Bullying: How You Can Take Action To Identify, Address and Prevent This Destructive Behavior

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Written by Lorene Reagan, RN, MS
Published in the August 2023 edition of EP (Exceptional Parent) Magazine. Sign up for this newsletter for free!

As we prepare to return to school, it is critical to ensure all children, including those with disabilities, are in an environment where they can learn, grow, and socialize without fear. This article describes bullying, its consequences, the increased risk children and adults with disabilities face, and prevention strategies.

WHAT IS BULLYING?

Bullying behavior is characterized by unwanted, aggressive behavior that involves a real or perceived power imbalance and is repeated or has the potential to be repeated over time. There are many different types of bullying, ranging from teasing and harassment to actual physical violence. It can occur in person, in writing, or through cyberbullying involving online or cell phone communications.

The magnitude of bullying behavior varies from annoying and emotionally hurtful verbal abuse, distressing social bullying designed to damage a person’s reputation, publicly embarrass or isolate them, to bullying involving physical assault. It’s not uncommon for bullying to begin with verbal taunting and harassment and then, if not addressed, escalate into physical abuse and assault. And people with intellectual and developmental disabilities are susceptible to and at even greater risk than others with disabilities of being bullied.

WHAT ARE THE CONSEQUENCES OF BULLYING?

We all know bullying hurts people in many ways. But did you know:

  • Bullying has serious negative consequences; those who are bullied can experience depression, low self-esteem, decreased academic achievement, health problems, and, in extreme cases, can be at risk for suicide[i].
  • People with disabilities can be bullied by family members, paid and unpaid caregivers, and other supporters, and may be reluctant to report it because of their dependence upon the caregiver and fear of retribution.

The adverse outcomes of bullying are not limited to those who are bullied. According to the US Department of Health and Human Services,[ii] children who are allowed to bully others are more likely to:

  • Abuse alcohol and other substances as adolescents and adults
  • Drop out of school, vandalize property, and engage in fighting
  • Engage in sexual activity earlier
  • Have criminal convictions and be abusive toward others, including their romantic partners, spouses, and children as adults

And those who witness bullying are more likely to:

  • Miss or skip school
  • Have increased mental health challenges, including depression and anxiety
  • Have increased use of tobacco, alcohol, and other drugs

Bullying directed at a person because of their disability may fall under the category of “disability harassment” and rise to the level of a civil rights violation under Section 504 of the Rehabilitation Act of 1973 or Title II or III of the Americans with Disabilities Act[iii]. Those who harass people because of their disability, as well as people and organizations who have a duty to prevent disability harassment, can run afoul of these laws if they fail to address and prevent bullying and harassment appropriately.

WHAT CAN WE DO TO PREVENT BULLYING?

We know that the roots of bullying behavior begin in childhood. According to the American Psychological Association,[iv] steps can be taken to address and prevent bullying. For example:

  • Create an environment that makes it clear bullying will not be tolerated and set positive expectations for both children and adults.
  • Ensure parents, educators, and others in the person’s life are knowledgeable and observant about when and where bullying tends to happen. Bullying generally occurs in areas where supervision is limited or absent such as in bathrooms, playrooms, parks, and on school buses. Cyberbullying via cell phones and computers occurs when access to these devices is not monitored.
  • Be alert to the safety of those most vulnerable to being bullied. Help the person develop a network of allies to reduce feelings of isolation and reduce opportunities for the person to be targeted for bullying.
  • If bullying is reported or observed, intervene immediately to stop it, record the incident and inform those responsible for addressing it.
  • Adults, including parents, educators, and others, are encouraged to be involved in school or community-based safety teams and antibullying task forces and engage and educate children and adults with (and without) disabilities about the skills for identifying, responding to, and preventing bullying.

Bullying has long-ranging consequences for those being bullied, the person exhibiting the bullying behavior, and those who are witnesses to this serious form of mistreatment. Taking steps to recognize, address and prevent bullying is critical to all children and adults’ emotional and physical well-being. And it is especially important for people with intellectual and developmental disabilities, who are at the highest risk for this type of abuse.  

[i] Centers for Disease Control and Prevention. People with Disabilities and Chronic Diseases: Information about Bullying. 2020. https://www.cdc.gov/ncbddd/disabilityandsafety/bullying.html

 

[ii] U.S. Department of Health and Human Services. Bullying and Youth with Disabilities and Special Health Needs. 2020. https://www.stopbullying.gov/bullying/special-needs

 

[iii] US Department of Justice Civil Rights Division. Guide to Disability Rights Laws. 2020. https://www.ada.gov/resources/disability-rights-guide/

 

[iv] American Psychological Association. Bullying. 2022. https://www.apa.org/topics/bullying/prevent

Unlocking Behaviors: Dental Health

Unlocking Behaviors: Dental Health

Co-written by Risley “Ley” Linder, MA, MED, BCBA & Craig Escudé, MD, FAAFP, FAADM
Published by Helen Journal

This article is part of a co-authored series on behavioral presentations in which a physician and a behavior analyst provide insight into real-life case studies to share their expertise on how behavioral issues can be addressed in an interdisciplinary fashion.

When it came to tennis, 37-year-old Tim was a huge fan. He loved watching how fast the players hit the ball back and forth, especially his favorite player Roger Federer. He knew the general timing of the US Open and other major tennis events and would watch as many matches as possible.

