Test of an Inhibitory Learning Model of Extinction in Treatment of Anxious Youth

Exposure therapy—which involves repeatedly exposing individuals to feared situations to
change their fear responses to and beliefs about those situations--has been a mainstay of
treatments for anxiety disorders since it was developed in the 1950s. Today, exposure therapy
is the most commonly-occurring treatment technique included in well-supported treatments for
anxiety disorders, and meta-analyses have indicated that exposure is more strongly associated
with treatment gains in anxious youth compared to non-behavioral interventions. Despite its
effectiveness, approximately 40% of anxious youth fail to achieve clinically significant
benefit from exposure therapy. This indicates that further research is needed regarding
strategies for optimizing exposure therapy so that it is effective for a greater proportion
of youth.

There is clearly a need to optimize exposure therapy for youth, but at the same time very
little empirical data exists regarding how exposure works or the best way to conduct
exposures. Common wisdom about exposure, based on emotional processing theory, dictates that
exposure works by breaking and eliminating conditioned fear responses through a process
called habituation. This viewpoint dictates that exposure should be conducted until
habituation occurs (i.e., until a physiological fear response reduces by at least 50%), and
that habituation both during and between exposure sessions is necessary for improvement. As
exposure therapy has evolved, other common practices have emerged that lack clear evidence
supporting their efficacy. For example, it is common clinical practice to encourage youth to
challenge their thoughts about a feared situation before and during an exposure (i.e.,
cognitive restructuring), even though clear evidence does not exist to support this practice.
Additionally, it is common for clinicians to create a "fear ladder" or "hierarchy" with
patients before beginning exposures. This hierarchy typically takes the form of a
rank-ordered list of exposures or feared stimuli from least to most difficult, and clinicians
move up this list systematically from the easiest to most difficult items during treatment.
Again, there is little clear evidence to support this practice.

More recent research on fear extinction indicates that exposure therapy does not cause threat
associations to disappear but rather leads to the formation of non-threat (i.e., inhibitory)
associations that compete with and weaken older threat associations. The goal of exposure
therapy, according to this model, is to strengthen these non-threat associations and weaken
threat associations. Research on inhibitory learning has turned many of the long-standing
exposure practices discussed in the previous paragraph on their head by providing new
guidelines for optimizing exposure therapy. Many of these new guidelines differ significantly
from common clinical practices and are designed to maximize learning of inhibitory
associations. These guidelines are as follows:

1. Design exposures that maximally violate a patient's expectations about how bad an
outcome would be or how often it will occur. In clinical practice, an exposure that
maximally violates expectancies is one that is terminated not when fear habituates or
reduces by a certain amount (e.g., "What is your fear rating?") but rather when the
patient's expectancy of a bad outcome is significantly reduced. (e.g., "What do you
think the chances are that X will happen?).

2. Do not instruct patients to change their thinking about a feared situation before or
during and exposure. The principle of maximum violation of expectancies dictates that
participants should not be encouraged to use cognitive reappraisal (e.g., strategies for
thinking more realistically or accurately) during an exposure, as such strategies reduce
the expectation that a negative outcome will occur and thus prevent maximum violation of
expectancy.

3. Introduce variability of stimuli into exposure tasks by moving up and down a fear ladder
randomly. Inhibitory learning theory suggests that clinicians should frequently vary the
difficulty of exposure to stimuli to create a consistently high level of emotion, which
has been associated with superior extinction learning. This guideline means that,
instead of moving up a fear hierarchy or ladder in a systematic way from least to most
difficult over time, and moving on to more difficult items after habituation to easier
ones has occurred, clinicians should design exposures that will allow patients to
achieve variable but generally high levels of fear or anxiety over the full course of an
exposure.

In this study, the investigators plan to test these clinical practice guidelines derived from
inhibitory learning against standard exposure practice. A few studies have empirically tested
these and/or other clinical practice guidelines established based on inhibitory learning in
clinical adult samples. However, no known studies have yet empirically tested the efficacy of
an inhibitory learning approach to exposure therapy in youth with anxiety or other emotional
disorders, nor have any known studies tested the acceptability or feasibility of such an
approach. Therefore, in this study the investigators propose to conduct a small-scale, pilot
randomized controlled trial (RCT) examining the feasibility, acceptability, and relative
efficacy of applying an inhibitory learning approach to exposure in youth. Up to 20 youth
will be randomized to one of two groups—standard exposure (SE) or exposure conducting
according to inhibitory learning principles (E + IL). Given the small n for this study, the
primary goal will be to assess feasibility and acceptability of an inhibitory learning
approach to exposure, while establishing the efficacy of this approach relative to SE is
exploratory. This study, along with planned larger-scale RCTs to follow, will help to inform
clinical care guidelines for best practice of exposure therapy with anxious youth.

Inclusion Criteria:

1. Primary or secondary diagnosis of an anxiety disorder

2. Ability of both child and caregiver to read and understand English

3. Ability of child and at least one caregiver to attend weekly sessions

Exclusion Criteria:

1. Diagnosis of autism spectrum disorder, intellectual development disorder, or limited
cognitive functioning (i.e., documented Intelligence Quotient [IQ]<80).

2. Diagnosis of a psychotic disorder or bipolar disorder

3. Severe and current suicidal ideation, history of suicide attempt in past six months,
or frequent and persistent self-injurious behavior

4. Diagnosis of a substance use disorder or significant, recent substance use

5. Any youth receiving concurrent individual therapy will also be excluded from the
study.