Bullying and victimization among Turkish children and adolescents: Examining prevalence and associated health symptoms

Abstract

Unlabelled:
Over the past decade, concerns about bullying and its effects on school health have grown. However, few studies in Turkey have examined the prevalence of bullying in childhood and adolescence and its association with health problems. The current study aimed to examine the prevalence and manifestation of bullying and victimization among male and female students aged 11-15 years. A second goal was to examine the physical and psychological symptoms associated with being a bully, victim and both a bully and a victim ('bully-victim'). Participants were 1,315 students from grades 5, 7, and 9, selected from three schools in Western Turkey. Twenty percent of the students were found to be involved in the cycle of bullying (5 % as a bully, 8 % as a victim, and 7 % as bully-victims). Bullies (although not victims) were found to show decreased levels of school satisfaction and school attendance. Being a victim or a bully-victim was associated with a significantly increased risk of experiencing a wide range of physical and psychological health symptoms (victims OR, 1.67-3.38; p < 0.01; bully-victims OR, 2.13-3.15; p < 0.01). Being a bully, in contrast, was associated with high levels of irritability (OR, 2.82; p < 0.01), but no other health concerns. Children that were bullies and victims were almost as vulnerable to health symptoms as children that were purely victims.

Conclusion:
These findings contribute to a better understanding of bullying in Turkish schools, emphasizing the negative effects of bullying involvement on health and well-being.

Full text

ORIGINAL PAPER
Bullying and victimization among Turkish children and adolescents:
examining prevalence and associated health symptoms
Sevda Arslan &Victoria Hallett &Esref Akkas &Ozlem
Altinbas Akkas
Received: 6 March 2012 /Accepted: 12 June 2012 /Published online: 27 June 2012
#Springer-Verlag 2012
Abstract Over the past decade, concerns about bullying and
its effects on school health have grown. However, few studies
in Turkey have examined the prevalence of bullying in child-
hood and adolescence and its association with health prob-
lems. The current study aimed to examine the prevalence and
manifestation of bullying and victimization among male and
female students aged 11–15 years. A second goal was to
examine the physical and psychological symptoms associated
with being a bully, victim and both a bully and a victim
(‘bully–victim’). Participants were 1,315 students from grades
5, 7, and 9, selected from three schools in Western Turkey.
Twenty percent of the students were found to be involved in
the cycle of bullying (5 % as a bully, 8 % as a victim, and 7 %
as bully–victims). Bullies (although not victims) were found
to show decreased levels of school satisfaction and school
attendance. Being a victim or a bully–victim was associated
with a significantly increased risk of experiencing a wide
range of physical and psychological health symptoms (vic-
tims OR, 1.67–3.38; p<0.01; bully–victims OR, 2.13–3.15;
p<0.01). Being a bully, in contrast, was associated with high
levels of irritability (OR, 2.82; p<0.01), but no other health
concerns. Children that were bullies and victims were almost
as vulnerable to health symptoms as children that were purely
victims. Conclusion: These findings contribute to a better
understanding of bullying in Turkish schools, emphasizing
the negative effects of bullying involvement on health and
well-being.
Keywords Bullying .Victims .Child .Turkey .Health
Introduction
Bullying can be defined as a repetitive physical or psycho-
logical pressure by a stronger person or group on a weaker
person [31,35,38], creating a power imbalance between the
bully and victim [6]. Bullying is reported to be most com-
mon in early adolescence [12]. Although bullying is a global
phenomenon [10,29,32,34], previous studies show great
variation in prevalence rates across countries. For example,
bullying prevalence has been shown to range from 6.3 % in
girls from Sweden to 41.4 % in Lithuanian boys [12].
Despite a wealth of research in more developed countries
across Europe and the USA, there have been relatively few
studies of bullying in less developed countries such as
Turkey. The need for improved research in this area has
been emphasized by recent media attention along with rec-
ommendations from the Turkish Ministry of Education,
UNICEF and other related institutions. In particular, few
studies have examined the physical and psychological
consequences of bullying; an important theme within the
current work [1,2,22].
