A cluster randomized controlled trial of child-focused psychiatric consultation and a school systems-focused intervention to reduce aggression

Peter Fonagy, Stuart W. Twemlow, Eric M. Vernberg, Jennifer Mize Nelson, Edward J. Dill, Todd D. Little, John A. Sargent

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131 Scopus citations


Background: While school-based anti-bullying programs are widely used, there have been few controlled trials of effectiveness. This study compared the effect of manualized School Psychiatric Consultation (SPC), CAPSLE (a systems and mentalization focused whole school intervention), and treatment-as-usual (TAU) in reducing aggression and victimization among elementary school children. Method: Participants were 1,345 third to fifth graders in nine elementary schools in a medium-sized Midwestern city who took part in a cluster-level randomized controlled trial with stratified restricted allocation, to assess efficacy after two years of active intervention and effectiveness after one year of minimal input maintenance intervention. Outcome measures included peer and self-reports of bullying, bystanding, and mentalizing behavior and classroom behavioral observations of disruptive and off-task behavior. Results: CAPSLE moderated the developmental trend of increasing peerreported victimization (p < .01), aggression (p < .05), self-reported aggression (p < .05) and aggressive bystanding (p < .05), compared to TAU schools. CAPSLE also moderated a decline in empathy and an increase in the percent of children victimized compared to SPC (p < .01) and TAU conditions (p < .01). Results for self-reported victimization, helpful bystanding, and beliefs in the legitimacy of aggression did not suggest significantly different changes among the study conditions over time. CAPSLE produced a significant decrease in off-task (p < .001) and disruptive classroom behaviors (p < .01), while behavioral change was not observed in SPC and TAU schools. Superiority with respect to TAU for victimization (p < .05), aggression (p < .01), and helpful (p < .05) and aggressive bystanding (p < .01) were maintained in the follow-up year. Conclusions: A teacher-implemented school-wide intervention that does not focus on disturbed children substantially reduced aggression and improved classroom behavior.

Original languageEnglish
Pages (from-to)607-616
Number of pages10
JournalJournal of Child Psychology and Psychiatry and Allied Disciplines
Issue number5
StatePublished - 2009


  • Anti-bullying intervention
  • Childhood aggression
  • Mentalization
  • Psychiatric consultation
  • Randomized controlled trial


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