Social Anxiety in Victimization and Perpetration of Cyberbullying and Traditional Bullying in Adolescents with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder

Round 1

Reviewer 1 Report

.

This paper refers to a cross sectional study carried out on a sample of adolescents (between the age of 11 and 18) diagnosed with autism spectrum disorder (n=219) and attention-deficit hyperactivity disorder (n=287) and their caregivers. The aim of the study was to examine the role of social anxiety in victimization and perpetration of traditional bullying and cyberbullying within these groups of teenagers. Logistic regressions were carried out to investigate the association between social anxiety and victimization/ perpetration related to the two different kind of bullying. After controlling for the effects of sex, age and autistic social impairments/ADHD symptoms the following results were found: for adolescents with ASD, social anxiety increased the risk of being a victim of cyberbulling and a perpetrator of traditional bullying; while for adolescents with ADHD, social anxiety increased the risk of being a victim of traditional bullying.

The authors also deepened the correlation between CP experienced during childhood and sleep problems during adolescence. Moreover, according to youth self-report, CP plus comorbidities conditions seems tio be related to  sleep problems during adolescence.

In general, considering the relevance of sleep health and the negative consequences of sleep problems on subject’s well-being, I appreciate the idea of exploring sleep problems during adolescence in subjects who experienced CP and comorbidities in childhood. In what follow, I also pointed out some revisions.

 

Abstract

Please mention the place of the study, age of the teenagers and the recruitment in a clinical setting.

 

Introduction

The structure of the introduction is clear and comprehensive  I would suggest checking if there is more up-to-date reference literature. Your data were collected a long time ago, the cited literature seems a bit dated, and a topic like Cyber bullying has been very updated in recent years, I therefore consider it very important to have a thorough review of the literature

Overall clear and structured introduction of the topic, describing bullying (both traditional and online) and social anxiety in relation to the specific group of adolescents considered, meaning those diagnosed with ASD and ADHD. I suggest to the authors to specify the acronyms when you refer for the first time to “comorbid depressive symptoms and/or attention-hyperactivity problems”.

“However, no study has examined the association of social anxiety with the perpetration of traditional bullying or involvement in cyberbullying” (line 93/94) . Revise this sentence, too general – for which subjects?

In regards to the sleep and sleep problems definition (theoretical framework), with the aim of improving your introduction paragraph, I think it could be necessary to expand the paragraph including a more detailed definition of sleep and most of all of sleep disorders. You rightly cited the work of Wang and colleagues (2016) however, in the methods paragraph you wrote “The sleep items from the CBCL are highly correlated with validated sleep measures such as the Child Sleep Habit Questionnaire (Becker et al., 2015), diagnoses of sleep problems (Becker et al., 2015; Wang et al., 2016)” and in this regard it might be interesting to also mention conditions related to sleep problems, for example, such as insomnia and parasomnia (Wang et al., 2016).

• McGlinchey, E. L. (2015). Sleep and adolescents. In Sleep and Affect (pp. 421-439). Academic Press.
• Bruce, E. S., Lunt, L., & McDonagh, J. E. (2017). Sleep in adolescents and young adults. Clinical medicine, 17(5), 424.

Methods

The methods were written well in general. Regarding the participants, you reported that the recruitment of adolescents was done between 2013 and 2016 for adolescents with ASD, and between 2012 and 2013 for adolescents between 2012 and 2013. I was wondering  why the author didn’t try to find a control group?

I suggest to the authors to restructure the paragraph. Inside the paragraph, I think it is not so clear the sample size subdivision compared to the numerosity reported in table 1. More in detail, it is not present a final and clear definition of the sample size for the clinical and non-clinical group. Moreover, I propose to the authors to insert the subjects’ median age also for time 8 of the study.

Recruitment characteristics, as well as exclusion criteria, are presented for both teenagers and caregivers. However, no other information is given regarding the caregivers. Even if they are not the focus of the study they completed questionnaires, so more information could be useful.

You well described the instruments used nevertheless, if we skip in the results section, it is no clear how the teachers’ answers to the questionnaires were taken into consideration for the statistical analysis. Furthermore, it is not specified how many parents (mother or father/mother+father) underwent the questionnaires. In regards to the procedure, it could be better writing a brief description of study’s times 2-7 and describe the setting used for questionnaires’ data collection. Finally, I want to ask to the authors if they have explored the presence of conduct problems at time 8 of the study, why they did not take into consideration as a covariate if subjects have embarked on a psychological support, and why did they consider maternal education as covariate. In regards to this last question, in the introduction, you rightly mentioned socioeconomic status – “confounding factors that influence both CP and sleep, such as socioeconomic status (SES), family functioning, and sex (Coté et al., 2002; Marco et al., 2012; Odgers, 2013)” – I suggest to the authors to do the same for the maternal education with the aim of supporting by scientific literature the use of this variable as a covariate

• Statistical analysis

I suggest describing your dependent variable in a separate paragraph.

Specify the reference category of your dependent variable used for multivariate logistic regression, and I suggest adding a better explanation about how the model was developed. It is not intuitive.

I propose to test your independent variable by using the Chi-squared test before proceeding with the logistic regression.

I suggest changing ‘multivariate logistic regression’ with ‘multinomial logistic regression’. It is unappropriated, there is a subtle difference, but it exists. 

• Results

Please check if the asterisks, related to statistical significance, reported on tables 2 and 3 are correct.

Table 1: Was it not possible to consider other demographic characteristics? [It was reported only gender and age]. In addition, I would propose to make the table clearer and more intuitive.

