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From the Centers for Disease Control and Massachusetts Department of Public Health

Study Finds Strong Link Between Bullying and Mental Health Problems, Family Violence, Drug and Alcohol Use

Those who both bully and are victims of bullying more likely to consider suicide, engage self-mutilation, and be abused at home

Middle and high school students who are both bullies and victims of bullying are three times more likely than students who are neither to seriously consider suicide, intentionally injure themselves, report being physically abused by a family member, witness violence in their family, and to use drugs and alcohol, says the Centers for Disease Control and Prevention (CDC).1  

"The findings of increased risk for bullies, victims, and bully-victims of being physically hurt by a family member or witnessing family violence underscore the association between bullying and events outside of the school,"  the study says. "A comprehensive approach that encompasses school officials, students, and their families is needed to prevent bullying among middle and high school students," the CDC concludes.

More bullying in middle school

Analyzing data obtained from the Massachusetts Youth Health Survey, researchers from the Massachusetts Department of Public Health and the CDC's National Center for Chronic Disease Prevention and Health Promotion found that:

  • sizable percentages of middle school (43.9%) and high school (30.5%) students were involved in or affected by bullying.
  • Among middle students, 26.8% reported being victims of bullying, 9.6% acknowledged being both bullies and victims of bullying, and 7.5% admitted to being bullies.
  • Among high school students, 15,6% said they were victims of bullying, 8.4% acknowledged being bullies, and 6.5% reported being bully-victims.
  • A significantly smaller percentage of middle school students (56.0%) than high school students (69.5%) were categorized as neither bullies nor victims. 

More male bullies than female bullies

  • Among both middle school and high school students, a greater percentage of males (9.9% for middle school and 12.1% for high school) than females (5.0% for middle school and 4.8% for high school) were categorized as bullies.
  • A greater percentage of females (29.8% for middle school and 17.8% for high school) than males (24.1% for middle school and 13.3% for high school) were categorized as victims.
  • No significant gender difference was observed in the percentage categorized as bully-victims, either in middle school or high school.

Mental health problems for bully-victims

The study found a strong association between being a bully-victim and mental health problems.

Compared with students who were neither bullies nor bullying victims, both middle and high school bully-victims were more likely to report seriously considering suicide (24.9% versus 4.5% for middle school; 22.5% versus 6.2% for high school); or intentionally injuring themselves (40.9% versus 8.4% for middle school; 28.5% versus 8.6% for high school).

Bully-victims and family violence linked

Compared with students who were neither bullies nor bullying victims, both middle and high school bully-victims were more likely to report being physically hurt by a family member (23.2% versus 5.1% for middle school; 20.4% versus 4.7% for high school), and witnessing violence in their family (22.8% versus 6.6% for middle school; 30.6% versus 7.2% for high school).

The study suggests associations between violent family encounters (i.e., being physically hurt or witnessing violence by a family member) and being bullied, bullying, and being a bully-victim.  Bully-victims are more likely to report violent family encounters than bullies, and bullies are more likely to report such encounters than victims.  "This finding expands upon previous documentation of an association between childhood exposure to family violence and subsequent mental health problems (e.g. anxiety and depression)5 and involvement in general physical aggression, dating violence, and weapon carrying.6

Alcohol and drug use linked to bullying

Sizable percentages of both bullies and bully-victims acknowledged recent use of alcohol (32.7% and 22.7%, respectively, for middle school students; 63.2% and 56.3%, respectively, for high school) and recent use of drugs (32.0% and 19.9%, respectively, for middle school; 47.2% and 41.0%, respectively, for high school).

By comparison, smaller percentages of bullying victims and students who had been neither bullies nor victims acknowledged recent use of alcohol (6.9% and 8.1%, respectively, for middle school students; 31.7% and 38.5%, respectively, for high school) and recent use of drugs (5.0% and 4.5%, respectively, for middle school; 19.6% and 23.1%, respectively, for high school).

Previous studies

Multiple studies have  previously documented the association between substance use, poor academic achievement, mental health problems, and bullying.2, 3 A small but growing body of research suggests that family violence is also associated with bullying.4

The results from the CDC study are consistent with previous findings that:

  • bullies and victims have an elevated risk for both depression and suicide3,8
  • risk factors are more common among bully-victims than students categorized as bullies or victims;8-10 and
  • being a bully is associated with alcohol and drug use.3,10

The results, however, differ from those presented in some earlier studies3,9 which found males more likely to be bullies and victims, although researchers speculated that the difference might be due to the fact that the CDC report defined bullying victimization broadly to include physical, verbal, and relational bullying, such as social exclusion and spreading rumors, which is more prevalent among female students.4

Pervasive public health problem

"Bullying is a pervasive public health problem requiring comprehensive solutions," says the report. "The results underscore the importance of primary bullying prevention programs and of comprehensive programs and strategies that involve families.  Although evidence of bullying prevention programs changing behavior among U.S. students is mixed,7 several violence prevention programs and strategies, including some involving families, have demonstrated effectiveness in decreasing violent behavior," the report notes. 

