The term “complex needs” has been used to describe individuals who have a range of multiple and co-occurring challenges that can be caused by individual-level factors (e.g., physical or psychological health problems, drug and alcohol issues) or broader social-economic factors (e.g., poverty, precarious housing or homelessness, child maltreatment and exposure to family violence, justice system involvement; Baldry & Dowse, 2013). These factors are often inter-related and multiple government and non-government services are often needed to adequately support children and families. For young people in adolescence and early adulthood, these compounding difficulties influence their ability to lead healthy and successful lives and often lead to a reliance on support from multiple services. While Baldry and Dowse (2013) explain that the term “complex needs” is heterogeneous and no single, consistent definition has been identified, it has been used to describe individuals who have multiple and co-occurring challenges that can be impacted by factors across different ecological levels (see Klassman et al., 2024 for a review). These factors included those relating to the individual (e.g., physical or psychological health challenges), as well as broader socioeconomic challenges (e.g., poverty, unstable housing or homelessness, exposure to child maltreatment and family violence, and justice system involvement). It is also recognised that for many children and young people described as having complex needs, familial circumstances also reflect these complexities and reflect the intergenerational disadvantage and trauma experienced by families (Baldry et al., 2012; Mendes & Snow, 2014).
Given the inconsistencies in definition, as well as the different ways data are captured on the diverse needs of children and families who require support services, it is difficult to estimate the number of children and young people experiencing complex needs. In one Australian jurisdiction, it is estimated that the number of child-protection involved families experiencing complex needs has increased over time, particularly in terms of exposure to domestic violence, drug and alcohol abuse and parental mental health issues (Bromfield, 2010). This assertion was supported by a recent report which estimated that, in a sample of families notified to child protection in 2014, 75 percent involved domestic and family violence, 58 percent and 51 percent involved parental substance use and mental health issues, respectively (Early Intervention Research Directorate, 2019).
From both a practice and service system perspective, young people’s complex needs are often not easily met by existing services. In some situations, services and practitioners may find it difficult to engage young people who have multiple complex needs. For example, challenges can arise when young people do not meet eligibility criteria for available services (e.g., mental health or disability); have previously been excluded from services (e.g., due to outstanding debts or aggressive behaviours. In some cases, young people may present with a range of these conditions, which makes it hard for their needs to be accommodated by any single service (Baldry et al. 2012; Malvaso & Delfabbro, 2015; Malvaso et al. 2016; Mendes & Snow, 2014). In addition, there are often young people who find it very difficult to engage with services or who appear unwilling or unable to forge productive relationships with adults in services designed to assist them. This resistance can result from a variety of factors, including: difficulties with social interactions (e.g., due to personality disorders, neurological disorders); coping strategies that result from experiences of significant adversity and trauma that make service engagement challenging; and a lack of engagement that may reflect feelings of disillusionment and disenfranchisement arising from previous negative experiences with services (Malvaso & Delfabbro, 2015; Malvaso et al., 2016). These various issues conspire to increase the probability of young people not receiving the support they need, resulting in further increased risk of becoming homeless; being exploited and abused; developing more complex problems; or becoming entrenched in justice and welfare systems (Baidawi et al. 2020).
Although there is evidence of these barriers across a number of studies, the focus has been on barriers and strategies to service engagement in specific population groups only, for example young people leaving out-of-home care placements (Malvaso & Delfabbro, 2015; Malvaso et al., 2016; Mendes & Snow, 2014), in the justice system (Mendes et al., 2014), or who are homeless (Black et al., 2018). These studies have highlighted numerous barriers that exist at both an individual and service level, and have made recommendations to enhance service coordination. However, there may be additional difficulties in developing co-ordinated approaches to guide practice when working with young people involved in services across multiple agencies that have not been systematically explored. A recent rapid evidence assessment of 18 studies meeting eligibility criteria for documenting or describing practice insights for service engagement with young people who have complex needs suggested that relational, structural and empowerment approaches to service delivery may be most beneficial, and that services which are flexible, collaborative and prioritise staff training may best meet the needs of children and young people experiencing challenges in multiple areas (Klassman et al., 2024).
Engaging with, and listening to, the perceptions and views of those responsible for delivery services to this population of young people is important for understanding the current and future directions of best practice in supporting young people with complex needs. Using practice wisdom in this way can inform the ongoing development of practice guidance and provide insight into opportunities to strengthen service delivery in this area. Therefore, this study sought to obtain, first-hand, information through a series of focus groups and interviews with practitioners and service delivery experts in an Australian jurisdiction to address the following key question: what are the barriers to, and strategies for, service engagement among young people experiencing complex needs?
Study Aims and Context
The current study aimed to gain deeper insight into the barriers to, and strategies for, service engagement among young people experiencing multiple complex needs. In an Australian jurisdiction, the lack of a coordinated approach to working with young people with complex needs has been identified by an agency - the Exceptional Needs Unit (ENU) in the Department of Human Services - whose remit is to assist those with exceptionally complex needs in overcoming barriers to accessing appropriate services and support. This agency helps young people to navigate the service system by bringing together multi-disciplinary practitioners across different services to coordinate targeted, individualised support for young people. However, this agency identified that there are currently no appropriate practice frameworks that exist to help guide practitioners across different services in supporting young people who have multiple and complex needs. To assist this agency in their goal to develop a practice framework that can enhance engagement between young people and various services across the system, researchers from an Australian university were commissioned to conduct research that can provide insight into current practice relating to service provision for young people with complex needs who have difficulties accessing mainstream supports.
Method
Interview Sample
Data were obtained from interviews with professionals working in organisations who have knowledge of, or contact with, young people aged 12–25 years in one Australian jurisdiction. Twelve interviews were conducted with 42 participants, which captured the views of 19 organisations spanning health, child protection, justice, housing and homelessness, disability, education and advocacy services. Seven interviews were conducted as focus groups with up to ten participants and five were one-on-one interviews.
Organisations and individuals were identified by an Australian government agency (The ENU) responsible for providing service coordination support for young people with complex needs. To the best of our knowledge, all possible organisations that work with these young people were invited to participate. The professionals involved included programme coordinators and service managers, service team supervisors, practitioners spanning multiple professions (including psychologists, social workers, and counsellors, support workers/mentors, advocates) and a researcher from a state university. Further details regarding the format and location of focus groups, as well as the roles of participants, are included in supplementary Table 1.
