Saavedra and Silverman LA

Question 1

Introduction

Answer 1

*Dr Wendy Silverman is a prof of psych+child psychiatry at Yale school of medicine (where she’s the director of the child safety center anxiety and mood disorders program).
*She was the graduate advisor + mentor of (Now Dr) Lisette Saavedra
*Saavedra (therapy) and Silverman (supervisor) say that they felt “this child’s phobia would be of likely and novel interest to the field + an awesome way to show linkage between clinical core + clinical science!
*Drs say advice that helps anxious children and us all: “you gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You must do the thing which you think you cannot do”.

Question 2

Psych being investigated-Phobias

Answer 2

🔵 This study explores the case of a nine-year-old boy with a phobia of buttons.
🔵 A phobia is an intense fear or anxiety that occurs every time a person comes into contact with a certain object or situation.
🔵 Common phobias include spiders, flying, heights, blood and injections.
🔵 While these things may be scary for many people, a person with a phobia experiences a level of fear that is much higher than you might expect based on the actual level of danger.
🔵 In fact, many people have phobias of things that are completely harmless.
🔵 People with phobias will do whatever they can to avoid their feared object/situation and this can lead to difficulties at home, school and/or work.

Question 3

Psych being investigated-Classical conditioning

Answer 3

🔵 One explanation of phobias is that they are learned through classical conditioning.
🔵 If a neutral stimulus (something that normally does not cause fear) is present at the same time as something scary, we may learn to associate the neutral stimulus with the scary stimulus.
🔵 The previously neutral stimulus is now called a conditioned stimulus because it triggers the same level of fear as whatever it was that scared us in the first place.
🔵 This is called expectancy learning.

Question 4

Psych being investigated-Evaluative learning

Answer 4

🔵 Evaluative learning is a special type of classical conditioning.
🔵 If a neutral stimulus is paired with something that the person finds really disgusting, the previously neutral stimulus may now provoke the same negative reaction as the disgusting stimulus.
🔵 Evaluative learning is not the same as expectancy learning.
🔵 The person does not expect the object to cause harm (they do not feel scared), they just experience an involuntary disgust reaction due to the strong association that has been made.
🔵 They now perceive or evaluate the previously neutral stimulus in a negative way but cannot always explain why.

Question 5

Psych being investigated-Operant conditioning

Answer 5

🔵 Saavedra and Silverman used the principles of operant conditioning in their treatment of the boy’s button phobia.
🔵 They used positive reinforcement (praise from his mother) to reward him for handling buttons during the therapy sessions.
🔵 This made it more likely that he would approach buttons in a positive way in the future.

Question 6

Background-diagnosing phobias

Answer 6

🔵 Diagnostic manuals are used to decide whether a person’s symptoms are severe enough to require a diagnosis and subsequent treatment.
🔵 These contain detailed criteria that must be met, including the duration and type of symptoms.
🔵 Saavedra and Silverman refer to a manual called the Diagnostic and Statistical Manual (DSM) from the USA.
🔵 This classification system lists more than 300 disorders organised into 22 different categories.
🔵 The boy in this study was diagnosed using a semi-structured interview schedule called the Anxiety Disorders Interview Schedule for DSM-IV-Child and Parent versions (ADIS-C/P), which was based on the DSM-IV criteria.

Question 7

Background-disgust

Answer 7

🔵 Disgust is an important human emotion that helps us to survive (i.e. it is adaptive).
🔵 The emotion of disgust can reduce risk, including feeling sick/nauseous, ensure that we avoid eating things that could make us ill – for example, contaminated food or bodily waste.
🔵 Researchers have also shown that through evaluative learning we can learn to associate a harmless stimulus with one which causes disgust and this leads to anxiety and avoidance of the object/situation.

Question 8

Background-Previous research

Answer 8

🔵 S+S’s study was important bc, at time, few researchers had studied disgust and its role in the development and maintenance of phobias (especially in children).
🔵 Previous researchers had studied injury phobias and found that targeting disgust was helpful in reducing symptoms.
🔵 Öst and Hugdahl (1981) and De Jong et al. (1997) had found that people with blood phobias had both a disgust and fear reaction when exposed.
🔵 However, no one had tried to remove a disgust reaction in a phobic child.

