ABSTRACT The UN estimates that globally between 2 to 8 million children live in orphanages and the countries of the former Soviet Union (fSU) and Eastern Europe have the highest number of children in institutional care worldwide--up to 1.3 million children. Due to the economic crisis following the collapse of the Soviet Union, Azerbaijan hosts a large population of “social orphans,” children left by destitute parents in state-run institutions. Years of deprivation, separation from parents, and maltreatment in orphanages severely heighten the risk of mental health problems among institutionalized children. However, current deinstitutionalization and family reunification initiatives provide basic case management services, but do not address the mental health problems of institutionalized children and do not attend to the poverty-related factors that led to institutionalization in the first place. To prevent mental health problems among 6-12 children from orphanages reunited with their biological or extended families in Azerbaijan, the proposed study will refine and test three evidence-based intervention approaches (a) family strengthening intervention; b) mental health screening and referral for treatment; and c) economic empowerment in the form of Child Savings Accounts). Based on the formative research conducted by the study team in collaboration with a local Community Collaborative Board, the intervention components have been adapted to maximize fit to the cultural context of Azerbaijan. In the proposed study, the adapted interventions will be tested with 400 child-caregiver dyads in a trial using the Multiphase Optimization Strategy (MOST) to compare different intervention components and identify the most optimal combination. The study will test effects of each intervention component on children's mental health outcomes (symptoms of depression, anxiety; disruptive behaviors; post-traumatic symptoms; and disturbances of attachment). If efficacious, the study results study could transform large-scale deinstitutionalization initiatives implemented by UNICEF or other organizations in Azerbaijan and in the fSU region. The study addresses top two challenges within the NIMH Grand Challenges in Global Mental Health Goal B (Advance prevention and implementation of early interventions): 1) to develop locally appropriate strategies to eliminate childhood abuse and 2) to develop interventions to reduce the long-term negative impact of low childhood socioeconomic status on mental health. Additionally, the goal of this R01 application is to strengthen the local research expertise in testing and adaptation of individual, family, and structural interventions for preventing child mental health problems. Through training and collaborative research, the project will enhance knowledge and skills in: 1) core components and mechanisms of change in preventive mental health interventions for children with a history of trauma, abuse and deprivation; 2) adaptation of multilevel evidence-based interventions and measurement tools to a new socio-cultural context of a fSU country; 3) methodological and statistical techniques for evaluating complex interventions with multiple components.

PROJECT NARRATIVE Living in institutional care such as orphanages puts children at high risk for emotional and behavioral problems that may lead to adult mental illness and risk of suicide. With 1.3 million children being raised in institutions in the former Soviet Union region, their mental health and longer-term developmental outcomes are a public health concern. Research and capacity building activities under this mechanism will support the development of an expertise in cultural adaptation, implementation and testing of interventions in the former Soviet Union region to: 1) address mental health problems among children with a history of institutionalization; 2) target underlying family level and structural risk and protective factors; and 3) strengthen collaborative international and regional community-academic partnerships to advance the mental health of children with a history of institutionalization in the post-Soviet Eurasia.