START NOW WebApp: Skill Training for Promoting Resilience

The AFQ-Y is a widely used and validated self-rating questionnaire for assessing Psychological Flexibility in youth and young adults. Participants answer 17 items indicating how true each item is for them on a 5-point Likert scale (0 = not at all true; 4 = very true). Higher total scores indicate lower PF. Items are based on ACT models of human suffering representing the theoretical concept of psychological inflexibility due to high cognitive fusion and experiential avoidance. Data will be assessed within 2 weeks before start of skills training (baseline, T1), within 2 weeks after end of skills training (post-treatment assessment, T2), as well as at 12 weeks (+/- 2 weeks) (T3) and 24 weeks (+/- 2 weeks) (T4) post skills training. Primary endpoint is the change in total score between baseline (T1) and follow-up (T3). Total scores can range between 0 and 68. Accordingly, a change in score can range between -68 to +68.

Increase in total score on the German version of the Connor-Davidson Resilience Scale (CD-RISC) in the 10-items version both in self-rating by participant and self-rating by caretaker. The CD-RISC refers to an individual's ability to endure difficult experiences. Answers are given on a 5-point Likert-Scale (0= not true at all; 4= true nearly all of the time). Total scores can range from 0 to 50, with change scores ranging from -50 to +50.

Increase in total score on the World Health Organization - Five Well-Being Index (WHO-5) in self-rating by participant. The self-report questionnaire contains five items on a 6-point Likert-Scale (5= all of the time; 0= none of the time). Respondents are asked to indicate how often they felt well during the last two weeks. Total scores can range from 0 to 25, with higher scores indicating greater well-being. Accordingly, change scores range from -25 to +25.

Increase in total score on the German 'General Self-Efficacy Scale - Skala zur Allgemeinen Selbstwirksamkeitserwartung' (SWE) in self-rating by participant. The questionnaire includes 10 Items and a 4-point Likert Scale (1= not true; 4= completely true). The scale reflects one's convictions on subjective controllability or competence expectations in different demand situations, with higher scores indicating a greater sense of self-efficacy. Total scores can range from 10 to 40, with change scores ranging from -40 to +40.

Reduction of all sub scores and total score on the Columbia Impairment Scale (CIS) both in self-rating by participant and external rating by caretaker. The 13-item questionnaire captures functional impairment in four domains: interpersonal relations, broad psychopathological domains, functioning in school or at work, and use of leisure time. It will be answered both by the participant as a self-report questionnaire, and by the caretakers as external raters. Items are answered on a 5-point Likert-Scale (0= no problem; 4= a very big problem). Total score can range from 0 to 52, with change scores ranging from -52 to +52.

Reduction of total score on the Patient Health Questionnaire 4 (PHQ-4) in self-rating by participants. The PHQ-4 is a ultra- short questionnaire with the two subscales depression and anxiety, and was evaluated a s a reliable, valid and precise screening tools for self reported depression, anxiety and general psychological distress. Answers are given on 4-point Likert-Scale (0=not at all, 3= nearly every day). Total score is determined by adding together the scores of each of the 4 items. Scores are rated as normal (0-2), mild (3-5), moderate (6-8), and severe (9-12). Total score ≥3 for first 2 questions suggests anxiety. Total score ≥3 for last 2 questions suggests depression.

Reduction of total score on Affective Reactivity Scale (ARI) both in self-rating by participant and external rating by caretaker. The ARI contains seven items to be scored on a 3-point Likert-Scale (0= not true, 1= somewhat true, 2= certainly true). As just the first six items are summed to the total score, it can range from 0 to 12, with change scores ranging from -12 to +12. The seventh item is analysed separately.

Reduction of total score on the Alcohol/Drug Use subscale of the MAYSI-2 in self-rating by participants. The MAYSI-2 is a brief screening tool designed for youth between the ages of 12-17 years, but it has been suggested that the screening tool may also be adequate for young adults as long as results are interpreted with caution.

The MAISY-2 contains 52 items across seven subscales: Alcohol/Drug Use, Anger-Irritability, Depression-Anxiety, Somatic Complaints, Suicide Ideation, Traumatic Experiences and Thought Disturbance. Respondents are asked about the presence of various thoughts, feelings or behaviours in the past few months, in a yes or no format. Each subscale contains different caution cut-offs.

Participants within the two intervention conditions can indicate their satisfaction with the training using the Client Satisfaction Questionnaire (CSQ) at T2 (post intervention). The CSQ was specifically developed to assess participants' experiences and satisfaction with START NOW. It contains eight items on a 4-point Likert-Scale (ranging from 0 to 3; response options are provided with smileys) and two open questions about what participants liked or would want to be changed within the training. Total scores can range from 0 to 24.

Satisfaction of facilitators of the group training guided by a facilitator condition will be assessed with the Trainer Satisfaction Questionnaire (TSQ) at T2 (post intervention), a 5 Min self-rating questionnaire. After the end of the intervention, focused group discussions are planned for all interested institutions regarding implementation and experiences with START NOW. The group discussions will be conducted as guided interviews for 1 hour with a maximum of 3 institute employees and recorded for later transcription (audio and video; destroyed after transcription; text anonymized) and qualitative analyses.

Social Atmosphere will be assessed by the German version of the Essen Climate Evaluation Schema (EssenCES). It is a short self-rating questionnaire, containing 17 items across three subscales: Therapeutic Hold, Patients' Cohesion and Mutual Support, and Experienced Safety. Responses are given on a 5-point Likert Scale (0= not at all, 1= little, 2= somewhat, 3= quite a lot, 4= very much). Total scores can range from 0 to 68 with higher scores indicating a better social climate. Accordingly, change scores can range between -68 to +68.

Inclusion/exclusion criteria throughout the course of the study (i.e., participation in concurrent CBT based skills training similar to START NOW., internet access, external placements/discharge, unauthorized leaves) will be screened/monitored with two specially designed Checklists.

The professional qualification of involved caretakers and facilitators, their experiences with START NOW or other forms of resilience trainings will be assessed with a short questionnaire.

For each institution, the quality of the group training guided by a facilitator will be rated by a START NOW facilitator during one session (either live or via online connection) using a Quality Assurance Form.