Dr Arnon Bentovim Good evening. You’re  very welcome, everyone, to this seminar   of the ACEs Special Interest Group, and I  hope you will have seen from the text that   the theme for this evening’s seminar, “Bullying  and Victimisation,” is going to be addressed by   our speaker to – this evening, Nora Trompeter, and  also, Lucy Bowes. So, I think that there’s – that   ACAMH is providing a tremendous amount of  information on this very important theme. And it’s interesting that last week, we had  the presentation from the group about the   issue of verbal abuse, and heard from Shanta  Dube, colleagues, about the very interesting   thinking going on about this. And really, it’s  part of the whole process of understanding the   extensiveness of adversity that children and young  people are exposed to and the – and their impact. I’m pleased to say that the newsletter from  our Special Interest Group will be landing in   your inboxes very shortly. And there’s  a tremendous range of very interesting   research going on at the moment looking  at the impact on neurological functioning,   understanding what are the factors which  mean that some individuals are – have   long-term impacts and others not? The  whole issue of the subjective appraisal   of experiences. There’s so much that we’re  beginning to understand about adversity. And this evening, our speaker, Nora Trompeter,  she’s a Research Fellow at University College,   in the Population, Policy and Practice  Department, and it’s been our great   privilege to hear from members of that department  who are contributing so much to our knowledge and   understanding. She completed her PhD in psychology  at Macquarie University and she lived in Sydney,   that extraordinary city. Now living here in  and not – extraordinary in a different way.   But she was interested in the theme of the link  between emotional dysregulation and adolescent   eating disorder symptoms. So, she’s concerned  with the social and emotional risk factors   for adolescent mental health problems,  particularly eating disorder and anxiety. But the presentation this evening is  going to look at the intriguing and   interesting and important relationship between  bullying victimisation and adverse childhood   experiences. And we know that both are linked  with mental health problems in adolescence,   but little has been known about the  overlap between the two factors, how   this impacts adolescent mental health problems.  And Nora’s going to present data from her study,   estimating the associations between ACEs,  bullying victimisation and mental health   problems, respectively, adjusting for sex, race,  ethnicity, country of birth, household income,   parental education and the study site. And we’ll  be discussing the implications for practice. So, this is a very important and a theme which  has particular relevance, but – as the nature   of bullying and victimisation becomes  even more complex with bullying online,   and the accounts of individuals who’ve been  harassed and bullying online indicate the   level of distress which can be associated. And  so, it’s so important to have a broad picture of   the background experiences of the adversity to  which these young people have been exposed, so   that we can really begin to have an understanding  of these processes and begin to know how can we   intervene and make a difference? So, Nora, perhaps  you’d like to introduce your presentation now. Please, may I just add, we do invite you,  put your questions in the Q&A and we’ll   hope to deal with as many as we can. This  is a very important function. It’s always   an issue when it’s a webinar and we can’t  talk to you directly, but good questions   and issues that you care to raise really  create a real dynamic. And I think that we   should have a very interesting discussion on this  important theme. So, thank you very much, Nora. Nora Trompeter Thank you so much, Arnon.  Hopefully, you can all see my slides. So,   yeah, thank you so much for having me  here today and for that kind introduction,   so – and all of those joining online. So, as  we said, today, I really want to share with   you some research looking at bullying and  adverse childhood experiences, especially   thinking about how these two concepts relate  to one another. What are their similarities,   what are their differences, and how do they  co-occur, or what might be happening if we see   these exposures combined in childhood? And what  that might mean for both practice and research,   as well. So, as Arnon said, there will  be time for questions, so do – if you do   have anything you would like to know more  about, or are curious about, or even just   want to share your thoughts, I do very much  encourage you to put those in the Q&A box. But to get us started with, and really thinking  about why this is important to think about in   the context of youth mental health. I think  it’s really important to acknowledge that,   unfortunately, both bullying experiences and  adverse childhood experiences are relatively   common. So, we don’t have great prevalence  data on either of these phenomena, actually,   but we can estimate that about 40% of young  people in the UK do report some level of   bullying. And if we’re looking at ACEs,  it’s estimated that in – again, in the UK,   about half of adults have experienced at least  one type of adverse childhood experience. So,   again, there’s a lot of variability within those  experiences and within those numbers, but just   acknowledging that both phenomena are relatively  common and do impact people significantly. Alright, so, what do we mean when  we use these terms? So, first,   thinking about bullying, we might all  have an idea what bullying looks like,   or we have a definition in our heads of what  it is, but if we’re thinking definitionally,   we would usually define bullying as a repetitive  intentional act where one person or a group is   hurting another person. And it often  also involves an imbalance of power,   whereby the bully has some kind of power over  the victim, whether that is real or perceived. It can also happen in a range of contexts, and  there has been a lot of change, if you think about   recent decades, on how bullying is experienced.  So, it can be physical, verbal, psychological.   It can happen face-to-face, or now, more  commonly, more – as well, in the online sphere. So, lots of different types of bullying and how  this might be experienced, but I do just want to   distinguish between two types of – broad types of  bullying that I think really help contextualise   this issue and types that are rele – really  relevant for practice [pause]. Here we go. So,   when we think about bullying, I think  most people really think about tra – a   traditional type of bullying, which is  often also called direct bullying. So,   this is your face-to-face bullying that  can either be physical, so pushing someone,   hitting, kicking, shoving someone, or something  like that, or verbal bullying, so name calling,   belittling someone, teasing. Although, I must  add, teasing here is really from a hurtful sense,   not in a friendly way. So, these are really  what we think about as direct bullying,   where there’s a face-to-face act and a  bully perpetrates against the victim. Another type of bullying that is, I think,  important to distinguish, is more indirect   forms of bullying. So, this includes relational  bullying, so excluding others on purpose,   spreading rumours, ridiculing someone  behind their back, and this often,   also, is where the, I guess, newer forms of  bullying fall into, with online bullying. So,   posting something deliberately hurtful on  social media, social exclusion, but also,   sending direct messages to someone with – that  again, are belittling or ridiculing. So, it’s,   kind of, what we think about when we have  bullying and we do have these