Child Psychiatry & Human Development

, Volume 48, Issue 3, pp 485–497 | Cite as

Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial

  • Glenn A. MelvinEmail author
  • Amanda L. Dudley
  • Michael S. Gordon
  • Ester Klimkeit
  • Eleonora Gullone
  • John Taffe
  • Bruce J. Tonge
Original Article


This study investigates whether the augmentation of cognitive behavior therapy (CBT) with fluoxetine improves outcomes in anxious school refusing adolescents (11–16.5 years). Sixty-two participants were randomly allocated to CBT alone, CBT + fluoxetine or CBT + placebo. All treatments were well tolerated; with one suicide-attempt in the CBT + placebo group. All groups improved significantly on primary (school attendance) and secondary outcome measures (anxiety, depression, self-efficacy and clinician-rated global functioning); with gains largely maintained at 6-months and 1-year. Few participants were anxiety disorder free after acute treatment. During the follow-up period anxiety and depressive disorders continued to decline whilst school attendance remained stable, at around 54 %. The only significant between-group difference was greater adolescent-reported treatment satisfaction in the CBT + fluoxetine group than the CBT alone group. These results indicate the chronicity of school refusal, and the need for future research into how to best improve school attendance rates.


School refusal Anxiety disorders Cognitive behavior therapy Fluoxetine 



The authors acknowledge the National Health and Medical Research Council (545968), beyondblue The National Depression Initiative and Financial Markets Foundation for Children. The authors thank A/Prof Neville King (retired) who made a substantial contribution to establishment of this study, the team of clinicians, Slade Pharmacy for preparation of the fluoxetine and placebo and all the participating adolescents and their families.


