OTC indicates over the counter.
eTable. Ordinal Logistic Regression of Victimization by Cyberbullying.
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Elgar FJ, Napoletano A, Saul G, et al. Cyberbullying Victimization and Mental Health in Adolescents and the Moderating Role of Family Dinners. JAMA Pediatr. 2014;168(11):1015–1022. doi:10.1001/jamapediatrics.2014.1223
Copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
This study presents evidence that cyberbullying victimization relates to internalizing, externalizing, and substance use problems in adolescents and that the frequency of family dinners attenuate these associations.
To examine the unique association between cyberbullying victimization and adolescent mental health (after controlling differences in involvement in traditional, face-to-face bullying) and to explore the potential moderating role of family contact in this association.
Design, Setting, and Participants
This cross-sectional, observational study used survey data on 18 834 students (aged 12-18 years) from 49 schools in a Midwestern US state. Logistic regression analysis tested associations between cyberbullying victimization and the likelihood of mental health and substance use problems. Negative binomial regression analysis tested direct and synergistic contributions of cyberbullying victimization and family dinners on the rates of mental health and substance use problems.
Frequency of cyberbullying victimization during the previous 12 months; victimization by traditional (face-to-face) bullying; and perpetration of traditional bullying.
Main Outcomes and Measures
Five internalizing mental health problems (anxiety, depression, self-harm, suicide ideation, and suicide attempt), 2 externalizing problems (fighting and vandalism), and 4 substance use problems (frequent alcohol use, frequent binge drinking, prescription drug misuse, and over-the-counter drug misuse).
About one-fifth (18.6%) of the sample experienced cyberbullying during the previous 12 months. The frequency of cyberbullying positively related to all 11 internalizing, externalizing, and substance use problems (odds ratios from 2.6 [95% CI, 1.7-3.8] to 4.5 [95% CI, 3.0-6.6]). However, victimization related more closely to rates of problems in adolescents that had fewer family dinners.
Conclusions and Relevance
Cyberbullying relates to mental health and substance use problems in adolescents, even after their involvement in face-to-face bullying is taken into account. Although correlational, these results suggest that family dinners (ie, family contact and communication) are beneficial to adolescent mental health and may help protect adolescents from the harmful consequences of cyberbullying.
Bullying contributes to various health problems in adolescents1,2 including anxiety and depression,3,4 suicidal ideation,5 self-harm,6-8 and disruptive behavioral problems.9 The rapid proliferation of online social media has drawn public attention to the issue of cyberbullying. About 1 in 5 adolescents has experienced online bullying in the past year,10,11 and studies found that cyberbullying—like traditional bullying—increases the risk for internalizing and externalizing problems12-14 and misuse of drugs and alcohol.15,16 A meta-analysis found that the odds of suicidal ideation was 3.1 times greater in adolescents who had experienced cyberbullying than in those who had not.17
However, it is unclear whether cyberbullying contributes to mental health problems primarily because of its overlap with traditional (face-to-face) bullying. Juvonen and Gross15 found that 85% of adolescents who were involved in online bullying were also involved in traditional forms of bullying. Other studies have found weak correlations between traditional bullying and cyberbullying.18,19 Given the invasive nature of cyberbullying and that it is so difficult for parents and educators to monitor, it is important to understand whether cyberbullying uniquely contributes to mental health and substance use problems independently of verbal or physical forms of bullying.20
It is also important to identify protective factors for youths who are exposed to cyberbullying. Research on traditional bullying found that parent or peer support moderates the harmful effects associated with bullying.21,22 Holt and Espelage23 found that peer support moderated the association between victimization and symptoms of anxiety and depression whereas maternal support did not. However, a study by Davidson and Demaray24 found fewer internalizing symptoms (eg, anxiety and depression) among adolescent female victims whose social support from parents was greater. Such findings may generalize to cyberbullying. However, we are unaware of prior research that specifically examined moderated effects of social supports on the relation between cyberbullying victimization and mental health nor on the mechanisms or modalities through which they operate.
Family dinners are one outlet through which family support is expressed and have established links to adolescent mental health and risk behavior.25 Research has found that the frequency of evening family meals predicts adolescent mental health and risk behaviors owing, in part, to family contact and communication and parental involvement.25,26 These are positive social assets for adolescent health that may provide opportunities for families to discuss online behavior and bullying and ways to cope with online harassment. However, it is unclear whether the frequency of family dinners has only direct links to adolescent health or can also moderate the health consequences of a specific stressor such as cyberbullying.
