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Bullying and Ostracism Experiences in

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 Original Article

Bullying and Ostracism Experiences in Children With Special

Health Care Needs
Kimberly A. Twyman, MD,* Conway F. Saylor, PhD, Danielle Saia, Eds,
Michelle M. Macias, MD,* Lloyd A. Taylor, PhD, Eve Spratt, MD*

ABSTRACT: Objective: Bullying experiences are becoming increasingly common in children and can have
devastating consequences. Ostracism threatens a childs need for self-esteem, sense of belonging, sense of
control, and meaningful existence. Recent literature suggests that children with special health care needs may
be at risk for these negative events and consequences. This study compares bullying and ostracism experi-
ences in children with and without various special health care needs. Methods: Participants aged 8 to 17 years
completed questionnaires during a routine primary care or subspecialty clinic visit. Children with learning
disabilities (N 34), attention deficit or hyperactivity disorder (N 100), autism spectrum disorders (N 32),
behavioral or mental health disorders (N 33), and cystic fibrosis (CF, N 22) were compared with 73 control
children with no diagnosis on Reynolds Bully-Victimization Scale scores and a 15-item pilot ostracism scale.
Results: Compared with the control group, children in the learning disabilities, autism spectrum disorders, and
attention deficit or hyperactivity disorder groups exhibited significant victimization scores on the Bully-
Victimization Scale, whereas the behavioral or mental health disorders group had increased mean victimiza-
tion scores. The learning disabilities group also reported clinically significant bullying. The CF group did not
report involvement as bullies or victims. All children with special health care needs groups had increased
mean frequency of threats to basic needs related to ostracism, and children with attention deficit or hyper-
activity disorder and autism spectrum disorders were at higher risk for ostracism experiences. Conclusion:
Children with special health care needs may be at higher risk for bullying, victimization, and ostracism. Further
research is needed to explore this relationship, especially as it relates to child adjustment. Children with
special health care needs should be asked about bullying and ostracism experiences and potential effects as
part of mental health screening.
(J Dev Behav Pediatr 31:18, 2010) Index terms: bullying, peer victimization, ostracism, children with special needs, children with chronic medical
conditions.

B ullying, also known as peer victimization, involves

the physical, verbal, or psychological abuse of a peer and
has become an increasingly reported problem in US
schools, with one large study1 reporting that 25% to
30% of children are involved in bullying. Unlike peer
conflict where the children involved are equally
matchedphysically and/or psychologically, bullying in-
volves a power imbalance between the aggressor and
the target, where the target has difficulty to defend him
or herself and feels helpless against the aggressor.2 Bul-
lying occurs over time, and the actions are intended to
harm the target.2 Children may be involved as bullies,
victims, or both as bully victims.2,3 Physical bullying is
the most visible, and involves actions such as hitting,
From the *Division of Developmental Pediatrics and Genetics, Department of
Pediatrics, Medical University of South Carolina; and Department of Psychology,
The Citadel, Charleston, SC.
Received June 24, 2009; accepted October 27, 2009.
Address for reprints: Kimberly A. Twyman, MD, Department of Pediatrics, Saint
Louis University, 1465 S. Grand Blvd., St. Louis, MO 63104; e-mail:
twymank@slu.edu.
Copyright 2010 Lippincott Williams & Wilkins
kicking, and taking ones belongings. Verbal bullying
involves teasing, taunting, spreading rumors, and
threats. The type and frequency of bullying varies with
age and gender. Younger children report more bullying
experiences than older children.1 Boys experience more
physical bullying,1 whereas girls more commonly report
more relational aggression.4
Bullying by means of electronic media (also known as
cyber-bullying) has had increased visibility and includes
spreading rumors via e-mail, web pages, social network-
ing sites, instant messaging, and text messaging by cell
phone. Cyber-bullying may be especially harmful be-
cause it can occur any time of day and have more
far-reaching effects.5 There is a significant variability in
the definition and frequency of cyber-bullying between
research studies, making it difficult to determine the true
impact of the problem. One national survey of middle-
and high-school students found that 43% of students
reported they were victims of cyber-bullying in the pre-
vious year.6
Ostracism is a type of social exclusion where the
target is completely ignored and made to feel like they
do not exist. Williams7 hypothesized a theoretical model