 Specifically, I think you have to specify the meaning of means and percentages regarding the income, maternal education, medication, sleep (self), and sleep (parent). For example, I did not understand what it means Sleep (self)=1.78(1.53) among CP group. In your subparagraph “Sleep”, you wrote “Total parent and self-report sleep scores were utilized in separate analysis, with higher scores indicating more sleep problems” however, it is not reported a cut-off value (if available) or values’ range.  For bypassing this inconsistence, I suggest to the authors to better describe the values’ meaning of variables examined inserting cut-off or values’ range inside the measures paragraph or as note of the table. Moreover, I think it could be also interesting doing, if possible, a descriptive statistical analysis for observing percentages related to the different kind of sleep problems assessed by YSR among CP, CP plus D, CP plus A, and CP plus D and A with the aim of evaluating if comorbidities also exacerbated different sleep problems. 

Comorbidity with other diseases (e.g. conduct disorder, oppositional defiant disorder or depressive symptoms) may influence relationship between social anxiety and traditional bullying or cyberbullying. Have you considered any comorbidities of participants other than intellectual disability, schizophrenia, bipolar disorder, difficulty communicating and/or cognitive deficits? If not, you may insert this consideration on limitations section.

Please explain better how do you asses the presence of intellectual disability, schizophrenia, bipolar disorder, difficulty communicating and/or cognitive deficits.

Could be interesting analyse if there are adolescents who are both bullying victims and perpetrators and observe them another possible logistic model.

 

Discussion and Conclusion

The reading is fluid also thanks to the subdivision into two distinct paragraphs for the two different pathologies. However, I propose to expand the discussion and the conclusion.

Appreciated that the discussion of the results is divided between victimization and perpetration of bullying, so to give specific interpretation of the results for each concept. It would be advisable to expand the discussion and give further interpretations on the found associations and absence of associations.

In limitation. To add that the participation of the study was voluntary, therefore also for this reason not fully generalizable.
Self-reported bullying experiences are taken into consideration. Are teenagers diagnosed with ASD and ADHD able to evaluate bullying events through the selected questionnaires?

In general, discussion section is a little meagre and it could be enriched with a deeper explanation of results and with more consideration about implication.

In the paragraph “Social Anxiety and Victimization of Cyberbullying and Traditional Bullying” (line 254), you affirm that any significant association between social anxiety and cyberbullying victimization was detected. Please, provide a possible explanation or hypothesis for this result.

In the paragraph “Social Anxiety and Perpetration of Cyberbullying and Traditional Bullying”, please, provide an explanation or hypothesis for the not significant association between social anxiety and traditional bullying perpetration among adolescents with ADHD.

I appreciate the link between CP, sleep problems, and risky behaviours such as substance use. Nevertheless, considering the potential link between sleep problems and substance use (Shibley, Malcolm, & Veatch, 2008; Nguyen‐Louie et al., 2018) and substance use and CP (Kuperman et al., 2001; Wu et al., 2010), I suggest to the authors to deep elaborate and speculate on an eventual intercorrelation between these three different factors. In line with that, concerning the associations emerged between higher levels of sleep problems and CP+D+A, I propose to the authors to allude to the effects of depression and ADHD on sleep. In what way comorbidities (CP+D+A) could have exacerbated higher levels of sleep problems compared to the other CP groups?

• Shibley, H. L., Malcolm, R. J., & Veatch, L. M. (2008). Adolescents with insomnia and substance abuse: consequences and comorbidities. Journal of Psychiatric Practice®, 14(3), 146-153.
• Nguyen‐Louie, T. T., Brumback, T., Worley, M. J., Colrain, I. M., Matt, G. E., Squeglia, L. M., & Tapert, S. F. (2018). Effects of sleep on substance use in adolescents: a longitudinal perspective. Addiction biology, 23(2), 750-760.

 

In 4.1 mention of further studies are warranted. Useful to mention this concept again in the conclusion and add how the overall results of the study could help expand literature. Underline the strengths of the results and how can help this specific population of teenagers.

It was briefly mentioned in the conclusion possible interventions derived by these results. Please expand what you mean with “social skill training”

“For adolescents with ASD and social anxiety, potential cyberbullying victimization must be detected early and stopped.” (line 290/291). Rephrase the sentence, not fully fitting.

Author Response

Reviewer 1

We appreciate your valuable comments. As discussed below, we revised our manuscript with underlines based on your suggestions. However, we found that some comments (Comments 3, 5, 7, 9, 15, and 24) seemed not be made for our manuscript; therefore, we did not respond to these sex comments. Please let us know if we need to provide anything else regarding this revision.

 

Comment 1

Abstract

Please mention the place of the study, age of the teenagers and the recruitment in a clinical setting.

Response

Thank for your suggestion. We added the place of the study (Taiwan), age of the teenagers (11-18 years old) and the recruitment in a clinical setting (“be recruited from the child psychiatry outpatient clinics”) into Abstract. Please refer to line 21-23.

 

Comment 2

Introduction

I would suggest checking if there is more up-to-date reference literature. Your data were collected a long time ago, the cited literature seems a bit dated, and a topic like Cyber bullying has been very updated in recent years, I therefore consider it very important to have a thorough review of the literature

Response

Thank you for your suggestion. We reviewed the studies on bullying involvement in adolescents with ASD and ADHD and cited 14 studies published in recent 5 years listed below into the revised manuscript.