Previous studies have highlighted the serious impact that
bullying can have on the health of children and adolescents
[11,15,16,19,25,48]. Physical and psychological harassment
can result in internal problems such as headaches or stomach-
aches coupled with external concerns such as decreased school
attendance or satisfaction. Depression, low self-confidence,
school anxieties, and somatic symptoms of worry, sadness,
S. Arslan (*):V. Hallett
Child Study Center, Yale University,
40 Temple Street, Suite 6B,
New Haven, CT 06510-2715, USA
e-mail: sevda.arslan@yale.edu
E. Akkas
Science and Art Center, Duzce Provincial Education Ministry,
81600, Duzce, Turkey
O. A. Akkas
School of Health, Duzce University,
Beci Kampusu, Konuralp Yerleskesi,
81600, Duzce, Turkey
Eur J Pediatr (2012) 171:1549–1557
DOI 10.1007/s00431-012-1782-9

and loneliness are also very common among the victims of
bullying [1,28,44,46]. In a large prospective study of 9- to 11-
year-olds (N01,118), Fekkes and colleagues [13]foundthat
victims of bullying had significantly higher chances of devel-
oping new psychosomatic and psychosocial problems com-
pared with children and adolescents who were not bullied.
Their longitudinal design led them to conclude that bullying
caused the health symptoms, rather than vice versa. Children
and adolescents who are bullied may also avoid coming to
class or, in severe circumstances, may protect themselves by
bringing weapons to school [2,23,33]. At worst, victimization
canalsoleadtosuicidalideation[28] and attempted suicide
among children and adolescents [24]. Rigby determined that
these negative consequences of bullying can be placed within
four overarching categories; (1) low mood; general unhappi-
ness and frustration (2) peer relationship difficulties; frequent
absence from school, low school satisfaction with school (3)
psychological harassment; depression, suicidal thoughts (4)
physical problems; diagnosed psychosomatic and/or medical
illnesses [37].
Although most studies of bullying have focused on vic-
tims, it is also important to consider the psychological and
physical symptoms associated with being a bully or a bully–
victim (both a victim and a bully) [2,10,13,15,17,22].
One previous study of 819 children and adolescents (aged
13–16 years) showed that boys who were bullies were
significantly more likely to experience somatic symptoms,
anxiety, depression and social dysfunction [6]. Being a bully
has also been associated with significantly increased rates
of suicidal ideation in adolescents [36]. Children and
adolescents who are both bullies and victims, may also
be at increased risk of somatic and emotional difficulties,
although few studies have addressed this question. One
exception was a study by Forero and colleagues [15], who
found that bully–victims (constituting 22 % of their sam-
ple of 3,918 children and adolescents) were twice as
likely to experience high levels of psychosomatic symp-
toms compared to participants who were not involved in
bullying problems.
The effects of bullying victimization may not be
limited to short term physical and psychological symp-
toms. Longitudinal investigations have shown that expo-
sure to bullying during childhood can result in
difficulties with low self-esteem, poor peer relationships
and high levels of depression later in adult life [3,41,
46]. Meltzer and colleagues [28] found that adults who
had been bullied earlier in life were more than twice as
likely to attempt suicide than controls. This long-term
impact can be particularly pronounced in individuals
with low levels of social support [39].
There have been few studies to date investigating the
physiological and psychological impact of bullying and
victimization in Turkish schools [1,2,22]. The most recent
study by Karatas and colleagues [22], investigated the health
effects of bullying exposure in 6th grade students (N092);
finding increased rates of headaches, crying, nervousness,
sleep problems and appetite changes in victims. Most
previous Turkish studies of the have focused on the
health-related symptoms attributed to the victims of bully-
ing [2,22] with limited investigation of bullies and bully–
victims. One study by Alikasifoglu and colleagues [1]
showed that bullies were more likely to be involved in
physical fights; while bully–victims were more likely to
partake in smoking, drinking and sexual activity. However,
no previous studies have explored the physical or psycho-
logical symptoms associated with being a bully and a
bully–victim.
The current study had three main goals. First, it aimed to
assess the prevalence of traditional bullying in the largest
sample of 11–15-year-olds in Turkey carried out to date.
