literature review in cyberbullying

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Cyberbullying: A Review of the Literature

23 Pages Posted: 9 Mar 2021

Saurav Chakraborty

University of Louisville; University of Louisville - Department of Computer Information Systems; University of Louisville

Anol Bhattacherjee

University of South Florida - College of Business Administration

Agnieszka Onuchowska

UNIVERSITY OF SOUTH FLORIDA

Date Written: March 8, 2021

This article reviews 142 academic papers on cyberbullying over the 1999-2018 time period with goal of identifying the salient causes and effects of cyberbullying and intervention mechanisms that can help combat cyberbullying. Our analysis finds that. This study contributes by investigating and understanding the drivers of this phenomenon along with looking at possible interventions which can be implemented to curb such behavior.

Keywords: Cyberbullying, Literature Review, Drivers, Interventions and Consequences

Suggested Citation: Suggested Citation

Saurav Chakraborty (Contact Author)

University of louisville ( email ).

Louisville, KY 40292 United States

University of Louisville - Department of Computer Information Systems ( email )

United States

University of Louisville

Tampa, FL 33620 United States

University of South Florida - College of Business Administration ( email )

4202 E. Fowler Avenue, BSN 3403 Tampa, FL 33620-5500 United States

UNIVERSITY OF SOUTH FLORIDA ( email )

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Cyberbullying in adolescents: a literature review

Cyberbullying is a universal public health concern that affects adolescents. The growing usage of electronic gadgets and the Internet has been connected to a rise in cyberbullying. The increasing use of the Internet, along with the negative outcomes of cyberbullying on adolescents, has required the study of cyberbullying. In this paper author reviews existing literature on cyberbullying among adolescents. The concept of cyberbullying is explained, including definitions, types of cyberbullying, characteristics or features of victims and cyberbullies, risk factors or causes underlying cyberbullying, and the harmful consequences of cyberbullying to adolescents. Furthermore, examples of programs or intervention to prevent cyberbullying and recommendations for further studies are presented.

Research funding: None declared.

Author contributions: Author has accepted responsibility for the entire content of this manuscript and approved its submission.

Competing interests: Author states no conflict of interest.

Informed consent: Not applicable.

Ethical approval: Not applicable.

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Cyberbullying: A Narrative Review

Grover, Sandeep; Raju, V. Venkatesh

Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Address for correspondence: Dr. Sandeep Grover, Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 4.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background:

With the rapidly expanding digital world over the past decade and more to the current context of the coronavirus disease 2019 pandemic, where online activities have replaced most of the offline activities, it is important to understand bullying, which has crossed from its traditional domain of offline to online and is understood as cyberbullying.

This review aims to assess the concept, types of cyberbullying, prevalence, risk and protective factors, conceptual models explaining cyberbullying, psychological impact, and preventive strategies for cyberbullying.

Methodology:

Internet sources (PubMed and Google Scholar) were searched for the available literature, and a narrative review was synthesized. Different types of cyberbullying are defined in the literature. The prevalence rates vary depending on the time frame of assessment being considered. The mean prevalence of victimization is 10%–40%, and the prevalence of perpetration is 3%–20%.

Results:

Different risk and protective factors have been identified for being a victim of cyberbullying and becoming a cyberbully. Cyberbullying can have a significant negative psychological impact on the victims. Prevention of cyberbullying involves guidance for parents, advice for schools, and guidance for the health-care providers. Cyberbullying is becoming a major issue for many teenagers, resulting in unforeseen deviances and negative effects in their lives.

Conclusions:

Efforts should be taken to successfully avoid and respond to it, as well as to provide kids with tools to lessen their own risk of victimization.

I NTRODUCTION

Bullying has traditionally been defined as undesirable, aggressive behavior among children with an actual or perceived power imbalance. Further, it is understood by its repetitive nature or potential of repetition over time. Bullying is defined by three key characteristics of behavior. To begin with, the behavior must be aggressive; second, there must be an power imbalance, meaning that bullies use their power, which could be in the form of physical strength, knowledge of potentially humiliating information, or popularity, to exert control over or injure others; and third, bullying behaviors must be repeated, meaning that they must occur more than once or have the potential to occur more than once. [ 1 ] Bullying is known to be existing for a long time, but with the advent of technology, it has changed its traditional way. Bullying victimization is believed to affect anywhere between 10% and 35% of teenagers, [ 2 ] and another meta-analytical review found mean prevalence rates of 35% for traditional bullying involvement. [ 3 ] However, over recent years, access to handheld devices and newer technologies among school-going children has led to the emergence of the concept of cyberbullying. According to the American Academy of Pediatrics, the introduction of portable technologies, such as cellular phones, digital cameras, and personal digital assistants, as well as simple access to social networking websites, has resulted in the emergence of technology-assisted bullying behavior, also known as “cyberbullying.” [ 4 ] After the beginning of the coronavirus disease 2019 (COVID-19) pandemic and changes in the functioning of schools and the education system, the rates of traditional bullying have reduced. In contrast, the data on cyberbullying report an increase, which is slight to a significant level, due to obvious changes to online education implemented worldwide. [ 5–8 ]

C ONCEPT AND D EFINITION

Although the concept of cyberbullying stems from traditional bullying, it is understood differently. It is considered as an umbrella term and is related to constructs such as “online bullying,” “cyber aggression,” “cyber violence,” “electronic aggression,” and “Internet harassment.” There is no consensus on definition of cyberbullying, and it is defined differently by different authors. [ 9 ] In the world of technology, i.e., the virtual world, defining cyberbullying is difficult because of various reasons or conceptual issues such as type of technology involved, the purpose of use of technology, what is said to whom and with what effect (intent), ambiguity with perception (teasing), from whom the content is being assessed, and the confusions surrounding the ages of individuals involved (cyberstalking/cyberharassment). [ 10 ]

In simple words, cyberbullying is defined as an indirect way of bullying involving technology. [ 11 ] Cyberbullying is also understood as “ using information and communication technologies (ICT) to repeatedly and intentionally harm, harass, hurt, and/or embarrass a target .” [ 12 ] Others have defined it as “ an aggressive, intentional act carried out by a group or individual, using electronic forms of contact, repeatedly and overtime against a victim who cannot easily defend themselves .” [ 13 ] According to another definition, it is understood as “ willful and repeated harm inflicted through computers, cell phones, or other electronic devices , [ 14 ] or as “the use of electronic communication technologies to bully others .” [ 15 ] Although there is no consensus on the definition of cyberbullying, there is an agreement on its components, which include the use of electronic media, deliberate acts to cause harm/harassment (intentional), aggression, repetition, a relationship marked by a power imbalance, anonymity (or the appearance of anonymity), and public exposure (i.e., it is in front of many audiences and for the majority of the time (due to its 24/7 nature). [ 9 , 11 , 12 , 14 ]

Cyberbullying differs from cyberstalking or cyberharassment by the age of the individual. When an adolescent is involved as a victim, the term used is cyberbullying, but it is known as cyberstalking or cyberharassment when a major is engaged. Some argue that there is no legal distinction between the two, other than that of age, and that cyberstalking is a form of cyberbullying. [ 10 , 16–18 ]

C YBERBULLYING V ERSUS T RADITIONAL B ULLYING

Cyberbullying differs from traditional bullying on some of the vital points. [ 19 ] To begin with, there is anonymity in that the offenders are not concerned with power imbalances. Furthermore, there is no direct way to determine the victim’s reaction. Empathy and remorse have a far lower chance of occurring. Second, the victim is accessible most of the time, i.e., 24 h a day, 7 days a week, 365 days a year, and the audience is broad. A message or any single act of online bullying remains accessible to the majority of the public until it is being removed by the perpetrator or removed or blocked by regulatory bodies. Hence, one act can have a long-lasting impact. Finally, the escape is more complex than the traditional bullying [ 3 , 15 , 20 ] [ Table 1 ].

T YPES /F ORMS OF C YBERBULLYING

Before understanding types of cyberbullying, it is essential to understand the various types of traditional bullying. Broadly, there are three types of traditional bullying, i.e., physical, verbal, and social or psychological bullying. [ 21 , 22 ] When someone’s body or goods are hurt, this is referred to as physical bullying. This form of behavior includes hitting, kicking, pinching, spitting, tripping, pushing, taking or damaging someone’s belongings, and using offensive or rude hand gestures. Malicious mocking, name-calling, improper sexual comments, taunting, threatening to hurt, and other forms of verbal bullying are all examples of verbal bullying. Bullying that is social or psychological, also known as relational bullying, involves harming someone’s reputation or relationships. It includes things such as purposefully leaving someone out of social situations, manipulating social relationships (asking other kids not to be friends with someone), spreading rumors about someone, publicly humiliating someone, blackmailing, or intimidating someone. [ 21 , 22 ]

The various types or forms of cyberbullying include flaming, harassment, cyberstalking, exclusion or ostracism, impersonation or masquerading, catfishing, trolling, fraping, sexting, and outing or trickery. [ 23 , 24 ] Flaming is understood as using hurtful language in E-mails, text messages, or chat rooms against an individual, i.e., an online fight or a brief, heated exchange between two or more individuals that occurs via any communication technology. [ 23 , 24 ]

Harassment is defined as the transmission of insulting or hurtful, hateful, and/or threatening messages on a regular basis. [ 23 ] Cyberstalking entails following someone online and sending them E-mails or texts in an attempt to scare, injure, or intimidate them. [ 23 ] Exclusion or ostracism is intentionally excluding someone from a group and making derogatory remarks/messages about him/her. [ 23 ] Impersonation, also known as masquerading, is the use of a fictitious identity to harm someone’s reputation by publicly publishing correct or misleading information about them. [ 23 ] Catfishing is a sort of deceitful action, in which a person develops a sock puppet social networking presence, or a false identity on a social networking account, with the intent of abusing, deceiving, or defrauding a specific victim. [ 23 ] Trolling is when someone purposefully harms another person by making derogatory or offensive comments. [ 23 ] Framing is understood as destroying a person’s reputation by exploiting their social networking accounts to post inappropriate content. [ 23 ] Sexting is the act of sending, receiving, or sharing sexually explicit messages, photographs, or images of oneself to others using mobile devices. Using a computer or other digital device could also be included. [ 25 ] Trickery is defined as deceiving someone into disclosing personal information and then sharing it with others. [ 23 , 24 ]

T HE M AGNITUDE OF THE P ROBLEM

Prevalence and incidence of cyberbullying victimization/perpetration are highly variable across studies because of factors such as a lack of consensus definition of cyberbullying, differences in ages and locations, reporting time frames (e.g., lifetime, 2 months, 6 months, etc.), the rate at which a person is labeled as a perpetrator or a victim, and the measurement used (single item vs. multi-items). [ 18 ]

Prevalence in previous year

Extensive sample size studies report average annual cyber victimization rates between 14% and 21%. [ 26 ] According to the US Department of Health and Human Services’ Center for Disease Control, 14.9% of high school students had been cyberbullied in the previous year. [ 27 ]

Prevalence in lifetime

A thorough review of the literature, which included data from 234 papers, showed an average lifetime incidence of cybervictimization to be 21% and an average lifetime incidence of cyberbullying perpetration to be 13%. [ 28 ]

Perpetuation

A critical review and meta-analysis of cyberbullying research among the youth showed a prevalence of perpetration to be 3%–20%. [ 18 ]

Opinions of the victims and parents

A study done on middle and high school children regarding their opinion, experiences, and response to cyberbullying showed that 44.5% of them were exposed to cyberbullying at least one time, 22.5% had exhibited actions that constituted as cyberbullying, and 53.2% became a witness of such actions at least once. [ 29 ] A study from the United States reported prevalence rates of cybervictimization to be 95% and that of cyberaggression to be 94% during the previous 2 months among the adolescents admitted to inpatient psychiatric hospitals. The study also showed that females were more often cybervictims and also exhibited cyberaggression. [ 30 ] According to an online poll, one (12%) in ten parents globally claim that their child has been the victim of cyberbullying, and one (24%) in four agreed that they know a child in their community who has been the victim of cyberbullying. [ 31 ] Another study revealed that 15% of children and young people reported being harassed or bullied online, 14% reported being harassed or bullied offline, and 71% reported no experience of either in the previous month. When they were asked to report their experience over the last year, the figures for online and offline bullying were 27% and 26%, respectively. When lifetime experience was considered, the figures were 39% and 49%, respectively. [ 32 ] Accordingly, it can be said that the prevalence of cyberbullying is influenced by the time frame being considered.

