Now We Are Together

In Kyrgyzstan, about 30 per cent of children with disabilities remain outside the early intervention and inclusive education system. Because of low family awareness, lack of resources, and agencies not cooperating enough these children often go without support during the most critical period for their development – from birth to eight years of age. To change this, UNICEF – with the Ministry of Labour, Social Welfare and Migration, the Ministry of Education and Science, and the Ministry of Health – launched a pilot transdisciplinary team (TDT) in Suzak district of Jalal-Abad region.

The project began in 2024 as part of the Government of the Kyrgyz Republic's Family Support and Child Protection Programme for 2018–2028, and the Accessible Country Programme. It is based on international experience of early identification of children at developmental risk and providing them with comprehensive assistance at local level.

What is a transdisciplinary team?

A transdisciplinary team is a systemic model in which health-care, education, and social protection professionals work as a single entity to support a child with a disability and their family. Previously doctors, social workers and teachers performed their functions separately. They might not have known about each other's problems, did not exchange information, and did not develop common solutions.

Now they are coming together, to discuss each child and family’s situation, create a unified family support plan, and connect village resources, local authorities, and most importantly, parents (who are members of the teams and actively participate in this process). The Suzak Transdisciplinary Team consists of only 7 people, but they are already supporting 25 children. Another 19 cases are in the process of being added to the caseload.

The decision to create the TDT was formalized at local authority level and agreed on with the relevant ministries. After that, the team attended a series of training sessions supported by UNICEF, including on early detection of developmental delays, parental support work, and family interaction ethics.

Children with developmental delays or disabilities are identified in several ways. First, this can be through observation during a visit to the Central Family Medicine Centre (CFMC) or the Family Ambulatory Point (FAP) – a nurse or doctor may notice developmental delays, such as speech and motor problems. The second option is home visits and case management conducted by social workers, including jointly with the akimat (district administration) and educational organizations (kindergartens and schools). Third, teachers and educators can report to the TDT if a child has learning and socialization problems.

After initial identification, the team – including the child’s parents – gathers and considers each case individually. They develop an individual family support plan, determining whether the child needs more specialized medical diagnosis, disability registration, or referral to a speech therapist, psychiatrist or children's institution. One responsible specialist from the TDT is assigned to accompany the family depending on their primary needs, such as assistance with document processing, help to receive a pension, or adapting the child to a group. The team follows a checklist, meetings are held regularly, and for visits – especially difficult or remote ones – the entire team gathers.

One of the important principles is that parents participate in the team’s work, and help is provided not only to the child but also to the parents. The family’s rights are explained, and they are given step-by-step instructions, and taught how to work with the child. The parent becomes part of the team.

Aliman* (name changed) will soon be four years old. She has epilepsy, and in the early years of her life, she did not speak, did not make eye contact, and did not respond to external stimuli. Her parents were working in Russia, and her grandmother, with whom the girl lived, refused to acknowledge the problems.

The grandmother only agreed to call the mother after a visit from a social worker. The mother returned, and the team developed a plan: examination, speech therapist, group registration and daily activities. The most unusual thing is that the girl only feels calm in the car. Therefore, the mother conducts activities with her in the car itself.

“At first, she was restless, throwing everything around. Now she sits, shows pictures, says: ‘mama’, ‘papa’ and ‘moo’. She knows how animals speak. It’s a miracle,” says the mother, Aliya* (name changed).

Now the family receives a disability pension. The girl is beginning to socialize, establishing connections with relatives, and showing interest in toys and books.

While the little girl is making progress, 11-year-old Rakhim* (name changed) is just beginning his path to recovery in another part of the village. When he came for a vaccination, nurse Zukhra Inamutdinova noticed that he was afraid to make eye contact, tense, and did not answer questions. She invited the mother to the clinic, and they conducted an examination.

“Previously, I would have noted that the child is physically healthy – and that would be it. But after the training, I realized that his behavior might be due to anxiety, stress, attention deficit hyperactivity disorder (ADHD), or autism,” explains Zukhra.

Rakhim has poor academic performance and anxiety and cannot express his thoughts. The psychiatrist did not make a serious diagnosis but recommended psychotherapy, gradual socialization, and work with the parents.

“At first, I denied everything. It seemed to me that if I said out loud that the child had difficulties, it would be like announcing a verdict. But the team supported me. I remember the meeting included the doctor, our teacher, and the social worker: all wanted to help. Now we are in touch with them 24/7, helping with the child’s socialization through home activities. Rakhim started smiling. He made a friend. My son even says he wants to be a policeman when he grows up, and he used to hardly talk to us,” says his mother, Guliya* (name changed).

There is another hero in this story: the mischievous and noisy Islam* (name changed). In his story, the first to raise the alarm was Shakhrinisa Yuldasheva, the head of the FAP. The boy is 3 years and 10 months old, and he could not speak at all. He only ran, or rather ran away from everyone, and did not even communicate with his parents.

“We sent him to a neurologist, then to a speech therapist. It turned out he has ADHD. Now he is taking medication and preparing for kindergarten. He has learned to ask for the potty and knows dozens of words. And most importantly, he has started making friends with other children,” she says.

Shakhrinisa Yuldasheva is the heart of this team. She has been trained, organizes meetings, and monitors progress. Last year, she walked to 612 houses in her area, some of which are 4 kilometres apart.

“I couldn't not go. They are our children. If we are not there now, they will grow up lonely. But if we are, they will become presidents,” she says.

On 8 March, her husband gave her a car: “so that it would be easier for my wife to help other families.” Now the car contains documents, books, toys and a first aid kit. Shakhrinisa goes out every day.

“We work on the basis of an order of three ministries: the Ministry of Labour and Social Protection, the Ministry of Education and Science, and the Ministry of Health of the Kyrgyz Republic, and with the consent of the local authority in the pilot area. We are not volunteers and did not come up with something on our own. There are seven people in the team: including a doctor, a nurse, a social worker, a teacher, and a coordinator, with a representative of the local government the latest to join. The way of working is not complicated, with four stages: initial identification, discussion at a meeting, action plan, and family support. The methods were explained to us by a UNICEF trainer: observation, survey, tests, referral to specialists, legal assistance, disability registration, and training of parents. Our goal is to bring children out of the risk group, involve them in society, and prevent additional disability or health-related conditions developing. Unlike in the past, we do not redirect the child from one specialist to another, but take joint responsibility for him," explains the head of the FAP.

The team’s work has changed attitudes towards children with developmental delays or disabilities in the village.

“Previously, parents of children with disabilities did not open their doors to us, and the children were isolated. They were not expelled, of course, but they did not communicate much, did not try to help their children, and kept to themselves. But now neighbours call and say: 'There is a boy there, please take a look. We want to help this family: teach us what to do,'” says social worker Gulnur Omusheva.

For example, Adyl* (name changed), who lives with his aunt, came to the TDT reception. He has seizures, stutters, and is afraid to go to school. Thanks to his aunt’s request and the coordinated work of the team, a psychologist started working with him. The team works with the aunt, helps to process documents, and plans further steps for the boy's adaptation in society.

“This is not a project. This is a new system for assisting children with disabilities and their families. We have stopped working alone. Now every child is in focus and under our supervision,” says coordinator Rano Koldosheva.

UNDP, UNICEF, and UNFPA are implementing a two-year project to advance the rights of persons with disabilities in Kyrgyzstan, under the overarching coordination of the United Nations system in Kyrgyzstan and with the support of the United Nations Partnership on the Rights of Persons with Disabilities (UNPRPD).