When Dr. Nina Fredland was an elementary and middle school nurse in Houston children came to her clinic with vague complaints such as headaches and stomach aches. Some students were hesitant to go to the playground, eat lunch in the cafeteria or walk unescorted to and from school.
Later, as a faculty member supervising public health nursing students working in a middle school, she recalls one seventh-grade student who told her things were bad at home and he "felt better" after hitting someone at school.
Fredland recognized how childhood exposures to violence can transfer to peer relationships, and nurturing healthy relationships can mitigate early aggressive behaviors such as bullying. She was convinced the best time to teach children about healthy, respectful relationships is early in life.
Fredland, a former U.S. Navy nurse, completed an Interdisciplinary Research Training on Violence Fellowship and received her Ph.D. from Johns Hopkins University. Her dissertation focused on how violent exposures and experiences affect physical, mental and behavioral health outcomes in middle school youth.
Now an assistant professor of nursing at The University of Texas at Austin, Fredland is collaborating with community agencies and schools in Central Texas to increase understanding of aggressive behaviors, including school age bullying and teen dating violence and how these experiences affect health and school performance.
"Increasing rates of youth violence including media-worthy, horrific violent school events have brought national attention to the phenomenon of bullying," Fredland said, adding that bullying may be the most common type of school violence.
"Millions of youth in the United States are involved in some form of bullying behavior either as the instigator, recipient, bystander or those who are victims, but sometimes go on to bully others."
Bullying behavior is unprovoked and repeated with malicious intent. A physical or psychological power imbalance exists between the instigator of the behavior and the recipient. Bullying covers a variety of behaviors. Bullying actions can be direct or indirect. Direct actions include physical contact, name-calling, mean looks and obscene gestures. Indirect actions include exclusion tactics, rumors and Internet or cyber attacks.
Bullying is associated with serious negative health outcomes affecting physical and psychological well-being and school performance.
"Nurses and nurse practitioners are well positioned in a variety of settings such as schools, ambulatory clinics, family practice sites and camps to identify unhealthy situations and to intervene in timely and appropriate ways," said Fredland, who also is a nurse practitioner.
"Nurses often are the ones who are confided in, consulted with and have opportunities to influence school health curricula," she said. "In addition to interacting with students, nurses interact with all stakeholders in the school community, including parents, administrators, teachers, staff and supplementary staff such as hall monitors, cafeteria workers, janitors, crossing guards and bus drivers."
Hurtful teasing and bullying have been associated with negative health outcomes such as sleep disturbances, anxiety issues, breathing problems, poor appetite and physical illness. Other manifestations include sadness, moodiness, loneliness, decreased self-confidence, poor body image and friendship issues. Thoughts of suicide and suicide acts have been linked with bullying as well.
In the last decade, bullying in the U.S. has received increasing attention among researchers. However, prevention strategies have seldom focused on primary prevention or included all students, said Fredland, adding that early antisocial peer behaviors are just beginning to be linked to later unhealthy romantic relationships.
She advocates designing programs directed at the very young adolescent.
After seeing a demonstration of Forum Theater, an interactive methodology introduced by the Brazilian dramatist Augusto Boal, at a "Nursing Networks for Violence Against Women International" conference, Fredland wondered if the method would work with middle school students to promote health and healthy relationships.
Fredland decided to partner with a local non-profit theater company, Theatre Action Project, to devise a script and develop a program that was developmentally and culturally appropriate for middle school youth. She received funding for a research study from the School of Nursing Center for Health Promotion and Disease Prevention Research. "Nurturing Healthy Relationships: An Arts-Based Intervention for Middle School Youth" was piloted in one public middle school in Central Texas.
The play's script addressed healthy and unhealthy relationships, including peer teasing and bullying, sexual bullying and harassment, cyber bullying and texting, and early signs of dangerous romantic relationships. More than 190 ethnically and economically diverse students in seventh grade health classes viewed and participated in the interactive play.
"Deciding on the best approach to deliver health messages to this age group is always a challenge," Fredland said. "Traditional classroom educational methods about health behaviors often turn off adolescents. And, developmentally, they have other priorities.
"Early adolescence, is a critical time to engage youth (ages 11 to 14 years) in health promoting activities before negative behaviors become normalized, particularly in relationship to peer and romantic (dating) behaviors."
Fredland said national statistics report that five million youth (29 percent) admitted experiencing some form of bullying behavior. The most recent Youth Risk Behavior Surveillance Survey found that 43 percent of male students and 28 percent of female students admitted physically fighting in the past year. Minority and younger students were more affected.
"Adolescents don't usually have an extensive repertoire of ways to handle difficult peer situations," she said.
Feelings of being disrespected are very common among young adolescents, Fredland pointed out. Often their coping responses are inadequate, resulting in negative consequences. Unchecked bullying behaviors could potentially later escalate to teen dating and adult intimate partner violence.
"Interactive theater is an incredible way to teach young people life skills, like respect, because it is fun, active and deeply engaging," said Karen LaShelle, executive and artistic director of Theatre Action Project. "The program combines role play, group activity and lively discussion, creating the stage for all students to be involved in learning."
Developing a sense of empathy is a key part in helping students understand how their actions affect others, and helps inspire them to be respectful, compassionate and even act as allies for people who are targets of disrespect and bullying, LaShelle said.
"We start teaching youth as young as kindergarten about respect," she said. "By the seventh grade, it is time to start really talking to youth about more mature topics like cyber bullying and sexual harassment, because sadly those are real-life problems students face every day in their schools."
Stopping bullying calls for a multi-faceted approach, Fredland said.
"We can't always fix things, and some young people are dealing with very complicated life circumstances," she said. "We can help them acquire a repertoire of skills to deal with hard situations and interact more positively with peers. The whole point is to nurture respectful, healthy relationships and find better ways to handle difficult situations.
"With our play, we wanted to open the door for young adolescents to have conversations about bullying and to learn how to behave in both peer and early romantic relationships."
Students thought the interactive theater method was a positive experience. They said they gained new knowledge about healthy relationships.
"Students felt comfortable participating in the process and thought their behavior and that of their classmates would likely change based on the new information learned," Fredland said.