two types of,   I guess, but they can als – they often  co-occur and have – do have similar outcomes. Then, turning, I guess, more  to the other side of this talk,   when we’re thinking about adverse childhood  experiences. In terms of definitions,   this one’s a little bit trickier, but  really thinking about highly stressful   and potentially traumatic events or situations  that occur during childhood or adolescence. So,   we’re really thinking, kind of, anywhere in that  childhood period something that happens that has   the potential to have a long-lasting effect  on adolescents. That sounds very vague and   could include a lot of things, which is,  I guess, one of the themes to this talk,   but I guessed, traditionally, these are  may – they’re ten, I guess, original ACEs. So, these are based on a study by Felitti in the  US in the late 1990s, so really, kind of, set   the scene for looking at ACEs. And they broadly  include areas that focus on child maltreatment,   so child abuse, but also, child neglect, and  then, broader themes around – relating to   household dysfunction. So, for example, parental  mental health problems or parental separation. So,   these are the, kind of, the core ten original  ACEs and there’s been a lot of study and research   based on these, I guess, original ACEs as per  that. It’s also been included in many of the,   kind of, screening programmes for ACEs  that include these, kind of, ten factors. And it begs the question, kind of, if we go back  to this really broad definition of what an ACE is,   as, like, whether these ten ACEs  are actually encompassing all what   we mean in terms of adversity. And there  have been many criticisms to this list,   to say it’s – and they are very important  factors that are not included. Also – so   we think this was in the last 20 years, there  may be other things that have happened that we   now think of adversities, that may have  been less occurrent 20 years ago. So,   yeah, just want to acknowledge that  there’s – these are the original ten. There are a lot of – there was a lot of debate  about what should and shouldn’t be on this type   of list, I guess, and one of the things that  often comes up, as well, are peer factors. So,   that these don’t include anything relating to peer  experiences, such as bullying, and I guess that’s,   kind of, where I want to focus on a little  bit more. If we were thinking about what is   bullying and how does that fit with our  idea of an adverse childhood experience? If we go back to what we think an  adverse childhood experience is,   it’s a highly stressful and traumatic event. We  could argue that bullying is a highly stressful,   potentially traumatic, event that occurs  during childhood or adolescence. And so,   this idea isn’t new. I’m not the first  person to raise this, and it has – so,   it has sometimes been included in – when we’re  thinking about adversity, and other times, not. So, let’s think about this concept a little  bit more [pause]. Yeah, there we go. Alright,   so, leading to the question whether bullying  victimisation should be considered an ACE? Is   it the same? Can we put it under this umbrella? Is  it different? Is it its own problem that shouldn’t   be merged with these other experiences? So, that’s  where I want to dig in a little bit further now. So, firstly, thinking about the similarities. I  already talked definitional wise. So, if we’re   looking at definitions, we can definitely  see some, kind of, overlap between the two   things. We can see that they are – both  occur during childhood or adolescence,   they are stressful, potentially traumatic.  But there’s some other important things,   as well, to consider. Firstly, there’s a high  co-occurrence between bullying and ACEs. So,   they’re also both linked with poor mental  health outcomes, and they also tend to be   more common amongst disadvantaged youth. So,  let’s look at these a little bit further. Alright, so, first, thinking about the  co-occurrence of bullying and ACEs. So, victims   of bullying are more likely to report a history  of ACEs compared to non-victims, and that is true   for both face-to-face bullying and online bull  – other forms of bullying. So, there’s something   going on that puts people, more likely adolescents  or children, who have experienced other forms of   adversity, to also experience bullying. And  there’s a bit of an idea of this – or the – a   theory called the “cycle of victimisation”  that often, kind of, says if someone starts   experiencing one form of victimisation, they will  also be more vulnerable to experience other types   of victimisation in the future. And this seems  to hold for the ACEs and bullying relationship,   whereby having experienced adversity – childhood  adversity, makes one more likely to, then,   also become the victim of bullying in – more  often, later in life, in adolescence. So,   there’s something going on between these two  concepts that place children at heightened risk. They’re also both linked with poor mental health  accounts. So – and the areas where they do overlap   the most is that both bullying and ACEs are  linked to heightened anxiety and depression.   They’re both linked to lower school attendance  and also, higher levels of substance use. So,   whether or – so, some of these outcomes are  experienced by people who experience – if we’re   looking at only people who experience bullying,  and then we look at people who experience ACEs,   we, kind of, see similar patterns in what happens  to them, both concurrently and later in life. So, we can, kind of, see, already, a pattern of,  well, they’re more likely to go together than not.   They have similar outcomes to one another. And  then, the last thing I just want to briefly touch   on in terms of prevalence, as well, both ACEs and  bullying are more common in areas of disadvantage   and they’re more common among low SES households  and both linked with lower education. So,   they also share some common risk factors, or  areas where they’re more commonly experienced. So, if you’re looking at all these  similarities, you’re thinking, well,   if they all go together, if they have similar  outcomes and they happen to similar people,   shouldn’t they maybe be considered  part of the same group or concept? So,   I just want to – now that we’ve talked  about similarities, thinking about some   of the differences. And I think the two key  differences that are really important to think   about in this context are the context in which  they occur and the timing at which they occur. Alright, and so, thinking about this a  bit further, when we’re thinking about   ACEs and especially the traditional original ACEs,  these mostly happen in a family context. They’re   related to child abuse and neglect, which are  experienced within the family context, but also,   family and household dysfunction, again, something  that’s experienced at home, in the family context.   