In May 2010, Massachusetts joined 44 other states with similar laws by enacting a comprehensive bullying prevention law that covers all types of bullying and requires all school districts to develop, adhere to, and update a plan to address bullying prevention and intervention in consultation with school staff members, families, and community members.

To assist schools in their efforts to implement comprehensive strategies to prevent bullying, other types of violence, and unintentional injuries, the CDC developed School Health Guidelines to Prevent Unintentional Injuries and Violence.

These guidelines include the following recommendations:

  1. establish a social school environment that promotes safety;
  2. provide access to health and mental health services;
  3. integrate school, family, and community prevention efforts; and
  4. provide training to enable staff members to promote safety and prevent violence effectively.

Because bullying is associated with many other risk factors, including exposure to violence outside of the school setting, comprehensive strategies that encompass the school, family, and community are most likely to be effective.

To assist schools and communities in their efforts to prevent youth violence, including bullying, the CDC has launched the national initiative, Striving To Reduce Youth Violence Everywhere (STRYVE), which promotes increased awareness that youth violence can be prevented using strategies based on the best available evidence. Links to resources are available on the STRYVE website.

Study details

To assess the association between family violence and other risk factors and being involved in or affected by bullying as a bully, victim, or bully-victim, the Massachusetts Department of Public Health and CDC analyzed data from the 2009 Massachusetts Youth Health Survey.

Students were asked two questions related to bullying:

  • The first question was "During the past 12 months, how many times have you been bullied at school (being bullied included being repeatedly teased, threatened, hit, kicked, or excluded by another student or group of students)?" Response categories ranged from zero times to 12 or more times. Those who reported being bullied one or more times were categorized as victims.
  • The second question, which immediately followed the first, consisted of two parts. Students were asked "Did you do any of the following in the past 12 months? a) bully or push someone around, and b) initiate or start a physical fight with someone." Response options for the second question were yes or no for each part. Those who responded yes to part "a" were categorized as bullies. Responses to part "b" were not considered in categorizing students as bullies because not enough information was available to determine whether or not initiating a physical fight should be considered bullying.

Responses to the two bullying questions were combined to create four mutually exclusive categories:

  1. Bullies were those who responded that they were not bullied but acknowledged that they were bullies;
  2. Victims were those who responded that they had been bullied but were not bullies;
  3. Bully-victims were those who responded both that they had been bullied and that they were bullies; and
  4.  "Neither" were those who responded that they had been neither bullied nor were bullies.

1. McKenna M, Hawk E, Mullen J. Bullying Among Middle School and High School Students -- Massachusett, 2009.  MMWR (2011). 60(15);465-471.

2. Gini G, Pozzoli T. Association between bullying and psychosomatic problems: a meta-analysis. Pediatrics 2009;123:1059--65.

3. 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 2001;285:2094--100.

4. Cook CR, Williams KR, Guerra NG, Kim TE, Sadek S. Predictors of bullying and victimization in childhood and adolescence: a meta-analytic review. Sch Psychol Q 2010;25:65--83.

5. Johnson RM, Kotch JB, Catellier DJ, et al. Adverse behavioral and emotional outcomes from child abuse and witnessed violence. Child Maltreat 2002;7:179--86.

6. Duke NN, Pettingell SL, McMorris BJ, Borowsky IW. Adolescent violence perpetration: associations with multiple types of adverse childhood experiences. Pediatrics 2010;125:e778--86.

7. Merrell KW, Gueldner BA, Ross SW, Isava DM. How effective are school bullying intervention programs? A meta-analysis of intervention research. Sch Psychol Q 2008;23:26--42.

8. Kaltiala-Heino R, Rimpelä M, Marttunen M, Rimpelä A, Rantanen P. Bullying, depression, and suicidal ideation in Finnish adolescents: school survey. BMJ 1999;319:348--51.

9. Haynie DL, Nansel T, Eitel P. Bullies, victims, and bully/victims: distinct groups of at-risk youth. Journal of Early Adolescence 2001;21:29--49.

10. Lyznicki JM, McCaffree MA, Robinowitz CB. Childhood bullying: implications for physicians. Am Fam Physician 2004;70:1723--30.

11. Robers S, Zhang J, Truman J. Indicators of school crime and safety: 2010. Washington, DC: US Department of Education, National Center for Education Statistics, and US Department of Justice, Bureau of Justice Statistics; 2010. Available at http://nces.ed.gov/programs/crimeindicators/crimeindicators2010External Web Site Icon. Accessed April 18, 2011.

Posted April 21, 2011 Updated August 2, 2018

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