1980) there may be links to some psychiatric disor-

ders. If we consider bullying as a type of antisocial or aggressive behaviour, we may take a

look at criminology research where studies on youths with antisocial behaviour predate re-

search into bullying. However, as with the early bullying research (Olweus, 1978) boys have

been more in focus in criminological studies. Female criminality was not studied until the

1970s (Junger-Tas, Ribeaud, & Cruyff, 2004).

While the biological sex hormone perspective does not prevail today, the neuropsy-

chological perspective has become of more interest, as it has been shown that hyperactivity

in particular is an early predictor for behaviour problems and involvement in crime (Herren-

kohl et al., 2000; Murray, Irving, Farrington, Colman, & Bloxsom, 2010). Males have been

shown to be overrepresented in at least three psychiatric categories where antisocial behav-

iour may be an aspect (Rutter, Giller, & Hagell, 1998; Wittchen et al., 2011). ADHD, which

is characterized by either significant inattention or hyperactivity and impulsiveness, or a

combination of the two (American Psychiatric Association, 2000) is today a controversial

topic in schools. The fact that boys are included to a greater degree in such diagnoses is used

in part to explain boys’ greater involvement in bullying behaviour, both among victims, bul-

lies and in particular as bully-victims. ADHD makes it problematic for individuals to read

social cues which may contribute to high rates of peer rejection and problems with social

relations (Wolraich et al., 2005). Several studies indicate associations between bullying behav-

iour and ADHD (Holmberg & Hjern, 2008; Montes & Halterman, 2007; Nordhagen et al.,

2005). However, studies have indicated that the gender difference plays itself out differently.

For example, one study found that males with ADHD were more likely to engage in bullying

behaviour, whereas females with ADHD were more exposed to victimisation (Bacchini, Af-

fuso, & Trotta, 2008). Kowalski and Fedina (2011) discuss that cyberbullying may be an im-

portant aspect for children and adolescents with social-skills deficits. They argue that alt-

34

hough, initially, the Internet might provide disabled children with ‘‘easier’’ means of relating

to peers, their social-skills deficits, lack of empathy, and emotional volatility will likely lead to

relational problems on the Internet as well as in the real world.

Socialization, cognitive influences and Internet habits

Social and cultural expectations have been widely viewed as impacting on boys’ and girls’

behaviour. Socialization processes and norms embedded in the school context have been put

forward for the creation and perpetuation of different normative and socially accepted be-

haviour for boys and girls in general, and aggressive behaviour in particular (Bussey & Ban-

dura, 1999; Chesney-Lind, 1989; Mouttapa, Valente, Gallaher, Rohrbach, & Unger, 2004).

Looking at normative behaviour on the Internet, Swedish adolescents’ Internet habits and

usage still show some obvious differences when seen from a gender perspective. While boys

aged 9-16 play more games and watch more video clips on the Internet, girls are more active

on social network sites (apart from Facebook), and in chatting and blogging, and they use

more sites where they can upload pictures for public display (Findahl, 2010; The Swedish

Media Council, 2010). International research has shown similar gender differences (Lucas &

Sherry, 2004; Muscanell & Guadagno, 2011; Pujazon-Zazik & Park, 2010). As girls are more

active on social network sites, and in chatting and blogging (Findahl, 2010; Pujazon-Zazik &

Park, 2010), they may also be more exposed to peer victimisation on the Internet compared

to boys.

Peer group pressure for “gender normative” forms of aggression may increase with

age. The transition from childhood to adolescence might encourage them with more “pre-

ferred” forms of aggression, but the increased verbal cognition which comes with age might

also explain the changed behaviour (Card, Stucky, Sawalani, & Little, 2008). While boys are

more socialized to use aggression (in particular direct aggression), girls have learned to use

less aggression, or use at least indirect aggression (Björkqvist, 1994; Lagerspetz, Björkqvist,

& Peltonen, 1988). In addition, research has shown that girls’ and boys’ lifestyles and social

relations show different characteristics. Girls seem to engage in fewer and closer friendships,

while boys report friendships that are more casual and greater in number (Lagerspetz et al.,

1988; Maccoby, 2003). As a result of this structure, girls may experience indirect aggression

35

as particularly hurtful because it targets these relations (Galen & Underwood, 1997; Under-

wood, Galen, & Paquette, 2001).

Bussey and Bandura (1999) address the psychosocial determinants and mechanisms

through which males and females are socialized using a model of social cognitive theory.

They argue that while some gender differences are grounded in biology, most of the stereo-

typical attributes and roles associated with gender are more of cultural origin (Bandura, 1986;

Bussey & Bandura, 1999). Bandura’s Social Cognitive Theory, briefly described, is based on

the idea that people observe others in order to learn. As children grow up and develop their

cognitive ability they can learn gender stereotypes from observing differential acts of male

and female models. However, it is not only the knowledge about gender differences that lead

people to personify a stereotype; there is also the social value of adopting it (Bandura, 1986;

Bussey & Bandura, 1999). Girls’ suggested tighter friendship structure (Galen & Underwood,

1997) may partly explain their extended use of blogs and other communication sites, but may

also be part in gaining popularity among peers. One recent study reported that Icelandic

adolescents who write blogs are more involved in various activities associated with higher

status among peers (Bjarnason, Gudmundsson, & Olafsson, 2011). This may indicate that

girls are more interested in a social dimension where communication is the main objective

whilst boys are more goal oriented, i.e. they use the Internet to do other things than just

communicate (Muscanell & Guadagno, 2011; The Swedish Media Council, 2010). As both

beauty and youth are highly emphasized in mainstream media (Egbert & Belcher, 2012) there

is a risk that increased popularity of exposing oneself online may create a greater emphasis

on appearance and consciousness of looks, especially among girls (Vandenbosch & Egger-

mont, 2012).

Gender differences in aggression may vary depending on the anticipated consequenc-

es of aggression, i.e., if boys display non-normative behaviour, they may suffer social conse-

quences because of it (Card et al., 2008). However, although these gender differences are still

rather distinct, the latest result from The Swedish Media Council (2010) shows an approxi-

mation between boys’ and girls’ habits since 2008 in almost all areas. Similar tendencies of

36

equalization in Internet usage across gender had been reported in 2004 from the US (Gross,

2004) and in the EU kids online report (Livingstone et al., 2011).

5.5 Reasons for bullying

Why does bullying exist? From a psychological and sociological perspective, it has been put

forward that the social hierarchy or social ranking to which we are subordinate plays an im-

portant role (Gilbert, 2000). Social status is a common feature in human life, and both adults

and children experience that an informal structure of social relations is formalized in every-

day settings, such as in school, where peers rank peers according to popularity and status. A

school class tends to maintain its character over several years and its composition rarely

changes in terms of students being excluded or included (Östberg, 2003). Some individuals

may use aggression and bullying tactics as strategies to accomplish goals and gain social

dominance in new groups (Pellegrini et al., 2010). While a bully is often considered as want-

ing to be “cool” and as striving for power, status and popularity, and as possibly having psy-

cho-social problems, the victim is often seen to be odd or as deviating from the norm in

some respect (Thornberg, 2013). Students that are victimised are usually at the bottom of the

peer status order and the latter have been named rejected children (Cook, Williams, Guerra,

Kim, & Sadek, 2010). However, a child can be rejected and yet perceived as popular (Salmi-

valli, 2010). In a recent study (Veenstra, Lindenberg, Munniksma, & Dijkstra, 2010) bullies

were actually rejected only by children to whom they represented a potential threat. Juvonen,

Graham and Shuster (2003) found that bullies were ranked as having the highest social status

and victims the lowest. However, the authors also found that classmates avoided both bullies

and victims and in particular bully-victims more than other classmates.

One’s position in the peer status hierarchy may partly be explained by mental health

and symptoms such as deviant behaviour and aggression and social withdrawal (Östberg,

2003). Another influence may be group norms. Ojala and Nesdale (2004) studying a preado-

lescent group found that bullying were considered to be much more acceptable when it was

consistent with group norms.

The application of social status on cyberbullying has been questioned since the hier-

archy in cyberspace is not a clear cut due to the possibility for individuals to decide how they

37

present themselves in front of others they meet in cyberspace and there is also a possibility

to alter their identities (Sherry, 1995). There is an opportunity for those with a low status in

the real world to alter the social hierarchies established within cyberspace, and it has been

hypothesized that victimised youths may take the opportunity to take revenge on bullies, or

even take the role of bullies and victimize others (Espelage, Rao, & Craven, 2012).

6 METHODOLOGICAL PROBLEMS IN BULLYING RESEARCH Operationalization and measuring

The understanding and meaning of the word bullying can differ greatly across countries and

cultures, and a range of factors can influence the answers that are given on a question of bul-

lying. These conceptual questions concerning bullying and how it should be measured in an

appropriate way has been widely debated (Boyce et al., 1995).

There are usually two ways to measure bullying: Either using a pre-defined question

or asking about specific situations of bullying, without explicitly using the word bullying.

Both ways has its advantages and disadvantages. For example, using a clear definition might

be needed to minimize room for subjective interpretations (Chida & Steptoe, 2009). Howev-

er, children might use their own perspective regarding bullying instead of assimilate a pre-

given definition (Sudak & Sudak, 2005). The two different assessment methods often results

in different prevalence rates, where the specific measures of bullying behaviour results in

higher bullying prevalence compared to pre-defined measure (Sawyer, Bradshaw, & O'Bren-

nan, 2008).

Conceptually, traditional bullying and cyberbullying have a lot in common but there

are also differences which can affect the operationalization and measurement of the two

types of bullying. In traditional bullying, the repeated behaviour stated in the definition is

often encompassed by the stricter cut-off point “2-3 times a month” or more often (Solberg

& Olweus, 2003). However, we often see the lower cut-off (e.g., “once or twice”) in cyber-

bullying research (e.g. Beran & Li, 2007; Slonje & Smith, 2008) which also refers to the dis-

cussion of repetition in cyberbullying.