Impact on coronavirus disease 2019 on cyberbullying

After the COVID-19 pandemic, there has been increased talk about cyberbullying, but only a few studies have evaluated the same. A population-based study from Canada evaluated the impact of COVID-19 on bullying prevalence rates. It included 6578 students of class 4–12 and reported far higher rates of bullying involvement before the pandemic than during the pandemic in all forms of bullying (general, physical, verbal, and social), with the exception of cyberbullying, where differences in rates were less pronounced. [ 5 ] Another study of online search data for real-time tracking of bullying trends found that as schools transitioned to remote learning in 2020, school bullying and cyberbullying searches dropped by 30%–35%. The gradual restoration to in-person education resulted in a return to prepandemic levels of bullying searches. The scientists theorized that this unusually positive effect could explain some of the recent conflicting results on the pandemic’s effects on students’ mental health and well-being. [ 7 ]

Data from India

There are limited data on the prevalence of cyberbullying in the Indian context. A survey by Forbes in 2018 that involved around 20 thousand adults from 28 countries reported that around 37% of parents from India reported that their child has experienced cyberbullying, which was the highest among the 28 countries. It was followed closely by Brazil (29%) and the United States (27%). [ 27 ] According to a survey conducted in Chandigarh, one out of every four adolescents in the city suffers from bullying at school, and the prevalence of cyberbullying was 2.7%. [ 33 ] As such, there is not much data on the effect of the COVID-19 pandemic on cyberbullying in children and adolescents in the Indian context. One study that surveyed 256 students before the pandemic and 118 students during the lockdown reported that the pandemic has affected susceptibility to cyberbullying. [ 8 ]

P LACE OF O CCURRENCE OF C YBERBULLYING

As stated in the definition, cyberbullying occurs through the use of ICT, such as social media (Facebook, Instagram, Snapchat, Twitter, and so on), cellular network short message service text messages, instant message services (WhatsApp, Facebook Messenger, I-message, and so on), E-mail, and so on. [ 34 ]

When a comparison of different types of social media platforms used by young people was studied, it was seen that more than half of the participants reported having been bullied in chat rooms (55%), followed by Flickr (44%), Tumblr (40%), and other instant messaging app (40%) and then followed by other platforms such as live gaming (33%), Twitter (33%), Facebook (32%), Snapchat (32%), YouTube (31%), Instagram (31%), and WhatsApp (27%). [ 32 ] It was also seen that the chances of cyberbullying increased with more time spent on social media. Only 3% of children and young people reported having been cyberbullied in the last year when their time on social media was <1 h/day. However, this figure increased to 19% when the time spent was 1–2 h/day, 24% when the time spent was 2–3 h/day, and 34% when the time spent on social media was more than 4 h/day. [ 32 ] An online poll involving more than 18,000 adults in 24 countries, 6,500 of whom were parents, reported that social networking sites such as Facebook are by far the most commonly reported platform for cyberbullying, with 60% mentioning them, and mobile devices and online chat rooms were a distant second and third, each with around 40%. [ 35 ] According to an Indian study, stalking is the most common type of cyberbullying (71.2%), followed by making insulting remarks (64.4%), leaking or sharing pictures/videos online (41.7%), and online harassment (22%). Furthermore, the majority of people who were subjected to cyberbullying experienced more than one type of cyberbullying. [ 8 ]

Individual’s use of social media to cyberbully varies according to their age. Online gaming (which allows players to communicate by headset and in-game text) has been identified as the most common method for elementary school students to engage in cyberbullying. [ 36 , 37 ] Cyberbullying is particularly widespread in teens on social media, with Twitter and Facebook being the most commonly utilized platforms. Public and private comments, status updates, and postings are the most prevalent ways in young adults. [ 38 ]

R ISK F ACTORS AND P ROTECTIVE F ACTORS

Various risk and protective factors have been identified for perpetuating cyberbullying and being a victim of cyberbullying [Tables 2 and 3 ]. [ 15 , 36 , 39–41 ]

W HY S OMEONE B ECOME A C YBERBULLY

Available literature suggests that various factors [ Table 4 ] propel youth to become a cyberbully. [ 42–46 ] As discussed earlier, anonymity is one of the essential factors contributing to cyberbullying. It is also conceptualized as a coping mechanism to deal with low self-esteem. Other factors contributing to becoming a cyberbully include lack of parental supervision, lack of information about the risks, peer pressure, and lack of knowledge about the punishment. [ 42–46 ]

T HEORIES OR M ODELS OF C YBERBULLYING

Different authors have proposed different models for understanding the phenomenon of cyberbullying. The commonly described models include Barlett and Gentile Cyberbullying Model, General Aggression Model, I-Cubed Theory, social-ecological diathesis–stress model, and conceptual model. [ 9 , 40 ]

Barlett and Gentile Cyberbullying Model

According to this model, anonymity in cyberspace and belief that one’s physical size does not contribute to a power imbalance online account for cyberbullying. [ 47 ] This paradigm, however, has been criticized for being overly basic. This approach also ignores individual-specific characteristics (such as self-control, moral disengagement, and technology use) as well as context-specific factors (e.g., monitoring of technology by the parents and lack of explicit policies on consequences for cyberattacks in the school). [ 9 ]

Generalized Aggression Model

According to this model, repeatedly playing violent games or being exposed to violent media content causes the learning, rehearsal, and reinforcement of aggression-related knowledge structures such as aggressive belief and attitude, aggressive perceptual schemata, aggressive expectation schemata, aggressive behavior scripts, and aggressive desensitization, all of which lead to an increase in aggressive personality. [ 48 ] Person-specific factors such as demographic variables and aggressive personality, as well as situation-specific factors such as social situation, peer group (e.g., presence of bystanders), and school climate influence current internal states via elements such as cognition, affect, and arousal system; which then influence appraisal and decision-making processes, leading to cyberbullying outcome behaviors. [ 9 ]

I-cubed Theory

This theory was developed by Slotter and Finkel, [ 49 ] which defines cyberbullying in terms of three major forces linked to violent behavior: instigating force, impelling force, and inhibiting force. [ 49 ] Situational events or circumstances that may normatively incite or arouse individuals to act aggressively are defined as instigating force; impelling force is defined as dispositional or situational factors that increase individuals’ likelihood to act aggressively, and inhibiting force is defined as dispositional or situational factors that increase individuals’ likelihood to override their urge to aggress, thereby reducing aggressive acts. [ 49 ] Victimization from cyberbullying and a sense of online disinhibition can increase a person’s inclination to engage in cyberbullying. [ 9 ]

Social-ecological diathesis–stress model

According to this model, the dynamic interplay of biological, social, and environmental elements helps in understanding bullying perpetration. This model takes into consideration the interaction of environmental factors (e.g., family, school, and neighborhood), child’s genetic vulnerabilities (e.g., temperament and personality), and individual risk and protective factors. [ 50 ] A child’s predisposition for aggression (due to genetic vulnerability, moral disengagement, etc.), prior experiences with bullying (environmental factors), moderating factors related to cyberspace (e.g., the strength of the disinhibition effect and one’s technological efficacy), and parental factors (e.g., parent–child relationships and monitoring of technology use by the child), influence cyberbullying. [ 9 ]

Conceptual model

This model explains cyberbullying through the ‘Five Cs,’ which include context (the online) where adolescents spend time (e.g., Instagram, chat rooms); contacts (i.e., online social relationships) they make; confidentiality (the level of confidentiality/privacy that is maintained); conduct (online technical skills and self-regulation); and the content they upload, use, and access. [ 51 ]

P SYCHOLOGICAL I MPACT OF C YBERBULLYING

Cyberbullying can have several negative psychological and behavioral impacts on children and adolescents [ 13 , 21 , 27 , 30 , 32 , 52–56 ] [ Table 5 ]. There is a dose–response relationship between being cyberbullied and the severity of the consequences in terms of negative psychological and behavioral effects. [ 52 ] The youth who are bullied the most are the most affected. [ 18 , 57 ] When the link between cyberbullying and mental health was investigated, it was noted that 60% of children and young people who had previously experienced a mental health problem reported being bullied online in the previous year, whereas 70% of children and young people who were currently suffering from a mental health problem reported being bullied online in the previous year. [ 57 ]

P REVENTION OF C YBERBULLYING

Prevention of cyberbullying is of paramount importance.

Guidance for parents

Parents should monitor their children’s screen time and make sure that they engage in much more offline activities than a computer, online game, or smartphone addiction. [ 13 , 24 , 31 , 58–64 ] Parents should encourage their children to turn off technology at set times, such as family meals or after a particular hour at night. Parents should be aware of their children’s Internet usage, online activities, and the apps and digital media they utilize. Parents should teach their children about safe Internet use practices, such as not sharing usernames or passwords with others, not disclosing personal information in profiles, chat rooms, or to others, not to respond to threatening messages without instantaneously informing an adult, and turning off gadgets if they receive threatening messages. Parents should teach their children how to make a strong password, not reveal passwords to anyone except a parent, or write it down where the parent can access it. The child must be aware that individuals they communicate with online may not be whom they claim they are, and also, the materials posted online may not be secure. Parents should discourage bullying others online by telling their children not to send mean or damaging messages or suggestive pictures and messages. Parents should earmark common areas for devices such as making sure that the child’s computer/laptop/tablet is kept in a shared space like the family room, and Internet access in the privacy of the child’s room should not be allowed. Parents should wait until their child is in high school to have their E-mail and other social media accounts. Even after giving these facilities, parents should know their child’s passwords. They should make it clear to their child that they reserve the option of accessing their accounts. Parents should encourage their children to use technology responsibly by teaching them to stop from sending personal or improper images of themselves or others. [ 13 , 24 , 31 , 58–64 ]

Parents should also teach their children that a post creates a permanent imprint that cannot be reversed. Parents should also tell the child to inform an adult about untoward events without having to be concerned about losing access to their technologies. Parents should also tell the child that if they indulge in the perpetuation of cyberbullying, strict punishments, such as confiscating cell phones and revoking privileges, for breaking the rule will be implemented. Parents should be aware and make their children aware of the functioning of social media platforms. Reporting, blocking, filtering software, and human and automatic detection systems are all available on most social media platforms to prevent and intervene in cyberbullying. To detect instances of cyberbullying, automatic detection using engineering features analyzes numerous properties of posts (e.g., language and emoticons). Because human moderators may perceive nuances in a language such as sarcasm or context-specific aggressiveness, automatic detection algorithms may be less effective. [ 22 , 24 , 58 , 64 ] [ Table 6 ].

Guidance for schools

Schools should foster a healthy school atmosphere and foster ties between students and their families. Schools should have clear, proactive Internet use and cyberbullying rules, procedures, and practices. Faculty, staff, and students should all be encouraged to develop social-emotional abilities. [ 65–68 ] Social-emotional character development is regarded as a key component of effective antibullying initiatives. [ 9 , 69 ] Teachers should be trained to recognize, respond to, and report cases of cyberbullying to the appropriate school channels. Workshops against cyberbullying should be held in schools. Parents should be educated on how and why children should not be allowed to use electronic communication devices as toys. [ 24 , 61 , 65–68 ]

There are various cyberbullying prevention programs across the world like, “Program IMPACT,” which is an interdisciplinary model of countering aggression and technological cyberbullying. “KiVa” is another program in Finland, which is a universal school-based program that addresses cyberbullying at school by working with teachers. “ConRed” program in Spain and “Surf-fair” program in Germany are also school-based programs. Other programs include “Cyber Friendly Schools” program in Australia, “The No Trap!” Program in Italy and “Tabby project” in Greece. [ 70 , 71 ]

Guidance for health-care providers

Questions concerning cyberbullying (either directly or by survey) should be asked by health-care practitioners at the initial assessment of children and adolescents and encourage parents to talk to children about limiting technology. [ 65 , 72 ] Health-care workers should increase awareness about safe cyber practices and disseminate information about early warning signs. They should teach children life skills to deal with the situations effectively. [ 9 ]

I DENTIFICATION AND I NTERVENTION

Early identification of cyberbullying is essential for early intervention to prevent further complications. It also avoids the child’s psychological, behavioral, and social problems. [ 58 , 73–76 ] There are few warning signs [ Table 7 ], and active surveillance of the same can help identify cyberbullying. [ 58 , 73–76 ] The parents should observe the child’s activities, emotions, and behaviors.

When parents observe any of the warning indicators, they should respond quickly. [ 61 ] They should gently engage in a conversation with the child, gain the child’s trust, and try to learn what is going on, when it began, and who is involved. [ 77 , 78 ] They should provide emotional support to the child and seek expert treatment if necessary. They should track down and block the bully’s phone number, so that he or she cannot send messages. [ 9 , 60 , 61 ] Parents should try to keep track of their children’s online activities, saving all of the bully’s chats, posts, and E-mails as evidence, taking screenshots of any offensive or harmful content or post, and reporting the bully’s phone number/account details to the service providers (many social networking platforms have this feature).

