Friday, 8 November 2013
Defining and responding to complex needs
The term “complex needs” is used to convey several different ideas sometimes specifically, and most often interchangeably. They include: “multiple disadvantage”, “multiple disabilities”, “multiple impairment”, “dual diagnosis”, “high support needs” and “multiple and complex needs”. Perhaps more usefully, complex needs can be thought of as implying both the breadth of need (multiple needs that are interrelated or interconnected) and the depth of need (profound, severe, serious or intense) and a combination of both. This is captured in The Department for Education definition of children with complex needs as having “a number of discrete needs that require additional support from more than one agency. Their needs are often chronic and may be lifelong. Different needs tend to interact, exacerbating their impact on the child's development and well-being.” Rather than use the term complex needs solely to describe an individual's characteristics, we also need to think about the wider social context of their lives. These young people may also be marginalised, present as high risk, and be hard to reach, and it is useful to also consider how current service arrangements and factors of poverty and exclusion impact on meeting multiple and complex needs; that is to recognise that children with complex needs are found in a social context and that in order to help we need to think of multiple, interlocking needs that span psychological, emotional, behavioural, health and social issues. Because these children are at the extreme of a continuum of needs they pose the greatest challenges to services. The term itself may be stigmatising, restricting access to some mainstream services. The broad and deep nature of the young person’s needs is often a contributing factor in placement breakdown, school exclusion and peer isolation. Complex needs can place a child on a self-fulfilling downward cycle of: • Placement disruption; • Seemingly growing needs and greater complexity; • Greater difficulty in finding out what will help them settle; • Further placement disruption. It can also be more difficult to meet basic needs (like dental and healthcare needs) because of issues around access and motivation, and their cultural identity needs can easily become ignored. In addition, judgements of success and failure are often made without clear understanding the level of complexity that these children may present. Enduring patterns of behaviour are unlikely to be changed easily; above all, these young people require time. For young people in the Looked After system, the breadth and depth of need may be hard to see: some may have major mental health needs in addition to other impairments; others may have additional difficulties with communication; many have difficulties that result from maltreatment and unstable, fractured lives. These young people present a challenge for services and for commissioners. In general, children with complex needs are not well served by provisions established to meet more general levels of difficulty, and even within specialist services it is not simple to understand what any individual young person may need to turn their life around. What is needed is a flexible and inclusive service that is able to assess, identify and meet individual needs. As well as the willingness to tolerate some uncertainty, it is necessary to develop understanding whilst working sensitively and knowledgeably with the particular issues for each young person. This must be founded on the expectation that young people will be involved in the assessment process, recognising that they are not only their difficulties and that they also have strengths, talents, interests and abilities. Whilst careful assessment is the basis of successful work with young people with complex needs, it is important to acknowledge the often deleterious effect of multiple assessments. Ethically, the point of assessment is to lead to helpful interventions, and yet, in complex cases, assessment can become an end in itself; faced with little sense of how to help it is easy to return for more assessments, but perhaps we should first be clear how this additional burden on the young person will help. Young people with complex needs that arise from maltreatment are likely to also present with “challenging behaviours”. Agreeing appropriate ways to provide care, protection and control can be highly problematic for young people who place huge pressures on those who work with them day-to-day. It is essential that we all try to take the young person’s perspective; their welfare must be paramount, and any responses to behaviour must be in the young person’s best interest and be part of a long-term plan to meet needs and encourage recovery. When deciding on therapeutic approaches and interventions we need to consider five key questions: 1. What research is available? 2. For who does this approach work best? 3. What alternatives might be tried? 4. How is a decision made to follow one course of action? 5. How is that decision reviewed and evaluated? We also need to consider the extent to which they are settled and stable before beginning more intense work. Many young people in specialist residential care have broad and deep needs, these needs are multiple and enduring. A helpful approach is to try to understand the individual, to keep sight of their perspective, to provide care, support and protection to help them turn their lives around. It is important to acknowledge that this difficult task is likely to also be slow, and that as well as providing individual therapies and treatments, much of the work to meet their wider social and psychological needs takes place in the wider, living-learning environments of home and school. What we most want is that, overcoming complex needs, our young people are able to get a successful life of their own.