Question 9

Example

Answer 9

Ants running on arm (UCS)-Disgust (UCR)

Flowers(NS)+Ants(UCS)=
Disgust (UCR)

Flower(CS)-Disgust(CR)

Question 10

Clinical case study

Answer 10

🔵 An in-depth investigation focused on significant aspects of an individual case, often involving behavior, mental health, or adjustment issues.
🔵 It is used to detect, diagnose, and treat psychological or behavioral problems through detailed observation and analysis.

Question 11

Saavedra and Silverman in brief

Answer 11

🔵 This case study describes how a young boy developed his phobias of buttons through evaluative learning, how the therapists confirmed his diagnosis of specific phobia and then how they went on to treat him using a combination of behavioural exposure and disgust imagery exposure and cognitions.
🔵 Saavedra and Silverman explain that targeting disgust in this unusual phobia was central to the success of the treatment.

Question 12

AIMS

Answer 12

1. Highlight the role of evaluative learning and disgust in the development and treatment of children’s phobias.
2. Test the efficacy (effectiveness) of imagery exposure as part of an exposure-based cognitive-behavioural treatment for a specific phobia of buttons.

Question 13

Research Methodology

Answer 13

🔵 example of a case study.
🔵 The researchers present an in-depth exploration of a single case of an unusual/rare condition: button phobia.
🔵 Both qualitative and quantitative data were provided using a variety of methods – structured interview, observation and the use of a psychometric scale to measure subjective distress.
🔵 The study was longitudinal as the boy’s behaviour was studied before, during and after treatment, and he also attended follow-up sessions at 6 and 12 months after treatment.

Question 14

Research Methodology-Measured Variables

Answer 14

🔵 The boy’s approach and avoidance behaviours were carefully observed and recorded during the therapy sessions.
🔵 Approach behaviours included touching, holding and manipulating the buttons.
🔵 A feelings thermometer was used to score the participant’s subjective level of distress on a nine-point scale ranging from 0–8

Question 15

Research Methodology-Sample

Answer 15

🔵 The pp was a nine-year-old Hispanic-American boy from Florida, USA.
🔵 He was selected for the study as his mother had brought him to the Child Anxiety and Phobia Program at Florida International University in Miami due to his phobia of buttons.
🔵 His phobia had started when he was five years old and the boy had been living with his condition for four years.
🔵 He did not have any other diagnosed disorders (e.g. obsessive-compulsive disorder, OCD).

Question 16

4 Methodology points

Answer 16

-Case Study
-Interview
-Rating Scale
-Observation

Question 17

Procedure-Initial assessment/Diagnosis

Answer 17

🔵 The boy + mother were interviewed using a semi-structured interview schedule called the Anxiety Disorders Interview Schedule for DSM-IV–Child and Parent versions (ADIS-C/P).
🔵 This interview allowed researchers to confirm that the boy met the criteria to be diagnosed with a specific phobia.
🔵 This was due to his marked and persistent avoidance of buttons.
🔵 Researchers also asked the boy and his mother about stressful life events that may have triggered the phobia.
🔵 Sometimes anxiety disorders can be triggered by traumatic events (e.g. sexual or physical abuse or accidents) and the researchers needed to rule this out before deciding on the best way to treat him.
🔵 They also checked to see whether he met the criteria for any other disorders, such as OCD.
🔵 Neither the child nor mother mentioned the key symptoms of OCD (recurrent, persistent and/or intrusive thoughts, impulses or images) and so this was ruled out.

Question 18

Procedure-Treatment:Behaviorral exposure

Answer 18

🔵 This phase included four 50-minute exposure-based treatment sessions, 30 minutes on his own and 20 minutes with his mother.
🔵 ● Creating a disgust/fear hierarchy: The boy worked with the therapists to create a list of 11 stimuli relating to buttons.
🔵 They used the feelings thermometer to help the boy identify how distressing each stimulus would be for him.
🔵 They then placed the stimuli into rank order from those that caused him the least distress [large denim jean buttons = 2/8] to the type of buttons that caused him greatest distress [small coloured and small clear plastic buttons = 8/8] (see Table 3.10).
🔵 ● In vivo exposures: These involved gradual exposures to buttons in vivo (in real life).
🔵 If the boy was able to tolerate the buttons, his mother would reward him with praise [positive reinforcement].
🔵 This is known as contingency management.

