Adding Insult to Injury: Bullying Experiences of Youth

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171 Moultrie Ave., Charleston, SC 29409. E-mail: .... agnostic and Statistical Manual of Mental Disorders (American Psychiatric ..... .880. Note. ADHD D attention deficit hyperactivity disorder; BVS D Bully–Victimization Scale;. CDI D Children's ...
Children’s Health Care, 39:59–72, 2010 Copyright © Taylor & Francis Group, LLC ISSN: 0273-9615 print/1532-6888 online DOI: 10.1080/02739610903455152

Adding Insult to Injury: Bullying Experiences of Youth With Attention Deficit Hyperactivity Disorder Lloyd A. Taylor and Conway Saylor Department of Psychology, The Citadel, Charleston, SC

Kimberly Twyman and Michelle Macias Department of Pediatrics, Medical University of South Carolina, Charleston, SC

This study tested the hypothesis that self-reported bullying and peer victimization in pediatric populations .n D 238/ diagnosed with attention deficit hyperactivity disorder (ADHD) would exceed that of peers with no diagnosis. Higher rates of victimization were reported by the youth with ADHD, but bullying rates were comparable for youth with ADHD and peers. Results suggest that students diagnosed with ADHD are at significantly higher risk for peer victimization, and its psychological impact on youth with ADHD who experience bullying—as victims, perpetrators, or both—are more likely to show psychosocial problems above and beyond their attention and social competence difficulties.

Bullying and peer victimization have recently gained significant attention in the pediatric literature. Monks and Smith (2006) described bullying as a behavior that is characterized by peer aggression with a power asymmetry where a perpetrator chronically engages in “picking on or harassment” of a victim. This aggression can be physical or verbal (W. M. Reynolds, 2003), can involve social exclusion (Beran & Violato, 2004), or can be achieved through electronic means using “cyberbullying” (Willard, 2007). Perpetrators of peer aggression Correspondence should be addressed to Lloyd A. Taylor, Department of Psychology, The Citadel, 171 Moultrie Ave., Charleston, SC 29409. E-mail: [email protected]

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who report not being victimized themselves are considered “bullies”; those who are targets of peer aggression, but not perpetrators, are considered “victims”; and those who engage in significant amounts of both are considered “bully– victims” (W. M. Reynolds, 2003). The behavioral and emotional outcomes and clinical histories of these three bullying groups are distinctive (Holt, Finkelhor, & Kaufman Kantor, 2007; Leff, 2007). Depending on samples and definitions (Nansel et al., 2001; Storch & Ledley, 2005), it is estimated that 20% to 30% of all school-aged children and adolescents have been exposed to peer victimization. This study examines bullying and victimization in patients with attention deficit hyperactivity disorder (ADHD), a population with characteristics that increase their vulnerability to bullying participation and its behavioral aftermath. Research suggests that children and youth with special health care needs (CYSHCN) may be particularly at risk to be victims of peer aggression. Some studies suggest that children with certain diagnoses are more likely to be bullies. In their analysis of data from the National Survey of Children’s Health, Van Cleave and Davis (2006) documented that in 6- to 17-year-old American children, parent-reported rates of bullying (23.5%), victimization (34.4%), and bully–victim rates (10%) were significantly higher in CYSHCN compared to non-CYSHCN. Smaller studies with more direct access to youth with specific diagnoses indicate an elevated risk for bullying and victimization in certain groups, including students with learning disabilities (Baumeister, Storch, & Geffken, 2008; Mishna, 2003), students with speech and language difficulties (Conti-Ramsden & Botting, 2004), children with diabetes (Storch et al., 2004), and children with obesity (Adams & Bukowski, 2008; Janssen, Craig, Boyce, & Pickett, 2004). Elevated rates of both internalizing and externalizing problems, as well as school adjustment problems, are often found in children and youth who are exposed to bullying as victims, bullies, or both (Nansel, Overpeck, Haynie, Ruan, & Scheidt, 2003). In a nationally representative longitudinal study, young children who were targeted as victims or bully–victims had additional adjustment problems at age seven, even after controlling for pre-existing internalizing and social problems at age five. This research emphasized the importance of intervention both to prevent initial bullying in more vulnerable youth and to prevent additional behavior problems and school adjustments that may be secondary to bullying exposure. ADHD is one of the most commonly diagnosed disorders of childhood (Giedd, 2000), with between 5% and 9% of school-age children meeting criteria for diagnosis (Kent & Craddock, 2003). Boys with ADHD are consistently diagnosed with more symptoms of impulsivity and hyperactivity compared to their female cohorts (Barkley, 2003). Boys are more often diagnosed with hyperactive

