March 2015, VOLUME135 /ISSUE Supplement 2

Social Dominance, School Bullying, and Child Health: What Are Our Ethical Obligations to the Very Young?

  1. Jodi Halpern, MD, PhDa,
  2. Douglas Jutte, MD, MPHa,
  3. Jackie Colby, PhD, MPHb, and
  4. W. Thomas Boyce, MDc
  1. aUC Berkeley-UCSF Joint Medical Program, School of Public Health, University of California-Berkeley, Berkeley, California;
  2. bRegional Ethics Department, Kaiser Permanente Northern California, Oakland, California;
  3. cDepartments of Pediatrics and Psychiatry, School of Medicine, University of California, San Francisco, California


BACKGROUND: Recent research shows that by age 5, children form rigid social hierarchies, with some children consistently subordinated, and then later, bullied. Further, several studies suggest that enduring mental and physical harm follow. It is time to analyze the health burdens posed by early social dominance and to consider the ethical implications of ongoing socially caused harms.

METHODS: First, we reviewed research demonstrating the health impact of early childhood subordination. Second, we used philosophical conceptions of children’s rights and social justice to consider whether children have a right to protection and who has an obligation to protect them from social harms.

RESULTS: Collectively, recent studies show that early subordination is instantiated biologically, increasing lifetime physical and mental health problems. The pervasive, and enduring nature of these harms leads us to argue that children have a right to be protected. Further, society has a role responsibility to protect children because society conscripts children into schools. Society’s promise to parents that schools will be fiduciaries entails an obligation to safeguard each child’s right to a reasonably open future. Importantly, this role responsibility holds independently of bearing any causal responsibility for the harm. This new argument based on protecting from harm is much stronger than previous equality of opportunity arguments, and applies broadly to other social determinants of health.

CONCLUSIONS: Social institutions have a role responsibility to protect children that is not dependent on playing a causal role in the harm. Children’s rights to protection from social harms can be as strong as their rights to protection from direct bodily harms.

  • social dominance
  • stress
  • bullying
  • social justice
  • ethics

Children as young as 3 to 5 gathered in preschool and elementary school form dominance-subordination hierarchies. This is a serious problem for 2 reasons. First, subordination has lasting health effects. Second, subordinates become implicitly acceptable targets for exclusion and rejection, increasing their chances of being bullied. Mounting evidence shows that experiencing persistent subordination can have serious long-term physical and mental health consequences. An important question then arises: do children placed in schools, where most social subordination and bullying occurs, have a right to be protected from these harms?

This article begins with a synthesis of empirical findings regarding the harms of early subordination. This leads to an ethical inquiry. We ask whether children have a right to be protected from such harm, and, if so, who is responsible to provide such protection?

Tracing Bullying Back to Social Hierarchies

Bullying has captured the public’s attention. With several highly publicized suicides of (sometimes very young) teens linked to bullying,1 society has discovered that serious bullying occurs with shocking frequency, especially with the recent onset of cyber-bullying. Cyber-bullying is especially riveting because it is new and literally epidemic; 50% of junior high children experience it.2 However, the age-old problem of direct face-to-face bullying is even more common, with at least 60% of children reporting being bullied in person during adolescence.3

While attempting to address bullying by solely punishing the few children who stand out as primary perpetrators, it is more effective to address how most children treat their vulnerable peers.4,5 Certain children are repeated targets of bullying, especially youth who are anxious, depressed, or those with developmental challenges or perceived as “gay.”6,7 When most children collude in ostracizing and ridiculing these vulnerable children, bullies target them.8,9 Current policies tend to focus on bullying in older children, but research shows that this shared view of children as acceptable targets develops very early. Within weeks of beginning preschool, children form stable social hierarchies, where subsets of children perceived as shy, passive, sensitive, or awkward, are routinely subordinated.10,11

Consider the Story of Sam

Sam is a shy boy whose preschool experience consisted of peaceable, independent play, with occasional forays into the confusion of group dynamics. Under preschool staff’s watchful supervision, Sam accommodated effectively to the demanding novelty and constant press of social interchange.However, kindergarten in public school was a greater challenge. Suddenly immersed in a seemingly hostile sea of new peers, Sam withdrew into spaces where he could “hide.” This new classroom, however, was not an easy place to disappear. More children, smaller space, and diminished oversight by 1 busy teacher created minimally regulated bedlam. More domineering children regularly seized his toys, paints, or seat. Sam was persistently reminded of his lower standing by routine physical and verbal attacks and exclusion. He emerged from the year even more reticent to engage (or certainly confront) other children, less confident in his own agency and value, and worried about his prospects for a safe and happy future in school.Sam’s story is common. Early social dominance is ubiquitous with preschool dominance-subordination behaviors ranging from verbal and physical competition for resources (eg, a toy or teacher’s attention)12,13 to violence.14 These early hierarchies are increasingly entrenched as children develop.15 Importantly, Kim and colleagues,16 among others, have shown that early marginalization makes children vulnerable to ongoing peer victimization and bullying.