Whereas bullying is quite different from that  in that it’s experienced in a peer context. If we’re thinking about face-to-face bullying,   it’s almost always experienced in the – outside  of the home, so commonly at school or at, kind of,   recreational activities. And even if  we’re thinking about cyberbullying,   which could happen anywhere, it still has that  peer context. It’s experienced in a situation   where young people are engaging with their  peers, or the res – other person who they’re   engaged with is a peer. So, quite different  contexts for how these are experienced. The other thing to think about  is timing. So, ACEs are commonly   experienced during early childhood, or  they persist throughout childhood. So,   these are issues that are often – happen  during early childhood and then persist,   or are re-occurring themes through someone’s  childhood and become, kind of, that – part   of that person’s childhood. Whereas bullying  victimisation is a bit different from that in   that it usually occurs during late childhood  and early adolescence, so, it’s, kind of,   a peak period as children enter school, bullying  becomes more common. It, kind of, peaks around   the early adolescent stage and then, bullying  rates decline as they get older. But really   important here, it tends to happen at a very  different developmental stage compared to ACEs. And if we’re thinking about that – how  that relates to the context, as well,   in our early development, we spend most of our  time with our – in our family context. As we’re   growing up, we’re mostly with our parents and  then, we slowly start engaging with peers, and by   the time it, kind of, comes around to school age,  and we’re going into adolescence, people spend,   increasingly, time with their peers and that’s  also when bullying is most prevalent [pause]. And so, great question, where does that  leave us? So, we have two concepts. They   are somewhat related, but they  are also somewhat different. So,   this is where I now want to talk a little  bit about some of the research we’ve done   to look at the relationship between  bullying and ACEs to try and, I guess,   untangle some of these questions a little bit  more. And we really thought about this from two   different ways they could both relate to another.  So, what type of associations might one find? So, we could think about them as cumulative,  where both bullying and ACEs independently   contributed to poorer outcomes. And  this – there is quite a lot of work,   just generally, on the cumulative effects of  adversity, that the more someone experiences,   the worse their outcomes will be. And it’s also  one of the key frameworks that underpins, I guess,   the work that came out of the original ACEs,  where someone is given a total score of ACEs to,   kind of, say, this is how much adversity has  someone experienced. But it doesn’t give any   information of what that experience  was, but simply a cumulative score. So – and the idea here was if bullying is  experienced it’s more cumulative in the   context of ACEs, it might fall more within  the umbrella of ACEs. If it’s cumulative,   then it, kind of, behaves like some of  the other ACEs that we can think about.   Whereas another way they could relate to one  another is more interactive. So, thinking,   okay, if someone has a history of childhood  experien – adverse childhood experiences,   if they then also experience bullying, maybe  that will worsen their outcomes. So, having   this history makes your effects worse compared  to it. So, it’s not just additive, but rather,   it interacts with one another, and that’s, kind  of, what I want to talk about a little bit now. Alright [pause]. Oh, there we go. Alright, so, as  I said, I do want to talk about this one study we   did in particular. So, this is for – we used data  from the ABCD study in the US. It’s a large study   being conducted, where adolescents are followed.  They’re currently being followed up yearly,   also in a pattern, and they have got a large range  of data. So, for our study, in particular, we used   information from over 8,000 early adolescents,  so they were aged around 12-years-old. And the   nice thing about this particular cohort is,  as well, they did place great emphasis on   ethnic diversity in the sample. So, we do  have a – and again, this is a US context,   but we do have some variability in there, which  isn’t always the case for research in this area. And they completed – so, at age 12, they completed  some self-report measures on bullying. So,   they were asked about their experiences in a  peer context, both relating to face-to-face   bullying and also, online forms of bullying. And  then, their parents reported on children’s mental   health and also, children’s experience of ACEs.  So, I think that’s just something important to   keep in mind whereby who reported on what. So, the  children reported on their bullying experience and   the parents reported on their children’s mental  health and their children’s experience with ACEs. Alright, so a bit more information about  the kind of group we’re looking at here. So,   when we’re looking at the number of ACEs  experienced, so we split this into no ACEs,   that was around 20% of the sample,  one ACE, around 36%, two 28 and then,   we got into the higher numbers of three ACEs,  13, and 4% four or more. So, keeping in mind at   this time, they were 12-years-old, as well,  so they’re – it was still during childhood. In terms of bullying, so lots of children reported  having experienced some type of bullying. So,   this was any occurrence of bullying, of around  70%. Most of this was what we would say are   the indirect forms of bullying, so relational,  reputational or cyberbullying. The more overt,   direct forms of bullying are a  little bit less prevalent, but also,   not as much cyberbullying, again, if we’re  thinking about these are 12-year-olds. So,   it might be a bit different for other age  groups. But yeah, just to give you, kind of,   a picture of the kind of children we’re looking  at here and what their histories were like. So, yes, so as I said, we wanted to  look at how bullying and ACEs, kind of,   go together when we’re looking at mental health  symptoms and there, we really see that we really   saw these cumulative effects. So, both having  experienced ACEs and having experienced cyber   – bullying victimisation were associated with more  internalising and more externalising of problems,   and they’re both independently. So, even when  accounting for the effects of one another,   we still saw an increase in the symptoms and  this was really following – yeah, oh, this   might show it a little bit better, really  showing a, kind of, cumulative pattern. So,   no interaction between them. It’s not  that having had the ACEs then made the   effects of the bullying stronger or weaker.  They’re really parallel, if we look at them. But we can see here, also, the dose dependent  relationship between ACEs and mental health   outcomes. So, the more they experience, the  poorer mental health outcomes they reported,   and same thing for – you can see in the  bottom line we have kids that weren’t bullied,   and in the top, we can see the kids that  were. So, they also reported higher problems,   and it was just, kind of, yeah, more was  worse, but having experienced just one,   or both of them, it didn’t mu – change the  relationship between these outcomes. Excellent. So, from the data we are looking at right  here, if we’re thinking about these two   different types of associations that we could  have between bullying and ACEs, it’s really the   cumulative model that was supported with  this data, whereby both bullying and ACEs   contributed independently to poor outcomes, but  didn’t really interact with one another [pause]. Alright. So, I was just – yeah, very quick run  through the results. If it – someone does want   more information, do put it in the Q&A. Happy  to chat about it later. But – and I want to   think it a little bit about what we can learn from  this and what this means more broadly. If we’re   thinking about – having thought about, kind of,  similarities and differences of ACEs and bullying,   we now know that they might follow more of a  cumulative relationship between one another. So,   what – where does that leave us,  essentially? And I think – also,   taking the context today, I wanted to touch  a little bit on implications for practice. I think it really lends itself to really  thi – to thinking about including bullying   in any screenings for ACEs or adversities,  especially if we’re thinking about adolescents,   so people who are at that stage where they  might be more likely to also experience   bullying. Because we can see that it has –  and we know this from past research, as well,   we know that bullying