Question 19

Procedure-Table of Hierarchy of distress (ratings)

Answer 19

1-Large denim jean buttons - 2
2-Small denim jean buttons - 3
3-Clip-on denim jean buttons -: 3
4-Large plastic buttons (coloured) - 4
5-Large plastic buttons (clear) - 4
6-Hugging mother when she wears large plastic buttons - 5
7-Medium plastic buttons (coloured) - 5
8-Medium plastic buttons (clear) -6
9-Hugging mother when she wears regular medium plastic buttons - 7
10-Small plastic buttons (coloured) - 8
11-Small plastic buttons (clear) - 8

Question 20

Procedure-disgust related imagery exposure

Answer 20

This phase included seven sessions where the therapists asked the boy to describe how buttons look, feel and smell and to explain how he felt while imagining them.

The therapists prompted him to imagine buttons of different sizes, including small ones, which he found most distressing.

They also used a technique called cognitive restructuring.(in essence chelp shape and change way they think).

Question 21

Procedure-Post treatment + follow up phase

Answer 21

The ADIS-C/P was used directly after treatment to measure the efficacy of the treatment and again 6 and 12 months later. (in which he did not meet phobia criteria anymroe-demonstrating sucess)

Question 22

Results-When did the phobias begin?

Answer 22

When asked about stressful life events that might have triggered his phobia, the boy recalled a day at kindergarten (nursery school).

He was working on an art project when he ran out of the buttons that he was gluing onto his poster.

He went to the front of the class to take some more buttons from a large bowl on his teacher’s desk. As he reached in, his hand slipped and the buttons fell onto him.

He said the event was distressing. He and his mother agreed that his avoidance of buttons had increased since this event and that he had not faced any other stressful or traumatic events that might be linked to his phobia.

Question 23

Results-How was the boys daily functioning affected?

Answer 23

To begin with, he did not have too many problems but gradually he became unable to touch/handle buttons.
-unable to get dressed by himself and his schoolwork suffered because he could not concentrate; he was too worried about touching his school uniform or anything that might have been touched by his shirt buttons.

-At home, he avoided clothes with buttons and people with buttons on their clothing.

Question 24

Progress in the first 4 sessions: behavioral exposure

Answer 24

Positive outcomes: The boy faced all 11 situations listed in his disgust hierarchy. Approach behaviours increased – for example, he could tolerate more buttons with each exposure.

Negative outcomes: Subjective ratings of distress (measured using the feelings thermometer) increased dramatically between sessions 2 and 3 and sessions 3 and 4.

He reported being more distressed by ‘medium, coloured buttons’ and ‘hugging his mother when she wears large plastic buttons’ than he was when he first created the hierarchy.

This was expected according to the theory of evaluative learning and disgust-based phobias, which differ from fear-based phobias.

Question 25

Data: Ratings of distress relative to manipulation of buttons in treatment exposure

Answer 25

(approx) Exposure session 1: -Num of buttons manipulated: 10 -Severity rating: 2 Exposure session 2: -Number of buttons manipulated: 20 -Severity rating: 3 Exposure session 3: -Number of buttons manipulated: 30 -Severity rating: 6 Exposure session 4: -Number of buttons manipulated: 40 -Severity rating: 8

Question 26

Results- The next 7 sessions: disgust related imagery and cognitions

Answer 26

In these sessions, the therapists asked the boy to describe buttons in detail—how they looked, felt, and smelled—while also encouraging him to explain how he felt imagining them. This disgust imagery exposure included prompts to visualize different sizes of buttons, focusing particularly on small buttons, which had previously caused the most distress. Additionally, cognitive restructuring techniques were employed to modify his reactions to these stimuli.

Question 27

Results: Table of subjective distress ratings, before,during,after disgust related imagery exposure.

