Responding to complex needs

Rankin & Regan (2004) identify the essence of complex needs as implying both breadth (multiple needs that are interrelated or interconnected) and depth of need (profound, severe, serious or intense needs).

According to Rosengard, Laing, Ridley & Hunter (2007), tamariki and rangatahi with complex needs may have experienced (or be experiencing) one or a combination of the factors including mental illness, physical or intellectual disability, developmental delay, substance abuse, challenging behaviour at school and/or home, poor living conditions, abuse or neglect, harmful sexual behaviour, and criminal behaviour. The level of complexity will vary depending on their support system (and its capabilities), and the identified need or needs of te tamaiti or rangatahi.

The impact of having a tamaiti or rangatahi with complex needs in a whānau or family can have both positive and negative consequences. On the one hand, the whānau or family may be proud about the accomplishments that te tamaiti or rangatahi has made; on the other they may feel sad that te tamaiti or rangatahi has missed certain opportunities as a result of their complex needs. In most cases, whānau or family will demonstrate incredible resilience and develop coping strategies to help them respond to challenging behaviours of te tamaiti or rangatahi. When whānau or family are struggling to respond to these complex needs, interventions need to empower them so that they remain in control of their lives and the life of te tamaiti or rangatahi (McConkey, Barr & Baxter, 2007).

In working with tamariki and rangatahi who have complex needs, keep in mind the following core values:

• Parents know their tamariki or rangatahi better than anyone else so treat them respectfully as equal partners
• Professional supports need to be coordinated and responsive to the needs of te tamaiti or rangatahi and whānau or family
• Risks to te tamaiti or rangatahi need to be managed in ways that provide safety and a quality of life for them and their whānau or family
• Partnership working across disciplines and agencies is essential (McConkey, et al., 2007).

When responding to tamariki or rangatahi with complex needs, there are some key things we can do to help us with deepening our understanding and to make a successful plan:

Encourage and assist te tamaiti or rangatahi to participate in decision-making and planning about their lives – Even when a tamaiti or rangatahi has complex needs, they still have a voice and a right to express their views about what needs to happen for them. This may not be easy to do, depending on the needs that te tamaiti or rangatahi presents with, and you may need to draw on the experience of others to help you (see next point), but their ownership of their plan is vital.

Consult widely – If a tamaiti or rangatahi has a disability, talk to your regional disability advisor as early as possible to ensure that our understanding of needs, strengths and risks and the plan have captured the main issues and looked at the wide scope of interventions available to te tamaiti or rangatahi. Are there other professionals or agencies that we should be consulting with (e.g. paediatrician, special health unit or school) that could better meet the needs of te tamaiti or rangatahi?

Do your research – Take the time to become a ‘pocket expert’ about the disability or special needs of te tamaiti or rangatahi. The internet, library and support agencies (e.g. Epilepsy Society) can provide educational material that will give depth to your assessment and inform your intervention. It will also be important to connect whānau or family with local support agencies that can give them practical advice and information.

Give support – whānau or family often struggle to provide care for a tamaiti or rangatahi with complex needs and continued crises can discourage a whānau or family to the degree that they want to ‘walk away’. We need to be attentive to the support needs of the whānau or family, involve them in the decision-making about te tamaiti or rangatahi, and discuss their support needs with providers. Make sure that there are regular liaison meetings between you, service providers and te tamaiti or rangatahi and their whānau or family to keep the needs at the forefront of decision-making for te tamaiti or rangatahi.

Provide a ‘one team’ response – If a tamaiti with complex needs offends, whānau or family are looking for an Oranga Tamariki response that is professional, effective and timely. The difference between youth justice and care and protection is an organisational issue, not a whānau or family issue, and we need to provide a response that best meets the needs of te tamaiti or rangatahi and their whānau or family. A robust plan will be made if youth justice and care and protection meet together following allocation and continue to meet or consult to ensure that the plan remains robust. Use the child/young person and family consult to identify gaps and make decisions about what response is needed. Remember, when a tamaiti or rangatahi offends a sound and collaborative plan will ensure that this first offence is their only offence.