Second, it explored the factors associated with ‘the bullying
cycle’(including victims, bullies and bully–victims) in
terms of home and school characteristics. Finally, it aimed
to assess the physical and psychological consequences asso-
ciated with being a victim, a bully and a bully–victim in
both males and females.
Materials and method
Participants
Participants included 5th, 7th, and 9th grade children and
adolescents (age 11–19) from primary, secondary and high
schools in Duzce city, a rural area in the western region of
Turkey. Nine schools were chosen (3 elementary (N0430),
3 secondary (N0450), 3 high schools (N0435)) at random
from all those affiliated with the National Education Minis-
try. Questionnaires were distributed to 1,350 children and
adolescents to ensure sufficient power. Of these, complete
data were available for 1,315 participants. Fifteen children
and adolescents did not consent to participate and 20 ques-
tionnaires were only partially completed. All classes were
co-educational, including both girls and boys.
Questionnaire design: structure and content
A 16-item self-report questionnaire was created to character-
ize the backgrounds of the participants in terms of home and
school characteristics. This measure included self-reported
items regarding demographic characteristics (e.g., social
economic status (SES) and parental employment), house-
hold variables (e.g., number of siblings, one or two-parent
family) and aspects of schooling (e.g., school achievement,
satisfaction and attendance). SES was operationalized by
asking the participants ‘How would you describe your
1550 Eur J Pediatr (2012) 171:1549–1557

family’s income?’scored either low, average, or high. Par-
ticipants reported their level of academic achievement
according to the five levels within the Turkish system (an
‘appreciation certificate’,a‘thanks certificate’, a direct pass,
passing with responsibility or repeating the year). For the
current analyses, these were divided into three achievement
categories: low, average, and high. Participants also reported
on whom they lived with (one parents, both parents, other
relatives), school satisfaction (either likes or dislikes school)
and their school attendance (frequently absent or rarely
absent).
Determination of Peer Victims and Bullies Scale (DPVBS)
This 56-item self-report questionnaire assessed the bullying
behaviors and victimization of children and adolescents over
the past six months. It constitutes an adaptation of the ‘Multi-
dimensional Peer Victimization Questionnaire’developed by
Maynard and Joseph [27], which included 27- items concern-
ing victimization only. This scale was translated into Turkish
by Gultekin and Sayil [20]. Pekel-Uludagli and
Ucanok [34] later added 27 additional items to measure bully-
ing behaviors (e.g. rewording ‘The other children hit me’to ‘I
hit other children’)[27]. Items are scored on a three-point
scale: not at all (0) once (1) or more than once (2). To assess
frequency of bullying involvement, participants were also
asked ‘How often have you bullied other children?’and
‘how often have you been bullied by other children?’scored
using the same three-point scale. Children and adolescents
scoring over one standard deviation above the mean on the
bullying items of the Determination of Peer Victims and
Bullies Scale (DPVBS) were classified as bullies for these
analyses. Participants scoring over one standard deviation
above the mean on the victimization items were classed as
victims. Finally, if participants scored over one standard devi-
ation above the mean on both the bullying and victimization
items, they were categorized as a bully–victim [6,20,27,34].
The scale showed a high level of internal consistency in the
current sample across the 27 bullying items (Cronbach alpha
0.90) and the 27 victimization items (Cronbach alpha 0.92).
Both the bullying items and the victimization items fall into
five categories: terrorizing behaviors (e.g., threats using a
weapon or knife, five items), overt bullying (e.g., kicking or
punching other children, eight items), teasing (e.g., name
calling, six items), relational bullying (e.g., causing harm to
others by manipulating their social relationships and reputa-
tion, four items), and attacks on property (four items; stealing
or damaging property). The Cronbach alpha scores were
acceptable to good for each of the bullying subscales (terro-
rizing, 0.78; overt, 0.85; teasing, 0.77; relational, 0.80; attacks
on property, 0.75) and victimization subscales (terrorizing,
0.70; overt, 0.79; teasing, 0.80; relational, 0.86; attacks on
property, 0.78)
Measure of health symptomatology
The current study used a self-reported measure of psycholog-
ical and physical symptoms, taken from the Health Behavior in
School-Aged Children study; a standardized, international col-
laborative investigation by the World Health Organization.