is linked to poor mental  health outcomes, and this is kee – this might   be similar to other types of adversity they  have experienced. So, screening for it can   help us maybe identify people who will –  are at heightened risk to either already   experience symptoms of poor mental health or go  on to experience symptoms of poor mental health. Secondly, I think there’s really scope to raise  awareness of the overlap between bullying and   ACEs, and this apply – I think, applies  to adversity more general, if we’re really   thinking about that these phenomena often don’t  occur in isolation. If something’s happening   to a young person, there’s – it’s likely that  there are other things going on in their lives,   as well, or would have happened in the past. So,  thinking about, okay, if someone is experiencing,   for example, problems with bullying, do they also  experience problems maybe in a family context? Or   they might go on to experience victimisation  in relationships and things like that. So,   really thinking about what that might  mean for that person and also, keeping in,   I guess keeping in mind that we don’t all esp  – and I think this is especially relevant when   we’re thinking about ACEs, we don’t always  know what has happened in a child’s life,   or what their family context looks  like. So, thinking about that, as well. And just broadly, as well, just providing extra  support for youth at risk for experiencing ACEs,   bullying and poor mental health,  and also, bullied youth. Yeah,   and we know these things are linked to poor  mental health outcomes, so intervening early,   when we know they might be experiencing something.  Even if we don’t know the whole picture for what   is going on, we might at least have some idea  that this person – a person is more likely to   experience poor mental health and be able to –  and also, to help them cope with the experiences   that they had, especially in a bullying context. And I just want to go back to the question I,   kind of, started with at the beginning, is  whether bullying should be considered an ACE.   I think there’s a lot more debate needed  around what we actually consider an ACE,   what is it and isn’t on the list. We see this as a  big problem in research, in particular, as, like,   some people include some things, other people  don’t, and then, what are we actually measuring? But I think if we’re thinking about this  very broadly, then, I think there’s enough   evidence to suggest that bullying is, kind  of, part of that childhood adversity group.   It’s – I think it’s similar enough in how  it presents and how it impacts young people,   and it is also serious enough that it  deserves this consideration. But maybe,   also, whether we need to think about ACEs,  and not just one umbrella, but thinking about   them in different contexts, where we might  think of bullying as a peer specific ACE. And there’s a lot more research coming out of  – on this recent – more recently, trying to,   I guess, group some of the ACEs, because  we’re saying, even with the original ones,   maybe not – they’re not all the same. They’re  all different experiences in their own right. So,   maybe we can think about this with ACEs, as well.  And we might have the more traditional forms,   which we could group into maltreatment  and family dysfunction, and then,   we have a separate type of ACE, for, I guess,  peer problems, and maybe as adolescents get older,   as well, also issues in – regarding  relationships might also encompass   some of the issues youth are experiencing  with discrimination, those kind of factors. And there is some emerging evidence that  this kind of framework is really helpful   and useful in understanding different  types of adversity. But I think there’s   a lot more we need to understand about  how these different types of adversities,   how they go together and how they  interact with one another, how – what   is the relationship between them? To really  untangle this and understand. And also,   think about it from a practical point of  view, what’s useful, what would help us   in, like, being able to understand the impacts  of adversity on youth mental health [pause]? Right – ooh [pause]. Yeah, there we go. So,  I talked a little bit about practice already,   but I think there’s also a lot more we need  to learn about these associations within   our research. And as Arnon said, there’s a  lot happening in this field at the moment,   but there’s still a lot of unanswered questions.  So, I think, very importantly, we really need to   understand these long-term relationships  between adverse childhood experiences,   bullying and out – mental health outcomes,  and really follow the same people to, kind of,   see how is this impacting the – them? How –  what might be some of the time ordering effects? Especially with a lot of the traditional ACE  research, it was often thinking about okay,   we have adults, let’s ask them what happened in  their childhood. Did these things happen to them?   And depending on whether – what happened, what  is their mental health like now? Whereas a lot   more research is now shifting focus on measuring  these things throughout childhood and then seeing   how is it impacting young people later? Which  is answering some really important questions   around not – is it – and overcoming some of the  limitations of maybe we only remember things if   we ha – they had a negative outcome on us,  as opposed to if we ask people at the time. There is also a lot I think we need to  disentangle in terms of the actual ACEs. So,   for most of what I talked about today,  I really just handled everything as an   umbrella term of adversity and then, looked at  bullying separately. But obviously, even within   that group of adversities, and there’s a lot of  heterogeneity and we can think there’s – some   of the ACE – even the traditional ACEs we have,  we’re grouping things like parental separation   and sexual abuse together, and saying, “Okay,  if you have one, you get the same score,” even   though we know that they have very different  impacts on children’s mental health outcomes. So, I think there’s a lot more work we need to  do in understanding what types of adversity are   particularly impactful when we’re thinking about  long-term outcomes and how they go together,   without losing the big picture, as well, of  just, sometimes, we just – we need to look   at adversity as a whole thing, rather than  getting into the nitty gritty. So, really   balancing those two aspects of getting detailed  information and not losing the big picture. So, yeah, so, a lot more work to be done, a  lot more to be understood, but I think there’s   some really exciting research coming out. I’m  looking forward to reading the newsletter, too,   seeing what’s been done recently. That’s all I  have for now, which means there will be plenty   of time for questions. You can also reach out  to me later, if you like, if you do have any   ongoing questions. So, I’ll leave that up for  a minute and then, I also have – and I can put   this up – back later. If you do want to read more  about the study I presented, you can read that   paper there with the QR code. I’ve got the link  there, as well. Yeah, and I will leave it there. Dr Arnon Bentovim Nora, there’s really  already been some really very interesting   questions which has come up, and I think  one of the ones, fairly straightforward,   is, “Are there cultural differences?” Because  you described, from the study, the rates,   and you indicated that perhaps a strength of the  particular im – the particular subject you’re   looking at is that there are good information  about ethnic differences. So, would you like   to comment on the issue of vulnerability in  different – across different ethnic groups? Nora Trompeter That is a really great question,  and unfortunately, it’s not something we   specifically looked at in our study to test if  there were differences in the associations we saw   by ethnicity. But I think it’s something that’s  really important that we’re looking at, especially   if we’re thinking about just marginalised  groups, as well, in particular, especially   in the bullying context. Because we know that  youth who are marginalised, or – come – are   diff – bullying is often perpetrated against  people who are perceived to be different. So,   they might be of a different culture group than  the majority of people at a school, for example,   or they might be of a different sexual orientation  or different gender identity, or something about   them is different. And that’s, kind of, where  a lot of the bullying, I guess, prays on. So, I think understanding, also, not the effects  of just bullying in general and how does bullying   affect, I guess, anyone or everyone, but  really, how is it experienced by people   who come from these marginalised groups?  