ORIGINAL ARTICLE
Bullying among Jordanian schoolchildren, its effects on school performance, and the contribution of general physical and dentofacial features Zaid B. Al-Bitar,a Iyad K. Al-Omari,b Hawazen N. Sonbol,b Hazem T. Al-Ahmad,c and Susan J. Cunninghamd Amman, Jordan, and London, United Kingdom
Introduction: The aims of this study were to investigate the experience of bullying in a representative sample of Jordanian schoolchildren in Amman, to look at its effect on school attendance and perception of academic performance, and to look at the contribution of general physical and dentofacial features to this phenomenon. Methods: This was a cross-sectional study in which a representative sample of sixth-grade students (11-12 years of age) from randomly selected schools was asked to complete questionnaires distributed in the classroom in the presence of the researchers. The final sample size was 920 children (470 girls, 450 boys). Results: The prevalence of bullying was 47% (n 5 433); significantly more boys reported being bullied than girls (P \0.001). The percentage of students subjected to name-calling was 40.9%. A significantly greater proportion of victims of bullying reported playing truant from school and disliking school than those who were not bullied. Teeth were the number 1 feature targeted for bullying, followed by strength and weight. The 3 most commonly reported dentofacial features targeted by bullies were spacing between the teeth or missing teeth, shape or color of the teeth, and prominent maxillary anterior teeth. Conclusions: This study demonstrated a high prevalence of bullying in Jordanian schools, with many children experiencing bullying because of their dental or facial appearance. (Am J Orthod Dentofacial Orthop 2013;144:872-8)
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he problem of bullying in children and adolescents has become a global concern.1 The prevalence of bullying in middle-school children in highincome countries ranges from 5% to 57%.2-4 Data from the global school-based Student Health Survey examining 19 middle- and low-income countries reported bullying prevalences from 21% to 58%.5 Bullying is aggressive behavior or intentional harm carried out repeatedly over time in a relationship
a Associate professor and head, Department of Orthodontics and Pediatric Dentistry, University of Jordan, Amman, Jordan. b Associate professor, Department of Orthodontics and Pediatric Dentistry, University of Jordan, Amman, Jordan. c Associate professor, Department of Oral and Maxillofacial Surgery, University of Jordan, Amman, Jordan. d Professor and program director of orthodontics, University College London, Eastman Dental Institute, London, United Kingdom. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Zaid B. Al-Bitar, Department of Orthodontics and Pediatric Dentistry, University of Jordan, PO Box 13850, Amman 11942, Jordan; e-mail, [email protected]. Submitted, July 2013; revised and accepted, August 2013. 0889-5406/$36.00 Copyright Ó 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.08.016
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characterized by an imbalance of power.2 This can be direct bullying, which includes physical aggression (hitting, kicking) and verbal aggression (insults, threats); and indirect bullying, which involves manipulation of social relationships (gossip, rumors, social exclusion).6 The most common form of direct aggression is verbal abuse, which usually involves name-calling.7,8 Bullying among children and adolescents can occur in any setting, but it typically occurs at school or on the journey to and from school.2,9 The reported prevalence of bullying in school-aged children varies from study to study as a result of differences in the ages of the participants, study designs, cultures, and time frames used to determine the frequency of bullying.7 Bullying appears to be common among adolescents, and its incidence seems to reduce with increasing age.2 A recent study looking at bullying in 8- to 18-year-old students in 11 European countries found that 20.6% of the entire group reported being bullied, with the United Kingdom having the highest prevalence (29.5%).10 The implications of bullying are far-reaching, and studies have found relationships between bullying and depression, low self-esteem and
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other mental and physical health problems,11,12 poor academic performance,13 and crime.14 Few studies have looked at the impact of dentofacial features on bullying in schools. Dental features have been found to be targets for nicknames, harassment, and teasing among schoolchildren.15,16 In a sample of 531 schoolchildren (ages, 9-13 years), 7% suffered bullying related to a dental feature.15 In a group of adolescents awaiting orthodontic treatment, the prevalence of teasing related to dental appearance was reported to be 15%.17 In addition, comments about teeth were considered more hurtful than comments regarding other features such as height and weight.15 Specific dental characteristics that have been described as potentially associated with an increased risk of bullying include increased overjet, maxillary crowding, and deep overbite.15,16,18,19 To date, only 1 study has investigated the prevalence of bullying in Jordan.20 This earlier work reported that bullying occurred in 44.2% of 12- to 16-year-old Jordanian schoolchildren, but the authors looked only at the prevalence of bullying without further analysis of this phenomenon. There are limited data regarding the factors contributing to bullying in the Middle East; no studies have addressed this issue in Jordan. Therefore, the aims of this study were to investigate the experience of bullying in a representative sample of Jordanian schoolchildren in Amman, the effect of bullying on school attendance and perceived effects on academic performance, and the contribution of general physical and dentofacial features to bullying. MATERIAL AND METHODS
Ethical approval for the study was obtained from the Jordanian Ministry of Education and the Deanship of Scientific Research of the University of Jordan. This was a cross-sectional study. We recruited a representative sample of sixth-grade students (ages, 11-12 years) in Amman, the largest city and capital of Jordan with a population of over 2 million. Twelve schools were randomly selected from a list of all schools in the 6 educational directories in Amman obtained from the Jordanian Ministry of Education. A representative sample of sixth-grade students was drawn from each of the 6 directories; in total, 3.2% of the sixth-grade students were recruited. A questionnaire modified from that of Shaw et al15 was distributed to all subjects (Appendix). This was a structured, anonymous, self-reported questionnaire divided into 3 main sections: (1) personal experience of bullying; (2) feelings toward school and school attendance, and perceived effect on academic performance;