Answer 27

Before the exposure sessions: -asked to imagine hundreds of buttons falling all over his body (Distress Rating-8) -imagine hugging his mother while she wore "a shirt full of buttons." (7) During exposure: -5 -4 After exposure: -3 -3

Question 28

Post treatment: 6&12 month follow up

Answer 28

Long-term assessments conducted at 6 and 12 months post-treatment confirmed the success of the intervention. The boy continued to demonstrate reduced distress levels when confronted with buttons, indicating lasting improvement.

Question 29

Conclusions

Answer 29

Following the disgust-related imagery exposure, the boy’s distress reactions significantly decreased across all scenarios. This suggests that exposure therapy incorporating cognitive restructuring and disgust-based imagery can be effective in treating phobias related to specific objects. The continued reduction in distress levels during follow-ups supports the long-term effectiveness of the intervention.

Question 30

Evaluation-Ethical issues-Informed consent

Answer 30

Informed Consent: A key strength of this study was that researchers obtained informed consent from both the boy and his mother. -The mother provided consent for both the initial assessment of her son’s condition and the subsequent treatment program. -Additionally, she consented to the case study being published. This was especially critical given the vulnerability of the child and his mother due to his severe phobia. Informed consent ensured that the boy was protected from potential psychological harm. Anonymity Concerns: -Despite the informed consent, there was a potential ethical weakness regarding anonymity. The study included detailed information about the triggering event—when the bowl of buttons tipped onto the boy in kindergarten—as well as his age, ethnicity, and location (Miami). -These details may have made him recognizable to his classmates or his kindergarten teacher. Since case studies often contain extensive personal information, anonymity is a common concern. -If the boy’s identity had been unintentionally revealed, he could have been exposed to greater risk despite his mother’s consent for publication.

Question 31

Evaluation-Methodological issues-Reliability-test retest reliability of the diagnostic interviews schedule.

Answer 31

A strength of the study was the use of the ADIS-C/P, which has demonstrated strong reliability in diagnosing specific phobias in children aged 6–11. Research by Silverman et al. (2001) tested children twice within 7–14 days and found a correlation of +0.84, showing that the boy’s diagnosis was highly reliable.

Question 32

Evaluation-Methodological issues-Reliability-Difficulty of replication

Answer 32

One limitation of the case study method is the difficulty in replicating the findings due to the lack of standardization. Therapy sessions are dynamic and tailored to the individual client’s needs. E.g if the boy was experiencing heightened distress during a particular session, the therapist might have adjusted the approach by engaging in additional conversation before continuing exposure exercises. This spontaneity means that the exact procedure cannot be replicated with another individual, making it impossible to test the study’s reliability through replication.

Question 33

Evaluation-Methodological issues-Validity-Longitudinal design

Answer 33

A strength of the study was the inclusion of follow-up sessions at 6 and 12 months. Some studies assessing therapy efficacy do not conduct follow-ups, or they only follow participants for a short time post-treatment. Since the boy remained symptom-free during both long-term follow-ups, this provides strong evidence that imagery exposure therapy can have lasting effects in treating disgust-related phobias in children. Without follow-up assessments, researchers would be unable to determine whether symptoms could return over time.

Question 34

Evaluation-Methodological issues-Validity-Case study method

Answer 34

Using the case study approach allowed researchers to collect rich and detailed data through various methods. The ADIS-C/P semi-structured interview was used for diagnosis. Observations documented how the boy interacted with buttons during therapy sessions, and his distress levels were measured using a thermometer scale. This use of triangulation—combining multiple methods of data collection—improved the validity of the study by ensuring comprehensive and well-supported findings.

Question 35

Evaluation-Methodological issues-Objectivity and Subjectivity

Answer 35

One major concern in the study is potential bias in self-reported data. Both the boy and his mother provided subjective accounts of his experiences, including his distress ratings and the impact of the therapy. There are several factors that may have influenced these responses: Mother's perspective: The mother might have unintentionally exaggerated or minimized her son’s distress due to her own emotional involvement. If she had heightened anxiety about his condition, she could have reported higher distress levels. Conversely, if she was eager for the therapy to succeed, she might have downplayed the severity of his reactions after treatment. Boy’s perspective: The boy may have felt pressure to please the therapists, influencing his reports of distress reduction. The fact that his therapy was being monitored and documented might have encouraged him to report progress even if he still felt discomfort. Thus, while the study’s results indicate a clear reduction in distress levels, they should be interpreted with caution due to the subjective nature of the data.