1. Dawson, A.E.; Wymbs, B.T.; Evans, S.W.; DuPaul, G.J. Exploring how adolescents with ADHD use and interact with technology. J Adolesc. 2019, 71, 119-137. doi: 10.1016/j.adolescence.2019.01.004.
2. Hennig,; Jaya, E.S.; Lincoln, T.M. Bullying mediates between attention-deficit/hyperactivity disorder in childhood and psychotic experiences in early adolescence. Schizophr Bull. 2017, 43, 1036-1044. doi: 10.1093/schbul/sbw139.
3. Hoover, D.W.; Kaufman, J. Adverse childhood experiences in children with autism spectrum disorder. Curr Opin Psychiatry. 2018, 31, 128-132. doi: 10.1097/YCO.0000000000000390.
4. Murray, A.L.; Zych, I.; Ribeaud, D.; Eisner, M. Developmental relations between ADHD symptoms and bullying perpetration and victimization in adolescence. Aggress Behav. 2021, 47, 58-68. doi: 10.1002/ab.21930.
5. Ochi, M.; Kawabe, K.; Ochi, S.; Miyama, T.; Horiuchi, F.; Ueno, S.I. School refusal and bullying in children with autism spectrum disorder. Child Adolesc Psychiatry Ment Health. 2020, 14, 17. doi: 10.1186/s13034-020-00325-7.
6. Tipton-Fisler, L.A.; Rodriguez, G.; Zeedyk, S.M.; Blacher, J. Stability of bullying and internalizing problems among adolescents with ASD, ID, or typical development. Res Dev Disabil. 2018, 80, 131-141. doi: 10.1016/j.ridd.2018.06.004.
7. Banneyer, K.N.; Bonin, L.; Price, K.; Goodman, W.K.; Storch, E.A. Cognitive behavioral therapy for childhood anxiety disorders: A review of recent advances. Curr Psychiatry Rep. 2018, 20, 65. doi: 10.1007/s11920-018-0924-9.
8. da Silva, J.L.; de Oliveira, W.A.; Braga, I.F.; Farias, M.S.; da Silva Lizzi, E.A.; Gonçalves, M.F.; Pereira, B.O.; Silva, M.A. The effects of a skill-based intervention for victims of bullying in Brazil. Int J Environ Res Public Health. 2016, 13, 1042. doi: 10.3390/ijerph13111042.
9. Hutson, E.; Kelly, S.; Militello, L.K. Systematic review of cyberbullying interventions for youth and parents with implications for evidence-based practice. Worldviews Evid Based Nurs. 2018, 15, 72-79. doi: 10.1111/wvn.12257.
10. Liu, M.J.; Ma, L.Y.; Chou, W.J.; Chen, Y.M.; Liu, T.L.; Hsiao, R.C.; Hu, H.F.; Yen, C.F. Effects of theory of mind performance training on reducing bullying involvement in children and adolescents with high-functioning autism spectrum disorder. PLoS One. 2018, 13, e0191271. doi: 10.1371/journal.pone.0191271.
11. Sciberras, E.; Mulraney, M.; Anderson, V.; Rapee, R.M.; Nicholson, J.M.; Efron, D.; Lee, K.; Markopoulos, Z.; Hiscock, H. Managing anxiety in children with ADHD using cognitive-behavioural therapy: a pilot randomised controlled trial. J Atten Disord. 2018, 22, 515–520. doi: 10.1177/1087054715584054.
12. Skeen,; Laurenzi, C.A.; Gordon, S.L.; du Toit, S.; Tomlinson, M.; Dua, T.; Fleischmann, A.; Kohl, K.; Ross, D.; Servili, C.; et al. Adolescent mental health program components and behavior risk reduction: A meta-analysis. Pediatrics. 2019, 144, e20183488. doi: 10.1542/peds.2018-3488.
13. Novin, S.; Broekhof, E.; Rieffe, C. Bidirectional relationships between bullying, victimization and emotion experience in boys with and without autism. 2019, 23, 796-800. doi: 10.1177/1362361318787446.
14. Becker, S.P.; Mehari, K.R.; Langberg, J.M.; Evans, S.W. Rates of peer victimization in young adolescents with ADHD and associations with internalizing symptoms and self-esteem. Eur Child Adolesc Psychiatry. 2017, 26, 201-214. doi: 10.1007/s00787-016-0881-y.

 

Comment 3

I suggest to the authors to specify the acronyms when you refer for the first time to “comorbid depressive symptoms and/or attention-hyperactivity problems”.

Response

This comment seemed not be made for our manuscript.

 

Comment 4

“However, no study has examined the association of social anxiety with the perpetration of traditional bullying or involvement in cyberbullying” (line 93/94) . Revise this sentence, too general – for which subjects?

Response

We added “among adolescents” into this sentence. Please refer to line 103.

 

Comment 5

In regards to the sleep and sleep problems definition (theoretical framework), with the aim of improving your introduction paragraph, I think it could be necessary to expand the paragraph including a more detailed definition of sleep and most of all of sleep disorders. You rightly cited the work of Wang and colleagues (2016) however, in the methods paragraph you wrote “The sleep items from the CBCL are highly correlated with validated sleep measures such as the Child Sleep Habit Questionnaire (Becker et al., 2015), diagnoses of sleep problems (Becker et al., 2015; Wang et al., 2016)” and in this regard it might be interesting to also mention conditions related to sleep problems, for example, such as insomnia and parasomnia (Wang et al., 2016).

• McGlinchey, E. L. (2015). Sleep and adolescents. In Sleep and Affect (pp. 421-439). Academic Press.
• Bruce, E. S., Lunt, L., & McDonagh, J. E. (2017). Sleep in adolescents and young adults. Clinical medicine, 17(5), 424.