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and (3) general physical characteristics and dentofacial features targeted in the victims of bullying. Before commencing the research, a pilot study was undertaken with 20 students from the sixth grade to test the clarity of the questionnaire and the language used. In a few instances, the words were beyond the sixth-grade reading level; this problem was overcome by adding 1 or 2 simple descriptions so that each child was more likely to understand. Before distributing the questionnaires, information packs were sent to all school principals, who in turn sent them to the parents. The packs contained a letter to the parents informing them of the study goals and a passive consent form. It was made clear to all parents that they could ask that their child not be included in the study if they wished. Then the questionnaires were distributed in the classroom in the presence of the teacher, and a researcher was present to clarify any items in the questionnaire that were not clear to any student. The sample consisted of sixth-grade Jordanian schoolchildren in Amman (ages, 11-12 years) with no orthodontic appliance in situ. Children were excluded if they had a diagnosed congenital anomaly or syndrome. Any questionnaire that was not completed correctly was excluded. The total number of sixth-grade students in Amman during the academic year 2011 to 2012 was 29,157 (15,072 girls, 14,085 boys). A sample size calculation was undertaken using the Web site http://www. raosoft.com/samplesize.html. A 5% margin of error was selected, along with a 95% confidence interval and 50% response distribution. The calculated sample size was 380 students; however, because the questionnaire did not require simple yes or no answers but asked some more complex questions, it was aimed to recruit at least double the number to achieve a representative sample. Statistical analysis
Analysis of the data was conducted using SPSS software (version 16.0; SPSS, Chicago, Ill). Descriptive statistics were calculated for all measures including sex and the study variables. Chi-square tests were performed to compare responses between the sexes and also between the victims of bullying and those who were not bullied. A P value of \0.05 was accepted as statistically significant throughout. RESULTS
A total of 960 questionnaires were distributed equally between boys and girls. Forty questionnaires were not completed correctly, giving a response rate of
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98%. The final sample comprised 920 students (470 girls, 450 boys); they represented 3.2% of all sixthgrade students in Amman. Table I shows the experience of bullying: 47% of the students (n 5 433; 247 boys, 186 girls) reported being bullied in the past month, and boys were significantly more likely to report being bullied than were girls (P \0.001). Of those who reported being bullied, 44% (n 5 191) were bullied by 1 student, 40% (n 5 172) by 2 to 5 students, and 16% (n 5 70) by a group of 6 or more students. Boys reported being bullied by 6 or more people significantly more often than did girls (52 boys compared with 18 girls; P \0.001). Thirty-five percent of the children (n 5 325) reported that they had bullied someone else in the past month, and significantly more boys than girls reported bullying others (P \0.001; Table I). Most of these children reported bullying 1 student (40%), followed by 22% bullying 2 children, 13% bullying 3 children, 7% bullying 4 children, 5% bullying 5 children, and the rest (13%) bullying 6 or more children. The respondents were asked whether they had a nickname, and 57.6% (n 5 530) answered yes to this question, with boys having nicknames more frequently than girls (P \0.004). Of those who had a nickname, 27.7% (n 5 255) liked it, and 31.4% (n 5 289) did not mind, but 40.9% (n 5 376) did not like their nickname being used and found it upsetting. There was no statistically significant sex difference (chi-square test, P 5 0.138). Of the children who reported having a nickname they disliked (n 5 376), few of them identified who called them by this name, but of those who did (n 5 191), it was most frequently peers (n 5 72) and siblings (n 5 51). The questionnaire inquired about feelings toward school, school attendance, and perceived effects on academic performance. The majority of students (82.7%; n 5 761) reported liking their school classes, and only a small percentage (6.7%; n 5 62) disliked classes; girls were more likely to express enjoyment of their classes than were boys (P 5 0.003). The respondents were also asked whether they liked school outside classes, and 79% (n 5 729) reported that they did, with only 8.8% (n 5 81) expressing dislike of this element of school. Girls liked school outside classes significantly more than their male counterparts (P 5 0.022; Table II). Playing truant from school was also an important issue; 15.7% (n 5 144) of the participants reported playing truant from school because of bullying; boys played truant more frequently than did girls (P 5 0.001). Table II shows the results for the respondents' feelings toward school, playing truant from school, and being a victim of bullying.
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Table I. Numbers of students who were victims of bullying or reported bullying other students Total Boys Girls (n 5 920) (n 5 450) (n 5 470) P (%) (%) (%) value Victim of bullying 433 (47) 247 (55) 186 (40) \0.001 189 (42) 136 (29) \0.001 Bullied someone else 325 (35)
Table II. Relationships between feelings toward
school, playing truant from school, and bullying Total Bullied Not bullied (n 5 920) (n 5 433) (n 5 487) (%) (%) (%) Class Hate Ambivalent Like Outside class Hate Ambivalent Like Playing truant 1 day 2-3 days 4 or more days
P value
62 (6.7) 97 (10.5) 761 (82.7)
45 (10.4) 55 (12.7) 333 (76.9)
17 (3.5) 42 (8.6) 428 (87.7)
\0.001
81 (8.8) 110 (12) 729 (79) 144 (15.7) 40 (4.3) 56 (6.1) 49 (5.3)
56 (12.7) 56 (12.7) 321 (74.1) 117 (27) 35 (8.1) 44 (10.2) 40 (9.2)
25 (5.1) 54 (11.1) 408 (83.7) 27 (5.5) 5 (1) 12 (2.5) 9 (1.8)
\0.001 \0.001
Some victims of bullying thought that bullying had harmed their school grades; 40% (n 5 171) stated that they believed their grades had been harmed a great deal, and 33% (n 5 141) thought that there had been a small effect. In contrast, 28% (n 5 122) did not think that bullying had any effect on their academic performance. When students were asked whether they were bullied for having good grades, 35% (n 5 151) answered yes. General physical characteristics and dentofacial features were targeted in the victims of bullying. Of the 433 students who reported being bullied, this was directed at various physical features (Table III). Teeth were the number 1 feature identified by students as a target for bullying, with 50% of the bullying victims recognizing its importance as a target. This was following by strength in 34% and weight in 31% of the students. There was no significant difference in reporting between the sexes for any physical feature. The dentofacial features that were identified as targets for bullying (n 5 433) are shown in Table IV. Spaced or missing teeth were commented on most frequently by 21.5% of those reported being bullied. This was followed by the shape and color of teeth (20.6%) and prominent anterior teeth (19.6%). There was no significant difference in reporting between the sexes for any of these dentofacial features.