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subtypes because they exhibit externalizing behaviors compared with girls (Stein, Marx, & Beard, 2004). It is important to differentiate ADHD symptomology from other disorders of childhood, particularly conduct disorder. Conduct disorder is characterized by aggression, including bullying and intimidating people or animals. Children with ADHD can have elevated risk for comorbid diagnosis of conduct disorder (Barkley, 2003), but aggression is not a diagnostic criteria for ADHD. Regardless of gender, externalizing behaviors and other symptoms of ADHD, including poor impulse control and reduced frustration tolerance, have the potential to lead to social difficulties for children with ADHD. Despite the intuitive connection between poor peer relationships associated with ADHD and bullying, few studies have directly examined bullying and its consequences in students with ADHD. A recent study explored the relation between ADHD and bullying in a sample of 577 fourth graders (10 years old) in Stockholm, Sweden (Holmberg & Hjern, 2008). That work found that ADHD symptoms were associated with bullying others and being a victim of bullying behavior. Students who bullied others were also found to have higher parental reports of behavior problems at home compared to those students with ADHD who were not engaged in bullying behaviors. The study illuminated the relation between bullying behavior and ADHD. However, the generalization of the findings to other-age children and to populations within the United States remains unclear. A retrospective study of children diagnosed with ADHD (Humphrey, Storch, & Geffken, 2007) correlated parental reports of peer victimization to psychosocial adjustment factors, using the Achenbach Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) along with the Children’s Depression Inventory (CDI; Kovacs, 1992) and the Revised Children’s Manifest Anxiety Scale (C. R. Reynolds & Richmond, 1978) if reported in the medical record. Children with ADHD whose parents reported peer victimization had higher scores in several CBCL subscales including anxiety, depression, social problems, delinquent behavior, and aggressive behavior. These rates were even higher in children with ADHD who had a comorbid psychiatric diagnosis. However, the study relied on parental reports of bullying experiences, which is not always accurate compared to children’s reports (Twyman, Saylor, & Macias, 2008). The purpose of this investigation was to explore the relation between ADHD and self-reported victimization and bullying behavior in school-age youth (aged 8–17). It was hypothesized that having a diagnosis of ADHD would increase the likelihood of bullying others, of being victimized by bullies, and of being a bully–victim. It was further hypothesized that within the population of youth with ADHD, students engaged in bullying (as victims or as bullies) would display significantly worse behavioral and emotional problems.

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METHOD Participant Selection In the summers of 2007 and 2008, 238 youth aged 8 to 17 and their parents, who were seeking care in primary care and subspecialty pediatric clinics, individually provided informed consent to participate by completing this institutional review board-approved protocol. Clinics included the Developmental–Behavioral Pediatrics and Adolescent Medicine clinics of a Southeastern tertiary care medical center, as well as a local, private pediatrics primary care practice. This convenience sample of 238 was drawn from a larger sample of 290 patients from these clinics who consented to participate. The 52 youth who failed to meet inclusion criteria were excluded because a diagnosis of ADHD could not be definitively verified or ruled out. Only children with a definitive diagnosis of ADHD based on multiple sources of data were included. Youth were invited to participate in the study if they were age 8 to 17 years old, had a stable medical condition, were willing and able to complete self-report items with 1:1 assistance, had a parent willing and able to complete parent questionnaires, and were enrolled in private or public school at the time of the study (i.e., not home schooled). This study of ADHD and bullying further required verifiable diagnoses (or confirmed absence of a diagnosis) based on physician or interdisciplinary team assessment and documentation in medical records. It was the standard practice of both clinic settings to evaluate ADHD based on current recommendations of the American Academy of Pediatrics (2005), which includes use of Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) criteria for diagnosis and assessment or direct evidence directly obtained from caregivers or parents and classroom teachers. Specifically, the Developmental and Behavioral Clinic routinely required both parent and teacher Conners’s forms be completed before patients are seen by the physician and interdisciplinary team (Conners, Parker, Sitarenios, & Epstein, 1998). The physician made final diagnosis in all cases using data from medical and psychoeducational history, interview, Connors’s forms, and psychological testing if indicated. In the primary care clinic, diagnosis was determined after patient interview, review of medical and psychoeducational history, and parent report. Measures routinely utilized include the Vanderbilt (Wolraich, Feurer, Hannah, Pinnock, & Baumgaertel, 1998) and Connors’s parent and teacher forms. In ambigious cases, patients were referred to a clinical psychologist for additional consultation as part of the evaluation process. The 52 out of the 290 individuals who consented but who were not included were excluded because a physician diagnosis of ADHD could not be definitively verified or because a diagnosis of something other than ADHD was verified. For example, a patient with a confirmed diagnosis of depression but no confimed diagnosis of ADHD was

