Beyond the clinic: a feasibility trial of the super skills for life program for childhood anxiety in Pakistan

The cultural adaptation of cognitive behavioral therapy (CBT) oriented school-based programs is essential to ensure contextual relevance, ecological validity, and implementation feasibility, particularly in low-resource settings. The feasibility trial of the Super Skills for Life Program (SSL—Children Version) involves its translation and adaptation in the cultural context of Pakistan. The trial also examined the fidelity, acceptability, feasibility and preliminary within-group changes of SSL intervention in reducing anxiety and depressive symptoms and enhancing self-esteem, social skills, and quality of life. The SSL program was translated and culturally adapted using the Planned Adaptation (PA) approach and subsequently evaluated in a mixed-methods feasibility trial. Feasibility, implementation fidelity, and acceptability were assessed using a mixed-methods approach, while preliminary within-group changes were evaluated through pre- and post-intervention assessments of 18 primary school children recruited from a private school system. The findings provided evidence that the intervention was delivered with high implementation fidelity with satisfactory markers of inter-rater reliability (κ = 0.99**). The feasibility outcomes demonstrated acceptability across children, parents, and teachers. The findings also suggested the practical feasibility of conducting a future cluster randomized controlled trial (cRCT), with only minor procedural changes in the methodology of SSL. The preliminary within-group changes indicated a significant reduction in anxiety ( t = 5.87, p < .001) and depressive symptoms ( t = 4.93, p < .001) at the post-assessment level. Furthermore, the findings provided evidence of improvements in self-esteem ( t = 4.04, p < .001), social skills ( t = 5.64, p < .001), and quality of life ( t = 3.25, p < .001) following the intervention. The culturally adapted SSL program demonstrated high implementation fidelity, high acceptability and feasibility alongside promising preliminary within-group changes for reducing anxiety and depressive symptoms as well as enhancing self-esteem, social skills and quality of life among primary school children in Pakistan. Trial Registration No: Trial is registered at Registry of Efficacy and Effectiveness Studies with ID is 12720.1v1 during the study on 28 May 2022. It has also been registered retrospectively at ClinicalTrials.gov with ID NCT07162402 on 18 august 2025.