Participant Recruitment
Author KK emailed the prospective participants. Author KK had no previous relationship with the participants. The names and emails of organisations were provided by the ENU. The recruitment method was purposive, meaning that participants were chosen to ensure a broad range of professionals from different sectors were involved to provide diverse perspectives on working with young people with complex needs. In some instances, snowballing methods were used where invited participants would nominate other individuals within the same organisation to participate either in addition to or instead of the recipient of the recruitment email. Similarly, if a participant knew of an individual who worked with young people with complex needs from a different organisation, they would suggest connecting with that individual. Of those that were nominated, all of were from organisations already nominated and contacted. Specific individuals within the organisation however were found based on these nominations.
Organisations were contacted via email to invite them to participate in this study. A time was then arranged for the interviewer to meet with interested participants at a place of their choice (usually in the organisations offices), or as part of a larger focus group with other organisations at a pre-specified time and location. Participants were also offered Zoom videoconferencing sessions if they were unable to attend in person. In total, 24 organisations were contacted, of which 19 agreed to participate (79%). The main reason for non-participation was non-response (n = 4), or unable to find a suitable time for participation within the project timeframe (n = 1).
Procedures
Ethics approval was obtained from The University of Adelaide, School of Psychology Human Research Ethics Sub-Committee (HREC approval number H-2020-20/26). Participants were provided with an information sheet and were asked to sign a consent form, or provide recorded verbal consent (for video participants) prior to beginning the interview. An interview protocol was developed and questions broadly focused on: 1) challenges and barriers associated with providing services to young people with complex needs, and 2) best practice examples and strategies for service engagement.
Interviews were conducted by authors CM and KK and were semi-structured. Sessions began with a consistent preamble to provide background information on the project. Participants were then asked pre-determined questions in a conversational manner. In some instances, the discussion covered some later questions in advance, and interviewers allowed those points to be made in a way that maintained the flow of discussion. Probes were used where appropriate to elicit more detailed responses from participants. The average duration of interviews was 68 min (min. 50 mins – max. 85 mins). All interviews were audio-recorded and transcribed verbatim by [author KK and research assistant NG]. Participant confidentiality was maintained through the assignment of numbers in place of names when transcribing interviews and analysing data.
Qualitative Research Paradigm and Approach
This qualitative study was guided using a descriptive interpretivist research paradigm as it considers the nature of experience from both the participants as well as the active role and reflexive process of the researchers involved (Bradshaw et al., 2017; Braun and Clarke, 2021).
Reflexive thematic analysis using an inductive approach was used as the guiding analytical framework for this study (Braun and Clarke, 2019; 2021). Reflexive thematic analysis is used to identify, analyse and generate patterns or themes within the data while centring the researchers position as an active participant in the interpretation of these themes (Braun and Clarke, 2019; 2021). This led to the development of themes based on the experiences and perspectives of participants involved, and allow the experiences of the researchers to provide a lens on the way that the data was interpreted and organised.
While our approach was predominantly inductive, we also applied a degree of deductive analysis, using existing research and theory as a guiding lens to organise themes around barriers and strategies at the service, system, and individual levels. For example, although the goal of this study was to understand individual level approaches, the researchers recognised that that individual level approaches are often limited by service and system restrictions within practice. This was also consistent with the responses provided by the participants, with multiple instances of the service and system restrictions limiting practice. Therefore, during the data analysis process, codes and themes were interpreted through this lens to account for the structural limitations of systems in practice.
Data Analysis
Reflexive thematic analysis was completed using processes as guided by Braun and Clarke (2006; 2019; Byrne, 2022). This involved researchers [author CM and KK] becoming familiar with the data by reading the transcripts numerous times. Initial codes were developed and colour-coded to represent patterns of shared meaning underpinned by a central organising concept which generated an overarching theme and potential subtheme. In many instances, there were numerous examples raised by participants which led to the generation of similar themes. This overlap meant that some of these became combined to form an overarching theme. Both researchers were involved in this process and would discuss thematic generation and determine appropriate classification of codes into relevant themes. This was an iterative and reflexive process which involved going back and forth between interpreting the data and developing themes, while reflecting on the individual lens of both researchers and the framework used.
Researcher Reflexivity
Researcher characteristics and reflexivity was considered throughout the research process given the potential for the roles and experience of researchers to influence the way that data is interpreted and organised (Olmos-Vega, et al. 2022). Researchers CM and KK were involved in the data collection and analytical process. Both researchers were recognised as having previous experience in supporting young people living in out of home care who may be considered to be experiencing multiple complex needs. Researcher CM has extensive experience in research and understanding the structure of the service system, as well as existing professional relationships with some of the participants involved in this study. This was unavoidable in a relatively small jurisdiction and service sector. This may have led to participants being more willing to share views, and influence the power structure that may be present during interviews. This was taken into consideration and reflexive practices undertaken during the interview procedures and data analysis, acknowledging potential underlying bias whilst also allowing the lens of experience guide these processes. This is consistent with reflexive thematic analysis, which recognises the subjectivity of the researcher provides both advantages and disadvantages, rather than a bias to be removed (Braun and Clarke, 2019; 2021).
Results
The participant’s views were captured across 20 principal themes differentiated into two overarching categories: 1) Barriers to engagement; 2) Strategies for engagement. The themes were then categorised into levels: 1) Systems; 2) Services; and 3) Individuals (see Table 1). Themes often overlapped across categories and levels, and therefore they have been organised in a way that best captures the issues raised rather than providing lengthy overlapping narratives. Each theme is discussed separately below.
Table 1
Summary of themes organised according to system, service and individual level barriers and strategies
Barriers | Strategies | |
|---|---|---|
System level | • Reactive, punitive and risk averse systems • Eligibility, transitions and mandate restrictions • Unresponsive systems • Funding service issues | • Flexible and intelligent systems • Supporting complex needs through multi-disciplinary teams • Prevention, early intervention and restorative practice |
Service level | • Lack of service coordination and information sharing • Unresponsive services • Staffing issues | • Characteristics of services • Characteristics of workers • Case coordination and collaboration • Staff training and reflective practice |
Individual level (young people) | • Experiences and characteristics • Issues arising due to complex needs • Barriers to engagement | • Building strong relationships • Approaches to facilitate better engagement • Strategies to set young people up for success |
System Barriers
System barriers fell into four themes: 1) Reactive, punitive and risk averse systems; 2) Eligibility, transitions and mandate restrictions; 3) Unresponsive systems; and 4) Funding issues.