38

Dichotomous or continuum

Usually, bullying is measured dichotomously, meaning that the individual is either classified

as a bully or not a bully, a victim or not a victim, a bully-victim or not a bully-victim. This

way of classification simplifies analysing but may not reflect all levels and dimensions of bul-

lying as research has shown that bullying can be placed on a continuum were other partici-

pant roles taks part in the bullying process, beside bullies, victims or bully-victims. Such con-

tinuum perspective suggests that bullies may harass their peers sometimes in a more subtle

and less frequent way, and that the students can be different and havemultiple roles in bully-

ing (Espelage & Swearer, 2003). Salmivalli and colleagues (Salmivalli, Lagerspetz, Björkqvist,

Österman, & Kaukiainen, 1996; Salmivalli, 2010) have studied other roles including those

joining the bully, also called “a bystander”, those who provide positive feedback to bullies,

those who withdraw from bullying situations, and those who takes the victims side. As re-

gards cyberbullying and the bystander phenomenon, Slonje, Smith and Frisén (2012) studied

the distribution of bullying material on the Internet and the motive of the distributors

among students in grades 5-9. The students were asked if they had been shown or sent any

type of information that was meant to cyberbully someone else and not them, and what they

did with the information. The result showed that while almost a fifth of the students said

they received such material, 6.0% reported sending or showing it to the victim in order to

bully him/her even further. Although these bystanders can be seen as bullies, they may not

see themselves as such. Thirteen percent made the victim aware of the situation (so called

“defenders”).

Self-reports

There are both advantages and disadvantages to self-report. Questionnaires can be adminis-

trated to a large setting with minimal costs, especially when using web-questionnaires, as no

paper or scanning is needed. There is also the possibility of getting a more nuanced picture

of the bullying behaviour in terms of different forms of bullying since the answers are not

reliant on consent from others. It is also possible to link other individual characteristics to

the given answers in order to better understand the issue of interest (Cornell & Bandyo-

padhyay, 2010). However, there are some limitations with self-reported bullying behaviour.

39

Firstly, there is the issue of the validity of the questions, as the reports depend on the stu-

dents’ understanding of the questions, and it may be unpleasant for the student to remember

certain situations. While some students may exaggerate their answers, and show “extreme

answers bias” (Furlong, Sharkey, Bates, & Smith, 2004), others may minimize or even deny

their involvement in bullying (Owens, Slee, & Shute, 2000). The reason for not labelling

oneself as a victim or bully can partly be explained by the fact that bullying involvement may

raise feelings of stigma and shame (Felix, Sharkey, Green, Furlong, & Tanigawa, 2011). In

one study which interviewed girls, the respondents were inclined to deny that their patterns

of behaviour were a form of bullying (Owens et al., 2000), which can be viewed as a form of

bystander behaviour. From a cyberbullying perspective, it may be possible that the bystander

does not perceive him or herself as a bully especially when the victim is not visible and no

direct reaction is encountered. So, there is a risk that the bullying prevalence rates are either

under-reported or over-reported. Using specific measures where the word bullying is not

included may make it easier to report bullying, without having to label it as bullying. The dis-

advantage is, however, that it can be hard to separate bullying from other forms of peer vic-

timisation or general aggression as not all of the traditional criteria for bullying are stated ex-

plicitly. However, there is always a risk of not capturing the forms of bullying behaviours

that do not get included explicitly, either in a definition or in a list of behaviours.

Classifications

From a methodological point of view, it is important to clarify whether mutually exclusive

types of bullying exposure or involvement are used or not. If groups are mixed (i.e. overlap-

ping of different groups), there might be an interfering bias in the analysis that makes it hard

to explore the “true” association for different types of bullying and e.g., mental health prob-

lems. The problem is highlighted in studies by Gradinger et al. (2009; 2011) and has been

acknowledged in all statistical analyses in this thesis.

Another aspect is the classification of bully-victims. Olweus (2009) argue that the rea-

son to distinguish between these two types of victims is because the “pro-active” victims

may be “a winner” in the interaction and do not have much in common with “passive” vic-

tims in terms of psychological and social adjustment.

40

Causality or associations

The theoretical starting point in bullying research is usually that victimised children are char-

acterized by features which invite and reinforce the attacks towards them (Egan & Perry,

1998). Numerous studies have shown that victims of peer victimisation and bullying are

characterized as, for example, anxious, insecure, suffering from low self-esteem, lonely at

school, internalizing and sometimes externalizing problems (Farrington, 1993; Gini & Poz-

zoli, 2009; Hawker & Boulton, 2000; Olweus, 1978; Olweus, 1997). However, the associa-

tion may cover both directions, that is, displaying such behaviour could be a result of being

bullied. Depressive symptoms and anxiety may also precede becoming a victim (Fekkes,

Pijpers, Fredriks, Vogels, & Verloove-Vanhorick, 2006). The other way is that the experience

of being victimised that lead to mental health problem, suggesting that being victimised is

directly related to children’s internalizing problems. These associations are complex since

they may be a consequence of being victimized, but there is also a possibility that low self-

esteem and internalizing problems might predict increases in peer victimisation over time.

Peers might view those children as “easy targets”.

7 THE “PREVENTIVE SCHOOL” PROJECT The current thesis is based on the data from The Preventive School (PS) project. The aim of

the PS project was to counteract the proposed negative spiral of mental health illness among

youth by strengthen social relations among students and school staff, a corner rock in the

process of improving mental health. The original idea of PS was born in light of a Swedish

governmental commission considered to strengthen the alcohol and drug prevention activi-

ties in schools, cooperation between school and parents, and between the school and leisure

organizations. In 2004, the Public Health Institute (FHI) who was responsible for the project

invited two counties and their municipal elementary schools to serve as pilot counties (Skåne

and Värmland). In Värmland, the municipalities Karlstad, Arvika and Sunne were invited to

participate. As the goal with PS in Karlstad was to promote mental health among children

and adolescents, the use of alcohol and drugs were considered hindrances for success. The

way to reach this goal was considered to offer the schools different kind of programs and

41

methods including different approaches to help students solving either individual problems,

or reach for all students at a universal level (Karlstad municipality, 2007). The programs7 and

methods that were chosen by the school managers in Värmland were Social Emotional

Training (SET), SkolKomet, and Motivating Interview (MI). Örebro Prevention Program

(ÖPP) were already initiated in the schools, but was still considered part of PS.

In the summer of 2008 the Government gave FHI a renewed commission including

50 million Swedish crowns to distribute to six municipalities. The purpose of the new com-

mission was to actively spread knowledge regarding the different ventures being used, and to

be a continuation of the already completed part of the PS project conducted during 2005-

2007. The announcement was made via the Public Health Institute's website and via differ-

ent networks to reach out to the country’s municipalities. About forty municipalities of in-

terest submitted an application. Karlstad was one of the six municipalities which were select-

ed. Approximately half of the funds would be by agreement between the municipality and

the university transferred to the extended university. Hence, the work with Karlstad munici-

pality and PS was intensified in close collaboration with Karlstad University. Three more

additional programs8 were included in this second round and made available for the school

districts, i.e., RePulse and Active Parenting, and Classroom Management (FHI, 2011a). The

specific aim with PS 2009-2011 was to promote the mental health among students with a

particular focus on bullying.

CFBUPH have conducted repeated questionnaire surveys including measures of stu-

dent health and health-related habits, as well as bullying and school environment. In addi-

7 SET is a Swedish manual based programs aiming at develop children and adolescents’ social and emotional ability

and is based on emotional intelligence and social behavioural learning theories (Kimber, 2009) and inspired by e.g.,

Promoting Alternative Thinking Strategies (PATHS) (Anttila et al., 2010).”SkolKomet” is a Swedish manual based

program which targets teachers in pree-school to Grade 9. The theoretical idea in SkolKomet is based on behavioral

learning principles and that the adult must change their way to communicate and interact with the child. ÖPP (or “Ef-

fect”, as it is now called) is a parent oriented method aiming at prevent early onset of alcohol, reduce binge-drinking,

an antisocial behavior and crime, among adolescents. Motivating Interviewing is a listening, goal oriented and client

centered counseling method (Brown & Miller, 1993). 8 RePulse aims at individual students having problems controlling their impulsivity and is based a cognitive perspec-

tive where a destructive behavior is viewed as something that has been learned. By providing the child with tools to

control the impulses it is believed to make thoughts, feelings, and behavior interact. Active Parenting aims at increas-

ing parents’ awareness and the theoretical idea is developmental theory and perspectives on learning. When the

parent changes behavior, the child will also change. Classroom management is based on social behavioral learning

theory and on strength protective factors and reduces risk factors (Karlstad municipality, 2007).

42

tion, CFBUPH studies have included perceived school climate and attitudes to prevention

and health-promoting work among teachers and principals, as well as experiences of bullying

among school students and school health staff. CFBUPF has studied processes as well as

outcomes. The projects members included one project leader and four doctoral students.

The aim of the research has been to provide material for following up and evaluating

prevention and health-promoting interventions in PS, as well as to map children and adoles-

cent mental health and study variation vis-à-vis socio demographics and changes over time.

43

8 PROBLEM SPECIFICATION AND AIMS The Western societies are facing new challenges in the wake of mental illness. One protec-

tive factor against mental health problems is the experience of good social relations, while

the opposite, negative social relations can be harmful for mental health and academic

achievement among students. Although Swedish children and adolescents report relatively

low bullying prevalence rates in comparison to other countries, bullying may nevertheless

increase the risk of severe consequences on mental health, both in a short and long term

perspective. New arenas for bullying including the Internet have changed the preconditions

for bullying and harassments among adolescents. It is imperative to continue to increase our

knowledge concerning bullying and in particular cyberbullying since it may take different

paths than traditional bullying. Adolescents are seen as an especially vulnerable group due to

bodily changes and transition into adulthood whereby this group is important to study. In

addition, as todays’ adolescents have grown up with a variety of easily available technology,

the phenomenon of cyberbullying may not be that surprising. However, it still increases the

challenges for school because of its transcending nature. Schools health care serves as an

important agency regarding bullying and mental health but less is known about how these

professionals work with bullying in schools. These gaps in research lead to the overall aim

with the current thesis.