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Table III. Physical features reported by victims of
bullying (n 5 433) Teeth Strength Weight Hair Height Clothes Eyes Nose Glasses Ears Lips Freckles Chin
n 216 149 133 131 118 112 80 74 74 73 62 50 38
% 50 34 31 30 27 26 19 17 17 17 14 12 9
Boys 124 88 72 74 67 64 45 38 42 50 37 23 25
Girls 92 61 61 57 51 48 35 36 32 23 25 27 13
Table IV. Dentofacial features identified as targets for bullying by victims (n 5 433) Total Dentofacial feature Spacing between teeth or missing teeth Shape or color of teeth Prominent anterior teeth Anterior open bite Crowding of teeth Gummy smile Prominent mandibular anterior teeth Retrognathic mandible Incompetent lips Prognathic mandible
n 93 89 85 61 33 19 18 14 12 11
% 21.5 20.6 19.6 14.1 7.6 4.4 4.2 3.2 2.8 2.5
Boys
Girls
n 53 49 50 35 20 12 14 9 8 10
n 40 40 35 26 13 7 4 5 4 1
DISCUSSION
This is the first study to investigate factors contributing to bullying among Jordanian school children and especially dentofacial features. Of course, the sociocultural context of 1 Middle Eastern country does not necessarily extend to the rest of the world; this limits the generalizability of the findings. However, these findings are important, and similar studies could be undertaken in other countries to determine the magnitude of the problem and to allow comparison of the results. The sample size in this study was good, with 920 students included in the analysis; this represented 3.2% of all sixth-grade students in Amman. The number of students was increased above the calculated sample size to investigate the contribution of a variety of dentofacial features to bullying. Some of these features have relatively low prevalences in the population; hence, a larger sample size was thought to be appropriate. Students with orthodontic appliances were excluded because this would have been a confounding variable when the aim of the study was to investigate bullying related to
existing dentofacial features rather than to orthodontic appliances. Children in the sixth grade (ages, 11-12 years) were selected because previous studies have reported that most children who were bullied were 12 years or younger, and this allowed our results to be compared with previous studies.5,8 Younger children were not included in the study because it would have been difficult to ensure adequate understanding of the questionnaire and guarantee that the questions were answered accurately. The children in this study were asked to complete a questionnaire regarding bullying. The original questionnaire used by Shaw et al15 was used with some additional questions to assess the impact of bullying on school performance and to look at other dentofacial features that could contribute to this phenomenon. Questionnaires have been used to investigate teasing and bullying in several cross-sectional studies.5,16 A questionnaire was used rather than interviews because the participants might not have disclosed embarrassing or painful memories and denied bullying during direct questioning in interviews.20 The questions regarding bullying were limited to a specific time interval of 1 month before questionnaire distribution to prevent any difficulty in recalling events related to bullying. However, there might still have been certain limitations in using this questionnaire because the participants could have differed in their interpretation of bullying behavior. In a previous study of 2457 Jordanian schoolchildren, the percentage of children who reported being bullied was 44.2%.5 This is similar to our results, with 47% of the subjects reporting being bullied in the past month. This prevalence was similar to that reported in other Middle Eastern countries such as Lebanon (33.6%) and Oman (38.9%) but higher than the reported figure for the United Arab Emirates (20.9%).5 The results of this study were also higher than similarly aged schoolchildren in the United Kingdom (15%),8 Holland (14%),21 and the United States (8.5%).22 These differences between countries might reflect cultural and social differences as well as antibullying programs in schools and nationwide policies against bullying, both found in countries where the prevalence of bullying is relatively low.23 In Jordan, bullying as a topic has been given great attention, yet there are no policies or support services to help those who are bullied or to prevent it. Significantly more boys reported being bullied than girls in this study; this agrees with previous research in Jordan.5 This was also seen in all 40 countries investigated in a study on bullying and victimization in
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adolescents, and this appears to be a reflection of bullying as a dominance strategy in boys.23 The percentage of students who were subjected to name-calling and did not like their nickname (40.9%) was similar to the percentage of students who reported being bullied (47%). This also agrees with previous research showing that the most common direct aggression was verbal abuse in the form of name-calling.21 As in most studies, peers were identified as most likely to be involved in name-calling.8,15,20 Bullying has been found to have negative effects with respect to feelings toward school and school attendance.24,25 In this study, significantly more victims of bullying reported playing truant from school (27%) compared with those who were not bullied (5.5%). This is similar to another survey in the United Kingdom that found that 20% of elementary, middle, and high school children said they would play truant from school to avoid being bullied.24 In another study in Turkey, 25% of the students who reported being bullied had unexplained absenteeism from school significantly more often than those who were not in the bullying cycle (15.9%).26 However, other researchers found that being a victim of bullying was not associated with lower attendance by elementary school students.27 We found that significantly more victims of bullying disliked both being in class and being outside class compared with those who were not bullied. This also agrees with previous research.27,28 There is a belief that bullying impairs concentration and academic achievement.22,29 In this study, when students were asked whether they believed that bullying harmed their grades, 40% of the victims answered yes. Furthermore, 35% of the victims believed that they were being bullied for their good grades. It therefore appears that bullying can be the result of multiple factors, including physical attributes and academic abilities. Teeth were the physical feature that appeared to be targeted most frequently by bullies, followed by strength and weight. In the study by Shaw at al,15 teeth were ranked fourth and preceded by height, weight, and hair. The difference in findings might be explained by the fact that dental esthetics have become a key factor in social attractiveness in our modern society.30,31 The dentofacial features about which victims were most commonly bullied were spaced or missing teeth, shape and color of teeth, and prominent maxillary anterior teeth. These findings were similar to those reported by Shaw et al,15 although in their study children identified dental features from pictures of other children with various dental features and measured their potential as targets for bulling and teasing. In our study, the children
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were asked which dentofacial features they had been bullied about. A recent study of orthodontic patients found that being bullied was significantly associated with a Class II Division 1 incisor relationship, increased overbite, increased overjet, and high need for orthodontic treatment as assessed with the aesthetic component of the index of orthodontic treatment need.16 Other dentofacial features not included in the study by Shaw et al but reported by victims of bullying in this study were the shape and color of the teeth, anterior open bite, gummy smile, and incompetent lips. A main limitation of this study is that our findings were based only on self-reported questionnaires without clinical examinations. However, it would have been technically difficult to conduct such examinations on a large sample in schools that lack clinical facilities. More importantly, it was feared that if students were examined clinically, it might make the whole procedure more personal, and they might not disclose any information about bullying. Therefore, this study can be regarded as a baseline that will give insight about bullying in Jordan. Further studies could be planned in the future to include clinical examinations and other age groups not included in this study. Further work should also be done to clearly determine whether orthodontic treatment reduces bullying. The results of this study highlight the importance of addressing the bullying problem in Jordanian schools, and it provides important data especially for the Ministry of Education, which is responsible for ensuring that students receive education in a safe and healthy environment, to create nationwide antibullying programs. In addition, dental and health care professionals should have a role in implementing preventive measures and programs to address the sources of this common phenomenon related to dentofacial characteristics. CONCLUSIONS
Our study demonstrated a high experience of bullying reported by Jordanian students, with a significant number of children being targeted for their dental and facial appearances. This has important implications for the dental profession as a whole and for orthodontists in particular. The possibility of distress caused by bullying must be considered when patients come to clinics, with advice provided as appropriate. ACKNOWLEDGMENTS
We thank Mahmoud Mohammad, Abdullah Abbushi, and Abedalrahman Shqaidef for their help in data collection.
