Competitive Memory Training (COMET) for Low Self-Esteem
in Children and Adolescents: A Pilot Study
E.B. Galesloot University of Amsterdam
Masterscriptie Orthopedagogiek
Pedagogische en Onderwijskundige Wetenschappen Eerste beoordelaar: mevr. dr. F.J.A. van Steensel
mevr. drs. M. Kuin
Tweede beoordelaar: mevr. Prof. dr. S.M. Bögels Studentnummer: 10284087
Contents
Abstract ... 3
Introduction ... 4
Self-esteem ... 4
Development of Self-esteem ... 5
High versus low Self-esteem ... 6
Consequences of a low Self-esteem ... 7
Current study ... 8
Hypotheses ... 9
Method ... 10
Participants ... 10
Procedure ... 11
Competitive Memory Training ... 12
Measures ... 13
Data analyses ... 15
Results ... 16
Effectiveness of the COMET for children and adolescents ... 16
Correlations ... 18
Discussion... 20
Abstract
Kuin and Peters developed a training for children and adolescents with a low self-esteem, based on the Competitive Memory Training (COMET). In this pilot study the effect of the adjusted training was measured in an individual setting (n = 10) and in a group setting (n = 25).
Participants were clinically referred children aged 8-22 years. Self-esteem, depressive mood and problem behavior were assessed with the CBSK, CBSA, RSES, CDI and CBCL. The pre- and post-test difference showed that the adjusted COMET is effective for improving self-esteem in children and adolescents. Additionally, a trend effect was found on depressive symptoms and medium – although not significant – improvements were found for behavior problems in general. Shortcomings of this study and possible clinical implications are discussed.
Keywords: self-esteem, COMET, children and adolescents
Samenvatting
Kuin en Peters hebben een training ontwikkeld voor kinderen en adolescenten met een laag zelfbeeld, gebaseerd op de Competitive Memory Training (COMET). In deze pilot studie is het effect gemeten van deze aangepaste training in een individuele setting (n= 10) en in een
groepsetting (n= 25). De deelnemers aan het onderzoek waren kinderen tussen de 8-22 jaar, uit de klinische setting. Zelfbeeld, depressieve symptomen en probleemgedrag werden gemeten middels de CBSK, CBSA, RSES, CDI en CBCL. De verschilscore tussen de voor- en nameting tonen dat de aangepaste COMET effectief is voor het verbeteren van het zelfbeeld in kinderen en adolescenten. Aanvullend is een trend effect gevonden voor een afname in depressieve symptomen en een middelgrote – ofschoon niet significante – vermindering in
gedragsproblemen. Tekortkomingen van deze studie en mogelijke klinische implicaties worden besproken.
Introduction
This thesis reports about a pilot study concerning the effectiveness of a protocol for children between eight and sixteen years old with a negative self-esteem. The training is based on the Competitive Memory Training (COMET) and is found to be effective for adults (Fluri & Korrelboom, 2010). COMET uses the competitive memory retrieval theory of Brewin (2006), where it is assumed that in the long-term memory every concept is associated with different meanings and qualifications. In COMET clients learn to make positive associations (Maarsingh, Korrelboom, & Huijbrechts, 2010). This is the first study on the effectiveness of this training adapted for clinically referred children and adolescents.
Self-esteem
Self-esteem refers to a person’s global appraisal of their positive or negative value, based on different roles and domains of life (Mann, Hosman, Schaalma, & De Vries, 2004). Self-evaluation of our behavior can have two different outcomes: we can hold ourselves responsible or not responsible for the action being evaluated. When we conclude that we are responsible, than we can evaluate our behavior as successful or unsuccessful. This is a specific self-attribution that refers to specific features or actions of the self. There is also a global form of attribution where the evaluation refers to the whole self (Lewis, 2008). Global self-esteem is an affective construct consisting of self-related emotions linked to worthiness, value, likeableness, and acceptance (Kernis, 2003).The global and the domain-specific form of self-esteem can be considered as either a trait or a state. A trait is stable over time, while a state fluctuates according to the immediate circumstances or situation (Crocker, Sommers, & Luhtanen, 2002).