Overall aim

The overall aim of this thesis is to study differences and similarities between traditional bul-

lying and cyberbullying among adolescents with respect to gender, psychosomatic problems,

and disabilities, and further gain knowledge about school health staffs’ experiences of bully-

ing among school students.

The specific aims are:

Study I

To examine gender differences among adolescents involved in traditional bullying and

cyberbullying.

44

Study II

To compare the association between mutually exclusive groups of cyberbullying and tradi-

tional bullying involvement and psychosomatic problems

Study III

To explore school health staff’s experience of bullying and their anti-bullying work among

school students

Study IV

To study the associations between disability, bullying and psychosomatic health among ado-

lescents, addressing two specific research questions: a) How is disability associated to differ-

ent kinds of bullying? b) Does disability modify the association between bullying and psy-

chosomatic problems among adolescents?

45

9 METHOD Table 1 presents an overview of study aims, subjects and methods.

Table 1: Overview of study aims, subjects and methods.

Study Aim Study design Study population

Analysis Years of data collection

I To examine gender differences among adolescents involved in traditional bullying and cyberbully-ing.

Cross-sectional population based study with question-naire

Two surveys. School stu-dents Grade 7-9 n=3012

Binary and multinomial logistic regres-sion analyses

Nov- Dec 2009 n=1,760 and n=1,252 =3,012

II To compare the association be-tween mutually exclusive groups of cyberbullying and traditional bullying involvement and psycho-somatic problems

Cross-sectional population based study with question-naire

School stu-dents Grade 7-9. Collapsed sample (2009-2010) N=3,820

Multinomial logistic regres-sion analysis

Nov-Dec 2010 n=2004

III To explore school health staff’s experience of bullying and their anti-bullying work among school students

Qualitative study with focus groups, semi structured questions (n=4)

School nurses and school social workers (n=16)

Qualitative content analy-sis

Nov 2011- Feb 2012

IV To study the associations be-tween disability, bullying and psy-chosomatic health among adoles-cents: a) How is disability associ-ated with different types of bully-ing? b) Does disability modify the association between bullying and psychosomatic problems?

Cross-sectional populations based study with question-naire

School stu-dents Grade 7-9. Collapsed sample (2009-2010) N=3,820

Multinomial logistic regres-sion analysis and linear regression analysis

9.1 Participants

Study I, II and IV

The first data collection in PS took place in November and December 2009 in Grades 7-9

(aged 13-15), with a participation rate of 82% (N=1,760). Eight of nine schools participated

using a web-based questionnaire.

In addition, CFBUPH also worked together with four other municipalities besides

Karlstad located in the north of Värmland who also conducted a health promotion project.

For that project, a similar questionnaire to the one in the PS, also developed by CFBUPH,

was used. The questionnaires included the same core questions on background and bullying

which made it possible to merge the data samples. In the north of Värmland, 83% and 1,252

adolescents in Grades 7-9 participated. For the two samples combined, 15 schools and 3,012

students participated (50.1% girls), with a participation rate of 83%.

46

The second data collection for Grades 7-9 took place in November 2010, with a par-

ticipation rate of 92% (N=2,004). All nine eligible schools participated. One school used

printed questionnaires instead of the web-based questionnaire.

Data set (Study I, II & IV)

For study I, the data sample included the northern municipalities (n=1,252) and the 2009 PS

sample (n=1,760), ending up with 3,012 students. In study II and IV, Grade 9 students from

2009, northern municipalities and Grades 7-9 from 2010 (n=3,820) were collapsed. By doing

this, no student were included twice.

Study III

All school nurses and school social workers working in elementary school (aged 6-15) were

invited to participate in the study. At time for the study, there were 16 eligible school nurses

and 12 eligible school social workers employed at 21 schools in the municipality, all females.

At every focus group occasion, one participant from each group reported illness which re-

sulted in two focus groups with school social workers (n=4, n=3) and two groups with

school nurses (n=6, n=3). All participants were about 30-60 years old. Those who choose

not to participate declared lack of time as reason.

9.2 Data collection

Procedure study I, II and IV

The first year of PS included planning and preparation for data collections, i.e., constructing

and preparing the web based questionnaire. At first stage, the schools’ preconditions for hav-

ing access to computers when filling in the questionnaire were systematically mapped.

Thereafter principals at the schools were contacted in order to schedule data collection. All

preparations and planning were made in collaboration with the Children and Youth Admin-

istration (BUF) in Karlstad, operation managers, and initially also a reference group.

In all data collections adolescents in Grades 7 and 8 and their parents received writ-

ten information such as rights to anonymity and the voluntary nature of participation. If they

47

did not wish to participate, they were asked to inform their teacher. Due to the 9th graders

higher age, information was only distributed to the students. However, the students were

asked to bring home the information letter to their parents as well.

The students used the school computers to complete the questionnaire. In order to

enter the questionnaire the students received a link and a randomly selected password gener-

ated by the computer program (Esmaker). A co-worker from each project was on site to in-

form and organize the data collection. The teachers were encouraged to stay in the class-

room. The questionnaire took approximately 30-40 minutes to complete.

The procedure for data collection was the same in 2010 as in 2009. The only thing

that was different was that one school used a printed questionnaire. The reason for this was

that the school thought that this would make things easier for the students. The collection

procedure was the same but the questionnaire was sent to be scanned in at Umeå University.

The questionnaires were scanned on files and sent back to Karlstad University.

Study III

Focus group is a kind of data collection that is basically a way of listening to people and

learning from them. A purposive sample is needed to generate productive discussions and

the process may contribute to sharing and comparing among the participants. The group

benefits from diverse perspectives and can maximize their compatibility and also the ability

to make comparisons between groups in the analysis (Morgan, 1997).

Composition of the focus groups

The groups were chosen to be homogeneous in terms of which position they had: school

nurse or school social worker. Homogeneity is commonly recommended in the literature in

order to facilitate interaction and discussion. Participants perceiving each other as fundamen-

tally similar can spend more time discussing the issues at hand, instead of explaining them-

selves to each other (Carey, 1994; Morgan, 1997). School nurses and school social workers

also have different tasks, and the use of different terms or jargon was believed to negatively

affect the flow of discussion. The participants were therefore divided into groups depending

48

on their schedule, resulting in two groups of school social workers and two groups of school

nurses. The participants knew each other as colleagues or acquaintances.

Group size in focus groups

It is sometimes suggested that the number of participants in a focus group should be at least

five, or sometimes even six to eight (Krueger & Casey, 2008). Due to the drop-out rate of

school nurses and school social workers, it was not possible to reach that group size. There

are different opinions regarding how to define a focus groups and when it should be called

“group interviews”. According to Barbour and Kitzinger “Any group discussion may be called a

focus group as long as the researcher is actively encouraging of, and attentive to, the group interaction.” (Bar-

bour & Kitzinger, 1998).

Procedure

All school nurses and school social workers working in elementary school were first in-

formed of the study via project colleagues working at BUF. Then they were contacted by the

researcher via e-mail. The participants were divided into groups depending on their schedule

and best time available. The sessions took place during daytime at Karlstad University be-

tween November 2011 and February 2012. The moderator (first author) led the sessions

with help from a research colleague. A set of focus group guidelines was developed for the

moderator, including an introduction to the meeting and probes designed to re-focus the

discussion if necessary. The participants were in situ informed about the aim of the study,

voluntariness, the right to terminate their participation, and agreement to the recording of

the session. Thereafter they had the opportunity to ask questions and to fill in the informed

consent form. After the digital audio recorder had been started, the first question was pre-

sented. The themes were followed up by questions without leading the discussion in any par-

ticular direction. When approximately 10 minutes remained and the discussion began to

fade, the moderator asked the participants whether they felt that anything had been left out,

or if they wanted to add something. The meeting lasted approximately 120 minutes, includ-

ing pre-information (10-15 minutes).

49

9.3 Items, questions and instruments

Background variables

Study I and II and IV included background data regarding questions of gender (boy/girl)

and Grade (7, 8, 9). Study I and II used the additional backgrounds questions about country

of birth (“In which country were you born?”; “In which country was your mother born”; “In

which country was your father born?”) with five response alternatives (“Sweden”; “Den-

mark, Norway, Finland or Iceland”; “Other country in Europe”; “Other country in the

world”; “Don’t know”) and family structure. The variable “Family structure” was addressed

with two questions. First, the participants were asked if they lived with both their parents. If

so, they were asked whether they had always done so (“Always together with mother and

father”) or lived with one parent at a time (“Mostly with my mother, sometimes with my fa-

ther”; “Mostly with my father, sometimes with my mother”; or “About the same with moth-

er and father, for example, alternating weeks”). There was no follow-up question if they an-

swered that they lived with only one parent or no parent.

Study I included additional questions of mobile-phone ownership (“Do you own

your own mobile phone?”) with response alternatives ”yes” and “no”; access to the Internet

(“Do you have Internet in your home that you can use?”) with response alternatives “yes”

and “no”; and number of computers at home (“How many computers does your family have

at home?”) with four response alternatives (“none”; “1”,”2”,”3 or more”).

Self-reported bullying/victimisation

The questions on traditional bullying were taken from the Olweus Bully/Victim Question-

naire (OBVQ) (Olweus, 1996b). For the purpose of the current study, two global questions

were used characterized by a definition, together with a question including the word “bully-

ing” (i.e. “How often have you been bullied at school in the past couple of months?” and;

“How often have you taken part in bullying another student(s) at school in the past couple

of months?”). Five response alternatives were given (i.e., “I have not been bullied/bullied

other students at school in the past couple of months”; “only once or twice”; “2 or 3 times a

month”; “about once a week” and; “several times a week”). A definition of bullying used in

50

the Swedish Health Behaviour in School-aged Children (HBSC) questionnaire was included

(Marklund, 1997):

We say a student is being bullied when another student, or a group of students, says or does nasty

and unpleasant things to him or her. It is also bullying when a student is teased repeatedly in a way

he or she does not like. But it is not bullying when two students of about the same strength quarrel

or fight. It is also not bullying when the teasing is done in a friendly or playful way.