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REFERENCES
16. Seehra J, Fleming PS, Newton T, DiBiase AT. Bullying in orthodontic patients and its relationship to malocclusion, self-esteem and oral health-related quality of life. J Orthod 2011;38:247-56. 17. O'Brien C, Benson PE, Marshman Z. Evaluation of a quality of life measure for children with malocclusion. J Orthod 2007;34: 185-93. 18. Helm S, Kreiborg S, Solow B. Psychosocial implications of malocclusion: a 15-year follow-up study in 30-year-old Danes. Am J Orthod 1985;87:110-8. 19. Gosney MB. An investigation into some of the factors influencing the desire for orthodontic treatment. Br J Orthod 1986;13: 87-94. 20. Whitney I, Smith PK. A survey of the nature and extent of bullying in junior/middle and secondary schools. Educ Res 1993;35:3-25. 21. Fekkes M, Pijpers FI, Verloove-Vanhorick SP. Bullying behaviour and association with psychosomatic complaints and depression in victims. J Pediatr 2004;144:17-22. 22. Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simons-Morton B, Scheidt P. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA 2005;285(16): 2094-100. 23. Craig W, Harel-Fisch Y, Fogel-Grinvald H, Dostaler S, Hetland J, Simons-Morton B, et al. A cross-national profile of bullying and victimization among adolescents in 40 countries. HBSC Violence & Injuries Prevention Focus Group; HBSC Bullying Writing Group. Int J Public Health 2009;54(Suppl 2):S216-24. 24. Sharp S. How much does bullying hurt? Educ Child Psychol 1995; 12:81-8. 25. Byrne B. Bullies and victims in school setting with reference to some Dublin schools. Ir J Psychol Med 1994;15:574-86. 26. Arslan S, Savaser S, Yazgan Y. Prevalence of peer bullying in high school students in Turkey and the roles of socio-cultural and demographic factors in the bullying cycle. Indian J Pediatr 2011; 78:987-92. 27. Glew GM, Fan MY, Katon W, Rivara FP, Kernic MA. Bullying, psychosocial adjustment, and academic performance in elementary school. Arch Pediatr Adolesc Med 2005;159:1026-31. 28. Haynie D, Nansel T, Eitel P, Crump A, Saylor K, Yu K. Bullies, victims, and bully/victims: distinct groups of at risk youth. J Early Adolesc 2001;21:29-49. 29. Schwartz D, Gorman A. A community violence exposure and children's academic functioning. J Educ Psychol 2003;95:163-73. 30. Kerosuo H, Hausen H, Laine T, Shaw WC. The influence of incisal malocclusion on the social attractiveness of young adults in Finland. Eur J Orthod 1995;17:505-12. 31. Olsen JA, Inglehart MR. Malocclusions and perceptions of attractiveness, intelligence, and personality, and behavioral intentions. Am J Orthod Dentofacial Orthop 2011;140:669-79.
1. Carney AG, Merrell KW. Perspectives on understanding and preventing an international problem. Sch Psychol Int 2001;22:364-82. 2. Olweus D. Bullying at school: basic facts and effects of a school based intervention program. J Child Psychol Psychiatry 1994;35: 1171-90. 3. Unnever JD, Cornell DG. The culture of bullying in middle school. J Sch Violence 2003;2:5-27. 4. Spriggs AL, Iannotti RJ, Nansel TR, Haynie DL. Adolescent bullying involvement and perceived family peer and school relations: commonalities and differences across race/ethnicity. J Adolesc Health 2007;41:283-93. 5. Fleming LC, Jacobsen KH. Bullying among middle-school students in low and middle income countries. Health Promot Int 2010;25: 73-84. 6. Nansel TR, Craig W, Overpeck MD, Saluja G, Ruan WJ. Health Behaviour in School-aged Children Bullying Analyses Working Group. Cross-national consistency in the relationship between bullying behaviors and psychosocial adjustment. Arch Pediatr Adolesc Med 2004;158:730-6. 7. Solberg ME, Olweus D, Endresen IM. Bullies and victims at school: are they the same pupils? Br J Educ Psychol 2007;77: 441-64. 8. Boulton MJ, Underwood K. Bully/victim problems among middle school children. Br J Educ Psychol 1992;62:73-87. 9. Pellegrini AD. Bullied and victims in school: a review and call for research. J Appl Dev Psychol 1998;19:156-76. 10. Analitis F, Velderman MK, Ravens-Sieberer U, Detmar S, Erhart M, Herdman M, et al. European Kidscreen Group. Being bullied: associated factors in children and adolescents 8 to 18 years old in 11 European countries. Pediatrics 2009;123:569-77. 11. Kumpulainen K, R€as€anen E. Children involved in bullying at elementary school age: their psychiatric symptoms and deviance in adolescence. An epidemiological sample. Child Abuse Negl 2000;24:1567-77. 12. Hawker DS, Boulton MJ. Twenty years' research on peer victimization and psychosocial maladjustment: a meta-analytic review of cross-sectional studies. J Child Psychol Psychiatry 2000;41: 441-55. 13. Pellegrini AD. Bullying during the middle school years. In: Sanders CE, Phye GD, editors. Bullying: implications for the classroom. San Diego, Calif: Elsevier; 2004. 14. Pepler D, Craig W, Jiang D, Connolly J. The development of bullying. Int J Adolesc Med Health 2008;20:113-9. 15. Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the salience of dental features among school children. Br J Orthod 1980;7:75-80.
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APPENDIX
9. How much do you think that school bullying harms your grades?
Questionnaire (translated from Arabic) Are you: male , female ,
(a) Not at all (b) Very little (c) A lot
What is your date of birth? / / 1. Have you been bullied by any student(s) from school in the past month? Yes No -
If your answer was YES, by how many students? (a) One person (b) A group of 2 to 5 students (c) A group of 6 or more students
If your answer was YES, how many students have you bullied? 0 1 2 3 4 5 6 or more
3. Have you ever skipped school because of bullying? Yes No 4. Do you have a nickname?
Yes
No
5. Who calls you by this name? (a) Siblings (b) Peers (c) Others 6. What do you think about being called by this nickname? (a) I like it (b) I do not mind it (c) I do not like it 7. How happy are you in your classes at school? (a) Unhappy (b) I am neither happy or unhappy (c) Happy 8. How happy are you in school outside of classes? (a) Unhappy (b) I am neither happy or unhappy (c) Happy
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(a) Not at all (b) Very little (c) A lot 11. Please answer yes or no to the following:
2. Have you bullied any student from school in the past month? Yes No -
10. How much do you get bullied because of good grades or for showing interest in schoolwork?
Yes
No
Have you ever been bullied about height? Have you ever been bullied about weight? Have you ever been bullied about strength? Have you ever been bullied about your eyes? Have you ever been bullied about your nose? Have you ever been bullied about your ears? Have you ever been bullied about your lips? Have you ever been bullied about your chin? Have you ever been bullied about your hair? Have you ever been bullied about freckles? Have you ever been bullied about your clothes? Have you ever been bullied about wearing glasses? Have you ever been bullied about your teeth?
12.