Vol. 31, No. 1, January 2010 www.jdbp.org | 1

of ostracism as threatening four of a persons basic
needs: the need for a sense of belonging, the need for
control over ones environment, the need for self-es-
teem, and the need for meaningful existence. This the-
oretical framework is based on several decades of older
research on social exclusion and ostracism.7 Studies in-
volving adults have shown that being ostracized for as
brief a period as 5 minutes has a significant negative
impact, producing feelings of sadness, anger, and nega-
tivity.7 Functional magnetic resonance imaging studies
have shown that when people are ostracized, the dorsal
anterior cingulate gyrus becomes activated, which is the
same area activated when people experience physical
pain.8 Williams and Nida9 propose that the effects of
ostracism may potentially be more devastating than bul-
lying, because victims of bullying are at least acknowl-
edged for their existence, whereas ostracism makes the
person feel invisible. Ostracism is similar to relational
aggression in that children are ignored and excluded in
both, making children feel rejected, lonely, depressed,
and isolated.4,7 No research shows the actual difference
between ostracism, rejection, and social exclusion. Will-
liams makes the distinction that ostracism can happen
even before an initial interaction (as seen in rejection),
and that usually it occurs without much explanation or
attention (as in social exclusion).
Children with special health care needs, including
physical disabilities, behavioral or emotional problems,
learning difficulties, and chronic medical illness may also
be at risk for bullying experiences. A review of epidemi-
ological data from the 2003 National Survey of Childrens
Health suggests that children with special health care
needs are at higher risk to be both victims and bullies
compared with children without special health care
needs, and are twice as likely to be considered a bully-
victim10; however, this study was based on a telephone
survey of parents. Children with attention deficit or
hyperactivity disorder (ADHD) often have social difficul-
ties and externalizing behaviors that place them at
higher risk for both bullying and victimization.11 A pre-
liminary study using part of our dataset conducted by
Taylor et al12 showed that children with ADHD had
increased mean victimization scores compared with chil-
dren with no diagnosis and reported more clinically
significant victimization. The study by Taylor et al was
performed with fewer participants than this study and
did not assess ostracism. Children with ADHD who are
victimized, especially those with comorbid diagnoses,
have also been shown to exhibit internalizing and exter-
nalizing behavior problems.12,13
Similarly, children with autism also have higher rates
of victimization.14 However, in another examination of
the data from the 2003 National Survey of Childrens
Health, Montes and Halterman15 found that children
with autism and comorbid ADHD were more likely to be
bullies than children without autism (59.8% versus
23.9%, respectively). Children with autism and no ADHD
2 Bullying in Children With Special Needs
symptoms were no more likely to engage in bullying
than children without autism.
Like children with ADHD and autism spectrum disor-
der, youth with learning disabilities may have immature
social development and are at greater risk of being tar-
gets of bullying,16 and children who have more severe
learning disabilities are victimized more often than chil-
dren with milder disabilities.17 Children with special
health care needs who receive special education services
are also more likely to be bullied than children in main-
stream classes,17 whereas children with special needs
who participated in an inclusion program reported less
victimization.18
Children with chronic medical conditions are at risk
for bullying and victimization, although in general they
are well liked by their peers.19 Children with Type I
diabetes report higher rates of relational victimization
and decreased prosocial peer support20 and are also at
risk for psychosocial maladjustment.21 Obese children
and adolescents have reported being victims more often
than their peers, and adolescents with obesity were also
more likely to be bullies and bully-victims.22 These chil-
dren were found to be less well liked by their peers and
made fewer friendships.23
Bullying and victimization can have devastating long-
term effects, including adjustment problems,24 26 aggres-
sive behavior,1 school problems,25 and high-risk behav-
ior.1 In a study by Juvonen et al.,24 victims reported more
loneliness and lower social status than their peers,
whereas bullies reported the opposite. Teachers also
reported that bully-victims have the most conduct prob-
lems.24 Ostracism has similar effects in adults, including
aggression, feelings of depression, and suicide attempts9
but has not been studied in children. Because of these
effects, it is critical to understand the bullying and ostra-
cism process as much as possible, so that effective inter-
ventions may be implemented.
Although a few studies have reported bullying expe-
riences in children with special health care needs, re-
search is extremely limited in this population, especially
in children with autism spectrum disorders, learning
disabilities, mental health disorders, in addition to chil-
dren with chronic medical conditions (e.g., cystic fibro-
sis). Many of the studies relied on parent report, which
may be an underestimate of childrens experiences with
bullying.27 In addition, very little research has examined
ostracism experiences in these groups. The purpose of
this study is to determine whether children with special
health care needs, including cystic fibrosis, autism spec-
trum disorders, learning disorders, ADHD, and behav-
ioral or mental health disorders, are at increased risk for
experiencing bullying or victimization and ostracism
compared with children without special health care
needs.
METHODS
This study involved responses of 312 children and a
corresponding parent seeking care in various primary
Journal of Developmental & Behavioral Pediatrics