The cyberbullying questions were adapted from Smith et al. (2008), and translated to Swe-

dish by Slonje and Smith (2008). For the purpose of the current study, two global questions

were used (i.e. “How often have you been cyberbullied in the past couple of months?”; and

“How often have you cyberbullied other student(s) in the past couple of months?”), with the

same response alternatives as for traditional bullying. The questions were introduced by stat-

ing that:

Cyberbullying is defined in the same way as traditional bullying (i.e. the definition used in Swedish

HBSC, Marklund, 1997, author’s note) but involves bullying through, for example, mobile phones

(calls or text messages), photo/video clips, E-mail, Chat-rooms, Web-pages, Instant Messaging (i.e.

MSN).

The recall period for the questions was the past couple of months. Hence, the student’s ref-

erence frame was the autumn term.

PsychoSomatic Problem scale

To measure mental health as an outcome, psychosomatic problems measured by the Psy-

choSomatic Problem scale (PSP scale) (Hagquist, 2008) was used in Study II and IV. This

scale consists of eight single items: “had difficulty in concentrating”; “had difficulty in sleep-

ing”; “suffered from headaches”; “suffered from stomach aches”; “felt tense”; “had little

appetite”; ”felt sad”; and “felt giddy”. The response categories for all of these items were

“never”, “seldom”, “sometimes”, “often” and “always”, referring to the last school year.

Psychometric analyses based on the Rasch model (Rasch, 1960/1980) justified the summa-

tion of raw scores. A high value on the PSP scale indicates more psychosomatic problems.

The PSP scale has shown high reliability and invariant properties, making it useful for meas-

uring psychosomatic problems in general populations of adolescents (Hagquist, 2008). Two

51

items, “felt sad” and “stomach ache”, showed Differential Item Functioning (DIF) across

genders; meaning that these two items worked differently for boys and girls. Given the same

location on the PSP-scale, girls tended to score higher than boys on these particular items.

Since DIF violates measurement requirements of invariance, DIF was resolved by splitting

both items into one item for boys (leaving girls a missing value) and one item for girls (leav-

ing boys a missing value). Rasch-analysis of the PSP- scale was conducted using the software

RUMM 2030. For a descriptive introduction of Rasch analysis, see Hagquist, Bruce and Gus-

tavsson (2009). Table 2 show the scale distribution among adolescents in the PS project.

Table 2. The PSP scale distribution among adolescents (N=3,820).

Valid Missing

3723 97

Mean Std. Error of Mean

-1.20612 .023211

Median -1.08800 Std. Deviation 1.416228 Variance 2.006 Skewness -.187 Std. Error of Skewness .040 Range 9.371 Minimum -4.954 Maximum 4.417

Disability

To measure disability in Study IV, a single question asking if the adolescents had a disability

(response categories “yes” and “no”) together with a definition was used:

By disability we mean that you have, for example, impaired movement, dyslexia, impaired vision or

hearing, or any other similar condition which might make things hard for you, either in or outside of

school. It may also mean that you have ADHD, epilepsy or diabetes.

Interview guide study III

The interview guide to Study III was based on three main questions, followed up by clarifi-

cations and further questions, depending on the discussion.

What have you experienced in terms of bullying among school students?

What are your experiences with those involved in bullying?

What is your experience of bullying prevention in schools?

52

9.4 Data analysis

Study I, II, IV

Bullying classifications were based on four global bullying questions and the answers to these

four questions were classified into unique and mutually exclusive groups. If a student had

indicated any type of bullying involvement, he or she was assigned a number ending up with

15 different exclusive bullying groups. Similar classifications are used by Gradinger et al.

(2009). Table 3 shows an example of the classification process were 1 indicates no bullying

behaviour and 2 indicates, bullying behaviour.

Table 3. Classification process – example of pattern of answers indicating a unique numerical series

ID-number

Traditional bully

Traditional victim

Cyber-bully

Cyber-victim

Classification numerical series

1 1 1 1 2 Cybervictim 1112 2 1 1 2 1 Cyberbully 1121 3 1 2 1 1 Traditional victim 1211 4 2 1 1 1 Traditional bully 2111 5 2 2 1 1 Traditional bully-

victim 2211

6

2 2 2 1 Traditional bully, traditional victim and cyberbully

2221

…. … … … … … ….

In all the current quantitative studies, contingency tables were presented to show frequencies

and percentages over the samples’ characteristics and bullying involvement rates. The cate-

gories traditional victims, cybervictims, traditional bullies, cyberbullies, traditional bully-

victims and cyberbully-victims were the main categories being analysed.

For the data collection of 2010 (n=2,004), any questionnaires considered not to be

serious were excluded from our analyses (n=23).

Study I

Associations between gender and the categories traditional victims, cybervictims, traditional

bullies, cyberbullies, traditional bully-victims and cyberbully-victims have been analysed with

multinomial regression analyses estimated by B (exp.) interpreted as odds ratios (OR) with a

95% confidence interval (95% C.I.). Statistical Package for the Social Sciences (SPSS) for

Windows (version 18.0, 19.0 and 20.0) were used for the analyses.

53

Study II

Associations between bullying involvement and psychosomatic problems have been analysed

with multinomial regression analyses estimated by relative risk ratios (RRR) with a 95% con-

fidence interval (95% C.I.). In order to take school clustering effects into account, robust

standard errors were calculated by multinomial regression analyses performed using STATA

11.2 software.

In order to specifically contrast the extreme groups of the PSP scale distribution, in-

dividuals located at/above the 75th percentile was compared with individuals at/below the

25th percentile. Further, in order to examine differences between bullying groups, an ANO-

VA-test was conducted, comparing the mean PSP-scores for traditional victims and

cybervictims. To formally test if there was a significant difference in relative risk ratios be-

tween different bullying groups, Z-scores was calculated manually (Zdiff.=(log.odds ratio1-

log.odds ratio2)/ (√(SE12 + SE22-2xCov.)).

For tentative purposes, an ordinary linear regression was conducted using the original

PSP-scale without any categorization. Variables for traditional- and cybervictims, traditional-

and cyberbullies and control variables (gender, grade, family structure, country of birth) were

constructed and analysed using dummy-regression coding. The linear regression analysis was

conducted using the SPSS 20.0 software.

Study III The data in study III were analysed with content analysis as described by Graneheim and

Lundman (2004). It was considered to be a suitable method for analysing the data because it

can be applied to data with variable depths. Content analysis aims at describing the phenom-

enon as it is and does not need pre-existing theoretical or philosophical commitment (Sande-

lowski, 2000). The analysis approach was inductive since there was not much prior

knowledge concerning the research question. In contrast, a deductive approach aims at test-

ing a theory (Elo & Kyngäs, 2008). The analysis method helped in structuring the text and

abstracting the data at a manifest level (Graneheim & Lundman, 2004).

Data were transcribed verbatim by the researcher. All texts from the focus groups

were at first read through to grasp their content. At stage 1, the author identified the mean-

54

ing units describing the participants’ experiences within the different topics. This could be

sentences, phrases or words. In stage 2, the meaning units were condensed and shortened

without losing their message. In stage 3, each condensed text section was labelled with a

code representing its content, without changing or adding words. At this step, the material

was presented to external researchers in order to discuss the preliminary findings and in-

crease the credibility of the analyses. The codes were then put into preliminary categories

and/or subcategories. In step 4, the subcategories were categorized into categories. Quota-

tions were presented in the result sections in order to confirm the categories and sub-

categories appearing in the analysis. Internal validity was also increased by critically discuss-

ing the results with other colleagues.

Study IV

Associations between disability and different unique bullying groups were analysed with mul-

tinomial regression analyses estimated by B (Exp.) interpreted as Odds Ratios (OR) with a 95

% confidence interval (95% C.I.). Further, in order to study if disability modified the associa-

tion between bullying involvement and psychosomatic problems (dependent variable), linear

regression analysis using the original PSP-scale without any categorization were used using

dummy-regression coding. In order to reach the most parsimonious model that fit the data

various nested models were compared with each other, e.g., models including interaction

terms were compared with the model including only main effects, (i.e., gender, grade and

disability). If the difference in the likelihood ratio Chi2 statistic between the models was not

significant (p<.05), the simpler model was chosen. All regression analyses were adjusted for

gender and grade. All analyses were conducted using the SPSS 20.0 software.

9.5 Ethical considerations

Ethics were considered throughout all parts of the project and studies. All information let-

ters stipulated the aim of the study, the voluntary nature of all respondents’ participation,

their right to withdraw at any time, as well as assurances of anonymity and confidentiality.

An application was sent to the regional committee of ethics, but since the data collections

did not include sensitive personal data, the project was not regulated by the Swedish act con-

55

cerning Ethical Review of Research Involving Humans. Only an advisory statement was

provided concerning informed signed consent regarding Grade 4 and 5 (Dnr. 2009/623). A

separate ethics application for the focus groups study was sent to the local committee and

was reviewed without any objections (Dnr. 2010/707).

The PS project

The requirement of confidentiality was followed using anonymous questionnaires for stu-

dents. Despite that there is always a risk that a participant may recognize her/his own char-

acteristics in a study. Since most of participating students were below the age of 15, regula-

tions required that both students and parents were informed of the study. If the parents did

not want their child to participate (or the student did not wish to) they were asked to inform

the teacher. Students in Grades 7 and 8 received two information letters, one to themselves

and one to the parents. Parents of students in the 9th grade did not receive an information

letter because of the students’ age, although the students were asked to take home the in-

formation letter to their parents. With this procedure, there is a risk that the information did

not reach all parents. This is a general problem, but due to the anonymous character of the

questionnaire and the age of the students in Grades 7 -9, we judged this not to be a problem.

Regarding data collection in schools, we considered throughout how we could make the stu-

dents feel sure that their answers would remain anonymous. Firstly, we encouraged students

to ask us to explain questions in the questionnaire if they did not understand, without an-

swering the questions for them, which teachers were also instructed to do. For that we had a

printed questionnaire so that students could point to questions of concern, without showing

us their answers on the computer screen. The students were also informed that they could

contact the school nurse if they felt like talking to someone after answering the question-

naire.

