1. Background

Bullying and aggressive behavior is a part of the culture in schools and communities worldwide [1-3]. The Centers for Disease Control and Prevention (CDC) states that bullying routinely impacts approximately a third of elementary school age children [1]. The World Health Organization (WHO) and Scrabstein and Leventhal note that youth are victims of, or participate in, acts of bullying or aggressive behavior [3,6]. The World Health Organization reports homicide is the fourth leading cause of death for youth ages 10 to 29 with the majority of these deaths being a male [3]. Many social sciences, education, and healthcare groups interested in developing a standard definition for bullying and aggressive behavior [1,4-6]. Research indicates there are differing perceptions regarding bullying and aggressive behavior.Often adults and youth do not have similar views of bullying and aggressive behavior [20,24-25]. For instance, adults may view teasing as an expected part of growing up but teasing has been noted to escalate into more aggressive behavior by children [20,24].Often addressing bullying behaviors falls to multiple members of the school setting such as the school nurse, the individual teacher, an athletic coach, a counselor or an administrator [5]. Without a welldeveloped plan to identify and address these behaviors it is difficult to change the culture of a school or community [5,24].

This lack of consensus results in inconsistent strategies to recognize and eliminate bullying in school and community settings [5,20,24]. Bullying and aggressive behavior can be interrupted and changed [4,7]. Aggressors and victims can learn alongside each other and develop better socialization skills, empathy for others, and conflict resolution tools [8].The author will address the broad impact of bullying and aggressive behavior, evidentiary support for the use of bibliotherapy as an intervention, potential for the development of the intervention, and evaluation tools to measure the success of the intervention.

2. School and Community Impact

Bullying and aggressive behavior impacts the individual, the family unit, community, school systems, and society as a whole [1,3,6]. Both individuals and small groups are responsible for initiating bullying activities [9]. The AMA and the Department of Education reported that almost up to one third of American children are affected by bullying and aggressive behavior in the school setting [2,4].Bullying is no longer limited to the play yard at school or as a young person walks home from school. Bullying in the 21st century means the aggressor can follow a young person all day every day [10].

While the advent of computers in the home has brought tremendous learning opportunities, an unintended consequence has been the development of cyber bullying. Cyber bullying encompasses email, and multiple forms of social networking [2,10]. Another area of bullying that follows the student is demeaning or aggressive language delivered through the cell phone as text messaging. The individual engaging in this type of virtual bullying is even further removed from the social pressures that might stop bullying behavior due to the physical and emotional distance cyber bullying provides [10].

Dolezal, McCollum, and Callahan and Dake, Price, and Telljohann state that victims of bullying visit healthcare providers frequently with general complaints of back pain, fatigue, muscle aches, headaches, sleep difficulties, non-specific anxiety or depression [11-12]. Data support that children experiencing bullying and victimization in school are twice as likely to miss school due to vague complaints and experience difficulty verbalizing fear of school [4]. Scrabsteing and Leventhal and Dake, Price, and Telljohann acknowledges that there is evidence to support that youth involved in bullying activities, as either the victim, observer, or instigator, have increased complaints of physical and psychological disorders, are at a higher risk for missing school and becoming a runaway, as well as alcohol and drug use, and injury [6,12]. At this time there is a lack of standardized education for healthcare providers regarding the subtle signs and symptoms of victimization or abuse, and this makes it difficult to track complaints related to victimization [9,11].

3. Review of Existing Evidence

These databases were utilized for a literature search: Pubmed, OVID, EBSCO, SagePub, Elsevier, and Scientific Direct. The Centers for Disease Prevention and Control, the Academy on Violence and Abuse, the National School Nurse Association, the State of Alabama Department of Education, the Statistical Analysis Center Alabama, the Bureau of Justice Statistics, the American Medical Association (AMA) websites, the World Health Organization, and the National Institutes of Medicine resources were searched for systematic reviews, metaanalyses, quantitative, task-force reports, and qualitative research. The search terms utilized were youth bullying, youth aggressive behavior, youth violence intervention, school nurse and bullying, and school violence. The literature search returned 230 articles, of these 56 were applicable to bullying, victimization, aggressive behavior, and bibliotherapy.