care and subspecialty pediatric clinics in a mid-sized
southeastern city in the United States from June to Au-
gust 2007 and 2008. Clinics included Developmental-
Behavioral Pediatrics, Pediatric Psychology, Cystic Fibro-
sis, and Adolescent Medicine Clinic tertiary care centers
and a local private pediatrics primary care practice. The
study was approved in advance by the institutional re-
view boards at all participating institutions.
Participant Selection
Children were invited to participate in the study if
they were aged 8 to 17 years, currently enrolled in a
public or private school (i.e., not home-schooled), were
in good health or had a stable medical condition, and
able to complete self-report items with 1:1 assistance if
needed. Of those families approached who met these
criteria, 81% consented to participate in the study. After
completion of the scheduled medical visit, the partici-
pants diagnoses were extracted from the medical
record. From the original group of 312 participants, the
following were selected for analysis: 34 children identi-
fied with a learning disability as verified by a docu-
mented psychoeducational or neuropsychological evalu-
ation in the medical record; 100 children with a
diagnosis of attention deficit or hyperactivity disorder
based on verification of standardized parent and teacher
rating scales, clinical interviews, and observations, vali-
dated by DSM-IV criteria28; 33 children met DSM-IV cri-
teria for various behavioral or mental health disorders
(23 had internalizing disorders such as anxiety and de-
pression, 6 had externalizing disorders such as opposi-
tional defiant disorder or disruptive behavior, and 4 had
both); 32 children had an autism spectrum disorder by
DSM-IV criteria, and 22 children had cystic fibrosis. The
severity of autism varied in our participants, but all
children in this group functioned at a level able to
complete the questionnaires with assistance. There were
also 73 child study participants who were otherwise
healthy and were seen for either a well visit or an acute
medical problem (e.g., upper respiratory infection or
ankle injury) and served as controls (NoDx group), for a
total of 294 participants. The demographics of the over-
all study population and each of the groups are shown in
Table 1. As expected, there were significant differences
for several of the factors, including race, gender, and
classroom placement, which reflect differences in the
general population between these groups. For instance,
children in the cystic fibrosis group were predominately
white. There was a higher percentage of male children
in the autism spectrum disorder and learning disabilities
groups. A larger proportion of children with autism
spectrum disorder and learning disabilities received re-
source room services or self-contained classroom place-
ment, and fewer were in honors classes. Eighteen of the
original 312 children had other various chronic med-
ical conditions (asthma, diabetes, etc.) and were ex-
cluded from analyses because of insufficient power to
study these conditions individually but did not differ
Vol. 31, No. 1, January 2010
from the control group on any demographic factors
except maternal education. A subset of the children
with attention deficit or hyperactivity disorder were
used in a preliminary study of bullying and victimiza-
tion by Taylor et al,12 although different analyses were
conducted, and the study did not assess ostracism.
Procedure
Parents and children independently completed self-
report measures; if the child was younger than 13 years
or required assistance, the measures were read to the
child by one of the investigators or a trained research
assistant. As compensation for participation, children
were given small trinkets, and each family was entered
into a raffle. Parents were asked to provide demographic
information including school category (public versus
private), grade and classroom placement, parents edu-
cation level and marital status, and estimated annual
income.
Measures
To assess childrens experiences as either bullies or
victims, child participants completed the Reynolds Bully-
Victimization Scale (BVS). The BVS contains 46 items
designed to assess bullying behavior and victimization
experiences in children and adolescents.3,29 The re-
sponses are scored within the bullying or victimization
subscale, and T-scores 60, based on age and gender
norms on either subscale are significantly increased rel-
ative to the normative sample on validation studies.3
Participants indicate the frequency they experienced
each item (e.g., someone kicked me) in the previous
month on a four-point Likert scale, with responses in-
cluding never, once or twice, three or four times, and
five or more times. The normative sample of this mea-
sure consisted of 2000 children in Grades 3 to 12. The
internal consistency reliability of both scales is 0.93,
with test-retest reliability coefficients of 0.81 and 0.80
for bullying and victimization, respectively. Significant
scores on the BVS have correlated with Beck Youth
Inventories of Emotional and Social Impairment on vali-
dation studies. The bullying scale has a moderately
strong correlation with the Beck Youth Inventories of
Emotional and Social Impairment (r .54 p .001) and
a moderate correlation with the anger scale (r .38, p
.001). The victimization scale has a moderately strong
correlation with the Beck Youth Inventories of Emo-
tional and Social Impairment anxiety (r .58, p .001)
and depression (r .50, p .001) scales, as well as the
anger scale (r .61, p .001).3
Childrens ostracism experiences were based on their
responses to the ostracism scale of the Bullying and
Ostracism Student Screen (Saylor et al, unpublished data,
2009), a three-part questionnaire developed for use in
this and other studies to screen for bullying and ostra-
cism. There is no known alternative scale for directly
screening for ostracism as defined by Williams. The third
part of the Bullying and Ostracism Student Screen is a
2010 Lippincott Williams & Wilkins 3
Table 1. Demographics of Study Population (in Percentages)
NoDx CF ASD LD ADHD B/MH
N 73 N 22 N 32 N 34 N 100 N 33