The focus group study In accordance with the confidentiality requirement, names and schools were deleted in the

results section to reduce the risk of recognition. Some quotations were also not used if they

could lead back to the respondent.

56

10 MAIN RESULTS

Discrepant gender patterns of involvement in traditional bullying and cyberbullying:

There were only small, if any, gender differences among traditional victims, but girls

were more likely than boys to be cybervictims. Secondly, whereas boys were more

likely to be traditional bullies, girls were equally as likely as boys to be cyberbullies.

Boys were more likely to be traditional bully-victims, while girls were more likely to

be cyberbully-victims.

No statistically significant differences in psychosomatic problems were found be-

tween cyberbullying and traditional bullying, either for victims or for bullies. Alt-

hough, all bullying groups were associated with more psychosomatic problems, and

the strongest association were found for bully-victims.

Three main categories concerning school social workers and school nurses experience

of bullying in school emerged from the qualitative content analysis: 1) “Anti-bullying

team”. 2) “Working style”, comprising two sub-categories, “Team member” and

“Single worker”; and 3) Perspectives on bullying”, comprising two sub-categories,

“Contextual perspective” and “Individual-oriented perspective”.

Showed a strong association between disability and being a bully-victim, in particular-

ly for being a combined bully-victim, i.e., to use and be exposed to bullying both in

traditional terms and via the Internet. We found no associations between bullies and

disabilities. Girls with disabilities were more likely to be victims, compared to girls

without a disability. No associations appeared for disability and bullies. The analyses

did not show that disability modifies the association between bullying and psychoso-

matic health.

Study I

The result showed that bullying is an overlapping and complex phenomenon (see the Venn

diagram in Study I). From the original 3,012 subjects, 845 had been involved in bullying in

some way. The largest group of adolescents involved in bullying was found among tradition-

57

al bullies, which comprised almost six times as many adolescents as the group of cyberbul-

lies.

The results from the multinomial regression analyses showed discrepant gender pat-

terns of involvement in traditional bullying and cyberbullying. First, while there were only

small, if any, gender differences among traditional victims, girls were more likely than boys

to be cybervictims when occasional cyberbullying was used as a cut-off point. Second,

whereas boys were more likely to be traditional bullies both at the lower (OR 0.6) and the

higher cut-off point (OR 0.3), girls were as likely as boys to be cyberbullies. Further, girls

were more likely to be cybervictims at the lower cut-off point (OR 2.0), but not at the higher

cut-off point. Regarding bully-victims, we conducted binary logistic regressions due to too

few observations. The result showed that girls were more likely than boys to be cyberbully-

victims (OR 3.4). The odds ratio for boys, on the other hand, was 0.18 for be traditional bul-

ly-victims.

Study II

The multinomial regression analyses showed that psychosomatic problems were significantly

associated with all types and groups of bullying. All analyses were repeated at the 90th vs the

10th percentile, but since the observations in some cells were too small to estimate adequate

risk ratios, only analyses using the 75th - 25th percentile were presented.

In order to formally test for differences between the relative risk ratios (RRR) be-

tween different groups, a z-score were calculated. If the z-score is above 1.96, the difference

is statistically significant at the 95% level. The main findings showed no significant differ-

ence at the 95% level between traditional victimisation and cybervictimisation (z = 1.36).

This was also confirmed by the ANOVA test.9 Interestingly, there was no significant differ-

ence in psychosomatic problems between cybervictims and cyberbullies (z = 1.37). Bully-

victims showed - in line with previous literature - significant difference from most other

groups.

9 The ANOVA showed, in accordance to the calculations of differences between risk ratios, no difference between

traditional victims and cybervictims (mean difference -.296, std. error .190. p<.720, C.I (-.798-.206).

58

In addition, tentative analysis using ordinary linear regression was conducted which

confirmed the general pattern from the logistic regressions analyses: all groups of bullying

involvement showed significantly higher levels of psychosomatic problems compared to

non-involved, even after adjustment for gender, grade, family structure and ethnicity.

Study III

Three main categories emerged from the analysis: 1) “Anti-bullying team”; 2) “Working

style”; and 3) “Perspectives on bullying”. “Anti-bullying team” describes the organizational

formalization of anti-bullying work at school. The term “Working style” indicates the differ-

ent roles played in the school’s anti-bullying team and in general preventive work. This cate-

gory comprises two sub-categories: “Team member” and “Single worker”. “Team member”

is characterized by more interdisciplinary work and more involvement in the school’s general

prevention activities, often at a universal level. Team members are often part of the school’s

anti-bullying team. The single workers’ contact with students is primarily individual, and their

work is characterized as less interdisciplinary, although some wish to work more interdisci-

plinary but are restricted by their work. Most single workers do not participate in the anti-

bullying team. However, they play a supportive role on the sidelines. They aim at being a

neutral player and at conveying to students the idea that they take nobody’s side in a bullying

situation. Finally, “Perspectives on bullying” encompasses the different views of what gives

rise to bullying and how bullying should be handled. This category comprises two sub-

categories: the “Contextual perspective”, where roles played and status apportioned are seen

as leading causes of bullying; and the “Individual-oriented perspective”, where students’ in-

dividual difficulties are viewed as giving rise to their involvement in bullying situations.

Study IV

Among boys (n=1,858), 18.0% reported “yes” to the disability question, as compared with

18.5% of the girls (n=1,942).

The multinomial logistic regression analyses including mixed victims, bullies and bul-

ly-victim (with no bifurcation into traditional bullying or cyberbullying) showed that having a

disability was significantly associated with being a bully-victim (OR 1.7, p=<.000). Further,

59

disability was significantly associated with being a mixed victim (OR 2.8, p=<.000). Howev-

er, having a disability was not significantly associated with being a mixed bully in any of the

analyses.

In the second multinomial logistic regression, analyses were conducted separated for

boys and girls, with the odds ratios of bullying for disabled students being compared to that

of non-disabled students. The result showed that having a disability was significantly associ-

ated with being a combined bully-victim, regardless of gender (p=<.000). Additional, refined

analyses based on grade and gender showed that boys with a disability in Grade 8 were more

likely to be traditional bullies. When analysing the 9th Grade, girls with disabilities were

shown more likely to be traditional bully-victims, combined bullies and combined bully-

victims, compared to girls without a disability. However, these significant associations can be

due to small group sizes and should be interpreted with caution.

The linear regression analysis including different bullying groups as independent vari-

ables and psychosomatic health problems as outcome measure showed that, based on a main

effect model and a model including interaction terms, having a disability and being a victim,

bully, combined bully-victim and non-combined bully-victims were independently associated

with psychosomatic problems. The relationship between bullying and psychosomatic prob-

lems was not modified by the presence of disability. None of the interaction terms showed

significance (victim × disability p=.896; bully × disability p=.987; combined bully-victim ×

disability p=.222 and non-combined bully-victims p=.491). This pattern was confirmed by

the incremental F test (F change =.538, F sig .708) comparing the main effect and models

with interaction terms.

11 DISCUSSION

The overall aim of this thesis was to study differences and similarities between traditional

bullying and cyberbullying among adolescents with respect to gender, psychosomatic prob-

lems, and disability, and to gain further knowledge about school health staff’s experiences of

bullying among school students. There were two different points of departure in the present

studies; three of the four studies (I, II and IV) are similar in that they are based on adoles-

60

cent self-reports and the conclusions drawn are based upon their answers. The question is

whether these results can be generalized to a similar population? It is likely that other 13-15

years old adolescents in Sweden would report approximate answers. The results from Study

III need to be tested with population-based, quantitative measures in order to confirm the

qualitative results.

So, what does the present thesis add to existing knowledge? Firstly, we know from

previous research that there are gender differences in bullying. Boys, as compared to girls,

are more likely to be involved in physical bullying as bullies and as bully-victims, whereas

girls tend to use non-physical means to bully (Wang et al., 2009). However, we know less

about the gender patterns of cyberbullying, as previous research has shown inconsistent re-

sults. Some studies have found that boys are more likely to be more involved in or exposed

to cyberbullying, mostly as bullies (Wang et al., 2009), and still others have found that girls

are more likely to be exposed or involved (Kowalski & Limber, 2007), and others have

found no gender differences (Smith et al., 2008). In addition, few studies have studied mutu-

ally exclusive groups or compared different groups of traditional bullying and cyberbullying.

My first study adds to the existing body of knowledge through the application of mutually

exclusive groups and by showing that girls are more exposed to, and involved in, cyber-

bullying compared to boys. Secondly, a large body of literature has established the associa-

tion between bullying and mental health; cross-sectional as well as causal inference studies

have shown that bullying can predict mental health problems (Fekkes et al., 2006). It has

been argued that cyberbullying would be more damaging to mental health than traditional

bullying (e.g., Campbell, 2005), but the empirical evidence is scant. Study II adds to the exist-

ing knowledge by examining different, mutually exclusive forms of bullying behaviour and

showing that all forms of bullying are associated with increased psychosomatic problems.

There was no difference found between traditional bullying and cyberbullying as regards to

psychosomatic problems. Thirdly, surprisingly few studies have been conducted concerning

the role of school health staff and their work with, and experiences of, bullying- especially in

a Swedish context- although we know that they often deal with students involved in bullying.

By using focus groups, Study III lends a contextual picture to the students’ answers, a pic-

61

ture provided through the experiences of school health staff when dealing with bullying in

school and their bullying-prevention work. Fourthly, the association between disability and

bullying is well supported in the literature (e.g., Olsson et al., 2013), as are the associations

for disability and mental health (e.g., Bosk, 2011), and bullying and mental health (Gini et al.,

2009). However, less is known about cyberbullying and disability, or if students with disabili-

ties suffer from more psychosomatic problems compared to adolescents without a disability,

i.e., if disability modify the association between bullying and mental health. As far as we

know, this is the first study to use a population-based sample in examining both traditional

bullying and cyberbullying among students with disabilities. It adds to existing knowledge by

showing that disabled adolescents are more likely to be combined bully-victims as compared

to their non-disabled counterparts. However, similarly to Sentenac et al. (2012) disability was

not found to modify the association between bullying involvement and mental health.

