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Bullying and suicide are inextricably linked, according to a comprehensive review of medical research published Monday. The findings suggest that cyberbullying may pose the greatest danger, which experts in the field say underscores the need for more safeguards to protect vulnerable children.

There has been considerable debate in recent years about whether young people are driven to suicide as a direct result of bullying, or as a result of underlying mental-health problems. The findings of the new study, led by Mitch van Geel of Leiden University in the Netherlands and his colleagues, suggest bullying is a risk factor in and of itself that increases the likelihood of suicide.

In an e-mail, van Geel said that some children may seek suicide as a "release or escape" or see it as "a plea for help."

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To conduct the study, researchers did a comprehensive review of the available scientific research on bullying and suicide. After examining the data from 34 studies, they found that children who experienced bullying were 2.2 times more likely to think about suicide and 2.5 times more likely to attempt it than peers who were not bullied. Children who were cyberbullied were 3.2 times more likely to contemplate suicide than their peers.

Debra Pepler, co-director of PREVNet, a federally funded national network of bullying researchers and resources, said the relationship between bullying and suicide is complex. While victims are at a higher risk for suicide, so are the adolescents who are doing the bullying. She noted that cyberbullying may be linked to higher suicide risks because of the public nature of it and the fact that online bullying can be conducted on such a wide scale over a short period of time.

The study underscores the fact that bullying has a very strong destabilizing effect on young people at a time in their lives when connections to their peers are more important than any other relationship, Pepler said. And being directly involved in any aspect of bullying should be seen as a "red flag."

"It's a sign for us that these children just aren't connected in the way that they should be to caring people in their world: caring adults who could help them navigate really complex issues; a school that is pro-active and prevents these issues."

Although there has been increased discussion about the need to put a stop to bullying, Pepler said that schools still need to adopt a system-wide approach that involves every student, teacher and classroom. Every student needs to feel they have a trusted adult they can speak to and school leaders should create an environment that recognizes bullying and puts a stop to it before it gets out of control, she said. Parents also have to develop and maintain strong relationships with their children to ensure they feel they have someone to talk to.

"A youth's sense of identity and safety and sense of self are so jeopardized if they don't have strong connections to families and school peers and others to help them put it into perspective and help them buffer the stress that comes with that," Pepler said.

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