Most social media networks have explicit reporting standards for cyberbullying, and they frequently assist in getting the abusive message taken down. If the bullying persists or becomes severe, such as the child getting sexual or physical threats, or if there is a suspicion of illegal conduct or criminality, parents should file a complaint with the local police’s cybercrime unit. [ 9 , 60 ] In India, to report cyberbullying, parents can send their complaint to [email protected] . [ 77 , 78 ] There are no unique anticyber bullying laws in India yet, but some of the Information Technology Act and Indian Penal Code sections can be used against cyberbullying [ Table 8 ]. [ 77 , 79 , 80 , 81–83 ] If there is any sort of sexual cyberbullying, the Protection of Children from Sexual Offences Act, 2012 (POCSO Act) can be used to protect children under the age of 18 years from sexual harassment, sexual assault, and pornography. [ 80 ]

Besides dealing with cyberbullying activity, it is crucial to address issues and various psychological and behavioral effects of cyberbullying with psychotherapeutic interventions such as cognitive behavioral therapy, assertiveness training, and transactional analysis in victim and anger management, problem-solving, and empathy skills in perpetrator. [ 53 ] In case of severe problems, pharmacological measures can be employed depending on the problem faced. [ 53 ]

E VIDENCE FOR P REVENTION AND I NTERVENTION S TRATEGIES FOR C YBERBULLYING

A systematic review that included 17 cyberbullying intervention programs identified education on cyberbullying for adolescents, enhancing adaptive coping skills, empathy training, peer mentors, communication and social skills, and digital citizenship as the most commonly used interventions. Changing attitudes, teamwork, teaching legal repercussions, teacher involvement, self-efficacy, norms, moral disengagement, behaving sensibly, and talking to an adult were also mentioned. [ 83 ] Cyberbullying education for parents was also vital, and it was incorporated in programs with considerable benefits. Lectures, discussion groups, role-playing, and group projects were among the intervention formats utilized in various studies, with program lengths ranging from 1 day to a complete school year. [ 83 ]

Another systematic review of cyberbullying intervention in the United States found 11 publications on cyberbullying interventions that were exclusively implemented in schools or on the Internet. Most studies focused on attitudes and intentions toward cyberbullying rather than actual cyberbullying activity. Despite the serious concerns about cyberbullying and its potentially harmful consequences, the author found that there appears to be a lack of effective evidence-based initiatives in place in the United States. [ 84 ] Another systematic review and meta-analysis included 24 articles (15 randomized controlled trials [RCTs] and nine studies with quasi-experimental design with before and after measures) published between 2000–2017. [ 55 ] The results suggested that cyberbullying intervention programs effectively reduce both cyberbullying perpetrations by around 10%–15% and victimization by around 14%. The effect sizes were more significant for RCTs than quasi-experimental study designs. [ 55 ]

R OLE OF P ROFESSIONAL B ODIES AND G OVERNMENT AND O THER O RGANIZATIONS IN C YBERBULLYING

The professional bodies, especially those involving mental health professionals, should work toward increasing the awareness of the schools, students, and parents about the cyberbullying and the provisions which are available to counter the same. They can also help in formulating policies which can help curb cyberbullying. Professional bodies can also help in managing the victims of cyberbullying by extending services to the needy victims and also to the perpetuators. The governments should come up with the more stringent laws against the perpetuators. Other organizations can also help in bringing together all the stakeholders and educate them about cyberbullying, how to identify the same, and the preventive measures.

C ONCLUSIONS AND F UTURE D IRECTION

Cyberbullying is emerging as a significant problem for many teens, leading to unexpected deviances and adverse outcomes in their life domains. Cyberbullying is not going away soon and is expected to increase due to rapid digitalization. Cyberbullying can have a significant negative impact on the mental health of the victims. Hence, it is important to make all the stakeholders aware of this menace. Efforts must be made to make all the children and adolescents aware about the legal provisions and how indulging in cyberbullying can land them in conflict with law. The victims of the cyberbullying should be enabled to report the same at the earliest and they should be educated as to how to protect themselves from further cyberbullying. The parents and teachers should focus on the certain behavior which may be indicative of being a victim or a perpetuator in the cyberspace. The parents and teachers should teach children and adolescents about safe behavior in the cyberspace. All efforts should be made to successfully avoid and respond to it, as well as to provide children and adolescents with tools to lessen their own risk of victimization. The elimination of cyberbullying risks will necessitate a coordinated and collaborative effort among diverse youth advocates.

Many aspects of cyberbullying are still not well researched and there is a need to further research in this area. There is a need to develop a universal definition and have methodologically sound research in this field, which can help formulate policies. Research should also focus on the long-term mental health implications of being a victim and a perpetuator of cyberbullying. Future research should incorporate techniques such as machine learning and artificial intelligence to understand the epidemiology, to detect the victims and perpetuators, and improve surveillance for cyberbullying.

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Cyberbullying: a review of the literature on harassment through the Internet and other electronic means

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1 Department of Educational and Social Policy, University of Macedonia, Thessaloniki, Greece. [email protected]
PMID: 20216351
DOI: 10.1097/FCH.0b013e3181d593e4

The present article is a review of the literature of cyberbullying. Main findings are summarized regarding issues of definition of cyberbullying, differences, and similarities with traditional bullying; its extent; the forms of cyberbullying; the characteristics of cyberbullies and cybervictims; the effects of cyberbullying on the psychosocial development of youth; age and gender differences of cyberbullying; and perceived causes of cyberbullying. In addition, the steps that can be undertaken by youth, parents, teachers, and schools to deal with the problem and possible pathways for interventions, from a public health perspective, at the individual, class, organizational, and community levels are presented from the literature. Finally, possible legal solutions deriving from both criminal and civil law are presented.

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Adolesc Health Med Ther

Current perspectives: the impact of cyberbullying on adolescent health

Charisse l nixon.

Pennsylvania State University, the Behrend College, Erie, PA, USA

Cyberbullying has become an international public health concern among adolescents, and as such, it deserves further study. This paper reviews the current literature related to the effects of cyberbullying on adolescent health across multiple studies worldwide and provides directions for future research. A review of the evidence suggests that cyberbullying poses a threat to adolescents’ health and well-being. A plethora of correlational studies have demonstrated a cogent relationship between adolescents’ involvement in cyberbullying and negative health indices. Adolescents who are targeted via cyberbullying report increased depressive affect, anxiety, loneliness, suicidal behavior, and somatic symptoms. Perpetrators of cyberbullying are more likely to report increased substance use, aggression, and delinquent behaviors. Mediating/moderating processes have been found to influence the relationship between cyberbullying and adolescent health. More longitudinal work is needed to increase our understanding of the effects of cyberbullying on adolescent health over time. Prevention and intervention efforts related to reducing cyberbullying and its associated harms are discussed.

Adolescents in the United States culture are moving from using the Internet as an “extra” in everyday communication (cyber utilization) to using it as a “primary and necessary” mode of communication (cyber immersion). 1 In fact, 95% of adolescents are connected to the Internet. 2 This shift from face-to-face communication to online communication has created a unique and potentially harmful dynamic for social relationships – a dynamic that has recently been explored in the literature as cyberbullying and Internet harassment.

In general, cyberbullying involves hurting someone else using information and communication technologies. This may include sending harassing messages (via text or Internet), posting disparaging comments on a social networking site, posting humiliating pictures, or threatening/intimidating someone electronically. 3 – 7 Unfortunately, cyberbullying behavior has come to be accepted and expected among adolescents. 8 Compared to traditional bullying, cyberbullying is unique in that it reaches an unlimited audience with increased exposure across time and space, 6 , 9 preserves words and images in a more permanent state, 10 and lacks supervision. 6 Further, perpetrators of cyberbullying do not see the faces of their targets, 11 and subsequently may not understand the full consequences of their actions, thereby decreasing important feelings of personal accountability. 9 This has often been referred to in the literature as the “disinhibition effect”. 12

Cyberbullying has emerged as a relatively new form of bullying within the last decade. 13 , 14 This new focus on cyberbullying has, in part, been driven by recent news media highlighting the connection between cyberbullying and adolescent suicides (US News, 2013 15 ), with one of the most recent cases involving Rebecca Sedwick, a 12-year-old girl from Polk County, FL, USA who jumped to her death after experiencing relentless acts of cyberbullying. Initial work on cyberbullying has focused on documenting prevalence rates, sex-related effects, and identifying similarities/differences to traditional forms of bullying. More recently, work has been conducted on establishing the psychosocial (for example, depression, anxiety) and psychosomatic correlates (for example, headaches, stomachaches) of cyberbullying.

Given that cyberbullying is a relatively new construct, it is important to note that there are still definitional and methodological inconsistencies throughout the literature. For example, some scholars have chosen to adopt a more conservative criterion to define cyberbullying (for example, “willful and repeated harm inflicted through the use of computers, cell phones, and other electronic devices” 3 , 6 ), while other scholars have used a more broad definition (for example, “using electronic means to intentionally harm someone else” 16 ). The term cyberbullying in this review will represent an umbrella term that includes related constructs such as Internet bullying, online bullying, and information communication technologies and Internet harassment. Another inconsistency in the literature includes the use of different reference points when assessing adolescents’ involvement with cyberbullying. For example, some researchers have asked adolescents to think about their experiences with cyberbullying within the last year, 17 – 19 while others have inquired about adolescents’ experiences within the past 9 months, 20 or the past couple of months. 21 , 22 Given these methodological inconsistencies, it is not surprising that the prevalence rates of cyberbullying victimization and perpetration vary widely. For example, prevalence rates for cyberbullying victimization range from 4%–72%, 23 , 24 with an average of 20%–40% of adolescents reporting victimization via cyberbullying. 25 Prevalence rates for cyberbullying perpetration also vary, ranging from 3%–36% 26 , 27 (Also unpublished data, Kowalski and Witte 2006). Although the variability is significant, the research is clear that cyberbullying is prevalent during adolescence and as such, merits further study.

The purpose of the current review is to explore the impact of cyberbullying on adolescent health across multiple studies worldwide. It is anticipated that this information can be used to increase the knowledge of practitioners, health care providers, educators, and scholars, and subsequently better inform prevention and intervention efforts related to reducing cyberbullying and its associated harm. The first section of this paper reviews the effects of cyberbullying victimization and perpetration on adolescent health. The next section includes a brief discussion of individual risk factors related to participation in cyberbullying. The third section highlights mediating and moderating processes related to the impact of cyberbullying on adolescent health. The final section addresses prevention and intervention efforts related to minimizing cyberbullying and its subsequent effect on adolescent health.

Effects of cyberbullying

The effects of cyberbullying have been predominantly explored in the area of adolescents’ mental health concerns. In general, researchers have examined the relationship between involvement with cyberbullying and adolescents’ tendency to internalize issues (for example, the development of negative affective disorders, loneliness, anxiety, depression, suicidal ideation, and somatic symptoms). This relationship has been explored among Finnish youth, 28 Turkish youth, 26 German youth, 29 Asian and Pacific Islander youth, 17 American youth, 20 youth living in Northern Ireland, 30 Swedish youth, 31 Australian youth, 32 Israeli youth, 33 Canadian youth, 34 Czech youth, 35 Chinese youth, 36 and Taiwanese youth. 37 Although not as prolific, past work has also examined the impact of cyberbullying on adolescents’ tendency to externalize issues (for example, through substance use, delinquency).

Cyberbullying victimization and internalizing issues

Past work has revealed a significant relationship between one’s involvement in cyberbullying and affective disorders. For example, results indicate that there is a significant relationship between cybervictimization and depression among adolescents, 20 , 38 – 43 and among college students. 44 Specifically, results showed that higher levels of cyberbullying victimization were related to higher levels of depressive affect. Raskauskas and Stoltz 45 asked adolescents open-ended questions about the negative effects of cyberbullying. Notably, 93% of cybervictims reported negative effects, with the majority of victims reporting feelings of sadness, hopelessness, and powerlessness. Perren et al 39 further investigated the relationship between depression and cybervictimization among Swiss and Australian adolescents by controlling for traditional forms of victimization. Their results demonstrated that cybervictimization explained a significant amount of the variance in adolescent’s depressive symptomology, even when controlling for traditional forms of victimization.

Cyberbullying has been conceptualized as a stressor. For example, Finkelhor et al 46 found that 32% of targets of cyberbullying experienced at least one symptom of stress. Similarly, targets of online harassment reported increased rates of trauma symptomology. 47 Relatedly, findings from the Second Youth Internet Safety Survey 48 indicated that 38% of adolescent victims reported that they were emotionally distressed (ie, extremely upset) as a result of being harassed on the Internet. Not surprisingly, Sourander et al 28 found that cybervictims feared for their safety. It is posited that cyberbullying is more stressful than traditional bullying, perhaps in part related to the anonymity of cyberbullying. Compared to traditional bullying, targets of cyberbullying are less likely to know their perpetrators. 4 In fact, in a recent American study, half of the targets who were cyberbullied reported that they did not know their perpetrators, 49 thereby contributing to increased fears related to the identities of their perpetrators. Literally, the perpetrators could be anyone; even the victims’ closest friends. 45 Consistent with these findings, a recent study conducted in the US found that cyberbullying victimization was related to adolescents’ increased fear of victimization, even when controlling for their past victimization experiences and disordered school environments. 50 Moreover, youth who were targets of cyberbullying reported increased feelings of embarrassment, hurt, self-blame, and fear. 41 , 51 In telephone interviews with adolescents about their experiences with online harassment, Finkelhor et al 46 reported that adolescents felt angry, embarrassed, and upset. Consistent with a myriad of other studies, the most common response to cyberbullying was anger, 6 , 18 , 51 , 52 followed by upset and worry. 52

However, reactions to being cyberbullied may depend on the form of cyberbullying. For example, Ortega et al 53 found that different forms of cyberbullying may elicit different emotional reactions – for instance, being bullied online may evoke a different emotional reaction than being bullied via a cell phone. In terms of predicting the most deleterious outcomes, past studies have shown that pictures/video images were the most harmful to adolescents. 9 In support of the need to examine unique contexts of victimization, results from a more recent study conducted in the US revealed that different forms of electronic victimization (ie, cell phones, computers) were related to different psychological outcomes, with victimization via the computer (for example, online posts, pictures, email) being more harmful to adolescents than victimization via the phone (for example, text messaging and phone calls). 42

Cybervictimization is related to disruptions in adolescents’ relationships. Specifically, targets of cyberbullying reported more loneliness from their parents and peers, 54 along with increased feelings of isolation and helplessness. 40 Not surprisingly, targets of cyberbullying reported fewer friendships, 41 more emotional and peer relationship problems, 28 lower school attachment, 35 , 54 and more empathy. 35 Past work has shown that adolescents who were victimized via cyberbullying were more likely to lose trust in others, 11 experience increased social anxiety, 20 , 42 , 56 and decreased levels of self-esteem. 20 , 24 , 29 , 41 – 44 , 57 , 58 Importantly, the relationship between cybervictimization and adolescents’ psychosocial problems remain even after controlling for relational and physical forms of victimization, 20 as well as school-based victimization. 42