The central research question addressed were whether there were any differences be-

tween cyberbullying and traditional bullying; and this was in fact shown in terms of differ-

ences in gender, and to a lesser extent in terms of disability, but not as far as mental health

outcomes were concerned. Due to recent amendments to the Swedish Education Act, the

reorganization of school health-care has becomes a point of particular interest. The student-

based studies indicated that the various forms of bullying are associated with different char-

acteristics. From a health-staff perspective, these differences are worthy of attention and may

prove useful in detecting vulnerable students.

The public health consequences of bullying

Swedish bullying rates are relatively low, which was confirmed by the current studies. How-

ever, given that about 10% or more of school students are occasionally involved in, or ex-

posed to, some type of bullying behaviour, either online and offline, and given the severe

consequences that bullying may have on an individual’s mental health and on society in gen-

eral, bullying must be considered a public-health issue (Feder, 2007). Results from Study II

showed that all types of bullying behaviour are associated with more psychosomatic prob-

lems, and Study IV showed that bullying is a rather common phenomenon among adoles-

62

cents with a disability. Hence, these adolescents may be at greater risk of future mental

health problems. Importantly, a particularly vulnerable category is the bully-victim. The re-

sults show that bully-victims are more likely to have a disability that they also report more

psychosomatic problems, which has been shown in other studies as well (e.g. Kaltiala-Heino

et al., 2000; Sentenac, Gavin et al., 2012). As these students may suffer from several difficul-

ties, they may, from a long-term perspective, experience more severe mental illness, making

achievement in school more difficult. In a similar vein, adolescents involved in or exposed to

multiple kinds of victimisation, such as both traditional bullying and cyberbullying, may be

experiencing greater difficulties (e.g., Gradinger et al., 2009).

It is possible that we are underestimating the total burden of peer victimisation and

bullying. As Hellström, Beckman and Hagquist (2013) have shown, using only a measure for

bullying may fail to capture many victims of peer victimisation. Many adolescents are ex-

posed to repeated peer aggression without considering themselves to be victims of bullying.

Hence, theoretically, the total burden of peer victimisation may be underestimated. This be-

comes an even more serious problem when looking at the results from another study by

Hellström, Beckman and Hagquist (2013) which showed no differences in psychosomatic

problems between bullying and peer aggression victimisation. If we underestimate peer vic-

timisation prevalence rates, we underestimate the problem as a whole and thus the time and

economic resources that should be devoted to the problem.

It has been argued that possible reasons for an individual not admitting to being a

bully or a victim in self-reports may include labelling (Link & Phelan, 2001; Thornberg,

2011) and feelings of stigma and shame (Felix et al., 2011). Being negatively labelled as dif-

ferent can be devastating for the victim’s social identity at school, leading to exclusion from

the group, culture or society and to stigmatisation (Link & Phelan, 2001). From a public-

health perspective, stigmatisation is a major problem for a large number of people. The

stigmatisation process is, however, complex: the bullying behaviour may be one aspect, but

the consequences of the bullying, or the reasons for the bullying (such as mental health

problems or a disability) may per se become a stigma.

63

Cyberbullying and traditional bullying

Although the cyberbullying research field has grown in the past few decades it is still in its

infancy, as the Internet arena and other cyber-tools are constantly changing and developing,

and become more nuanced and integrated into our daily lives. The rapid development of

ICT makes this an even more important arena to study. Parents and schools, face new chal-

lenges, since situations initiated outside school hours may become manifest in school. One

might indeed be forgiven for thinking that cyberbullying has not reached its plateau, despite

studies such as the present one showing that traditional bullying is still more common than

cyberbullying (see also Slonje & Smith, 2008; Slonje et al., 2012), we might assume that

cyberbullying has not reached its plateau. However, since nearly already 90% of adolescents

use Internet-based tools, it is likely le that the prevalence rate will not rise that much; instead

there is a risk that the behaviour online will become more inventive and thus more harmful.

It is too early to say how, or if, we are being affected by the new communication me-

dia. There have been theoretical attempts to explain how cyberbullying can affect mental

health (e.g., Campbell, 2005; Kiriakidis & Kavoura, 2010), but some of these attempts have

been shown to be lacking, as new research provides us with more knowledge. In Study II, no

difference in psychosomatic problems appeared between cyberbullying and traditional bully-

ing, which is contrary to what has been suggested. Interestingly, Ortega et al. (2012) actually

found the reverse: students exposed to or involved in cyberbullying actually reported less

anger, fewer negative emotions, and less defencelessness and embarrassment compared to

those exposed to, or involved in, traditional bullying. The authors suggest that students ex-

periencing cybervictimisation have a greater sense of control over what is happening than

victims of traditional forms of bullying. It is also possible that bullying and aggression on the

Internet has become normalized behaviour. Furthermore, despite the potentially wide audi-

ence in the cyber context, cyberbullying can be perceived as a distant phenomenon, given

the absence of face-to-face confrontation with the perpetrators. As Smith et al. (2008) found

in focus groups, some kinds of cyberbullying do not seem to be considered as serious as tra-

ditional bullying among students, “because you are not hurt physically and can take avoiding action so

far as messages are concerned.” (Smith et al., 2008, p.383).

64

There are empirical indications that the experience of cyberbullying are not as

straightforward as earlier discussion would have us believe. It is also important to remember

that the interpretations of the effects of cyberbullying have been made by adults who may

not have a full understanding of the cyber-world, nor of its risks and possibilities; and that,

since today’s adolescents live much of their social life in the virtual world, they might well

respond no differently to online situations as to offline. However, as mentioned, there seem

to be subtle differences between the various kinds of media technologies used to harass oth-

ers (Smith et al., 2008), which needs to be further studied.

The two cases described in the introduction section (the Instagram case and beauty

contest) give an indication as to how the Internet, behind the scenes, can dull us to others’

feelings. There is a possibility that the bully feels less empathy for the victim when not seeing

his or her facial expressions (Slonje & Smith, 2008). The cases described also both include

girls as main characters. The gender aspect corresponds to the results in Study I, showing

that girls were more likely to be exposed and involved in cyberbullying behaviour compared

to boys. Although the results show rather modest odds ratios even when using the occasion-

al cut-off, these are still interesting findings, especially when interpreting them in light of In-

ternet habits and usage, and within the framework of socialization and friend networks. Alt-

hough there are still gender differences in Internet usage (The Swedish Media Council,

2010), an alignment tendency has been reported both nationally (The Swedish Media Coun-

cil, 2010) and internationally (Gross, 2004; Livingstone et al., 2011). This may not be that

surprising. The same tendency in gender alignment has been reported in other externalized

behaviour as well, such as alcohol drinking and smoking (Danielsson, Wennberg, Hibell, &

Romelsjö, 2012).

Female adolescents have been shown to report higher levels of poor mental health

(Hagquist, 2010a). The reasons for this are yet unclear, but given the argument that girls may

be more vulnerable to mental-health risk factors (bullying behaviour, alcohol drinking, etc.)

than boys, an increased involvement or exposure to such behaviour may possibly increase

the risk of additional mental health problems. Furthermore, Study IV showed that girls with

a disability were more likely to be a victim, while no association was found for cybervictims

65

and disability. One possible explanation for this may be that students, and in particular girls,

with a visible disability may be more exposed to “face-to face” peer victimisation in school. It

could be that a visible disability provokes or scares other students, who react with impulsive

verbal acts. This might be experienced more among girls due to normative beliefs regarding

behaviour and looks, and be less of a problem for boys. From another perspective, it may be

that students with a disability are more vulnerable and feel more exposed to the gazes of

others than students without a disability. They may feel themselves to be a victim and thereby

become one (Sentenac, Gavin et al., 2012).

This part of the discussion leads us to the question: Are cyberbullying and traditional

bullying conceptually the same or different phenomena? My results show that traditional bul-

lying and cyberbullying are different in some aspects and similar in others, although, the dif-

ferences are not that large. The real differences seem instead to be in the type of bullying,

and perhaps the amount of exposure or involvement. For example, disabled adolescents

were more likely to be combined bully-victims, and bully-victims were shown to experience

more psychosomatic problems. Based on my results and previous literature, I would suggest

that traditional bullying and cyberbullying are rather two sides of the same coin, albeit that

cyberbullying may require different definition criteria, as has been discussed by Menesini et

al. (2012).

Preventing bullying

The bullying phenomenon is not new. According to theories such as those to do with social

hierarchy, social ranking and status, this is an inherited human behaviour (Gilbert, 2000).

Some would argue that nothing can be done about bullying and that it will always exist

wherever there is human interaction. However, studies have shown that bullying behaviour

in schools can be reduced by actively combatting it (Ttofi & Farrington, 2011). It has also

been shown that school climate is associated with bullying behaviour in schools, meaning

that where there is a possibility of working towards a more positive school climate, bullying

rates and other externalized problem behaviour can be reduced (Thapa et al., 2013).

66

Because bullying is a complex phenomenon and stems from different sources, it may

be argued that schools should use different approaches to combat different types of bullying,

i.e., traditional bullying and cyberbullying. However, owing to the fact that the two forms of

bullying share similarities and the fact that there is a considerable overlap between them, ge-

neric interventions aimed at combatting bullying in general have also been shown to be suc-

cessful in reducing cyberbullying (Cross, Li, Smith, & Monks, 2012). This has received em-

pirical support in Finnish schools (The KiVa program) (Salmivalli & Pöyhönen, 2012) and in

Sweden (Englund, 2011).

As found in Study III, both individual and contextual factors influence bullying be-

haviour. And both dimensions may be equally difficult to do anything about. The individual-

oriented perspective can turn bullying into a contextual problem, as well as medical, as the

individual’s behaviour may be reinforced by the surrounding environment. Parents, peers

and staff may be part of denormalising behaviour; hence, self-stigmatisation may occur on

the student’s part and the surrounding environment may be less tolerant. Interestingly, Study

IV also indicated that disability played an important role in bullying. However, this was most

clearly seen among the bully-victims, supporting the results from Study III indicating disabil-

ity to be an important aspect of bullying. I believe there is an important distinction to be

made between bully-victims and bullies, as there was no association found between bullies

and disability. As bully-victims seem to suffer disability more frequently, and report more

psychosomatic problems, we need to highlight this group of adolescents.