If you answered yes to being bullied about your teeth, chin, or lips, please select which items on the following list you have been bullied about (you may select more than one answer): Yes
No
Top front teeth sticking out Bottom front teeth sticking out Chin sticking out Chin too far back Crooked teeth Shape or color of teeth Having a gap between the teeth or having missing teeth Top front teeth not covering your bottom teeth and having gaps between the front teeth when your back teeth are biting together Showing too much gum above your upper front teeth when you smile Being unable to close your lips comfortably or showing too much of your front teeth
American Journal of Orthodontics and Dentofacial Orthopedics
Bullying among Jordanian schoolchildren, its effects on school performance, and the contribution of general physical and dentofacial features Zaid B. Al-Bitar,a Iyad K. Al-Omari,b Hawazen N. Sonbol,b Hazem T. Al-Ahmad,c and Susan J. Cunninghamd Amman, Jordan, and London, United Kingdom
Introduction: The aims of this study were to investigate the experience of bullying in a representative sample of Jordanian schoolchildren in Amman, to look at its effect on school attendance and perception of academic performance, and to look at the contribution of general physical and dentofacial features to this phenomenon. Methods: This was a cross-sectional study in which a representative sample of sixth-grade students (11-12 years of age) from randomly selected schools was asked to complete questionnaires distributed in the classroom in the presence of the researchers. The final sample size was 920 children (470 girls, 450 boys). Results: The prevalence of bullying was 47% (n 5 433); significantly more boys reported being bullied than girls (P \0.001). The percentage of students subjected to name-calling was 40.9%. A significantly greater proportion of victims of bullying reported playing truant from school and disliking school than those who were not bullied. Teeth were the number 1 feature targeted for bullying, followed by strength and weight. The 3 most commonly reported dentofacial features targeted by bullies were spacing between the teeth or missing teeth, shape or color of the teeth, and prominent maxillary anterior teeth. Conclusions: This study demonstrated a high prevalence of bullying in Jordanian schools, with many children experiencing bullying because of their dental or facial appearance. (Am J Orthod Dentofacial Orthop 2013;144:872-8)
T
he problem of bullying in children and adolescents has become a global concern.1 The prevalence of bullying in middle-school children in highincome countries ranges from 5% to 57%.2-4 Data from the global school-based Student Health Survey examining 19 middle- and low-income countries reported bullying prevalences from 21% to 58%.5 Bullying is aggressive behavior or intentional harm carried out repeatedly over time in a relationship
a Associate professor and head, Department of Orthodontics and Pediatric Dentistry, University of Jordan, Amman, Jordan. b Associate professor, Department of Orthodontics and Pediatric Dentistry, University of Jordan, Amman, Jordan. c Associate professor, Department of Oral and Maxillofacial Surgery, University of Jordan, Amman, Jordan. d Professor and program director of orthodontics, University College London, Eastman Dental Institute, London, United Kingdom. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Zaid B. Al-Bitar, Department of Orthodontics and Pediatric Dentistry, University of Jordan, PO Box 13850, Amman 11942, Jordan; e-mail, [email protected]. Submitted, July 2013; revised and accepted, August 2013. 0889-5406/$36.00 Copyright Ó 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.08.016
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characterized by an imbalance of power.2 This can be direct bullying, which includes physical aggression (hitting, kicking) and verbal aggression (insults, threats); and indirect bullying, which involves manipulation of social relationships (gossip, rumors, social exclusion).6 The most common form of direct aggression is verbal abuse, which usually involves name-calling.7,8 Bullying among children and adolescents can occur in any setting, but it typically occurs at school or on the journey to and from school.2,9 The reported prevalence of bullying in school-aged children varies from study to study as a result of differences in the ages of the participants, study designs, cultures, and time frames used to determine the frequency of bullying.7 Bullying appears to be common among adolescents, and its incidence seems to reduce with increasing age.2 A recent study looking at bullying in 8- to 18-year-old students in 11 European countries found that 20.6% of the entire group reported being bullied, with the United Kingdom having the highest prevalence (29.5%).10 The implications of bullying are far-reaching, and studies have found relationships between bullying and depression, low self-esteem and
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other mental and physical health problems,11,12 poor academic performance,13 and crime.14 Few studies have looked at the impact of dentofacial features on bullying in schools. Dental features have been found to be targets for nicknames, harassment, and teasing among schoolchildren.15,16 In a sample of 531 schoolchildren (ages, 9-13 years), 7% suffered bullying related to a dental feature.15 In a group of adolescents awaiting orthodontic treatment, the prevalence of teasing related to dental appearance was reported to be 15%.17 In addition, comments about teeth were considered more hurtful than comments regarding other features such as height and weight.15 Specific dental characteristics that have been described as potentially associated with an increased risk of bullying include increased overjet, maxillary crowding, and deep overbite.15,16,18,19 To date, only 1 study has investigated the prevalence of bullying in Jordan.20 This earlier work reported that bullying occurred in 44.2% of 12- to 16-year-old Jordanian schoolchildren, but the authors looked only at the prevalence of bullying without further analysis of this phenomenon. There are limited data regarding the factors contributing to bullying in the Middle East; no studies have addressed this issue in Jordan. Therefore, the aims of this study were to investigate the experience of bullying in a representative sample of Jordanian schoolchildren in Amman, the effect of bullying on school attendance and perceived effects on academic performance, and the contribution of general physical and dentofacial features to bullying. MATERIAL AND METHODS
Ethical approval for the study was obtained from the Jordanian Ministry of Education and the Deanship of Scientific Research of the University of Jordan. This was a cross-sectional study. We recruited a representative sample of sixth-grade students (ages, 11-12 years) in Amman, the largest city and capital of Jordan with a population of over 2 million. Twelve schools were randomly selected from a list of all schools in the 6 educational directories in Amman obtained from the Jordanian Ministry of Education. A representative sample of sixth-grade students was drawn from each of the 6 directories; in total, 3.2% of the sixth-grade students were recruited. A questionnaire modified from that of Shaw et al15 was distributed to all subjects (Appendix). This was a structured, anonymous, self-reported questionnaire divided into 3 main sections: (1) personal experience of bullying; (2) feelings toward school and school attendance, and perceived effect on academic performance;
