In our own work, we reviewed major social factors that seem to promote violence in children who felt persecuted, bullied or misunderstood in the school environment (Twemlow et al., 2002). Some of the items summarized in the Figure represent our direct collaboration with the Federal Bureau of Investigation's psychiatrically informed model (O'Toole, undated), with information from the Secret Service Safe School Initiative's behavioral/case-management approach (Vossekuil et al., 2000).
Issues that should alert the clinician include previous warning(s) of problems, ambiguous threatening messages, availability of guns, victimization at school, concern expressed by adults or peers, interest in hate and weaponry Web sites, out-of-character changes in emotion and interests, and families with low emotional closeness and little knowledge of their child's life.
A dizzying array of curriculum-based interventions address essential skills such as conflict resolution, peer mediation, anger management, improved communications, social skills, decision making and impulse control, among others. Other programs emphasize recreational arts, mentoring, character development and after-school activities. These efforts--especially in high schools--are often linked with increased metal detectors and security, video surveillance, and collaboration with local police.
The connection between drug and alcohol(Drug information on alcohol) abuse and violence has been well-established, and a variety of programs, including Drug Abuse Resistance Education (D.A.R.E.), have attempted to educate children about drug and alcohol abuse. However, they have had disappointing results (Ringwalt et al., 1994). Other innovative models such as D.A.R.T. (Development and Risk Together) promote wellness, with links to healthy development and prevention of violent behaviors (Guerra, 2003).
Complex interventions aimed at altering the social climate of the school are difficult to evaluate and replicate, partly because of the inherent complexity of social interventions. This creates difficulties in study integrity and problems with quantifying and standardizing data. The Blueprints for Violence Prevention system <www.colorado.edu.cspv/blueprints/> has a listing of various evidence-based programs for violence prevention. Replication is a requirement for the highest classification of effectiveness.
Very few programs ever meet these criteria. Various programs have had relatively disappointing results in the United States and elsewhere (Smith and Ananiadou, 2003). Table 1 lists some Blueprints model programs and one of our programs that have had promising results (Greenberg et al., 1998; Henggeler et al., 1998; Olweus et al., 1998; Sussman et al., 2002; Twemlow et al., 2001b, 1999; Webster-Stratton et al., 2001).
Wilson et al. (2003) reported on a well-designed meta-analysis of 221 school-based interventions designed to reduce aggressive behaviors. Eighty percent of the interventions were research-based demonstration programs and 90% of the studies were conducted in the United States. Very few studies of non-research routine interventions were available. However, effect sizes in those non-research studies were much lower than those for research interventions, where efforts were made to increase buy-in and fidelity. Respectable overall effect sizes of 0.25 for research programs translated into about a 7% reduction in fighting in schools. Specific intervention strategies had effect sizes grouping in the 0.25 to 0.33 range, with behavioral classroom management techniques and counseling showing the strongest effects. These were followed closely by improved academic services and programs promoting social skills, conflict resolution and communication skills.
Although consulting psychiatrists may feel slightly out of their element with interventions that do not focus on at-risk or ill children, the pervasiveness of the problem means that schools will often ask for a professional opinion (see Shafii and Shafii  for a summary of current research). Smith and Ananiadou (2003) summarized worldwide efforts to assess large-scale, school-based anti-bullying interventions. Efforts to prevent bullying have been moderately successful, and are more successful the younger the children involved are. Although most systemic interventions have addressed middle school and high school students, some have addressed programs for elementary schools (Twemlow et al., 2001b, 1996).