This study incorporated repeated cross-sectional surveys
among 11, 13, and 15 year-olds in representative samples of
schools in participating countries [10]. The measure used 12
items to assess health status. In the current study, each symp-
tom was dichotomized prior to analysis, according to the
method described by Due and colleagues [10]. As the health
symptoms were scored slightly differently, dichotomizing in
this way helped to standardize scoring and ease interpretation
of the regressions. For eight symptoms (headache, stomach-
ache, backache, feeling low, bad temper, nervousness, difficul-
ties in getting to sleep, and dizziness) the frequency was
dichotomized into every day/more than once a week/about
every week versus about every month/rarely/never. ‘Loneli-
ness’was dichotomized into very often/rather often versus
sometimes/never. ‘Tired in the morning’was dichotomized
into once a week or more versus less. The two remaining
symptoms, ‘feeling left out of things’and ‘feeling helpless’
were divided into always/often versus sometimes/rarely/never.
Procedure
The study was approved by the University of Duzce. Written
permission to collect the data was obtained from the Duzce
Provincial Education Ministry. The schools were chosen from
a list provided by the Department of Education and informed
about the study by letter. Potential participants were informed
about the purpose of the study, that consent was strictly
voluntary and that they could withdraw at any time. Data
collection forms were distributed in a class setting and partic-
ipants were instructed not to interact with each other when
answering. It took participants an average of 40 min to answer
the data collection forms. All responses were anonymous,
with no identifying information collected.
Analysis
Exploratory analyses of the demographic data were carried
out using the statistical software program SPSS 19. Chi-
squared analyses were used to determine whether the stu-
dent’s status (as a victim, bully, bully–victim or neither) was
associated with their grade (5th, 7th, 9th), gender, self-
reported SES (low, average, high), school satisfaction,
school achievement (below average, average, above aver-
age) and school attendance (frequently/rarely absent). Pair-
wise chi-squared tests were used to explore any significant
associations (e.g. comparing bullies to non-bullies, victims
Eur J Pediatr (2012) 171:1549–1557 1551

to non-victims, bully–victims to non-bully–victims). Owing
to positively skewed distributions, each of the DPVBS sub-
scales (for both the bullying and victimization scales) was
dichotomized into high (above the median for the whole
sample) and low (below the median) scores. Chi-squared
analyses were then used to determine whether there were
differences in these scales by gender. Finally, logistic regres-
sion was used to assess the associations between the
involvement in the bullying cycle (as bully, victim, bully–
victim) and each dichotomized health symptom, covarying
for class, self-reported SES and gender.
Results
Table 1presents the demographic characteristics of the full
sample (N01,315, 53 % male), including household and
school-related factors.
Self-reported prevalence of bullying
The majority of children and adolescents in the current sample
1,056 (80 %) had not been involved in bullying, as either an
aggressor or a victim. Of the participants involved in the
bullying cycle, 66 (5 %) were classified as bullies according
to the DPVBS, 105 (8 %) were victims and 88 (7 %) were both
bullies and victims (bully–victims). A significant sex differ-
ence was observed in terms of the proportion of children and
adolescents classed as bullies, victims, bully–victims, or unin-
volved (χ
2
(3)015.20; p<0.01). Chi-squared analyses
revealed this difference was driven by a greater proportion
of boys (7 %) than girls (3 %) that were classified as bullies
(χ
2
(1)011.44, p<0.01).
Boys and girls showed different types of bullying and
victimization behaviors, as shown in Fig. 1. This graph
presents the standardized mean scores across the scales of
the DPVBS for children and adolescents involved in all areas
of the bullying cycle (N0259), separated by gender. Of these
participants, girls reported higher levels of victimization than
boys for all scales, except overt bullying. This difference
reached significance for teasing (χ
2
(1)011.45, p< 0.01) and
relational victimization (χ
2
(1)021.28, p<0.01). Although
boys reported higher levels of bullying behaviors than girls
for all of the DPVBS scales, the difference reached signifi-
cance only for overt bullying (χ
2
(1)011.63, p<0.01).
