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syndrome need to be based on population data that
include births and terminations of pregnancy.
We acknowledge the role of South Australian midwives and
neonatal nurses in providing perinatal data and of doctors in
providing data on congenital abnormalities; the contribution of
staff of the South Australian Births Defects Register and the
Pregnancy Outcome Unit in processing and collating data on
babies with Down’s syndrome, births, and terminations of preg-
nancy; and the staff of the department of cytogenetics and
molecular genetics, Women’s and Children’s Hospital, and of the
department of cytogenetics, Queen Elizabeth Hospital, for pro-
viding cytogenetic data.
Contributors: AC initiated and planned the study, reviewed
the literature, performed the univariate analysis, participated in
the interpretation of data, and wrote the paper. KAM performed
the Poisson regression analysis and participated in the planning
of the study, the interpretation of data, and writing the paper.
RJK participated in the planning of the study, the validation of
some case details, the retrieval and preparation of data for
analysis, and editing the manuscript. EAH participated in plan-
ning the study, interpreting the data, and editing the manuscript.
AC and KAM are guarantors for the paper.
Funding: None.
Conflict of interest: None.
1 Schimmel MS, Eidelman AI, Zadka P, Kornbluth E, Hammerman C.
Increased parity and risk of trisomy 21: review of 37 110 live births [with
commentary by R Lilford]. BMJ 1997;314:720-1.
2 McCullagh P, Nelder JA. Generalised linear models . 2nd ed. London: Chap-
man and Hall, 1989.
3 SAS Institute. SAS/STAT Software: The GENMOD procedure, release 6.09.
Cary, NC: SAS Institute, 1993.
4 Halliday J, Lumley J, Watson L. Comparison of women who do and do
not have amniocentesis or chorionic villus sampling. Lancet
1995;345:704-9.
(Accepted 27 February 1998)
Bullying in schools: self reported anxiety, depression, and
self esteem in secondary school children
G Salmon, A James, D M Smith
Evidence exists of considerable problems with bullying
and bullied children in secondary schools. In the larg-
est survey in the United Kingdom to date 10% of
pupils reported that they had been bullied “sometimes
or more often” during that term, with 4% reporting
being bullied “at least once a week.”
1
The impact of the
introduction of policies on bullying throughout a
school seems to be limited.
1
The commonest type of
bullying is general name calling, followed by being hit,
threatened, or having rumours spread about one.
1
Bul-
lying is thought to be more prevalent among boys and
the youngest pupils in a school.
2
We are unaware of any study that has examined the
mental health problems of children who are being bul-
lied. We assessed self reported anxiety, depression, and
self esteem in bullied children and those who were not
bullied and in bullies and those who were not bullies.
Subjects, methods, and results
Four questionnaires (the Olweus bully/victim,
2
the
short mood and feelings,
3
the revised children’s mani-
fest anxiety incorporating a lie scale,
4
and the
Rosenberg self esteem
5
questionnaires) were anony-
mously completed by 904 pupils aged 12-17 in years
8-11 in two coeducational secondary schools. School A
is a non-selective school in a socially disadvantaged
urban area. School B is a rural grant maintained school
in an area with a higher than average proportion of
high social class households.
Logistic regression models were fitted to the
proportions of bullied or bullying children using
stata. Categorical variables were school, school year,
and sex. Anxiety, lying, esteem, and depression scores
were treated as continuous variables. The table shows
the odds ratios of the fitted logistic regression models.