Cyberbullying and suicidal behavior

Several researchers have examined the association between involvement with cyberbullying and adolescent suicidal behavior. 34 , 38 , 44 , 55 , 59 This relationship has been explored among middle school, high school, and college students. For example, Hinduja and Patchin 59 surveyed American middle school students and examined the relationship between involvement in cyberbullying (either as a victim or perpetrator) and suicidality. The results revealed that both targets and perpetrators of cyberbullying were more likely to think about suicide, as well as attempt suicide, when compared to their peers who were not involved with cyberbullying. This relationship between cyberbullying and suicidality was stronger for targets, as compared to perpetrators of cyberbullying. Specifically, targets of cyberbullying were almost twice as likely to have attempted suicide (1.9 times), whereas perpetrators were 1.5 times more likely compared to their uninvolved peers. 59 Klomek et al 38 looked at the relationship between cybervictimization, depression, suicidal ideation, and suicidal attempts among American high school students. Their study results showed that cyberbullying victimization was related to increased depressive affect and suicidal behavior. Similarly, using an even larger high school sample, Schneider et al 55 also found a positive relationship between cybervictimization and suicidal behavior. This relationship has recently been documented among college students as well. 44

In an effort to control for possible confounding variables, researchers have examined the unique contribution of cyberbullying in predicting suicidal behavior and depressive symptomology above and beyond adolescents’ sex, and their involvement in relational, verbal, and physical bullying. Bonanno and Hymel 34 surveyed Canadian adolescents and found that cybervictimization and cyberbullying contributed to adolescents’ depressive symptomology and suicidal ideation over and above their sex and involvement in traditional forms of bullying (ie, face-to-face bullying). Moreover, adolescents’ involvement in cyberbullying was a stronger predictor of suicidal ideation than it was for depressive symptomology. These researchers posited that perhaps, given the public and permanent nature of the computer, along with the perceived lack of control and anonymity involved, targets of cyberbullying might experience a loss of hope, thereby magnifying the relationship between cyberbullying and suicidal ideation. Those adolescents who were both victims and perpetrators of cyberbullying experienced the greatest risk for suicidal ideation. 34

In sum, past work has documented the positive relationship between adolescents’ involvement in cyberbullying and suicidal behavior. That is, the more adolescents are involved in cyberbullying, the more likely they are to engage in suicidal behavior; this relationship was stronger for targets than for perpetrators of cyberbullying. Recent research has expanded upon these findings and examined the potential experience(s) that might mediate the relationship between cyberbullying and suicidal behavior. 60 In a recent study of American high school students, Litwiller and Brausch 60 found that adolescents’ substance use and violent behavior partially mediated the relationship between cyberbullying and suicidal behavior, such that increased substance use and involvement in physical violence predicted increased adolescent suicidal behavior related to cyberbullying. Further, Litwiller and Brausch 60 conceptualized substance use and violent behavior as coping processes that adolescents might use to address the physical and psychological pain associated with their experiences related to cyberbullying. This study underscores the need for not only educators and health care professionals, but also parents, guardians and mentors - all caring adults to play a role in addressing adolescents’ substance use and violent behavior. Results from this study suggest the need for health care providers, educators, and caring adults to equip adolescents with constructive coping strategies to effectively address cyberbullying.

Cyberbullying (both victims and perpetrators) and somatic concerns

There have been relatively few studies examining the effect of cyberbullying on adolescents’ physical health. Of those studies that have been conducted, a significant relationship between cyberbullying and psychosomatic difficulties has been established. For example, Kowalski and Limber 21 surveyed American adolescents and found that those youth who were both victims and perpetrators of cyberbullying experienced more severe forms of psychological (for example, anxiety, depression, and suicidal behavior) and physical health concerns (for example, problems sleeping, headache, poor appetite, and skin problems). Additionally, adolescents’ grade level moderated these negative effects, with high school students who were both perpetrators and victims of cyberbullying reporting the highest levels of anxiety, depression, and the most physical health problems. Similarly, Beckman et al 22 surveyed Swedish adolescents and found a positive relationship between involvement with cyberbullying and psychosomatic difficulties, including increased difficulty sleeping, stomachaches, headaches, and a lack of appetite, with adolescents who were both victims and perpetrators experiencing the most severe psychosomatic symptoms. Finally, Sourander et al 28 investigated the relationship between cyberbullying and psychiatric and psychosomatic problems among Finnish adolescents. Their study results showed that cybervictims and cyberbully/victims were more likely to experience somatic problems, including difficulty sleeping, headaches, and stomachaches, as compared to their unaffected peers. Notably, in a recent large-scale study of adolescents in Stockholm, Sweden, Låftman et al 61 found that being a target of cyberbullying was associated with poorer physical health (for example, headaches, stomachaches, poor appetite, sleep disturbances, and so on), even when controlling for traditional bullying. Given that health care providers are often on the front lines responding to adolescents’ somatic concerns, it is imperative that these professionals are adequately trained in the area of cyberbullying. For example, health care providers can be trained to effectively screen adolescents’ for psychological and physical health issues related to cyberbulling experiences. Subsequently, it seems logical for medical schools and residency programs to consider coursework in digital networking or online social networking to increase the medical community’s knowledge regarding the health correlates related to cyberbullying. 62

Cyberbullying victimization and externalizing issues

Although not as well documented, the effects of cyberbullying victimization are also related to adolescents’ externalizing problems. For example, among a sample of youth living in the US, Ybarra et al 63 found that those adolescents who were harassed online were more likely to use alcohol, drugs, and carry a weapon at school. In fact, victimized youth were eight times more likely than their peers to carry a weapon to school in the past 30 days. In a study of Asian and Pacific Islander youth, Goebert et al 17 found that cyberbullying victimization was associated with adolescents’ increased substance abuse. For example, targets of cyberbullying were 2.5 times more likely to use marijuana and participate in binge drinking compared to their peers. Similarly, other studies have documented a significant relationship between increased cyberbullying victimization and increased substance use. 13 , 43 Finally, cyberbullying victimization was also related to increased levels of traditional bullying (for example, physical aggression, stealing) among a sample of adolescents living in Hong Kong. 36 (See Table 1 for a summary of cross-sectional studies examining the relationship between cyberbullying victimization and negative health correlates.)

Findings from literature on cyberbullying victimization and adolescent health using cross sectional design

Study	Ages	N	Negative health outcomes
Beckman et al, 2012	13–16 years	3,820	Increased psychosomatic symptoms
Beran and Li, 2005	7th–9th graders	432	Increased anger and sadness
Beran and Li, 2007	7th–9th graders	432	Decreased concentration
Bonanno and Hymel, 2013	8th–10th graders	399	Increased suicidal ideation and depression
Campbell et al 2012	6th–12th graders	3,112	Increased anxiety, depression, and social difficulties
Chang et al, 2013	10th graders	2,992	Decreased self-esteem and increased depression
Dempsey et al, 2009	11–16 years	1,665	Increased social anxiety
Devine and Lloyd, 2012	10–11 years	3,657	Increased negative affect, increased loneliness, poorer relationships with parents and peers
Didden et al, 2009	12–19 years	114	Increased depression and decreased self-esteem
Dooley et al 2012	10–16 years	472	Increased depression, emotional symptoms, and conduct and peer problems
Fredstrom et al, 2011	9th graders	802	Decreased self-esteem, increased social stress, anxiousness and depression, while controlling for school-based victimization
Goebert et al, 2011	9th–12th graders	677	Increased negative feelings; increased substance use
Hinduja and Patchin, 2007	6–17 years	1,388	Increased anger and frustration, increased school violence and delinquency
Hinduja and Patchin, 2008	Under the age of 18 years	1,378	Increased substance use (marijuana), school problems, and delinquent behaviors
Hinduja and Patchin, 2010	6th–8th graders	1,963	Increased suicidal thoughts and attempts
Jackson and Cohen, 2012	3rd–6th graders	192	Increased loneliness, lower rates of peer acceptance, decreased levels of optimism about peer relationships, and fewer friendships
Juvoven and Gross, 2008	12–17 years	1,444	Increased social anxiety
Katzer et al, 2009	5th–11th graders	1,700	Decreased self-concept
Klomek et al, 2008	13–19 years	2,342	Increased depression and suicidality
Kowalski and Limber, 2013	6th–12th graders	931	Decreased psychological and physical health
Laftman et al, 2013	15–18 years	22,544	Decreased physical health
Litwiller and Brausch, 2013	14–19 years	4,693	Increased suicidal behavior
Mitchell et al, 2007	10–17 years	1,501	Increased depression and substance use
Olenik-Shmesh et al, 2012	13–16 years	242	Increased loneliness and depression
Patchin and Hinduja, 2006	9–17 years	577	Increased frustration, anger, and sadness
Perren et al, 2010	7th–10th graders	1,694	Increased depression while controlling for traditional forms of victimization
Price and Dalgleish, 2010	Under 25 years	548	Increased sadness and fear; decreased friendships, self-esteem and self confidence
Randa 2013	12–18 years	3,500	Increased fear of victimization
Schneck and Fremouw, 2012	18–24 years	799	Increased depression, anxiety and suicidality
Schneider et al, 2012	9th–12th graders	20,406	Increased psychological distress
Sourander et al, 2010	13–16 years	2,215	Increased psychosomatic and emotional/peer problems
Wang et al, 2011	6th–10th graders	7,313	Increased depression
Wigderson and Lynch, 2013	6th–12th graders	388	Increased anxiety, depression and decreased self-esteem
Ybarra et al, 2007	10–15 years	1,588	Increased alcohol and drug use; increased behavior problems and weapon-carrying at school

Does sex matter with respect to cyberbullying victimization?

The answer to this question is not clear. Thus far, the literature is inconsistent with respect to sex-related effects and the prevalence rates for cybervictimization. Some studies have found no sex differences, 5 , 6 , 13 , 24 , 26 , 29 , 31 , 57 , 64 – 66 while other studies have found sex effects documenting higher prevalence rates for females. 9 , 11 , 40 , 61 This sex effect indicating increased prevalence rates of cyberbullying among females has been documented among both younger and older adolescents. For example, among 10- and 11-year-olds, Devine and Lloyd 30 found that girls were more likely to be victims of cyberbullying compared to boys. Kowalski and Limber 4 found similar sex-based effects, documenting increased prevalence rates among adolescent females in 6th, 7th, and 8th grade. The same pattern has also been found among high school students. 17 This sex-based effect documenting increased prevalence rates for cybervictimization among females compared to males is consistent with research showing that females are more likely to be online for social networking, while males are more likely to be online for gaming. 68 Subsequently, the sheer frequency of females’ online social networking behavior may provide them with more opportunities than males to become involved with cyberbullying. 69

Only a few studies have documented higher prevalence rates for cyberbullying among males. For example, among German adolescents, Katzer et al 29 found that males reported more victimization online than females. Among a sample of adolescents living in Cyprus, males were also at a higher risk for cybervictimization. 70 Finally findings from a recent study conducted in Hong Kong indicated that males were more likely to be victimized via cyberbullying than females. 36 In sum, with the exception of a handful of studies, the majority of research conducted to date has demonstrated no sex effects related to cyberbullying victimization.

Cyberbullying perpetration and problem behaviors

Generally speaking, studies that have examined the impact of cyberbullying perpetration on adolescent health have shown that those adolescent perpetrators of cyberbullying were more likely to engage in problem behaviors including higher levels of proactive and reactive aggression, property damage, 23 illegal acts, 71 substance use, delinquency, 72 , 74 and suicidal behavior. 34 , 59 , 71 Cyberbullying perpetration has been positively associated with hyperactivity, relational aggression, 74 conduct problems, 19 , 28 , 71 smoking, and drunkenness. 22 , 28 Results from a recent study surveying Australian adolescents found that those youth who cyberbullied others reported more social difficulties, as well as more stress, depression, and anxiety compared to their peers who were not involved in any type of bullying. 75 On the other hand, cyberbullying perpetration has been related to adolescents’ decreased levels of self-esteem, 76 self-efficacy, 36 prosocial behavior, perceived sense of belonging, 36 and safety at school. 28 Cyberbullying perpetration has also been associated with adolescents’ negative emotions such as anger, sadness, frustration, fear, and embarrassment. 19 , 72 , 77 Disruptions in relationships have also been associated with cyberbullying perpetration among youth, including lower levels of empathy, 36 , 74 increased levels of depression, 34 weaker emotional bonds with caregivers, lower parental monitoring, and increased use of punitive discipline. 73 Finally, perpetrators of cyberbullying were more likely to rationalize their destructive behaviors by minimizing the impact they had on others. For example, they were more likely to believe that their bullying behavior was not that harsh and that it did not bother their victims that much. 75 (See Table 2 for a summary of cross-sectional studies examining the relationship between cyberbullying perpetration and negative health correlates.)