There was a significant association between a student’s
grade (5, 7, 9) and their involvement in the bullying cycle
(victim, bully, bully–victim, uninvolved; χ
2
(3)022.81, p<
0.01). Chi-squared analyses showed that this was driven by
a higher number of bully–victims in grade 5 (47 %) than in
grades 7 (22 %) and 9 (21 %) (χ
2
(2)011.16, p< 0.01). There
was also a low proportion of bullies (15 %) in grade 7
compared to grades 5 (41 %) and 9 (44 %) (χ
2
(2)09.01,
p00.01). Involvement in the bullying cycle was significantly
associated with school attendance (χ
2
(3) 013.48, p<0.01),
driven by a higher proportion of bullies (20 %) and bully–
victims (21 %) being frequently absent compared to victims
(10 %) or participants not involved in bullying (9 %). School
satisfaction was also associated with involvement in the bully-
ing cycle (χ
2
(3)020.53,p<0.01). Chi-squared analyses
showed that bullies had a lower level of school satisfaction
(29 % were dissatisfied) compared to the rest of the sample
(χ
2
(1) 017.20, p<0.01), including victims (17 %), bully–
victims (11 %) and participants uninvolved in bullying (11 %).
There was no association between involvement in the bullying
cycle and a child’s level of school achievement (p>0.05).
According to student self-report, 699 (53.2 %) of the children
and adolescents were from a family of average SES, 480
(36.5 %) were from a family of high SES and 36 (10.3 %)
were from a family of average SES. There was no association
between involvement in the bullying cycle and SES (p>0.05).
Bullying and health symptoms
Results from the logistic regression analyses are provided in
Table 2, showing the association between involvement in
the bullying cycle (as victim, bully or bully–victim) and
psychological and physical health symptoms (frequent vs.
infrequent). All significances are reached after controlling
for age, gender and SES. Participants in each group (victim,
Table 1 Self-reported demographic and household/school character-
istics of the full sample (N01,315)
Variable n%
Gender Males 613 46.6
Female 702 53.4
Grade 5 (age 11–14) 433 32.9
7 (age 14–16) 420 31.9
9 (age 16–19) 462 35.1
Social Economic Status High 480 36.5
Average 699 53.2
Low 136 10.3
Whom does the student
live with?
Lives with both parents 1,192 90.6
Lives with one parent 89 6.8
Live with other relatives 34 2.6
Academic Achievement Above average 741 56.3
Average 451 34.3
Below average 123 9.4
School satisfaction Likes School 1,152 87.6
Dislikes School 163 12.4
School attendance Frequent absence 150 11.4
Rare absence 1,165 88.6
1552 Eur J Pediatr (2012) 171:1549–1557

bully, bully–victim) were compared to all other children and
adolescents in the full sample.
Victims Being a victim of bullying was associated with
increased likelihood of experiencing all of the physiological
and psychological symptoms that were assessed in the cur-
rent study. In particular, victims were over three times as
likely as other participants to often feel left out of things
(OR, 3.12; p<0.01) and to feel helpless (OR, 3.38; p<0.01).
They were also over twice as likely to experience frequent
loneliness (OR, 2.51; p<0.01), low mood (OR, 2.11; p<
0.01), tiredness in the morning (OR, 2.69; p<0.01) and
sleep difficulties (OR, 2.17; p<0.01).
Bullies Children and adolescents that were classified as
bullies in the current sample were significantly more likely
to experience frequent symptoms of irritability compared to
the rest of the sample (OR, 2.82; p<0.01). Being a bully was
not significantly associated with any of the other psycho-
logical or physiological symptoms assessed here.
Bully–victims Compared to the rest of the sample, partici-
pants who were both bullies and victims were more likely to
experience 10 out of 12 of the health symptoms that were
assessed. In particular, they were over three times as likely
as other children and adolescents to feel left out of things
(OR, 3.15; p<0.01). They were also over twice as likely to
experience frequent backache, sleeping difficulties, tired-
ness in the morning, dizziness, low mood, irritability,
nervousness, loneliness, helplessness (for odds ratios see
Table 2). The only symptoms that were not significantly
associated with being a bully–victim were frequent head-
aches and stomachaches.