Relative risk (per unit increase in variable) of Down’s syndrome for age, parity, gravidity, and previous miscarriage, 1986-95 and 1986-90, South Australia
Variable
Births and terminations Births only
1986-95 (284 cases of Down’s
syndrome, 197 912 births)
1986-90 (128 cases of Down’s
syndrome, 98 561 births)
1986-95 (171 cases of Down’s
syndrome, 197 912 births)
1986-90 (100 cases of Down’s
syndrome, 98 561 births)
Relative risk (95% CI) P value Relative risk (95% CI) P value Relative risk (95% CI) P value Relative risk (95% CI) P value
Univariate analysis
Age 1.202 (1.142 to 1.266) 0.0001 1.170 (1.097 to 1.247) 0.0001 1.129 (1.103 to 1.155) 0.0001 1.131 (1.099 to 1.165) 0.0001
Parity 1.256 (0.997 to 1.581) 0.0769 1.260 (0.946 to 1.677) 0.1461 1.235 (1.105 to 1.380) 0.0006 1.245 (1.078 to 1.438) 0.0059
Gravidity 1.176 (0.988 to 1.398) 0.0931 1.168 (0.940 to 1.452) 0.1944 1.131 (1.036 to 1.235) 0.0099 1.107 (0.977 to 1.254) 0.1269
Previous miscarriage 1.148 (0.769 to 1.715) 0.5307 1.066 (0.599 to 1.896) 0.8338 1.078 (0.849 to 1.370) 0.5526 0.883 (0.559 to 1.394) 0.5751
Multivariate analysis
Parity and age:
Parity 0.964 (0.777 to 1.196) 0.7378 0.990 (0.751 to 1.306) 0.9442 1.038 (0.942 to 1.145) 0.4554 1.032 (0.912 to 1.168) 0.6215
Age 1.206 (1.142 to 1.273) 0.0001 1.171 (1.093 to 1.254) 0.0001 1.125 (1.098 to 1.153) 0.0001 1.128 (1.094 to 1.163) 0.0001
Gravidity and age:
Gravidity 0.961 (0.810 to 1.141) 0.6463 0.972 (0.778 to 1.215) 0.8006 0.987 (0.909 to 1.071) 0.7541 0.949 (0.846 to 1.065) 0.3637
Age 1.208 (1.143 to 1.276) 0.0001 1.173 (1.095 to 1.258) 0.0001 1.130 (1.102 to 1.159) 0.0001 1.138 (1.100 to 1.177) 0.0001
Previous miscarriage and age:
Previous miscarriage 0.929 (0.642 to 1.344) 0.6865 0.875 (0.516 to 1.483) 0.6003 0.933 (0.777 to 1.121) 0.4480 0.743 (0.529 to 1.044) 0.0584
Age 1.205 (1.142 to 1.270) 0.0001 1.173 (1.098 to 1.254) 0.0001 1.131 (1.103 to 1.159) 0.0001 1.138 (1.098 to 1.179) 0.0001
Papers
Highfield
Adolescent Unit,
Warneford Hospital,
Oxford OX3 7JX
G Salmon,
senior registrar in
child and adolescent
psychiatry
A James,
consultant in child
and adolescent
psychiatry
continued over
BMJ 1998;317:924–5
924 BMJ VOLUME 317 3 OCTOBER 1998 www.bmj.com
For anxiety, esteem, lying, and depression the odds
ratios are for a change of one standard deviation of
6.22, 4.92, 2.13, and 5.44 respectively (pooled SD). The
prevalence of being bullied “sometimes or more often”
was 4.2%. Significant variables (P < 0.05) for being bul-
lied were school, sex, and anxiety and lying scores;
school year approached significance (P = 0.06). The
prevalence of bullying others “sometimes or more
often” was 3.4%. Significant variables (P < 0.05) for
being a bully were school year, sex, and anxiety, lying,
and depression scores. The esteem score featured in
neither model.
Boys in year 8 in school A with high anxiety and
lying scores were most likely to be bullied. Girls in year
9 in school B with low anxiety and lying scores were
least likely to be bullied. Boys in year 10 with low anxi-
ety and lying scores and high depression scores were
most likely to be bullies. Girls in year 8 with high anxi-
ety and lying scores and low depression scores were
least likely to be bullies.
Comment
Bullied children tend to be in the lower school years.
The low prevalence of bullying (4.2%) may reflect the
effectiveness of bullying interventions already in place
in the two schools. Our data support the idea that bul-
lied children are more anxious and bullies equally or
less anxious than their peers.
2
New findings from the
study are the relation between having a high lying
score and being bullied and having a high depression
score and being a bully. The male to female ratio of
bullies (3:1) is lower than that previously reported
(4:1).