This study examined the association between cyberbullying victimization and mental health and substance use problems in adolescents and whether this association is moderated by family contact and communication. This study addressed gaps in the literature by first examining the association between cyberbullying and various mental health and substance use problems in adolescents. We controlled individual differences in involvement in traditional (face-to-face) bullying to examine the unique association between cyberbullying and health. We then explored the potential moderating role of family communication and contact—operationalized by the frequency of family dinners—on the relation between cyberbullying and health. We hypothesized that cyberbullying relates more closely to health problems among youths who have fewer family dinners.
The 2012 Dane County Youth Assessment evaluated health and health behaviors in a sample of 20 385 high school students in 49 middle schools and high schools across a Midwestern US state.27 The number of participants per school ranged from 31 to 1554. The survey was voluntary, anonymous, and administered electronically at school. A waiver of parental consent was granted by notifying parents 4 weeks in advance of survey administration, inviting them to review the survey at their school district office and allowing them to opt out. More than 90% of students in most districts participated. The University of Illinois institutional review board approved the study procedures27; child written assent was obtained.
We excluded 1551 cases (7.6% of the sample) for which cyberbullying data were unavailable, resulting in a final sample of 18 834 adolescents. Removed cases were slightly older than the remaining sample (15.3 vs 15.0 years; t = −6.9; P < .001) and included fewer girls (35.9% vs 50.5%; χ21 = 104.1; P < .001) and fewer low-income students (10.1% vs 19.2%; χ21 = 78.9; P < .001). Their removal did not change the composition of the remaining sample. Participants were 50.7% girls and ranged in age from 12 to 18 years (mean [SD], 15.0 [1.7] years). With respect to race/ethnicity, 70.0% of the sample self-identified as white; 7.6% as black; 6.6% as Hispanic; 7.0% as mixed; and the remaining 8.8% as either Asian, Native American, Middle Eastern, or other. Also, 23.5% (95% CI, 18.8-28.9) of the sample qualified for free or reduced-cost school lunches (Table 1).
The frequency of cyberbullying victimization was measured with the item “In the past 12 months, how often have you been bullied, threatened, or harassed through the Internet or text messaging (never, rarely, sometimes, or often)?” The Bullying and Victimization subscales of the University of Illinois Aggression Scales measured the occurrence of face-to-face bullying.28 The Bullying Subscale contained 6 items that measured the frequency of harassing, upsetting, or making fun of other students; spreading rumors; starting arguments; or socially excluding others (0 = never, 1 = 1-2 times, 2 = 3-4 times, 3 = ≥5 times; α = 0.87). The Victimization Subscale contained 4 items that measured the frequency of being picked on, made fun of, called names, and hit or pushed by other students (0 = never, 1 = 1-2 times, 2 = 3-4 times, 3 = ≥5 times; α = 0.86). Bullying perpetration scores ranged from 0 to 18 and victimization scores ranged from 0 to 12.
The survey also measured the presence of 5 internalizing problems (anxiety, depression, self-harm, and suicidal attempt in the previous 12 months, and suicidal thoughts in the previous 30 days), 2 externalizing problems (physical fighting and vandalizing property in the previous 30 days), and 4 substance use problems that may represent attempts to cope with cyberbullying (≥3 episodes of drunkenness, ≥3 episodes of binge drinking [≥5 alcoholic drinks on a single occasion] in the previous 30 days, and prescription drug misuse and over-the-counter [OTC] drug misuse during the previous 12 months). Drunkenness and binge drinking were assessed in a subsample of 6454 students owing to a technical issue during data collection. This subsample did not differ from the remaining sample on any demographic or health variable.
Family dinners were measured with the item “In an average week, how many days do you eat evening meals with your family (0 to 7)?” This item was consistent with prior studies of family dinners and adolescent health.25,26 Other relevant survey items assessed age, sex, and qualification for free or reduced-cost school lunches, which was used to indicate low household income.
The data were weighted to ensure a balanced representation of the sample across school districts. Confidence intervals were adjusted according to design effects of school cluster. We used ordinal regression to examine the contributions of age, sex, low household income, and involvement in traditional bullying to the frequency of cyberbullying victimization. Logistic regression was then used to estimate odds ratios (ORs) of mental health and substance use outcomes as a function of cyberbullying exposure, with other differences in age, sex, low household income, and involvement in traditional bullying held constant. Finally, the direct and interactive effects of victimization and family dinners on the number of reported internalizing, externalizing, substance use, and total problems were tested using negative binomial regressions. All analyses were performed using Stata/SE 13.1 (StataCorp).
