Can a transdiagnostic, blended ecological momentary intervention improve self-esteem in youth with low self-esteem and prior exposure to childhood adversity?

Childhood trauma or other adverse childhood situations are associated with a higher risk of mental disorders in adult life. Research has shown that ecological momentary interventions (EMIs) are suitable for producing improvement in self-esteem using age- and context-appropriate customized interventions. Still, there is little evidence from clinical trials to support this concept.

A new study in JAMA Psychiatry reports on the results of a four-year randomized clinical trial (RCT) comparing usual care alone or coupled with SELFIE, a form of EMI, in young people with a history of adversity during childhood.

While mental disorders are often first diagnosed in adolescence and early adult life, the seeds are sown in childhood in a large proportion of cases. Recent work suggests that the early clinical presentation may be hard to recognize but result in adult mental disorders – the so-called transdiagnostic framework.

Since it is almost impossible to prevent childhood exposure to adversity, secondary prevention in the form of interventions that aim to mitigate the negative consequences is achievable and promising in its potential usefulness.

One such intervention targets a major result of childhood adversity, low self-esteem, which is likely to be linked to adult mental disorders. This is supported by findings demonstrating that momentary self-esteem as measured with Ecological Momentary Assessment (EMA), may mediate later mental ill-health.

The SELFIE intervention uses such findings to design EMIs in youth who have already shown signs of early mental ill-health. These are aimed at targeting individual needs in each situation at a given moment, in real time, thus enhancing resilience and wellbeing by improving momentary self-esteem on a daily and routine basis.

The current Netherlands multi-center study took place from December 2018 to December 2022, comprising equal numbers of participants from secondary mental health services and the general population. Participants were between 12 and 26 years of age, and all showed low self-esteem.

While most described an abusive childhood, physical and sexual abuse were reported in 37% and nearly 60% of cases.

All were randomized to either care as usual (CAU) or CAU with a blended EMI (CAU-EMI) comprising face-to-face interactions as well as email- and app-based conversations personalized to each individual. The researchers measured self-esteem using validated tools at baseline and after the intervention, as well as after six months. In addition, they evaluated self-beliefs and general mental disorders, if present, the quality of life, the presence and type of other symptoms as observed by the researchers, and the level of functioning.

What did the study show?

There were ~175 participants, the mean age being 21 years. Almost 90% were female, and the type of childhood adversity ranged from emotional neglect or abuse through bullying (indirect or verbal) or conflict between the parents.

The continuation rate was 87%, while 81% made it to follow-up. Following the intervention, the mean self-esteem score was higher in the CAU-EMI group than in the CAU group, and this persisted at follow-up. Additionally, the secondary outcomes showed a small to moderate benefit, including higher momentary self-esteem and positive mood.

These included a reduction in negative self-esteem and negative self-beliefs but a boost in positive self-esteem and positive self-beliefs. The youngsters in the CAU-EMI group reported less mental ill-health and had a better quality of life.

However, the scientists were unable to capture any observable reduction in externally apparent symptoms or mental distress. There was no improvement in their level of functioning or emotional wellbeing.

What are the implications?

The results of this pioneer RCT on the efficacy of EMI show an increase in self-esteem and improved mental health outcomes. The youngsters engaged with the intervention at moderate to high levels without obvious adverse effects. The care taken in designing the intervention paid off in that there were no access or availability barriers to this care.

“Taken together, these findings are highly relevant for furthering our understanding of self-esteem as a transdiagnostic mechanism while, at the same time, contributing to the growing knowledge of EMI development and implementation.”

Researchers need to understand how and why this works. The lack of improvement in clinical symptoms and level of functioning must be probed by modified EMI methodology and longer follow-up periods.

Since the majority of participants in this study were female and Dutch, future work must include more males at risk and people from other languages and cultures. “Further work should focus on implementing this novel EMI in routine public mental health provision.”