Findings from literature on cyberbullying perpetration and adolescent health using cross sectional design

Study	Country	Ages	N	Negative health correlates
Beckman et al, 2012	Sweden	13–16 years	3,820	Increased risk for mental health issues
Bonanno and Hymel, 2013	Canada	8th–10th graders	399	Increased suicidal ideation and depression
Campbell et al, 2013	Australia	6th–12th graders	3,112	Increased stress, social difficulties, depression and anxiety
Hinduja and Patchin, 2007	US	5th–11th graders	1,700	Decreased self-concept
Hinduja and Patchin, 2010	US	6th–8th graders	1,963	Increased suicidal behavior
Patchin and Hinduja, 2010	US	6th–8th graders	1,963	Decreased self-esteem
Patchin and Hinduja, 2011	US	6th–8th graders	1,963	Increased negative emotions
Schneck and Fremouw, 2013	US	18–24 years	856	Increased aggression, illegal behavior and suicidality
Sourander et al, 2010	Finland	13–16 years	2,215	Decreased prosocial behavior and perceived safety at school
Wong et al, 2014	China	12–15 years	1,917	Decreased psychosocial health and sense of belonging to school
Ybarra and Mitchell, 2004	US	10–17 years	1,501	Increased delinquent behavior, substance use
Ybarra and Mitchell, 2004	US	10–17 years	1,501	Poor parent–child relationships, increased substance use, and delinquency
Ybarra and Mitchell 2007	US	10–17 years	1,501	Increased aggression and rule-breaking behavior

Similar to cyberbullying victimization, sex-related effects for cyberbullying perpetration have also been inconsistent. For example, some studies have found an increase in female perpetration, 78 while other studies have indicated an increase in male cyberbullying perpetration. 11 , 36 , 61 Still yet, some researchers have found no sex differences in the prevalence of cyberbullying perpetration. 9 , 13 , 19 , 23 More research is needed before we are able to draw firm conclusions regarding the role of sex in cyberbullying perpetration.

What about those adolescents who are both victims and perpetrators of cyberbullying?

Notably, of researchers who have compared all three roles in cyberbullying, those adolescents who were both perpetrators and targets (ie, bully/victims) experienced the most adverse health outcomes, including decreased psychological and physical health. 21 , 22 , 28 , 34 , 40 Specifically, these adolescents reported increased levels of depression, substance use, and conduct problems compared to their peers who were either only targets or perpetrators. 23 , 21 Adolescents who were both targets and perpetrators of cyberbullying also reported poorer relationships with their caregivers, and higher levels of victimization and perpetration offline, compared to their peers. These results suggest that this group of adolescents (ie, bullies/victims) may experience increased risk for associated negative health outcomes, and as such, may require extra support from health care professionals, educators, and caring adults. However, we currently know relatively very little about this group of adolescents. 79 More work is needed to increase our understanding of this potentially vulnerable group of adolescents.

Taken together, results from a myriad of studies worldwide suggest that involvement in cyberbullying puts adolescents at risk for increased internalizing problems including depression, anxiety, suicidal ideation, and psychosomatic concerns (for example, difficulties sleeping, headaches, and stomachaches), as well as a loss of connection from parents and peers, thereby threatening adolescents’ basic fundamental need for meaningful connections. 80 In addition, participation in cyberbullying also places adolescents at risk for increased externalizing issues, such as substance use and delinquent behavior.

How do the developmental changes in risk factors affect subsequent cyberbullying?

Recently, researchers have begun to examine how developmental changes in adolescent risk factors affect subsequent involvement in cyberbullying behavior. For example, Modecki et al 81 recently investigated the role of increasing developmental problems (ie, problem behavior and poor emotional well-being) among adolescents (number [N] =1,364) in predicting subsequent involvement in cyberbullying over a 3-year period, while controlling for sex and pubertal timing. The study findings demonstrated that adolescents’ developmental increases in problem behavior across grades 8 through 10 predicted their involvement with cyberbullying in grade 11. Specifically, developmental decreases in self-esteem and increases in problem behavior (ie, substance use, aggressive behavior, and delinquency) predicted adolescents’ cybervictimization and perpetration in grade 11. Interestingly, self-esteem was measured with items assessing identity and efficacy (for example, “How often do you feel satisfied with who are?” “How often do you feel sure about yourself?”). Results from this study suggest that heath care professionals and educators should carefully examine the trajectory of students’ sense of self, as well as problem behaviors (for example, physical aggression and substance use) during adolescence in an effort to reduce subsequent involvement with cyberbullying. Further, these results showed that adolescents who experienced increased depression in grade 8 were at higher risk for both cybervictimization and cyberperpetration in grade 11.

Researchers have also begun to examine the risk factors that may be related to involvement with cyberbullying behavior. For example, Sticca et al 67 examined longitudinal risk factors related to cyberbullying among 7th grade students. Their results showed that traditional bullying and rule-breaking behavior (for example, damaging property, cigarette/alcohol use) were the strongest predictors of cyberbullying perpetration, followed by the frequency of online communication (these researchers did not look at cyberbullying victimization). In sum, these study results showed that those adolescents who bullied others in the “real world” were more than four times likely to bully someone online several months later. These results suggest that effective prevention and intervention efforts designed to reduce cyberbullying may include early detection of delinquent behaviors offline, including substance use and aggressive behavior. Moreover, results from another recent longitudinal study demonstrated that adolescents’ loneliness and social anxiety predicted increases in subsequent cyberbullying victimization. 82 These results suggest that adolescents who are socially vulnerable may be at increased risk for experiencing online victimization.

Potential mediating and moderating processes that may influence the effect of cyberbullying on adolescent health

The message of past studies is clear: there is a cogent relationship between cyberbullying and negative adolescent health outcomes. In light of the negative impact of cyberbullying on adolescent health, it is imperative that future research examines potential mediating and moderating processes that might influence the impact of cyberbullying on adolescent health. We know that not all adolescents who experience cyberbullying report negative outcomes. 6 , 72 Subsequently, individual differences among adolescents need to be considered when examining the impact of cyberbullying on adolescent health. For example, according to the transactional theory of stress and coping, 83 the impact of cyberbullying does not solely depend on the event alone, but also on how the adolescent responds to the situation. We know that how adolescents respond to stressors (for example, cyberbullying) is influenced by a myriad of factors related to the individual adolescent, the context, and the stressor itself. 83 – 86 Moreover, the language we choose also affects how adolescents respond to stressors – language can either undermine or optimize adolescents’ responses. For example, the word “victim” tends to conjure up a sense of helplessness and a loss of control. 87 The word “target”, on the other hand, communicates deflection; that the individual has the power to deflect the aggressive behavior, thereby empowering the adolescent. 87 Subsequently, it follows that an adolescent who is identified as a “victim” may be more reluctant to seek help compared to an adolescent who is identified as a “target”. Clearly, the choice of language affects individuals’ ensuing responses. More work is needed to increase our understanding of these and others factors that may help to protect adolescents from adverse health outcomes. Adopting a contextual framework allows researchers to identify potential protective and at-risk variables that may mediate or moderate the effects of cyberbullying on adolescents’ health outcomes. Researchers and practitioners could then use this garnered knowledge to develop and sustain effective prevention and intervention programs to reduce cyberbullying behaviors and their associated harm. With that said, there is currently little known about how experiences with cyberbullying may interact with adolescents’ coping strategies, sex, and social support.

Coping strategies

Schenk and Fremouw 44 examined the coping strategies used by targets of cyberbullying. Their results revealed that targets of cyberbullying generally cope with cybervictimization by telling someone, avoiding friends or peers, getting revenge, and withdrawing from events, thus potentially undermining important social connections. However, Slonje and Smith 9 found that 50% of targets did not tell anyone, 35.7% told a friend, 8.9% told a parent or guardian, and 5.4% told someone else. Notably, the majority of targets do not tell adults, 10 , 88 – 91 with one study reporting up to 90% of adolescents not telling an adult about their experiences related to cyberbullying. 24 Although these studies have begun to identify the coping strategies used by targets of cyberbullying, the majority of these studies have not examined the effectiveness of these strategies in terms of reducing or promoting subsequent at-risk behavior. Strategy effectiveness is an important construct to study, as we begin to identify those strategies that help to reduce the negative effects of cyberbullying. For example, results from a recent longitudinal study conducted in the Netherlands by Völlink et al 93 demonstrated that adolescents’ use of emotion-focused coping strategies negatively affected their subsequent psychological (for example, depression) and physical health (for example, chest tightness, headaches). Past work has shown that adolescents’ coping strategies can mitigate or reduce the negative impact of cyberbullying, 87 and as such, they should be examined further.

Future work should also continue to examine the role of sex in moderating the relationship between cyberbullying and adolescents’ health. Although, as discussed earlier several studies have examined the sex effects related to the prevalence rates of cyberbullying, we know relatively very little about how sex may moderate the relationship between cyberbullying and adolescent health. In other words, is it possible that females may be more adversely affected by cyberbullying than males? This is an important question to consider when examining adolescent health outcomes. Of the few studies that have been conducted, inconsistent findings have been reported. For example, some studies have found that females are more likely to be distressed by cyberbullying than males, 18 , 93 , 94 while others have reported no sex differences. 20 Still yet, recent work conducted by Kowalski and Limber 21 revealed that among adolescents who were both perpetrators and targets of cyberbullying, males experienced more negative psychological (for example, depression and anxiety) and physical health concerns (for example, headache, problems sleeping, and skin problems) than females. In sum, future studies are needed to elucidate the potential role of sex in moderating the relationship between involvement with cyberbullying and adolescent health outcomes.

Social support

Research suggests that different forms of support may mitigate the effects of traditional forms of victimization on psychological well-being. 95 – 97 There are, however, very few studies that have examined how different forms of social support might mitigate the impact of cyberbullying on adolescent health. An exception to this is a recent study conducted by Machmutow et al, 93 who examined the moderating effects of different coping strategies on the relationship between cybervictimization and depressive symptoms using a longitudinal design. Results from their study showed that adolescents’ social support and feelings of helplessness predicted their depressive symptomology over time. Specifically, close feelings of social support mitigated the negative impact of cyberbullying on depressive symptomology, whereas feelings of helplessness increased depressive symptomology. Similarly, Fanti et al 70 examined how different forms of social support (ie, peer, family, and school) influenced the prevalence of cyberbullying. Using a longitudinal design, Fanti et al 70 found that adolescents’ family social support (for example, “I get the emotional support I need from my family”) was a protective factor for both cyberbullying victimization and cyberbullying perpetration, such that family social support was related to decreases in cyberbullying behaviors one year later, even after accounting for other risk factors. These results suggest that family social support may be an important protective factor in guarding against the negative health correlates of cyberbullying, and thus merits further scrutiny.

Prevention and intervention

Given the deleterious effects of cyberbullying, effective prevention and intervention efforts must be a priority. However, studies that investigate effective prevention and intervention efforts to address cyberbullying are currently lacking. 98 The few studies that have addressed prevention efforts related to cyberbullying suggest that attention be directed towards enhancing adolescents’ empathy and self-esteem, decreasing adolescents’ problem behaviors, promoting warm, nurturing relationships with their parents, and reducing their time spent online. For example, researchers who conducted a recent study with Turkish adolescents found that those adolescents who were less empathic were more at risk for engaging in cyberbullying. Their study results demonstrated that the combined effect of affective (ie, experiencing someone else’s feelings) and cognitive (ie, taking another’s perspective) empathy played a vital role in influencing adolescents’ participation in cyberbullying. Specifically, activating adolescents’ empathy was related to less negative bystander behavior. Results from this study suggest that future prevention and intervention efforts be targeted towards increasing adolescents’ affective (for example, “My friends’ feelings don’t affect me”) and cognitive empathy (for example, “I can understand why my friend might be upset when that happens”) in an effort to reduce participation in cyberbullying. 99 Empathy training seems particularly important given the nature of cyberspace and the lack of nonverbal cues available. For example, adolescents may be less inclined to experience empathy for targets online in part because they are not privy to the targets’ facial expressions. Subsequently, prevention efforts may need to explicitly demonstrate the hurt targets’ experience in order to activate adolescents’ empathic responses. 94

Recent findings also suggest that prevention efforts directed towards reducing cyberbullying should address adolescents’ self-esteem, as well as specific problem behaviors. Findings from a recent study revealed that developmental decreases in adolescents’ self-esteem predicted their subsequent involvement in cyberbullying both as a perpetrator and as a target. 81 Additionally, developmental increases in adolescents’ problem behaviors (for example, substance use, delinquency, and aggressive behaviors) also predicted their involvement in cyberbullying in subsequent grades. Building on the work of Patchin and Hinduja, 76 these results direct educators and health care professionals to focus on adolescents’ emotional well-being during the early high school years, paying particular attention to those adolescents who experience steep declines in their self-esteem, as well as adolescents who experience steep inclines in problem behaviors including substance use and delinquency.

In terms of parental relationships, study findings suggest that health care professionals and educators should work toward helping adolescents and their parents establish warm, nurturing relationships that include close adult monitoring. This is consistent with recent suggestions by the American Academy of Pediatrics that encourage parents to participate in open discussions with children and adolescents about their online behavior, as well as to implement the necessary safeguards to protect youth from engaging in cyberbullying behaviors. 100 Clearly, meaningful social connection is key to effective prevention and intervention efforts. 101 Finally, results from a recent study conducted by Hinduja and Patchin 102 suggest that adolescents’ socializing agents (ie, friends, family, and adults at school) play an important role in whether or not adolescents choose to cyberbully others. Surveying a random sample of 4,441 adolescents, the study results showed that adolescents who believed that several of their friends were involved with cyberbullying were more likely to cyberbully others themselves. These results suggest the need for prevention efforts designed around correcting the “misperceived” norm of cyberbullying. Additionally, the results also indicated that adolescents who believed that the adults in their lives would hold them accountable for their involvement with cyberbullying were less likely to participate in cyberbullying, thus suggesting the important role that adults play in the lives of adolescents in terms of reducing cyberbullying behaviors.