Response

This comment seemed not be made for our manuscript.

 

Comment 6

Methods

Regarding the participants, you reported that the recruitment of adolescents was done between 2013 and 2016 for adolescents with ASD, and between 2012 and 2013 for adolescents between 2012 and 2013. I was wondering why the author didn’t try to find a control group?

Response

We agree that a control group can provide more information for the association between social anxiety and cyberbullying and traditional bullying involvement. We added it as one of limitations of this study as below into the revised manuscript. Please refer to line 350-352.

“Fourth, whether the associations between social anxiety and cyberbullying and traditional bullying involvement found in adolescents with ASD and ADHD found in this study exist in adolescents without ASD and ADHD warrants further study.”

 

Comment 7

I suggest to the authors to restructure the paragraph. Inside the paragraph, I think it is not so clear the sample size subdivision compared to the numerosity reported in table 1. More in detail, it is not present a final and clear definition of the sample size for the clinical and non-clinical group. Moreover, I propose to the authors to insert the subjects’ median age also for time 8 of the study.

Response

This comment seemed not be made for our manuscript.

 

Comment 8

Recruitment characteristics, as well as exclusion criteria, are presented for both teenagers and caregivers. However, no other information is given regarding the caregivers. Even if they are not the focus of the study they completed questionnaires, so more information could be useful.

Response

Thank you for your suggestion. We added the data of sex, age and marriage status in caregivers into Table 1. Please refer to line 231.

 

Comment 9

You well described the instruments used nevertheless, if we skip in the results section, it is no clear how the teachers’ answers to the questionnaires were taken into consideration for the statistical analysis. Furthermore, it is not specified how many parents (mother or father/mother+father) underwent the questionnaires. In regards to the procedure, it could be better writing a brief description of study’s times 2-7 and describe the setting used for questionnaires’ data collection. Finally, I want to ask to the authors if they have explored the presence of conduct problems at time 8 of the study, why they did not take into consideration as a covariate if subjects have embarked on a psychological support, and why did they consider maternal education as covariate. In regards to this last question, in the introduction, you rightly mentioned socioeconomic status – “confounding factors that influence both CP and sleep, such as socioeconomic status (SES), family functioning, and sex (Coté et al., 2002; Marco et al., 2012; Odgers, 2013)” – I suggest to the authors to do the same for the maternal education with the aim of supporting by scientific literature the use of this variable as a covariate

Response

This comment seemed not be made for our manuscript.

 

Comment 10

I suggest describing your dependent variable in a separate paragraph.

Response

We descrived the dependent and independent variables in the paragraphs subtitiled in “2.2. Measures for Dependent Variables” and “2.3. Measures for Independent Variables”. Please refer to line 142 and 168 .

 

Comment 11

Specify the reference category of your dependent variable used for multivariate logistic regression, and I suggest adding a better explanation about how the model was developed. It is not intuitive. I propose to test your independent variable by using the Chi-squared test before proceeding with the logistic regression.

Response

Thank you for your suggestion. We added the results of Chi-square and t tests into the revised manuscript. We also added the explanation about how the multinomial logistic regression analysis models were developed. The changes were described below.

Methods

“The differences in demographic characteristics, autistic social impairment, ADHD and oppositional defiant symptoms, and social anxiety between adolescents with various types of bullying involvements were examined using Chi-square and t tests. The variables with statistical significance in Chi-square and t tests were entered into logistic regression analysis to examine their associations with bullying involvement.” Please refer to line 213-218.

Results

“Table 2 presents the results of Chi-square and t tests comparing demographic characteristics, autistic social impairment, ADHD and oppositional defiant symptoms, and social anxiety between adolescents who involved and did not involve in cyberbullying. The results showed that ASD victims of cyberbullying had greater social anxiety than nonvictims, whereas no difference in social anxiety between ASD perpetrators and nonperpetrators of cyberbullying was found. No difference in social anxiety between ADHD adolescents who involved in and did not involve in cyberbullying was found. Moreover, ASD cyberbullying perpetrators were older than nonperpetrators, whereas no difference in age between ASD cyberbullying victims and nonvictims was found. ADHD adolescents who involved in cyberbullying were older than those who did not involve.” Please refer to line 233-242.

“Table 3 presents the results of Chi-square and t tests comparing demographic characteristics, autistic social impairment, ADHD and oppositional defiant symptoms, and social anxiety between adolescents who involved and did not involve in traditional bullying. The results showed that ASD victims and perpetrators of traditional bullying had greater social anxiety than did nonvictims and nonperpetrators. ADHD victims of traditional bullying had greater social anxiety than nonvictims, whereas no difference in social anxiety between ADHD perpetrators and nonperpetrators of traditional bullying was found. Moreover, ASD perpetrators of traditional bullying had greater autistic social impairment than did nonperpetrators.” Please refer to line 247-255.

“The associations of social anxiety with cyberbullying and traditional bullying involvement were further examined using logistic regression analysis. Because that the results of t tests did not show significant difference in social anxiety between cyberbullying perpetrators and nonperpetrators in adolescents with ASD or ADHD (Table 2), the associations of social anxiety with cyberbullying perpetration was not examined using logistic regression analysis. Moreover, the result of a t test showed significant differences in social anxiety and autistic social impairment between ASD perpetrators and nonperpetrators of traditional bullying (Table 3), social anxiety and autistic social impairment were entered into multinomial logistic regression to examine their associations with traditional bullying perpetration.” Please refer to line 260-269.

 

Comment 12

I suggest changing ‘multivariate logistic regression’ with ‘multinomial logistic regression’. It is unappropriated, there is a subtle difference, but it exists. 