The child/young person and family consult

Seek specialist knowledge – When a tamaiti or rangatahi is exhibiting harmful or concerning sexual behaviour, they still have the needs for belonging, education and whānau or family relationships that all tamariki and rangatahi have. Assess these needs, recognise the importance of keeping other tamariki and rangatahi safe, and provide the right therapeutic interventions. When a tamaiti or rangatahi is involved in harmful or concerning sexual behaviour or this is suspected, it is important to access specialist knowledge to assess risk and therapeutic needs to bring about the best outcome for te tamaiti or rangatahi.

As practitioners, working with some of our country's most vulnerable and at risk tamariki and rangatahi, we need to be particularly aware of and knowledgeable about the following complex needs:

Substance abuse: The teenage years are often associated with drug use, usually alcohol and marijuana, and this is being seen more and more in our younger population as well. Multiple substance misuse tends to be common, with two-thirds of New Zealand adolescents with marijuana dependence also having a dependence on alcohol (Fraser & Tilyard, 2010). Research completed with secondary school students in 2007 found that 72 per cent of students had used alcohol, and 61 per cent were currently drinking alcohol. Of those students currently drinking alcohol, 30 per cent reported drinking weekly or more often, and 34 per cent said they had engaged in binge drinking (5 or more drinks within 4 hours) in the previous four weeks (Fortune, Watson, Robinson, Fleming & Denny, 2010).

Substance abuse can result in immediate and long-term health and social problems (including mental illness) and can affect intellectual development and educational achievement. Certain factors like a lack of connection with their whānau or family, school and community also put rangatahi at risk of substance abuse (Stone & Matthews, 2009). Genetics also play a role, with research showing that tamariki of addicted parents are more at risk for alcoholism and other drug abuse than are other tamariki (Goodwin, 1985; Kumpfer, 1999).

When you are working with a tamaiti or rangatahi who you believe is abusing alcohol and/or drugs, talk with them about the extent of their substance use and its impact on their day-to-day life and for tamariki aged 12 years and older, apply the SACS screen. If you find that substance abuse is an issue for them, remember there are drug and alcohol specialists within your local community who can help you figure out what to do next – give them a call to see what they suggest. Also, your office colleagues will no doubt have a wealth of knowledge about what they have already tried and what has and hasn't worked that they can pass on to you.

Mental illness: Around 20 per cent of tamariki and rangatahi in New Zealand are estimated to have mental health disorders or problems, with similar types of disorders being reported across cultures, and about half of mental health disorders begin before the age of 14 years (Fraser & Tilyard, 2010). The most prevalent mental health disorders among rangatahi in New Zealand are anxiety disorders, depression and conduct disorder. Males tend to have higher rates of conduct disorder and attention-deficit hyperactivity disorder while depression and anxiety disorders are higher for females. In general, mental illness in rangatahi leads to emotional distress, impaired functioning, physical ill-health and increased suicide risk. As well, rangatahi who present with one disorder are at increased risk of other disorders. For example, concurrent symptoms of anxiety and behavioural disturbances are present in almost all cases of depression, between 50% and 80% of rangatahi with depression will also meet the criteria for another mental disorder, and conduct disorder and/or oppositional disorder occur in around 25% of rangatahi with depression (NZGG, 2008).

Mental illness is particularly common amongst tamariki and rangatahi who are involved with Oranga Tamariki, with one in five having a formal mental health diagnosis recorded on their file (Department of Child, Youth and Family Services, 2000). Conduct and oppositional disorders are likely to be present in 85 per cent of the population of rangatahi who offend, while 30 to 40 percent of tamariki and rangatahi we work with are likely to suffer from a depressive or anxiety disorder (Department of Child, Youth and Family Services, 2000).

Working with tamariki and rangatahi who have a mental illness can be challenging. It is often difficult to know what to do or where to go to get help for them. Added to this, whānau or family of these tamariki and rangatahi will often be stressed and tired from trying to manage and provide support. We need to develop a two-pronged approach whereby we support and advocate for te tamaiti or rangatahi while also supporting their whānau or family.

Keep in mind that culture and religious beliefs can influence the way a tamaiti or rangatahi and their whānau or family view mental illness. Even if you (as the social worker) are the same ethnicity as te tamaiti or rangatahi, don't make the assumption that you will both share the same world view. When working with a tamaiti or rangatahi who is from a different culture to your own, get advice from colleagues in your office, an appropriate cultural advisor, kaumātua, kuia, or religious or community leader.

