Cyberbullies and Cybervictims -- What's the Clinician's Role?

An Expert Interview With Gwenn Schurgin O'Keeffe, MD

Carol Peckham


October 25, 2010

About the Interviewee

Gwenn Schurgin O'Keeffe, MD, FAAP, is a pediatrician, health journalist, and chief executive officer of Pediatrics Now (, an online health and communications company. She is also the author of Cybersafe: Protecting and Empowering Digital Kids in the World of Texting, Gaming and Social Media .

The Interview

Medscape: Dr. O'Keeffe, could you define cyberbullying?

Dr. O'Keeffe: Cyberbullying is bullying with the use of technology -- any type of technology: Facebook, cell phones, email, anything digital or electronic where the message has a harassing or hurtful element to it. Just to be clear, with bullying there has to be pure intent to cause negative consequences for the other person. It's not an accidental comment that happened to hurt somebody's feelings.

Medscape: Would cyberbullying also have to be public?

Dr. O'Keeffe: No, not necessarily. Just like schoolyard bullies don't need an audience to cause harm to their victims, cyberbullies don't need an audience to wreak havoc on theirs. In both situations, the bully is going to try to humiliate and cause harm to the victim, but not necessarily with the intent of that message going viral.

Medscape: Are there any profiles or risk factors for cybervictims that would differentiate them from the traditional schoolyard victims?

Dr. O'Keeffe: Interestingly, we're still sort of sorting that out: what makes a cyberbully and a cybervictim. What's different from the schoolyard victim? It's not as straight forward as we would think. Typically, cybervictims tend to feel more vulnerable once they've been cyberbullied compared with kids who have been bullied without technology. This may be due to their inability to see and often know the bully or to know how many people have read about the incident or if it will occur again. Bullying online seems to create much more anxiety than in a schoolyard setting, which feels much more contained and controlled. We do know that girls tend to be cyberbullied more than boys are, and cybervictims tend to be heavy online users. However, there's no profile where you can definitely say, "You're going to be cyberbullied more than somebody else."

Medscape: I would think that girls who are bullies are more apt to be online bullies than physical bullies. Are there more female than male cyberbullies?

Dr. O'Keeffe: We think there's a slight gender difference in the typical cyberbully, but there are some conflicting data on that. If you try to draw a typical profile of the cyberbully, they tend to be heavy online users. Many are girls -- think of the movie Mean Girls. They seem to have aggressive personalities, they want to create attention, and maybe they have trouble making friends. As with typical schoolyard bullying, cyberbullies have often been bullied themselves, and many seem to have some trouble with delinquency and have had poor parenting. However, we're also dealing with young and developing people who are learning powerful technology and trying to communicate through it. There's a fine line between poor communication and harassment, so we may be seeing a reflection of our kids and teens stepping into digital mine fields at times and not knowing how to get out of them.

Medscape: So you think some people who are considered to be cyberbullies would be surprised by this accusation.

Dr. O'Keeffe: I do think that part of the problem is that we don't teach our kids how to use technology correctly. We have to teach them to be good digital citizens, just like we teach them how to drive a car safely, or walk across the street, or cook. We don't take such care with their lives online, and digital accidents are happening and increasing. We need to teach them digital social etiquette just as we have with other forms of communication.

In a way, this mean behavior is understandable because they don't know how to use the technology. Although it doesn't excuse the behavior, looking retrospectively, we can see how it may have occurred. They are kids, and they are just doing what they know how to do. Most don't understand the rules of behavior or how to communicate to begin with. Also, they're all emotion at times. You add anonymity, and it makes sense that they're going to shoot from the hip. If adults are having trouble with this stuff, certainly teens and younger kids will too.[1]

Medscape: How does cyberbullying compare to schoolyard bullying in terms of its psychological impact?