Theme 1. Reactive, punitive and risk averse systems
Participants described the system as reactive, with the term “crisis-driven” being referred to consistently. As one clinician stated: “Everyone gets into these reactive states of engagement and they work counter-intuitively to each other and it becomes really dangerous” (participant 20, clinician). Another participant described the reactive system as unproductive in meeting the needs of young people because “you can’t do it working at a symptom level, you have to do working underneath at that kind of causal level.” Participants expressed a desire to improve the way the system responds to young people, but described staffing and funding issues as major barriers. As one participant stated, “we’re trying to get better at it, but you know, as a tiny organisation it’s so hard to do any kind of proactive work when we’re so struggling just to be reactive.” (participant 3, youth advocate).
Another descriptor was “Punitive” in that the system often seemed to be focused on punishing young people rather than being sympathetic to the underlying problems. This appeared to be particularly true for young people who traversed both the child protection and youth justice systems. As one participant said: “their behaviour is criminalised … simply because they mucked up. Any other person in a normal family wouldn’t have police come over for kicking a hole in the wall.” (participant 4, manager).
In five interviews, respondents reported that the system and agencies within it had become risk averse, particularly as a result of incidents that had attracted negative media attention. One respondent stated that: “coroner’s investigations into these sorts of situations haven’t helped and so if something adverse happens to this child we’re going to be hung out in the court of law” (participant 22, manager). This risk aversion was thought to lead to attempts to diffuse responsibility by engaging many different agencies and workers.
Theme 2. Eligibility, transitions and mandate restrictions
Participants described how the legal remits of the agencies they work for can limit the range of services available to young people with complex needs.As an example, one respondent explained the difficulties in advocating for young people, when their remit only enabled advocacy when the young person was held in custody. Other participants described issues related to handover between mandatory and voluntary services, for example, “We can try to and encourage them to engage with other services or supports but often if they are not with a mandated service and its voluntary that’s where that consistency can drop off.” (participant 7, clinician), Similar “siloing” of services also related to funding, with services often only able to engage with young people defined by funding agreements, for example, those of a certain age. These funding-based restrictions were also discussed in relation to services that could not work with young people after the age of 18.One particular frustration was the inability to assist young people once they left out-of-home care after being on statutory guardianship orders.
Theme 3. Unresponsive systems
Participants described how the “system responses meet the needs of systems” and not young people.They expressed concerns that, despite having had contact with several agencies, young people were often not properly assessed for particular issues or conditions essential for providing services that will meet their needs. One participant described how young people “have gone through a multitude of systems, they’ve gone through education, in and out of youth justice … and they haven’t had the right assessments about their disability needs” (participant 7, manager). Several participants gave similar examples and referred to these as “missed opportunities”, which were seen as consequential for subsequent, more serious problems that could have been avoided if picked up earlier, especially when these problems were related to intellectual functioning or undiagnosed disabilities. The system was described as unresponsive to trauma and that one was: “dealing with a system that actually doesn’t understand trauma and actually can’t respond to trauma in a way that’s respectful, kind and compassionate, and so that adds another layer of complexity” (participant 29, clinician).
Despite strategic documents with statements that promised culturally responsive services, participants reported that achieving this at a system level with young people who have complex, competing needs is a major challenge. Here again, the siloed nature of systems can lead to duplication or fragmentation in the way cultural responses are provided, as pointed out by a respondent: “every agency around the table is saying they’re got one [a cultural advisor] too, so there’s no one central position for that cultural knowledge either” (participant 27, advocate). A related concern was the over-reliance on agency employees to provide cultural knowledge with this being prioritised over the knowledge from families and communities.
Theme 4. Funding issues
Funding issues were highlighted by participants as one of the main drivers of the system not being responsive to the needs of young people. This was viewed as reinforcing siloes between services, driving strict and inflexible eligibility criteria that often exclude young people who have complex needs, and sometimes also led to the duplication of services. This latter issue related mostly to the idea that multiple, underfunded services who have brief periods of engagement with young people and are unable to provide the intensive supports required over sustained periods. This leads to young people often moving on from service to service, sometimes receiving multiple assessments, but not actually receiving any therapeutic response. Numerous participants referred to this issue leading to “over-servicing”. One practitioner described this issue in the following way:
In terms of service support, I find that young people with complex needs might have a worker allocated to each one of those needs, and they feel totally overwhelmed by the amount of services they engage with … you’re having a case conference where literally 25 people are there, and if I find that confusing and overwhelming, how is that going to be for a young person? (participant 7, practitioner),
Although participants recognised that case conferences were being used as a system response to ensuring young people are receiving the support they need, participants described how this did not always lead to a resolution in the often siloed approach to providing services to young people with complex needs. One participant likened such conferences to “seagulls fighting over a chip”. Another participant described the impact of over-servicing on the young people:
You go into a case conference and they [the workers] go, ‘oh I’m there Monday, I’m there Tuesday, I’m there Wednesday’ … just to try and put yourself in that empathy space to know what that must feel like with someone knocking on your door every day of the week demanding something of you, and then you’re expected to go to school and get a job. It’s so much. (participant 18, manager)
Summary of system barriers
Overall, system issues appeared to be one of the most reoccurring barriers to engaging with young people. In every interview, participants described reactive, punitive and risk averse systems that were unresponsive to the needs of young people. The system was described as being comprised of agencies that are restricted in their remits to engage with young people who traversed multiple systems, that were restrained by funding issues, and that operated in siloes leading to fragmented service delivery.
System Strategies
Strategies to improve service engagement at a system level for young people with complex needs fell broadly into three main themes: 1) Flexible and intelligent systems; 2) Supporting complex needs through multi-disciplinary teams; 3) Prevention, early intervention and restorative practice.
