Early Adolescent Skills for Emotions (EASE)-Pilot Cluster Randomized Controlled Trial (cRCT) in Public Schools of Rural Pakistan

Self-rated Pediatric Symptom Checklist (PSC) will be used to assess psychosocial distress of adolescents. Pediatric symptom checklist has 35 items and assesses psychosocial problems on 3 subscales; externalizing, internalizing and attention problems with cut-offs of 7, 5, 7 respectively. Items are rated on a three-point Likert scale (0= Never, 1= Sometimes, 2=Often). Total score is calculated by summing the responses of all items. Higher score indicates greater psychosocial distress. The recommended cutoff for identifying children and adolescents with psychosocial distress using Pediatric Symptom Checklist in a new setting is ≥ 28.

The somatic symptoms questionnaire will be used to measure stress management among adolescents. It consists of 10 items, rated on a 3-point scale (0=not true, 1=somewhat true, 2= very true or often true) based on the occurrence of the symptoms. Total score is calculated by summing the responses of all items. Higher score indicates frequent occurrence of somatic symptoms.

It is a self-reporting questionnaire with 25 items. It consists of five sub-scales with five items each. Two of these sub-scales, 'positive problem orientation' and 'negative problem orientation', assess functional and dysfunctional cognitive and emotional orientations towards solving problems. The three remaining sub-scales, 'rational problem solving', 'impulsivity-carelessness style', and 'avoidance style', assess problem-solving skills and behavioral style. The total score of this scale varies between 0 and 20 points. Highest scores correspond to better social problem-solving abilities.

It assesses perceived emotional support. Respondents are instructed to list the gender and first initial of three important people in each of three relationship categories: family members, non-family adults, and friends. Using a four-point scale (hardly at all to very much), respondents answer the following questions about each person listed: "How much do you talk to them about personal concerns?" "How close do you feel to them?" and "How satisfied are you with the help and support they give you?" How much do they talk to you about their concerns? Three support variables are created by averaging all ratings for all persons listed within each relationship category: perceived support from family, non-family adults, and peers. Scores range from 1 to 4.

PHQ-9, adapted for adolescents will be used to assess depression symptoms and severity among adolescents. The nine items of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM-IV. It is used to monitor the severity of depression and response to treatment. Items are rated on a 4-point Likert scale with 0= Not at all, 1= Several Day, 2= More than half the days, 3= nearly every day. Total score is calculated by summing the responses of all items. Higher score indicates higher incidence of depression symptoms. PHQ-9 total score for the nine items ranges from 0 to 27. PHQ-9 scan also be used to screen presence of depressive symptoms in adolescents; where score 0-4 indicates 'absence of depressive symptoms', score 5-9 indicates 'mild depression', score 10-14 indicates 'moderate depression', 15-19 indicates 'moderately severe depression', score 20-27 indicates presence of 'severe depression'.

Pediatric Quality of Life (PedsQL) (Varni, Seid & Rode, 1999) will be used to measure child's health related quality of life during the past month. The scale measures child´s quality of health on four subscales namely, physical functioning, emotional functioning, social functioning and school functioning. The items are rated on 4 points Likert scale ranging from (1) 'no problem' to (4) 'almost always a problem'. Items are then reverse-scored and linearly transformed to a 0-100, so that higher scores indicate better quality of life. This tool yields a total score (all 23 items), physical health summary score (8 items), psycho-social health summary score (10 items) and school functioning score (5 items).

Peds-QL family impact module will be used to assess parents' health related quality of life. PedsQL family impact module is a 36-item scale that measures quality of life on 6 sub-scales namely; physical functioning, emotional functioning, social functioning, cognitive functioning, communication, worry, daily activities and family relationships. Items are rated on a 5-point Likert scale (0 = never to 4 = almost always). Total score is calculated by summing all 36 items divided by the number of items answered. The parent health related quality of life summary score (20 items) is computed as the sum of the items divided by the number of items answered in the physical, emotional, social, and cognitive functioning scales.

Alabama parenting scale will be used to measure parenting practices. Alabama parenting scale is a 42 item measure that encompasses five dimensions of parenting: (1) positive involvement with children, (2) supervision and monitoring, (3) use of positive discipline techniques, (4) consistency in the use of such discipline and (5) use of corporal punishment. Items are rated on a 5-point Likert scale (1 = never to 5 = almost always). Total score is calculated by summing all items.

The cost of health services utilization from the time proceeding assessment will be assessed with the adapted Client Services Receipt Inventory (CSRI). It has been adapted to use for the families of children with psycho-social distress. It measures the utilization of various health and social care services including time and opportunity losses by the families in the care of their child with psycho-social distress.

The short version of the Warwick-Edinburgh Mental Well-being Scale will be used to evaluate the mental well-being of children. Statements of the measure are positively worded with five response categories from 'none of the time' to 'all of the time'. Children and young people are asked to describe their experiences over the past two weeks. Higher scores indicate higher positive mental well-being