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excluded from the study. A patient with ADHD only or a patient with ADHD and comorbid depression (both verified) was included in the group referred to as ADHD and comorbid diagnosis. In summary, three kinds of participants were included: participants with a verifiable ADHD diagnosis, participants with a verifiable ADHD and comorbid diagnosis, and participants verified by physician record to have no diagnosis (NoDx). Parents and children completed a number of self-report measures while in clinic waiting areas. If the child was under 13 years of age or required assistance, the measures were read to the child by a research assistant. Otherwise, parents and children completed the measures independently, with assistance available from the research assistants as needed. As compensation for participation, children were given small trinkets, and each family was entered into a raffle for cash prizes awarded at the end of each summer. Following completion of the participant’s scheduled visit, diagnostic information was extracted from the patient’s medical record. Of the 238 eligible participants, 144 children were identified as having ADHD based on verified diagnosis, and 94 were confirmed to have NoDx. For some analyses, the 92 patients with ADHD as their sole diagnosis (ADHD only) were examined seperately from the 52 who had comorbid diagnoses of learning disabilities, behavioral or emotional diagnoses, or both (ADHD C Dx). The majority (80%) of the NoDx sample was recruited from the primary care outpatient office. Seventy-four percent of the youth with ADHD only and 96% of the ADHD C Dx group were drawn from the developmental pediatric specialty clinic. Tables 1 and 2 summarize the child and family characteristics by diagnostic groups and for the full sample. The samples with and without ADHD and the ADHD subgroups were significantly different on age and gender, a fact that was taken into account in analyses, despite W. M. Reynolds’s (2003) Bully–Victimization Scale (BVS) t scores being norm-referenced scores calculated by gender and grade.

Measures Reynolds’s BVS. Participants’ bullying and victimization experiences were assessed using W. M. Reynolds’s (2003) BVS. The BVS is a 46-item, well– validated, and reliable measure designed to assess bullying behavior and victimization experiences in children and adolescents, consisting of two subscales: bullying and victimization. This commonly employed measure has been shown to demonstrate acceptable evidence of reliability and validity. In initial sample of 2,000 students, internal consistencies of the BVS bullying and victimization subscales were 0.93. Median test-retest reliability was 0.84. Factor analysis and correlational studies confimed content validity and factor structure for the BVS

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TABLE 1 Summary of Participant Characteristics for Youth Aged 8 to 17 With NoDx, ADHD Only, or ADHD C Dx Variable Gender Male Female Age group 8–12 13–17 Race White Black Other Clinic DBP Primary care Adolescent School Elementary Middle High Public Private Special educational programming Resource Self-contained Honors

NoDx

ADHD Only

ADHD C Dx

Full Sample

43 57

60 40

73 27

56 44

36 64

65 35

60 40

52 48

58 39 3

62 33 5

70 26 4

62 34 —

11 56 33

74 13 13

96 2 2

55 27 18

31 32 37 74 26

53 33 14 81 19

60 21 19 86 13

46 30 24 80 20

20 5 50

49 8 13

71 29 12

42 11 28

Note. NoDx D no diagnosis; ADHD D attention deficit hyperactivity disorder; ADHD C Dx D ADHD with comorbid diagnosis; DBP D developmental and behavioral pediatrics.

and its subscales (W. M. Reynolds, 2003). Bullying and victimization subscale t scores > 60th percentile, based on grade and gender norms on either subscale, are clinically significant. Questions asked participants to rate bullying behavior occurring in the previous month on a 4-point Likert scale, ranging from 1 (never) to 4 (five or more times). Children were classified as a “bully,” a “victim,” or a “bully–victim” if their scores were in the clinically significant range in one or both subscales. Emotional and behavioral measures. Parents completed the CBCL (Achenbach & Rescorla, 2001). The CBCL–Parent Report form was designed to address the problem of defining behavior problems in children ages 6 to 18 empirically (Achenbach, 1991; Achenbach & Rescorla, 2001). It reports internalizing, externalizing, and total problem behavior concerns on several sub-

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TABLE 2 Summary of Family Characteristics for Parents of Youth Aged 8 to 17 With NoDx, ADHD Only, or ADHD C Dx Variable Marital status Married Single Separated or divorced Income < $10,000 $10,000–$25,000 $25,000–$50,000 $50,000–$75,000 $75,000–$100,000 > $100,000 Mother’s education > 12th grade High school or GED Partial college Four-year college Grad./Prof. Father’s education > 12th grade High school or GED Partial college Four-year college Grad./Prof.

