EMI for Reducing Psychological Distress in Young Adults With Multiple ACEs: A RCT Study

• EMI (Behavioral): The ecological momentary intervention (EMI) is a 2-week smartphone-based intervention delivered in participants' daily lives. At the beginning of the intervention, participants will watch an approximately 10-minute psychoeducational video introducing the psychological principles underlying the intervention and the purposes of the exercises. They will then receive instructions on how to use the EMI program. During the intervention period, participants will receive brief ecological momentary assessments (EMAs) assessing their current emotional state. Based on their reported emotional valence, the program will provide tailored intervention content. When participants report negative or neutral emotional states (emotional valence ≤ 0), they will receive a negative-emotion module. This module includes brief breathing and grounding exercises, identification and labeling of current emotions, identification of potentially catastrophic or negative self-referential thoughts, cognitive reapprais

Primary outcomes

• Psychological Distress [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Psychological distress will be assessed using the 6-item Kessler Psychological Distress Scale (K6). Each item is rated on a 5-point frequency scale from 0 to 4. Item scores are summed to produce a total score ranging from 0 to 24, with higher scores indicating greater psychological distress.
• Catastrophizing [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Catastrophizing will be assessed using the catastrophizing subscale of the 18-item Cognitive Emotion Regulation Questionnaire (CERQ-18). The CERQ-18 consists of nine 2-item subscales. Each item is rated on a 5-point scale from 1 to 5. The two catastrophizing items are summed to produce a subscale score ranging from 2 to 10, with higher scores indicating more frequent use of catastrophizing as a cognitive emotion regulation strategy.
• Self-Esteem [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Global self-esteem will be assessed using the 10-item Rosenberg Self-Esteem Scale (RSES). Each item is rated on a 4-point scale from 1 to 4, with negatively worded items reverse-scored. Item scores are summed to produce a total score ranging from 10 to 40, with higher scores indicating higher levels of global self-esteem.
• Emotional clarity [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Emotional clarity will be assessed using the Lack of Emotional Clarity subscale of the 18-item Difficulties in Emotion Regulation Scale-Short Form (DERS-SF). The subscale consists of two items, each rated on a 5-point scale from 1 to 5. Item scores are summed to yield a total score ranging from 2 to 10, with higher scores indicating greater difficulties in emotional clarity.

