A Healthcare Provider’s Guide to Bullying

In an effort to combat and draw attention to the seriousness of Bullying, OCMS partnered with Marlene Seltzer, MD, Director of the Beaumont Children’s Hospital NoBLE Anti-Bullying Program and Rob Iwrey, Esq. (and staff) at The Health Law Partners, P.C., to develop informational materials that would assist physicians in recognizing the signs of bullying and the services available to victims and their families.

IMPORTANT FACTS ABOUT BULLYING

“Bullying” is defined as any unwanted, aggressive behavior(s) by another youth or group of youths that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated. Bullying may inflict harm or distress on the targeted youth including physical, psychological, social or educational harm.
Bullying behavior can start as early as pre-school, however it typically peaks in late elementary/early middle school and is known to continue into high school (can continue into higher education and the workplace also). It is estimated that approximately 28% of 6th-12th graders have reported being bullied, unfortunately, as children age, many do not report encounters to adults at all. It has been suggested that 160,000 students stay home from school, every day, for fear of being bullied and is also attributable for countless physical and mental injuries (including deaths) of children and young adults throughout the United States.

Types of bullying:

• Physical – causing bodily injury; also taking or destroying a person’s belongings • Verbal – making disparaging comments, taunting, threatening, or intimidating • Social – sometimes referred to as indirect or relational: hurting someone’s relationships or reputation through means such as gossip, rumors or exclusion • Cyber – bullying via electronic communication including: emails, texts, websites, social media, embarrassing photos, rumors, and fake profiles
Symptoms of Bullying (not an exhaustive list):

Physical:
• pain- headache, abdominal, musculoskeletal • enuresis • change in sleeping patterns • change in eating patterns • fatigue • dizziness • more frequent URI’s Youth at Higher Risk for Being Targeted:
• those who are overweight/obese
Mental:
• anxiety • depression • loneliness • decreased self-esteem • substance use/abuse • self-harm/cutting • suicidal ideation/attempts • those with autistic spectrum disorder or developmental disabilities • LGBTQ • those with disabilities (physical, learning, emotional)

What to do if a Youth has been EXPOSED?
• encourage dialogue and listen non-judgmentally • validate their feelings and the seriousness of their situation • evaluate for suicidal ideation • provide a message of support and education • both youth and parents may need support, education, and guidance • witnesses are also at risk and need support and education • youth may need a referral for counseling or psychiatric evaluation • youth/parents may need information about Michigan’s anti-bullying law • treatment/evaluation of any medical problems, secondary to bullying
Recommendation(s) for Physicians:
• screen all youth for exposure to bullying, as part of medical history, screening for all roles (target, perpetrator, witness) and types • consider screening older youth without family/friends present • ask simple, age appropriate questions • ask both general and specific questions (giving examples may be helpful)
• for younger children, ask questions like “what are lunch and recess like at your school?” or if they get teased at school (may yield more information than using the word “bullying”)
• written questions can be used in addition to verbal questions
IMPORTANT REMINDERS:
• bullied youth may feel ashamed, humiliated, and/or that they are at fault • witnesses may feel decreased self-worth if they did nothing to intervene, or joined in • youth who bully may not take responsibility for their actions, blame the victim, or have previously been a victim • perpetrators may be well connected socially or may be isolated • sibling bullying confers the same risks
What to do for a Patient who has been BULLIED?
If a patient has been bullied, physicians should consider referring the patient to one or more of the following:
• emergency room (for an acutely suicidal patient)
• mental health provider • law enforcement • school staff responsible for the implementation of bullying policy/enforcement pursuant to Matt’s Safe School Law (discussed below)
• community, school and/or local health facility anti-bullying programs (e.g., Beaumont Children’s Hospital anti-bullying program)

The patient and parents should be advised of Matt’s Safe School Law:
“Matt’s Safe School Law” was passed in 2011. Since June of 2012, the law (MCL 380.1310b) requires all public school districts in Michigan to implement policies and procedures prohibiting bullying and setting forth an appropriate response to incidents/complaints.
Added to Matt’s Safe School Law in January 2015 was Senate Bill 74 which now includes cyberbullying as a prohibited type of bullying in Michigan schools. Schools will have to report any cyberbullying, assure confidentiality of people who report, and report any instances to the State Department of Education.

School bullying policies MUST include, at a minimum:
• a statement prohibiting bullying of a pupil • a statement prohibiting retaliation or false accusation against a target of bullying, a witness, or another person with reliable information about an act of bullying • a provision indicating that all pupils are protected under the policy and that bullying is equally prohibited, without regard to its subject matter • a procedure for reporting an act of bullying • a procedure for prompt investigation of a report of violation of the policy or a related complaint • A procedure for each public school to document any prohibited incident that is reported and a procedure to report all verified incidents of bullying and the resulting consequences, including discipline and referrals
NOTE: The law also provides that parents and/or others who report bullying,
in good faith, are immune from potential liability arising out of a bullying incident.

Mandatory Reporting Requirements for Physicians:
Michigan law requires medical care providers and institutions to make police reports of all people who present suffering from violently-inflicted injury (MCL 750.411). This law applies regardless of the patient’s relationship with the person who inflicted the injury (i.e., it applies to bullying, child abuse [which has additional reporting requirements not discussed here], domestic violence and violent injuries generally).

