Optimizing Multilevel Mental Health Prevention for De-Institutionalized Children in Azerbaijan: Insights from a Factorial Clinical Trial Using MOST

Background and Purpose: Approximately 2.7 million children worldwide reside in institutional care, with post-Soviet and Eastern European countries reporting the highest rates of institutionalization—exceeding the global average by more than fivefold. As these regions undergo ongoing deinstitutionalization reforms, the transition from institutional to family-based care has presented significant challenges for both children and caregivers. In this context, providing appropriate, culturally responsive interventions is essential to support the well-being of affected families. This study aims to generate evidence on the effects of culturally adapted, multi-level interventions for deinstitutionalized children and their caregivers.

Methods: This NIH-funded clinical trial (ClinicalTrials.gov Identifier: NCT05396625) evaluated the individual and combined effects of three culturally adapted interventions which aimed at addressing mental health problems among children aged 7 to 12 (N=434) transitioning from residential institutions to family-based care (N=305 families) in Azerbaijan. These interventions included: (1) a 12-session family-strengthening intervention originally developed for low-income communities in the United States; (2) an asset-based economic empowerment intervention, involving 8-session financial education for children and parents and matched child savings accounts; and (3) trauma-focused mental health services guided by the Attachment, Regulation, and Competency (ARC) framework. Each intervention was tailored to incorporate local cultural values and caregiving needs of deinstitutionalized children. To identify the most effective combination of interventions, the study employed the Multiphase Optimization Strategy (MOST) using a fractional factorial design with eight experimental conditions. Data were collected at baseline and at a one-year follow-up using both child- and caregiver-reported surveys, as well as digital, non-linguistic assessments such as the WISC-V and CANTAB.

Results: At the caregiver level, families who received interventions that included economic empowerment components demonstrated a significant reduction in parent-reported stress levels (d= –0.20, p < .05), as well as a significant improvement in authoritative parenting style (d=0.34, p < .001), compared to families who did not receive the economic empowerment component. Additionally, caregivers who received only the family strengthening intervention showed a significant increase in the use of self-distraction emotional regulation strategies compared to caregivers in other conditions (d = 0.43, p < .05).

At the child level, children from families in the economic empowerment intervention condition demonstrated significant improvements in both the raw scores (d = 0.24, p < .05) and scaled scores (d = 0.31, p < .05) of the WISC-V Block Design subtest. These results suggest that the intervention may enhance specific cognitive abilities, such as spatial reasoning and visual-motor integration, compared to children in other conditions.

Conclusions and Implications: Findings highlight the importance of integrating economic empowerment components into programs that support children transitioning from institutional care to family-based settings. While traditional interventions have focused primarily on mental health services and family strengthening, results suggest that addressing economic insecurity can further reduce caregiver stress, enhance parenting practices, and improve child cognitive outcomes. These outcomes point to the need for a more holistic, multi-level service model—one that not only attends to psychological and relational factors, but also considers the structural barriers families face, particularly economic instability.