To see is there, maybe, something specific   going on that is particularly harmful for them?  Especially viewing that in a broader context,   like something with ACEs, I think, would  be really interesting, but unfortunately,   not something we specifically looked at. So,  I can’t give you an answer to the question,   other than to say that I think it’s a really  important question to ask and to look into. Dr Arnon Bentovim The other thing that  a number of people have raised is the   important issue of the link between experiences  of bullying and actually – and victimisation,   and actually becoming the bully, the notion  of the cycle that you described earlier. And   I wonder if you’d like to comment on the  issue of the origin of bullying itself.   The experience you’ve described, but the  origin of the externalising behaviour that   is bullying and how this relates to  the theme you’ve been speaking about. Nora Trompeter Yeah, absolutely. Again,  I think that’s a really great question,   and interesting, also, something that I think  Researchers are looking at more and more,   especially as we’re now looking into online  forms of bullying. With traditional forms of   bullying, there was always the – this power  imbalance, where usually, the perpetrator   was proba – maybe stronger than the victim. So, it  was difficult for the victim to then bully others,   or they had some kind of, I guess, like, social  imbalance over it. So, it wasn’t as common,   traditionally, to have people who were  both victims and perpetrators of bullying. But we’re seeing it more and more in the  online context where this power imbalance   is really – it’s not as relevant a concept,  or it can quickly change if you – for example,   someone can be anonymous, and then, you don’t  know who that person is. It's also much easier to   react. So, if someone is being bullied and they’re  experiencing all these negative emotions and maybe   – or having trouble coping with the experience,  it’s much easier for them to then, I guess,   act on that impulsively, maybe, or have an outlet  for that in terms of externalising it to then   perpetrate bullying against others. That is a bit  harder if someone is in a face-to-face context. So, yeah, I also – yeah, I do wonder, as well,  I thought it was interesting we didn’t see any   differences ex – internalising and externalising  problems in our study. It was very, very similar,   but I wonder if, obviously, when we’re  thinking about the “bully victims,” as   they’re often referred to, we’re really  thinking about the kids who are struggling   with externalising behaviours. So, I think that  might be something to look into a bit further.  We were a bit limited in our study at looking  at perpetration. The questions for it weren’t   as good. We didn’t have as many questions in  the – on it, and it’s a difficult concept to   capture with self-report, as well, because,  well, children sometimes may not report that   they are – bully other people. It’s not something  someone might want to disclose about themselves,   or that someone is overly aware of that –  or remember. We often talk about, kind of,   memory bias in self-report, and there is  something to be said that it’s probably   more salient to report on a victimisation  experience than it is on a perpetration one. Dr Arnon Bentovim Yes, thank you.  It’s an obviously very interesting,   an important issue, and I think the point  you make about the way in which the net can,   in a sense, change the power balance  and, therefore, the individual,   who may feel a tremendous sense of grievance  as a result of bullying, can, in a sense,   turn the tables in a way that perhaps  would be much less possible face-to-face. Other interesting points that have come  up. I think there was one particularly the   – from the research perspective, which  I think – from Natalie Lamb, who asks,   “Could you provide more details about how  you can distinguish cumulative effects and   multiplicative effects to conclude that the  effects are not multiplicative? How the graphs   are produced.” In other words, could you say some  – because this is a really key issue, isn’t it,   of whether factors are act – working independently  or whether one is reinforcing and triggering the   other? Because there’s certainly some research  on the bi-relationship between certain activities   which, in fact, increase senses of trauma  or increased senses of stress and anxiety,   so that that’s very much multiplicative. But could  you say something and more – how you managed to   distinguish between these two different processes,  ‘cause that’s an important issue, I think? Nora Trompeter Yeah, absolutely, and that’s a  great question. So, I guess from a very – yeah,   from how we tested this, to answer your question.  So, I think we first looked at it as in – if we   think about our statistical model and we put in  – entered both ACEs and bullying, and, kind of,   looked, okay, if we combine these things together  as trying to explain mental health outcomes,   do they both contribute to the model, as in  independently? So, if we account for one,   does adding the other do anything? And there,  where we saw these and that’s when – what we   think of as cumulative effects, we said adding  both was – explained more than if we just had one,   and adding one over the other also  explained some extra information. So,   we could see that they’re both, in their  own right, adding to mental health problems. So, that was the first. But then, as I said,  we wanted to test whether they interact with   one another, and there, we’re really testing,  okay, if in addition to that, we, kind of,   multiply the effect of these two individual  effects, is that significant? Which it wasn’t,   and I showed you the graphs and I think  that there, we – you can really, often,   sometimes see these multiplicative effects really  well. Because if you’re thinking about cumulative   effects, it looked a lot – would look a look – a  lot – ah, would look a lot like what I showed you,   where we have two parallel lines, where it says  the effects for someone in the bullying group   is the same as someone in the non-bullying group.  They both move up and down the graph the same way. Whereas if we had, kind of, an interactive  effect, we might see that in a no-bullying group,   they have, kind of, a – the slope would  be different. So, you might see one line   moving a bit lower, whereas the other one is  a bit steeper, and then, we could say, okay,   there’s clearly a difference between these  two groups in how the relationship between   ACEs and outcomes is. So, really thinking about  is the slope between these two groups different? I hope that explained it. I know it’s  a really complex concept to understand. Dr Arnon Bentovim Well, thank you for  having a go. That’s – it’s beginning to   be much clearer. I think an interesting point  made by Stefan Davis, who says that he’s been   “intermittently involved with the implementation  of the Circle of Friends to help victims,” and   wonders if there’s “any research regarding  this in relation to ACEs.” And some further   questions about the Circle of Friends, in other  words, therapeutic approaches and vulnerability. I mean, in a sense, what I found myself very  much thinking about is what are the signals?   