Theme 1. Flexible and intelligent systems
The need for an intelligent system that had the capacity to monitor and evaluate how well the system as a whole responds to the needs of young people was identified. For example, participants spoke about the data infrastructure required to support monitoring how many young people were involved in multiple services. This included greater information sharing between agencies and services; the ability to link data from different agencies; service system mapping to get a better understanding of pathways through the system; and, the need for fast-tracking referral processes through agencies whose responsibility it was to facilitate service coordination and ensure timely responses.
Theme 2. Supporting complex needs through multi-disciplinary teams
Participants spoke about the importance of supporting young people through multi-disciplinary and multi-agency services and care teams. The importance of agencies understanding their role within a care team, a need for shared responsibility and appropriate time for handover to other agencies were strongly emphasised. The most common idea was to ensure that there was an agency (and key worker) willing to take the lead on coordination as a way to facilitate accountability among all agencies involved. This was seen as an approach that could assist to break down the siloed approach to service delivery. Participants also suggested that a mentor or other trusted person (e.g., family member) that could be part of these teams to facilitate the engagement and smooth handovers between agencies or in the transition from one service to another.
Theme 3. Prevention, early intervention and restorative practice
Participants emphasised the need for more early intervention and prevention strategies at the system level to reduce the burden of later consequences. Included in this imperative was the need to address intergenerational trauma and to respond more effectively to young people in the early stages of their care. These points were raised in conjunction with discussions of the value of restorative practice and how this could be used to assist the system in responding to young people. For example, “bringing together all the people that are involved in the case, for example, the family, the children, the extended family, the services that are involved, for them to get together and talk about the issue, and to find out a solution and how they can support each other” (participant 34, practitioner).
Summary of system strategies
Participants highlighted whole-of-system strategies that could help to facilitate service engagement. These included intelligent and flexible systems with the capacity for data linkage across agencies to assist in understanding young people’s pathways through the system. This could be complemented by detailed system mapping of agencies and services to better understand points of contact, referral pathways and service capacity. Another important element was the value of assigning a lead agency or worker as responsible for ensuring effective service coordination when multiple agencies were involved. Finally, there was a focus on prevention, early intervention and restorative practices to reduce higher risk pathways and the subsequent need for more intensive services.
Service Barriers
System level barriers fell broadly into three themes: 1) Lack of service coordination and information sharing; 2) Unresponsive services; and 3) Staffing issues.
Theme 1. Lack of service coordination and information sharing
Reference to services operating in siloes and of a general lack of service coordination across multiple interviews. Participants spoke about difficulties in coordinating case conferences due to schedule clashes, case loads and competing priorities, making it difficult for services to be held accountable for their areas of responsibility. Inter-service communication was said to be lacking and affected by differing agendas amongst individuals in care teams. Lack of information sharing between agencies as a barrier to service coordination and case progression. This was described as impacting negatively on engagement: “[young people] are asked the same questions from different agencies over and over again and I guess it must impact their view of government services or any services as a whole” (participant 1, mentor).
Theme 2. Unresponsive services
Participants described how mainstream services are not conducive to the needs of young people, with most services reliant on unrealistic expectations on young people with complex needs and limited support networks to contact them and make appointments.
Services are based on that model, you know attending appointments in a certain location really require in the mainstream, to start with a functioning family system around them to help them, and make them do that themselves … it’s really a population that needs that assertive outreach (participant 26, counsellor).
Themes relating to service unavailability due to long waitlists, stringent eligibility criteria, operating hours and engagement methods inappropriate to meet the needs of young people were commonly raised by participants. Services were described as “inflexible”, operating on a 9am to 5 pm weekday model, and appointment-based. The time-limited nature of services was raised as a barrier, with participants noting that engagement is not an immediate process: “A couple years of engagement, that’s what it takes, that’s the extent you need a commitment and there is not a lot of services that are able to provide that” (participant 25, psychologist).
The idea that services are punitive towards young people who “fail” to engage was raised with participants describing situations where young people were refused access to services or lost their accommodation due to non-engagement and behavioural problems. Even when young people were receiving a service, participants described how this could be inconsistent, with multiple examples examples raised of young people frequently experiencing changes in cases managers, placement changes and a general lack of awareness of the services they should be receiving.
Participants described how unresponsive services often resulted in young people “falling through the gaps”, with one youth justice professional explaining that “there has been a lot of missed opportunities for things like assessment” (participant 6, case manager). Participant also described how services struggle to meet the needs of young people with communication difficulties, intellectual disabilities or language delays where they may require different mechanisms of communication. The lack of communication support was similarly raised in terms of immigrant and refugee populations who may require interpreters or communication specialists.
Theme 3. Staffing issues
Staffing issues emerged as a significant theme, including challenges such as high staff turnover, high caseloads, worker burnout, vicarious trauma, and insufficient support and training. As described by one respondent: “Workload comes at a cost. It’s quite taxing on people … high sick leave, which is really obviously linked to a dissatisfaction with the work or, you know, feeling burnt out or not supported” (participant 31, practitioner). Some participants also felt that, due to the pressures and demands of the work, limited opportunities for debriefing led to detrimental outcomes: “without that debrief and that capacity for staff to share with one another they just take that home and that’s really detrimental effects for everyone involved” (participant 20, therapist). Others described issues of worker retention, especially relating to Aboriginal workers.
It can be really hard to attract and retain Aboriginal people in human services because of turnover and, and obviously, the absolute exhaustion, about being, you know, a one stop shop, whatever is your business, outside of nine to five paid work hours (participant 34, practitioner).
The most prominent theme about staff training related to a lack of cultural competency and responsiveness. Participants described how this was evident at an organisational level and that the uptake of cultural consultation was not sufficient. Another example was in relation to trauma-informed care, where workers received training but felt that it was not adequate to translate into practice.
Summary of service barriers
Participants identified multiple barriers to engagement at a service level, including: difficulties around case coordination and information sharing; characteristics of services that rendered them unresponsive to the needs of young people; staffing issues in attracting and retaining staff in challenging areas of practice where block funding and short-term contracts are the norm and often coincided with worker burnout and vicarious trauma; and a lack of support and training for workers.
Service Strategies
Strategies for engagement at a service level clustered into four main areas for improvement. This included: 1) Characteristics of services; 2) Characteristics of workers; and 3) Case coordination and collaboration; and 4) Staff training and reflective practice.
