Saavedra & Silverman (2002)

Aim To understand the causes of a button phobia in a child. To treat a child’s phobia of buttons using disgust and fear responses.


  • To understand the causes of button phobia (koumpounophobia) in a child.
  • To treat a child’s phobia of buttons using disgust and fear responses.

Classical conditioning was investigated by Ivan Pavlov. Classical conditioning is learning through association. 2 stimuli (neutral and unconditioned) are linked together to produce a new learned response. Some psychologists believe that phobias can be learned and unlearned just like other behaviours. Phobias may be caused by evaluative learning which is a type of classical conditioning where the individual forms an association between a previously neutral stimulus and a negative emotion.

Hepburn and Page (1999) – Page, in his study of adults with a blood phobia, found that treating patients’ disgust and fear would help them to make progress.

Research Method, Design and Variables
It was a case study involving one participant. His life history and treatment were studied in-depth. Data were collected using self-report measures. The boy and his mother were interviewed about the onset of his phobia and the subsequent behaviour.

A 9-year-old Hispanic American boy.
He started showing symptoms for 4 years prior to the start of the study when he knocked over a bowl of buttons in front of his class and teacher.
Sampled through the opportunity sampling technique.
The boy and the mother gave informed consent to participate and publish the results.

The DSM-IV (4th edition of the Diagnostic and Statistical Manual of Mental Disorders) was used to diagnose him with button phobia (koumpounophobia). The results of the treatment were measured using a 9-point scale of disgust known as the 'Feelings thermometer'.

An exposure-based treatment programme that tackled cognition and behaviours was used. With the suggestion of the boy, a special disgust and fear hierarchy using a distress rating from 0-8 was devised, with 8 being ‘small clear plastic buttons’ and 0 being 'large denim buttons'. The boy was asked to rate 11 different scenarios that included buttons. The subjective ratings were used as a Feelings Thermometer.

Interventions used

2 interventions were used:

  1. Positive Reinforcement Therapy ➔ a behavioural therapy based on operant conditioning. Using positive reinforcement principles, contingency management was applied. The boy was rewarded for showing less fear and for handling the buttons. The mother provided positive reinforcement if the boy successfully completed the gradual exposure to buttons. Sessions lasted for about 30 minutes with the boy alone, and 20 minutes with the boy and his mother.
  2. Imagery Exposure ➔ Imagery exposure therapy was based on classical conditioning using the Vivo method. An interview with the boy revealed that he found buttons touching his body disgusting and believed that buttons smelled unpleasant. This formed the basis for disgust imagery exercises. The boy was asked to imagine buttons falling on him, and consider how they looked, felt, and smelled. Exposures progressed from images of larger to smaller buttons, in line with the boy's fear hierarchy.

The boy had 4 sessions of behavioural exposure to the buttons using the hierarchy. Then 7 sessions were planned to look into his disgust imagery and cognitions. He got to know what he found disgusting about buttons and, researchers used self-control and cognitive strategies with him to change these thoughts.


Positive reinforcement therapy
The boy was observed approaching the buttons more positively. His objective ratings of distress increased between sessions 2 and 3. By session 4, the number of items on the hierarchy increased in dislike from the original scores.
Despite his behaviour to the fearful stimuli improving, his feelings of disgust and fear increased by the end of the therapy. Findings were consistent with evaluated learning.
Despite the behavioural change, evaluative reactions are unchanged or have increased.

Imagery exposure therapy
The therapy was successful in reducing his rating of distress. For example, when he had to imagine buttons falling on him, prior to imagery therapy/cognitive restructuring, he rated the experience as 8 on a scale of 0 to 8. This rating decreased to 5 midways through the session, and was just 3 by the end of the session.
The boy was followed up 6 and 12 months after treatment and at both times he did not meet the DSM-IV criteria for a specific phobia anymore. He could wear clear plastic buttons on his school uniform shirt.


  • Emotions and cognitions relating to disgust are important in the development and maintenance of a phobia.
  • Imagery exposure has a long-term effect on reducing distress relating to specific phobias as it tackles negative evaluations.

Strengths and Weaknesses

  • The study is highly valid as the participant was studied over a period of time.
  • Standardised measures such as the Feelings Thermometer were used.
  • Quantitative data collected show the improvements seen which were highly likely due to the treatment.
  • Qualitative data collected was helpful in understanding the reasons underlying phobias.
  • They got rid of his phobia.
  • The sample is difficult to generalise from as the case is less likely to be representative of the general population.
  • The study is subjective as the boy created his own hierarchy of disgust/fear and gave personal ratings.
  • The case study involved building rapport with the participant thus, there is less room for objectivity researcher bias may take place, further compromising validity.
  • There might have been demand characteristics shown as the boy was fully aware he was undergoing therapy; this might have affected the ratings he gave.

Application to real life
Shows how therapy based on classical conditioning can be used to treat some phobias. It also shows the long-term improvement from exposure therapies.

Nature vs Nurture
Classical conditioning relies solely on a nurture-based explanation of learning. Phobias are not innate but, are considered to be products of negative experiences with previously neutral stimuli.

Use of children in psychological research
The boy and the mother gave informed consent. The study was highly distressing however, researchers aimed to improve his quality of life which may justify the temporary distress caused during the treatment.