Who becomes subordinated? A key finding is that despite surface differences, targeted children exhibit shared, preexisting physiologic sensitivity to stress.11 Some will eventually receive a developmental or psychiatric diagnosis (eg, attention-deficit/hyperactivity disorder, autism spectrum), but most will not. Rather, this same interpersonal sensitivity can be a social asset in less-aggressive settings.17

From a policy perspective, it is critical that, although this article focuses on new biologic findings, sociologic factors remain very important. Being from a different racial or cultural group or being of lower socioeconomic status increases health risks overall, as well as vulnerability to dominance.1820

Health and Social Consequences

Research increasingly links early subordination with enduring changes in stress response associated with substantial risks to later mental and physical health.21,22 Preschoolers in higher social positions have healthier neuroendocrine systems and suffer fewer chronic medical conditions.23,24 Conversely, early subordination sets into motion a vicious cycle of biological reactivity to stress, engendering further exclusion and more anxiety, loneliness, and depression. Children targeted for bullying have significantly more physical health complaints (eg, difficulty with sleeping, headaches, abdominal pain, and overall poorer health) and worse psychosocial and emotional adjustment.2527 Depression and suicidal ideation and behavior are dramatically elevated among bullied children.28,29

Importantly, domination need not include physical maltreatment to result in harm. Both indirect and relational aggression (eg, verbal abuse) can damage psychological and physical health,30,31 suggesting that social subordination itself is harmful.

The enduring stress response patterns of childhood subordination suggest that early childhood may represent a developmental “critical period” during which social experiences have disproportionately large effects.32 The varied health effects, dependent on when the dominance occurs,33,34 suggest that the impact may be mediated by genes regulating neuroendocrine function and behavior during specific developmental periods.35 This early encoding of subordinate experience into the developing brain’s circuits could profoundly influence a child’s developmental trajectory, realization of life potential, and risks for psychiatric and biomedical disorders over the full life course.31 Such risks are heightened among children of families of lower socioeconomic status with already-increased risk of worse health outcomes.36

This emphasis on an early critical period in which children develop enduring physiologic patterns might suggest that it is relatively hopeless to intervene past the very early years. However, the stress reactivity developed in association with subordination may later exert both risk-augmenting and risk-protective effects, depending on the child’s social context.37 That is, such children show an enduring biological sensitivity to context.16,20,38 Physiologically, the same child on high alert in an unstable, stressful environment may actually better absorb the positive attributes provided in a supportive, nurturing environment. Thus, older, biologically sensitive children in more protected and nurturing settings thrive.

Ethical Analysis

In light of the serious health consequences, is there an ethical obligation to prevent or mitigate the harms of early subordination? If so, who owes protection to vulnerable children?

Is There an Obligation to Intervene?

To discover if there is an obligation to children who might suffer as a result of early subordination, we need to consider the corollary question: whether children have a right to protection from avoidable harms during childhood. Every right implies a correlative obligation.39 If children have such a right, then we must also ask on whom the correlative duty of protection falls: their parents, their teachers, their pediatricians, or society-at-large?

Negative rights, or the right to not be harmed, are our most fundamental rights, resting on our rights to our own bodies and selves: rights not to be killed, violated, or left worse off because of another’s interference.40 What is the nature of the harms involved in subordination in early childhood? Being treated as Sam was depreciates his feelings about himself, his self-efficacy, his interest in attending school, his learning ability, and his general well-being during early childhood.