Response

We changed ‘multivariate logistic regression’ with ‘multinomial logistic regression’ in the revised manuscript. Please refer to line 268.

 

Comment 13

Results

Please check if the asterisks, related to statistical significance, reported on tables 2 and 3 are correct.

Response

In the revised manuscript we described the values of p directly instead of using the asterisk. Please refer to Tables 2 (line 245), 3 (line 258) and 4 (line 273).

 

Comment 14

Table 1: Was it not possible to consider other demographic characteristics? [It was reported only gender and age]. In addition, I would propose to make the table clearer and more intuitive.

Response

Thank you for your suggestion. We added parental marriage status (married and live together vs. divorced or separated) into the revised manuscript and examined the differences in parental marriage status between adolescents with various bullying involvement.

“The present study examined adolescents’ age, sex, and parental marriage status (married and live together vs. divorced or separated).” Please refer to line 201-202.

Please refer to Tables 1 (line 231), 2 (line 245) and 3 (line 258).

 

Comment 15

Specifically, I think you have to specify the meaning of means and percentages regarding the income, maternal education, medication, sleep (self), and sleep (parent). For example, I did not understand what it means Sleep (self)=1.78(1.53) among CP group. In your subparagraph “Sleep”, you wrote “Total parent and self-report sleep scores were utilized in separate analysis, with higher scores indicating more sleep problems” however, it is not reported a cut-off value (if available) or values’ range.  For bypassing this inconsistence, I suggest to the authors to better describe the values’ meaning of variables examined inserting cut-off or values’ range inside the measures paragraph or as note of the table. Moreover, I think it could be also interesting doing, if possible, a descriptive statistical analysis for observing percentages related to the different kind of sleep problems assessed by YSR among CP, CP plus D, CP plus A, and CP plus D and A with the aim of evaluating if comorbidities also exacerbated different sleep problems. 

Response

This comment seemed not be made for our manuscript.

 

Comment 16

Comorbidity with other diseases (e.g. conduct disorder, oppositional defiant disorder or depressive symptoms) may influence relationship between social anxiety and traditional bullying or cyberbullying. Have you considered any comorbidities of participants other than intellectual disability, schizophrenia, bipolar disorder, difficulty communicating and/or cognitive deficits? If not, you may insert this consideration on limitations section.

Response

Thank you for your suggestion. We added oppositional defiant symptoms rated by caregivers on the SNAP-IV into the revised manuscript and examined the differences in oppositional defiant symptoms between adolescents with various bullying involvement.

“Moreover, caregivers of adolescents with ASD and ADHD also rate their adolescents’ oppositional defiant symptoms on the subscale of the SNAP-IV. A high total score of the subscale indicates greater oppositional defiant symptoms. The Cronbach’s α values of the oppositional defiant subscale were 0.92 in adolescents with ASD and 0.91 in adolescents with ADHD.” Please refer to line 195-199.

Please refer to Tables 1 (line 231), 2 (line 245) and 3 (line 258).

 

Comment 17

Please explain better how do you asses the presence of intellectual disability, schizophrenia, bipolar disorder, difficulty communicating and/or cognitive deficits.

Response

Thank you for your suggestion. We detected adolescents’ intellectual disability, schizophrenia, bipolar disorder, difficulty communicating and cognitive deficits based on the clinical diagnosis of child psychiatrists and chart records. Child psychiatrists also screened caregivers’ cognitive difficulties. We added the explanations in the revised manuscript. please refer to line 133-136.

 

Comment 18

Could be interesting analyse if there are adolescents who are both bullying victims and perpetrators and observe them another possible logistic model.

Response

Mental health of adolescents who are both victims and perpetrators of bullying really need attention. However, there were small numbers of victim-perpetrators in this study. Therefore, we added it as one of limitations of this study and addressed that the associations of social anxiety with involvement in cyberbullying and traditional bullying warrant further study on larger samples of adolescents ASD ad ADHD. Please refer to line 353-359.

“Fifth, research has found that compared with pure victims and perpetrators (victim-perpetrators) of bullying, those who are both victims and perpetrators of bullying have worse mental health [65-68] and social function [67]. However, there were small numbers of victim-perpetrators in this study; for example, only 4.6% of adolescents with ASD were victim-perpetrators of cyberbullying. The associations of social anxiety with involvement in cyberbullying and traditional bullying warrant further study on larger samples of adolescents ASD ad ADHD.”

 

Comment 19 

Discussion and Conclusion

It would be advisable to expand the discussion and give further interpretations on the found associations and absence of associations. In general, discussion section is a little meagre and it could be enriched with a deeper explanation of results and with more consideration about implication.

Response

Thank you for your suggestion. We added more discussion about the results and the implication of this study as below.

4.1.

“...In order to stop the vicious cycle, both social anxiety and traditional bullying victimization should be the targets of intervention. Skill-based interventions address making friendships, self-control, emotional expressiveness, empathy, assertiveness and solution of interpersonal problems may reduce the risk of traditional bullying victimization [55]. Specifically, the effectiveness of the theory of mind performance training has been approved on reducing bullying victimization in children and adolescents with high-functioning ASD [56]. Regarding social anxiety, exposure-based cognitive behavioral therapy (CBT) is a well-established intervention with positive evidence to relieve social anxiety [57]. Especially, specific programs have been developed to meet specific needs of children with comorbid ASD and anxiety [58,59]. Research has also identified interpersonal skills and emotional regulation as the two effective program components of interventions to promote mental health during adolescence [60].