2
This may indicate that bullying interventions are
having more of an impact on the direct bullying char-
acteristic of boys and less on the indirect bullying more
common among girls.
Our results should be viewed with caution because
our study is small, but they suggest factors that could be
important.
Contributors: GS and AJ initiated the study and designed the
protocol. GS collected and collated the data. DS performed the
analyses. GS, AJ, and DS interpreted the results, discussed their
meaning, and wrote the article. AJ is the guarantor for the study.
Funding: Oxfordshire Health Services Research Fund.
Conflict of interest: None.
1 Smith PK, Sharp S, eds. School bullying: insights and perspectives. London:
Routledge, 1994.
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 Angold A, Costello EJ, Messer SC, Pickles A, Winder F, Silver D. Develop-
ment of a short questionnaire for use in epidemiological studies of
depression in children and adolescents. Int J Methods Psychiatric Res
1995;5:136.1-13.
4 Reynolds CR, Richmond BO. What I think and feel: a revised measure of
children’s manifest anxiety. J Abnormal Child Psychology 1978;6:271-80.
5 Rosenberg M. Conceiving the self. New York: Basic Books, 1986.
(Accepted 13 May 1998)
Summary statistics and details of fitted models. Values are numbers of schoolchildren unless stated otherwise
Variable
Being bullied or bullying Details of fitted logistic regression model
No Yes Parameter Odds ratio (95% CI) z P value
Bullied children (mean score for being bullied >2)
School:
A 377 24
B/A 0.37 (0.16 to 0.87) −2.29 0.022
B 489 14
School year:
8 224 16
9 237 8 9/8 0.34 (0.11 to 1.05) −1.88 0.060
10 194 9 10/8 0.51 (0.16 to 1.61) −1.14 0.253
11 211 5 11/8 0.53 (0.16 to 1.76) −1.03 0.302
Sex:
Male 439 23
Female 427 15 Female/male 0.36 (0.15 to 0.89) −2.22 0.026
Mean (SD) score:
Anxiety 9.71 (6.00) 17.71 (6.75) Anxiety 3.24 (1.78 to 5.91) 3.83 <0.001
Esteem 29.27 (4.75) 24.97 (6.38) Esteem 1.15 (0.66 to 2.00) 0.49 0.627
Lying 2.52 (2.10) 3.37 (2.33) Lying 1.96 (1.33 to 2.89) 3.39 0.001
Depression 5.88 (5.13) 12.92 (7.95) Depression 1.45 (0.83 to 2.54) 1.29 0.196
Bullying children (mean score for bullying others >2)
School:
A 382 19
B/A 0.63 (0.26 to 1.49) −1.06 0.290
B 491 12
School year:
8 235 5
9 235 10 9/8 4.65 (0.95 to 22.84) 1.89 0.058
10 189 14 10/8 8.37 (1.77 to 39.62) 2.68 0.007
11 214 2 11/8 1.31 (0.17 to 9.79) 0.26 0.795
Sex:
Male 439 23
Female 434 8 Female/male 0.24 (0.08 to 0.72) −2.57 0.010
Mean (SD) score:
Anxiety 10.11 (6.27) 8.32 (5.24) Anxiety 0.36 (0.18 to 0.71) −2.96 0.003
Esteem 29.08 (4.8) 29.48 (5.93) Esteem 1.32 (0.75 to 2.31) 0.96 0.337
Lying 2.59 (2.19) 2.13 (1.31) Lying 0.41 (0.23 to 0.76) −2.87 0.004
Depression 6.12 (5.46) 7.77 (5.22) Depression 3.29 (1.63 to 6.66) 3.32 0.001
Papers
Centre for Statistics
in Medicine,
Institute of Health
Sciences, Oxford
OX3 7LF
D M Smith,
senior medical
statistician
Correspondence to:
Dr James
Tony.James@oxmhc-tr.
anglox.nhs.uk
925BMJ VOLUME 317 3 OCTOBER 1998 www.bmj.com