Development of Self-esteem
At the age of four months most children are able to distinguish themselves from others. Self-recognition is the realization that one's own reflecting image is the self as seen by others (Rochat & Striano, 2002). Research indicates that children aged 15 to 18 months demonstrate emotional expression of embarrassment, empathy and envy; emotions that are only possible to express when the child has self-recognition (Lewis, 2006). Around this age, children also begin to recognize their body as their own when standing in front of a mirror, and they construe an image of how their body appears to others (Rochat & Striano, 2002). Around the third year, a child has the capacity to evaluate its behavior against a certain standard. This capacity of evaluation creates a new set of emotions called self-conscious evaluative emotions. They are now able to show the emotions pride, shame and guilt (Lewis, 2006). Eight- to eleven-year-old children look at themselves in terms of smart, good looking, friendly in comparison to other children. Judgment about themselves becomes more specific and judgments are generated for a broader range of domains (Harter, 1999). During adolescence, cognitive development gives children the ability to use abstract thinking and introspection (Harter, 1999). With respect to the trajectory of self-esteem from childhood to adolescence it is found that (1) the critical years for self-esteem are before the high school period (Chubb, Fertman, & Ross, 1997), (2) a decrease in esteem occurs around the age of 12 years (Simmons & Rosenberg, 1975), and (3) self-esteem becomes more stable during the adolescence (Chubb et al., 1997). Erol and Orth (2011) examined the development of self-esteem in adolescence and young adulthood longitudinally (age 14 to 30 years) and found that self-esteem increased moderately during adolescence and more slowly during young adulthood. There was no difference among women or men in their self-esteem trajectories.
The development of self-esteem during childhood and adolescence depends on several individual and social factors (Harter, 1999). Parents are assumed to influence the self-esteem of
their child. For example, it has been found that self-esteem in children is positively related to parent rearing behaviors of encouragement of independence, parental acceptance, and a secure attachment to parents (McCormick & Kennedy, 1994). Research of Felson and Zielinski (1989) indicates that parental support also affects child self-esteem, however, this seems more
important for girls compared to boys. That is, parental support explains more than three times as much variance in change of self-esteem for girls than for boys, and of parental support only parental praise was found to have a significant effect on the self-esteem of boys (Felson & Zielinski, 1989). According to Sieving and Zirbel-Donisch (1990) self-esteem of children increases when parents establish realistic expectations, treat their child with respect, listen attentively, be open to their feelings and avoid judgmental comments (Sieving & Zirbel-Donisch, 1990). Children and adolescents judge scholastic competence and behavioral conduct to be most important to parents, and social acceptance, physical appearance, and athletic
competence to be most important to peers. Among younger children parental approval has been found to be more predictive of self-worth than approval from peers. In addition, although peers may become more important as one moves into adolescence, the influence of parental approval on self-worth remains central (Harter, 1999).
High versus low Self-esteem
When negative self-evaluation corresponds with the reality, it can be an impetus for changing behavior. This makes the self-evaluation functional. However, in many cases a low self-esteem is dysfunctional (Olij et al., 2006). Low self-esteem is based on a sense of failure to succeed, whereas high self-esteem is based on the belief that someone is able to succeed. Both persons with a high and low self-esteem prefer to succeed, but people with a high self-esteem expect to succeed more often than people with a low self-esteem (Baumeister & Tice, 1985). Children develop a positive self-esteem in a natural setting by fulfilling development
People with high self-esteem are motivated to enhance their self-image, whereas people with low self-esteem are more concerned about protecting their image. People with a low self-esteem strive to appear competent and avoid failure, while people with a high self-esteem strive to appear outstanding or above average (Baumeister, Tice, & Hutton, 1989). For example, when confronted with a threat to their self-worth, people with a high self-esteem seek social contact with others, while people with a low self-esteem avoid social contacts (Park & Maner, 2009).