Discussion
Two hundred fifty-nine (20 %) children and adolescents in
the current sample were involved in the bullying cycle as a
bully, 66 (5 %), a victim, 105 (8 %), or a bully–victim, 88
(7 %). These findings were in keeping with a prior Turkish
study, which revealed similar rates of bullies (5 %), victims
(6 %), and bully–victims (6 %) in a large sample (N01,670)
of 9th and 10th grade students [4]. A study by Alikasifoglu
placed estimated slightly higher, finding that 22 % of
Turkish high school students (N03,519) were the victims
of bullying, 9 % were bullies and 9 % were bully–victims
[1]. In a cross-country bullying study, Nansel and colleagues
[29] revealed a high degree of variability in the prevalence
of bullying involvement (as victim, bully or both) across
Europe and the USA. Estimates of bullying involvement
ranged from 9 to 54 %, with an average of 11 % across 25
countries. This suggests that bullying behaviors in Turkey
are of a similar frequency to some of the more developed
European countries and the USA.
In the current study, a greater proportion of boys than
girls reported that they carried out bullying, in keeping with
previous findings [7,26,29,41,45,47]. In particular, boys
reported significantly higher levels of overt bullying behav-
iors than girls. This was in line with previous studies show-
ing that boys prefer to bully others in more direct and
aggressive ways than girls [5,32,35]. In their previous
study of Turkish children and adolescents, Alikasifoglu
and colleagues [2] also found that many more boys (n0
1,301, 61 %) than girls (n0419, 22 %) participated in
physical violence. This result may reflect, in part, the social
and cultural norms of Turkish society, where males typically
display more outwardly aggressive behavior than females.
Fig. 1 Frequency of each
bullying and victimization
subtype (overt, teasing,
terrorizing, relational, damage
to property) according to the
DPVBS—as rated by
participants involved in the
bullying cycle (bullies, victims
and bully–victims; N0259).
Footnote: Error bars represent
standard error of
the mean
Eur J Pediatr (2012) 171:1549–1557 1553

In contrast, girls in the current sample were more likely than
boys to be the victims of teasing and relational bullying, in
keeping with some previous findings [4,53]. One exception
was a study by Rigby, which found that boys and girls were
similarly likely to be bullied through name calling, teasing
and deliberate exclusion [40].
A student’s involvement in the bullying cycle was also
associated with a number of school-related characteristics.
First, bullies in the current sample reported more frequent
absences than other participants and also lower levels of
school satisfaction. Bully–victims (n088,) reported more
frequent absences but showed a similar level of school
satisfaction as participants who were not involved in the
bullying cycle. Victims did not report significantly reduced
attendance or school satisfaction. These mixed findings are
somewhat in keeping with previous studies showing nega-
tive impacts of bullying behaviors on attendance and school
enjoyment [42]. For example, the cross-national survey by
Nansel and colleagues [29] showed that bullies reported
poorer school adjustment than other students (in their sam-
ple of 113,200 children and adolescents aged 11 to 15). The
current findings do, however, stand in contrast to previous
work that revealed decreased school satisfaction in the
victims of bullying [15,18].
There were mixed findings in the current sample concerning
school class (grades 5, 7, 9) and involvement in the bullying
cycle. There was no association between a student’sgradeand
being a victim of bullying. However, compared to the other
grades, a significantly higher proportion of participants in grade
5 were bully–victims and a significantly lower proportion of
participants in grade 7 were bullies. These mixed findings
require further investigation using age as a continuous variable.
In previous work, bullying behavior has been found to decrease
with age, potentially owing to improved coping mechanisms
over time [8,44,52]. There were no associations between
school achievement and bullying involvement in the current
sample, in contrast to some previous work [42,51].
Children and adolescents are vulnerable to a variety of
physical, psychological, and social changes. Friendships
and family relationships can become increasingly strained;
with social acceptance and positive feedback becoming
particularly important. Becoming involved in bullying at
this age, as either a bully or victim, has been shown to have
long-term impacts on the mental and physical well-being of
individuals in later life [16,23,42]. The current study was
the first to examine the physical and psychological health
symptoms associated with both bullying and victimization
in Turkish children and adolescents.
