A Dangerous Precedent

Earlier this week, a federal judge ordered the Pittsburgh Public Schools to pay $55,000 to settle a lawsuit filed by a mother, who claimed her adolescent daughter was bullied into anorexia.

According to the lawsuit, the plaintiff’s daughter, now 15, was bullied relentlessly at school in 6th and 7th grades. A group of boys taunted her and made degrading remarks of a sexual nature, insinuating that she was fat and ugly. The girl stopped eating lunch at school in attempt to avoid being teased by these boys, who ridiculed her for eating and being fat. Although the girl’s teacher, principal, and guidance counselor were aware of the bullying, they did nothing to intervene. The girl began losing weight, and by the middle of her 7th grade year, her weight was dangerously low and she was diagnosed with anorexia nervosa, for which she was treated at an inpatient psychiatric clinic. The plaintiff, whose daughter now attends private school, sued the school district, her daughter’s middle school, and her principal, claiming that her daughter developed anorexia as a result of their inaction.

I disagree with this ruling, and I think it sets a dangerous precedent.

Before I state my points of contention, I will make several points very clear:
• Bullying has the potential to cause extreme distress. It is cruel, harmful, and absolutely inexcusable.
• All schools should have clear, written policies about bullying and sexual harassment. All students, parents, and faculty must be aware of these policies. School faculty and administrators must enforce these policies to the best of their abilities.
• School faculty and administrators have a responsibility to provide a safe learning environment for all students, and have a duty to intervene at the first sign of bullying.
• Students who engage in bullying behavior should be punished appropriately. If the bullying continues, they should be expelled.

In this particular case, the bullies did some terrible things; they must be held responsible for their actions and punished appropriately. The school faculty and administration were certainly negligent; they must be held accountable for their inaction and punished appropriately. The school district was remiss not to have a bullying policy, and they should be compelled to create one. The victim suffered horribly as a result, and she deserves to heal from this trauma and to attend school in a safe environment. And the buck stops here. I do not believe that the bullies or the negligent school personnel are responsible for this child’s mental illness.

To create a legal precedent in which school officials are held legally or financially liable for a child’s mental illness is dangerous on several levels:
• It implies that the actions of children can cause another child to develop a mental illness.
• It implies that the actions or inactions of adults can cause a child to develop a mental illness.
• It implies that anorexia nervosa is (or can be) the result of teasing or bullying.
• It reinforces the popular but antiquated and unsupported notion that anorexia nervosa is the result of some deep-seated trauma.
• It implies that this child would not have developed anorexia nervosa if she had not been bullied.
• It neglects the horrific experiences of tens of thousands of other children who have been bullied and have suffered silently, but have not developed anorexia nervosa.
• It invalidates the experiences of the tens of thousands of children and adults who have never been bullied or traumatized in any way, but nonetheless have developed anorexia nervosa.

Imagine being a prepubescent boy and being held responsible for causing a classmate’s severe mental illness. Don’t get me wrong – I am in no way defending the behavior of these bullies. They did cruel things and they must be punished. But they did not make this girl develop a life-threatening brain disorder. They couldn’t have, even if they wanted to! Similarly, the school faculty and administrators were obviously negligent and made some terrible mistakes, but they did not cause this child to develop a mental illness.

The most recent scientific evidence strongly suggests that anorexia nervosa is a biologically-based, genetically transmitted brain disorder which is triggered by malnutrition and then becomes self-perpetuating. Children with anorexia come from all walks of life. Some are popular, confident, social, happy, and well-adjusted before their illness begins. Others are depressed, anxious, introverted, teased, or unstable before they develop anorexia. Some children develop anorexia after a stressful event, which could be as benign as a starting middle school or as serious as rape. For many children, the onset of anorexia nervosa does not coincide with a major stressor, but rather spirals out of control during an attempt to “eat healthy,” get in shape for sports, or lose a few pounds for prom.