Consequences of a low Self-esteem
According to Mann et al. (2004) self-esteem can be a protective factor and a non-specific risk factor in physical and mental health. A high self-esteem can lead to better health and social behavior, while a low self-esteem is associated with mental disorders and social problems; e.g. depression, suicidal tendencies, eating disorders, anxiety, violence and substance abuse (Mann et al., 2004; Leitenberg, Yost, & Carroll-Wilson, 1986; Neumark-Sztainer, Story, French, & Resnick, 1989; Beck, Brown, Steer, Kuyken, & Grisham, 2001; Donnellan,
Trzesniewski, Robins, Moffitt, & Caspi, 2005; McGee & Williams, 2006). Not surprisingly, a low self-esteem is a frequently encountered problem in mental health (Sukumaran, Vickers, Yates, & Garralda, 2003; Olij et al., 2006). Although a negative self-esteem is not by itself a diagnosis in the DSM-IV, many patients suffer from it. A negative self-esteem can be seen as a disorder transcending problem, which may be comorbid with one or several other diagnoses (Olij et al., 2006). For example, a low self-esteem is part of the clinical picture of some adult patients with an eating disorders or depression (Korrelboom, De Jong, Huijbrechts, & Daansen, 2009; Korrelboom, Marissen, & Van Assendelft, 2011). In addition, adolescents diagnosed with attention deficit hyperactivity disorder (ADHD) are also found to report a lower self-esteem, compared to a comparison group of students without ADHD matched on age, gender and grade point averages (Shaw-Zirt, Popali-Lehane, Chaplin, & Bergman, 2005). Moreover, a low self-esteem has been linked to addictive behavior, including drinking, smoking, eating, gambling
and compulsive sexual behaviors (Marlatt, Baer, Donovan, & Kivlahan, 1988). Research has found that students with learning disabilities have lower academic self-concepts than students without disabilities (Elbaum & Vaughn, 2001; Montgomery, 1994) and an association was found between social anxiety and children’s negative self-perceptions (Ginsburg, La Greca, & Silverman, 1998). Thus, a low self-esteem is associated with various forms of
psychopathology and children who suffer from psychiatric disorders tend to have lower self-esteems.
Current study
It is important to focus on self-esteem interventions for children and adolescents, because self-esteem may lead to more (mental) health care problems. For example, McGee and Williams (2000) conducted a longitudinal study to examine the predictive associations between both global and academic self-esteem in late childhood and preadolescence. The authors found that levels of global self-esteem significantly predicted adolescent report of eating problems, suicidal ideation and multiple health compromising behaviors. It is often assumed that a
successful treatment of the patients’ primary disorder will automatically lead to an improvement of low self-esteem (Fennell & Jenkins, 2004), however, many patients continue to report a low self-esteem after successful treatment of their primary disorder. In these circumstances, some clinicians suggest that low self-esteem must be treated separately (Fennell & Jenkins, 2004). In addition, there is also some evidence to suggest that in order to improve children’s self-esteem therapist should concentrate specifically on self-esteem during treatment, rather than assuming that low self-esteem can be altered indirectly by targeting other problem behaviors (Haney & Durlak, 1998). For example, depression and low self-esteem have multiple similarities, however these are two different concepts. Most of the depressed people have negative distorted views of the self. Recurrent or chronic depression might be a product of enduring negative beliefs about the self. Simply treating depression may leave the perceptions of one-self unchanged with the
consequence that the patient remains vulnerable to future difficulties, even if mood problems improve in the short term (Fennell, 2004).
This thesis reports about the effectiveness of a pilot study of a modified COMET targeting low self-esteem in children and adolescents. In this pilot study, the effectiveness of the training will be evaluated by using a questionnaire that evaluates both domain specific and global self-esteem, a questionnaire that measures depressive symptoms and a questionnaire that measures problem behavior more broadly. The primary research question is: Is COMET for children and adolescents effective in improving the child’s self-esteem? Additionally, it was examined if certain characteristics such as gender, age and treatment condition (group versus individual treatment), were related to treatment effectiveness.
