IMIPRAMINE IN THE TREATMENT OF SCHOOL REFUSAL

School refusal (school phobia) is a common childhood and adolescent psychiatric syndrome with significant short-term and long-term sequelae. There is a need for controlled treatment studies in this area. The current proposal is to evaluate the efficacy of the tricyclic antidepressant imipramine and placebo in the treatment of school refusal patients employing a double-blind, parallel design, both administered in combination with a 4-week behavioral school reentry program. Children and adolescents with school refusal are a heterogenous population comprised of diagnostic subgroups including those with anxiety disorder only, depressive disorder only and both anxiety and depressive disorders (Bernstein & Garfinkel, 1986; Bernstein, in press). Although there is a high frequency of anxiety and depressive disorders in school refusers, only two controlled studies have evaluated tricyclic antidepressants in the treatment of school refusal (Gittelman-Klein and Klein, 1971,1973; Berney et al, 1981). The results of these investigation are contrasting. Therefore, further research is needed. 200 children and adolescents will be evaluated. Assessment instruments including the Diagnostic Interview for Children and Adolescents - Revised - Adolescents Version (DICA-R-A) and Diagnostic Interview for children and Adolescents - Revised - Parent Version (DICA-R-P), as well as clinician, self-report, parent and teacher rating scales, will define diagnoses and severity of symptomatology. Based on composite information form DICA-R-A and DICA-R-P, 105 subjects with comorbid anxiety and depressive disorders will be randomized to two treatment cells: 8 weeks imipramine or placebo in combination with a 4-week behavioral school reentry program. The school reentry program occurs during the first four weeks of medication treatment. A treatment manual describes details of the school reentry program. Anxiety and depression rating scales and weekly school attendance records are dependent measures of treatment response. Efficacy of treatment will be evaluated with repeated measures analyses of variance. All subjects will be reevaluated at one year after completing the treatment study to gather follow-up data.