What are the responses that children and young  people, who’ve been exposed to the multiplicity of   adversity, and I agree with your idea that we need  to think adversity in a much more holistic way,   what is it that these children or young people  convey that somehow or other marks them out as   vic – as “potential victims,” again? And  what are the – what are those very – those   key elements that take – that create this  process that’s so powerful and harmful? Nora Trompeter Yeah, absolutely. It’s a  really good question. I’m not aware of anything   research-wise on this. I’m not sure if you are,  Arnon. But yes, and I think – but I think it’s   a good question, and I think this leads back to  some of the problems with – when we have these,   I guess, silos, where we think about bullying as  one issue and we think about adverse childhood   experience as a different issue. And then  we in – develop interventions maybe for one,   and we develop interventions for another, but  we don’t really think about them together,   or as co-occurring, and it’s like, okay, what do  we do with a young person if they have both? Is   there something that we could do to help them  that would address their unique situation?   Rather than say, “Okay, so, ACEs, here’s a  list of interventions we could pick from,   and okay, bullying, here’s a list of  things we could look at.” But really   thinking about that a little bit more.  Yeah, I don’t have a good answer, but… Dr Arnon Bentovim No, well, it’s a  very – it’s an interesting – it’s a   very interesting and important issue about  the signals – the interactive signals. Interesting, again, Fiona Swan makes a point here  that “Neurodiversity adds another layer to the   issue of ACEs and bullying, anxiety, and their  reactions impact on how they’re affected.” And I   think that the whole issue of neurodiversity and  individuals who may – there’s, as you commented,   there’s a good deal of vulnerability in these  young people, who very much describe high levels   of bullying and victimisation so frequently. And  presumably, there is something about the failure   to interact in a way which manages situations,  and which make people vulnerable, but through   particular response that, as it were, triggers  a sense of anger and so on. And I think there’s   growing information about the way in which  abusive and neglectful experiences can result   in a sense of grievance and anger and those less  so. So, I think that the nature of the individuals   and their interaction must play a role here. Nora Trompeter Yeah, absolutely, and again,   I think this is a great point to make, and I  think neurodiversity, in particular, is of real   importance when we’re looking especially  at bullying experiences. So, I, kind of,   touched on this already, but how bullying, kind  of, preys on differences, I guess. So, we know   that children who are neurodiverse are more likely  to become victims of bullying and – because they   interact differently than neurotypical peers,  and so, they’re more likely to experience   these things. But also, they ex – prob – they  experience bullying differently than other peers. So, it’s – I think it’s both of these things  that we need to keep in mind. Just they’re   both more vulnerable to experience  bullying in the first place. But then,   also, the effects and how that is processed  is a little bit different and needs to be,   yeah, just acknowledged or catered for  when we’re dealing with these youths. Dr Arnon Bentovim Yes, thank you. I think  that that’s correct. And comments from other   participants that “Abuse and neglect and  bullying all happen in schools and sadly,   by adults in schools,” and those of our colleagues  here who heard about the verbal abuse within   schools certainly will attest to that. And  colleagues are really describing the important   role of supportive work and the Circle of Friends,  presumably, really to really pro – to provide a   social context for individuals which will counter,  as it were, the sense of adversity victimisation. One interesting point came up was whether  there’s “more a tendency to – for more   internalising responses to be more prevalent  than externalising in this particular group.”   I’m not sure whether – what the balance was  in the research and from your experience. Nora Trompeter That’s really  – a really good question. So,   both from our research and as far as I’m  aware, from the research that exists,   it’s really both that are at heightened risk.  So, there doesn’t seem to be particular going   either way, that it’s more internalising or  more externalising. But instead, I think what   it’s pointing at is we probably also have really  different trajectories, so that – and we need to   explore individual differences here. So, there’ll  be some kids that experience bullying ACEs,   and they will develop more along the  externalising problem path. And then,   we’ll have other kids that experience  this – maybe the same thing, essentially,   but they’ll go more towards an ex – internalising  trajectory, or maybe a mix between these symptoms. And I think this is where we also need a lot  more understanding of what it is, and that –   what is it, maybe, about the experience? What  is it about the person? All of those things to,   kind of, understand, okay, what’s the most  likely outcome for this person, and how can   we best support them? Because I think it’s one  thing to say, “Oh, we know there’s going to be   poor mental health outcomes,” but I think it’s  even – it would be even better if we could say,   “Okay, we have this young person. We know  this is what their experience has been like.   We know that probably they’re most likely  to experience problems with externalising,   for example.” And we can give them specific  resources and we can help them specifically   with those kind of issues. Rather than just  saying, “Okay, maybe we can do something for   their mental health in general.” I  think both are important, but again,   understanding more about what it is that really  leads a person to go down one path or another. And we can see that in terms of severity, as  well, especially with both bullying and ACEs,   that whilst there is a, kind of, a  cumulative effect in terms of dose,   we also know that it doesn’t explain everything.  So, someone could experience very little, I guess,   and have very poor outcomes, and some other  person can experience much more of these,   or to a greater extent, and their mental health is  relatively okay. So, again, we need to understand   more about what is it that then happens to, kind  of, link these two things, and what explains the   variability in outcomes to really provide better  support, that is better tailored? And also, we’re   not just using, I guess, severity or frequency as  our only indicator of what is considered risky. Dr Arnon Bentovim Yes, that – thank you, that’s  very interesting. Of course, there’s quite a bit   of research coming through at the moment which is  looking at the spectrum of threat or deprivation.   