Descriptive statistics on the main study variables are shown in Table 1. A depressive episode was the most commonly reported mental health problem, found in 18.9% of the sample. Less common problems were suicide attempts (4.8%) and the misuse of OTC drugs (5.1%) and prescription drugs (6.4%). These results also showed that 18.6% of the sample had experienced cyberbullying at least once during the previous 12 months, although only 2.2% had experienced it often. As shown in the eTable in the Supplement, cyberbullying was more common in girls than in boys (OR, 2.95; 95% CI, 2.54-3.44) and increased with each additional year of age (OR, 1.07; 95% CI, 1.03-1.11) and involvement in traditional (face-to-face) bullying, either as the target (OR, 1.37; 95% CI, 1.33-1.40) or an aggressor (OR, 1.12; 95% CI, 1.08-1.16). Family dinners per week negatively related to the odds of cyberbullying (OR, 0.91).
The first hypothesis was tested using logistic regression analyses (Table 2). Eleven regression models included sex, age, low household income, face-to-face bullying involvement (perpetration and victimization), family dinners, and cyberbullying victimization (entered as dummy variables with rarely, sometimes, and often responses compared with a never reference group). The odds of substance use problems (binge drinking, drunkenness, and prescription and OTC drug misuse) and externalizing problems (fighting and vandalism) were lower in girls than in boys, and the odds of internalizing problems (high anxiety, depression, self-harm behaviors, suicidal thoughts, and suicide attempt) were higher in girls. Age negatively related to all 11 problems, with each additional year of age reducing ORs from 19% (suicide attempt) to 3% (binge drinking). Low household income related to higher ORs of internalizing problems (anxiety, depression, self-harm, suicidal thoughts, and suicide attempts), externalizing problems (fighting and vandalism), and OTC drug misuse. The perpetration of face-to-face bullying positively related to the ORs of all health problems. Victimization by face-to-face bullying positively related to some outcomes (fighting, depression, self-harm, suicidal thoughts, and suicide attempts) and negatively related to others (binge drinking, drunkenness, and prescription and OTC drug misuse). In other analyses (not shown), victimization from traditional bullying positively related to all 11 outcomes when cyberbullying was removed from these models, which suggests its relation to substance use problems was mediated by cyberbullying. Family dinners negatively related to all health outcomes (range, OR, 0.79; 95% CI, 0.76-0.82 [OTC drug misuse] to OR, 0.95; 95% CI, 0.92-0.98 [fighting]).
With these differences taken into account, cyberbullying victimization related to elevated ORs of all 11 mental health and substance use problems. Adolescents who were most often victimized (compared with those who were never victimized); had more than twice the ORs of having been drunk, gotten into a fight, vandalized property, and had suicidal thoughts; more than 3 times the ORs of binge drinking, high anxiety, self-harm, and suicide attempt; and more than 4 times the OR of misusing prescription drugs and OTC drugs. Figure 1 shows the predicted probabilities of mental health and substance use problems by cyberbullying (adjusted for differences in sex, age, low household income, and involvement in face-to-face bullying).
We then combined these outcomes into composite variables that represented rates of internalizing problems (α = 0.74), externalizing problems (α = 0.44), substance use problems (α = 0.86), and total problems (α = 0.78). Table 1 shows descriptive statistics on these variables. Table 3 shows the results of 4 regression analyses with the incident rate ratios of each outcome reported. Incident rate ratios represent changes in the rate of symptoms attributed to 1-unit differences in the predictor variable. Girls reported lower rates of externalizing problems and higher rates of internalizing and substance use problems than boys. Age positively related only to the rate of substance use problems, whereas low household income and the perpetration of face-to-face bullying positively related to all problem areas. Victimization by face-to-face bullying increased the rates of internalizing and externalizing problems but not substance use problems.
Finally, family dinners moderated the relations between cyberbullying and the rates of internalizing, externalizing, substance use, and total problems (Table 3). We probed these interactions by estimating predicted rates of each problem by level of bullying and the frequency of family dinners (Figure 2). In each domain, health disparities across levels of victimization tended to narrow as family dinners increased. For example, at 4 or more dinners per week, there was an approximately 4-fold difference in the rates of total problems between no victimization and frequent victimization. At zero dinners per week, this difference was more than 7-fold.