Tim enjoyed snacking on almonds and other nuts while watching tennis. One year, during the US Open, he decided he didn’t  want almonds and even knocked them off the table a couple of times. He began to get a bit agitated at various times of the day or night, and his support staff wasn’t sure  what was going on. After a few weeks, Tim became quite a challenge, hitting out at others, wanting to stay in his room more, and even eating less.

Tim was taken to his primary care physician for an evaluation. He underwent a physical exam, and nothing unusual was found except for a 5-pound weight loss since his last visit six months prior. Because of his agitation, he was then seen by a psychiatrist. Staff were concerned that he was endangering himself and others during his episodes of agitation. He was started on psychotropic medication in an attempt to reduce his aggression. It seemed to work for a while, but then the agitation ramped up again. After several psychiatry visits and medication adjustments, the recommendation was made to move Tim to an in-patient psychiatric setting for evaluation.

A relatively new nurse who had recently attended a conference about behavioral changes in people due to underlying medical conditions attended Tim’s final team meeting before he was to be committed. She recalled hearing at the conference how dental issues can cause agitation. She recognized that Tim had not had a dental evaluation in the last three years because of COVID restrictions and his inability to wear a mask. 

Medical Discussion

Primary care physicians are not dentists. (No surprise there). But in the situation described above, primary care clinicians are often asked to evaluate a person with a change in behavior to rule out underlying medical causes. Most people, if they have tooth pain, automatically know to see a dentist and don’t show up at the family physician’s office for an evaluation. But for many people with a limited ability to use words to communicate, agitation is often the first indicator of discomfort, and the initial assessment is usually by a primary care clinician or a psychiatrist. Primary care clinicians aren’t necessarily used to thinking about dental causes of pain because most people will go to the dentist first. 

Anything that causes pain in a person’s mouth can make them agitated around mealtimes (due to the anticipation of pain with chewing). They can also spit out food, prefer soft foods over crunchy foods, refuse to go to the dinner table, refuse oral care, and can even be aggressive.

Behavioral Discussion

Tim’s decreased desire to snack on nuts and watch the greatest tennis player of all time is an entirely preventable situation. Dr. Escudé listed a few behaviors that can happen when a person has pain and/or discomfort in their mouth. It’s  important to recognize these types of behaviors, but Tim’s situation allows us to discuss another area of behavior: acute vs. chronic behaviors. 

Acute vs. Chronic Behaviors

Tim’s preference for snacking on nuts and watching tennis is something that had occurred for many years, and there was an acute change in behavior.

Tim’s acute change in behavior was characterized by changes in:

  • Preferences
  • Routines
  • Medical issues, such as unintended weight loss. 

Sudden changes in behavior and/or new behaviors are more likely to happen because of changes in a person’s environment (e.g., new job) or medical issues (e.g., toothache), as opposed to more chronic issues (e.g., psychiatric symptoms). 

For Tim, having never been prescribed psychotropic medications, the acute onset of psychiatric symptoms in middle age is not a likely cause for the change in food and activity preferences.  

Observing and Assessing

When observing and assessing acute onset behaviors, thinking about three key areas is important. 

  1. First, has anything changed in their environment? Can we clearly identify a change that would account for the rapid change in preferences? 
  2. Second, what is the timeline of changes? When did the behavior change(s) start? Sometimes using events instead of time to track changes can be helpful. For example, “Tim was eating nuts while watching Wimbledon in July, but he wasn’t during the US Open in August. What could have happened in the last month?”  
  3. Lastly, it’s important to note if the behaviors happen across time, setting, and people. If they only happen at one particular time, in a specific setting, or with certain people, they are more likely to be environmental, as opposed to medical-based behaviors that are more likely to happen across time, settings, and people.  
Outcome

The nurse recalled what she learned at the conference and recommended that Tim have a dental evaluation before being admitted to the psychiatric hospital. Tim was found to have several abscessed teeth. After they were all treated, his pain resolved. They tapered off his psychotropic medication, and he made up for all the tennis he missed— and the eating. Tim avoided a psychiatric admission and likely additional psychotropic medicines because of the nurses’ insistence on a dental evaluation. 

The Authors

Risley “Ley” Linder 
Ley is a Board-Certified Behavior Analyst with an academic and professional background in gerontology and applied behavior analysis. Ley’s specialties include behavioral gerontology and the behavioral presentations of neurocognitive disorders, in addition to working with high-management behavioral needs for dually diagnosed persons with intellectual disabilities and mental illness. He is an officer on the Board of Directors for the National Task Group on Intellectual Disabilities and Dementia Practices, works closely with national organizations such as the National Down Syndrome Society, and is the owner/operator of Crescent Behavioral Health Services based in Columbia, SC.

Dr. Craig Escudé
Dr. Craig Escudé is a board-certified Fellow of the American Academy of Family Physicians, the American Academy of Developmental Medicine, and President of IntellectAbility. He has more than 20 years of clinical experience providing medical care for people with IDD and complex medical and mental health conditions. He is the author of “Clinical Pearls in IDD Healthcare” and developer of the Curriculum in IDD Healthcare,” an eLearning course used to train clinicians on the fundamentals of healthcare for people with IDD.