Beliefs about cyberbullying

Adolescents’ beliefs are important motivators of their behaviors. 103 Past work has shown that youths’ normative beliefs and attitudes about aggression are related to subsequent physical aggression, 104 , 105 as well as relational aggression. 106 More recently, research has been conducted to investigate how adolescents’ beliefs about aggression influence their involvement in cyberbullying behaviors. 107 , 108 Study results have indicated that youth who endorse attitudes supporting aggressive behaviors (for example, that it is okay to call some kids nasty names) are significantly more likely to report higher rates of cyberbullying compared to their peers. 107 , 108 A recent study conducted among American middle school students found that students who engaged in cyberbullying were more likely to endorse supportive attitudes related to aggressive behavior. 108 In addition to individual attitudes, classroom-level attitudes (although with somewhat weaker effects) were also predictive of cyberbullying behavior. 107 These results at the classroom level suggest the importance of establishing and maintaining positive classroom climates, reflecting respectful treatment of all individuals. Overall, these results suggest that prevention work in the school setting is important in order to reduce cyberbullying behavior.

Finally, past studies have shown that the frequency of online communication increases the risk of cyberbullying victimization and perpetration. 6 , 13 , 23 , 24 , 26 , 48 , 63 , 67 , 109 Subsequently, helping adolescents to self-regulate their time spent online may decrease their involvement with cyberbullying behaviors. This is particularly important given adolescents’ struggles to manage their impulses. 110

Past research has suggested that social support may be a powerful protective factor in mitigating the negative effects associated with cyberbullying. 70 , 93 In order for adolescents to receive the necessary support they need to reduce the associated harmful effects of cyberbullying, they must be willing to seek help. However, several studies suggest that targets of cyberbullying rarely seek help from adults at school (for example, from teachers). 19 , 26 , 111 Instead, the majority of adolescents are silent 111 and are not likely to tell adults when they are victimized via cyberbullying. 6 , 9 There are at least four possible reasons why adolescents are not likely to tell adults about their cyberbullying experiences. First, it could be that adolescents do not feel connected to adults, and subsequently do not seek their help when in distress. If this is true, then it is imperative that adults at school intentionally reach out to adolescents in an effort to establish trusting, caring relationships. This can be done through a variety of strategies including the development of engaging classroom activities, as well as activities designed around special adolescent interests. Prevention efforts could include helping adolescents establish and maintain meaningful social relationships with their peers. Adults at school can be trained to connect older peers with adolescents who are at risk for having fewer peer connections. A recent study conducted by Burton et al 108 found that adolescents who were more attached to their peers were less likely to be involved in cyberbullying. Effective mentoring programs could be another strategy used to increase positive peer attachments among adolescents. School mentoring programs can be developed to connect adolescents to caring mentors and/or adults. Health care providers and educators can routinely screen adolescents to identify those who do not have at least one meaningful relationship with a peer and/or an adult.

Another reason that adolescents may be reluctant to tell adults about their experiences related to cyberbullying may be that youth tend to tend to think that cyberbullying is not a serious issue, and thus, they do not need help. Research has found some support for this claim. For example, Agatston et al 112 found that adolescent males living in the US were less likely to view cyberbullying as a serious problem. A third reason why adolescents may not tell adults about cyberbullying may be that they do not consider the adults in their school to be helpful resources in addressing cyberbullying. 112 These results suggest that additional training may be needed for school personnel to identify effective ways to address cyberbullying in the school setting. Several good resources have been provided online for educators. 113 A fourth reason why adolescent targets may not be willing to seek help could be related to their increased feelings of shame and helplessness. 40 Letting targeted youth know it is not their fault may be one promising cognitive strategy that may increase adolescents’ likelihood to seek help. Recent findings from the Youth Voice Project 114 suggest that adolescents’ use of cognitive reframing strategies are effective tools that are likely to lead to positive outcomes for targeted youth.

Individual treatment is needed for all involved to effectively address cyberbullying. For example, adolescents can be trained to develop effective strategies to increase their self-control 115 and empathy towards others. 99 Recent research has also demonstrated the need for targets of cyberbullying to be trained in effective coping strategies. 116 Importantly, Bauman 117 suggests that counseling for the perpetrator needs to be restorative in nature and not punitive. Too often, schools tend to punish and isolate the perpetrator without any consideration for restoration with the target – a needed ingredient for optimizing adolescents’ subsequent outcomes. Given the associated feelings of isolation, it is important for counselors to help targets of cyberbullying establish and maintain meaningful connections with others.

Bystanders are an important part of intervention efforts. Similar to face-to-face bullying, there are often many peers who witness or are exposed to cyberbullying. Recent findings from the Youth Voice Project compared strategy effectiveness among adolescents’ self-strategies, peer strategies, and adult strategies in response to various forms of peer mistreatment. 114 Results from this large-scale study showed that peer strategies (or bystander actions) were much more effective in terms of leading to positive outcomes for targeted youth than were self- or adult strategies. 114 This was true for both traditional bullying and cyberbullying. Interestingly, the bystander actions that were most likely to lead to positive outcomes for targeted youth were not confrontational, but instead were quiet acts of support (ie, spent time with the targeted student, talked to them, encouraged them, listened to them, and called or messaged them at home). However, the Youth Voice Project data also revealed that over half (51%) of the mistreated youth reported that their peers “did nothing” about the situation and “ignored what was going on”. 114 Clearly, more research is needed to better understand the processes underlying positive bystander behavior.

What predicts positive bystander behavior?

A recent study conducted with Czech adolescents examined whether adolescents’ age, sex, self-esteem, tendency toward prosocial behavior, and problematic peer relationships influenced their support of cyberbullied peers. 35 The results showed that only adolescents’ tendency towards prosocial behavior positively predicted supportive bystander behavior. 35 This study also examined how contextual variables might influence adolescents’ bystander support of cyberbullied peers. Study findings showed that existing relationships with the target, distress experienced by witnessing the victimization, and direct appeal for help predicted positive, supportive bystander behavior. On the other hand, having a strong relationship with the perpetrator repressed supportive bystander behavior. These results are consistent with past work documenting the importance of empathy, as well as the importance of training adolescents to ask for help from their peers. Importantly, these results also underscore the significance of developing and maintaining prosocial relationships among adolescents. Recent researchers in Belgium used an experimental paradigm to investigate the effect of contextual variables on bystander actions in response to a hypothetical cyberbullying incident. 118 Their study results showed that among Flemish adolescents, bystanders were more likely to help the target when they perceived the cyberbullying to be more severe, which suggests that we need to help adolescents understand the seriousness of cyberbullying.

What predicts negative bystander behavior?

In a recent study conducted in Poland, researchers used an experimental paradigm to examine the individual factors that might influence adolescents’ negative bystander behavior in response to cyberbullying. 119 The results indicated that negative bystander behavior (as measured by the decision to forward a negative message about someone) was more likely to occur in private contexts, as compared to public contexts. For example, adolescents were likely to behave in more antisocial ways when they thought only one or a few observers would see their behavior (ie, private conditions). These findings suggest that it is important for adolescents to understand that in reality, their online behavior is seen by a wide audience and is, in fact, “public”. The results also showed that negative bystander behavior was more likely among adolescents who had previous experiences with cyberbullying perpetration. Finally, consistent with past work, study findings demonstrated that both affective and cognitive empathy reduces negative bystander behavior. Overall, the results suggest that educators, health care professionals, and caring adults should continue to promote adolescents’ prosocial relationships, affective and cognitive empathy, as well as help adolescents to seek out positive forms of social support. Although initial research has begun to examine the effect of bystanders in the context of cyberbullying, more work is needed to understand how bystander actions may influence the relationship between cyberbullying and associated health outcomes. Another recent study using an experimental paradigm to examine individual factors related to negative bystander behavior was conducted in Belguim. 118 Results from this study indicated that bystanders were more likely to “join in” on the bullying when the other bystanders were good friends as opposed to acquaintances. Consistent with past work, 114 sex-related effects were found, such that females were more likely to comfort and defend the target, give advice to the target, and report the incident. On the other hand, males were more likely to reinforce the cyberbullying by telling the perpetrator that they thought it was funny. 118 These sex-related effects indicate that adolescent males may require extra training related to providing positive support to peers who have been victimized via cyberbullying.

In sum, raising awareness among educators, health care professionals, parents, and adolescents regarding the serious nature of cyberbullying may be a first step in addressing the harmful effects of cyberbullying. Moreover, it is important for caring adults and mentors to proactively reach out to adolescents and establish meaningful relationships with them that persist over time. Additionally, training adults and adolescents in effective strategies to address cyberbullying is needed to mitigate the associated negative effects of cyberbullying. Finally, addressing adolescents’ beliefs around cyberbullying both at the individual and classroom level should be at the core of prevention and intervention efforts. 108 School counselors and health care providers may be in a prime position to initiate training for school personnel, parents, and adolescents alike. 120

When should prevention and intervention efforts begin?

It is important for researchers to begin looking at how younger children interface with technology. Cyberbullying prevention and intervention programs should target all grade levels. 121 The research is clear that cyberbullying begins before adolescence. 122 To date, however, the majority of studies investigating cyberbullying have primarily included teenagers ( Table 1 and Table 2 ). Although teenagers are an important population to study given their salient developmental concerns, 110 more work is needed to examine how younger adolescents (for example, 9–11-year-olds) are affected by cyberbullying experiences. Englander, from the MA Aggression Reduction Center (MARC; http://marccenter.webs.com/ ), has begun to study the prevalence of technology among younger children. Her work has shown that over 90% of children are already immersed online by the time they are 8 years old. This has implications for involvement in subsequent cyberbullying. For example, research has demonstrated that owning a “Smartphone” in elementary school increases a child’s risk for being involved with cyberbullying both as the target, as well as the perpetrator. 122 Devine and Lloyd 30 examined Internet use and psychological well-being among 10- and 11-year-old children living in Northern Ireland. Their results showed a moderate, significant relationship between cybervictimization and psychological well-being. Specifically, children who experienced more victimization online were likely to experience more negative affect, more loneliness, and poorer relationships with their parents and peers. Similarly, Jackson and Cohen 122 found a positive relationship between loneliness and cyberbullying victimization among 3rd through 6th graders. Further, cyberbullying victimization was related to fewer friendships, lower rates of optimism in describing peer relationships, and lower peer acceptance. Additional work is needed with this younger age group to help increase our understanding of the impact of cyberbullying on adolescent health.

In sum, research has demonstrated that cyberbullying victimization and perpetration have a significant detrimental impact on adolescents’ health ( Table 1 and Table 2 ). In fact, the studies reviewed herein suggest that cyberbullying is an emerging international public health concern, related to serious mental health concerns, with significant impact on adolescents’ depression, anxiety, self-esteem, emotional distress, substance use, and suicidal behavior. Moreover, cyberbullying is also related to adolescents’ physical health concerns.

It is important to note that the majority of studies investigating the relationship between cyberbullying behaviors and adolescent health have been correlational in nature. While correlational studies are an important first step to understanding the impact of cyberbullying, longitudinal studies are now needed to increase our understanding of how cyberbullying experiences affect adolescents’ health over time. By using longitudinal designs, we are able to test whether adolescents’ depressive symptoms, social anxiety, or suicidal tendencies related to cyberbullying are antecedents or consequences. For example, it is possible that depressive symptomology could either be an antecedent or an effect of cyberbullying victimization. Longitudinal study designs permit us to examine both of these possibilities with more clarity. As discussed in the section titled, “How do the developmental changes in risk factors affect subsequent cyberbullying?”, an emerging body of work has begun to use longitudinal designs to examine the risk factors related to increased involvement with cyberbullying perpetration and victimization over time. However, more longitudinal work is needed to increase our understanding of the temporal nature of variables related to cyberbullying experiences.

Findings from the current literature have significant implications for health care professionals, educators, and caring adults. First and foremost, the studies described throughout urge educators, counselors, and health care professionals to address cyberbullying when assessing adolescents’ physical and psychological health concerns. It is clear that adolescents who are involved in cyberbullying experiences require support. However, evidence suggests that the majority of adolescents do not seek help from adults when involved in cyberbullying. Therefore, it is important to take a proactive approach. Support could come from multiple professional communities that serve youth: educational (for example, professionals working in the schools); behavioral health (for example, clinicians treating adolescents with mental health concerns); and medical (for example, pediatricians asking about cyberbullying experiences during sick and well visits). Sensitive probing about cyberbullying experiences is warranted when addressing adolescent health issues such as depression, substance use, suicidal ideation, as well as somatic concerns. Routine screening techniques can be developed to assist in uncovering the harm endured through cyberbullying to help support adolescents recovering from associated trauma. Finally, the study findings described above also suggest a strong need for comprehensive, school-based programs directed at cyberbullying prevention and intervention. Education about cyberbullying could be integrated into school curriculums and the community at large, for example, by engaging adolescents in scholarly debates and community discussions related to cyberbullying legislation, accountability, and character.

The author reports no conflicts of interest in this work.

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Long-Term Consequences of Cushing Syndrome: A Systematic Literature Review

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Soraya Puglisi, Anna Maria Elena Perini, Cristina Botto, Francesco Oliva, Massimo Terzolo, Long-Term Consequences of Cushing Syndrome: A Systematic Literature Review, The Journal of Clinical Endocrinology & Metabolism , Volume 109, Issue 3, March 2024, Pages e901–e919, https://doi.org/10.1210/clinem/dgad453

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It is held that the condition of endogenous chronic hypersecretion of cortisol (Cushing syndrome, CS), causes several comorbidities, including cardiovascular and metabolic disorders, musculoskeletal alterations, as well as cognitive and mood impairment. Therefore, CS has an adverse impact on the quality of life and life expectancy of affected patients. What remains unclear is whether disease remission may induce a normalization of the associated comorbid conditions. In order to retrieve updated information on this issue, we conducted a systematic search using the Pubmed and Embase databases to identify scientific papers published from January 1, 2000, to December 31, 2022. The initial search identified 1907 potentially eligible records. Papers were screened for eligibility and a total of 79 were included and classified by the main topic (cardiometabolic risk, thromboembolic disease, bone impairment, muscle damage, mood disturbances and quality of life, cognitive impairment, and mortality).