Hypotheses
A randomized controlled trial of Ekkers, Korrelboom, Huijbrechts, Smits, Cuijpers, and Van der Gaag (2011) demonstrated the effectiveness of COMET for self-esteem in elderly depressed adults. In addition, Maarsingh, et al. (2010) examined the effectiveness of COMET in adults with a low self-esteem and depression. Self-esteem and autonomy changed significantly, and the depressive complains of the patients decreased after having followed COMET. According to Fluri and Korrelboom (2011), COMET is an effective treatment for low self-esteem in patients with various psychopathologies. This is consistent with the research of Korrelboom et al. (2009) targeting low self-esteem in patients with eating disorders. In addition, self-esteem was more improved in the condition were COMET was added to treatment as usual as compared to treatment as usual only condition (Korrelboom et al., 2009). Thus, COMET seems effective for adults with a low self-esteem. Haney and Durlak (1998) conducted a meta-analysis review of 116 studies, to evaluate the effectiveness of interventions to change self-esteem in children and adolescents. This study reported that treatment programs are effective in changing self-esteem. Moreover, interventions with a specific focus on changing self-esteem where significantly more
effective than programs focused on another target, such as problem behaviors or social skills. In sum, we assume that COMET for children will be effective to increase self-esteem because (1) COMET was found effective in adults and the components of this training is maintained in the adapted child/adolescent version, and (2) the training is specifically targeting self-esteem which may result in a higher effectiveness when compared to addressing self-esteem indirectly by targeting problems associated with the primary disorder (Haney & Durlak, 1998).
With respect to the additional research question, which examines characteristics of the participants, there is no information available to assume that the effect of the training will be depending on the age or gender of the participants. As regards to the difference in group versus individual setting, no hypotheses are made beforehand. The COMET protocol can be applied in either a group or an individual setting (Korrelboom et al., 2011). Up to now, the effectiveness of the COMET was examined using a group setting (Maarsingh et al., 2010), and have not been investigated in an individual setting.
Method
Participants
In this pilot study, 35 Dutch children (12 boys, 23 girls) participated. They were
between 9 and 22 years (M = 15.26, SD = 3.74). Of the children, 16 followed regular education, and 15 followed special education. The participants can be divided into two groups. The first group consisted of 10 participants who received the training in an individual setting (6 boys, 4 girls; Mage =10.20, SD = 1.229). The second group consists of 25 participants who received training in a group setting (6 boys, 19 girls; Mage = 17.28, SD = 2.072).The participants of the group setting were significantly older than the participants of the individual group, t (33) = 10.07, p < .001). There was also a significant difference in gender (t (33) = 2.095, p =.044). There were more girls in the group setting than in the individual setting.
The inclusion criteria for participation in the study were as follows: (1) the children had to be between the ages of 8-22 years and (2) they had to have a low self-esteem as determined by therapists. Exclusion criteria for participation in the study were as follows: acute trauma, severe depression/suicidal risk, psychotic symptoms, and severe behavior problems. Children who had a psychiatric disorder other than the exclusion criteria, such as ADHD or PTSD, were not excluded. Ten participants had more than one disorder. For the presence of the disorders, see Figure 1.
Figure 1. Number of present disorders in study for individual and group setting.
Procedure
Clients were referred to several secondary mental health care centres in the Netherlands and when inclusion criteria were met, they were asked to participate. Participants and their parents received a briefing on the pilot study. The participants signed informed consent and the study was approved by the Ethical committee of the University of Amsterdam.
Parents of the children in the individual training condition were asked to complete the Child Behavior Checklist (CBCL), and children were asked to complete the Children’s Depression Inventory (CDI) and according to age they were asked to fill in either the self-competence scale for children (CBSK) or the self-self-competence scale for adolescents (CBSA). The first assessment was followed by the COMET consisting of 6 or 7 sessions. After the training, a post-assessment was conducted in which the participants filled in the same questionnaires. The children in the group setting were assessed with the CBSA and the Rosenberg Self-Esteem Scale (RSES), and were measured at pre- and post-treatment. The CBCL was added later to the study and therefore only four completed pre- and post-tests of the CBCL for the group setting were available.
Therapists who applied the COMET in a group setting were trained by Peters who developed the group based training, and therapists using the individual training were trained by Kuin who developed the individual variant of the COMET for children.