FAQ’s Related to Filing a Report:

Under what circumstances must a report be made?
A report must be made immediately when any person suffering from any wound or other injury inflicted by a knife, gun, or other deadly weapon, or by other means of violence, comes or is brought to any hospital or pharmacy in Michigan, or is under the care of a physician or surgeon in Michigan. “Other means of violence” may include, but are not limited to, beating, biting, strangling, hitting, kicking, punching, and slapping.
Who must report? Any physician or surgeon who has a person under his or her care who is suffering from a wound or injury inflicted by any violent means MUST REPORT. Every person, firm, or corporation conducting any hospital or pharmacy in Michigan, or the person managing or in charge of the hospital or pharmacy, to which the person suffering from the wound or injury inflicted by any means of violence comes, or is brought MUST REPORT. All nursing personnel and staff are encouraged to notify a physician when such a situation exists. Failure to report is a criminal misdemeanor.

What about physician-patient privilege?
Michigan law states that the physician-patience privileges that exist under Michigan law do not apply to reports made pursuant to this law and are not valid reasons for a failure to comply with the reporting law. For this reason, reporting as required by the law is also exempt from HIPAA. Moreover, the physician-patient privilege is not a defense to a misdemeanor charge for failure to report injuries inflicted by violence.

Can a patient sue me?
The reporting law includes a specific grant of civil and criminal immunity for people who make good faith reports under this law. Any person who makes a report under this section is presumed to have acted in good faith. Of course, this immunity only applies to reporting and does not extend to any act of omission that amounts to professional malpractice.

To whom must the report be made?
The report must be made to the police department in the jurisdiction in which the hospital, pharmacy, physician, or surgeon is located. If there is no local police department, the report must be made to the county sheriff.

How must the report be made?
The report must be made by BOTH telephone and in writing.
What must be reported? The report must state the name and residence of the injured person, if known; the whereabouts of the injured person; the cause, character, and extent of the injuries; and may state the identification of the perpetrator, if known.

What may happen then?
Further investigation and prosecution, if any, will be handled by the police department and prosecutor where the violence causing the injury was committed. For this reason, in addition to the mandatory report, a patient may wish to report the violence directly to the police department in the jurisdiction where the violence occurred. The mandatory report does not ensure that arrest or prosecution will follow.

What must the patient be told?
Although the law does not require that the patient be informed about the mandatory reporting, it is recommended that the patient be informed for their personal safety and to get them involved in the process. If the patient requests that you do not report, you may explain that reporting is mandatory but limited to the information required by law.
What must be documented regarding the report? Document the fact that a report was made by phone and in writing, when the report was made, and to whom at what phone number and address. If an investigating officer is involved, note the name of the officer, badge number, report number, phone number, and any action taken. If a report to Adult or Child Protective Services is filed note this as well. Keep the original of this report in the file, and fax a copy to the local law enforcement agency. Retain the fax confirmation page with the original copy of the report.
A sample report is attached at the end of this pamphlet.

FOR MENTAL HEALTH PROFESSIONALS

Action to Protect a Patient from Harm to Self (or Others):
When a patient, who is the victim of bullying, expresses intent to harm him/herself, a mental health provider has discretion to seek hospitalization of the patient, even if the patient is not amenable to referral.

Involuntary Admission:
Under Michigan law, a patient may be involuntarily hospitalized to protect the patient or others. The law requires that the patient be determined to be a “person requiring treatment,” which, in relevant part is one of the following criteria:
1. An individual who has a mental illness, and who as a result of that mental illness can reasonably be expected within the near future to intentionally or unintentionally seriously physically injure himself, herself or another individual, and who has engaged in an act or acts or made significant threats that are substantially supportive of that expectation.
2. An individual who has mental illness, whose judgment is so impaired that he or she is unable to understand his or her need for treatment and whose continued behavior as the result of this mental illness can reasonably be expected, on the basis of competent clinical opinion, to result in significant physical harm to himself, herself, or others.
If either of these criteria are met, involuntary admission into a psychiatric hospital can be pursued. A “Petition/Application for Hospitalization” must be completed by anyone with the requisite knowledge, however, to have a patient taken into protective custody, a Clinical Certificate must also be signed by a psychologist or psychiatrist as well. Under Michigan law, a law enforcement officer who is provided with a completed Petition/Application for Hospitalization and a signed Clinical Certificate will take a patient into custody and take the patient to the appropriate pre-admission screening unit or hospital, however, when a patient expresses intent to harm others, a mandatory duty can also be triggered. A template of the Petition/Application for Hospitalization and Clinical Certificate can be located and printed from the Oakland County Medical Society website at www.ocms-mi.org/web_ government.htm:

Duty to Report:
State law requires disclosure of mental health recipient’s records to a public agency to prevent harm to other individuals, including harm that could result from bullying. Required Duty to Warn/Duty to Protect Others (MCL 330.1946)

FOR MENTAL HEALTH PROFESSIONALS

FAQ’s by Mental Health Professionals on Reporting:

Who must report?
A “mental health professional,” which includes psychiatrists, psychologists, certified social workers, social workers, social work technicians, licensed professional counselors, marriage and family therapists, and musical therapists treating a patient who communicates a threat of physical violence against a reasonably identifiable third person and has the apparent ability and intent to carry out the threat in the near future has a duty to take action. If a patient is being treated through a team in the hospital, the hospital shall designate a person to communicate the threat to necessary persons or agencies.

To whom must the action be directed?
One or more of the following must be done in a timely manner:
• hospitalize the patient or initiate proceedings to hospitalize the patients; and/or • make a reasonable attempt to communicate the threat to the third person and to the local police or county sheriff’s department where the third person lives or for the area where the patient lives, or the state police • if the threatened party is a minor or otherwise declared incompetent, in addition to the steps above, the mental health professional must notify the Department of Social Services in the county where the minor lives and also notify the minor’s custodial parent, non-custodial parent, or legal guardian, whoever is most appropriate.

How should the report be made?
The report should be made by telephone and in writing (letter, fax, email, etc.).

What must be reported?
The exact nature of the threat must be communicated.