Dr. O'Keeffe: Studies have shown that cyberbullying has a much more profound impact than traditional schoolyard bullying.[2] In the schoolyard, kids feel pretty self-contained. They know who their bully is, and they know if they tell an adult or a teacher, it can get handled. The bully is put in his place. The victim feels safe; he or she feels empowered. The event can really end very quickly. With cyberbullying, often you don't even know who the bully is. If you're lucky, there's a name attached to the message. However, very often the message comes in anonymously, and the child feels very anxious. They wonder, "Has the message gone out to the whole world. Am I going to be stalked and harassed by this person for a long time?" This can really go on [for a long time] and have a very profound impact on the life of the child and on their self-esteem. They can become depressed, and we know kids can get suicidal.

Medscape: Are there any types of specific tips for recognizing children who might be cybervictims?

Dr. O'Keeffe: Parents need to have a high index of suspicion that their child may be suffering from cyberbullying, for example, if they observe that their child is anxious, or depressed, or losing sleep. In addition, the child is probably communicating through his or her device in a way that was different from before. For example, the child might suddenly avoid the technology, not want to text, leave the cell phone at home, or suddenly not check his or her Facebook profile. Or, conversely, such children may check their email or profiles more often and get upset or act strangely after using it.

Studies currently report that cyberbullying occurs in a third of kids who use technology. Of those kids, most do not report the incident to even a trusted adult. Parry Aftab, a highly regarded internet safety attorney who has surveyed young people across the country, found that they report cyberbullying only 5% of the time.[3]

Knowing we're in the dark most of the time, parents then need to have a very high index of suspicion that something is going on with their kids. And, if young people come to their parents and say, "I think I have a problem," they are not making it up; it's very hard for teenagers to confess to parents and adults about what is going on in their lives. So, take them seriously. Clinicians and parents have to make great efforts to empower children and get them to communicate with us about their digital lives.

Medscape: At least with online technology, there's a record.

Dr. O'Keeffe: Exactly. So second, parents should print the record and start a paper trail. See if they can put a name to it. They should read the message and make sure their child is not in any danger. If the message is threatening, they need to go to the police right away. If it isn't, they still need to sort it out and ask themselves, "Do I need to go to the school? Or is this something we can handle as a family?" Whether it is or isn't threatening, parents need to figure out if their child is okay or if they need medical or mental healthcare. If there are issues, such as headaches, stomach aches, anxiety, or other signs that trigger suspicion of bullying, then parents need to involve the pediatrician.

If the child seems fine, parents may just be able to sit down and come up with a plan at home. For example, they might just need to block the message. If it came in through the cell phone, they can work with their phone carrier, or if it came through email, with their email carrier. If came in through social media, that person can be blocked. Sometimes that's all anyone needs to do to protect their child from that bully.

If it's a perpetrator the child knows personally, then the next question is, "Will this become an offline problem, and am I going to need to help my child further?" This is a more complicated problem, and parents need to talk to school administrators about that.

Medscape: What role would clinicians play in these scenarios?

Dr. O'Keeffe: It is very much a clinician's job to help a family negotiate this situation because often parents just don't know what to do. So, if the pediatrician or primary care clinician gets the call, "My child's been cyberbullied, what next?" they should bring the family in and work with them on assessing the situation. What is going on with the child or teenager? Does the child have any medical or psychiatric issues that need to be addressed? Is the child safe? On that first day, everyone may be feeling shell-shocked, but don't forget that the other shoe is going to drop because usually the cyberbullying continues.

Furthermore, like the parent, the clinician needs to understand that kids who report cyberbullying aren't making it up. Many pediatricians don't recognize that these are health issues because the child is thinking, "I may have just opened up Pandora's box, and the whole school's going to know." So, at that moment the child may seem calm, but the clinician needs to put a plan in place and tell the child, "Okay, if you start to feel anxious, if you start to get stomach aches, if you start to get headaches, if you start to have trouble sleeping, if your grades go down -- if any of these things start happening, you call me and we will address them." The pediatrician or primary care clinician can keep tabs on anxiety and sleep and depression and be the conduit to a mental health provider.

Medscape: What if a parent came to you as a pediatrician and said, "My child is a cyberbully. What can I do to change his or her behavior?"