Existing evidence indicates strong support for universal schoolbased interventions to reduce bullying and aggressive behavior [7]. Prothrow-Stith and Bandura have long supported active intervention in the school setting to introduce appropriate interpersonal skills and correct bullying and aggressive behavior [13-14]. Prothrow-Stith, the CDC, and Scrabstein and Leventhal hold the opinion that bullying and aggressive behavior should be considered a public health issue and appropriate resources should be applied to address it [1,6,13]. Prothrow-Stith, and Scrabstein and Leventhal do not believe that implementing more stringent punishment is the best intervention, but rather the development of a long-range plan for altering these behaviors is needed across communities and public schools [6,13]. Providing a structured program to promote appropriate socialization, problem solving skills, and a school and community culture that will not tolerate bullying and aggressive behavior is a better solution [6-7,13-14].

4. Intervention Theory: Social Cognitive Theory

The Social Cognitive Theory (SCT) provides a clear model to demonstrate multiple influences pressing on youth, as well as an orderly process to implement change [15]. The SCT states that actions are determined by the relationship between the individual, activities, the community, and the family [15]. Bandura believes that behavior is determined by individual choice, previous socialization, impact of the community and family, and an individual’s personality [15]. When utilizing SCT, a change in actions is accomplished through influencing or modifying one or more areas of inter-relationship. The opportunity to affect change through several points of impact creates a solid framework for a bullying and aggressive behavior intervention. Youth ages 8 to 10 are beginning to look to peers for cues on social behavior and interaction [16]. Youth accomplish a significant portion of social development during this stage and can leave this stage with strong or poor self-esteem based on peer interaction (16). This aligns with an important component of SCT. The conviction that the individual can exert influence over actions impacting lived experiences [14-15]. The development of the ability to positively influence others in response to an individual or the group is important to appropriate social interaction.

Kinzie conducted a literature review of studies designed to alter health behaviors and discovered that most behavior modification projects combined multiple theories [17]. The researchers applied various components of the theories to specific areas of behavior modification believing that these areas better addressed the successful implementation of change. The Health Behaviors Model, Gagne’s Nine Events of Instruction, the Diffusion Model, and the Social Cognitive Theory were most often combined to develop teaching strategies for many populations [17].

5. Bibliotherapy as an Intervention for Bullying and Victimization

Universal school-based interventions are effective in reducing bullying activities, and improving the overall culture of the school [7]. Hendershot, Dake, Price, & Lartey acknowledge that the lack of a standardized definition for and recognition of bullying activities can diminish the effectiveness of the intervention [5]. A cohesive approach to addressing the problem of bullying is necessary to provide a united face to the faculty, staff, students, and parents [5]. Boxer, Goldstein, Musher-Eizenman, Dubow, and Heretick believe an intervention should include aspects of socialization to allow the aggressor and victim to better recognize and interpret the social cues of others [8]. Improving the ability to appropriately recognize social cues allows the bully and the victim to de-escalate episodes. Interventions that include activities to bring the culture of the school closer to a uniform recognition of what constitutes bullying and aggressiveness has been shown to have greater longevity [8]. While there are numerous strategies recommended in the literature, bibliotherapy has long been recognized as an effective intervention to address the need for change in bullying and victimization behavior [18].

Hahn et al., recommend the utilization of universal school-based programs when developing an intervention to address bullying [7]. Several interventions are considered to be school-based interventions, but universal interventions are intended to apply the intervention across the city or county wide school system, a single school, or a specific grade within a school [19]. An additional component of school-based intervention is directed toward the youth or youths engaged in bullying or aggressive behavior [19]. Another form of intervention is designed to open the intervention up toinvolve the student, parents, school, and community [19]. A particular strength of this third form of intervention is the involvement of many different individuals in direct contact with the student’s world.

Bibliotherapy is considered both an individual and universal schoolbased intervention. It is well suited for utilization with an individual or across several grades, the entire school, or an age group [25]. While there are numerous strategies recommended, bibliotherapy has long been recognized as an effective intervention to address the need for change in bullying and victimization behavior [18]. Several bibliotherapeutic interventions are described in the literature. One intervention included faculty observing students to identify and establish behaviors the program would consider as bullying behaviors prior to implementing bibliotherapy [25]. Other school programs have established behaviors considered to be bullying or aggression toward an individual or group [20].

