School refusal is another disorder with emerging treatment data in the literature. King and Bernstein define school refusal as difficulty attending school that is associated with emotional distress, especially anxiety and depression. Separation anxiety and school phobia have been used interchangeably; however, several studies focus on treatment of school refusal as its own entity apart from separation anxiety. School refusal affects approximately 5% of all school-age children. There is a bimodal peak for age of onset—5-6 years and 10-11 years of age. There have been two studies that support the efficacy of CBT for school refusal since 1992. In a trial by King et al, 34 children ages 5-15 years were randomly assigned to a four-week cognitive-behavioral intervention which included six individual therapy sessions evenly distributed across the four-week treatment period with the child, five with the parents involving training in behavior management skills with the goal being school attendance, and one session with the teacher or a wait-list control condition. The results indicated that CBT is efficacious in the treatment of school-refusing children. Eighty-eight percent of the CBT children in contrast to 29% of the wait-list children showed clinical improvement in school attendance. Last and colleagues conducted a study randomizing 56 children to either a 12-week CBT group or an attention-placebo control group. The CBT condition consisted of graduated in vivo exposure, cognitive restructuring and coping self-statement training. The attention-placebo control group received educational-support therapy. The findings revealed no statistically significant differences between the CBT children and the educational-support-therapy children. Both groups showed improvements on a variety of measures, including school attendance.

Generally, medications are considered as part of a multimodal treatment plan for children and adolescents diagnosed with anxiety disorders (Generic Desyrel is a modified cyclic antidepressant). To our knowledge, there is only one study that has investigated a multimodal treatment for school refusal. Bernstein and colleagues investigated the efficacy of eight weeks of imipramine versus placebo, with each group receiving cognitive-behavioral therapy for the treatment of school-refusing adolescents. A noteworthy fact regarding this study is that major depressive disorder was not an exclusion criterion as it is in many of the other studies reviewed. Anxiety and depressive symptoms improved for both groups; however, school attendance lagged in the placebo group. The low response rate with the placebo-plus-CBT group can be explained by the fact that school refusers with comorbid depression and anxiety have more severe symptoms. These findings support a multimodal treatment approach using pharmacotherapy plus CBT.