Dr. O'Keeffe: When a child is a cyberbully, first and foremost it boils down to a communication issue. It usually involves issues of self-esteem and fitting in socially, and they often have trouble in school. [Once caught] they will be ostracized by the families of the victims and watched like a hawk by the school administrators, who worry that this child will cyberbully again because this behavior typically has been going on a long time. These cyberbullies are going to face a very tough time fitting back into society and school in a way where they can be comfortable.

I think the first thing to do is to bring the child into the office and talk about what's been going on. "Why do you think you do this?" Help the child own the issue. It's rare that a family will acknowledge that their child is a bully or a cyberbully, but if they do, that's the first step toward healing. I would get the family into counseling and help the child learn to accept what's happening, learn better ways to communicate, and address any issues at school. Probably this child has been bullied himself or herself.

If a pediatrician or other clinician is aware of what's happening in a child's social circle, their academic life, their degree of self-esteem, then the clinician can intervene early and help a family regroup. Unfortunately, nowadays, office visits are so short that pediatricians don't really have the time to focus on all of those areas.

Medscape: In relating to people in the cyberworld, one issue is the physical and temporal dissociation, so that one doesn't experience one's effect on another person. There's also the speed at which one can deliver a message, which makes it easier to behave impulsively. Do you have any specific advice on how to avoid or reduce these effects?

Dr. O'Keeffe: Yes, in my book Cyber Safe I use the mnemonic RITE, which helps young people learn to post appropriately.

Read any message that you write before you post it.
Imagine if you were receiving that message whether it would be hurtful in any way.
Think about whether it needs to be sent now or if it can wait.
E is enter. You only want to hit "Enter" and send that message when you are sure that that message is the right one to send at the right time.

This mnemonic helps teach families and children to avoid becoming a cyberbully or cybervictim. Usually most messages can wait before you send them, even if it is 5 or 10 minutes. Once written, the writer, whether young or old, should read it again and make sure it needs to be sent. If the writer isn't sure, they should have an adult or friend read it and help assess whether it is written just out of anger or not.

Sometimes it is [cathartic to express feelings] in writing, and the writer can use the message therapeutically and then erase it. Young people don't understand this, but we can mentor them and say, "You know what? It was great that you wrote that. Do you feel better now?" And, with luck, the child will respond, "Okay." Then you can just [advise] them to delete it and move on. We need to teach kids to really take the time to do that.

Clinicians who see children are in a wonderful position to help because our young patients are actually using their cell phones and texting in our offices, so we can actually throw these pearls out to them while we're doing our physical exam. It doesn't have to be part of a specific consultation on cyberbullying.

Medscape: It's very easy to be hurtful in email because there's no vocal tone that might soften certain language. What about young people who hurt each other unintentionally?

Dr. O'Keeffe: There is a type of cyberbullying called inadvertent cyberbullying, in which you don't mean to hurt someone but you do it nonetheless. You send the message accidentally, but it still goes out and is still harassing because the sender wasn't careful to send it appropriately.

Medscape: What are the cell phone issues that parents need to be aware of that can help ward off cyberbullying?

Dr. O'Keeffe: I think parents don't realize that cell phones tend to be the conduit for behavior because they're the grab-and-go devices. You can also use them not only for texting but to access social networking sites. Parents may not understand the shorthand behind texting and how kids can quickly shoot from the hip that they're angry or upset.

Medscape: Are there other cyber abuses beyond bullying that parents need to know about?

Dr. O'Keeffe: Yes, there are all sorts of cousins to cyberbullying, including cyberstalking, cyberharassment, and just plain old cyber-meanness. The point is that even if you don't know how to label it, if a child gets concerning digital communication from somebody and it bothers them enough that their behavior is changing, then the parent needs to do something.

Medscape: Could you talk a bit about sexting?

Dr. O'Keeffe: Sexting is one of our next biggest issues. It's usually the transmission of digital images via technology and cell phones. Even worse than cyberbullying, sexting always has legal ramifications. If young people who do it get caught, they are thrust into the legal system. Depending on their state's laws, they can even be tried and labeled as sex predators. So it's very, very important that everyone is educated about this problem. Even though it's beyond the scope of what we're talking about today, pediatricians are in a very unique position to remind families that if you're going to get cell phones for your kids, it does come with a responsibility.