Theme 1. Characteristics of services
Participants provided insight into the structural aspects of services that would render them more conducive to engagement for young people. Service flexibility was a reoccurring theme across interviews, with participants emphasising that services should not be governed by strict eligibility criteria. For example, one participant stated “Not have three strikes you’re out” and “to have that flexibility instead of an arbitrary cut off so it’s more about when the child needs to move on, and there’s that bend of flexibility to accommodate for that”(participant 3, advocate). A further suggestion was the need for flexibility in assessments processes, as described by one case manager: “Whether those assessments can be more flexible or done with more input from observation of other people in their lives, as opposed to engaging with them directly with that young person who doesn’t have that capacity” (participant 6, case manager). However, the idea of using multiple informants in assessments needed to be balanced by child-centred approaches that incorporated the views of the young person.
Participants also believed that creative approaches were more effective for engagement, for example: “really good practice is skills, knowledge, understanding, but also, elements of it are really hard to characterise, like creativity.” Others spoke about “thinking outside the box” and “incidental therapy” in less conventional settings, for example, “the magic doesn’t always happen when you’re sat down two feet away from each other having a conversation like it gets in the car when you’re doing something”(participant 35, clinician). It was recognised that evidence-based approaches to engaging with young people are required, but that this evidence-based needs to be developed: “we get stuck on this evidence-based practice even though the evidence is not built on these kids, it might be great for those on different ends.” Alternative approaches for engaging with young people with disabilities were viewed as particularly important, especially with those who are nonverbal and require assistive and augmentative communication techniques.
The physical structure of services was raised as important. Drop-in centres were suggested as a way to build engagement. One manager described the benefits of their communal drop-in space: “The office helps as well. Yeah, space with the pool table with PlayStation, they can just come and hang out.” (participant 37, manager).
Theme 2. Characteristics of workers
Participants described qualities of workers essential to building the relationships required to facilitate service engagement, including persistence, consistency and an assertive engagement style. The most effective way to these build relationships was through assertive outreach.
That’s why we try to build that connection straight away… you know be at the front door every time, keep showing, keep little things they might need help with like Centrelink, food shopping or like real small stuff which is nice so they can see like we’re not going away, when you can get that type of longer-term results (participant 1, mentor).
Outreach and home visits were viewed as the best way to begin to build that relationship. A number of participants suggested that for those young people who are particularly resistant to engagement, building a relationship with family members was an important starting point. Participants believed that it was the worker’s responsibility, not the young person’s, to facilitate engagement:
I think the other thing that’s really important … is also the assertive part of what we do, yeah, which is basically the understanding that a young person doesn’t necessarily have the capacity to engage. And so it’s incumbent upon us to actually make that connection rather than, you know, expecting them to come in for a session or two, you know, the onus is on us to engage them (participant 36, practitioner).
The theme of being “trauma-informed” was commonly raised s at the service and individual worker level. However, at the worker level, participants felt that this needed to extend beyond “trauma-informed” to more specialist trauma services. Similarly, workers also need to have a deep cultural understanding in responding to needs of young people from diverse backgrounds. This was especially highlighted in relation to Aboriginal young people with suggestions this could be achieved through attracting Aboriginal workers, but also in upskilling non-Aboriginal workers.
Theme 3. Case coordination and collaboration
Expanding on the theme of multi-disciplinary teams from a service perspective, participants expressed the need for better case-coordination, collaboration, and workforce training. For example, “I think clients from complex needs really benefit from, and people from different disciplines looking at different solutions for the problems they’re facing” (participant 10, clinician). Case co-ordination was also viewed as beneficial for maintaining engagement especially when multidisciplinary care team approaches were used to wrap support around the young person, and teams that talk to each other consistently promote accountability. Collaboration between services could also be facilitated through better information sharing, but also by workers taking the time read through information that has been collected and shared by other agencies.
Theme 4. Staff training and reflective practice
The importance of training workers in different aspects of service provision was consistently emphasised by participants. They spoke about the importance of cultural training, and in ensuring that workers have a deep understanding of how culture influences engagement. For example, as one respondent said, “something that we really strive within our trainings that we provide is to get people to start thinking differently and understanding that culture is so layered” (participant 37, manager). Others spoke about the value of training in trauma-informed approaches. However, participants felt that this needed to be more than just a tick-box approach and the importance of being able to translate these approaches in practice. For example, “Trauma informed practice as a training isn’t like I can learn how to use Microsoft Excel and now I can have that skillset” (participant 19, manager).
Participants also emphasised the need for workers to be trained in reflective practice and the importance of self-awareness. It was acknowledged that some workers receive a lot of training but it is about translating what they learn into practice, which is where reflective practice can be used. This was also seen as a positive way to reduce worker burnout and engage in the debriefing process.
Summary of service strategies
A number of service level strategies were identified, including: changes to service structures and processes to allow for flexibility and creativity, such as more flexible working hours and drop-in centres; consulting young people in understanding factors that would better facilitate service engagement; use of assertive engagement approaches, such as outreach visits, flexibility, persistence and consistency; creative approaches at both the service and worker level in recognition that each young person is different and will respond to different approaches; enhanced case coordination strategies and multi-agency collaboration; and better training for staff (particularly in reflective practice).
Individual-Level Barriers
Individual level barriers engagement fell broadly into three central themes: 1) Experiences and characteristics; 2) Issues arising due to complex needs; and 3) Barriers to engagement.
Theme 1. Experiences and characteristics
Participants were asked to describe some of the challenges young people with complex needs face and some of the characteristics or issues that made it challenging to engage them in services. Young people were described as having: trauma-related behaviours; difficulty in trusting others; mental health problems; disabilities or developmental delays; involvement in criminal behaviour; and, problems with drug and alcohol use. Trauma and maltreatment were the most common experiences. It was common for participants to describe young people as having a multitude of issues often co-occurring, with layers of complexity that often fall short of systems and services capacity to respond effectively. This included barriers relating to trauma histories and the lack of trust the systems put in place around relational connection. This would then be compounded by challenges including transience, drug abuse, intellectual disability or learning difficulties.
Young people who had extended involvement with government agencies were identified as lacking trust in services and workers. Participants believed distrust hindered young people’s willingness to engage with services, and that building this trust takes a lot of time. Issues of racial bias were also described regarding young people from Culturally and linguistically diverse (CALD) and Aboriginal and/or Torres Strait Islander backgrounds, further exacerbating feelings of marginalisation and not belonging. The impact of intergenerational trauma of Aboriginal young people was also raised as having a significant effect on these communities, often adding to their complexity.