Early involvement of mental health services is vital to ensure tamariki and rangatahi are appropriately assessed and provided with the safety, services and supports they need. Also, pay particular attention to tamariki and rangatahi who are displaying suicidal ideation or self-harming behaviour. Use the appropriate screens and assessments and follow up any concerns immediately with the right people. If you have the slightest concern, talk to your supervisor or practice leader to make sure you are on the right path.

Disability: Data gathered by Statistics New Zealand in 2006 found that 10 percent of tamariki and rangatahi in New Zealand aged 14 years and under had a disability. Of these tamariki and rangatahi, the majority (46 percent) had special education needs which included learning or developmental difficulties and learning difficulties such as dyslexia, attention deficit disorder and attention deficit hyperactivity disorder. The next most common disability types were chronic condition or health problems such as severe asthma, cerebral palsy and diabetes (39 percent), and psychiatric or psychological disabilities (21 percent). Just over half of tamariki and rangatahi with disability (52 percent) were noted as having a single disability; the remaining (48 percent) had multiple disabilities (Statistics New Zealand, 2007).

Remember that a tamaiti or rangatahi with a disability will have similar hopes and dreams to others their age, even though they will likely face greater challenges and barriers to achieving their dreams. Think about what you and others in your community can do to help them reach their full potential.

When working with a whānau or family who are caring for a tamaiti or rangatahi with a disability, your assessment needs to include conversations with the whānau or family about what supports they require (i.e. respite, home help, educational support) so they can provide the best care possible. Keep in mind that whānau or family in lower socio-economic areas and low-income households are generally less likely to know what supports are available to them and how they can access these supports (Ministry of Health, 2004).

Talk to your regional disability advisor about your next steps, and make a referral to the Needs Assessment and Service Co-ordination (NASC) service who will help identify the needs and disability supports available to te tamaiti or rangatahi. Put your mind to thinking about what this tamaiti or rangatahi needs now and in the future. If te tamaiti or rangatahi is in our custody and likely to remain there until they are at least 17 years old, find out how you can make sure they have a smooth transition to adult services. What work needs to be done now to involve te tamaiti or rangatahi (and their whānau or family) in the decisions around this?

Working with disability and learning supports, mental health and ACC

Harmful sexual behaviour: It is estimated that tamariki and rangatahi are responsible for about one-third of all sexual abuse against tamariki and rangatahi (Grubin, 1998), although the actual incidents of sexual abuse are likely to be higher due to low reporting rates. Other research by Venziano & Veneziano (2002) found that of all adult sex offenders, around half had committed their first offence as a rangatahi with subsequent escalation in frequency and severity. Tamariki and rangatahi who display harmful sexual behaviour are likely to be male (92 percent), have social skills deficits, lack sexual knowledge, and have high levels of social anxiety (Righthand & Welch, 2001; Veneziano & Veneziano, 2002). For some tamariki and rangatahi, the combination of the above characteristics can create difficulties for them in forming healthy relationships and lead them to meet their needs through unhealthy and abusive interactions with tamariki and rangatahi.

Any work undertaken with a tamaiti or rangatahi who displays harmful sexual behaviour requires a coordinated interagency approach which helps them to be accountable for their behaviour and make the necessary changes while also protecting the community. The earlier that te tamaiti or rangatahi receives help and support, the more likely it is that their change in behaviour will be long-lasting. The severity of their sexual behaviour will also need to be considered – for lower level harmful sexual behaviour (e.g. masturbating in public) it may be more appropriate to provide in-home support; a higher level of harmful sexual behaviour (e.g. sexual intercourse with a tamaiti) could require specialist residential treatment. Talk with your supervisor about the best approach to take.

It is important to also consider the possibility that the harmful sexual behaviour of te tamaiti or rangatahi may have stemmed from abuse they themselves have been subjected to and they will need extra support to help them address any residual feelings from this experience.