“...Socially anxious adolescents lacking the adequate social skills for peer interaction in the real world may escape from their social anxieties online. However, spending much time on the internet may increase the risk of exposure to cyberbullying victimization [61] and aggravate adolescents’ social anxiety. In addition to applying specific CBT programs to reduce social anxiety in youth with ASD [58], intervention programs for cyberbullying are important. Education on cyberbullying for the adolescent, coping skills, empathy training, communication and social skills, and digital citizenship are the most frequently used intervention components [62].

“...It is possible that adolescents with ADHD may have different abilities of detecting social clues on the internet, frequencies and qualities of peer interactions, and internet activities compared with those with ASD, as well as that these differences resulted in various associations between social anxiety and cyberbullying victimization between adolescents with ASD and ADHD. Further study is warranted to examine possible etiologies that may account for the disparate results.”

Please refer to line 290-319.

4.2.

“Research proposed that traditional bullying perpetration provokes negative reactions from others, resulting in further social exclusion and increased social anxiety for the perpetrators [27]. It is possible that the social anxiety caused by peer rejections after perpetrating traditional bullying develops only in adolescents with ASD but not in those with ADHD. However, it is also possible that social anxiety may trigger perpetration of traditional bullying in adolescents with ASD but not in those with ADHD. Further study is warranted to examine the hypothesis.”

Please refer to line 324-331.

 

Comment 20

In limitation. To add that the participation of the study was voluntary, therefore also for this reason not fully generalizable.

Response

Thank you for your suggestion. We listed it as one of limitations as below into the revised manuscript. Please refer to line 350-353.

“Fourth, whether the associations between social anxiety and cyberbullying and traditional bullying involvement found in adolescents with ASD and ADHD found in this study exist in adolescents without ASD and ADHD warrants further study.”

 

Comment 21
Self-reported bullying experiences are taken into consideration. Are teenagers diagnosed with ASD and ADHD able to evaluate bullying events through the selected questionnaires?

Response

Thank you for your reminding. The self-reports are the common method to detect bullying involvement in adolescents with ASD and ADHD. We also excluded adolescents with intellectual disability and significant cognitive impairment to reduce the possibility of misunderstanding the questionnaires. However, we agree that other information sources are needed to confirm the accuracy of the self-reported bullying involvement. We added the explanation as below into the revised manuscript. Please refer to line 344-348.

“Moreover, the self-reports are the common method to detect bullying involvement in adolescents with ASD [63] and ADHD [64]. We also excluded adolescents with intellectual disability and significant cognitive impairment to reduce the possibility of misunderstanding the questionnaires. However, further information from teachers and peers may be useful to determine the accuracy of self-report on bullying involvement in schools.”

 

Comment 22

In the paragraph “Social Anxiety and Victimization of Cyberbullying and Traditional Bullying” (line 254), you affirm that any significant association between social anxiety and cyberbullying victimization was detected. Please, provide a possible explanation or hypothesis for this result.

Response

We added the hypothesis as below into the revised manuscript. Please refer to line 304-311.

“Socially anxious adolescents lacking the adequate social skills for peer interaction in the real world may escape from their social anxieties online. However, spending much time on the internet may increase the risk of exposure to cyberbullying victimization [61] and aggravate adolescents’ social anxiety. In addition to applying specific CBT programs to reduce social anxiety in youth with ASD [58], intervention programs for cyberbullying are important. Education on cyberbullying for the adolescent, coping skills, empathy training, communication and social skills, and digital citizenship are the most frequently used intervention components [62].”

 

Comment 23

In the paragraph “Social Anxiety and Perpetration of Cyberbullying and Traditional Bullying”, please, provide an explanation or hypothesis for the not significant association between social anxiety and traditional bullying perpetration among adolescents with ADHD.

Response

We added the hypothesis as below into the revised manuscript. Please refer to line 324-331.

“Research proposed that traditional bullying perpetration provokes negative reactions from others, resulting in further social exclusion and increased social anxiety for the perpetrators [27]. It is possible that the social anxiety caused by peer rejections after perpetrating traditional bullying develops only in adolescents with ASD but not in those with ADHD. However, it is also possible that social anxiety may trigger perpetration of traditional bullying in adolescents with ASD but not in those with ADHD. Further study is warranted to examine the hypothesis.”

 

Comment 24

I appreciate the link between CP, sleep problems, and risky behaviours such as substance use. Nevertheless, considering the potential link between sleep problems and substance use (Shibley, Malcolm, & Veatch, 2008; Nguyen‐Louie et al., 2018) and substance use and CP (Kuperman et al., 2001; Wu et al., 2010), I suggest to the authors to deep elaborate and speculate on an eventual intercorrelation between these three different factors. In line with that, concerning the associations emerged between higher levels of sleep problems and CP+D+A, I propose to the authors to allude to the effects of depression and ADHD on sleep. In what way comorbidities (CP+D+A) could have exacerbated higher levels of sleep problems compared to the other CP groups?

• Shibley, H. L., Malcolm, R. J., & Veatch, L. M. (2008). Adolescents with insomnia and substance abuse: consequences and comorbidities. Journal of Psychiatric Practice®, 14(3), 146-153.
• Nguyen‐Louie, T. T., Brumback, T., Worley, M. J., Colrain, I. M., Matt, G. E., Squeglia, L. M., & Tapert, S. F. (2018). Effects of sleep on substance use in adolescents: a longitudinal perspective. Addiction biology, 23(2), 750-760.

Response

This comment seemed not be made for our manuscript.