However, it is subordination’s enduring and widespread impact across functional domains and over time that makes the harm so great. Young schoolchildren are in a critical period of developing their stress response patterns and self-efficacy. Sensitive children subjected to unfettered dominance by peers develop more extreme and enduring patterns of stress reactivity, which puts them at risk for future bullying and exclusion. By adolescence, they show increased rates of depression, anxiety, and substance dependence. Psychological harms interact with biological harms, creating long-term physical illness risks too (see earlier in this article). These biopsychosocial repercussions of subordination interfere with a child’s expected trajectory into the future, so there is no doubt that such treatment can cause harm to children. The more important question, and the one to which we are now just beginning to get an answer, is whether these harms can be prevented or ameliorated by specific interventions. Thankfully, the answer is that interventions can make a difference.41

Early subordination raises questions of moral responsibility, not only because children are so young, but because of its pervasive and enduring impact. Children have a right to protection of the capacities needed to pursue their future life prospects because they cannot protect those capacities. This right has been formulated as “a child’s right to an open future.”42,43 Both health-related and non–health-related capacities are crucial to help keep a child’s future sufficiently open. For example, literacy plays a crucial role, so that failing to educate girls fails to protect their right to an open future.44 “The goods at risk for children…include not only their current and future health but also their evolving and future liberty….”45

The most demanding interpretation of the right to an open future is that all children deserve a broad range of options in life. However, we are making a more limited, but stronger claim: although children face different opportunities, every child has a right not to have his or her own capacities foreclosed on. This is a negative right to not have one’s existing potential overly constrained, whether by social barriers or by psychological or physiologic insults. Let us call this the child’s right to develop his or her expectable potential under “good enough” social conditions.

Court cases have established the state’s obligation to protect children’s “right to an open future” even against their parents’ values. Parents cannot make education and health choices for their children that would overly restrict their capacities as adults.43,46,47

Whose Responsibility Is It to Protect Children From Subordination?

Young children are vulnerable and cannot protect their own interests. Society conscripts children into school, assuming the parental duty of safeguarding them. Society therefore has a fiduciary duty to protect each child from harm in school.

Note that rights and duties of this type transcend utilitarian considerations. For example, one cannot claim that because attending school is better than not attending school, that schools have met their obligations. Moral responsibilities to protect rights are not calculated this way. A parent who otherwise provides good care is not permitted to occasionally abuse his or her children, even if on balance this is better for them than utter neglect. Nor does society deem it ethical for employers to expose workers unnecessarily to occupational hazards based on the claim that being employed benefits the person overall (compared with unemployment). Although schools may benefit children overall, this does not reduce the moral obligation to protect children in school.

Further, because children are extremely vulnerable, they rely on school protection more than adults rely on workplace protection. Although it may be difficult for adults to leave noxious work environments, it is possible. It is not possible for children to leave a toxic school environment, at least not in the same self-motivated way. To do so, they must appeal to the very adults who put them in the noxious situation in the first place. Their dependence on protection in school is thus more akin to a prisoner’s dependence on safeguards. Case and state law establish that society holds special responsibility for harm done to prisoners when inadequate supervision and other shortages fail to prevent harm.48,49 We believe that society has this same fiduciary obligation to children, an obligation created through a combination of conscription and dependency.

Usually we hold an agent to have the highest moral obligation if the agent is the cause of the harm, and schools do not actually cause the harm. Doesn’t this mean that schools are, at worst, negligent, rather than morally responsible for the harm?

No. We think that schools are morally responsible for the harm because of their special role in children’s lives. Roles come with special responsibilities. A bystander who watches one child abuse another is negligent. A parent, in contrast, who knowingly tolerates one sibling abusing another is more than negligent; he or she is actually regarded as responsible for harm, even though not the direct cause.

Thomas Pogge50 suggests how, in certain contexts, failure to protect can be morally equivalent to direct responsibility for harm. He argues that if a babysitter agrees to care for an infant, and then leaves the infant alone, and the infant drowns, the babysitter is as responsible for the harm as if he or she directly caused it. Pogge’s50 justification is surprising, though, because he goes on to say that the babysitter actually did cause the harm by accepting the job, thus triggering a causal chain ending with the drowning. Had the babysitter not accepted, another more attentive babysitter would likely have been hired and the infant would not have drowned.

Although we agree with Pogge’s50 assignment of responsibility, we prefer an alternative explanation of why the babysitter is morally responsible. The mere fact that a person’s actions are part of a causal chain is insufficient to conclude that the babysitter is morally responsible for the harm that results. If I ask you to meet me, and this contributes to your getting hit by a car, I may play the same causal role as the babysitter, but not the same moral role. Ethically important in the babysitter example is not the causal chain set into motion by the babysitter accepting the position, but rather an extracausal fact. The babysitter knowingly accepted the responsibility to protect the infant, and then did not meet that responsibility. Closely scrutinizing this case points us away from a causal account to a role responsibility account.

