Any mental health clinician working with children knows too well the devastating and long-term emotional effects of bullying and violence. Drs. Twemlow and Sacco, both leading researchers and clinicians in the field of bullying and violence prevention, raise questions about and address some of the most vexing problems in this area, including the interconnections between the family, the school, and the community as well as how bullying develops and the role of the psychiatrist in addressing school violence (1). The fact that the title of this book includes the word “preventing” is not insignificant. This ambitious text not only explores the range and complexity of the problems of violence and bullying in schools, but it also addresses the challenge of preventing bullying and school violence.

This is truly an impressive book with a pragmatic focus that aims to provide the reader with a conceptual framework to address the daunting problems of school violence and bullying. It offers an in-depth perspective on the topic, which will be of value to all mental health clinicians involved in school consultations. It differs from many other books as well as programs in this area, which tend to argue for one particular approach or for overly simplified antibullying or antiviolence programs. I found it appealing that the focus of the book was based on providing a way for the clinician to formulate and analyze the complex dynamics and group processes involved in diverse situations of school violence. Most impressively, the authors do not shy away from the potentially sensitive and politically incorrect topic of how teachers and administrators can become bullies and perpetuate violence in schools. These are “loaded issues” in school consultation. By not resorting to the use of abstruse psychoanalytic terminology, the authors make psychoanalytic insights accessible to the general reader. They explain the value of in-depth appreciation of the processes of mentalization while taking a systems-based approach that is highly attuned to the social context in which violence and bullying occur.

One area of difficulty in school consultation is when the role of the psychiatrist is reduced to providing a psychiatric diagnosis for the violent student. While this role is an important one, a diagnosis for the offending student does not explain as much as some would like to believe about what happens in a school when a violent incident occurs. Twemlow and Sacco's dynamic group approach challenges the psychiatrist to become a leader of a mental health team charged with the task of making effective changes in the school environment to reduce and eradicate violence and bullying. With regard to prevention, one of the key arguments of the authors is that therapeutic interventions need to target the interlocking systems of the family, the school, and the community, and the authors' demonstration of how this can realistically occur is convincing.

It is notable that each chapter was thoughtfully crafted from a pragmatic perspective, including sections on providing mental health consultation to agencies intervening with violent children, assessment of at-risk children, and risk and threat assessment of violent children. I appreciated that a range of different school environments with unique problems were incorporated in the discussion, including issues specific to lower-income inner city schools as well as those specific to affluent school districts. The divergent ways in which violence and bullying are expressed in these different contexts are highlighted. Each chapter concludes with a series of well-organized clinical pearls titled “Key Clinical Concepts,” which reinforce the major points that are made in the chapter.

In the initial chapters, the authors begin by delineating the range of complexity of the problem of school violence, making connections between what occurs in the school and what goes on in the community, in families, and in agencies involved with violent children. Different dimensions of school violence are analyzed in chapters 4–7. In chapter 4, titled “A Staging Paradigm,” the authors present case studies in school violence and divide the problems into five patterns: repetitive school disruptions (pattern 1), acute case of child aggressor or victim (pattern 2), highly submissive victim or aggressive young student (pattern 3), child with self-injurious or self-defeating behavior (pattern 4), and truants and dropouts (pattern 5). In chapter 5, titled “Bullying Is a Process, Not a Person,” the complex processes involved in bullying are examined. Bullying is explicated as a group power dynamic and the result of shame in a public setting, and thus bullies will only do what bystanders allow. The authors make a compelling argument for the position that examining “what renders a school environment coercive and humiliating introduces a way to understand the power dynamics of the family and community and the role this social drama plays in the creation of a peaceful school learning environment” (p. 141).

Many children and adolescents referred by schools for psychiatric consultation present with highly complex clinical pictures that do not fit neatly into classic diagnostic categories. These real-life clinical challenges are minimally addressed in the existing literature, yet child and adolescent psychiatrists are viewed as leaders in making both psychiatric and educational recommendations in these difficult situations. However, they are often in a dilemma regarding not only the student's diagnostic and psychiatric treatment needs but also how to guide the parents and school administrators to a collaborative agreement that is in the best interests of the child. Other challenges may include risk assessments for students who are making threats in school (2) as well as the intricacies of interfacing with lawyers, educational advocates, and psychiatric emergency department staff. This text is important because it addresses many of these concerns. Each chapter is relevant to the day-to-day work of the school psychiatrist. Chapters 7–10 focus on critical aspects of the assessment of violent children as well as redefining the role of the psychiatrist as a team leader in this process. Chapter 10, titled “Risk and Threat Assessment of Violent Children,” provides an excellent delineation of how to conduct a threat assessment and includes focused, practical suggestions for the clinician. Each chapter is replete with complex case examples that ring true as actual cases with which those of us involved in this field often struggle. Far too often, texts of this nature do not include case examples, and those that are cited tend to be oversimplified and unrealistic. In this book, the cases are quite detailed, compelling, and relevant. They highlight the deep levels of distress experienced by children who are caught up in the difficulties of school bullying and violence. Ironically, the length and details of some of the case examples and the smaller font in which they are presented initially appeared somewhat daunting to this reader; however, once one starts reading the cases, it will be easy to become engrossed. Perhaps one drawback is that the interventions in these cases almost uniformly had successful outcomes. Including situations with less than optimal outcomes and analyzing why such outcomes occurred may have made the cases more thought-provoking and realistic.

Preventing Bullying and School Violence is an important book on a compelling topic. The authors provide a masterful approach and set the standard for thoughtful psychiatric consultation on the pervasive problem of violence in our schools.