My point is that some children are simply “wired” for anorexia nervosa, which can be triggered by relatively minor stressors or relatively benign bouts of under-nutrition. It doesn’t make sense to “sue the trigger” when it is just that – a trigger. If we can sue a school district – and win tens of thousands of dollars – for allowing a child to be bullied into anorexia, where does it end? If a child develops an eating disorder after reading a book on nutrition, do we sue the publisher? If an 18-year-old becomes anorexic while struggling to adapt to the social and academic challenges of college life, do we sue the university?

If a teenager develops and eating disorder after being raped, the rapist should be tried and convicted and incarcerated. But the eating disorder, in my opinion, is irrelevant to the outcome of the trial. The rapist should be incarcerated for the same length of time (for life, in my opinion) regardless of whether the victim develops any mental illness afterwards, because he committed a violent crime. The crime is no more or less heinous based upon the particular pre-existing neurological makeup of his victim.

It is well-known amongst mental health professionals that a psychotic break can be triggered by “high expressed emotion,” such as bullying or family conflict, in a person who has the underlying neurobiological predisposition. Do we then sue the school for allowing a child to be “bullied into schizophrenia?” Do we sue the parents for arguing too much and thus causing their son’s psychosis?

I have the deepest sympathy for this plaintiff, and especially for her daughter. No doubt, they have both suffered horribly. This mother is only doing what she believes is best for her dear child, and I’m sure she believes she is helping other children in the process. The judge who approved of this settlement is, likewise, only trying to ensure that justice is served. He or she probably has no intimate knowledge of the etiology of anorexia nervosa, and probably has no idea what some of the negative ramifications of his ruling could be.

If the lawsuit had been simply about protecting children from bullying, I would have supported it 100%. I cannot, however, support a lawsuit which enshrines bullying as a legally valid cause of anorexia.

6 Replies to “A Dangerous Precedent”

  1. I feel like sometimes all the argument over trigger vs. cause is semantics.

    So I actually looked up the definition of cause:

    1. a person or thing that acts, happens, or exists in such a way that some specific thing happens as a result; the producer of an effect

    2. the reason or motive for some human action

    I think it is wrong to say that bullying caused her AN. But I ALSO think it is wrong to say that genetics caused her AN and THIS is where I feel yourself and most Maudsley advocates have missed the point.

    AN is a multi-causal disorder. In fact, most psychiatric disorders are likely multi-causal. To single out ANY one factor as a sole cause is misleading. Bullying DID NOT cause her AN because she required a genetic prediposition to develop the condition in the first place. Similarly, genetics DID NOT cause her AN because a series of triggers was required to begin the process of development of an ED.

    You wrote:

    “It implies that the actions of children can cause another child to develop a mental illness.
    • It implies that the actions or inactions of adults can cause a child to develop a mental illness.”

    I think this is an accurate argument IF the predisposition is already present. Depending on the sensitivity of the child, inaction or action of others COULD have been the trigger which set off a mental illness. It could be said that if the child had NOT be bullied and had been raised in a safe and supported environment she would never have developed AN. In this case, I would say that both the genetics AND the bullying (trigger) were the cause as BOTH are required for the disorder to occur — one is NOT sufficient and AN does not develop in a vacuum.

    You wrote:

    “• It neglects the horrific experiences of tens of thousands of other children who have been bullied and have suffered silently, but have not developed anorexia nervosa.
    • It invalidates the experiences of the tens of thousands of children and adults who have never been bullied or traumatized in any way, but nonetheless have developed anorexia nervosa.”

    This is a gross generalization and I don’t think the fact that ONE individual’s AN was triggered by bullying in any way undermines or invalidates the suffering of other children who were bullied and did not go on to develop this disorder. Similarly, I don’t think this invalidates adults/children who have AN but have not had a similar trigger. The nature of the genetic predisposition and environmental context will determine the trigger.