Although the limited patient numbers in many studies preclude definitive conclusions, most recent evidence supports the persistence of increased morbidity and mortality even after long-term remission. It is conceivable that the degree of normalization of the associated comorbid conditions depends on individual factors and characteristics of the conditions. These findings highlight the need for early recognition and effective management of patients with CS, which should include active treatment of the related comorbid conditions. In addition, it is important to maintain a surveillance strategy in all patients with CS, even many years after disease remission, and to actively pursue specific treatment of comorbid conditions beyond cortisol normalization.

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Published: 02 July 2024

Unravelling the complexity of ventilator-associated pneumonia: a systematic methodological literature review of diagnostic criteria and definitions used in clinical research

Markus Fally 1 ,
Faiuna Haseeb 2 , 3 ,
Ahmed Kouta 2 , 3 ,
Jan Hansel 3 , 4 ,
Rebecca C. Robey 2 , 3 ,
Thomas Williams 5 ,
Tobias Welte 6 ,
Timothy Felton 2 , 3 , 5 &
Alexander G. Mathioudakis 2 , 3

Critical Care volume 28 , Article number: 214 ( 2024 ) Cite this article

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Ventilator-associated pneumonia (VAP) is a prevalent and grave hospital-acquired infection that affects mechanically ventilated patients. Diverse diagnostic criteria can significantly affect VAP research by complicating the identification and management of the condition, which may also impact clinical management.

We conducted this review to assess the diagnostic criteria and the definitions of the term “ventilator-associated” used in randomised controlled trials (RCTs) of VAP management.

Search methods

Based on the protocol (PROSPERO 2019 CRD42019147411), we conducted a systematic search on MEDLINE/PubMed and Cochrane CENTRAL for RCTs, published or registered between 2010 and 2024.

Selection criteria

We included completed and ongoing RCTs that assessed pharmacological or non-pharmacological interventions in adults with VAP.

Data collection and synthesis

Data were collected using a tested extraction sheet, as endorsed by the Cochrane Collaboration. After cross-checking, data were summarised in a narrative and tabular form.

In total, 7,173 records were identified through the literature search. Following the exclusion of records that did not meet the eligibility criteria, 119 studies were included. Diagnostic criteria were provided in 51.2% of studies, and the term “ventilator-associated” was defined in 52.1% of studies. The most frequently included diagnostic criteria were pulmonary infiltrates (96.7%), fever (86.9%), hypothermia (49.1%), sputum (70.5%), and hypoxia (32.8%). The different criteria were used in 38 combinations across studies. The term “ventilator-associated” was defined in nine different ways.

Conclusions

When provided, diagnostic criteria and definitions of VAP in RCTs display notable variability. Continuous efforts to harmonise VAP diagnostic criteria in future clinical trials are crucial to improve quality of care, enable accurate epidemiological assessments, and guide effective antimicrobial stewardship.

Ventilator-associated pneumonia (VAP) stands as the most prevalent and serious hospital-acquired infection observed in intensive care units [ 1 ]. VAP prolongs hospital stays, durations of mechanical ventilation, and is associated with considerable mortality and an increase in healthcare costs [ 2 , 3 ].

Diagnosing VAP can be challenging for clinicians as it shares clinical signs and symptoms with other forms of pneumonia as well as non-infectious conditions [ 4 ]. The most recent international clinical guidelines define VAP as the presence of respiratory infection signs combined with new radiographic infiltrates in a patient who has been ventilated for at least 48 h [ 5 , 6 ]. While the guidelines developed by ERS/ESICM/ESCMID/ALAT do not provide a detailed definition of signs of respiratory infection [ 5 ], the ATS/IDSA guidelines mention that clinical signs may include the new onset of fever, purulent sputum, leucocytosis, and decline in oxygenation [ 6 ]. However, the ATS/IDSA guideline panel also acknowledges that there is no gold standard for the diagnosis of VAP [ 6 ]. This lack of a standardised definition is further highlighted by the varying, surveillance-based definitions of VAP provided by the Centre for Disease Control (CDC) and the European Centre for Disease Control (ECDC) [ 7 , 8 ]. These definitions, focusing on a combination of clinical, radiological, and microbiological signs to identify cases of VAP, were established to standardise reporting and facilitate the monitoring of infections in healthcare settings. However, the criteria given by the CDC and ECDC may not always align with the diagnostic criteria used by clinicians to confirm or rule out the condition [ 9 , 10 , 11 ].

Variations in the eligibility criteria applied to VAP can have a significant impact on systematic reviews and meta-analyses that assess different interventions, primarily due to the potential lack of comparability among the studied populations [ 12 ]. Furthermore, the incidence of VAP may be underestimated when excessively strict diagnostic criteria are employed [ 13 , 14 ].

A recent systematic review conducted by Weiss et al. focused on inclusion and judgment criteria used in randomised controlled trials (RCTs) on nosocomial pneumonia and found considerable heterogeneity [ 15 ]. However, the authors only considered RCTs evaluating antimicrobial treatment as interventions, did not distinguish between hospital-acquired pneumonia (HAP) and VAP, and did not evaluate definitions of the term "ventilator-associated".

The objective of this systematic review was to provide a concise overview of the diagnostic criteria for VAP recently used in RCTs, as well as the definitions attributed to the term "ventilator-associated". Its findings will provide valuable insights to a forthcoming task force, which aims to establish a uniform definition and diagnostic criteria for VAP in clinical trials. The task force will be made up of representatives from prominent international societies with an interest in VAP, as well as patient partners with lived experience. The harmonisation of the diagnostic criteria for VAP in upcoming clinical research are vital for enhancing patient care, enabling accurate epidemiological studies, and guiding successful antimicrobial stewardship programs.

Protocol and registration

The protocol for this systematic review was registered in advance with the International Prospective Register of Systematic Reviews (PROSPERO 2019 CRD42019147411), encompassing a broad review focusing on pneumonia outcomes and diagnostic criteria in RCTs. Recognising the limitations of discussing all findings in one manuscript, we opted to produce several focused and comprehensive manuscripts, all employing the same fundamental methodology, as registered with PROSPERO. While a previous publication focused on outcomes reported in RCTs on pneumonia management [ 16 ], the current submission specifically addresses diagnostic criteria for VAP.

Eligibility criteria

We included RCTs that were registered, planned, and/or completed that: (1) enrolled adults with VAP; and (2) assessed the safety, efficacy and/or effectiveness of pharmacological or non-pharmacological interventions for treating VAP.

We have excluded systematic reviews, meta-analyses, narrative reviews, post hoc analyses from RCTs, observational studies, case reports, editorials, conference proceedings, and studies that do not exclusively focus on pneumonia (such as trials including patients with pneumonia alongside other diseases). Additionally, studies on pneumonia subtypes other than VAP, such as pneumonia without specifying a subtype, community-acquired pneumonia (CAP), healthcare-associated pneumonia (HCAP), and HAP, have also been excluded. To maintain focus and relevance, studies on Coronavirus Disease 2019 (COVID-19) were excluded from this systematic review, as the viral aetiology and distinct clinical management protocols differ significantly from the nature and treatment strategies of VAP. RCT protocols were only included if the results have not been previously published in another article included in this systematic review. Due to resource constraints and the lack of multilingual expertise within the review team, this systematic review was restricted to English-language RCTs.

Information sources and search

On 20 May 2024, we searched MEDLINE/PubMed, and the Cochrane Register of Controlled Trials (CENTRAL) for RCTs published between 1 January 2010 and 19 May 2024. We used electronic algorithms introducing a combination of controlled vocabulary and search terms as reported in the Appendix.

Study selection

Two reviewers (FH, MF) independently screened titles and abstracts to identify eligible studies using Rayyan [ 17 ]. In case of disagreement, a third reviewer was consulted (AGM). After immediate exclusion of duplicates using EndNote X9, four reviewers (AGM, FH, JH, MF) independently checked for eligibility at full-text level. The results of the selection process are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 18 ].

Data collection process

We developed an extraction sheet as endorsed by the Cochrane Collaboration [ 19 ]. The extraction sheet was independently tested by three reviewers (AGM, FH, MF) on five randomly selected studies and adapted to ensure good inter-reviewer agreement. The extraction sheet contained the following elements: (1) study ID, name, reference and NCT number; (2) type of pneumonia: CAP, HCAP, HAP and/or VAP; (3) diagnostic criteria for pneumonia; (4) definition of setting; (5) study origin, design, populations, interventions, and outcomes.

Four reviewers (AGM, FH, JH, MF) extracted data from the eligible studies. Data were extracted sequentially from either a manuscript containing published results, a published protocol, or, upon obtaining a trial registration number from CENTRAL, from one of the designated trial registries, such as ClinicalTrials.gov, the Clinical Trials Registry India (CTRI), the Chinese Clinical Trial Registry (ChiCTR), the European Clinical Trials Database (EudraCT), the Iranian Registry of Clinical Trials (IRCT), the Japan Primary Registries Network (JPRN), and the Japanese University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR). Cross-checking of all extracted data was performed by a second reviewer (AGM, AK, MF, RR, TW). Disagreements regarding data collection were resolved by discussion between all reviewers.

Synthesis of results

The findings were consolidated through a combination of narrative and tabular formats. The presentation encompassed the quantitative representation of each diagnostic criterion in terms of numerical values and proportions. Additionally, we provide an analysis of the various combinations of diagnostic criteria employed in RCTs in a sunburst diagram and a tabular format, along with an examination of the definitions attributed to the term "ventilator-associated".

Risk of bias

The main goal of this systematic review was to explore the diagnostic criteria used in clinical trials for diagnosing VAP. It covered trials with published protocols and/or results, as well as those only registered in a trial database. The varying levels and gaps in the information provided by the various sources made it difficult to conduct a reliable and meaningful risk of bias assessment for all included studies. However, for RCTs with published data, risk of bias was evaluated by four reviewers (AGM, JH, MF, RR) using the Risk of Bias in Randomized Trials 2 tool (RoB-2 tool), as endorsed by the Cochrane Collaboration [ 20 ].

Study selection and characteristics

A total of 7173 records were identified through the databases MEDLINE and CENTRAL, as illustrated in Fig. 1 . Following the removal of duplicate entries, a screening process involving the evaluation of titles and abstracts was conducted on 5652 records. Among these, 650 records were deemed potentially eligible for inclusion. Ultimately, our review included 119 studies that specifically focused on VAP (Table S1 in the Appendix, the full dataset is available online [ 21 ]).

PRISMA flowchart showing study selection

The total number of patients in the 119 identified studies was 21,289. Among these studies, 83 focused exclusively on VAP, while the remaining studies encompassed various subtypes of pneumonia in addition to VAP (see Table 1 ). The majority of these studies were registered, and their protocols were accessible either through publication in a journal article or on a clinical trial platform. Results were accessible in 56.3% of cases, while both results and the protocol were accessible in 36.9% of cases. In 40.3% of the included studies, data could only be obtained from a trial registry platform, with ClinicalTrials.gov being the primary platform in 36 out of 48 cases, and ChiCTR (n = 2), CTRI (n = 3), EudraCT (n = 3), IRCT (n = 2), JPRN (n = 1) and UMIN-CTR (n = 1) in the remaining cases.

Diagnostic criteria were provided in 51.2% and the term “ventilator-associated” was defined in 52.1% of the studies, respectively. Of the 20 studies (16.8%) that referred to previously published diagnostic criteria, 13 cited the Clinical Pulmonary Infection Score (CPIS) [ 22 ], while the remaining referred to national and international guidelines.

We evaluated the risk of bias in 67 studies with published results using the RoB-2 tool. The overall assessment showed that 25% of the studies were at high risk of bias, 30% were at low risk of bias, and the remaining 45% had some concerns about potential bias. These results indicate variability in the methodological quality of the studies included in the review. The overall risk of bias and the detailed results of our assessments for the 67 studies are displayed in the Appendix (Figures SF1-SF2).

Diagnostic criteria for VAP

Pulmonary infiltrates.

Of the 61 studies on VAP that provided diagnostic criteria, 59 (96.7%) included the radiological evidence of a new or progressive pulmonary infiltrate.

Clinical signs and symptoms

The most frequently included clinical signs and symptoms were fever (86.9%), hypothermia (49.1%), sputum (70.5%), and hypoxia (32.8%). Different cut-off values were employed to define fever and hypothermia, as indicated in Table 2 . The majority of studies, accounting for 45.2%, utilised a cut-off of > 38 degrees Celsius (°C) to define fever, while 13.2% of studies used a cut-off of ≥ 38°C. In the case of hypothermia, the most commonly employed cut-off value was < 35°C, which was utilised in 43.3% of studies that included hypothermia as a criterion. Only a minority of studies provided information on the site of temperature measurement. Oral measurement was the most frequently employed method, followed by axillary and core temperature measurements (further details are displayed in Table S2 in the Appendix).

