Opinion

Our current systematic review of the literature, however, is finding no adequately designed evaluation studies.  This creates the first problem: we have no way of judging which responses are most cost-effective.  The obvious explanation for this lack of evaluation is that it is difficult - young people with multiple and complex needs are a hard group to access and engage.

Perhaps a good place to start is to ask how these young people differ from the majority of adolescents who may experiment with drugs and alcohol, become disengaged from the education system, exhibit anti-social behaviour and periodically participate in petty crime? The answer most likely lies in the aetiology of their risk behaviour, and not simply the number of risk behaviours present: if the aetiology of their risk behaviour is grounded in adverse experiences from childhood – physical, emotional or sexual abuse, or neglect – then effective responses need to address both the presenting risk-behaviours and their aetiology. It is this aetiology that brings complexity, not just the presence of multiple risk-behaviours.

However interesting, this explanation is of limited help in understanding which interventions will be most effective for different combinations of risk-behaviours and their causes.  We need a more precise understanding of the problems: how many are at risk of suicide, and to what extent?  What are their drug and alcohol use patterns?  How resilient are they?  This lack of precision in our understanding creates the second problem.  It means intervention responses are likely to be hit and miss, and it highlights the need for measures of these risk behaviours that are accurate and reliable.  Our current systematic review has also identified a lack of high-quality measures with which to accurately quantify or describe harms.  So not only do we need a better understanding of the precise type and extent of risk behaviours among this group, we need to examine whether our traditional measurement tools, such as self-report, are feasible methods of obtaining data that are of adequate accuracy and reliability.

Despite the uncertainty, we have some clues.  Long-term childhood adversity studies suggest some young people develop a greater degree of resilience than others.  It’s not clear why, but the current best guess is that it is likely a product of the interaction of three levels of factors: individual (e.g. personality and/or genetic traits); interpersonal (e.g. relationships with family, friends, and peers); and community (e.g. the quality of the institutions, including schools and criminal justice systems, with which they interact).  The relative importance of these three levels of factors for resilience is unclear (and may itself be individualistic) but, if the concept is accurate, it suggests that our intervention response for young people with multiple and complex needs will also need to be complex, in the sense of comprising multiple components that can simultaneously target these different levels of factors, but also tailored to individual need: some young people will need more help to cope with dysfunctional family relationships, some will need modified community institutions (e.g. alternate models of schooling), and some will need to learn to temper their anti-social behaviours.  Penny Mitchell and her team in Melbourne have cleverly applied this multi-component approach to individual psycho-social therapy, but the apparent multi-level nature of the problem suggests this may need to be combined with more ecological approaches to simultaneously target relationships and community factors.  This brings us to a third problem: what combination of factors should be targeted to achieve optimal results, and how might these combinations change over time as young people’s needs change?

Researchers at NDARC, the University of New England, the Hunter Medical Research Institute and James Cook University will be partnering with NGOs in communities in NSW and Queensland to evaluate a multi-component, ecologically-based intervention for young people with multiple and complex needs (e.g. http://backtrack.org.au/).  These community-based programs are built on the practical knowledge and skills of the NGO staff themselves, to which we hope to add our evaluation experience.  We aim to clearly define the program components, the characteristics of the risk behaviours of the program participants, the cost-effectiveness of the programs and develop insights into why and how the intervention does, or does not, deliver outcomes.  The final piece of the puzzle is the problem of dissemination, or scaling-up: How might the program be tailored to other communities? What might communities do to support the uptake of effective programs in their own communities?  How might governments support that process?

This evaluation will not provide all the answers but, at present, services are largely left alone to meet the significant demands of young people with multiple and complex needs.  Although there is a lot to learn, building more partnerships between services and researchers will help reduce the size of the current knowledge gap.  Analogies are always fraught with danger but, to illustrate the point, surgery was once a blunt, clumsy, occasionally effective and mostly traumatic procedure.  But over time researchers and practitioners have grappled with the complexities of injury and disease, and the physiological and psychological responses of individuals, to create highly targeted, less invasive and more individualised treatment.  We have made a start, but we have a long way to go in responding more effectively to young people with multiple and complex needs.  We can, and we will, get better.