Gender
Male 42.5 40.9 78.1* 70.6* 62* 54.5
Female 57.5 59 21.9 29.4 38 45.5
Mean age (yr) 13.1 12.4 11.0 11.3 11.6 12.6
Race
White 61.6 90* 66.7 66.7 59.8 78.1
African-American 35.6 0 30 27.3 36.1 15.6
Other 2.7 9.1 3.3 6.1 4.1 6.3
School type
Public 69.7 72.7* 90 81.3 82.5 81.8
Private 30.3 27.3 9.7 18.8 17.5 18.2
Honors classesa
No 39.7 52.4 75* 94* 81.6* 63.6
Yes 57.5 47.6 25 2.9 13.3 33.3
Resource servicesa
No 82 77 34.4* 8.8* 49* 60.6*
Yes 13 9 65.6 88.2 51 36.4
Self contained
No 94.4 100 65.6* 73.5* 84.8 81.8
Yes 2.8 0 21.9 23.5 13.1 15.2
Respondent
Mother 87.7 90.9* 90* 79.4 84.8 87.9
Father 12.3 0 3.3 11.8 4 9.1
Other 0 2 6.7 8.8 7 3
Maternal education
HS 20.5 27.2 13.3 39.4 22.7 21.2
College 50.7 59.1 56.7 29.5 64.9 60.6
Graduate school 28.8 13.6 30 12.1 12.4 18.2
Income
50,000 32.9 59.1 60.7* 50 41.2* 33.4
50,000100,000 28.8 27.3 10.7 28.1 34 36.4
100,000 38.4 13.6 10.7 21.9 24.7 30.3
CF, cystic fibrosis; ASD, autism spectrum disorders; LD, learning disabilities; ADHD, attention deficit or hyperactivity disorder; B/MH, behavioral or mental health
disorders.
a
Percentages do not add up to 100% as some parents did not know if children were placed in these classroom environments.
*p .05.