    If an individual develops cancer from exposure to an environmental toxin in the workplace, does this “trigger” invalidate other causes of that same cancer? No, it merely provides information relevant to this individual and perhaps general risks for developing the cancer.

    Similarly, for all those who were exposed but did not develop cancer, can we now say that the toxin is not a problem for these individuals because they did not develop cancer? I don’t think this can be argued either and no rational person would conclude this. I can see where you are coming from but your logic is faulty. . .

    Just some thoughts, but I firmly believe that targeting genetics as a cause of AN is JUST as faulty as targeting bullying, etc. To find a CAUSE of a disorder which may be different for EACH individual we must take into account ALL factors of varying weights.


  2. A:),

    Thank you for your very thoughtful response. You’ve certainly got me thinking, and after some reflection I have come to agree with some of your points.

    First, though, let me clarify that the Maudsley approach is agnostic with regards to the cause of AN. This means that strict Maudsley practitioners don’t claim to know what causes AN, and don’t believe that it is necessary to know the cause in order to treat it effectively.

    While I am a proponent of the Maudsley approach, I don’t follow it strictly by the book and don’t necessarily agree completely with the manualized form. I, personally, am not entirely agnostic. I firmly believe, based on my training and knowledge of the research, that AN is a biologically based, genetically transmitted brain disorder which is triggered by malnutrition in susceptible individuals.

    After reading your post, I have come to agree that saying biology or genetics cause AN is just as faulty an argument as saying bullying causes AN. If a person with the predisposition to AN never experiences a nutritional deficit, the underlying brain condition will not be activated and she will not develop the disease.

    The unfortunate reality of our society is that most girls will, at some point in their lives, decide to diet, eat “healthy,” participate in competitive sports, or just lose a few pounds, all perfectly typical and benign behaviors which will usually lead to AN in those who are vulnerable. Even for those who never diet, a temporary unintentional nutritional deficit due to illness, stress, surgery, or depression can be enough to trigger the disease in those who are wired for it.

    But you are correct – biology / genetics alone are not sufficient to develop AN.

    Being bullied about her weight led to this girl’s dieting, and her dieting triggered her predisposition to AN. We have no idea whether this girl would have developed AN in the absence of bullying. It is likely, however, that she would have restricted her diet at some point during adolescence for some reason, or gotten a stomach bug, or lost her appetite due to stress, and subsequently developed AN.

    You are right that it was an overgeneralization to state that this case invalidates the experiences of other AN sufferers who have not been bullied or otherwise traumatized. My concern is simply that some sufferers and parents do not understand why they or their children developed AN because they have had a “good life.” I think it is important for people to recognize that AN afflicts people from all backgrounds, from stable homes as well as abusive ones, from happy lives as well as horrible ones.

    Thanks again for your very wise comments.

  3. I have just now come to realize that there was no dangerous precedent after all! It seems as though I misunderstood the newspaper article and the potential implications of this case, probably due to the fact that I have no legal training.

    A parent advocate, who also happens to be a lawyer, read the newspaper story and posted the following on a forum for parents of eating disordered children:

    “Judging by the newspaper story, it appears what happened in this case is that the student and family sued the school district for harm caused to the student by the bullying. The two sides then reached a compromise to settle the case out of court. The court never made any determination, therefore, about whether the bullying in fact had caused or contributed to the development of anorexia, since the parties decided voluntarily to resolve their differences by a settlement. The student and family then, apparently, changed their minds and decided they didn’t want to settle after all for the amount of money they had previously agreed to accept in compromise. So the school district went to court to enforce the settlement agreement. The judge agreed that the plaintiffs’ agreement to compromise and settle was binding, so the case was dismissed, the settlement agreement was enforced, and the court never reached the merits of the dispute, including whether the damages claimed (anorexia) were the causal result of bullying or not. No need to worry. Since the parties decided to compromise and settle the dispute out of court, this case won’t have any effect as precedent one way or another on the question of whether bullying causes or contributes to the development of eating disorders.”