  1. 1.
    Berg I, Nursten JP (1996) Unwillingly to school. RCPsych Publications, LondonGoogle Scholar
  2. 2.
    Flakierska-Praquin N, Lindström M, Gillberg C (1997) School phobia with separation anxiety disorder: a comparative 20-to 29-year follow-up study of 35 school refusers. Compr Psychiatry 38:17–22CrossRefPubMedGoogle Scholar
  3. 3.
    Berg I (1992) Absence from school and mental health. Brit J Psychiatry 161(2):154–166CrossRefGoogle Scholar
  4. 4.
    King NJ, Bernstein G (2001) School refusal in children and adolescents: a review of the past 10 years. J Am Acad Child Psychiatry 40(2):197–205CrossRefGoogle Scholar
  5. 5.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Association, Washington, DCCrossRefGoogle Scholar
  6. 6.
    Melvin G, Tonge B (2012) School refusal. In: Sturmey P, Hersen M (eds) Handbook of evidence-based practice in clinical psychology. Wiley, HobokenGoogle Scholar
  7. 7.
    Maynard BR, Heyne D, Brendel KE, Bulanda JJ, Thompson A, Pigott TD (2015) Treatment for school refusal among children and adolescents: a systematic review and meta-analysis. Res Social Work Prac. doi: 10.1177/1049731515598619
  8. 8.
    King NJ, Tonge B, Heyne D, Pritchard M, Rollings S, Young D et al (1998) Cognitive-behavioral treatment of school-refusing children: a controlled evaluation. J Am Acad Child Psychiatry 37(4):395–403CrossRefGoogle Scholar
  9. 9.
    Last CG, Hansen C, Franco N (1998) Cognitive behavioral treatment of school phobia. J Am Acad Child Psychiatry 37(4):404–411CrossRefGoogle Scholar
  10. 10.
    Heyne D, King NJ, Tonge B, Rollings S, Young D, Pritchard M, Ollendick T (2002) Evaluation of child therapy and caregiver training in the treatment of school refusal. J Am Acad Child Psychiatry 41(6):687–695CrossRefGoogle Scholar
  11. 11.
    Heyne D, Sauter FM, Van Widenfelt B, Vermeiren R, Westenberg PM (2011) School refusal and anxiety in adolescence: non-randomized trial of a developmentally sensitive cognitive behavioral therapy. J Anxiety Disord 25(7):870–878CrossRefPubMedGoogle Scholar
  12. 12.
    Bernstein GA, Borchardt CM, Perwien AR, Crosby RD, Kushner MG, Thuras PD et al (2000) Imipramine plus cognitive-behavioral therapy in the treatment of school refusal. J Am Acad Child Psychiatry 39(3):276–283CrossRefGoogle Scholar
  13. 13.
    Geller B, Reising D, Leonard HL, Riddle MA, Walsh BT (1999) Critical review of tricyclic antidepressant use in children and adolescents. J Am Acad Child Psychiatry 38(5):513–516CrossRefGoogle Scholar
  14. 14.
    Walsh BT, Giardina E-GV, Sloan RP, Greenhill L, Goldfein J (1994) Effects of desipramine on autonomic control of the heart. J Am Acad Child Psychiatry 33(2):191–197CrossRefGoogle Scholar
  15. 15.
    Hazell P, Mirzaie M (2013) Tricyclic drugs for depression in children and adolescents. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD002317.pub2 Google Scholar
  16. 16.
    Gordon M, Melvin GA (2014) Prescribing for depressed adolescents: office decision-making in the face of limited research evidence. J Pediatr Child Health 50:498–503CrossRefGoogle Scholar
  17. 17.
    NICE (2013) Surveillance report for CG28: Depression in children and young people: identification and management in primary, community and secondary care.
  18. 18.
    Treatment for Adolescents Depression Study Team (2004) Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression. J Am Med Assoc 292(7):807–820CrossRefGoogle Scholar
  19. 19.
    Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT et al (2008) Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New Engl J Med 359(26):2753–2766CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Goodyer I, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S et al (2007) Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial. Brit Med J 335(7611):142–150CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Melvin G, Tonge B, King NJ, Heyne D, Gordon M, Klimkeit E (2006) A comparison of cognitive-behavioral therapy, sertraline, and their combination for adolescent depression. J Am Acad Child Psychiatry 45(10):1151–1161CrossRefGoogle Scholar
  22. 22.
    Birmaher B, Axelson DA, Monk K, Kalas C, Clark DB, Ehmann M et al (2003) Fluoxetine for the treatment of childhood anxiety disorders. J Am Acad Child Psychiatry 42(4):415–423CrossRefGoogle Scholar
  23. 23.
    Emslie G, Heiligenstein J, Wagner K, Hoog S, Ernest D, Brown E (2002) Fluoxetine for acute treatmemt of depression in children and adolescents: a placebo-controlled, randomized clinical trial. J Am Acad Child Psychiatry 41(10):1205–1215CrossRefGoogle Scholar
  24. 24.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DCGoogle Scholar
  25. 25.