Theme 2. Issues arising due to complex needs
Participants reported that housing was a significant issue for young people, which makes it more difficult for services to be able to engage them. In support of this view, a practitioner reported a large proportion of their clients were currently, at risk of or had previously been homeless:
So we have just in the last quarter, we supported 309 young people aged 16 to 25. And the majority of them, the majority of them either experienced homelessness or have experienced some sort of homelessness before even turning 18, or they’re at risk for homelessness. (participant 31, practitioner)
Homelessness and unstable housing made it difficult for services to locate young people as they are often transient between houses, with access to stable housing viewed as a major issue. Participants also reported how young people experience isolation and marginalisation from their community, “one of the really big problems is that these kids are left, and the isolation around these kids is incredibly damaging for these kids” (participant 27, advocate). Another participant pointed out: “And you know, they don’t have support. At the end of the day. A lot of our young people, they have disengaged from the community, they have had family breakdown, they feel so lost and alone” (participant 38, clinician).
Theme 3. Barriers to engagement
Participants were asked to provide insight into barriers specific to engaging young people with complex needs. Many participants reported that young people lack the ability to understand or comprehend services and system processes and this makes it harder for them to engage with services. They described how services and systems place a lot of pressure and demands on young people, requiring them to attend and participate in multiple services. One participant summarised this:
From a capacity point of view, [for] some it’s impossible for them to easily, you know, be responsible for turning up at a place of certain times, simply because of the nature of the traumas occurred for them. And so, you know, that’s like asking a dog for brain surgery (participant 36, practitioner).
System and service demands were said to contribute to “systems fatigue”, whereby young people feel overwhelmed by the various services imposed on them and therefore leading to a resistance to engagement. Participants believed that over time, young people felt let down by systems and services and therefore developed a sense of maladaptive resiliency where they feel that only they can help themselves.
Another issue raised by various respondents were difficulties in forming relationships with young people. Young people were described as having a poor “relationship blueprint” due to previous experiences of trauma and attachment issues in early life. “It’s the inability to attach, to trust anyone or have relationships, to never really experience positive relationships” (participant 24, advocate). Participants felt that young people’s difficulties in establishing a trusting relationship prevented them from not being able to engage with services, which can lead to further negative consequences. Many participants also highlighted how communication difficulties can impair engagement. For example, Young people with a disability or speech delay were described to have difficulty engaging with service providers and were referred to as being in the “too hard basket” due to communication difficulties. Another example raised was difficulties engaging young people from refugee backgrounds, whose first language is not English. Not having interpreters or alternative methods of communicating with young people were primarily the reasons for these barriers to communication, and that services were not equipped to work with young people with communication barriers “I think it’s often hard for mainstream services to engage with people with complex communication difficulties” (participant 42, practitioner).
Summary of individual barriers
Participants identified a number of barriers to service engagement at the individual practice level, including: characteristics and experiences of young people, such as maltreatment, trauma, and disadvantage, that were viewed as the underlying causes of challenging behaviours; the way these behaviours are compounded by systems and services that are not designed to effectively meet their needs; young people’s distrust in services and challenges in building successful relationships; and disability, deficits in communication, or a lack of social networks to help young people navigate complex systems.
Individual strategies
Participants were asked about strategies for engaging young people with complex needs. These strategies were summarised into three main themes: 1) Building strong relationships; 2) Approaches to facilitate better engagement; and 3) Strategies to set young people up for success.
Theme 1. Building strong relationships
Particpants emphasised the importance of building strongrelationships and fostering trust, viewing relational approaches as essential for effective engagement and overcoming barriers around trust and trauma. For example:
What the kid actually needs is 1 or 2 stable relationships, to challenge their relationship blue print and challenge how they view relationships. Then, they start to have the building blocks like navigate school safely or have peer relationships at school or apply for jobs (participant 17, psychologist).
The importance of making the young person feel safe was raised as a relational strategy. When working with young people with developmental trauma, it was reported that creating a sense of security and safety can help to alleviate their hypervigilance and reduce their anxiety. By doing so, this can help the young person to trust the practitioner more and allow relationship building to occur more effectively.
[A practitioner’s] only job here is to support safety in a relationship with this young person. Forget everything else for now, just consolidate and you know build, have fun, play, laugh do all that stuff that consolidates that feeling of safety and connection… and then get to more explicit strategies (participant 25, psychologist).
In particular, one participant described their experience in interviewing young people from residential care and their desire to have positive relationships, to feel safe and to be able to be understood better. “You’re talking to these children, they want simple things, they just want to be safe, they want to have a secure, stable and they want to trust somebody, but they do not have that” (participant 39, practitioner).
Another relational strategy commonly highlighted was the need for practitioners to be consistent, reliable and persistent when working with young people. For example, a participant stated “you have to have continuity… consistent continuity and stable relationships.” One provider summarised an example of this approach:
She sat out in the courtyard and spoke to me, so that was over a period of about a year, and I saw her about… well first time I didn’t see her, but then it was about the fourth time that she was prepared to talk to me, so…you can break down, but it takes so much energy, and it takes a consistency of approach, it takes respect and it takes relationship building … that’s the only way you are going to really get anywhere I suppose (participant 24, advocate).
Participants described young people as testing the boundaries to determine if they could trust an individual before engaging with them and the importance of workers being persistent and dependable: “I think showing your ability to stick by. Yes. So trust is going to take a lot to build. I [young person] need to feel that there is some kind of dependability there” (participant 36, practitioner).
Participants also emphasised the need for workers to be authentic in their approach when engaging with young people as it helps to build better relational connection, for example, “it’s not just seeing the young person as a person, but also, being a person whatever your title is. Bring that authenticity” (participant 26, counsellor). Another participant stated, “being genuine because kids will smell out anything script” (participant 22, manager).
Theme 2. Approaches to facilitate better engagement
Honesty and/or transparency was raised by multiple professionals as an effective way to facilitate better engagement when working with young people. “I think that ability to be able to engage is also its offering that honesty and transparency to a young person as well” (participant 36, practitioner). Participants believed that being honest and transparent creates a sense of trust between the young person and the worker. Participants noted that young people were able to pick up on when a worker was not being truthful. “Transparency is key. I mean, we don’t sugar-coat like, we can be honest with young people” (participant 37, manager).
