Transdiagnostic intervention improves self-esteem in youths exposed to childhood adversity

A transdiagnostic, blended ecological momentary intervention (EMI) improves self-esteem in youths with prior exposure to childhood adversity, the SELFIE trial has shown.

Childhood adversity, including physical, emotional or sexual abuse, neglect, verbal or indirect bullying, and parental conflict, is one of the strongest risk factors for mental disorders. “In recent years, we have seen a shift in focus toward transdiagnostic frameworks, which broadly posit that early clinical phenotypes [eg, low self-esteem] are nonspecific and may result in a range of mental disorders later in life,” wrote the researchers. “Targeting low self-esteem in youths with exposure to childhood adversity is a promising strategy for preventing adult mental disorders.” [JAMA Psychiatry 2024; 81:227-239]

“EMIs offer a unique opportunity for real-time tailoring of interventions to what individuals need in a given moment and context,” pointed out the researchers. To evaluate the efficacy of a novel, 6-week transdiagnostic EMI with three face-to-face sessions and email contacts delivered by trained mental health professionals, the researchers conducted the randomized clinical SELFIE trial in 174 youths with exposure to childhood adversity and low self-esteem (Rosenberg Self-Esteem Scale [RSES] <26; mean age, 20.7 years; female, 89 percent) from December 2018 to December 2022.

Participants were randomly assigned to receive care as usual (CAU; ie, standard health care and social services) or blended EMI plus CAU. Primary outcome data on RSES self-esteem were provided by 153 participants (87.9 percent) postintervention and 140 participants (80.5 percent) at 6-month follow-up.

RSES self-esteem was significantly higher in the blended EMI + CAU group vs controls across both postintervention and follow-up (B, 2.32; 95 percent confidence interval [CI], 1.14–3.50; p<0.001; Cohen d-type effect size [Cohen d], 0.54).

Small to moderate effect sizes signalled beneficial effects on secondary outcomes with blended EMI + CAU vs CAU only, including lower levels of negative self-esteem (B, -3.78; 95 percent CI, -6.59 to -0.98; p=0.008; Cohen d, -0.38), negative schematic self-beliefs (B, -1.71; 95 percent CI, -2.93 to -0.48; p=0.006; Cohen d, -0.39) and self-reported general psychopathology (B,-17.62; 95 percent CI, -33.03 to -2.21; p=0.03; Cohen d, -0.34), higher levels of positive self-esteem (B, 3.85; 95 percent CI, 1.83–5.88; p<0.001; Cohen d, 0.53) and positive schematic self-beliefs (B, 1.58; 95 percent CI, 0.41–2.75; p=0.008; Cohen d, 0.38), as well as better quality of life (B, 1.16; 95 percent CI, 0.18−2.13; p=0.02; Cohen d, 0.33) across postintervention and follow-up period.

“Although primary prevention of childhood adversity continues to be of prime importance, it remains difficult to achieve,” commented the researchers. “The transdiagnostic, blended EMI allows delivery of youth-friendly, adaptive interventions for improving self-esteem and secondary outcomes.”

“[Our] findings are highly relevant for furthering understanding of self-esteem as a transdiagnostic mechanism and contribute to the growing knowledge of EMI development and implementation,” highlighted the researchers. “Further work should focus on implementing the novel EMI in routine public mental health provision.”