An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents☆,☆☆

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Highlights

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    Anxiety and obsessive–compulsive disorder often onset in childhood and adolescence

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    Youth with these conditions exhibit deficits in inhibitory learning during extinction

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    Extinction learning is a central process in exposure-based cognitive behavior therapy

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    Exposure strategies that optimize inhibitory learning may compensate for deficits

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    Further research is needed to evaluate inhibitory learning strategies in youth

Abstract

Although exposure-based cognitive-behavioral therapy (CBT) is efficacious for childhood anxiety and obsessive–compulsive disorder (OCD), many youth do not adequately respond to treatment. Extinction learning is an important process in exposure-based CBT. However, youth with anxiety disorders and OCD exhibit impairments in extinction processes that are best characterized by deficits in inhibitory learning. Therefore, the utilization of strategies to optimize inhibitory learning during exposures may compensate for these deficits, thereby maximizing extinction processes and producing more robust treatment outcomes for exposure-based CBT. This paper reviews several strategies to optimize inhibitory learning in youth with anxiety disorders and OCD, and presents practical examples for each strategy. This paper also highlights the difference between inhibitory learning-based exposures and prior conceptual approaches to exposure therapy in clinical practice. It concludes with a discussion of future directions for clinical research on inhibitory learning and exposure-based CBT in youth.

Section snippets

Deficits in Extinction Learning in Youth With Anxiety Disorder and OCD

Although the etiology of anxiety disorders and OCD is multifactorial, the processes of fear conditioning and extinction learning are suggested to play an important role in the development, persistence, and treatment of these conditions (Duits et al., 2015, Lewin et al., 2014, Lissek et al., 2005). Fear conditioning refers to the process of learning that something is dangerous. It takes place when an emotionally neutral stimulus (called a conditioned stimulus,(CS) becomes paired with an aversive

Inhibitory Learning Strategies to Maximize Extinction During Exposures

Given the identified deficits in extinction learning among youth with anxiety disorders and OCD, there is likely clinical value to utilizing strategies that optimize inhibitory learning in order to strengthen extinction learning and improve clinical outcomes. Based on experimental studies, several clinical strategies to optimize inhibitory learning during exposure therapy have been suggested for adults with anxiety disorders and OCD (Abramowitz and Arch, 2014, Arch and Abramowitz, 2015, Craske

Differences Between Inhibitory Learning-Based Exposures, Classic Habituation-Based Exposures, and Behavioral Experiments Used in Cognitive Therapy

There are clear differences in theoretical orientation between inhibitory learning-based exposures and the classic habituation-based exposures or the behavioral experiments employed in cognitive therapy. Table 1 outlines the differences between these three approaches to exposures across several variables: overarching exposure goal, primary purpose, exposure hierarchy, gradation, distress level, frequency, duration, and discontinuation of safety signals/behaviors. While the overarching goal,

Discussion

Evidence-based CBT for youth with anxiety disorders and OCD is efficacious, but there is a clear need to enhance both the short- and long-term therapeutic outcomes. Several approaches to enhance outcomes have been explored, and include the augmentation of CBT with psychiatric medications and cognitive enhancers to facilitate extinction learning. The augmentation of CBT with serotonin reuptake inhibitor (SRI) medications has led to greater therapeutic outcomes in some clinical trials (Pediatric

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    ☆

    The authors declare that there are no conflicts of interest.

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    Support for this article comes in part from the National Institute of Mental Health (NIMH) of the National Institutes of Health (NIH) under award T32 MH073517. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or NIH.

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