Although schools have a responsibility to do something about bullying or harassment

that has started outside school, if the involved students have a connection with the same

school (such as cyberbullying incidents) parents must also play their part. They, as well as

teachers, should be educated about cyberbullying (Mishna et al., 2011). According to the

EU-kids online survey (Duerager & Livingstone, 2012), restrictive parental mediation reduces

online risks, but it also reduces children’s online opportunities and skills. Furthermore,

through active parental mediation (i.e., talking to the child, staying nearby, encouraging the

child to explore the Internet) children’s Internet usage was found to be associated with a

67

lower risk of harm. Further, it was found that parental technical mediation, such as using a

filter, did not reduce online risk encounters.

School staff are challenged in many ways. The challenges of working together in the

same direction and bringing together different perspectives are discussed in Study III. Study

III indicated the importance of the role of the family – as both a risk factor as well as a buff-

ering factor for bullying involvement, which is also supported in the literature (e.g., Barboza

et al., 2009). Another significant group of adults, who are not studied in the current thesis

but who must nevertheless be highlighted, are teachers. In order to achieve effective preven-

tive and health-promoting activities, a variety of adults and a broad collaboration between

personnel, including teachers, is needed (Anderson-Butcher & Ashton, 2004). Frey et al

(2005) suggest that the role of school health staff in this context should be to support the

teacher as the primary interventionist, rather than the sole provider of direct services.

The Preventive School project was shown to represent a valuable input for many

schools in their organization. The essential contribution of the PS was to let schools choose

which program they considered most suitable for their purposes. Although some principals

voiced the opinion that the PS was controlled from the top, a majority of those who re-

ceived competence training within the different programs were pleased and saw the benefits

for their school. In this way a municipality takes charge of its health promoting work. The

work of combatting bullying is important in socializing children away from engagement in

aggressive behaviour (Barboza et al., 2009; Underwood et al., 2001). It also shows a united

front against bullying behaviour. However, while starting up a project may be a good initia-

tive, there are some challenges. Firstly, the word “project” has a negative connotation, as it

implies a time limit; instead, such interventions are best integrated into a school’s every-day

activities. Secondly, experience from the PS project shows the importance of letting princi-

pals and teachers feel that measures are chosen according to a “needs inventory” and that

the decision to use certain programs to improve children’s health is not a top-down decision.

None of the current schools choose a bullying prevention program; instead most of the pro-

grams were aimed at improving social relations, both among students and between teachers

and students.

68

Methodological discussion

Data collection

During the data collection we strived for high standard procedures by letting all project

members follow a protocol with instructions on what to say and what to do. According to

Cross and Newman-Gochar (2004), lack of standards for classroom administration, or if the

administrator feel uninspired when conducting the study, the result may be affected in a neg-

ative way: there may, for example, be a larger internal dropout.

Considering the circumstances when we conducted the first data collection in the

winter of 2009, i.e., just a few weeks before the Christmas holidays and with limited numbers

of computers in most schools, the participation rate must nonetheless be considered relative-

ly high – 82% and 90%. Nevertheless, we revisited the schools many times in order to cap-

ture those students who had been absent during the ordinary session. The participation rate

and the population-based design of the project increase the external validity, and the results

may be generalized to similar groups.

Did the drop-out affect the results? The question can be stated thus: Which students

did not participate, and why? Was it those who usually skip school? If so, are they at particu-

lar risk of mental-health problems? Are they victims or bullies? If so, we are probably dealing

with an underestimation of prevalence rates regarding poor health outcomes and bullying.

Based on information from teachers and principals, the major factor in the drop-out rates

seemed to be influenza. If that was the case, there is a substantial random component in

transmission, and this would suggest that it was not the same students missing in the differ-

ent surveys.

The questionnaire

The main difference between the sample in 2009 and 2010 was that one school was allowed

to use a paper questionnaire instead of the web-based one. The literature does not provide

many studies comparing web questionnaires and paper questionnaires, at least not among

adolescents in a school setting. One Swedish study conducted among adults found that

compliance (willingness to answer questions about lifestyle and health) was higher for the

web questionnaires than for printed questionnaires (Bälter, Bälter, Fondell, & Lagerros,

69

2005). However, we did not find any obvious differences in internal drop-out, hence we do

not think that using different types of questionnaires affected the students’ perception nor

the results since the procedures were similar in all other aspects.

One limitation is that the questionnaire was not pre-tested among Grade 7-9 stu-

dents; only among Grade 4-5 students (many of the questions were similar). However, we

checked how the students perceived the questions by writing down every query that the stu-

dents had about the questions, i.e., which question they did not understand and why they did

not understand it. Thereafter, we systematically went through responses from students in all

classes and identified patterns in questions and tried to elucidate why they were problematic.

This may be viewed as a form of checking face validity. We also went through all question-

naires in order to look at answer patterns. Based on this information, we added, improved

and removed some questions for the 2010 questionnaire.

In the 2009 questionnaire, as compared to the 2010 one, there were no filtering func-

tion for the questions on bullying, meaning that the students had to answer a rather compre-

hensive battery of questions if they had not been bullied themselves (they then had to tick in

the box “I have not been bullied/bullied others” for every question). It was assumed that this

would increase the internal drop-out. The internal drop-out analysis showed that there were

a larger proportion of boys who had skipped these questions, compared to girls (mean 5%)

across the four global bullying questions. The largest dropout had to do with questions re-

garding the bullying of others, both with regard to traditional bullying and cyberbullying, and

across both genders. In the 2010 sample, the mean internal drop-out on bullying questions

decreased to 3%. Moreover, both studies were conducted in the autumn term. As a means of

capturing school-related bullying, when the students interact with their peers, this approach

is fruitful. However, if the study had been conducted during summertime, it is possible that

the rates of cyberbullying could have risen, if those students who are frequently victimised

continued to be victimized.

Bullying items

As bullying is a major topic, we reviewed the literature in order to find the “optimal” bully-

ing questions. The “Olweus bully/victim questionnaire” was considered to be in common

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use, internationally accepted and validated (Kyriakides, Kaloyirou, & Lindsay, 2006). In addi-

tion, questions regarding cyberbullying were used from the Smith et al. (2008) study, which

was translated into Swedish by Slonje and Smith (2008). Some limitations were experienced:

Second, as regards the questions about cyberbullying, there were no questions asking about

different types of cyberbullying, meaning that the measure became rather “blunt” and un-

specific. Cyberbullying can include both text messages and video clips, which have been

shown to be perceived as worse among adolescents (Smith et al., 2008).

We used a definition from the Swedish version of Health Behaviour of School Chil-

dren (HBSC) (Marklund, 1997; WHO, 1997). The reason was that we considered the defini-

tion by Olweus to be too wide to fit our questionnaire. However, by using an earlier version

of the HBSC definition, we left out the aspect of social exclusion. Further, we applied the

same definition to the cyberbullying questions, meaning that the criteria of power imbalance

and repetition were introduced in the cyberbullying questions, although we argue that these

criteria may not be as applicable to cyberbullying as they are to traditional bullying. How this

actually affects the results remains unknown, but if the students read the definition and ap-

plied it to cyberbullying, one consequence may be a possible under-reporting of cyberbully-

ing. Likewise, if the students took the definition into careful account, traditional bullying

might also be under-reported, as social exclusion was not included.

In the questionnaire, the question about traditional bullying was placed first and the

question about cyberbullying last. This means that students may have included cyberbullying

when they answered the question about traditional bullying, and the group with involvement

in both cyberbullying and traditional bullying may have been overestimated. If so, this could

partly explain the overlapping of traditional bullying with cyberbullying behaviour. However,

as the definition of traditional bullying did not exclude cyberbullying per se, the answers giv-

en by the students were not wrong, but rather indicate that adolescents do not separate

cyberbullying from traditional bullying and that they may see the cyber world as integrated

into everyday life.

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Disability item

While the question regarding disability managed to target a large group of students with dis-

abilities, information having to do with specific disabilities or chronic conditions was inevi-

tably lost. It could be argued that the labels for some disabilities are emotionally loaded and

if question were put about specific disabilities an underestimation might have occurred. Put

the other way around, it could be tempting for some students to fill in specific disabilities

(such as ADHD) or maybe even all the disabilities suggested. In addition, there are diagnoses

that are often grouped together, and it may well have been impossible to analyse associations

between specific disabilities.

Self-reports The majority of data in the current thesis were based on students’ self-reported data, given in

web-based questionnaires. One strategy to minimize non serious answering was for re-

searchers to be present on the data-collecting occasions and ask teachers to encourage their

students to fill out the questionnaire in a serious manner. In the 2010 survey, every ques-

tionnaire was reviewed in order to do a validity screening procedure (Cornell & Bandyo-

padhyay, 2010). The guidelines included carefully considering questionnaires that had too

many extreme answers, sustainable internal drop-out or a series of items marked in the same

way. 23 questionnaires were excluded. All such questionnaires were documented with the

reason for their exclusion and were also reviewed by at least two project members.

Classification

Bullying was analysed either dichotomously or trichotomously, meaning that an individual

was classified as a victim, bully, or bully-victim with regard to traditional bullying and cyber-

bullying. This classification may not capture or reflect all levels and dimensions of bullying,

but the classification was considered justified for the purposes of the articles. Further, the

groups were mutually exclusive, which reduced the risk of misclassification bias and thus

increased the internal validity of the results.

72

The PSP scale The linear PSP variable can either be analysed as a continuous variable or categorized using

for example percentiles or percentiles. The choice of using percentiles in Study II was based

on theoretical aspects. I wanted to capture the most vulnerable students, that is, adolescents

with higher levels of psychosomatic problems, and compare them to adolescents with mild-

er, or lower, or no psychosomatic problems. Treating PSP as a continuous variable implies

that I utilize more information from each observation.