 

Comment 25

In 4.1 mention of further studies are warranted. Useful to mention this concept again in the conclusion and add how the overall results of the study could help expand literature. Underline the strengths of the results and how can help this specific population of teenagers.

Response

Thank you for your suggestion. We strengthened the contents of Conclusion by adding new contents as below. Please refer to line 365-374.

“It is not easy for caregivers and teachers to detect bullying victimization occurred in the cyberworld; therefore, social anxiety can be used as an indicator for early detecting and stopping bullying victimization among adolescents with ASD. CBT, behavioral intervention, and theory of mind performance training that may reduce the severities of social anxiety and bullying involvement should be integrated into intervention programs for children and adolescents with ASD and ADHD. Further study is warranted to examine possible etiologies such as the characteristics of social interactions and the contexts of internet activities and interactions that may account for the disparate results of the associations between social anxiety and bullying involvement between adolescents with ASD and those with ADHD.”

 

Comment 26

It was briefly mentioned in the conclusion possible interventions derived by these results. Please expand what you mean with “social skill training”

Response

We expanded the description for “social skill training” as below in the revised manuscript.

“In order to stop the vicious cycle, both social anxiety and traditional bullying victimization should be the targets of intervention. Skill-based interventions address making friendships, self-control, emotional expressiveness, empathy, assertiveness and solution of interpersonal problems may reduce the risk of traditional bullying victimization [55]. Specifically, the effectiveness of the theory of mind performance training has been approved on reducing bullying victimization in children and adolescents with high-functioning ASD [56]. Regarding social anxiety, exposure-based cognitive behavioral therapy (CBT) is a well-established intervention with positive evidence to relieve social anxiety [57]. Especially, specific programs have been developed to meet specific needs of children with comorbid ASD and anxiety [58,59]. Research has also identified interpersonal skills and emotional regulation as the two effective program components of interventions to promote mental health during adolescence [60].” Please refer to line 290-302.

“CBT, behavioral intervention, and theory of mind performance training that may reduce the severities of social anxiety and bullying involvement should be integrated into intervention programs for children and adolescents with ASD and ADHD.” Please refer to line 367-370.

 

Comment 27

“For adolescents with ASD and social anxiety, potential cyberbullying victimization must be detected early and stopped.” (line 290/291). Rephrase the sentence, not fully fitting.

Response

We rewrote this sentence as below. Please refer to line 365-367.

“It is not easy for caregivers and teachers to detect bullying victimization occurred in the cyberworld; therefore, social anxiety can be used as an indicator for early detecting and stopping bullying victimization among adolescents with ASD”

Reviewer 2 Report

Overall, this is a well written and insightful manuscript. I do have a few queries that warrant further interrogation before I feel that the paper should be published. First, could the authors consider putting more detail in the abstract relating to their results e.g. significance levels for associations / Odds Ratios perhaps? The literature review is, on the whole, up to date, well structured and logical. However, there are a few references from the late 1990s in there - these are now over 20 years old and therefore I wonder if the study team could update these citations or acknowledge that this work is dated in some way?

Could the authors explain why the data was collected quite a long time ago? Is there a particular reason for delay in dissemination?

Finally, why were caregivers invited to participate where the focus was on adolescents? They are not mentioned anywhere in the results or discussion. Could the study team clarify this in the paper please? There should be a rationale for this somewhere and this should possibly be mentioned in the abstract, which suggests data was collected only from adolescents? There is also no mention of collecting data from caregivers in the aims of the study - this warrants tightening.

Author Response

Reviewer 2

We appreciate your valuable comments. As discussed below, we revised our manuscript with underlines based on your suggestions. Please let us know if we need to provide anything else regarding this revision.

 

Comment 1

Overall, this is a well written and insightful manuscript. I do have a few queries that warrant further interrogation before I feel that the paper should be published. First, could the authors consider putting more detail in the abstract relating to their results e.g. significance levels for associations / Odds Ratios perhaps?

Response

Thank for your comment. We added the values of Odds Ratios and their 95% Confidence Interval into Abstract. Please refer to line 27-31.

“The results indicated that after the effects of sex, age, and autistic social impairment were controlled, social anxiety increased the risk of being a victim of cyberbullying (Odds Ratios [OR] = 1.048; 95% Confidence Interval [CI]: 1.013-1.084), a victim of traditional bullying (OR = 1.066; 95% CI: 1.036-1.097), and a perpetrator of traditional bullying (OR = 1.061; 95% CI: 1.027-1.096) in adolescents with ASD. After the effects of sex, age, and ADHD symptoms were controlled, social anxiety increased the risk of being a victim of traditional bullying in adolescents with ADHD (OR = 1.067; 95% CI: 1.039-1.096).”

 

Comment 2

The literature review is, on the whole, up to date, well structured and logical. However, there are a few references from the late 1990s in there - these are now over 20 years old and therefore I wonder if the study team could update these citations or acknowledge that this work is dated in some way?

Response

Thank you for your suggestion. We reviewed the studies on bullying involvement in adolescents with ASD and ADHD and cited 14 studies published in recent 5 years listed below into the revised manuscript.