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and (3) general physical characteristics and dentofacial features targeted in the victims of bullying. Before commencing the research, a pilot study was undertaken with 20 students from the sixth grade to test the clarity of the questionnaire and the language used. In a few instances, the words were beyond the sixth-grade reading level; this problem was overcome by adding 1 or 2 simple descriptions so that each child was more likely to understand. Before distributing the questionnaires, information packs were sent to all school principals, who in turn sent them to the parents. The packs contained a letter to the parents informing them of the study goals and a passive consent form. It was made clear to all parents that they could ask that their child not be included in the study if they wished. Then the questionnaires were distributed in the classroom in the presence of the teacher, and a researcher was present to clarify any items in the questionnaire that were not clear to any student. The sample consisted of sixth-grade Jordanian schoolchildren in Amman (ages, 11-12 years) with no orthodontic appliance in situ. Children were excluded if they had a diagnosed congenital anomaly or syndrome. Any questionnaire that was not completed correctly was excluded. The total number of sixth-grade students in Amman during the academic year 2011 to 2012 was 29,157 (15,072 girls, 14,085 boys). A sample size calculation was undertaken using the Web site http://www. raosoft.com/samplesize.html. A 5% margin of error was selected, along with a 95% confidence interval and 50% response distribution. The calculated sample size was 380 students; however, because the questionnaire did not require simple yes or no answers but asked some more complex questions, it was aimed to recruit at least double the number to achieve a representative sample. Statistical analysis
Analysis of the data was conducted using SPSS software (version 16.0; SPSS, Chicago, Ill). Descriptive statistics were calculated for all measures including sex and the study variables. Chi-square tests were performed to compare responses between the sexes and also between the victims of bullying and those who were not bullied. A P value of \0.05 was accepted as statistically significant throughout. RESULTS
A total of 960 questionnaires were distributed equally between boys and girls. Forty questionnaires were not completed correctly, giving a response rate of
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98%. The final sample comprised 920 students (470 girls, 450 boys); they represented 3.2% of all sixthgrade students in Amman. Table I shows the experience of bullying: 47% of the students (n 5 433; 247 boys, 186 girls) reported being bullied in the past month, and boys were significantly more likely to report being bullied than were girls (P \0.001). Of those who reported being bullied, 44% (n 5 191) were bullied by 1 student, 40% (n 5 172) by 2 to 5 students, and 16% (n 5 70) by a group of 6 or more students. Boys reported being bullied by 6 or more people significantly more often than did girls (52 boys compared with 18 girls; P \0.001). Thirty-five percent of the children (n 5 325) reported that they had bullied someone else in the past month, and significantly more boys than girls reported bullying others (P \0.001; Table I). Most of these children reported bullying 1 student (40%), followed by 22% bullying 2 children, 13% bullying 3 children, 7% bullying 4 children, 5% bullying 5 children, and the rest (13%) bullying 6 or more children. The respondents were asked whether they had a nickname, and 57.6% (n 5 530) answered yes to this question, with boys having nicknames more frequently than girls (P \0.004). Of those who had a nickname, 27.7% (n 5 255) liked it, and 31.4% (n 5 289) did not mind, but 40.9% (n 5 376) did not like their nickname being used and found it upsetting. There was no statistically significant sex difference (chi-square test, P 5 0.138). Of the children who reported having a nickname they disliked (n 5 376), few of them identified who called them by this name, but of those who did (n 5 191), it was most frequently peers (n 5 72) and siblings (n 5 51). The questionnaire inquired about feelings toward school, school attendance, and perceived effects on academic performance. The majority of students (82.7%; n 5 761) reported liking their school classes, and only a small percentage (6.7%; n 5 62) disliked classes; girls were more likely to express enjoyment of their classes than were boys (P 5 0.003). The respondents were also asked whether they liked school outside classes, and 79% (n 5 729) reported that they did, with only 8.8% (n 5 81) expressing dislike of this element of school. Girls liked school outside classes significantly more than their male counterparts (P 5 0.022; Table II). Playing truant from school was also an important issue; 15.7% (n 5 144) of the participants reported playing truant from school because of bullying; boys played truant more frequently than did girls (P 5 0.001). Table II shows the results for the respondents' feelings toward school, playing truant from school, and being a victim of bullying.
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Table I. Numbers of students who were victims of bullying or reported bullying other students Total Boys Girls (n 5 920) (n 5 450) (n 5 470) P (%) (%) (%) value Victim of bullying 433 (47) 247 (55) 186 (40) \0.001 189 (42) 136 (29) \0.001 Bullied someone else 325 (35)
Table II. Relationships between feelings toward
school, playing truant from school, and bullying Total Bullied Not bullied (n 5 920) (n 5 433) (n 5 487) (%) (%) (%) Class Hate Ambivalent Like Outside class Hate Ambivalent Like Playing truant 1 day 2-3 days 4 or more days
P value
62 (6.7) 97 (10.5) 761 (82.7)
45 (10.4) 55 (12.7) 333 (76.9)
17 (3.5) 42 (8.6) 428 (87.7)
\0.001
81 (8.8) 110 (12) 729 (79) 144 (15.7) 40 (4.3) 56 (6.1) 49 (5.3)
56 (12.7) 56 (12.7) 321 (74.1) 117 (27) 35 (8.1) 44 (10.2) 40 (9.2)
25 (5.1) 54 (11.1) 408 (83.7) 27 (5.5) 5 (1) 12 (2.5) 9 (1.8)
\0.001 \0.001
Some victims of bullying thought that bullying had harmed their school grades; 40% (n 5 171) stated that they believed their grades had been harmed a great deal, and 33% (n 5 141) thought that there had been a small effect. In contrast, 28% (n 5 122) did not think that bullying had any effect on their academic performance. When students were asked whether they were bullied for having good grades, 35% (n 5 151) answered yes. General physical characteristics and dentofacial features were targeted in the victims of bullying. Of the 433 students who reported being bullied, this was directed at various physical features (Table III). Teeth were the number 1 feature identified by students as a target for bullying, with 50% of the bullying victims recognizing its importance as a target. This was following by strength in 34% and weight in 31% of the students. There was no significant difference in reporting between the sexes for any physical feature. The dentofacial features that were identified as targets for bullying (n 5 433) are shown in Table IV. Spaced or missing teeth were commented on most frequently by 21.5% of those reported being bullied. This was followed by the shape and color of teeth (20.6%) and prominent anterior teeth (19.6%). There was no significant difference in reporting between the sexes for any of these dentofacial features.