15-item ostracism scale that asks three items about the
frequency the child experiences ostracism for a total
Ostracism Experiences score. The measure asks three
items each about threats to the childs need for a sense
of belonging, control over ones environment, a percep-
tion of meaningful existence, and self-esteem. The re-
sponses to the latter 12 items are tabulated for a total
Ostracism Needs Threats score. Children respond to
each item on a five-point Likert scale, including almost
never, once or twice, sometimes, many times, or almost
all the time. This measure was standardized on four
hundred twenty-six 10- to 14-year-old students in the
school and clinic setting. Chronbachs [alpha] for ostra-
cism experiences and the effects of ostracism ranged
from .60 to .83. Item test-retest reliability ranged from
0.64 to 1.00 (Saylor et al, unpublished data, 2009).
Statistical Analysis
Data were analyzed using SPSS for Windows statistical
software package, version 15.0. Each of the diagnosis
groups (cystic fibrosis, autism spectrum disorder, learn-
ing disabilities, attention deficit or hyperactivity disor-
der, and behavioral or mental health disorders) were
compared individually to the no diagnosis group. Demo-

4 Bullying in Children With Special Needs Journal of Developmental & Behavioral Pediatrics
graphics, including age, sex, race or ethnicity, school
placement, school type, parent income, marital status,
and maternal education, were compared between each
of the diagnosis groups and the control group. To ex-
plore which populations would experience bullying and
victimization to an extent that warranted further clinical
evaluation or intervention, 2 analyses and odds ratios
were used to compare each group of children with
special health care needs with the no diagnosis group on
the basis of significant bullying, victimization, ostracism
experiences, or ostracism needs threats. The cutoff for
bullying and victimization was a BVS subscale T score in
the significant range, i.e., 60. An ostracism experi-
ences scale score 9 (indicating an average score
greater than sometimes on the three ostracism expe-
riences questions) was considered significant for ostra-
cism experience categorization, because this score cor-
relates with depression symptoms (Saylor et al,
unpublished data, 2009). Hierarchical linear regression
analyses were used to statistically weigh in the variance
accounted for by age and gender in addition to diagnosis
on mean BVS bullying and victimization and Bullying and
Ostracism Student Screen ostracism experiences and os-
tracism needs threats scores. The level of statistical sig-
nificance was set at p .05. Because 2 were analyzed
for multiple groups, a Bonferroni correction was calcu-
lated to keep the Type I error rate at 0.05: 0.05/5 0.01.
RESULTS
Bullying and Victimization
As shown in Table 2, the percentage of children
reporting a significantly increased victimization score
(Bully-Victimization Scale [BVS] 60) was greater in chil-
dren with children with autism spectrum disorder (ASD)
and attention deficit or hyperactivity disorder (ADHD)
with three to four times the odds of victimization com-
pared with the NoDx group (ASD: OR 4.43; 95%
confidence interval [CI] 1.4213.86; ADHD: OR
4.46: 95% CI 1.7311.48). The learning disabilities
group was the only diagnostic group to report a higher
percentage of children reporting significant bullying
scores (OR 5.74; 95% CI 1.7718.56). Because of
the reported differences in bullying experiences in boys
versus girls and younger children versus older children,1
Table 2. Percentage of Children with Significantly Increased Victimization, Bullying, and Ostracism Scores
BVS Victimization
Percent 2 p Percent
NoDx 8.5 7.0
CF 14.3 0.625 NS 9.1
ASD 29.0 7.287 .007 6.5
ADHD 29.2 10.803 .001 12.5
LD 24.2 4.823 .028 30.3
B/MH 21.2 3.354 NS 12.9
BVS, bullying and victimization; CF, cystic fibrosis; ASD, autism spectrum disorders; ADHD, attention deficit or hyperactivity disorder; LD, learning disabilities;
B/MH, behavioral or mental health disorders; NS, not significant.
Vol. 31, No. 1, January 2010
hierarchical linear regression analyses evaluating mean
BVS bullying and victimization subscale scores control-
ling for the effects of age and gender were also per-
formed. As shown in Table 3, a diagnosis of learning
disabilities and ADHD correlated with higher mean bul-
lying scores, whereas all the children with special
health care needs diagnoses except cystic fibrosis pre-
dicted higher mean victimization scores. For the ASD
group, diagnosis age was the strongest model for
predicting victimization although diagnosis also con-
tributed on its own.
Ostracism
Of all the groups, children with ASD had the highest
percentage reporting an ostracism experiences score of
9 (i.e., average score on these three items greater than
sometimes) as shown in Table 2 and were eight times
more likely to report significant ostracism over the
NoDx group (OR 8.00, 95% CI 2.60 24.58). A
significant percentage of children with ADHD also re-
ported a significant ostracism experiences score (OR
4.06, 95% CI 1.5710.46). Children with cystic fibro-
sis, learning disabilities, and behavioral or mental health
disorders also had increased rates of ostracism experi-
ences compared with the NoDx group but not statisti-
cally significant. Hierarchical logistic regression analyses
controlling for age and gender also showed that diag-
noses of ASD, ADHD, and behavioral or mental health
disorders were predictors for increased mean ostracism
experiences scores (Table 3). For the ADHD group,
diagnosis and gender were predictors in the strongest
model, although diagnosis alone was responsible for a
significant percentage of the variance. All children with
special health care needs diagnoses predicted increased
mean total ostracism needs threats, with a stronger
model of gender and diagnosis in the learning disabilities
group.
DISCUSSION
Many interesting associations were found between
bullying, victimization, and ostracism in our groups of
children with special needs. Several groups, including
children with autism spectrum disorder (ASD), learning
disabilities (LD), and attention deficit or hyperactivity
BVS Bullying BOSS Ostracism Experiences
2 p Percent 2 p
8.6
.101 NS 22.7 3.186 NS
.012 NS 42.9 15.680 .001
1.330 NS 27.6 9.319 .002
9.876 .002 18.2 2.012 NS
.921 NS 21.2 3.249 NS
2010 Lippincott Williams & Wilkins 5
Table 3. Linear Regression Analyses of Mean Bullying, Victimization, Ostracism Experiences, and Ostracism Needs Threats for Each Diagnosis
Group Compared with NoDx Group, Controlling for Age and Gender
CF ASD LD
R 2
F R 2
F R2 F

BVS bully .269 .072 7.96**

BVS victim .295 .087 9.52** .227 .052 5.543*
Diagnosis age (yr) .375 .140 8.037**
Ostracism Experiences Score .471 .222 27.43***
Ostracism Needs Threats Score .411 .169 18.26*** .403 .162 18.60*** .407 .166 20.04***
Diagnosis gender .338 .214 13.65***
ADHD B/MH

BVS bully .180 .032 5.52*

BVS victim .260 .067 11.93** .243 .059 6.41*
Ostracism Experiences Score .294 .086 15.65*** .262 .069 7.43**
Diagnosis gender .258 .032 11.10***
Ostracism Needs Threats Score .297 .088 16.07*** .230 .053 5.64*
CF, cystic fibrosis; ASD, autism spectrum disorders; LD, learning disabilities; BVS, bullying and victimization; ADHD, attention deficit or hyperactivity disorder;
B/MH, behavioral or mental health disorders.
*p .05, **p .01, ***p .001.