Although schools do not have the same role responsibilities that parents have, they do have at least a babysitter’s responsibility. We certainly expect schools to take reasonable measures to protect children from physical harms on the playground by having adult-supervised play so that even children who fail to follow rules and fall do not get badly hurt. Similarly, children ought to be protected from repeated subordination.

An additional argument for a strong obligation to protect each child’s right to an open future comes from the social contract between parents and society regarding each child’s opportunities in life. Society requires children to attend school in preparation for participating in the political and economic sphere. Public policy and educational mission statements emphasize the mission of public education as developing each child’s career and life skills and capacities for future learning.51,52 Parents entrust children to schools, relying on society’s promise to safeguard each child’s capacities.

Further, society’s obligation is based not just on children’s individual rights, but on the necessary conditions for a just society. Social justice (not distributive justice) depends on educational institutions providing conditions for fair political and social processes. John Rawls53 argues that the conditions for self-respect are among the most important, or primary, goods that institutions must protect. Rawls53 defines self-respect not as some interior mental state, but as a socially formed attitude, and Rawls53 suggests that this aspect of self-respect may be the most important primary good. He describes how social institutions must facilitate the development of “confidence in one’s ability to fulfill one’s intentions.” This sense of self-efficacy is what we see harmed in Sam’s case.

Of course, schools alone do not determine self-efficacy. Parents and caregivers play a greater role and have the strongest moral responsibility to help children develop self-respect, but that does not reduce the school’s responsibilities. If a child with phenylketonuria is cognitively impaired because the parents did not feed the child the specialized diet required, society’s obligation to provide special education for the impaired child is not mitigated. We have shown that society has a role responsibility to protect children and to promote just institutions, even though it may not be directly, causally, responsible for the harm to children. Crucially, because society’s moral responsibility is not based on causal attribution, it is not decreased in cases in which parents, or in the case of subordination, peers, are the primary cause of the problem.

To summarize: first, and most importantly, fixed social subordination constrains future capacities, and children have a right to be protected from such harm. Second, society conscripts children into schools and gains parental cooperation by promising that schools will be full fiduciaries, not only protecting children from physical harm, but also safeguarding and nourishing the child’s future opportunities. Society thus makes a promise, assuming responsibility for promoting each child’s right to a reasonably open future. Finally, as a formative social institution, our educational system has a role responsibility to provide the support needed to prevent damaging dominance hierarchies, enabling children to develop a healthy sense of self-efficacy and normal physiologic capabilities, for these capacities are primary goods influencing overall life prospects.


In this article, we hope to have made 2 novel arguments for why we need to pay attention when children are repeatedly subordinated in their early school years. The first synthesized empirical findings to suggest that fixed subordination early in the school years creates serious risks of future mental and physical health problems and predisposes children to be later targets for bullying.

The second, an ethical argument, builds on the social contract involved in mandating school attendance (most parents are unable to home school). Our argument differs from most current approaches to ethics in public health in 2 ways: first, we did not rely on utilitarian arguments. Although there is likely great aggregate harm to public health because of early exposure to unfettered dominance,54 the utilitarian goal of improving aggregate health does not specify that any specific child has an actual right not to be harmed, or that any party has a corresponding duty to stop children from being harmed. In contrast, our argument is stronger, specifying rights and duties. Society has a fiduciary duty to protect each child’s existing capacities to develop and function well in society. In addition, we pointed to society’s institutional justice responsibilities to protect the primary social goods of all.

This ethical analysis makes use of a novel conception of moral responsibility, arguing that moral responsibility is independent of causal responsibility. Importantly, showing that society’s responsibility to intervene is independent of causal responsibility obliges us to move policy forward to protect children now, regardless of ongoing debates regarding the causation of health disadvantages.55 Additionally, we anticipate that this explication of society’s role responsibilities to protect children will be of more general use in addressing the ethical issues at stake in considering the social determinants of health and health inequalities.56,57


We thank Megan Gaydos, Katie Hasson, Maria Porter, and Andrea Spillmann for editorial and research assistance.


    • Accepted December 19, 2014.
  • Address correspondence to Jodi Halpern, MD, PhD, Joint Medical Program, 570 University Hall, University of California-Berkeley, Berkeley, CA 94720. E-mail: jhalpern{at}
  • All authors conceptualized and designed this paper, drafted and revised the manuscript, and approved the manuscript as submitted.

  • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

  • FUNDING: Supported by National Institute of Mental Health grant R01 MH062320-03 (WT Boyce, principal investigator). Funded by the National Institutes of Health (NIH).

  • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.