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Table III. Physical features reported by victims of
bullying (n 5 433) Teeth Strength Weight Hair Height Clothes Eyes Nose Glasses Ears Lips Freckles Chin
n 216 149 133 131 118 112 80 74 74 73 62 50 38
% 50 34 31 30 27 26 19 17 17 17 14 12 9
Boys 124 88 72 74 67 64 45 38 42 50 37 23 25
Girls 92 61 61 57 51 48 35 36 32 23 25 27 13
Table IV. Dentofacial features identified as targets for bullying by victims (n 5 433) Total Dentofacial feature Spacing between teeth or missing teeth Shape or color of teeth Prominent anterior teeth Anterior open bite Crowding of teeth Gummy smile Prominent mandibular anterior teeth Retrognathic mandible Incompetent lips Prognathic mandible
n 93 89 85 61 33 19 18 14 12 11
% 21.5 20.6 19.6 14.1 7.6 4.4 4.2 3.2 2.8 2.5
Boys
Girls
n 53 49 50 35 20 12 14 9 8 10
n 40 40 35 26 13 7 4 5 4 1
DISCUSSION
This is the first study to investigate factors contributing to bullying among Jordanian school children and especially dentofacial features. Of course, the sociocultural context of 1 Middle Eastern country does not necessarily extend to the rest of the world; this limits the generalizability of the findings. However, these findings are important, and similar studies could be undertaken in other countries to determine the magnitude of the problem and to allow comparison of the results. The sample size in this study was good, with 920 students included in the analysis; this represented 3.2% of all sixth-grade students in Amman. The number of students was increased above the calculated sample size to investigate the contribution of a variety of dentofacial features to bullying. Some of these features have relatively low prevalences in the population; hence, a larger sample size was thought to be appropriate. Students with orthodontic appliances were excluded because this would have been a confounding variable when the aim of the study was to investigate bullying related to
existing dentofacial features rather than to orthodontic appliances. Children in the sixth grade (ages, 11-12 years) were selected because previous studies have reported that most children who were bullied were 12 years or younger, and this allowed our results to be compared with previous studies.5,8 Younger children were not included in the study because it would have been difficult to ensure adequate understanding of the questionnaire and guarantee that the questions were answered accurately. The children in this study were asked to complete a questionnaire regarding bullying. The original questionnaire used by Shaw et al15 was used with some additional questions to assess the impact of bullying on school performance and to look at other dentofacial features that could contribute to this phenomenon. Questionnaires have been used to investigate teasing and bullying in several cross-sectional studies.5,16 A questionnaire was used rather than interviews because the participants might not have disclosed embarrassing or painful memories and denied bullying during direct questioning in interviews.20 The questions regarding bullying were limited to a specific time interval of 1 month before questionnaire distribution to prevent any difficulty in recalling events related to bullying. However, there might still have been certain limitations in using this questionnaire because the participants could have differed in their interpretation of bullying behavior. In a previous study of 2457 Jordanian schoolchildren, the percentage of children who reported being bullied was 44.2%.5 This is similar to our results, with 47% of the subjects reporting being bullied in the past month. This prevalence was similar to that reported in other Middle Eastern countries such as Lebanon (33.6%) and Oman (38.9%) but higher than the reported figure for the United Arab Emirates (20.9%).5 The results of this study were also higher than similarly aged schoolchildren in the United Kingdom (15%),8 Holland (14%),21 and the United States (8.5%).22 These differences between countries might reflect cultural and social differences as well as antibullying programs in schools and nationwide policies against bullying, both found in countries where the prevalence of bullying is relatively low.23 In Jordan, bullying as a topic has been given great attention, yet there are no policies or support services to help those who are bullied or to prevent it. Significantly more boys reported being bullied than girls in this study; this agrees with previous research in Jordan.5 This was also seen in all 40 countries investigated in a study on bullying and victimization in
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adolescents, and this appears to be a reflection of bullying as a dominance strategy in boys.23 The percentage of students who were subjected to name-calling and did not like their nickname (40.9%) was similar to the percentage of students who reported being bullied (47%). This also agrees with previous research showing that the most common direct aggression was verbal abuse in the form of name-calling.21 As in most studies, peers were identified as most likely to be involved in name-calling.8,15,20 Bullying has been found to have negative effects with respect to feelings toward school and school attendance.24,25 In this study, significantly more victims of bullying reported playing truant from school (27%) compared with those who were not bullied (5.5%). This is similar to another survey in the United Kingdom that found that 20% of elementary, middle, and high school children said they would play truant from school to avoid being bullied.24 In another study in Turkey, 25% of the students who reported being bullied had unexplained absenteeism from school significantly more often than those who were not in the bullying cycle (15.9%).26 However, other researchers found that being a victim of bullying was not associated with lower attendance by elementary school students.27 We found that significantly more victims of bullying disliked both being in class and being outside class compared with those who were not bullied. This also agrees with previous research.27,28 There is a belief that bullying impairs concentration and academic achievement.22,29 In this study, when students were asked whether they believed that bullying harmed their grades, 40% of the victims answered yes. Furthermore, 35% of the victims believed that they were being bullied for their good grades. It therefore appears that bullying can be the result of multiple factors, including physical attributes and academic abilities. Teeth were the physical feature that appeared to be targeted most frequently by bullies, followed by strength and weight. In the study by Shaw at al,15 teeth were ranked fourth and preceded by height, weight, and hair. The difference in findings might be explained by the fact that dental esthetics have become a key factor in social attractiveness in our modern society.30,31 The dentofacial features about which victims were most commonly bullied were spaced or missing teeth, shape and color of teeth, and prominent maxillary anterior teeth. These findings were similar to those reported by Shaw et al,15 although in their study children identified dental features from pictures of other children with various dental features and measured their potential as targets for bulling and teasing. In our study, the children
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were asked which dentofacial features they had been bullied about. A recent study of orthodontic patients found that being bullied was significantly associated with a Class II Division 1 incisor relationship, increased overbite, increased overjet, and high need for orthodontic treatment as assessed with the aesthetic component of the index of orthodontic treatment need.16 Other dentofacial features not included in the study by Shaw et al but reported by victims of bullying in this study were the shape and color of the teeth, anterior open bite, gummy smile, and incompetent lips. A main limitation of this study is that our findings were based only on self-reported questionnaires without clinical examinations. However, it would have been technically difficult to conduct such examinations on a large sample in schools that lack clinical facilities. More importantly, it was feared that if students were examined clinically, it might make the whole procedure more personal, and they might not disclose any information about bullying. Therefore, this study can be regarded as a baseline that will give insight about bullying in Jordan. Further studies could be planned in the future to include clinical examinations and other age groups not included in this study. Further work should also be done to clearly determine whether orthodontic treatment reduces bullying. The results of this study highlight the importance of addressing the bullying problem in Jordanian schools, and it provides important data especially for the Ministry of Education, which is responsible for ensuring that students receive education in a safe and healthy environment, to create nationwide antibullying programs. In addition, dental and health care professionals should have a role in implementing preventive measures and programs to address the sources of this common phenomenon related to dentofacial characteristics. CONCLUSIONS
Our study demonstrated a high experience of bullying reported by Jordanian students, with a significant number of children being targeted for their dental and facial appearances. This has important implications for the dental profession as a whole and for orthodontists in particular. The possibility of distress caused by bullying must be considered when patients come to clinics, with advice provided as appropriate. ACKNOWLEDGMENTS
We thank Mahmoud Mohammad, Abdullah Abbushi, and Abedalrahman Shqaidef for their help in data collection.
