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

Abstract

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.

Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents

“…One study reported two trials that were treated independently for analyses 55 and another compared a drug+CBT group vs. a placebo+CBT group and was therefore excluded from the drug and placebo response analyses 59 . Characteristics of the thirty-six included trials (sTable 1) and details regarding heterogeneity and publication bias (S3) can be found in the Supplemental Material.…”

Practitioner Review: School refusal: developments in conceptualisation and treatment since 2000

“…As noted above, Melvin et al. () found that after intervention some students improved significantly in their school attendance and emotional symptoms, but few were free of anxiety symptoms over the period of follow‐up. Other studies (Flakierska, Linstrom, & Gillberg,,; Kearney, ; McCune & Hynes, ) suggest that at least one‐third of young people who have presented with school refusal (as the term is used in the present paper) are likely to experience serious adjustment difficulties in adulthood.…”

“…It was found that a significantly greater proportion of the medicated children achieved the target 75% attendance rate by the end of the treatment. However, given the health risks of this type of medication, and its limited impact in reducing adolescent depression (Hazell & Mirzaie, ), its use is not recommended (Melvin et al., ). Melvin et al.…”

“…Melvin et al. () employed an RCT design to examine whether augmenting CBT with fluoxetine improved school attendance and mental health for adolescents refusing school. Participants were selected on the basis of: <50% attendance for the past 4 weeks, evidence of severe emotional upset, an absence of characteristics of conduct disorder and parent evidence that parents had made reasonable attempts to enforce attendance.…”

Differentiation Between School Attendance Problems: Why and How?

“…A direct reference to different SAP types appeared in Broadwin's (1932) account of "a form of truancy ... [which] occurs in a child who is suffering from a deep-seated neurosis" (p. 254). Thereafter, efforts to identify SAP types burgeoned (e.g., Eisenberg, 1958;Kahn & Nursten, 1962;Partridge, 1939;Reid, 1985) and subdivisions within SAP types were also proposed. In the 1980s reviews of SR subtyping appeared.…”