Question 36

Evaluation-Methodological issues-Generalisations and ecological validty: Generalising beyond the sample

Answer 36

Since the study is a case report based on a single Hispanic-American nine-year-old boy, its findings might not easily generalize to other populations. Several factors affect generalizability: The therapy was conducted by highly trained experts at a prestigious university clinic. Children undergoing similar therapy in less resourced environments or with less experienced therapists may not achieve the same results. Cultural and familial differences may influence responses to exposure therapy. The imagery exposure technique was successful for this boy, but its effectiveness could vary for children from different backgrounds. Additionally, ecological validity—the extent to which findings apply to real-world situations—is limited by the controlled clinical setting. While the therapy helped the boy within that environment, there’s no certainty that the same intervention would be equally effective outside of structured sessions.

Question 37

Issues and Debates: Use of children in psych research

Answer 37

This study involved working with a nine-year-old child, which raises important ethical and methodological considerations. The researchers used age-appropriate tools such as a specially adapted version of the Anxiety Disorders Interview Schedule (ADIS-C/P) and a feelings thermometer to measure distress, ensuring the child’s responses were as accurate as possible. However, young children may struggle to articulate their feelings fully, affecting data reliability.

Question 38

Issues and debates Applications to everyday life

Answer 38

The findings suggest that disgust-based phobias may require specialized therapeutic approaches beyond traditional exposure therapy. One key takeaway is that therapists should be trained to target disgust, rather than focusing solely on fear. Training programs could integrate imagery exposure techniques more effectively to treat similar cases. Saavedra and Silverman’s study indicates that some phobias cannot be treated successfully through standard exposure therapy alone, making imagery-based methods an essential tool for therapists.

Question 39

Reflections

Answer 39

Saavedra and Silverman’s findings highlight the potential of imagery exposure in treating disgust-related phobias. While traditional exposure therapy has long been used to treat specific phobias, this study demonstrates that disgust-based anxiety requires different interventions. Further research should explore whether imagery exposure could be useful for other types of phobias. Additionally, future studies could investigate how therapist expertise and cultural differences impact the effectiveness of this treatment.

Question 40

Classification Systems

Answer 40

🔵 Classification systems help psychiatrists (medical doctors specialising in the diagnosis, prevention and treatment of mental disorders) and clinical psychologists to decide whether a person has a specific disorder or not and, if so, which disorder they have. 🔵 The DSM is used in many countries around the world but was originally published in 1952. 🔵 It has been revised several times since, and in 2001 (when Saavedra and Silverman completed their study) it had been updated four times. 🔵 This is why it is referred to as DSM-IV – the IV stands for four in Roman numerals. 🔵 In 2013, the fifth version was released and it is now referred to as DSM-5. 🔵 Another commonly used system is the International Classification of Diseases and Related Health Problems (the ICD), which is published by the World Health Organization. 🔵 This system has also seen many revisions and the newest version, ICD-11, will be used from 2022. 🔵 Some countries also have their own systems, such as the Chinese Classification of Mental Disorders (CCMD-3).

Question 41

Saavedra and Silverman initially employed positive reinforcement therapy, but they transitioned to a different approach due to unintended outcomes...

Answer 41

Initially treated using positive reinforcement therapy where his mother rewarded him for handling buttons. While this led to some behavioral improvements, it also unexpectedly increased his feelings of disgust, and his distress levels rose over time. Recognizing that the treatment wasn't effectively addressing the emotional root of the phobia, the therapists discontinued the positive reinforcement approach. They then shifted to imagery exposure therapy, where the boy imagined distressing button-related scenarios. This targeted his disgust response directly. Over several sessions, his distress levels significantly decreased. Follow-up assessments at 6 and 12 months showed lasting improvement—he could wear buttons without fear or disgust. This was successful. In vivo tehrapy exposure also helped.