disorder (ADHD), reported more clinically significant
bullying and/or victimization experiences. Similar to
other studies,16,17 children with LD reported higher
mean victimization scores when adjusted for age and
gender, but in contrast to these studies, we also found
these children may also be more involved as bullies. This
study expands on the findings of our earlier study of
ADHD and victimization,12 where children with ADHD
reported increased mean victimization scores and more
clinically significant victimization than children with no
diagnosis. Children with LDs susceptibility to bullying
and victimization may be a result of reduced social com-
petence. A meta-analysis by Kavale and Forness revealed
that the majority of children with LD have social skills
deficits that make it less likely for them to be accepted
by their peers or to be chosen as a friend.29 These
children were shown to have difficulty in interpreting
nonverbal cues, communication messages, and feelings
associated with those messages.29 Children with ADHD
may also exhibit impulsivity and externalizing behaviors,
which place them at higher risk of being perpetrators or
targets of bullying.12,30 The ADHD groups susceptibility
to victimization may be related to other research show-
ing these children are also less well liked by peers and
have fewer friends, because they have difficulty in mon-
itoring their behavior in social situations.30 Children
with ASD may lack quality friendships to protect them
from bullying.31 Although poor social interaction with
peers is inherent in individuals with high functioning
autism, it is not clear that this is completely related to
lack of desire to socially interact. Indeed, one study
showed that children with autism reported higher de-
grees of loneliness (perhaps a better indicator of desire
for peer involvement) than typically developing peers
and poorer understanding of the relationship between
loneliness and social interaction.31 Therefore, it is not
surprising to find that our ASD group reported the high-
est percentages of clinically significant victimization,
similar to findings in another study,14 and almost half of
children with ASD reported clinically significant ostra-
cism experiences. This is particularly troubling, because
chronic ostracism is proposed in empirically supported
model of Williams and Nida9 to result in depleted coping
skills, and may ultimately result in acceptance of the
ostracism message of alienation, depression, helpless-
ness, and worthlessness. Also, people who have been
ostracized may eventually stop seeking others for sup-
port, further ostracizing themselves from the group.9 For
children who already have difficulty in establishing and
maintaining peer friendships such as those with ADHD,
ASD, and LD, ostracism may be particularly devastating.
Children with cystic fibrosis would not be expected
to have social difficulties aside from not being able to
participate in certain activities but may be perceived as
physically weaker and are therefore vulnerable to peer
victimization; however, our analyses did not support this
hypothesis. This is consistent with a review of prior
research showing many children with chronic illness
make friends and feel supported by their peers.19 Al-
though our study did not show that children with cystic
fibrosis have more ostracism experiences, the data sug-
gest that their reactions to ostracism (i.e., threats to the
four basic needs) may be greater than healthy children
when they do experience it, possibly because they rely
on their peers for support.
Finally, children with mental health disorders were no
more likely to report clinically significant bullying and
victimization than their peers, although their diagnosis