NoDx

ADHD Only

ADHD C Dx

Full Sample

68 13 19

67 18 15

54 27 18

65 18 17

3 15 14 13 21 34

10 15 15 20 15 26

20 14 14 22 8 22

10 15 15 18 16 28

8 15 26 28 23

6 12 40 28 14

10 29 33 16 12

8 17 33 25 17

7 21 25 24 22

7 28 22 31 12

8 33 28 27 4

7 26 25 27 15

Note. NoDx D no diagnosis; ADHD D attention deficit hyperactivity disorder; ADHD C Dx D ADHD with comorbid diagnosis; GED D general equivalency diploma; Grad./Prof. D graduate school or professional school.

scales including anxious–depressed, withdrawn–depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, and aggressive behavior. This measure has also been shown to have adequate psychometric properties, including test-retest reliability falling within the range of 0.95 to 1.00. Interrater reliability has been found to be between 0.93 to 0.096, and the internal consistency fell within the range of 0.78 to 0.97. T scores were normed for age and gender based on responses to 113 questions on a 3-point Likert scale. T scores > 63 are considered to be in the borderline clinically significant range, with scores > 65 on the subscales and > 70 on the total problem scales considered to be clinically significant. Parents were also asked to provide demographic information, which included school category (public vs. private), number of family members, education levels of parents, marital status, number of siblings in the home, and estimated annual income.

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Students completed a 10-item Short Form of Kovacs’s (1992) CDI (CDI–SF), which has been shown to correlate highly with the original form. Items are rated on a scale of 0 to 2 in order to reflect the frequency with which a feeling or behavior related to depression has occurred in the last 2 weeks.This measure has been shown to have good reliability and validity (Kovacs, 1992). The CDI–SF t score was used as a gross indicator of self-reported depression symptoms, but CDI–SF alone does not allow for diagnosis. In keeping with ethical requirements, parents or children could elect to not finish all measures. Small variations in the participant numbers for individual analyses reflected omission of participants with incomplete or missing forms.

RESULTS Comparisons Between Youth With and Without ADHD The hypothesis that participants with ADHD would be elevated in bullying compared to participants with NoDx was tested two ways. The first, simplest, and cleanest comparison was a t test comparison between NoDx and ADHD only. The second analysis added children with ADHD C Dx, which allowed for confirmation of the NoDx versus ADHD groups in a broader, more diverse, and clinically representative sample. The latter analyses of covariance (ANCOVAs) also allowed for explicit examination of gender and age, although the BVS t score had already accounted for variability due to these factors. Independent t tests used to compare the ADHD-only and NoDx groups revealed that 88 youth with ADHD only, who completed the BVS, were significantly more likely to report being victimized by peers—t.178/ D 3:48, p < :001—compared to the 92 youth with NoDx. ANCOVAs, with gender and age as covariates, were used to compare three groups: NoDx, ADHD only, and ADHD C Dx. This analysis revealed main effects for diagnosis on BVS victimization scores, F .2; 27/ D 6:37, p < :002. The highest victimization t scores were in the ADHD-only group (M D 54:28), followed by the ADHD C Dx (M D 52:77), and the youth with NoDx (M D 48:08). Gender and age were not significant in the model. The youth in the ADHD-only group did not report a higher rate of selfreported bullying behavior on the BVS compared to peers with NoDx, t.178/ D 1:72, p < :09. Furthermore, comparison of the three diagnostic groups using ANCOVAs yielded no significant findings for self-reported bullying. Bullying categories were created based on BVS norm-referenced t scores > 60 for bullying (bully), victimization (victim), both (bully–victim), or neither (minimally affected by bullying D minimal). Chi-square analyses revealed a trend for higher rates of victim group placement in participants with ADHD,

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FIGURE 1 Percentages of student diagnostic groups categorized into victim only, bully– victim, bully, or minimal exposure (Minimal ex) groups based on Bully–Victimization Scale t scores > 60. Note. ADHD D attention deficit hyperactivity disorder; ADHD C Dx D ADHD with comorbid diagnosis.