Secondary outcomes

• Depressive Symptoms [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Depressive symptoms will be assessed using the 9-item Patient Health Questionnaire (PHQ-9). Each item is rated according to symptom frequency over the preceding 2 weeks on a 4-point scale from 0 (not at all) to 3 (nearly every day). Item scores are summed to produce a total score ranging from 0 to 27, with higher scores indicating greater severity of depressive symptoms.
• Anxiety Symptoms [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Anxiety symptoms will be assessed using the 7-item Generalized Anxiety Disorder scale (GAD-7). Each item is rated according to symptom frequency over the preceding 2 weeks on a 4-point scale from 0 (not at all) to 3 (nearly every day). Item scores are summed to produce a total score ranging from 0 to 21, with higher scores indicating greater severity of anxiety symptoms.
• Eating Disorder Symptoms [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Eating disorder symptoms will be assessed using the Chinere version of the 12-item Eating Disorder Examination Questionnaire-Short Form (EDE-QS). Each item is scored from 0 to 3. Item scores are summed to produce a total score ranging from 0 to 36, with higher scores indicating greater severity of eating disorder symptoms.
• Insomnia Severity [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Insomnia symptoms will be assessed using the 7-item Insomnia Severity Index (ISI). Each item is rated on a 5-point scale from 0 to 4. Item scores are summed to produce a total score ranging from 0 to 28, with higher scores indicating greater insomnia severity.
• Somatic Symptom Severity [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Somatic symptoms will be assessed using the 15-item Patient Health Questionnaire (PHQ-15). Each item is rated on a 3-point scale from 0 (not bothered at all) to 2 (bothered a lot). Item scores are summed to produce a total score ranging from 0 to 30, with higher scores indicating greater somatic symptom severity.
• Suicidal Ideation [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Suicidal ideation will be assessed using the first five screening items of the Beck Scale for Suicide Ideation (BSS). Each item assesses suicidal thoughts and attitudes over the preceding week, and is rated on a 3-point scale from 0 to 2. Item scores are summed to produce a total score ranging from 0 to 10, with higher scores indicating greater severity of suicidal ideation.
• Self-Injurious Behavior [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Self-injurious behavior will be assessed using four self-developed items. These items assess whether participants engaged in self-injury during the preceding week, the frequency of self-injurious acts, the number of days on which self-injury occurred, and the perceived likelihood of engaging in self-injury again. Higher values indicate more frequent self-injury or greater perceived likelihood of future self-injury.
• Urges to Engage in Self-Injury [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Urges to engage in self-injury will be assessed using the 5-item Alexian Brothers Urge to Self-Injure Scale (ABUSI). The scale assesses the frequency, intensity, duration, difficulty resisting, and overall severity of self-injury urges over the preceding week. Each item is rated on a 7-point scale from 0 to 6. Item scores are summed to produce a total score ranging from 0 to 30, with higher scores indicating greater severity of self-injury urges.
• Urgency [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Negative and positive urgency will be assessed using the Negative Urgency and Positive Urgency subscale of the Short UPPS-P Impulsive Behavior Scale (SUPPS-P), respectively. Each subscale contains 4 items rated on a 4-point scale from 1 to 4. After appropriate reverse scoring, the four items are summed to produce a score ranging from 4 to 16, with higher scores indicating a greater tendency to act impulsively when experiencing intense emotions.
• Aggression [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Aggression will be assessed using the 12-item Brief Aggression Questionnaire (BAQ). The scale measures four dimensions of aggression: physical aggression, verbal aggression, anger, and hostility. Each item is rated on a 7-point scale from 1 (extremely uncharacteristic of me) to 7 (extremely characteristic of me). After reverse-scoring the relevant item, scores are summed to produce a total score ranging from 12 to 84, with higher scores indicating greater levels of aggression.
• Functional Impairment [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Functional impairment will be assessed using the Sheehan Disability Scale (SDS). The scale contains 3 items assessing impairment in work or school, social life, and family life or home responsibilities. Each item is rated from 0 to 10. The three items are summed to produce a total score ranging from 0 to 30, with higher scores indicating greater functional impairment.
• Life Satisfaction [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Life satisfaction will be assessed using the 5-item Satisfaction With Life Scale (SWLS). Each item is rated on a 7-point scale from 1 to 7. Item scores are summed to produce a total score ranging from 5 to 35, with higher scores indicating greater satisfaction with life.
• Study Retention Rate [post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Study retention will be assessed as the proportion of enrolled participants who complete the post-intervention and follow-up assessment.
• Intervention acceptability [post-treatment (2 weeks)]: Intervention acceptability will be assessed using an adapted version of the Chinese Acceptability of Intervention Measure (cAIM). In addition to the original cAIM items, the adapted measure includes items assessing participants' willingness to recommend the intervention to friends and their willingness to continue using the intervention, informed by Wang et al. (2024). All items are rated on a 5-point scale from 1 (completely disagree) to 5 (completely agree), with higher scores indicating greater perceived acceptability of the intervention.