Competitive Memory Training
The theory of Brewin is a central concept of the Competitive Memory Training (COMET) (Maarsingh et al., 2010). Brewin (2006) developed a model about competitive memory retrieval, in which it is assumed that in the long-term memory every concept is
associated with different meanings and different qualifications a person gives itself. There is an ongoing competition between these different qualifications, in which some meanings are easier to activate than others. When a qualification is activated from the long-term memory, this qualification becomes more associated with the concept and the other qualifications will be inhibited. In psychopathology, the dysfunctional thought frequently wins from the functional thought (Brewin, 2006). For example, people with a low self-esteem feel boring and worthless too often or too strong without these feelings being justified, while the qualifications to describe themselves as competent are inaccessible. In COMET clients learn to facilitate activation of the
functional, more positive thoughts. The emotional significance of the functional meaning is increased by using imagery, positive self-verbalizations, posture, facial expression and music (Maarsingh et al., 2010). The modified COMET, used in this pilot study, is adapted for children and adolescents. Kuin (2013) constructed a workbook in which children and adolescents can perform assignments. The assignments consisting of games, puzzles, questions and tasks, contribute to a positive self-image. In addition, children and adolescents keep a ‘positive diary’ in which they write down which positive things they did or happened that day. This is how the clients learn to focus on positive things. Another adaptation of the training for children and adolescents is to involve the parents. The parents participate in assignments and receive
information about their contribution to obtaining and maintaining a child’s positive self-esteem.
Measures
The Child Behavior Checklist (CBCL) is an empirically derived measure to obtain competencies and behavior problems of children from 4–18 years old. The questionnaire is completed by parents or caretakers and contains 118 items to assess specific behavioral and emotional problems. Parents rate their child on how true each item is at present or within the past 6 months. A sample item is: does too young for her age (0 = not true; 1 = somewhat or sometimes true; and 2 = very true or often true). Items can be summed to obtain a total score, two broadband scales, internalizing and externalizing problems, and eight subscales:
Withdrawn, Somatic Complaints, Anxious/Depressed, Social Problems, Thought Problems, Attention Problems, Delinquent Behavior and Aggressive Behavior. Cronbach’s alpha for total problems is good; α = .92. The test–retest reliability over a period of 2 weeks was .91 for total problems score. The good reliability and validity of the CBCL have been replicated for the Dutch translation (Verhulst, Van der Ende, & Koot, 1996). In the current study, Cronbach’s alpha was .95 for the pre-test and .89 for the post-test.
The Children’s Depression Inventory (CDI) is a self-report inventory assessing mood problems or depressive symptoms in children and adolescents from 7-18 years. The CDI contains 27 items, each consisting of three self-report statements graded from 0 to 2 (with a total score ranging between 0 and 54). A sample item is: I am sad once in a while (0); I am sad many times (1); I am sad all the time (2). The child is instructed to complete the CDI based on how he or she has been feeling during the preceding 2 weeks. The internal consistency of the CDI is good; α = .84 (Terwogt, Rieffe, Miers, Jellesma, & Tolland, 2006). In the current study, Cronbach’s alpha was .77 for pre-test and .39 for post-test.
Two Dutch versions of the Harter's Self Perception Profile where used to measure esteem, one version for children and one version for adolescents which are named the self-competence scale for children (CBSK) and the self-self-competence scale for adolescents (CBSA). The CBSK is a self-report inventory assessing self-competence of children from 8-12 years. The CBSK contains 36 items; each containing two statements. The child is asked to choose between the two statements, and then to decide whether the description is completely true or somewhat true. A sample item is: Some children find that they are very good at their
schoolwork (1 = completely true) or (2 = a little true); but other children worry about whether they are doing their schoolwork well (3 = a little true) or (4 = completely true). The CBSK consists of six competence subscales: scholastic competence, social acceptance, athletic
competence, physical appearance, behavior, and global self-worth. The sub-scales do not have a strong reputation for internal consistency and validity, however, at this time it is the only
instrument available for determining the sense of self-esteem among children aged 8-12. The internal consistency for the total score is good; α = .81 (Terwogt, Rieffe, Miers, Jellesma, & Tolland, 2006). In the current study, Cronbach’s alpha was .90 for pre-test and .79 for post-test. The CBSA is a self-report inventory assessing behavioral and emotional problems and skills of children from 12-18 years old. The questionnaire is the same as the CBSK, but with items
adapted for older children (adolescents). A sample item is: Some young people are not satisfied with how they look (1 = completely true) or (2 = a little true); but other young people are satisfied with how they look (3 = a little true) or (4 = completely true). The CBSA consists of eight competence subscales: scholastic competence, social acceptance, athletic competence, physical appearance, behavior, global self-worth, and friendship and romantic love. In the study of Paliwoda, Feltzer, and Sinnema (2006), the reliability of the various subscales of the CBSA were acceptable to good; Cronbach's α ≥ .72, n = 44. The reliability of the total score of the CBSA was found to be good; Cronbach's α ≥ .89 (Paliwoda, Feltzer, & Sinnema, 2006). In the current study, Cronbach’s alpha was .94 for pre-test and .90 for post-test.