6 Bullying in Children With Special Needs Journal of Developmental & Behavioral Pediatrics
predicted increased mean victimization scores. Similarly,
they reported increased mean ostracism experiences
and needs threats scores, although they were no more
likely than the control group to report clinically signifi-
cant experiences. Several studies have shown an associ-
ation between victimization and psychiatric problems,
including anxiety and poor self-esteem,32 but it is often
difficult to determine whether the mental health prob-
lems these children experience are a cause or effect of
bullying. Because our population of children with behav-
ioral or mental health disorders had more internalizing
problems (anxiety and depression) rather than aggres-
sive behavior, their difficulties may not be apparent to
other students, which may reduce their likelihood of
being targeted. There is also the possibility that they
could be underreporting their experiences.
This study has several limitations, including its retro-
spective nature, which may introduce recall bias. Al-
though interviewing study participants over the summer
may result in underreporting of bullying experiences,
this was designed to make it easier for them to recall
all events occurring in the previous year without the
influence of an isolated recent event that may cause
them to overestimate their overall experiences with
bullying. This study also relies on self-report measures,
which may over- or underestimate bullying experi-
ences; however, clinically, it may be important to
intervene if a child feels they are victimized or ostra-
cized, even if they are overestimating their experi-
ences. Obtaining peer and/or teacher reports may
have provided additional information about the fre-
quency and type of bullying, victimization, and ostracism.
An additional limitation includes potential confounding
bias in the disproportionate school placement (ASD,
ADHD, and LD) and race (cystic fibrosis) representa-
tion in some of our groups. However, we believe that
these populations reflect the characteristics of these
groups in the general population. Although our small
sample size limits generalization, this study provides
an important preliminary evaluation of many of these
groups, and future studies involving a larger, nation-
ally representative population of children with special
health care needs (CSHCN) would be helpful and
would allow for more elaborate statistical analysis.
Further studies are needed to determine the role of
CSHCN and their peer relationships in bullying and
ostracism, because this may allow for more effective
interventions.
The finding of children in many of our CHSCN groups
with experiences in the significant range supports the
conclusion that bullying, victimization, and ostracism are
significant problems for many CSHCN. Involvement in
bullying, victimization, and ostracism seems to be a
problem for many children regardless of diagnosis, sug-
gesting the need to identify these issues in mental health
screening. Past studies have also overwhelmingly advo-
cated for mental health screening for children with and
without special health care needs who are involved with
Vol. 31, No. 1, January 2010
bullying and victimization, because they have shown
that these children have a significant risk for depression,
anxiety, aggressive behavior, and suicide.26,33,34 For pri-
mary care physicians, there are great opportunities to
address this periodically during preventative care visits,
but brief surveillance could be performed by any health
care provider in a discussion with the child about school
and his or her peers. The American Academy of Pediat-
rics has recognized bullying and victimization as signifi-
cant problems and has updated their policy statement on
youth violence to outline the need for health care pro-
viders to address these issues and appropriately treat or
refer for violence-related problems.35 There are re-
sources available for pediatricians to address bullying
and other issues related to youth violence, including a
program called Connected Kids: Safe, Strong, Secure.36
A few of the groups in this study reported significant
ostracism experiences. This is concerning, because os-
tracism has been hypothesized to be just as damaging as
bullying and has the potential to create long-term mental
health problems for those who significantly experience
it.9 Those who experience ostracism typically will either
become more prosocial to fit in with the group, or they
develop aggressive behavior.7 Children who do not have
adequate social skills to fit in with the group (such as is
sometimes seen in CSHCN) may have to resort to aggres-
sive behavior to get their needs met or completely with-
draw and further isolate themselves.7 Health care pro-
viders and educators may need to refer to a mental
health provider if the child shows signs of the problems
associated with bullying and ostracism.
Although educational systems generally serve as the
primary setting for intervention, health care providers
can provide resources to help parents address the issue
with school, such as Take a Stand, Lend a Hand, Stop
Bullying Now37 campaign of Health Resources and Ser-
vices Administration. Health care providers and families
are also encouraged to work with the schools to pro-
mote a safe environment for children. There are a few
intervention strategies that have been effective for re-
ducing bullying in schools,2,38 and these may need to be
adapted for children who have learning differences and
be sensitive to the types of bullying these children ex-
perience. An effective intervention program should also
include efforts to address and prevent ostracism.
Further research may help explain why CSHCN have
these experiences. Ideally, a national, prospective longi-
tudinal study would help us better understand the char-
acteristics that influence bullying and victimization and
the subsequent social and psychological outcomes in
these groups. Additional study is needed to explore the
relationship of bullying and ostracism in CSHCN with
child adjustment and to determine what mental health
interventions would be most appropriate for these prob-
lems. Finally, intervention studies are necessary to eval-
uate the effectiveness of bullying prevention programs
in these groups.
2010 Lippincott Williams & Wilkins 7
ACKNOWLEDGMENTS
This study was financially supported by the Medical University of