Being a victim of bullying in the current sample was
associated with more frequent occurrences of all the health
symptoms examined. These included physical symptoms
(e.g., headaches, stomachaches, backaches and dizziness),
and psychological symptoms (e.g., nervousness, loneliness
and irritability). In particular, victims were over three times
Table 2 Associations between bullying, victimization and self-reported health symptoms
Health
symptom
a
Victim (N0105) Bully (N066) Bully–Victim (N088)
Nwith frequent
symptoms (%)
Odds Ratio (95 %
CI)
Nwith frequent
symptoms (%)
Odds ratio (95 %
CI)
Nwith frequent
symptoms (%)
Odds ratio (95 %
CI)
Headache 51 (48.6) 1.81 (1.20–2.73)** 22 (33.3) 1.10 (0.64–1.89) 37 (42.0) 1.48 (0.94–2.32)
Stomach ache 22 (21.0) 1.94 (1.16–3.23)** 6 (9.1) 0.66 (0.28–1.58) 17 (19.3) 1.62 (0.92–2.88)
Backache 35 (33.3) 1.91 (1.24–2.96)** 19 (28.8) 1.36 (0.78–2.37) 33 (37.5) 2.49 (1.56–3.95)**
Sleeping
Difficulties
53 (50.5) 2.17 (1.45–3.27)** 28 (42.4) 1.56 (0.93–2.61) 50 (56.8) 2.89 (1.85–4.53)**
Tired in the
morning
76 (72.4) 2.69 (1.72–4.19)** 37 (56.1) 1.22 (0.74–2.02) 60 (68.2) 2.20 (1.38–3.50)**
Dizziness 32 (30.5) 1.71 (1.09–2.67)* 16 (24.2) 1.23 (0.68–2.21) 30 (34.1) 2.19 (1.37–3.51)**
Feeling Low 38 (36.2) 2.11 (1.37–3.25)** 18 (27.3) 1.57 (0.88–2.78) 31 (35.2) 2.13 (1.33–3.40)**
Irritable 59 (56.2) 1.67 (1.11–2.51)* 45 (68.2) 2.82 (1.65–4.82)** 59 (67.0) 2.78 (1.75–4.42)**
Feeling nervous 30 (28.6) 1.84 (1.17–2.91)** 15 (22.7) 1.43 (0.78–2.63) 30 (34.1) 2.76 (1.71–4.46)**
Feeling lonely 28 (26.7) 2.51 (1.56–4.04)** 14 (21.2) 1.93 (1.03–3.63) 23 (26.1) 2.79 (1.66–4.70)**
Feeling left out
of things
60 (57.1) 3.12 (2.06–4.71)** 21 (31.8) 1.06 (0.61–1.83) 50 (56.8) 3.15 (2.01–4.94)**
Feeling helpless 45 (42.9) 3.38 (2.22–5.15)** 16 (24.2) 1.29 (0.72–2.34) 31 (35.2) 2.32 (1.45–3.71)**
Results from univariate logistic regression models, adjusting for self-reported SES, school grade and gender
a
Health symptoms were dichotomized prior to logistic regression into frequent vs infrequent occurrence (see “Materials and method”section for
full details). For each logistic regression, frequent symptoms were compared to infrequent symptoms
*p<0.05; **p< 0.01
1554 Eur J Pediatr (2012) 171:1549–1557

as likely as other participants to feel helpless and left out of
things. A similar association between victimization and
health problems has been described in previous studies
across childhood and adolescence [13,14,17,22,30,49,
50] and across different countries in Europe and the USA [8,
27]. One previous study also showed increased physical and
psychological symptoms in Turkish 9th and 11th grade
students (N04,153) who had been bullied [2]. Of note, it is
not possible within the current cross-sectional design to deter-
mine the direction of this association. For example, it may be
that the experience of bullying leaves young people vulner-
able to developing physical symptoms and psychological
difficulties. However, conversely, it may be that children and
adolescents with existing health difficulties may be targeted
more frequently by bullies. One previous study addressed
these alternatives using a longitudinal design, finding that
health symptoms appeared to be a consequence of prior vic-
timization at school [24]. It is important that these consequen-
ces are monitored, particularly as victimization has also been
linked with increased risks anxiety [44], depression [21,43],
and suicidal ideation [9].