For tamariki and rangatahi who have been victims of sexual abuse, whether by an adult or a peer, we need to think about the impact that the abuse has had on them. Consider the range of emotions that te tamaiti or rangatahi might be experiencing – guilt, fear, isolation, sadness, anger, helplessness, shame. Research shows that tamariki and rangatahi who have been sexually abused are more likely to abuse alcohol and drugs, display inappropriate sexualised behaviour, experience anxiety and depression, negative peer involvement, self-harming and behavioural problems, and that these adverse effects may well endure into adulthood (Cleaver & Webb, 2007).

We need to be sensitive to what te tamaiti or rangatahi is going through, and provide them with the specialist support they need to get their life back on track. Remind te tamaiti or rangatahi that they did nothing wrong, and be there for them when things aren't going so well. Keep an eye on their state of mind, and if you are concerned about their mental health, get help for them immediately.

Offending behaviour: According to a report released by the Ministry of Justice in 2010, apprehension rates of tamariki and rangatahi aged 10 to 16 years declined from 1995 to 2008, especially in the last three years. The rate was highest in 1996 at 2,469, dropping to 1,908 in 2008. However, while overall offending decreased, the rate of violent apprehensions among rangatahi aged 14 to 16 years rose – from 167 per 10,000 people in 1995 to 198 in 2008. The number of rangatahi who were prosecuted also increased, up to 28.1 per cent of apprehensions in 2007 from 13.2 per cent in 1995 (Ministry of Justice, 2010).

A lot of times, tamariki and rangatahi who offend will also be dealing with care and protection issues, and we need to work together as an organisation to meet their needs. It won't be important to te tamaiti or rangatahi and their whānau or family who helps them, just as long as they receive the assistance and support they need. We must use our models, tools and resources to build and deepen our understanding of the strengths, risks and needs of te tamaiti or rangatahi to inform the plan for te tamaiti or rangatahi. Remember to involve te tamaiti or rangatahi, their whānau or family and other professionals in planning and decision-making – tamariki and rangatahi have the right to have the chance to say what they want their life to look like and are likely to have better outcomes if we give them this chance.

Organising my practice

Tiaki Oranga

Department of Child, Youth and Family Services (2000). Towards Well-being: Responding to the Needs of Young People. Wellington.

Grubin, D. (1998). Sex Offending against Children: Understanding the Risk. Police Research Series paper 99. London, Home Office

Fortune, S., Watson, P., Robinson, E., Fleming, T., Merry, S., & Denny, S. (2010). Youth’07: The Health and Wellbeing of Secondary School Students in New Zealand: Suicide Behaviours and Mental Health in 2001 and 2007. Auckland: The University of Auckland.

Fraser, T. & Tilyard, M. (2010). Childhood depression. Best Practice Journal: Special Edition, Dunedin.

Goodwin, D.W. (1985). Alcoholism and genetics. Archives of General Psychiatry, 42, 171-174.

Kumpfer, K.L. (1999). Outcome measures of interventions in the study of children of substance-abusing parents. Pediatrics: Supplement, 103 (5): 1128-1144.

McConkey, R., Barr, O. & Baxter, R. (2007). Complex Needs: The Nursing Response to Children and Young People with Complex Physical Health Care Needs. Belfast, Ireland: Department of Health, Social Sciences and Public Safety/University of Ulster.

Ministry of Health (2004). Living with Disability in New Zealand. Wellington.

Ministry of Justice (2010). Child and Youth Offending Statistics in New Zealand: 1992 to 2008. Wellington.

NZGG (2008). Identification of Common Mental Disorders and Management of Depression in Primary Care: An Evidence-based Best Practice Guideline. Wellington, New Zealand: Guidelines Group.

Rankin, J. & Regan, S. (2004). Meeting Complex Needs: The Future of Social Care. London, UK: Turning Points/Institute of Public Policy Research.

Righthand, S. & Welch, C. (2001). Juveniles who have Sexually Offended: A Review of the Professional Literature. Washington, D.C.: Office of Juvenile Justice & Delinquency Prevention.

Rosengard, A., Laing, I., Ridley, J. & Hunter, S. (2007). A Literature Review on Multiple and Complex Needs. Edinburgh, Scotland: Scottish Executive Social Research.

Veneziano, C. & Veneziano, L. (2002). Adolescent Sex Offenders: A Review of Literature. Trauma, Violence & Abuse Journal, 3, 247-260.