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

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 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 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 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 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 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 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 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.

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 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 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 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 will be assessed as the proportion of enrolled participants who complete the post-intervention and follow-up assessment.

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.