There are very real effects of bullying that can last well past the days of recess and gym class, according to a new report published Feb. 20 in the Journal of American Medical Association, Psychiatry.

As part of a study, more than 1,400 Western North Carolina children between the ages of 9 and 16 in 11 different counties were asked on average four to six times about their experiences with bulling. From the data, researches created categories based on whether the participants were solely bullies, solely victims, neither, or a combination of both, identified as “bullies/victims.”

The report showed that children who were both bullies and victims had a higher chance of developing depression and panic disorders, and were at an increased risk when it came to suicide later in young adulthood. Children who only acted as bullies—not victims, had an increased risk of antisocial personality disorder.

“Victims and bullies/victims had elevated rates of young adult psychiatric disorders, but also elevated rates of childhood psychiatric disorders and family hardships,” the study stated. “After controlling for childhood psychiatric problems or family hardships, we found that victims continued to have a higher prevalence of agoraphobia, generalized anxiety, and panic disorder.”

Bullying is defined as “unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance,” according to information released by the Department of Health and Human Services. The behavior is considered to be repeated actions that carry “the potential to be repeated, over time.”

“The effects of being bullied are direct, pleiotropic, and long-lasting, with the worst effects for those who are both victims and bullies,” the report stated.

Bullying can take three different forms, according to the Department of Health and Human Services, which include verbal, social, and physical torment, which includes everything from hitting and punching to breaking another person’s personal belongings and making “mean or rude hand gestures.”

Verbal bullying consists of “teasing,” “inappropriate sexual comments, taunting, threatening to cause harm,” while social bullying can include “leaving someone out on purpose” or actively spreading rumors.

The CDC estimates that 20 percent of high school students deal with some type of bullying that can have far reaching effects with the help of social media.

The Department of Health and Human Services recommends that all bullying be addressed immediately when noticed with a calm and collected attitude.

Adults are also encouraged to not try to make bullies or victims explain their actions in a public forum, and time should be taken with each child individually before making all parties involved apologize or come to an agreement after an altercation.