  4. Dr. Ravin,

    I’m a fan of your blog, but I take exception to your sense of liability for the victim of bullying.

    While I certainly understand your argument that there is no evidence that bullying would lead one to develop an eatting disorder, I think that you miss the point.

    Yes, many people are bullied and not all of them develop an eatting disorder, but the school was liable for all reasonable consequences of its failure to act, to include the emotional distress of the child.

    As a licensed clinical psychologist, would you be able to say with any degree of medical certainty that absent the bullying, the child would have developed an eatting disorder?

    Keep up the good work. Best wishes.


  5. Sean,

    Thank you for raising this issue.

    I am viewing this case through the lens of my academic training, which is in psychology, not law. I don’t know enough about the law to determine whether the school is legally liable for this child’s anorexia nervosa (AN).

    It sounds as though we have two distinct yet related questions here:

    1.) Did bullying cause this student’s AN? (and more generally, CAN bullying cause a brain disorder?)
    2.) Is the school legally liable for the development of this student’s AN?

    Perhaps the answer is no to #1 but yes to #2.

    An underlying brain predisposition is necessary, though not sufficient, for developing AN. Less than 1% of adolescent girls have this brain predisposition. This student’s anorexia nervosa was triggered by a period of malnutrition as the result of dieting, and she began dieting in response to bullying.

    While I cannot say with 100% certainty that this girl would not have developed AN if she had not been bullied, I do know that it is very likely that she would have dieted at some point in her adolescence, as most adolescent girls do, and that her dieting would have triggered AN because she is biologically vulnerable. And even if she had never dieted, her AN could easily have been triggered by a low nutrition as a result of illness, surgery, fasting for religious purposes, intense athletic training, or vegetarianism.

    So my psychological opinion is that this girl most likely would have developed AN at some point in her adolescence whether or not she had been bullied.

    I do believe that the school is responsible for the emotional distress that this child suffered as a result of their inaction. The school, in my opinion, should be responsible for the distress caused to ANY child as a result of their negligence, regardless of whether said child has a mental illness.

    Whether the school is legally liable for her AN is beyond the scope of my training.

  6. Dr. Ravin, thanks for your earlier comments. I appreciated that you were able to consider my point of view. 🙂

    I think the difficulty is that it is your opinion that she may have dieted at some point during adolensce REGARDLESS of the bullying.

    I don’t think this is as clear cut as it is made out to be. We have no studies on the percentage of individuals who have the behavioural predisposition of AN vs. those who go onto develop AN, but it is likely not 100%. I think in this case we CAN say that the bullying was the trigger that began the process and therefore it was PART of the cause of the brain disorder. Period.

    We cannot say for SURE whether the student would have developed AN in the absence of these events and I don’t know if this fact has any relevance to the issue at hand. She DID develop AN as a result of the bullying and therefore that is relevant and has affected her mental health.

    Even if she had dieted, could we still say as a certainty that she would have developed AN? This dieting attempt brought on by bullying may have been more severe than one brought on by simple experimentation. Similarly, the presence of a diet is not the sole causal factor in the development of AN. The bullying may have worsened her critical thinking, perfectionistic tendencies, etc. which allowed the AN/diet to seem a more feasible option than it would have been had she been undisturbed.

    I really don’ t think the development of AN is simply:

    Predisposition + malnutrition = AN

    I don’t know if we can say for certain that it is that clear cut. There may need to be other psychological factors present for development.

    Individuals do have some control over their own behaviour — even adolescents. Consider, if the individual is otherwise psychologically healthy, he or she may be able to see the futility/irrationality of the diet/AN (despite its apparent benefits) and therefore alter the behaviour/progression of the illness before it becomes clinical.

    As I stated earlier, AN is a complex, multi-causal psychiatric disorder. I think it is fair to say also that the mechanism of the disorder is also just as complex. . .

    Just some thoughts.


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