Previous studies of the health effects of bullying have
focused largely on the outcomes for victims [1,10,22,30,
54]. Only a limited number of studies examined the health
problems of the bullies themselves [13,16,25], reporting
mixed findings. The current results showed that bullies were
almost three times as likely to experience frequent symp-
toms of irritability compared to the other participants in the
sample. However, being a bully was not associated signifi-
cantly with other health symptoms. This was in keeping
with a previous study showing that, of children and adoles-
cents involved in the bullying cycle, pure bullies (who were
never victimized) had the least physical and psychosomatic
health problems [55]. In contrast, other studies have shown
that bullies experience higher levels of headaches [13], bed-
wetting [13], hyperactivity, sleep problems and feeling tense
[16]. Of note, the small number of bullies in the current
sample (N066) may offer limited the power to detect sig-
nificant associations using logistic regression. Again, the
direction of the association remains unclear in the present
study. While being a bully may heighten irritability levels, it
is also likely that irritable children and adolescents are more
prone to become bullies.
In the current sample, children and adolescents that were
both bullies and victims were at increased risk for 10 out of the
12 health problems assessed, including physical symptoms
(e.g., backaches, dizziness, tiredness) and psychological con-
cerns (e.g., feeling nervous, lonely and helpless). This sug-
gested that they were greater at risk of health symptoms than
the pure bullies, and were almost as vulnerable as pure vic-
tims. These findings are in keeping with previous work in
other countries, showing that bully–victims are particularly
prone to concerns such as externalizing behaviors [25], poor
emotional adjustment [29] and physical symptoms (e.g.,
repeated sore throats, colds, and coughs) [55]. In the only
previous Turkish study to address this issue, Alikasifoglu
and colleagues [1] found that bully–victims were even more
vulnerable to health problems than either bullies or victims
alone. Further research is now required to determine what
places young people at risk of becoming both a bully and a
victim and how the profiles of these individuals differ from
others in the bullying cycle.
The current study included a large sample, from a country
that has received limited research attention in the field
of bullying. However, a number of limitations must be
addressed. The study used solely self-report data, including a
student rating of family SES and parental education. Caution
is needed when interpreting these data, as children and ado-
lescents may be somewhat limited in their judgments of
household characteristics. Similarly, individuals may differ
significantly in their subjective perception of bullying and
victimization. Replication of these findings using corrobora-
tion from multiple informants (parents, teachers and peers)
would be beneficial. It should be noted that the categorization
of bullies, victims and bully–victims was based on the mean
and standard deviation of DPVBS scores in the current sam-
ple. Consequently, caution is needed when comparing these
findings directly to other studies that have used this measure.
As mentioned previously, the direction of causation between
bullying exposure and health concerns cannot be examined
using this cross-sectional sample. Further longitudinal inves-
tigation will be vital to disentangle any causal relationships
between bullying and health in Turkey and to explore medi-
ating influences such as family SES. Finally, the current
sample was drawn from a rural region in Western Turkey.
Consequently, caution is needed when generalizing these
findings to children and adolescents from more urban areas
across the country.
Conclusion
The current findings help to further elucidate the difficulties
with bullying that are observed within Turkish primary,
secondary and high school secondary schools. Here, the
effects of bullying exposure were found to depend both on
a student’s gender and their role in the cycle of bullying
(as bully, victim or bully–victim). Both victims and bully–
victims showed higher levels of health concerns, including
physical and psychological difficulties. This information is
vital for schools and health professionals, who must be
aware of the risk factors and secondary consequences of
bullying exposure for young people. Vigilance is vital at
home and school, to prevent the negative impact of bullying
on school satisfaction, achievement, and psychological and
physical well-being.
Eur J Pediatr (2012) 171:1549–1557 1555

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