Additionally the Rosenberg Self-Esteem Scale (RSES) was used to assess global self-esteem in the group setting. The RSES contains 10 items, each rated by the respondent from 1 to 4 (with total scores ranging between 10 and 40). The scale has five negatively worded items and five positively worded items. Scores between 25 and 35 are within normal range; scores below 25 suggest a low self-esteem. A sample item is: I feel that I am a person of worth, at least on an equal plane with others (1 = strongly agree; 2 = agree; 3 = disagree; and 4 =
strongly disagree). The RSES is one of the most widely used measures of self-esteem. Previous studies have reported acceptable to high internal consistencies with Cronbach’s alpha’s ranging from .72 to .88 (Gray-Little, Williams, & Hancock, 1997). In the current study, Cronbach’s alpha was .86 for pre-test and .93 for post-test.
Data analyses
One participant dropped out of the training and this case was excluded for analyses. Missing data was handled by replacement by the mean. The skewness and kurtosis values give information about the symmetry of the distribution and the ‘peakedness’ of the distribution. There was one high statistic (4.955) for the kurtosis of the scale ‘global self-worth’ from pre-test CBSK/A, however, the Kolmogorov-Smirnov (which statistically investigates the normal
distribution) was not found significant. To test for statistical outliers, the total scores of pre- and post-test were transformed into standardized Z scores. When the standardized Z score falls outside the confidence interval of -3.29 and +3.29 the score might be an outlier (Tabachnick & Fidell, 2007). Using this method, no outliers were found.
The effectiveness of the COMET was evaluated using Paired Samples T-test. To indicate the magnitude of the difference between pre- and post-test, an effect size (Cohen’s d) was calculated. We used Cohen’s (1988) criteria of .30 for a small effect, .50 for a medium effect and .80 or above for a large effect. In addition, the correlations between pre-post
difference scores and the variables gender (girls vs. boys), age and setting (group vs. individual) were examined by Bivariate Correlations.
Results
Effectiveness of the COMET for children and adolescents
Means of pre- and post-test as well as the results of the paired-samples t-test are
presented in Table 1. Results showed no significant difference in scores of pre- and post-test on the scales ‘scholastic competence’ and ‘friendship’. However, there was a significant difference in pre-test and post-test (t (17) = 2.444, p = .026, two-tailed) on the scale ‘social acceptance’. The effect size was medium (d = 0.631). This means that there was a medium increase in participants’ feelings of social acceptance after the COMET. Furthermore, there was a medium significant difference between pre-test and post-test (t (18) = 2.397, p = .028, two-tailed) on the scale ‘physical appearance’ (d = 0.752), meaning that there was a medium increase in how positive the participants feel about their physical appearance. The scale ‘athletic competence’ showed a trend significant difference between pre- and post-test (t (17) = 1.937, p = .070, two-tailed). This effect was small (d = 0.426). Scores on how positive participants rated their ‘behavioral conduct’ were increased from pre to post-test (t (16) = 2.966, p = .009, two-tailed)
with a large effect (d = 0.885). Finally, the scale ‘global self-worth’ showed a significant difference between pre- and post-test (t (16) = 2.975, p = .009, two-tailed). The effect size was large (d = 0.941). This means that there was a large increase on how positive the participants feel about their global self-worth after the COMET.
There was a significant difference between pre- and post-test (t (9) = 3.886, p = .004, two-tailed) on the RSES. The effect size was large (d = 1.256), meaning that there was a large increase in self-esteem after the participants had followed COMET.