Another approach for facilitating engagement emerged having a key worker or trusted individual responsible for advocating for the young person (like a mentor, carer or close family member as a conduit/advocate). This was also viewed as a system and service level strategy, but also at the individual level, where the importance of having a trusted person in this role was emphasised. The trusted person could then “vouch” for other services to help to forge a relationship between services and the young person, and mitigate communication barriers. “You know start vouching that from a trusted person would go a long way for kid with complex needs, because they’re that… nervous of new people and new things, that there is no trust, so it’s finding someone that the young person values to build your relationship with” (participant 27, advocate)Participants consistently emphasised the importance of having flexibility within practice at the individual level. Examples included having the flexibility to meet the young person at alternative locations, “to be flexible to some degree, to be able to meet people at different locations at different times” and having flexibility within their discussions with young people, “But also having the flexibility to allow them to discuss any topic that they will, that they will want, there are no limits” (participant 30, professor).
Participants also highlighted the use of informal approaches for better service engagement. They used the example of dressing and acting informally, and creating an environment that was more youth friendly: “Yeah, you know, and even the way we kind of dress and act, and it’s a much more relaxed environment. It makes us really approachable” (participant 38, clinician)). Other participants spoke about the effectiveness of having an informal drop-in service where young people could come in on their own accord, which creates less pressure than formal appointment-based services.
Theme 3. Strategies to set young people up for success
Participants emphasised the importance of using a strengths-based approach when engaging with young people. It was suggested that focusing on strengths will help to set young people up for success as they can achieve a sense of mastery over small tasks. By helping the young person to find their strengths, it can help them to engage in more prosocial behaviours and lead to better engagement. For example:
It’s actually about skilling that client up because they know themselves better than anybody, and they’ve got the innate ability to help themselves, learn what it is and that’s what we want from them, we can learn to empower them to believe that as well, and drive the network around them (participant 28, psychologist).
Participants also noted the need for more skill-based learning which can help to develop independence and empower young people:
Skill-based learning that might be able to be more intensely supported, so then these young people have an option around, you know, actually obtaining some level of skill learning or trade or education that then can sort of see them in creating their own meaning and identity as well (participant 36, practitioner).
Summary of individual strategies
Many of the engagement strategies identified were applicable across all three levels: systems, services and individual practice. At the individual practice level, emphasis was placed on: building strong, supportive relationships through worker flexibility, honesty and transparency, persistence, authenticity and creativity; the use of informal approaches or incidental therapy, such as driving or art therapy; trauma-informed approaches to engagement; vouching for other workers to facilitate engagement with other services; and focusing on strengths, which could then facilitate skills attainment over time.
Discussion
The purpose of this study was to identify barriers to, and strategies for, service engagement among young people who have complex needs. A total of 20 principal themes were identified and themes could be differentiated into two overarching categories; namely, barriers to engagement, and strategies for engagement. Themes were organised according to three levels: systems, services; and, individuals. The findings from this study reinforced how individual level strategies are difficult to tease apart from broader service and system issues. There was significant overlap between themes, with a number of themes cutting across all three levels. These included the need for: flexibility across all levels of the system from individual practice to whole-of-system strategies; a less punitive and more trauma-informed system, services and approaches to individual level practice; better workforce training and development; better information sharing and joined-up systems; and enhanced case coordination through lead agencies.
The need for flexibility was recommended, not only at the individual practice level, but also within services and systems. It was emphasised that those working with young people who have complex needs must be flexible in their approach and should allow multiple opportunities for engagement using such methods as assertive outreach, being more persistent and adopting an adaptive approach to provide. These ideas are supported in the literature on engaging with young people with complex needs (Almqvist & Lassinantti, 2018, Bryant, 2001; Malvaso et al. 2016; Gilligan, 1998; Mendes, 2006; Mitchell & Selmes, 2007; Stein, 2012; Wharne, 2005). However, it became clear through the interviews that practitioners felt that their ability to be flexible was often constrained by inflexibility at a service and system level. Services are often restricted by eligibility criteria, block funding, and legal remits which govern the services they are responsible for providing, when, and to whom. This leads to siloed approaches at the system level in which time- and resource-poor services were seen to be competing for funding and were under pressure to achieve outcomes according to their remits (and according to which their “performance” is measured).
Such themes relating to punitive responses to complex needs also emerged at a system, service and individual level. Young people who have multiple problems are expected to navigate a complex system structure, engage with multiple services all with difference eligibility criteria, all while trying to meet their day-to-day responsibilities. Service constraints arose from the challenges associated with having to manage caseloads and waitlists, legal restrictions, inflexible funding models. Services are further able to refuse service if rules are breached (e.g., the young person becomes involved in the criminal justice system and can no longer be supported in some accommodation or housing services).
A further issue is that legal remits can be age-limited, for example, child protection’s statutory responsibilities ending at age 18 (or 21 in some circumstances). However, the consequences of the trauma experienced and the need for continued support may extend beyond this age and this is often recognised by professional workers in this area. This research further indicated that services for young people with complex needs in the 18 to 25 age bracket are lacking. Such observations have led to greater attention being directed towards international frameworks where the legal remits of child protection agencies are extended beyond the age of 18 to encompass the post-care period (Stein, 2012). Recently, the Australian State of Victoria have also introduced the “home stretch model”, where support is available to care leavers up to the age of 21. South Australia has introduced a similar initiative, but this support is primarily available to young people in foster care. In Victoria, there is also a dual-track model for young adults involved in the justice system where adult courts are able to sentence young people up to age 21 who commit offences to detention in the youth justice system instead of adult prison. Research into service continuity has demonstrated that time-limited interventions or services do not facilitate long-lasting benefits for those involved in multiple services (Crane et al. 2013; Ungur et al. 2014). Research that has also explored the effectiveness of flexible funding models have demonstrated the benefit of this funding approach and reported better outcomes (Sullivan et al. 2019). Although this research has been focused on domestic violence survivors, it nonetheless emphasises the need for funding models to be more flexible for populations with complex needs.