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REFERENCES
16. Seehra J, Fleming PS, Newton T, DiBiase AT. Bullying in orthodontic patients and its relationship to malocclusion, self-esteem and oral health-related quality of life. J Orthod 2011;38:247-56. 17. O'Brien C, Benson PE, Marshman Z. Evaluation of a quality of life measure for children with malocclusion. J Orthod 2007;34: 185-93. 18. Helm S, Kreiborg S, Solow B. Psychosocial implications of malocclusion: a 15-year follow-up study in 30-year-old Danes. Am J Orthod 1985;87:110-8. 19. Gosney MB. An investigation into some of the factors influencing the desire for orthodontic treatment. Br J Orthod 1986;13: 87-94. 20. Whitney I, Smith PK. A survey of the nature and extent of bullying in junior/middle and secondary schools. Educ Res 1993;35:3-25. 21. Fekkes M, Pijpers FI, Verloove-Vanhorick SP. Bullying behaviour and association with psychosomatic complaints and depression in victims. J Pediatr 2004;144:17-22. 22. Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simons-Morton B, Scheidt P. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA 2005;285(16): 2094-100. 23. Craig W, Harel-Fisch Y, Fogel-Grinvald H, Dostaler S, Hetland J, Simons-Morton B, et al. A cross-national profile of bullying and victimization among adolescents in 40 countries. HBSC Violence & Injuries Prevention Focus Group; HBSC Bullying Writing Group. Int J Public Health 2009;54(Suppl 2):S216-24. 24. Sharp S. How much does bullying hurt? Educ Child Psychol 1995; 12:81-8. 25. Byrne B. Bullies and victims in school setting with reference to some Dublin schools. Ir J Psychol Med 1994;15:574-86. 26. Arslan S, Savaser S, Yazgan Y. Prevalence of peer bullying in high school students in Turkey and the roles of socio-cultural and demographic factors in the bullying cycle. Indian J Pediatr 2011; 78:987-92. 27. Glew GM, Fan MY, Katon W, Rivara FP, Kernic MA. Bullying, psychosocial adjustment, and academic performance in elementary school. Arch Pediatr Adolesc Med 2005;159:1026-31. 28. Haynie D, Nansel T, Eitel P, Crump A, Saylor K, Yu K. Bullies, victims, and bully/victims: distinct groups of at risk youth. J Early Adolesc 2001;21:29-49. 29. Schwartz D, Gorman A. A community violence exposure and children's academic functioning. J Educ Psychol 2003;95:163-73. 30. Kerosuo H, Hausen H, Laine T, Shaw WC. The influence of incisal malocclusion on the social attractiveness of young adults in Finland. Eur J Orthod 1995;17:505-12. 31. Olsen JA, Inglehart MR. Malocclusions and perceptions of attractiveness, intelligence, and personality, and behavioral intentions. Am J Orthod Dentofacial Orthop 2011;140:669-79.
1. Carney AG, Merrell KW. Perspectives on understanding and preventing an international problem. Sch Psychol Int 2001;22:364-82. 2. Olweus D. Bullying at school: basic facts and effects of a school based intervention program. J Child Psychol Psychiatry 1994;35: 1171-90. 3. Unnever JD, Cornell DG. The culture of bullying in middle school. J Sch Violence 2003;2:5-27. 4. Spriggs AL, Iannotti RJ, Nansel TR, Haynie DL. Adolescent bullying involvement and perceived family peer and school relations: commonalities and differences across race/ethnicity. J Adolesc Health 2007;41:283-93. 5. Fleming LC, Jacobsen KH. Bullying among middle-school students in low and middle income countries. Health Promot Int 2010;25: 73-84. 6. Nansel TR, Craig W, Overpeck MD, Saluja G, Ruan WJ. Health Behaviour in School-aged Children Bullying Analyses Working Group. Cross-national consistency in the relationship between bullying behaviors and psychosocial adjustment. Arch Pediatr Adolesc Med 2004;158:730-6. 7. Solberg ME, Olweus D, Endresen IM. Bullies and victims at school: are they the same pupils? Br J Educ Psychol 2007;77: 441-64. 8. Boulton MJ, Underwood K. Bully/victim problems among middle school children. Br J Educ Psychol 1992;62:73-87. 9. Pellegrini AD. Bullied and victims in school: a review and call for research. J Appl Dev Psychol 1998;19:156-76. 10. Analitis F, Velderman MK, Ravens-Sieberer U, Detmar S, Erhart M, Herdman M, et al. European Kidscreen Group. Being bullied: associated factors in children and adolescents 8 to 18 years old in 11 European countries. Pediatrics 2009;123:569-77. 11. Kumpulainen K, R€as€anen E. Children involved in bullying at elementary school age: their psychiatric symptoms and deviance in adolescence. An epidemiological sample. Child Abuse Negl 2000;24:1567-77. 12. Hawker DS, Boulton MJ. Twenty years' research on peer victimization and psychosocial maladjustment: a meta-analytic review of cross-sectional studies. J Child Psychol Psychiatry 2000;41: 441-55. 13. Pellegrini AD. Bullying during the middle school years. In: Sanders CE, Phye GD, editors. Bullying: implications for the classroom. San Diego, Calif: Elsevier; 2004. 14. Pepler D, Craig W, Jiang D, Connolly J. The development of bullying. Int J Adolesc Med Health 2008;20:113-9. 15. Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the salience of dental features among school children. Br J Orthod 1980;7:75-80.
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APPENDIX
9. How much do you think that school bullying harms your grades?
Questionnaire (translated from Arabic) Are you: male , female ,
(a) Not at all (b) Very little (c) A lot
What is your date of birth? / / 1. Have you been bullied by any student(s) from school in the past month? Yes No -
If your answer was YES, by how many students? (a) One person (b) A group of 2 to 5 students (c) A group of 6 or more students
If your answer was YES, how many students have you bullied? 0 1 2 3 4 5 6 or more
3. Have you ever skipped school because of bullying? Yes No 4. Do you have a nickname?
Yes
No
5. Who calls you by this name? (a) Siblings (b) Peers (c) Others 6. What do you think about being called by this nickname? (a) I like it (b) I do not mind it (c) I do not like it 7. How happy are you in your classes at school? (a) Unhappy (b) I am neither happy or unhappy (c) Happy 8. How happy are you in school outside of classes? (a) Unhappy (b) I am neither happy or unhappy (c) Happy
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(a) Not at all (b) Very little (c) A lot 11. Please answer yes or no to the following:
2. Have you bullied any student from school in the past month? Yes No -
10. How much do you get bullied because of good grades or for showing interest in schoolwork?
Yes
No
Have you ever been bullied about height? Have you ever been bullied about weight? Have you ever been bullied about strength? Have you ever been bullied about your eyes? Have you ever been bullied about your nose? Have you ever been bullied about your ears? Have you ever been bullied about your lips? Have you ever been bullied about your chin? Have you ever been bullied about your hair? Have you ever been bullied about freckles? Have you ever been bullied about your clothes? Have you ever been bullied about wearing glasses? Have you ever been bullied about your teeth?
12.
If you answered yes to being bullied about your teeth, chin, or lips, please select which items on the following list you have been bullied about (you may select more than one answer): Yes
No
Top front teeth sticking out Bottom front teeth sticking out Chin sticking out Chin too far back Crooked teeth Shape or color of teeth Having a gap between the teeth or having missing teeth Top front teeth not covering your bottom teeth and having gaps between the front teeth when your back teeth are biting together Showing too much gum above your upper front teeth when you smile Being unable to close your lips comfortably or showing too much of your front teeth
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