Professor Bruce Tongea, Associate Professor Neville Kinga, Dr Michael Gordonb, Mr Neil Colec , Dr Glenn Melvina, Dr Ester Klimkeitd, Dr John Taffed, Dr Leanne Rowee
a Monash University School of Psychology, Monash Medical Centre
b Consultant Psychiatrist, Southern Health
c Depression Awareness Research Project, Mental Health Research Institute of Victoria
d Monash University Centre for Developmental Psychiatry and Psychology
e Victorian Faculty of the Royal Australian College of General Practitioners
beyondblue Victorian Centre of Excellence
Project completion year
The aim was to investigate whether combined Cognitive Behaviour Therapy (CBT) and antidepressant medication treatment of young people who refuse to go to school (aged 11 to 15.5 years), particularly those with co-morbid depression, improved their response to treatment and longer term outcome.
Young people who refused to go to school were enlisted to participate in the study. Those who had less than 50 per cent attendance rates (with parental knowledge) in the four weeks before treatment and also had a diagnosis of an anxiety disorder were enrolled for participation.
One group received CBT only, a second received CBT along with the antidepressant fluoxetine and a third group received CBT treatment along with a placebo. The CBT comprised twelve 50-minute sessions over approximately 12 weeks. Parent therapy was conducted concurrently with CBT sessions. The antidepressant medication (or placebo) was prescribed and monitored by a child psychiatrist or a supervised child psychiatry registrar. Fluoxetine doses started at 10 mg and increased to a maximum of 60 mg, as required. After the initial 12 weeks of medication there was a maintenance phase treatment for a further 12 weeks, followed by monthly monitoring for a further three months. Acute and maintenance treatment brought treatment length to six months.
Self-report, doctor, parent and teacher tests variously measured the participants’ anxiety, depression, self-efficacy, general health and emotional response before, during and after treatment, and one year after treatment.
At the time of reporting eight families were actively involved in the program. Twenty-two families completed the program, including the 12-month follow-up assessment, and five more were scheduled to complete six or 12-month review assessments.
The project also aimed to train GPs and community youth mental health workers based in regional areas to identify and manage the anxiety and depression in young people refusing to attend school.
Insufficient participation prevented the opportunity for reliable conclusions about whether antidepressant medication combined with CBT is superior to CBT alone. Medication was generally well-tolerated and no participants ceased medication due to side effects, which were minimal.
Implications for policy, practice and further research
The randomised controlled trial has received funding from the National Health and Medical Research Council to implement a three-year continuation of this study.
An adapted version of the school refusal manual has been completed and nine staff members trained in treatment procedures and program delivery. Fortnightly team meetings are held as well as regular supervision for clinical staff. Presentations and workshops have been conducted at schools and clinics across Victoria.
The school refusal program — in which one clinician works with the young person and another with a parent or parents — has been established and is a useful treatment for young people experiencing significant emotional distress at the prospect of going to school.