2 .2; N D 232/ D 5:71, p < :057; but there were no significant differences in bully group placement. Because of the comparable rates of bullying, chi-square analyses comparing the four bullying groups—minimal, victim, bully, bully– victim—to the diagnostic groups—NoDx, ADHD only, ADHD C Dx—were not significant, despite different victimization rates. Figure 1 illustrates the rates of bullying and victimization in each diagnostic group.

Comparison of Youth With ADHD Who Are Bullied Versus Youth With ADHD Who Are Not Bullied A second set of analyses compared participants with ADHD who reported elevated bullying involvement versus participants with ADHD reporting minimal bullying involvement. There were no participants in these analyses who did not have ADHD. For this analysis, only students in the ADHD-only group were included, as the dependent measures were expected to be confounded by known differences in students with comorbid diagnoses. To test the hypothesis that youth with ADHD would have additional emotional or behavioral problems if they were also exposed to significant levels of bullying, t tests were used to compare victim versus non-victim scores on parentreported adjustment and social competence on the CBCL and child-reported depression on the CDI. Comparisons revealed significantly worse emotional or behavioral problems for youth with ADHD who were categorized by BVS scores as “victims” versus youth with ADHD who were not victims. Despite

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being comparable on the CBCL attention subscale, the CBCL withdrawn subscale, and the CBCL social competence scores, the victim group was significantly higher than the non-victim group on self-reported depression, parentreported internalizing and externalizing scores, and most other CBCL factor scores. Table 3 illustrates the comparisons between emotional and behavioral scores of the victim and non-victim groups within the population of students with ADHD. Analyses of variance with Duncan’s post hoc tests comparing the CBCL and CDI scores of bullies, victims, bully–victims, and minimally affected groups of participants (again, all with ADHD and no comorbid diagnoses) similarly revealed significant differences among bullying groups on everything except attention and social competence scores. Duncan’s post hoc tests revealed that bully–victims in the ADHD-only group were consistently highest on both parentreported internalizing scores and self-reported depression scores.

TABLE 3 Summary of t Tests Comparing 46 Youth With ADHD Only Who Were Significantly Elevated on the BVS ‘‘Victim’’ Subscale Versus 42 Youth With ADHD Only Who Were Not Significantly Elevated on the BVS ‘‘Victim’’ Subscale BVS Victim < 60 Variable CDI (%) CBCL broadband scores Internalizing Externalizing Total Subscale t scores Aggression Anxiety Attention Delinquent behavior Somatization Social problems Thought disturbance Withdrawn Activity School Social Total

BVS Victim > 60



SD



SD

43.70

5.60

49.10

8.90

53.00 53.70 56.40

9.90 10.20 9.40

58.00 59.90 62.30

56.40 55.60 64.10 56.40 55.00 57.80 57.10 56.90 43.60 39.90 43.80 41.20

7.70 6.50 8.90 6.10 6.10 6.40 8.60 8.00 9.40 9.20 9.80 10.20

61.30 58.60 66.80 60.10 58.60 62.40 61.50 59.50 45.90 37.70 43.30 40.90

t

df

p

3.40

86

.001

11.10 13.30 10.10

2.18 2.41 2.78

83 83 83

.040 .020 .007

11.80 9.10 10.70 9.00 8.20 9.10 9.30 9.60 13.30 7.70 12.40 9.60

2.30 1.71 1.29 2.21 2.29 2.75 2.24 1.36 0.91 1.14 0.22 0.14

83 83 83 83 83 83 83 83 81 75 78 71

.030 .100 .200 .030 .030 .007 .030 .030 .360 .260 .830 .880

Note. ADHD D attention deficit hyperactivity disorder; BVS D Bully–Victimization Scale; CDI D Children’s Depression Inventory; CBCL D Child Behavior Checklist.