Biochemistry criteria

Fifty-four studies (88.5%) incorporated white blood count abnormalities as part of their diagnostic criteria for VAP. Conversely, only one study included an elevation of procalcitonin (PCT) as a diagnostic factor, and none of the identified studies included C-reactive protein (CRP). The specific thresholds for leucocytosis and leucopoenia varied across studies, with leucocyte counts ranging from greater than 10,000/mm3 to greater than 12,000/mm3 for leucocytosis, and less than 3,500/mm3 to less than 4,500/mm3 for leucopoenia (Table 3 ).

Combinations of diagnostic criteria

All definitions of pneumonia were composite in nature and required the fulfilment of a minimum number of predetermined criteria for the diagnosis to be established. In 90.2% of the studies the presence of a new pulmonary infiltrate was a mandatory criterion. Two studies did not include an infiltrate as criterion, whereas the remaining studies (n = 4) included the presence of an infiltrate in their criteria, it was, however, not required for a diagnosis.

The most commonly employed set of diagnostic criteria (18/61, 29.5%) consisted of a pulmonary infiltrate along with two or more additional criteria. However, these additional criteria varied across studies (Fig. 2 ). A quarter (17/61) of the included studies that provided diagnostic criteria required the fulfilment of all individual criteria for diagnosis, including an infiltrate. An infiltrate and one or more additional criteria were used to establish a diagnosis of VAP in 14.8% of studies (9/61). A total of 38 different combinations of diagnostic criteria for VAP were used in the 61 identified studies. A full set of these criteria is displayed in Table S3 in the Appendix.

The different combinations of diagnostic criteria used in VAP RCTs. CXR radiological evidence of a new infiltrate; T temperature criterion; WBC white blood count criterion; dys/tach dyspnoea and/or tachypnoea; O2 hypoxia; auscultation auscultation abnormalities

Definition of “ventilator-associated”

We noted that 52.1% of included studies incorporated a specific definition of the term “ventilator-associated” (Table 4 ). A total of nine distinct definitions were identified across 62 RCTs. The definition most commonly used was “onset after > 48 h of mechanical ventilation” (82.3%). Other definitions employed varying time thresholds, ranging from 24 h to seven days. Additionally, certain studies introduced supplementary criteria to further delineate the concept of “ventilator-associated”, such as administration of antibiotics prior to mechanical ventilation, duration of hospitalisation, or the timing of extubation.

Summary of evidence

This systematic review provides a concise overview of the diagnostic criteria for VAP used in RCTs and the definitions attributed to the term “ventilator-associated”. A total of 119 studies on VAP, published or registered between 2010 and 2024, were included, spanning a total of 21,289 patients. The majority of studies focused exclusively on VAP, while some also included other subtypes of pneumonia alongside VAP. Diagnostic criteria were provided in only 51.2% of the studies, and the term “ventilator-associated” was defined in only 52.1% of the studies. The most commonly utilised definition for “ventilator-associated” was “onset after > 48 h of mechanical ventilation”, used by 82.3% of studies providing a definition.

In clinical practice, the diagnosis of VAP is often based on a combination of clinical signs, laboratory results, and imaging findings, yet these are not without their limitations [ 8 ]. Our systematic review revealed considerable heterogeneity among diagnostic criteria for VAP in recent RCTs. Various combinations of specific criteria were employed to define VAP, leading to significant variability. Moreover, commonly used criteria were defined in different ways, with variations observed in the thresholds set for fever/hypothermia, as well as leucocytosis/leucopoenia.

Several criteria that were used in the studies included in our review have been shown to be insufficient for confirming a diagnosis of VAP. One of the most important criteria, included in the majority of reviewed RCTs, a new or progressive pulmonary infiltrate, has previously been reported to be of limited diagnostic value due to a lack of specificity [ 14 ]. Additionally, criteria like fever/hypothermia and the measurement of biomarkers such as leukocytes, CRP, and PCT may not be effective in diagnosing or excluding VAP in various clinical settings [ 4 , 23 , 24 ]. Despite this, CRP is widely used and has demonstrated some clinical value in predicting VAP [ 25 ]. It is, therefore, surprising that none of the RCTs included in our review employed CRP as a diagnostic criterion.

Overall, the findings of our systematic review underline the diverse nature of VAP, with different diagnostic criteria increasing the risk of both over- and underdiagnosis of VAP [ 14 , 26 ]. There have been attempts to diagnose VAP more objectively, one of these being the development of the CPIS in 1991, a six-component score that 10.9% of studies included in our review referred to [ 27 ]. This score includes different cut-offs for body temperature, leucocyte counts, tracheal secretion appearances, oxygenation levels and radiographical changes to estimate the risk for VAP. However, the CPIS has been shown not to be superior to other diagnostic criteria, and, therefore, its application remains controversial [ 8 , 11 , 22 , 28 ]. Other commonly applied criteria, such as the surveillance-based criteria by the ECDC and CDC, did not seem to be accurate enough to detect true cases of VAP either [ 9 , 10 , 11 ]. Furthermore, there is limited agreement between the two surveillance-based criteria, which has previously resulted in different estimates of VAP events [ 29 ].

In lieu of definitive diagnostic scores or sets of diagnostic criteria to detect all true cases of VAP, the findings of our systematic review indicate the need for more homogeneous diagnostic criteria in future RCTs, to assure their comparability. Currently, international guidelines avoid providing clear diagnostic criteria for VAP [ 5 , 6 ]. Given the significance of establishing strong consensus definitions for high-risk conditions like VAP, it is essential to emphasise even further that a uniform definition is crucial not only for advancing therapeutic research but also, and perhaps more importantly, for refining diagnostic methods. Together with core outcome sets, these definitions can help to improve the likelihood of attaining robust and reliable findings in forthcoming systematic reviews and meta-analyses [ 16 , 30 ].

Strengths and limitations

We used a comprehensive search strategy which included multiple databases and a wide range of search terms, ensuring broad identification of all potentially relevant trials. Additionally, the inclusion criteria were clearly defined, and the study selection process was conducted independently by multiple reviewers to minimise bias. The extraction sheet used for data collection was tested for inter-reviewer agreement and adapted accordingly. Another strength is the open availability of the complete dataset, maximising the transparency and reproducibility of our findings.

However, the following limitations need to be acknowledged. Firstly, the review only included RCTs conducted in English, which may have introduced language bias. This approach was adopted to ensure feasible and reliable data analysis within the scope of the resources available.

Additionally, the exclusion of studies focusing on pneumonia subtypes other than VAP may limit the generalisability of our findings. Furthermore, the lack of diagnostic criteria and definitions in a significant proportion of included studies suggests a potential reporting bias. This might be reinforced by the fact that 40.3% of data were received from trial registry platforms. Compared to final manuscript publications, reporting of eligibility criteria is often incomplete on registry platforms, therefore this must be highlighted as a limitation [ 31 ].

This systematic review provides an overview of diagnostic criteria for VAP used in RCTs and the definitions attributed to the term “ventilator-associated”. Our findings highlight the heterogeneity and lack of standardisation in commonly used diagnostic criteria, as well as the variability in definitions of "ventilator-associated" across clinical trials. We emphasise the need for a uniform definition of VAP to enable better comparability between studies and interventions. The results of this review will inform the work of an upcoming task force aimed at establishing such standardised criteria.

Availability of data and materials

Raw data are accessible via the Open Science Framework (OSF) at osf.io/v3 × 42. This link is referenced in our manuscript (Ref. 21).

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Acknowledgements

We would like to acknowledge and honour the contributions of Prof. Tobias Welte, who was a vital member of our research team and co-author of this manuscript. Prof. Welte passed away after the initial submission of this work but before its final acceptance. His insights and expertise were invaluable to the development of this research, and he remains deeply missed by the team. We dedicate this work to his memory.

Open access funding provided by Copenhagen University This study was partly supported by the NIHR Manchester Biomedical Research Centre (BRC, NIHR203308) as well as the Capital Region of Denmark (Region Hovedstaden). The funders had no role in study design, data collection or analysis, decision to publish, nor preparation of the manuscript. Dr Jan Hansel was supported by an NIHR Academic Clinical Fellowship in Intensive Care Medicine. Dr Rebecca Robey was supported by an NIHR Academic Clinical Fellowship in Respiratory Medicine. Dr Alexander G. Mathioudakis was supported by an NIHR Clinical Lectureship in Respiratory Medicine. All authors have completed a ICMJE uniform disclosure form detailing any conflicts of interest outside the submitted work that they may have. None of the authors have conflicts directly related to this work.

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Markus Fally

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Faiuna Haseeb, Ahmed Kouta, Rebecca C. Robey, Timothy Felton & Alexander G. Mathioudakis

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Faiuna Haseeb, Ahmed Kouta, Jan Hansel, Rebecca C. Robey, Timothy Felton & Alexander G. Mathioudakis

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MF: conceptualisation, methodology, software, formal analysis, investigation, data curation, writing—original draft, visualisation, project administration. FH: conceptualisation, investigation, data curation, validation, writing—review and editing. AK, JH, RCR and TWI: data curation, validation, writing—review and editing. TWE: conceptualisation, investigation, methodology, resources, validation, writing—review and editing. TF: conceptualisation, investigation, methodology, resources, validation, writing—review and editing, supervision. AGM: conceptualisation, investigation, methodology, software, resources, validation, writing—review and editing, project administration, supervision, funding acquisition, project administration.

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Additional file1 (docx 807 kb), search strategy, medline/pubmed.

#1: pneumonia [mh]

#2: bronchopneumonia [mh]

#3: pleuropneumonia [mh]

#4: Healthcare-Associated Pneumonia [mh]

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#9: pleuropneumonia [ti]

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#20: children [mh] NOT adults [mh]

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#23: #18 NOT #22

#24: #10 AND #23

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Fally, M., Haseeb, F., Kouta, A. et al. Unravelling the complexity of ventilator-associated pneumonia: a systematic methodological literature review of diagnostic criteria and definitions used in clinical research. Crit Care 28 , 214 (2024). https://doi.org/10.1186/s13054-024-04991-3

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Silent Screams: A Narrative Review of Cyberbullying Among Indian Adolescents

Vijayarani M , G. Balamurugan , +5 authors Tamilselvi S
Published in Cureus 6 August 2024

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First, it is well-established in the research literature that bullying is often associated with shame, guilt, and stigma for both students who ... Vivolo-Kantor A. M., Martell B. N., Holland K. M., Westby R. (2014). A systematic review and content analysis of bullying and cyber-bullying measurement strategies. Aggression and Violent Behavior ...
Cyberbullying : a literature review
Cyberbullying : a literature review . Abstract . Technology is becoming more prevalent each day, with that a new form of bullying is happening. The new form is cyberbullying. It is form of bullying that takes place over cell phones, email, websites, and chat rooms. While cyberbullying is a form of bullying, there are differences between ...
Current perspectives: the impact of cyberbullying on adolescent health
The term cyberbullying in this review will represent an umbrella term that includes related constructs such as Internet bullying, online bullying, and information communication technologies and Internet harassment. ... Findings from literature on cyberbullying victimization and adolescent health using cross sectional design. Study Ref citation ...
Review Cyberbullying in higher education: A literature review
This literature review was created to raise awareness of this continuing trend of cyberbullying among college students with higher education students, administrators, and faculty. Ultimately, the literature presented has led the writers of this review to examine areas for future research as discussed below. This review defined cyberbullying as any.
Working in a virtual world: : A meta-analytic investigation of cyber
R. Baloch, Cyber bullying and its emotional impact on employees performance with mediating role of psychological distress and moderating role of management support, ... Perceived organizational support: A review of the literature, Journal of Applied Psychology 87 (4) (2002) 698-714,. Crossref. Google Scholar
Literature review highlights environmental impact of intravitreal
Intravitreal injections have a large environmental impact, estimated to be around 210 million kg of CO2 equivalent per year in the U.S. alone, according to a presenter at the American Society of ...
Long-Term Consequences of Cushing Syndrome: A Systematic Literature Review
Long-Term Consequences of Cushing Syndrome: A Systematic Literature Review - 24 Hours access EUR €38.00 GBP £33.00 USD $41.00 Rental. This article is also available for rental through DeepDyve. Advertisement. Citations. Views. 1,243. Altmetric. More metrics information. Metrics. Total Views 1,243. 711 Pageviews. 532 PDF Downloads. Since 8/1 ...
Unravelling the complexity of ventilator-associated pneumonia: a
Ventilator-associated pneumonia (VAP) is a prevalent and grave hospital-acquired infection that affects mechanically ventilated patients. Diverse diagnostic criteria can significantly affect VAP research by complicating the identification and management of the condition, which may also impact clinical management. We conducted this review to assess the diagnostic criteria and the definitions of ...
Silent Screams: A Narrative Review of Cyberbullying Among Indian
DOI: 10.7759/cureus.66292 Corpus ID: 271779866; Silent Screams: A Narrative Review of Cyberbullying Among Indian Adolescents @article{M2024SilentSA, title={Silent Screams: A Narrative Review of Cyberbullying Among Indian Adolescents}, author={Vijayarani M and G Balamurugan and Sanjay Sevak and Kusum Gurung and Bhuvaneswari G and Sangeetha X and Thenmozhi P and Tamilselvi S}, journal={Cureus ...
Agricultural object detection with You Only Look Once (YOLO) Algorithm
Secondly, we conducted a systematic literature review on 30 selected articles to identify current knowledge, critical gaps, and modifications in YOLO for specific agricultural tasks. The study critically assessed and summarized the information on YOLO's end-to-end learning approach, including data acquisition, processing, network modification ...