The Role of Trauma in School-Based Functioning Among Deinstitutionalized Children in Azerbaijan: Preliminary Results from a Factorial Clinical Trial

Background and Purpose: Nearly half of all children in institutional care globally live in Central and Eastern Europe and Post-Soviet (CEE/CIS) nations. Children placed in this care often exhibit poor psychosocial outcomes associated with the trauma of separation from family and limited support in institutions. Given these concerns, efforts to reunite families in CEE/CIS nations have become widespread, including in Azerbaijan. Yet, there are few services available to families as children reintegrate into schools and face critical academic and psychosocial challenges. This study examines the prevalence of school-based difficulties among deinstitutionalized children, with special attention paid to the role of trauma. Preliminary intervention effects on child outcomes are also presented.

Methods: This NIH-funded clinical trial (ClinicalTrials.gov: NCT05396625) tests the effectiveness of three interventions on the psychosocial functioning of 7-12-year-olds (N=400) during the transition from institutional to family care in Azerbaijan: family strengthening, economic empowerment (Child Savings Accounts), and trauma-informed mental health services. This trial utilizes an innovative Multiphase Optimization Strategy (MOST), a fractional factorial design with eight experimental conditions (2³=8) wherein families are assigned to one or more intervention arms to determine the most optimal combination. Academic, social-emotional, and behavioral outcomes are measured through baseline and one-year follow-up assessments completed by children, caregivers, and teachers. Cognitive functioning is assessed through computerized paradigm tests (CANTAB).

Results: At baseline, over one-third (37%) of deinstitutionalized children scored above the CRIES-8 cutoff for clinically significant symptoms of PTSD. Trauma symptoms were significantly higher among children living in households experiencing economic hardship related to food security (p<.05), housing (p<.10), and school preparedness (p<.05). According to teacher-reported SDQ, 33.3% of all children exhibited problems with peers, 34% exhibited hyperactivity, and 20% of children exhibited high or very high levels of emotional problems. Boys displayed poorer total SDQ scores (p<.01) and teacher-reported ADHD symptoms, with nearly one-quarter above the clinical cutoff (p<.10). Older children exhibited worse emotional (p<.05) and internalizing (p<.10) SDQ scores.

Children exhibiting trauma symptoms were significantly less likely to complete homework (p<.01) and more likely to be sent to the principal’s office (p<.10). Exhibiting clinically significant trauma symptoms appears to be a significant predictor of poorer overall behavior (p<.10) and SDQ emotional problems (p<.05). In baseline CANTAB assessments, 16% of children presented as impaired (below 1 SD of z-score) in executive functioning (SOC) and 18% in visuospatial working memory (SSP). Symptoms of trauma were associated with lower emotional bias (EBT Happy vs. Sad, p<.05) and SSP (p<.01).

Preliminary follow-up results suggest that children who received a trauma-informed mental health intervention demonstrated a significant decrease in clinician-rated HoNOSCA score (Cohen’s d=3.4, p<.001), which assesses child mental health functioning. Children in families that received both family strengthening and economic interventions exhibited a reduction in depression symptoms at follow-up (Cohen’s d=0.6, p < .05).

Conclusions and Implications: Deinstitutionalized children exhibit significant difficulties in academic, social-emotional, behavioral, and cognitive functioning. Programs that address child trauma and adversity at multiple levels (individual, family, and structural) have the potential to improve child functioning at home and in the school setting.