South Carolina Institutional Research Fund through a resident grant
(to K.A.T.) and The Citadel Foundation through a faculty grant (to
C.F.S.). The authors thank Rachel Santorelli, Lynn Woggaman, Mi-
chael Flasch, and Kimberly Veronee for their assistance with this
study, as well as the families and clinics who participated.
REFERENCES
1. Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simmons-Morton B,
Scheidt P. Bullying behaviors among US youth: prevalence and
association with psychosocial adjustment. JAMA. 2001;285:
2094 2100.
2. Olweus D. Bullying at School: What We Know and What We
Can Do. Oxford, United Kingdom: Blackwell Publishing; 1993.
3. Reynolds WM. Reynolds Bully-Victimization Scales for Schools.
San Antonio, TX: The Psychological Corporation; 2003.
4. Crick NR, Grotpeter JK. Relational aggression, gender, and
social-psychological adjustment. Child Dev. 1995;66:710 722.
5. Willard NE. Cyberbullying and Cyberthreats: Responding to the
Challenge of Online Social Aggression, Threats, and Distress.
Champaign, IL: Research Press; 2007.
6. National Crime Prevention Council (NCPC). Teens and
cyberbullying: executive summary of a report on research.
Available at: http://www.ncpc.org/resources/files/pdf/bullying/
Teens%20and%20Cyberbullying%20Research%20Study.pdf.
Accessed October 9, 2009.
7. Williams KD. Ostracism. Annu Rev Psychol. 2007;58:425 452.
8. Eisenberger NI, Lieberman MD, Williams KD. Does rejection
hurt? An fMRI study of social exclusion. Science. 2003;302:
290 292.
9. Williams KD, Nida SA. Is ostracism worse than bullying? In:
Harris MJ, ed. Bullying, Rejection, and Peer Victimization: A
Social Cognitive Neuroscience Perspective. New York, NY:
Springer; 2009.
10. Van Cleave J, Davis MM. Bullying and peer victimization among
children with special health care needs. Pediatrics. 2006;118:
e1212 e1219.
11. Holmberg K, Hjern A. Bullying and attention-deficit-hyperactivity
disorder in 10-year-olds in a Swedish community. Dev Med Child
Neurol. 2008;50:134 138.
12. Taylor L, Saylor C, Twyman K, Macias M. Adding insult to injury:
bullying experiences of youth with attention deficit
hyperactivity disorder. J Child Health Care. In press.
13. Humphrey JL, Storch EA, Geffken GR. Peer victimization in
children with attention-deficit hyperactivity disorder. J Child
Health Care. 2007;11:248 260.
14. Little L. Middle-class mothers perceptions of peer and sibling
victimization among children with Aspergers syndrome and
nonverbal learning disorders. Issues Compr Pediatr Nurs. 2002;
24:4357.
15. Montes G, Halterman JS. Bullying among children with autism
and the influence of comorbidity with ADHD: a population
based study. Ambul Pediatr. 2007;7:253257.
16. Baumeister A, Storch E, Geffken G. Peer victimization in
children with learning disabilities. Child Adolesc Soc Work J.
2008;25:1123.
17. Thompson D, Whitney I, Smith PK. Bullying of children with
special needs in mainstream schools. Support Learn. 1994;9:
103106.
18. Saylor CF, Leach JB. Perceived bullying and social support in
students accessing special inclusion programming. J Dev Phys
Disabil. 2009;21:69 80.
19. La Greca AM, Bearman KJ, Moore H. Peer relations of youth
with pediatric conditions and health risks: promoting social
8 Bullying in Children With Special Needs
support and healthy lifestyles. J Dev Behav Pediatr. 2002;23:
271280.
20. Storch E, Milsom VA, DeBraganza N, Lewin AB, Geffken GR,
Silverstein JH. Peer victimization, psychosocial adjustment, and
physical activity in overweight and at-risk-for-overweight youth.
J Pediatr Psychol. 2007;32:80 89.
21. Devine KA, Storch EA, Geffken GR, Freddo M, Humphrey JL,
Silverstein JH. Prospective study of peer victimization and social-
psychological adjustment in children with endocrine disorders.
J Child Health Care. 2008;12:76 86.
22. Janssen I, Craig WM, Boyce WF, Pickett W. Associations
between overweight and obesity with bullying behaviors in
school-aged children. Pediatrics. 2004;113:11871194.
23. Zeller MH, Reiter-Purtill J, Ramey C. Negative peer perceptions
of obese children in the classroom environment. Obesity. 2008;
16:755762.
24. Juvonen J, Graham S, Schuster MA. Bullying among young
adolescents: the strong, the weak, and the troubled. Pediatrics.
December 1, 2003. 2003;112:12311237.
25. 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
1031.
26. Sourander A, Jensen P, Ronning JA, et al. What is the early
adulthood outcome of boys who bully or are bullied in
childhood? The Finnish from a boy to a man study. Pediatrics.
2007;120:397 404.
27. Twyman KA, Saylor CF, Macias MM. Can parents identify their
child as a target of bullying? Paper presented at: Pediatric
Academic Societies Meeting; May 4, 2008; Honolulu, HI.
28. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR). Washington, DC: American Psychiatric Association;
2000.
29. Kavale KA, Forness SR. Social skill deficits and learning
disabilities: a meta-analysis. J Learn Disabil. 1996;29:226 237.
30. Hoza B, Mrug S, Gerdes AC, et al. What aspects of peer
relationships are impaired in children with
attention-deficit/hyperactivity disorder? J Consul Clin Psychol.
2005;73:411 423.
31. Bauminger N, Shulman C, Agam G. Peer interaction and
loneliness in high functioning children with autism. J Autism
and Dev Disord. 2003;33:489 506.
32. Gini G, Pozzoli T. Association between bullying and
psychosomatic problems: a meta-analysis. Pediatrics. 2009;123:
1059 1065.
33. Bond L, Carlin JB, Thomas L, Rubin K, Patton G. Does bullying
cause emotional problems? A prospective study of young
teenagers. BMJ. 2001;323:480 484.
34. Klomek A, Sourander A, Niemela S, et al. Childhood bullying
behaviors as a risk for suicide attempts and completed suicides:
a population-based birth cohort study. J Am Acad Child Adolesc
Psychiatry. 2009;48:254 261.
35. American Academy of Pediatrics. Policy statement: role of the
pediatrician in youth violence prevention. Pediatrics. 2009;124:
393 402.
36. American Academy of Pediatrics. Connected Kids: Safe, Strong,
Secure. Available at: www.aap.org/ConnectedKids/. Accessed
October 7, 2009.
37. Health Resources and Services Administration. Stop Bullying
Now. Available at: www.stopbullyingnow.hrsa.gov/adults/default.
aspx. Accessed September 14, 2009.
38. Vreeman RC, Carroll AE. A systematic review of school-based
interventions to prevent bullying. Arch Pediatr Adolesc Med.
2007;161:78 88.
Journal of Developmental & Behavioral Pediatrics