This study found that cyberbullying related to every mental health and substance use problem that was measured, even after exposure and involvement in face-to-face bullying were statistically controlled. The findings suggest that the health consequences of cyberbullying are not completely attributed to its co-occurrence with face-to-face bullying and is therefore a legitimate focus of preventive interventions.12,14 The results also showed evidence of a moderating role of family contact and communication on the associations between cyberbullying and the rates of internalizing, externalizing, and substance use problems. Family dinners shared a negative association with mental health and substance use problems, and these associations strengthened as cyberbullying became more frequent.
It is important to interpret the frequency of family dinners as a proxy of several contextual factors that may support and protect adolescent health. With more frequent dinners comes more regular family contact, which facilitates parental guidance and support, open communication with parents and siblings, and opportunities for adolescents to express problems and concerns as they arise.25,26 Therefore, family dinners are indicative of a broad set of family characteristics that may promote adolescent health and buffer the impact of stressful situations on adolescent functioning.29
The results also showed that cyberbullying victimization was more common among girls than boys but not closely related to age nor to disadvantaged socioeconomic backgrounds. Other studies found similar sex differences in cyberbullying30-32 and relational aggression,33 whereas some found no sex differences in cyberbullying.34 It is possible that the girls in our study were more likely to report bullying than boys.35,36 Unfortunately, without data from multiple informants or data on the perpetration of cyberbullying, we were unable to verify an underreporting of victimization among boys and examine the sex distribution of groups of victims, perpetrators, and bully victims.
The strengths of this study included a large sample and an assessment of multiple health domains including self-harm, suicidal thoughts, and suicide attempts. Such data are rarely reported in the pediatric literature and are helpful in documenting the level of distress associated with cyberbullying. Additionally, the focus on family dinners rather than general perceptions of family support provided practical information to families about one way to support youths who are victimized online. The limitations of the study included a single item measure of cyberbullying that did not capture all the criteria of commonly used bullying assessments (ie, power differential between aggressors and victims), the potential underreporting of victimization by boys, and the cross-sectional design, which precluded firm conclusions regarding the direction of the effects between victimization, family dinners, and health problems. The associations between these variables were likely transactional. Adolescents with emotional or behavioral problems may become the targets of cyberbullying, become reluctant to interact with their families, or both.9
Furthermore, based on these findings, we did not conclude that cyberbullying alone is sufficient to produce poor health outcomes nor that family dinners alone can inoculate adolescents from such exposures. Such an oversimplified interpretation of these associations disregards other exacerbating and protective factors throughout the social environment.37 Instead, these findings support calls for integrated approaches to protecting victims of cyberbullying that encompass individual coping skills and family and school social supports.38-40 Given the evidence that peer and parent support can moderate the association between bullying and health outcomes, it is important to identify the mechanisms through which these positive outcomes can be achieved. This study suggests that regular family dinners are one such mechanism. However, future research should consider other sources of social support that help reduce cyberbullying and its harmful effects on adolescent health.
Cyberbullying uniquely relates to internalizing, externalizing, and substance use problems in adolescents. The associations are not explained by involvement in traditional (face-to-face) forms of bullying. However, their strength is moderated by the frequency of family dinners. Health care professionals should be aware of the potential health risks associated with cyberbullying and the benefits associated with regular and frequent family contact. Further study is needed to identify other paths through which social support can protect adolescents from the risks associated with online bullying.
Corresponding Author: Frank J. Elgar, PhD, Institute for Health and Social Policy, McGill University, 1130 Pine Ave W, Montreal, QC H3A 1A3, Canada (email@example.com).
Accepted for Publication: June 5, 2014.
Published Online: September 1, 2014. doi:10.1001/jamapediatrics.2014.1223.
Author Contributions: Dr Elgar had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Elgar, Saul, Craig, Koenig.
Acquisition, analysis, or interpretation of data: Elgar, Napoletano, Saul, Dirks, Craig, Poteat, Holt.
Drafting of the manuscript: Elgar, Napoletano, Saul, Poteat.
Critical revision of the manuscript for important intellectual content: Elgar, Saul, Dirks, Craig, Poteat, Holt, Koenig.
Statistical analysis: Elgar, Saul.
Obtained funding: Elgar.
Administrative, technical, or material support: Koenig.
Study supervision: Elgar, Craig.
Conflict of Interest Disclosures: None reported.
Funding/Support: The study was supported by grants from the Social Sciences and Humanities Research Council (435-2014-2160) and Canada Research Chairs Programme.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.