In other words, is there a balance of threat  in the adversity which children and young   people have been exposed to? Are they exposed  to violence in the home? Have they had physical   or emotional abuse, verbal abuse? In other words,  powerful negative experiences, or is there a sense   of deprivation, of loss, that the – there is a  failure of responsiveness and a failure to nurture   and failure to care, more on the neglect spectrum? And I think it’s interesting now to see the   research that’s coming through that  indicates that particular, as it were,   particular atmospheres of threat or deprivation  in the lives of children and young people,   do have a differential effect. And I think that’s  beginning to be one important dimension to look   at, isn’t it, I think, and may have a  rele – and may be very relevant here? Nora Trompeter Yeah. No, thank you so much for  bringing it up. I do think it’s a really important   framework that – to explore in relationship to  adversity, and I think it can really help us   make sense of a lot of the experience and how we  can understand them, more broadly. And I’m really   interested to see how bullying fits into this  framework, because I can see it being on both   ends of the spectrum, where it’s both a threat,  as in someone who’s being bullied experiences a   threat to the – their – maybe their own  wellbeing. They’re being – yeah, it can   be really – a really threatening experience,  especially if we’re looking at the different   types of forms of bullying. So, it can really  be more aligned with those kind of experiences. But in the same way, because  it is in this social context,   I can – it’s – I also think about it as a form  of deprivation. If someone’s being bullied,   they might be deprived of important social  connections that they would have, or they’re being   excluded from certain opportunities, which then  deprive them of even – whether it’s with peers,   or they might not engage in after school  activities, or they might engage less at   school. So, it is, kind of – it, kind of, touches  on both of those concepts at the same time,   of being both threatening and depriving to the  individual. And yeah, so, how this framework   can be applied to bullying, I think, would  be really interesting to further explore. Dr Arnon Bentovim Yes, and of course, we’re  learning so much more about genetic influences   on responsiveness, and I think the paper which  we have in our newsletter from Andrea Danese   about the perception of experiences. And their  research demonstrated, in longitudinal study,   that individuals with actual objective  experiences recorded in their notes and   in their history of abuse and neglect, that if  those experiences were not perceived in that way,   as abuse and neglect, they did not have the  same subjective impact. And it’s the subjective   response that really is the core of what is  associated with harmful mental health impacts. And I think – I assume that this is  going to be an important factor here,   how do individuals experience the  bullying? How do they experience   adversity? How do they perceive it? How  do they see it? How do they – and that   has such an important element on their – on the  longer-term impacts, doesn’t it? Interesting… Nora Trompeter Yeah. Dr Arnon Bentovim …question,  one of our participants, Ebru,   says that is son “has been emotionally abused  from his Teacher” and his son “has had enough,   told the parent, “Talked to the school,” the  class was changed,” but he “doesn’t know what   happened to the Teacher, really.” And I think  the whole issue of bullying policies within   schools and what influence that has,  and it’s certainly an important issue,   in terms of the recognition of bullying as a  major issue that’s got to be taken onboard. Nora Trompeter Yeah, absolutely, and I think  in particular, it really goes both ways. And   we know that with anti-bullying policies,  we know that if schools, in particular,   have strong anti-bullying policies that are  consistently enforced, that both reduces the   incidence of bullying in the first place,  but also, for kids who are being bullied,   the – their outcomes are better compared  to schools where they don’t have these   policies. Potentially, because they feel taken  seriously, they know how to act upon these. And one thing that’s often really important  for victims of bullying is being able to do   something productive about the experience and  being able to dissociate the experience from   oneself, but you’re saying, “This happened  to me, and I can follow these steps,   and these are productive, and these  will help me cope.” Rather than,   “I have experienced this and now I  feel helpless and lost and no-one is   responding to this.” Which can then, kind of,  avalanche into more mental health problems. So, it’s really important to not only stop  bullying happening in the first place,   but also, help the people who  are being bullied. So, yes,   strong policies that are consistently  enforced at schools are win-win. Dr Arnon Bentovim Yes, I think it’s right.  In a sense, what you’re saying is that the   importance of promoting resilience within school  context. Which really mean to try to ensure that   experiences which are toxic, toxic stress is  transformed to ordinary stressful experiences,   which can be managed and can be coped with, and  one can learn from, rather than be overwhelmed   by. And indeed, Natalie Lamb has asked  us for “comments or thoughts about the   effectiveness of statutory requirements in  terms of schools’ behaviour policy or other   macro level public health interventions  and policies,” and wonders about that. And of course, we all note with interest that  Wales has introduced a really powerful policy   in terms of developing trauma-informed schools,  trauma-informed policy, for – at all levels. And   I think that’s – that this is very much  an issue in terms of its effectiveness,   but I’m not sure if you’ve got a comment about  how effective such policies can be, and…? Nora Trompeter Yeah, so, I think it’s a  really good question. I don’t know if we   have really good evidence, at a really high  policy level, of how effective these are,   just because they tend to be very difficult  to assess and really examine. But I definitely   think – so, what we know from a school  level approach that having really good   and clear policies has positive outcomes  on students. And we also know that raising   awareness and actually labelling things  and providing context also helps a lot. So, actually saying, “This is what bullying  is and this is not okay, we don’t accept this   type of behaviour,” that already makes  a big difference for individuals, again,   both in preventing the behaviour and also, to help  victims of it deal with it. Where, like you said,   we can turn something that could be a toxic  stress into a stressor that it wasn’t pleasant,   but we can do something about it. We can  stop the experience. It doesn’t happen   again. We have helpful tools to help us  cope, and then, it doesn’t have to become   this thing that has a big impact on our lives. So, I think these things can have a big impact   and especially know this from other areas, once we  start, yeah, I guess talking about these things or   acknowledging things, and saying – and what is  and isn’t acceptable behaviour. So, for example,   we’re seeing this more recently in terms of  weight dimi – discrimination. There has been   some legislation in the US coming in saying it’s  now discriminatory to, yeah, discriminate against   someone based on their weight, which wasn’t,  I guess, a protective characteristic before. Now, we can say, it’s like, and we can  slowly see when these things come into place,   that we can say maybe a behaviour was previously  considered normative or socially acceptable,   just by putting these steps into  place to say, “This is not okay.   