There was a trend significant difference between pre-test and post-test (t (7) = -2.265, p = .058, two-tailed) on the CDI. The effect is large (d = -0.914). The participants had a lower score on depressive symptoms/mood problems after completing the COMET.
No significant difference between pre- and post-test (t (6) = -1.436, p = .201, two-tailed) was found on the total score of the CBCL. However, the effect size was medium (d = -0.578), meaning that there was a medium decrease in problem behavior of the participants after having followed COMET.
Table 1
Paired-samples T-test: the Difference between Pre-test and Post-test; Mean (M), Standard Deviation (SD), T-test (t), Corresponding significance (p), Cohen’s d (d) and Group Size (n).
Note. *p < .05; **p < .01; CBCL = Child Behavior Checklist; CBSK/A = self-competence scale for children and for adolescents; CDI= Children’s Depression Inventory; RSES = Rosenberg Self-Esteem Scale.
ᵃCBSA only
Correlations
Table 2 displays the correlations between the pre-post-test difference score (‘COMET effectiveness score’) and setting (individual or group setting), gender and age. A significant correlation between gender and the effect on the CBSK/A was found. There was a significant correlation between gender and ‘athletic competence’ (p ≤ .05). This was a positive correlation, meaning the training was more effective for girls on the scale athletic competence than it was for boys. No significant correlations were found between setting of the training and the pre-post-test difference scores. This means that the effect of the training is not associated with the individual or group setting. A significant correlation between age and the effect on the CBSK/A
Measure n Pre-test Post-test Difference
M SD M SD t p d CDI 8 12.250 5.258 8.500 2.449 -2.265 .058 -0.914 RSES 10 22.80 4.392 29.80 6.546 3.886 .004** 1.256 CBCL 7 42.929 14.211 35.500 11.354 -1.436 .201 -0.578 CBSK/A Scholastic competence 15 30.867 35.104 43.067 28.078 1.163 .264 0.384 Social acceptance 18 34.889 37.029 57.167 33.455 2.444 .026* 0.631 Athletic competence 18 43.556 34.926 58.056 33.057 1.937 .070 0.426 Physical appearance 19 33.368 30.093 55.684 29.218 2.397 .028* 0.752 Behavioral conduct 17 28.412 28.189 56.529 34.970 2.966 .009** 0.885 Friendshipᵃ 9 35.667 31.847 39.222 37.709 .286 .782 0.102 Global self-worth 17 16.882 25.891 45.353 34.077 2.975 .009** 0.941
was found. There was a significant correlation between the age of the participants and
‘scholastic competence’, p < .05. This correlation was negative meaning that a higher age was associated with less improvement in scholastic competence. Finally, a significant correlation between age and ‘global self-worth’ was found, p < .01. This was a negative correlation meaning that a higher age was associated with less improvement in global self-worth.
Table 2
Bivariate Correlations between Effect Size and the Variables Setting, Gender and Age: Pearson Correlation (r), Significance 2-tailed (p), Group Size (n)
Effect score: Post-test – Pre-test n Setting Gender Age
R P r p r p CDI 8 NA NA .114 .788 -.230 .584 RSES 10 NA NA >0.001 1.000 .170 .639 CBCL 7 .180 .700 .723 .067 -.603 .152 CBSK/A Scholastic competence 15 .417 .122 -.121 .668 -.678 .005* Social acceptance 18 .001 .995 -.335 .174 -.267 .284 Athletic competence 18 .041 .870 .532 .023* -.207 .411 Physical appearance 19 -.075 .760 .109 .657 -.177 .467 Behavioral conduct 17 .252 .330 -.295 .250 -.362 .153 Friendshipᵃ 9 NA NA -.659 .053 -.334 .380 Global self-worth 17 .375 .138 -.433 .083 -.548 .023*
Note. *p < .05; **p < .01 NA = Not applicable (CDI was not administered in the group setting, while RSES and CBSA were not administered in the individual setting); CBCL = Child Behavior Checklist; CBSK/A = self-competence scale for children and for adolescents; CDI= Children’s Depression Inventory; RSES = Rosenberg Self-Esteem Scale.