1. Dawson, A.E.; Wymbs, B.T.; Evans, S.W.; DuPaul, G.J. Exploring how adolescents with ADHD use and interact with technology. J Adolesc. 2019, 71, 119-137. doi: 10.1016/j.adolescence.2019.01.004.
2. Hennig,; Jaya, E.S.; Lincoln, T.M. Bullying mediates between attention-deficit/hyperactivity disorder in childhood and psychotic experiences in early adolescence. Schizophr Bull. 2017, 43, 1036-1044. doi: 10.1093/schbul/sbw139.
3. Hoover, D.W.; Kaufman, J. Adverse childhood experiences in children with autism spectrum disorder. Curr Opin Psychiatry. 2018, 31, 128-132. doi: 10.1097/YCO.0000000000000390.
4. Murray, A.L.; Zych, I.; Ribeaud, D.; Eisner, M. Developmental relations between ADHD symptoms and bullying perpetration and victimization in adolescence. Aggress Behav. 2021, 47, 58-68. doi: 10.1002/ab.21930.
5. Ochi, M.; Kawabe, K.; Ochi, S.; Miyama, T.; Horiuchi, F.; Ueno, S.I. School refusal and bullying in children with autism spectrum disorder. Child Adolesc Psychiatry Ment Health. 2020, 14, 17. doi: 10.1186/s13034-020-00325-7.
6. Tipton-Fisler, L.A.; Rodriguez, G.; Zeedyk, S.M.; Blacher, J. Stability of bullying and internalizing problems among adolescents with ASD, ID, or typical development. Res Dev Disabil. 2018, 80, 131-141. doi: 10.1016/j.ridd.2018.06.004.
7. Banneyer, K.N.; Bonin, L.; Price, K.; Goodman, W.K.; Storch, E.A. Cognitive behavioral therapy for childhood anxiety disorders: A review of recent advances. Curr Psychiatry Rep. 2018, 20, 65. doi: 10.1007/s11920-018-0924-9.
8. da Silva, J.L.; de Oliveira, W.A.; Braga, I.F.; Farias, M.S.; da Silva Lizzi, E.A.; Gonçalves, M.F.; Pereira, B.O.; Silva, M.A. The effects of a skill-based intervention for victims of bullying in Brazil. Int J Environ Res Public Health. 2016, 13, 1042. doi: 10.3390/ijerph13111042.
9. Hutson, E.; Kelly, S.; Militello, L.K. Systematic review of cyberbullying interventions for youth and parents with implications for evidence-based practice. Worldviews Evid Based Nurs. 2018, 15, 72-79. doi: 10.1111/wvn.12257.
10. Liu, M.J.; Ma, L.Y.; Chou, W.J.; Chen, Y.M.; Liu, T.L.; Hsiao, R.C.; Hu, H.F.; Yen, C.F. Effects of theory of mind performance training on reducing bullying involvement in children and adolescents with high-functioning autism spectrum disorder. PLoS One. 2018, 13, e0191271. doi: 10.1371/journal.pone.0191271.
11. Sciberras, E.; Mulraney, M.; Anderson, V.; Rapee, R.M.; Nicholson, J.M.; Efron, D.; Lee, K.; Markopoulos, Z.; Hiscock, H. Managing anxiety in children with ADHD using cognitive-behavioural therapy: a pilot randomised controlled trial. J Atten Disord. 2018, 22, 515–520. doi: 10.1177/1087054715584054.
12. Skeen,; Laurenzi, C.A.; Gordon, S.L.; du Toit, S.; Tomlinson, M.; Dua, T.; Fleischmann, A.; Kohl, K.; Ross, D.; Servili, C.; et al. Adolescent mental health program components and behavior risk reduction: A meta-analysis. Pediatrics. 2019, 144, e20183488. doi: 10.1542/peds.2018-3488.
13. Novin, S.; Broekhof, E.; Rieffe, C. Bidirectional relationships between bullying, victimization and emotion experience in boys with and without autism. 2019, 23, 796-800. doi: 10.1177/1362361318787446.
14. Becker, S.P.; Mehari, K.R.; Langberg, J.M.; Evans, S.W. Rates of peer victimization in young adolescents with ADHD and associations with internalizing symptoms and self-esteem. Eur Child Adolesc Psychiatry. 2017, 26, 201-214. doi: 10.1007/s00787-016-0881-y.

 

Comment 3

Could the authors explain why the data was collected quite a long time ago? Is there a particular reason for delay in dissemination?

Response

The data analyzed in this study did be collected quite a long time ago. The two papers examining the association between social anxiety and bullying involvement in adolescents with ASD (van Schalkwyk, G.; Smith, I.C.; Silverman, W.K.; Volkmar, F.R. Bullying and anxiety in high-functioning adolescents with ASD. J Autism Dev Disord. 2018, 48, 1819-1824) and ADHD (Koyuncu, A.; Alkin, T.; Tukel, R. Development of social anxiety disorder secondary to attention deficit/hyperactivity disorder (the developmental hypothesis). Early Interv Psychiatry 2018, 12, 269-272) inspired us. We found few published papers examining this topic are few; therefore, we analyze our data and submitted the results.

 

Comment 4

Finally, why were caregivers invited to participate where the focus was on adolescents? They are not mentioned anywhere in the results or discussion. Could the study team clarify this in the paper please? There should be a rationale for this somewhere and this should possibly be mentioned in the abstract, which suggests data was collected only from adolescents? There is also no mention of collecting data from caregivers in the aims of the study - this warrants tightening.

Response

Thank you for your reminding. The present study invited caregivers of adolescents with ASD and ADHD to rate the severities of adolescents’ ASD and ADHD.

• We added “their caregivers” into Abstract of the revised manuscript. Please refer to line 23.
• We also added the data of “sex, age and marriage status in caregivers” into Table 1. Please refer to line 231.
• We added the results of examining differences in caregivers’ marriage status between adolescents who involved and who did not involve in bullying into Tables 2 and 3. Please refer to line 245 and 258.

Round 2

Reviewer 1 Report

I thank the authors for the extensive work of updating the literature and revising