One limitation by trichotomising the PSP scale is using percentiles based on the dis-

tribution. The level of psychosomatic problems is relative, meaning that there are no clinical

cut-off points to what is considered a mild or a severe problem. And it is important to un-

derline that a psychosomatic problem is not a psychiatric illness, therefore we do not dichot-

omize into “diagnosis” or “no diagnosis”. Due to low bullying prevalence rates, the 25th per-

centile was compared to the 75th percentile in the current thesis/study. However, additional

analysis including the higher cut-off point, 90th vs. 10th percentile, was conducted in order to

see if the results pointed in the same direction, which they did.

Focus groups

In qualitative research the term trustworthiness comprises credibility, dependability, and

transferability (Graneheim & Lundman, 2004). Credibility was enhanced by discussions

among the authors which resulted in agreement regarding labelling and sorting of data. By

including quotations from the transcribed text, showing similarities within categories and

differences between categories, credibility was enhanced further (Graneheim & Lundman,

2004). Dependability refers to the stability of data over time. The focus group discussions

were conducted over a four-month period, which may not be that long time interval in the

context of bullying experiences in school. Hence, the consistency and dependability of the

results were enhanced. In terms of transferability, as we asked the respondents about their

own experience, rather than asking them for their beliefs on the topic, we thereby strength-

ened the transferability of the current results in to other groups and contexts (Graneheim &

Lundman, 2004).

73

One limitation of the focus-group study could be the relatively small groups. Varia-

tions in results may have been larger if there had been more participants in the groups. An

alternative method considered was to conduct individual interviews with the participants,

which could have generated different results. However, for the purpose of the study, the use

of focus groups was considered justified and the discussions were considered rich, displaying

a good group dynamic. As the population of interest was school nurses and school social

workers in in the current municipality, recruiting more participants was not possible.

The methodological issues in Study III concern the way participants were divided in-

to groups, i.e., the advantages and disadvantages with choosing homogenous or heterogene-

ous focus groups. We used homogenous groups. The advantages of this approach may be

that the participants can feel comfortable holding discussions within their profession, and

are allowed to use the same jargon. On the other hand, one of the disadvantages may be that

the participants feel too comfortable and are not sufficiently challenged to engage in deeper

reflection, in which case larger variations might have appeared.

Causality or associations The choice of analyses in the current studies are not designed to make any conclusions re-

garding causality between gender, mental health and disabilities. As discussed by Arseneault

et al. (2008), environmental factors may increase the risk of victimisation, which, in turn,

may lead to mental illness. This process do not suggest a causal effect between being bullied

and mental illness, instead familial factors may explain why bullied children have mental

health problems. Children with externalizing problems, especially hyperactivity, can be expe-

rienced as irritating or provoking (Card & Hodges, 2008) where the general hypothesis may

be that hyperactivity increases the risk of being a victim or bully. As referred to in Study II,

Turner et al. (2006) suggest checking for other factors that may affect internalizing problems.

This could however be problematic since adverse home conditions may be difficult to assess.

When it comes to Study IV and the association between disability and bullying, research has

shown that children and adolescents with disabilities are at greater risk of being exposed to

victimisation. The general assumption is that individuals who are already experiencing such

74

difficulties are victimised because of their condition, but, as previously mentioned, some

conditions such as hyperactivity may predict involvement in bullying.

12 CONCLUSIONS AND IMPLICATIONS

Child and adolescent well-being has become an important issue on the political agenda and is

one of the main focuses of public health in Sweden. To achieve our goals as a society, any

necessary intervention in this area needs to occur in the early years of a person’s life. Much

attention has already been given to children’s well-being, but there is still much to do. Bully-

ing and peer victimisation is one of several complex issues in this regard that must be taken

into serious consideration. Bullying is not only of individual concern, but also of public con-

cern.

The main contribution of this thesis is that it provides a deeper understanding of

cyberbullying in comparison to traditional bullying, while giving greater insight into the role

played by school health staff and their perspectives on bullying. The studies examine issues

that have previously received insufficient attention, if any at all. Many additional questions

have been raised during this journey. Bullying is a complex phenomenon and it takes on dif-

ferent forms along with the changes in society. In the wake of the Internet’s rapid develop-

ment, we are all challenged – parents, schools and researchers alike – to keep up with a

younger, digitally savvy generation. Yet technical devices are not weapons, unless used as

such. It is important that we help children and adolescents to understand the consequences

of their actions on the Internet, just as we must in real life. The absence of adult presence on

the Internet only increases the risk of undesirable situations arising.

Cyberbullying and traditional bullying should not be regarded as separate phenomena.

Rather, they are, in many respects, two sides of the same coin. Some of the present results

may provide a basis for discussion for schools when planning intervention and health pro-

motion strategies. This thesis highlights the role of disability in bullying, showing that ado-

lescents with disabilities are more likely to be exposed to, and be involved in, bullying in

some capacity, often as bully-victims. Here it was evident that bully-victims with a disability

were also using both traditional means and cyber means to a greater extent. Previous re-

75

search has constantly shown bully-victims to be a particularly vulnerable group. Hence, this

is a group that needs more attention. These findings may be of particular interest to school

health staff.

It was also evident that in order to combat bullying, both contextual and individual

approaches are necessary, meaning that we need to take into account the structure surround-

ing the students as well as the individual. We must see the whole problem, not just selected

components. However, the individual perspective can be difficult to handle and there is a

risk of blaming the victim, bully, or bully-victim, or of not fully facing up to the situation

while relieving the individual of responsibility. Striking a balance can be a challenge, but

must nevertheless be highlighted and discussed.

Creating a safe and supportive school environment is an investment in mental-health

capital and lays the foundation for a child’s healthy development and positive outlook on

life. Tackling bullying – whether online or offline – is a crucial part of the process. This the-

sis will hopefully encourage schools to look at this vital issue in greater depth, and offer food

for thought to health staff looking to optimize their resources.

Future directions

There are still research areas to be explored within the field of Internet-usage in general and

cyberbullying in particular. More needs to be known about the influence of various forms of

ICT on mental health and well-being among the young. The measurements used in the field

of mental health and cyberbullying require further refinement and greater conformity if use-

ful international comparisons are to be made. The gender differences reflected in bullying

and in Internet usage ought to be taken into account in the development of psychometric

standards.

Within a Swedish context, future research could usefully follow the development of

the newly legislated Team for Student Health in the Swedish school system and its role in

tackling bullying; initial focus might best be put on the new role assigned to school social

workers.

The importance of the link between researcher and school cannot be emphasized

enough. Maintaining strong contacts with schools is vital for social-science researchers if

76

they are to collect reliable and valid data. In return, researchers need to keep schools in the

feedback loop.

77

Acknowledgment

This thesis has been a journey, filled with knowledge, wonderful experiences and of course a

whole lot of psychosomatic problems. There are so many persons I am grateful to. Probably,

most of the people I want to acknowledge do not even know that they have had the impact

that they have. My gratitude goes to…

My principal supervisor, Prof. Curt Hagquist, who is always enthusiastic and positive, no

matter what. Your patience is incredible, and you always manage to turn a setback into a

challenge and never show irritation or tiredness. You always talk about science with passion.

Thank you for introducing me to research, pushing me and giving me this incredible oppor-

tunity to achieve one of my goals.

To my supervisor, Assoc. Prof. Magnus Stenbeck, for valuable advice and enriching discus-

sions.

Thanks to those who have, along the way, has given me valuable comments and feedback on

papers and cappa: Carl-Johan Törnhage, Mikael Svensson, Mona Sundh, Huan Shu and Lena

Marmstål-Hammar. For valuable comment on paper III, thanks to Bengt Starrin, Bodil

Wilde Larsson, Charli Eriksson, and Daniel Bergh.

To Värmland County Council and Karlstad University for their financial support for my

Ph D studies.

To Roald McManus for reviewing this thesis, constantly being in a standby mode.

Thanks to the participating schools, students and teachers in “Skolan förebygger” and to Bo

Thåqvist and Stefan Gräsberg for good co-work.

Thanks to my beloved colleagues and friends at CFBUPH: Lisa Hellström, Louise Persson,

Daniel Bergh, Maria Souza-Nilsson and Stefan Persson for all their support and time, for

tears shared and laughter enjoyed; to Lisa, my academic twin, for being my roommate and

for always being there when everything felt impossible. Our talks and discussions about life

in general and bullying in particular have been invaluable. To Daniel, for always listening to

78

me and giving me both personal and scholarly advice, for always having time for me, even

though I know you didn’t. To Louise and Stefan for your friendship, which I value highly

(‘Yes, we have no bananas’). Thank you friends at Public Health, a special thanks goes to

Malin Larsson for welcoming me to Karlstad when I was new.

I also want to acknowledge the two persons who led me into research, Stefan Sörensen and

Lena Hellström at Mälardalen University. Stefan, you believed in me and that’s why I got

were I am today. Lena, all that time we spent together doing research is a period I will never,

never forget.

To my BFFs in Västerås, Camilla and Lena. Love you.

And last, but not least, I want to pay my gratitude to my family: my mother Eva, my father

Mats, and my brother Daniel for always supporting and believing in me; and to my beloved

Mikael, for your love and support.

To my family…

79

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Traditional Bullying and Cyberbullying among Swedish Adolescents

Bullying is considered an important public health issue, given the harmful consequences that it entails. Bullying among adolescents has changed character in recent times with the advent of the internet and the mobile phone.

This thesis looks at the differences between traditional bullying and cyberbullying among adolescents, focusing on gender, psychosomatic problems and disability, and gives an insight into health staff’s experience of bullying in schools. It consists of four studies, three based on surveys undertaken among 3,800 Swedish adolescents in Grades 7, 8 and 9. A fourth study uses focus groups consisting of school social workers and school nurses.

The results show that some adolescents are more likely than others to be involved in bullying. The studies also indicate that some adolescents involved in bullying are more likely to experience higher levels of psychosomatic health problems. This thesis also discusses contextual and individual approaches adopted by schools in the prevention of bullying.

DISSERTATION | Karlstad University Studies | 2013:31

ISSN 1403-8099

ISBN 978-91-7063-509-0