This is not how we treat people,” they  can become, I guess, prevented. But also,   for the people who are experiencing them,  it gives them a tool to deal with it. Dr Arnon Bentovim And how to help schools,  and I think you’ve given some very interesting   definitions about different forms, direct and  indirect, forms of bullying. And of course,   we’ve all been very much aware of the  issues around the death of Brianna Ghey   and her killing and the whole issue of  how the net can, as it were, give models   of bullying and models of harmful behaviour,  which can have such dire and terrible effects. Nora Trompeter Yeah, and I think it’s – it is  a real challenge for schools, and I know that   it is something that schools have been, yeah,  thinking about working with for a long time,   with the – when we think about bullying. And  it does change in context, like we talked   about. I think there’s – there are probably  a lot of different ways that schools can go   about dealing with bullying. Like I talked about,  having anti-bullying policies that are clear and   consistently enforced, but also, clear ways of  finding support for people who are experiencing   bullying, that they know what to do. So, they know  who to talk to and they know where they can find   support, and that they’re actually supported  and believed when they report such instances. I also think – I find this sometimes  comes up when people say, “Oh, schools,   they don’t want to get involved in bullying, or  say there is no bullying problem at the school.”   I think it’s almost impossible for schools to  know that, that there’s no bullying going on,   or it’s not a problem, and so, I think, yeah,  be great for everyone to provide these, kind of,   support systems. It’s not to say if bullying  happens, it’s not necessarily the fault of the   school just because it happened there. It may or  may not, but to acknowledge that there’s a role   they can play in both preventing instances  and also helping people when it happens. And obviously, it becomes more difficult  if we’re thinking about cyberbullying,   and there’s not a lot of people that want to  get involved in that space, understandably.   It is very messy and complicated, but I think we  need to at least give young people the tools and   avenues to say, “This is what might be happening,  this is what you can do if it is happening, and   this is who you can talk to,” and being a, yeah,  supportive adult can make a really big difference. Dr Arnon Bentovim Yes, thank you, and I  mean, one comment from Lavinia Dowling,   who says that “If bullying is being  dealt with better, improved support,   does the bully not usually resort to being  more covert?” I also find it very concerning   when schools insist they don’t have bullying  in their premises, even more so now than ever,   when we – when there’s a risk of mental  health issues being dismissed in schools. So,   I think that, of course, there will be  enormous variation in terms of responses. Nora Trompeter Yeah, absolutely, and I think  – so, a gen – a – from a research perspective,   generally, there – if there are, I guess,  real systems in place and real, kind of,   prevention work being done at a school,  they do lead to lower rates of bullying,   that don’t just become more covert, but  actually reduce bullying. A lot of it,   as well, is it’s often a group phenomena,  whereby bullying is somewhat supported by   others or encouraged by peers. So, even just  being able to change the culture in which it –   can make it less likely for some kids to engage in  bullying, if they were previously doing it. Also,   to become more popular or to, kind of, hold  onto that position of power. But I guess   if the social context changes, then, they  might – their behaviour might also change. Dr Arnon Bentovim Yeah, thank you. Nora Trompeter What I can see as being  less helpful, if it’s more of a superficial   prevention of bullying, to say, “We don’t” –  kind of, if someone calls each other names,   then there are really strict, kind of,  punishment for it, but it doesn’t deal   with the actual problem, and then, kids will  find other ways. They will just text each other,   for example, instead of saying it in front of the  Teacher. So, yes, I can see that being a problem,   but I think the – yeah, the solution is  here to have meaningful prevention work. Dr Arnon Bentovim Yes, and comments  introduce some interesting points. I   think Stefan Davis mentions the “development  of interventions, such as youth mental health,   first aid and peer mediation,” which is a useful  approach. And also, Sharon Grey mentions the   “Thrive Approach to support developmentally around  powering over, and adults in educational settings   unconsciously using unhelpful approaches.” So, the  bystander intervention is important. “Workplaces”   a con – colleague mentions, Christine Price,  “inadvertently depriving staff of connections and   opportunities.” So, I think that this raises  the whole issues within workplace, within   different contexts within schools, prevention  and a culture to really stand up to bullying,   I think. So, interesting reflections  from our participants about this issue. Nora Trompeter Yeah, absolutely, and yeah,  I’d just like to say I really like those   points being raised there, as well, about,  yeah, the things like bystander interventions   and helping people cope. And like I said, as  well, if this is a social phenomena, as well,   we can do a lot by strengthening the peer  support system, as well, and changing the   social contexts in which peers engage with one  another. And often, as well, with bullying,   we also see that bystanders are also affected  by it. If they – even if they’re not the ones   being bullied, even witnessing bullying and it  can be quite distressing for young people. So,   it can also be really helpful for them to know  what they can do if they see this and can help   their own mental health and whilst also  helping their peers. The feeling of being   helpless in these kind of contexts can be  also very distressing for young people. So,   I think it’s all around really good  to have those kind of support systems. Dr Arnon Bentovim Thank you very much, indeed,  and I think it’s been a very interesting seminar,   and thank you all participants for the points  that you’ve raised. Because I think bullying   is such a core experience for young people  and a core – and I think that if we think   about the presentation at the last seminar  about verbal abuse, and it links to bullying,   the range of bullying behaviour that you described  at the beginning and its incidence. And I think   it’s very striking how many children report  both experiences of bullying and persistent   and intensive bullying. And to understand that we  have to ask the question, “What else has happened   to you as well as this particular incident of  bullying which is so distressing?” And I think   that what’s – the idea that comes through is that  these are individuals who often have quite an   extensive vulnerability and therefore, it’s very  important to understand and to support and to get   the appropriate help in terms of developing  resilience, in terms of managing experiences. So, I think that we’ll – I think we’ll stop at  this point. I think we have managed to deal with   most of the questions and points that have been  raised. Thank you, everybody, for raising them,   and thank you, Nora. And just to remind everyone  that the slides and your presentation will be on   the ACAMH Web shortly, in the next few days, and  that you’ll be able to really think about these   very interesting results we’ve heard about. And to  remind everyone that we’re looking – next month,   Heather Taussig from Denver is going to be talking  about peer support, in a sense, for children and   young people who are in foster – who’ve been  fostered. So, I think the theme continues. So, thank you very much and thank  you for participating and thank you,   Nora, for an interesting  presentation and for your results,   which really bring together some  important themes. So, thank you. Nora Trompeter Great. Thanks for having me and  thanks for the great questions and comments. Dr Arnon Bentovim Pleasure. Thank you very much.