    Albano A, Silverman W (1996) The anxiety disorders interview schedule for DSM IV, child version: clinician manual. Oxford University Press, New YorkGoogle Scholar
  26. 26.
    Silverman WK, Saavedra LM, Pina AA (2001) Test–retest reliability of anxiety symptoms and diagnoses with the Anxiety disorders interview schedule for DSM-IV child and parent versions. J Am Acad Child Psychiatry 40(8):937–944CrossRefGoogle Scholar
  27. 27.
    Jones SH, Thornicroft G, Coffey M, Dunn G (1995) A brief mental health outcome scale-reliability and validity of the Global Assessment of Functioning (GAF). Brit J Psychiatry 166(5):654–659CrossRefGoogle Scholar
  28. 28.
    Guy W (1976) Clinical global impression scale. The ECDEU assessment manual for psychopharmacology-revised. Volume DHEW Publ no. ADM 76, 338, pp 218–222Google Scholar
  29. 29.
    Dahlke F, Lohaus A, Gutzman H (1992) Reliability and clinical concepts underlying global judgments in dementia: implications for clinical research. Psychopharmacol Bull 28(4):425–432PubMedGoogle Scholar
  30. 30.
    Zaider TI, Heimberg RG, Fresco D, Schneier F, Liebowitz M (2003) Evaluation of the clinical global impression scale among individuals with social anxiety disorder. Psychol Med 33(4):611–622CrossRefPubMedGoogle Scholar
  31. 31.
    Kovacs M (1985) The children’s depression inventory (CDI). Psychopharmacol Bull 21:995–998PubMedGoogle Scholar
  32. 32.
    Smucker MR, Craighead WE, Craighead LW, Green BJ (1986) Normative and reliability data for the children’s depression inventory. J Abnorm Child Psychiatry 14(1):25–39CrossRefGoogle Scholar
  33. 33.
    Reynold CR, Richmond BO (1985) Revised children’s manifest anxiety scale (RCMAS) manual. Western Psychological Services, Los AngelesGoogle Scholar
  34. 34.
    Wisniewski JJ, Mulick JA, Genshaft JL, Coury DL (1987) Test–retest reliability of the revised children’s manifest anxiety scale. Percept Motor Skills 65(1):67–70CrossRefPubMedGoogle Scholar
  35. 35.
    Heyne D, King NJ, Tonge B, Rollings S, Pritchard M, Young D et al (1998) The self-efficacy questionnaire for school situations: development and psychometric evaluation. Behav Change 15(1):31–40CrossRefGoogle Scholar
  36. 36.
    Achenbach TM, Rescorla LA (2001) Manual for the ASEBA school-age forms and profiles. University of Vermont Department of Psychiatry, BurlingtonGoogle Scholar
  37. 37.
    Tonge B, Dudley A, Melvin G, Heyne D, Rollings S (2006) School Refusal Program Consumer Satisfaction Questionnaire. Unpublished questionnaireGoogle Scholar
  38. 38.
    Heyne D, Rollings S (2002) School refusal (parent, adolescent and child training skills). BPS Blackwell, OxfordGoogle Scholar
  39. 39.
    Klein RG, Abikoff H, Barkley R, Campbell MJ et al (1994) Clinical trials in children and adolescents. In: Prien R, Robinson D (eds) Clinical evaluation of psychotropic drugs. Raven Press, New YorkGoogle Scholar
  40. 40.
    Posner K, Oquendo M, Gould M, Stanley B, Davies M (2007) Columbia classification algorithm of suicide assessment (C-CASA): classification of suicidal events in the FDA’s pediatric suicidal risk analysis of antidepressants. Am J Psychiatry 164(7):1035–1043CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Tanner JM (1962) Growth at adolescence. Charles C Thomas, Springfield, ILGoogle Scholar
  42. 42.
    StataCorp (2013) Stata statistical software: release 13. StataCorp LP, College StationGoogle Scholar
  43. 43.
    Carless BI, Melvin GA, Tonge BJ, Newman LK (2015) The role of parental self-efficacy in adolescent school-refusal. J Fam Psychol 29(2):162–170CrossRefPubMedGoogle Scholar
  44. 44.
    King NJ, Tonge B, Heyne D, Ollendick T (2000) Research on the cognitive-behavioral treatment of school refusal: a review and recommendations. Clin Psychol Rev 20(4):495–507CrossRefPubMedGoogle Scholar
  45. 45.
    Berman SL, Weems CF, Silverman WK, Kurtines WM (2000) Predictors of outcome in exposure-based cognitive and behavioral treatments for phobic and anxiety disorders in children. Behav Ther 31(4):713–731CrossRefGoogle Scholar
  46. 46.
    Rubenstein JS, Hastings EM (1980) School refusal in adolescence: understanding the symptom. Adolescence 15:775–782PubMedGoogle Scholar
  47. 47.
    Hammad TA, Laughren TP, Racoosin JA (2006) Suicide rates in short-term randomized controlled trials of newer antidepressants. J Clin Psychopharm 26(2):203–207CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Centre for Developmental Psychiatry and Psychology, Department of Psychiatry, School of Clinical Sciences at Monash HealthMonash UniversityNotting HillAustralia
  2. 2.Early in Life Mental Health ServiceMonash HealthClaytonAustralia

Personalised recommendations