Bibliotherapy is effective in changing the culture of a school. Bibliotherapy has been utilized in numerous ways through poetry writing, drawing, creative writing such as story-telling, and the development of plays for members of the school to present to the entire school or class [5,24]. Gregory and Vessey identify three phases for effective use of bibliotherapy interventions, the recognition of the problem, purging, and understanding [20]. A key recommendation for the selection of a book series is the element of problem solving [20]. Often redirecting student aggression with positive methods of communication and problem solving are effective [20]. Bibliotherapy introduces characters in text that appeal to children at different stages of growth and development [18,20]. The age appropriate characters lead the students through lessons in empathy, caring, socialization, team building, and problem-solving. The goal is to encourage the students to see how specific behaviors make others feel, and to provide interaction that can lead to better socialization, and problem-solving skills [20].

As there is strong evidence to support the use of universal schoolbased interventions, the goal should be to utilize bibliotherapy across an entire grade, age group, or school system for one academic year for evaluation of effectiveness as an intervention for bullying. Based on stages of growth and development and SCT, selecting students in grades three, four, or five would be best [15-16]. Parents, faculty, and members of the community can come together to research a book series, pursue funding for the purchase of the series and training, and participate in the use of the series within the school. The bibliotherapy series should be selected based upon relevance to the student population, culture, age appropriateness, ease of use, and interesting stories. Parents and faculty for the grade, age, or school system selected should participate in the reading program. The reading program should utilize both parents and faculty members to devote at least 30 minutes of reading time to the student’s each day. It would be feasible to take one class period and introduce the bibliotherapy series.

6. Evaluating the Effectiveness of Bibliotherapy

The SCT model and the Context, Input, Process, and Product (CIPP) model complement each other well in developing and evaluating a bibliotherapy protocol for a school-based intervention. The models were chosen due to the recognition of the impact that human behavior has on changing health related behaviors [14]. Establishing the problem, the school culture, and gathering input pertinent to issues surrounding bullying and aggressive behavior occurs in the context and the pre-contemplation/contemplation phases [21,25]. During these phases an assessment is made of the interest for change among the stakeholders, the beliefs and feelings of the stakeholders regarding the chosen intervention, and the assets available to aid in implementing the intervention [22]. Preparation and input phases should include a thorough literature review of current interventions utilized within school systems. It is essential to develop a working knowledge of the issues specific to the school culture, community, and the bullying activities. The combined information gathered from the previous phases narrows the choices regarding the possible interventions. The research will provide a focus for the goals of the intervention. The implementation phase involves the development of the timeline, activities to be included, outcomes expected, and measurement tools to be utilized. Product and maintenance phases will include the evaluation of the intervention and the potential for continuing the intervention [23].

The effectiveness can be evaluated by tracking the number of incidences of bullying or aggressive behavior prior to, during, and after the intervention. The expectation is that there will be a reduction in the reported and observed cases of bullying or aggressive behaviors, students will report a decrease in being bullied or participating in bullying behavior, the culture of the school will support positive methods of dealing with problems between peers, greater acceptance of others, and age appropriate socialization.

The context, input, process, and product (CIPP) model can be utilized effectively when evaluating the bibliotherapy intervention [21-23]. The context stage requires an understanding of the issue that requires change, the tasks and time necessary to develop an intervention, and evaluation of the potential interventions [21]. The input stage requires research of other options, and a further refinement of an intervention [21].The process stage requires continuous review of the intervention during implementation with the goal being to determine what, if any, alterations are necessary [23]. The product stage evaluates the success of the intervention and determines if change has occurred [23]. The intervention can be viewed as successful if each stage of the CIPP model is met during development, implementation, and evaluation.

7. Conclusion

There are numerous recent examples in the media, both in America and across the globe, of the tragic impact that bullying can have on youth, the family, the school, and local community. In the past youth experiencing victimization by peers could expect a break within the sanctity of the home. But the prevalence of cell phones, the home computer, and unsupervised access to the internet by young people has elevated the level of bullying to a 24 hour-a-day experience [2,10].

Universal school-based interventions are effective [7,13]. Utilizing an intervention that involves the youth, family, school, and the community can have a greater impact then isolating the bully for an intervention activity [8]. There are significant short and long term effects for both the victim and the aggressor. The prevalence of young people choosing to commit suicide rather than face attending school each day indicates the need for members of the healthcare profession, education community, general community, and families to evaluate how American schools are acknowledging and addressing the problem [2-3,4,6].

Competing Interests

The author declare that there is no competing interests regarding the publication of this article.