The study also suggested that trauma-informed and culturally-responsive practices are required across all levels of the service system to better facilitate engagement. This includes additional training for practitioners, especially when working with CALD and Aboriginal and Torres Strait Islander young people (Posselt et al, 2017). Bӓӓrnhielm et al.’s (2014) study supports the need for workforce training and cultural competency when working with CALD communities as it can lead to an increased understanding and better service responses. Having regular supervision, debriefing and a supportive environment has been shown to reduce the impacts of burnout and vicarious trauma (Ashley-Binge & Cousins, 2020).
Another challenge was problems in information sharing. At the system level, difficulties in linking data across systems leads means there is no population level view of the different pathways and trajectories of young people through the system. Participants felt that this issue could be remedied by better information sharing at a systems level, as well as more detailed system mapping to actually understand what services are available and whether young people are being connected with these services. For example, there has been research into how linked administrative data can be used to build intelligent information infrastructure to help us understand what works at a system level for vulnerable populations (see Malvaso et al., 2020). It is recognised that this is the type of information needed to increase capacity to understand whole-of-system efforts in prevention and early intervention of major social problems, such as child maltreatment.
The lack of information sharing was also identified as leading to over-servicing at the service and individual level. Participants spoke about young people with complex needs often being engaged with too many services, and this was actually counter-productive to meeting their needs. The young person can then become overwhelmed by these multiple and often competing expectations, which may then lead to further disengagement and a devaluing of the relationship building process with individual agencies or practitioners. Other research on service providers for complex needs has also found that having too many professional people involved acted as barrier to care for young people (Almqvist & Lassinantti, 2018). Accordingly, one of the key strategies identified that could help to resolve some of these issues was around better multi-disciplinary service coordination through a lead agency. The value of multi-disciplinary teams in responding to complex needs of young people is well-supported (Almqvist & Lassinantti, 2018; Ryan et al. 2017). Better coordinated and multi-level services are more consistent, promote accessibility and participation and are useful for achieving outcomes because no single service is relied upon; however, having a lead agency responsible for service coordination was viewed as the best way to ensure young people were receiving the required support and to hold services accountable to meeting their responsibilities (Almqvist & Lassinantti, 2018). Alam and Griffiths (2016) research also supported this idea and described the use of a “management control system” in inter-agency collaboration.
Overall, findings from this research suggest there are a number of opportunities across system, service and individual levels to enhance service engagement with young people who experience multiple and complex needs. This information can be used to inform the design and implementation of practice guidance that helps to ensure consistency, efficacy and equity in the application of knowledge, skills and supports across services and over time. From this study, best practice guiding principles as developed from participants’ insights are summarised in Table 2.
Table 2
Best practice guiding principles based on participants’ suggestions
Domain | Principle |
|---|---|
Service system priorities | • Centralised and coordinated case management • Avoid duplication to reduce systems fatigue • Non-punitive and restorative approaches • Open door policies • No strict time limits on service accessibility • Young person friendly physical structures • Capacity for outreach • Family-inclusive • Governance, e.g., community views are prioritised |
Staff training priorities | • Ongoing professional development • Reflective practice • Cultural competency • Relationship building and trauma-informed practice |
Engagement priorities | • Focus on both short-term and long-term goals • Strengths-focused • Innovative and opportunistic engagement, e.g., through art, sport • Flexibility, consistency and reliability • Assertive engagement • Trauma-informed |
Limitations
Despite the strong themes and overarching narrative of this research, there are some limitations. Interviewees were identified by a government agency based on their knowledge of existing services and systems, thus leading to potential selection bias. Focus group research is vulnerable to limitations such as group discussions going off course, hesitancy to share honestly in a group setting, and potential peer pressure; however, this was mitigated in some ways by the large sample size, and by individuals being given the option to participate in individual interviews. Young people were not involved in this study, therefore their opinions and views were represented by services and professionals they engage with, which has its limitations as it can be filtered, or misrepresented. We also note an overrepresentation of youth justice professionals and an underrepresentation of practitioners from other systems such as child protection and education. These systems are often pivotal in supporting young people with complex needs, and additional perspectives from these sectors could potentially enrich the findings. While it is difficult to assess the impact of these variations in representation, we believe the results reflect a broad spectrum of system interactions with young people. For example, many of these young people may be common clients across multiple systems and participants, such as youth advocates, routinely support young people involved with multiple services (e.g., child protection). Despite these limitations, the sample size of 40 participants represents a reasonable and well represented sample for this research.
Further research would be needed to test developed practice frameworks based on these themes, to ensure that in practice this would improve the experience of young people. Ideally, this would include the voices of the young people themselves. A growing body of research is documenting the importance of incorporating living experience perspectives to improve service design and delivery (Day et al., 2022; Johns et al., 2022; Verschuere et al., 2012). The findings from this study could be used as a starting point for consultation with service users and those with living experience and used to promote co-production approaches in service development. Further research would also be of benefit to explore which of these themes of improvement is the most vital for change – for example, is training staff the most vital, or is case coordination the biggest change agent, or are both needed for real change to occur.
Conclusion
Despite the cross-cutting nature of the themes, numerous strategies that can be employed to better facilitate engagement between services and young people who have complex needs were highlighted. However, it was evident that these strategies could not be limited to individual practice level because broader service and system level changes are needed in order to best meet the needs of young people who require support from multiple services. A unique agency exists in an Australian jurisdiction [blinded for peer review] to coordinate services and mitigate and navigate some of the systemic and service challenges and is striving to meet the recommendations within this paper. However, what is needed is a service industry commitment across youth services to implement these strategies and reduce these barriers for young people with complex needs to avoid the ongoing systems trauma and improve the outcomes for young people when they do seek help.
Supplementary information
The online version contains supplementary material available at https://doi.org/10.1007/s10826-024-02973-1.
Acknowledgements
We would like to thank Neophytos Georgiou for assistance in interview transcriptions. Thank you to all who gave up their time to participate in this study. The views expressed in this paper do not necessarily reflect the view of government affiliation.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no competing interests.
Ethics Approval
Ethics approval for the study was obtained from the University of Adelaide’s Human Research Ethics Committee (HREC approval number H-2020-20/26).
Consent to Participate
Participants were provided with an information sheet and were asked to sign a consent form, or provide recorded verbal consent (for video participants) prior to beginning the interview.
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