University of Chicago-led study funded by NICHD could lead to better mental health for children being raised in residential institutions

Leyla Ismayilova, Associate Professor at the University of Chicago School of Social Service Administration, has received a five-year R01 research grant to adapt and evaluate strategies for mitigating mental health issues among children leaving orphanages and residential institutions in Azerbaijan as a part of the deinstitutionalization reforms. The study is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) under the Global Brain and Nervous System Disorders Research Across the Lifespan initiative. If successful, the study results could inform large-scale deinstitutionalization initiatives in Azerbaijan and other post-Soviet countries by providing empirical evidence of which specific strategies may best help children and parents during the reintegration and family reunification process. “Most deinstitutionalization initiatives in the region are focused on getting children out of the institutional care system. While it is a critical first step, most countries do not have formal mechanisms that track or monitor how well these children are doing following the deinstitutionalization. Without providing additional support services, children who have gone through years of adversity during developmentally critical years may struggle to readjust to the family, school and community environment.” Ismayilova said.  

The U.N. estimates that between 2 to 8 million children globally live in orphanages or other types of residential institutions. The countries of the former Soviet Union and Eastern Europe have the highest rate of institutional care worldwide with almost one million children in residential care. Post-Soviet countries overcoming the period of political instability, economic crises, and social disruptions following the collapse of the Soviet Union host a population of so-called “social orphans,” whose destitute parents, often single mothers, are left with no choice but to place the children they cannot support alone in state-run institutions that provide free education, food, clothing, and shelter.

Although they gain access to education, these children in socially secluded institutional environments are at high risk for emotional and behavioral problems that may lead to mental health issues (e.g., depression, social withdrawal), risk of suicide, or substance abuse problems in adulthood. In Russia, which borders Azerbaijan to the north, one in three children who leave residential care becomes homeless, one in five ends up with a criminal record, and one in ten commits suicide. The scope of the problem is immense. In response to these grim statistics, most countries in this region have been implementing de-institutionalization reforms aimed at closing down the public residential institutions. 

While returning to the family environment is typically associated with better psycho-social outcomes, the social sector agencies in the region need culturally-tailored interventions to address children’s emotional challenges and guide parents as they go through the family reunification and reintegration process. In a prior study, funded by SSA’s Center for Health Administration Studies (CHAS), Ismayilova and her team demonstrated that reunited families face multiple issues and conflicts. Parents often feel unprepared to help their children deal with deep sadness, the loss of trust, difficulties concentrating at school, intense feelings of anxiety, and uncontrolled anger or impulsivity. These often result from years of separation, life in a socially isolating and restrictive environment, abuse and other emotional trauma children experience before or while being in institutions.

Furthermore, most parents reuniting with their children face the same financial pressures they did prior to placing their children in institutions, which exacerbates parental stress and may in turn contribute to family conflicts. Most of the caregivers are single mothers who divorced their husbands, often in response to domestic violence and a husband's heavy alcohol or drug use. The strong local stigma against divorce often leads to these women being ostracized by close family members, leaving them without economic and social support. Parents receive minimal public benefits, if any, and face challenges finding employment. Family financial instability can further undermine the benefits of deinstitutionalization. 

To address these difficulties, the research team will rigorously evaluate which of three different approaches could best assist children reintegrating from institutions with their families: a) a group-based program helping families strengthen their supportive parenting skills and understand the role of trauma in managing child behavioral problems; b) screening and connection to mental health services, and c) an asset-based economic program providing savings accounts for children to help their families save for education, housing, or small business start-ups. Connecting families to financial institutions and resources goes beyond providing cash benefits that could quickly be depleted and may potentially lift families out of poverty.

“None of these interventions are particularly novel by themselves. There is sufficient research evidence from other parts of the world that these interventions can improve wellbeing of vulnerable children and families,” Ismayilova said. The value of this study is also in a methodologically distinctive innovation: it will use Multiphase Optimization Strategy (MOST) to compare these different intervention components and identify if and how they should be combined. “Knowing which specific services are most effective could be particularly important for transitional countries with limited financial and mental health resources,” Ismayilova said. 

Not only will the study offer and evaluate direct services to families, it will also build multidisciplinary teams and will train local mental health clinicians in preventive family-focused and trauma-informed approaches to improve social and mental health care for children. As part of this study, local practitioners will learn how to work with children who have experienced multiple traumatic events throughout their lives such as being exposed to violence and loss. The practitioners will address this trauma as well as the negative psychological consequences of institutionalization by focusing on enhancing children’s resilience, emotion regulation and coping skills.

The study will also strengthen the capacity in child development and child mental health research in this region, bringing together international and local researchers, practitioners and social policy makers. Using a theory- and data-driven approach to develop and evaluate country-specific solutions accounting for local cultural factors could improve the services and policies for children from institutions. 

The interdisciplinary research team includes internationally recognized researchers from the University of Chicago School of Social Service Administration and Department of Public Health Sciences, Washington University in St. Louis, Harvard University and the Pediatrics Department of Boston Children’s Hospital, along with local partners from the National Mental Health Centre under the Azerbaijan Ministry of Health, and SOS Children’s Villages-Azerbaijan, part of a global federation that works to protect and care for children in need.

--Steve Koppes