Other outcomes

• Alcohol Use [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Alcohol use will be assessed using the 3-item Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). The scale assesses alcohol consumption over the preceding 12 months, including drinking frequency, typical quantity of alcohol consumed, and frequency of heavy episodic drinking. Each item is rated on a 5-point scale from 0 to 4. Item scores are summed to produce a total score ranging from 0 to 12, with higher scores indicating greater alcohol consumption and increased risk of hazardous drinking.
• Externalizing Behaviors [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Externalizing behaviors will be assessed using an 11-item self-developed questionnaire. The questionnaire assesses the frequency of externalizing behaviors over the preceding 2 weeks, including rule-breaking, verbal and physical aggression, and impulsive behaviors. Each item is rated on a 5-point scale from 0 to 4, with higher scores indicating more frequent occurrence of externalizing behaviors. Item scores are summed to produce a total score ranging from 0 to 44, with higher scores indicating greater levels of externalizing behaviors.
• Psychotic-Like Experiences [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Psychotic-like experiences will be assessed using the 16-item Prodromal Questionnaire (PQ-16). The questionnaire assesses perceptual abnormalities, unusual thought content, and negative symptoms. Each item is rated as either present (1) or absent (0), with endorsed experiences further rated for associated distress on a 4-point scale from 0 (no distress) to 3 (severe distress). The total symptom score ranges from 0 to 16, and the total distress score ranges from 0 to 48, with higher scores indicating more psychotic-like experiences or greater associated distress, respectively.
• Complex Posttraumatic Stress Disorder Symptoms [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Complex posttraumatic stress disorder (CPTSD) symptoms will be assessed using the International Trauma Questionnaire (ITQ). The questionnaire includes 12 symptom items assessing posttraumatic stress disorder (PTSD) symptoms and disturbances in self-organization (DSO), along with 6 additional items assessing associated functional impairment. Each item is rated on a 5-point scale from 0 (not at all) to 4 (extremely). The 12 symptom items are summed to produce a total score ranging from 0 to 48, with higher scores indicating greater severity of CPTSD symptoms.
• Self-Compassion [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Self-compassion will be assessed using the 12-item Self-Compassion Scale-Short Form (SCS-SF). Each item is rated on a 5-point scale from 1 (almost never) to 5 (almost always). Negatively worded items are reverse-scored, and an overall mean score ranging from 1 to 5 is calculated, with higher scores indicating greater self-compassion.
• Difficulties in Emotion Regulation [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Difficulties in emotion regulation will be assessed using the 18-item Difficulties in Emotion Regulation Scale-Short Form (DERS-SF). The scale measures six dimensions: emotional awareness, emotional clarity, nonacceptance of emotional responses, difficulties engaging in goal-directed behavior, impulse control difficulties, and limited access to emotion regulation strategies. Each item is rated on a 5-point scale from 1 (almost never) to 5 (almost always). After reverse-scoring the relevant items, scores are summed to produce a total score ranging from 18 to 90, with higher scores indicating greater difficulties in emotion regulation.
• Cognitive Emotion Regulation Strategies [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: Cognitive emotion regulation strategies will be assessed using the 18-item Cognitive Emotion Regulation Questionnaire-Short Form (CERQ-18). The questionnaire measures nine strategies: self-blame, other-blame, rumination, catastrophizing, acceptance, positive refocusing, refocus on planning, positive reappraisal, and putting into perspective. Each item is rated on a 5-point scale from 1 (almost never) to 5 (almost always). Each strategy is assessed using two items, with subscale scores ranging from 2 to 10. Higher scores indicate more frequent use of the corresponding cognitive emotion regulation strategy.
• Self-esteem Instability [baseline, post-treatment (2 weeks), 2-week follow (4 weeks), 4-week follow-up (6 weeks)]: The Labile Self-Esteem Scale was used to measure the stability of self-esteem. The LSES consists of five items, each rated on a 5-point scale from 1 ("strongly disagree") to 5 ("strongly agree"). The total score is the sum of all items (range: 5-25), with higher scores indicating more unstable self-esteem.

Sex: All, ages: 18 Years to 29 Years

Inclusion Criteria:

* Aged 18-29 years.
* History of relatively high exposure to adverse childhood experiences (ACEs), defined as having experienced at least two types of ACEs.
* Presence of psychological distress, defined as a score of 5 or higher on the 6-item Kessler Psychological Distress Scale (K6).
* Able to read and understand Chinese fluently.
* Owns a smartphone with reliable internet access and is able to perform basic smartphone operations.
* Willing to participate in the study and provide informed consent.

Exclusion Criteria:

* Current or previous diagnosis of a mental disorder by a psychiatrist.
* High suicide risk as assessed using the self-report screening version of the Columbia-Suicide Severity Rating Scale (C-SSRS).