Discussion
In the current pilot study, the effect of the COMET for children and adolescents was examined. Preliminary support for the effectiveness of the adjusted COMET was found. More specifically, COMET was effective for improving self-esteem (CBSK, CBSA, RSES) in the group and individual setting. In addition, a trend effect was found on depressive symptoms (CDI) and medium – although not significant – improvements were found for behavior problems in general (CBCL). These effects were consistent with the hypotheses.
The results are in line with previous findings of the effectiveness of COMET for low self-esteem in adults (Ekkers et al., 2011; Maarsingh et al., 2010; Fluri & Korrelboom, 2011). It seems that self-esteem can be enhanced also for children and adolescents by using a short term cognitive behavioral therapy (CGT). In addition, positive effects for depressive symptoms (CDI) and behavior problems (CBCL) were demonstrated. The decrease in depressive symptoms may be explained by (1) an overlap in depressive symptoms and negative self-esteem; that is, a negative self-esteem is often seen in children with mood disorders (Korrelboom et al., 2011), and (2) an overlap between the COMET and a treatment of
depression. That is, Kuin (2013) has added elements of CBT for children with depression to the COMET for children and adolescents. Alternatively, the decrease in depressive symptoms as well as the decrease in behavioral problems could be explained by a positive self-esteem being a protective factor for physical and mental health (Mann et al., 2004).
Additionally, the correlations between pre-post difference scores and the variables gender, age and setting were examined. The results showed some significant correlations between treatment effectiveness and gender, and between treatment effectiveness and age. According to the results, the COMET was more effective for girls on how they felt about their athletic competence. Inspection of the means demonstrated that girls’ self-esteem about their athletic skills improved while boys’ self-esteem in this domain remained stable. However, it is
important to note here that the self-esteem of boys in this domain was already higher at the beginning of the training compared to girls (M boys = 47.8 against M girls = 39.7) indicating that there was more room for improvement for girls. This corresponds with other research on gender differences in self-esteem, where it was found that boys scored higher than girls on athletic competence in general (Quatman & Watson, 2001; Leadbeater, Kuperminc, Blatt, & Hertzog, 1999). Further, it was found that the effectiveness of the COMET was related to age in a direction that higher age was associated with less effect. This correlation was found for
scholastic competence and global self-worth. It might be that self-esteem is more stable during the adolescence, and it might then be harder to change it. There were no significant differences in the effectiveness of the training between the group setting and the individual setting.
Although this is consistent with the idea that the COMET protocol can be applied in either a group or an individual setting (Korrelboom et al., 2011), it should also be noted that participants were not randomly assigned to an individual or group setting.
The present study has several limitations. The first limitation is one of the inclusion criteria for the participants. The therapist could determine whether the patient was suffering from a low self-esteem or not. This was not always confirmed by the questionnaires. However, 80 % of the participants had percentile scores for global self-esteem lower than 25% on the CBSK and CBSA indicating that – as a group – most children and adolescents had a rather low self-esteem. Second, there was no check on the amount and content of the regular treatment that patients in both conditions received next to the COMET, and treatment integrity was not
formally checked. A third limitation is that different measurements were used in the group setting and the individual setting. For example, the participants of the individual setting filled in the CDI and the CBCL, but these measures were not (consequently) assessed in the group setting. In contrast, the RSES was administered in the group setting but not in the individual setting. The use of different measurements makes the comparison between the group and
individual setting limited. Fourth, the Cronbach’s alpha in the post-test of the CDI was notable low (α =.39). Therefore the results of the CDI should be interpreted cautiously. The low
Cronbach’s alpha may be explained due to the small variance in scores among participants; that is, most of the participants scored low on almost all items of the CDI. Finally, it is important to determine whether the positive results of COMET for negative self-esteem remain in the longer term. Although other studies of the effectiveness of the COMET in adults show lasting effects up to 3 months (Korrelboom et al., 2011),the current study can only report on the effect directly after treatment.
Given that low self-esteem is an important comorbid aspect of many disorders and is considered a risk factor for relapse, the COMET might be a valuable addition to the regular procedures used in treating these patients. This study provides preliminary evidence that
COMET is an effective add-on intervention for children and adolescents to improve self-esteem and these first results warrant further investigation of this intervention. More specifically, a longer follow-up period and a comparison control group should be added to examine exactly how effective COMET is.
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