So, when you talk to young people about the proper use of the features of the cell phones, that includes the camera, the Internet, and any other feature that allows the dissemination of a message, photo, or video.

Medscape: Is there anything that pediatricians or family physicians can do in general to deal with cyberbullying and cybersecurity?

Dr. O'Keeffe: It's not the clinician's job to necessarily get involved with the schools and law enforcement, but it is their job to support the family and help the family recognize that they're available for medical consultation and support, including assistance in finding proper psychiatric and behavioral healthcare.

Likely the most beneficial role, though, is in education. Pediatricians and family physicians could post information in their office, such as "Here's how you can help your kids learn about proper use of cell phones," or "Here's how you can help kids ward off digital issues." This is a simple way of getting information out without taking away time from your office.

Many physicians these days send out digital or printed newsletters, for example as reminders or information for annual flu shots. They could also include cyberbullying prevention information, such as cell phone safety tips.

I realize clinicians are busy, but they don't necessarily need to be the educator on this issue. They can help families find key resources, which might include my book and Website Cybersafe or other useful Websites (see Resources, below).

Medscape: How would you summarize the physician and parental roles?

Dr. O'Keeffe: This is happening to average kids because of social issues and their inability to always know the proper uses of technology due to their evolving development. I'm advocating that parents learn the technology and teach their kids how to use it smartly as they do many other safety areas in their kids' lives, such as cooking in the kitchen and driving a car. If clinicians can encourage parents to do that during routine visits, I think parents will feel more empowered that they can parent their kids in the digital arena, and more kids will have the skills to avoid digital mishaps that lead to cyberbullying and sexting.

Also, most clinicians today are trying to catch up on all of these issues, and if they're not, they should be. The more pediatricians and family physicians become savvy with the technology, the more parents will feel comfortable turning to them. It's sort of a, "Which came first, the chicken or the egg?" I believe parents are going to be calling their physicians more on these issues, so the professionals are going to have to catch up. It's all going to happen at the same time, so my best advice for pediatricians and family physicians is: don't wait until you start getting the deluge of calls from parents on these issues. Don't wait for the crisis. Learn about it now.

Summary Points

  • Cyberbullying is bullying with the use of technology, and there has to be pure intent to cause negative consequences for the other person.

  • Cybervictims may tend to be more vulnerable once they've been victimized online compared with in the schoolyard. In fact, studies have shown that cyberbullying has a much more profound impact than traditional schoolyard bullying.

  • Cyberbullying behavior often occurs because young people are often emotional and don't understand the rules of behavior or how to communicate to begin with. In addition, anonymity and the ease at being able to send a message increases the risk for this behavior.

  • Parents need to have a high index of suspicion if they observe physical and behavioral changes related to changes in their child's communication through their devices.

  • Parents and clinicians should take seriously any concern expressed by their child about cyberbullying.

  • Parents should print out all records of cyberbullying behavior and assess for degree of harm, including those that might require legal steps.

  • Simple steps to stop cyberbullying include blocking the bully on social media and working with email and phone carriers to block messages from the bully.

  • Use the mnemonic RITE, which helps young people learn to post appropriately.

    • Read any message that you write before you post it.

    • Imagine if you were receiving that message whether it would be hurtful in anyway.

    • Think about whether it needs to be sent now or if it can wait.

    • E is enter. You only want to hit "Enter" and send that message when you are sure that that message is the right one to send at the right time.

  • Sexting is particularly dangerous behavior because it has legal ramifications. If young people do it and get caught, they can be tried and labeled as sex predators.

  • The pediatrician or primary care clinician plays a major role in protecting children from cyberbullying.

    • They can monitor mental and physical health effects and serve as the conduit to a mental health provider.

    • They can post information in their office.

    • If they send out regular mailings to patients, they can include information on cyberbullying.

    • They can help families find key resources (see Resources, below)


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