## _Children 36-72 months_

The AIM-ECD Direct Assessment (DA) was used for children 36-72 months (Pushparatnam et al., 2021). The AIM-ECD measures ECD in four domains: early literacy, early numeracy, executive functioning, and social emotional development. The AIM-ECD DA is structured into 14 subtasks, with a total of 77 questions/tasks, administered in a series of activities directly with the child. The AIM-ECD has previously been used in Khyber Pakhtunkhwa as well as other parts of Pakistan (Hentschel et al., 2024; Seiden et al., 2024). Items were designed to be used in various cultural or linguistic contexts with minimal adaptation (i.e., inclusion of literacy in both English and Urdu). Items are scored based on percentage correct with enumerators giving credit if items were responded to correctly in Pashto. The AIM-ECD Caregiver Report (CR), made up of 29 core items across early literacy, early numeracy, executive functioning, and social emotional development, was also utilized. Given the high correlation between the AIM-ECD DA and the AIM-ECD CR (corr=.71, p<.05), the AIM-ECD DA results were used as the primary outcome and the AIM-ECD CR results are available upon request.

## _<mark>Maternal Mental Health Measures</mark>_

_Depression._ Maternal depression was measured by the Self-Reporting Questionnaire (SRQ-20), which has previously been used in Pakistan and has been found to be valid and reliable for screening for depressive disorders in rural Pakistan (Husain et al., 2006). The SRQ-20 contains 20 yes/no questions, with higher scores indicating higher levels of depression, and was found to have a high internal consistency reliability, with a Cronbach’s alpha of .89 in this sample.

_Anxiety._ Maternal anxiety was assessed using the General Anxiety Disorder 7-item questionnaire (GAD-7). This 7-item questionnaire has been found to be valid in the Gilgit province of Pakistan (Ahmad et al., 2017) and has subsequently been used in other assessments of anxiety in Pakistan (Yasmin et al., 2021). The GAD-7 was found to have a high internal consistency reliability, with a Cronbach’s alpha of .80 in this sample.

_Parenting Stress._ Parenting stress was measured using an adapted version of the Parental Stress Scale (PSS), which has previously been validated in Urdu in Punjab (Bilal et al., 2021). The adapted version used in this survey was designed by Ugarte et al., 2024 for Rohingya refugees in Bangladesh. The 10-item parenting stress scale used in this sample was found to have a high internal-consistency reliability, with a Cronbach’s alpha of .85 in this sample.

# <mark>Independent (Stressor and Other Covariate) Variables</mark>

A variety of known stressors and correlates of maternal mental health and child development were also assessed. Stressors, including food insecurity, poverty, flooding impact, experiences of domestic violence, felling unsafe in one’s community, discrimination, living in a rural area, lack of enrollment in ECE, and low maternal educational attainment have consistently been associated with lower levels of maternal mental health conditions and child development across contexts (e.g., Hentschel et al., 2023; Iqbal & Ali, 2021; Reed et al., 2012: Sitwat et al., 2015; Yousuf et al., 2023) Other covariates, such as refugee status and child age, were also assessed.

_Refugee Status._ At the time of the survey, sensitivities around “refugee status” were particularly heightened. As such enumerators were asked to keep notes on interviews to help identify whether 7