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DISCUSSION The results of this preliminary study support the hypothesis that children who are diagnosed with ADHD may be at increased risk to be bullied by their peers (victimization). This investigation, which was conducted within the context of primary care and subspecialty clinics where children often present with behavior difficulties, demonstrates further that those patients with ADHD who are victims of bullying by their peers, although comparable to other patients with ADHD on scales of attention and social competence, exhibit significantly more internalizing and externalizing problems, by both parent and child report. Although this retrospective investigation does not allow us to draw conclusions regarding the sequence of victimization and bullying, it seems likely that the features of ADHD increased both primary and secondary vulnerability. A student with ADHD might be more likely to act out against another child in frustration or ill-conceived effort to be part of a social group without thinking through the consequences. Once victimized by peers, a student with ADHD might also be more likely to retaliate before thinking the action through. The significance of the relation between ADHD and bullying is important as clinicians and educators begin to implement primary bullying prevention strategies for patients with (and without) ADHD and secondary prevention strategies for patients known to be victimized by peers. Bullying and being bullied has been found to be associated with increased mental health difficulties and physical problems in school-aged children (Juvonen, Graham, & Schuster, 2003). In addition, children who are bullied are often at increased risk to be victimized again, even in other school settings, and to become bullies themselves (Saylor, Twyman, & Saia, 2008). The impact of bullying and being bullied on the mental and physical health of children potentially exacerbates pre-existing social and behavioral difficulties among children with externalizing behavioral disorders, such as ADHD. Children with ADHD are at risk for social and educational difficulties apart from the influence of bullying. It is essential that evaluations and interventions target attention difficulties, emotional and behavioral needs, and peer relationships. Whereas others have documented both the vulnerability of students with ADHD symptoms to bullying and the cost of bullying exposure to children’s psychosocial adjustment, this study makes several important additions to the growing literature. This is one of the first published studies of bullying and ADHD to involve pediatric patients diagnosed by their physicians whose standard of practice involved adherence to the American Academy of Pediatrics guidelines for diagnosis of ADHD. In addition, this study asked the patients with ADHD themselves about their bullying experiences rather than just asking their parents. Twyman et al. (2008) demonstrated that parents may greatly underestimate school bullying relative to the pediatric patients themselves. Furthermore,

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this study compares patient report to large normative samples for their gender and age (W. M. Reynolds, 2003). A certain amount of bullying exposure may be an unavoidable part of being in school and may even inoculate children against the stress, building resilience. However, the “victims” identified in this study reported bullying experiences disproportionate to others their age. Also of note is that even the patients whose BVS scores classified them as having “minimal exposure” may have personally experienced events that were traumatic or disruptive for them. Although the BVS (W. M. Reynolds, 2003) is a useful research tool, it may be impractical for primary care physicians or even specialty clinics to incorporate a 46-item questionnaire into their routine surveillance procedures. Brief screening tools to facilitate inquiry about physical, verbal, and cyberbullying are available (Jellinek, Patel, & Froehle, 2002; Saylor, Smyth, Twyman, & Taylor, 2008) and should be considered. Pediatricians are often the first people parents turn to when their child has ADHD or emotional and behavioral problems (Cohen, Cohen, Kasen, & Velez, 1993). It is vital that assessment and intervention be considered in the context of the child’s perception of his or her school environment and bullying experiences, especially if the child has ADHD. Implications for Practice This investigation highlights the need to tailor intervention strategies to specific pediatric–child populations at risk for bullying behavior. Although there has been significant debate in the literature regarding the relations between mental health difficulties and bullying behavior (Holmberg & Hjern, 2008; Shin Kim, Leventhal, Koh, Hubbard, & Boyce, 2006), the work of Holmberg and Hjern and the results of this investigation provide sufficient data to warrant the need to develop, pilot, and evaluate interventions that specifically meet the unique needs of youth with ADHD—interventions that factor in attention and impulsivity issues likely to impact bullying behavior among these susceptible children. As Holmberg and Hjern observed, interventions designed to provide “more individual-oriented approaches may be more appropriate choices of treatment” for children with ADHD (p. 137). This research provides additional evidence demonstrating a link between ADHD and bullying behaviors. Clinicians should be aware of this link as the clinical ramifications are significant, including augmenting of psychosocial difficulties among these children. Children with ADHD, who are already at risk for difficulties with learning and social endeavors, are at higher risk to be bullied and are likely to experience exacerbation of psychosocial problems when they are involved in bullying as victims, perpetrators, or both. Future studies among children with externalizing behavior difficulties are needed to demonstrate the generalization of these findings across behavioral disorders. In addition, future

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studies should be conducted among preschool children evidencing behavioral difficulties within the classroom setting to support the conclusions across developmental stages. Interventions designed to address bullying within pediatric and school settings should employ strategies to augment their effectiveness among children with ADHD.

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