Supporting children in families with complex needs: Nine tips for practitioners who feel out of their depth

This paper is for you if you ever feel overwhelmed, underequipped or out of your depth due to the complexity of the needs of the children and families you work with. It was written based on research and literature developed within the child and family services sector. However, given the general nature of the guidance provided in this paper, it may also be of use for practitioners in numerous sectors that involve children and families.

Many health and welfare services focus on specific issues or problems—mental health, substance use, parenting education, homelessness, and so on. Practitioners are employed based on their expertise in working with these specific issues. The obvious problem with this model is that a large proportion of individuals and families do not fit neatly into the categories of our siloed service systems. They face numerous interrelated difficulties, and often have entrenched unmet needs that individual agencies struggle to meet in isolation (Superu, 2015).

Researchers, policymakers and service managers generally present organisational-level solutions to the difficulties of working with families with complex needs, including interagency collaboration, wraparound service models and multi-systemic approaches. Such solutions are clearly important and should be among the main strategies in long-term efforts in meeting the needs of families.

However, organisational-level solutions might not feel like they are much help to you in your day-to-day work with families. Perhaps your organisation is currently funded to provide a specific service, such as parenting education, yet most of the families who come through your door have much more pressing needs. Maybe you work in a rural area where there are few other agencies that you can collaborate with. Perhaps you struggle to refer clients on because the specialist services in your area have very strict eligibility criteria. Whatever the reason, you are not alone in working with families whose problems seem to fall outside the scope of your training, expertise or professional role.

The term ‘complex needs’ refers to families who experience numerous, chronic and interrelated problems. Depending on the profession, families in such positions may also be referred to as ‘families with multiple and complex needs’, ‘hard-to-reach families’, ‘vulnerable families’, or ‘families with entrenched disadvantage’ (Superu, 2015).

Families with complex needs frequently experience problems that span social, economic and health domains. These can include mental health difficulties, physical health problems, disability, substance use, domestic and family violence, social exclusion, poverty, unemployment and homelessness (Bromfield, Sutherland, & Parker, 2012). Such families are often described as having both ‘breadth of need’ (i.e. multiple interconnected needs) and ‘depth of need’ (i.e. particularly severe or serious needs) (Rankin & Reagan, 2004).

Families with complex needs do not represent as a homogenous group. Each family presents with a particular mix of strengths and difficulties, which can change over time; it is unlikely families will forever present with complex needs. Indeed, some researchers have suggested that it is more useful to speak of families living in ‘complex environments’, as this avoids the suggestion that complex needs are inherently associated with particular families (Superu, 2015).

You may have heard people labelling families with complex needs as ‘hard-to-reach’. From the perspective of families, it is probably more accurate to speak of services that are ‘hard to access’. Families can face many challenges in accessing services, including lack of knowledge of the services available to them, inadequate transport to attend services, feelings of intimidation due to inexperience with services, and a history of negative experiences with services (McDonald, 2010).

In 2013, the Australian Productivity Commission estimated that around 5% of Australia’s working-age population experiences multiple forms of disadvantage (McLachlan, Gilfillan, & Gordon, 2013). Such figures help to give some sense of the number of families living with complex needs. Yet certain population groups, such as Aboriginal and Torres Strait Islander communities, have higher numbers of families experiencing deep and persistent disadvantage. This is due to numerous factors, including historical and ongoing dispossession, marginalisation, and racism (McLachlan, et al., 2013).

How can living in a family with complex needs impact children?

The difficulties experienced by families with complex needs can have both immediate and long-lasting harmful effects on children’s health and wellbeing. Children exposed to difficulties such as parental mental illness, parental substance use and domestic and family violence face increased risk of internalising (i.e. emotional), externalising (i.e. behavioural) and physical health problems in childhood, adolescence and adulthood. They are also more likely than others to experience child abuse and neglect (Bromfield, Lamont, Parker, & Horsfall, 2010).

While individual family vulnerabilities can compromise children’s wellbeing, research demonstrates that the combined effect of multiple interconnected problems can greatly raise children’s risk of harm. For example, research on ‘cumulative harm’ indicates that the ‘unremitting daily impact of [multiple harmful circumstances and events] on the child can be profound and exponential, and diminish a child’s sense of safety, stability and wellbeing’ (Bromfield & Miller, 2012, pg. 5). Similarly, research on ‘adverse childhood experiences’ (ACEs; e.g. domestic and family violence, parental health problems) demonstrates that, when compared to exposure to a single ACE, exposure to multiple ACEs substantially raises children’s chances of experiencing internalising and externalising problems (Hughes et al., 2017).

There are many resources that can assist you in understanding exactly how living in a family with complex needs impacts on children, including literature on early brain development, trauma and attachment. For example, researchers investigating brain development have used the term ‘toxic stress’ to describe how prolonged activation of the brain’s stress management systems can ultimately disrupt the brain’s architecture, leading to problems with emotional regulation, impulse control and hyperactivity (Shonkoff et al., 2012). Similarly, the term ‘complex trauma’ is used to describe the effects of prolonged exposure to traumatic events in childhood, which can have negative implications for almost every domain of children’s lives including their memory, attention, interpersonal relationships, and sense of purpose and meaning (Cook et al., 2005).

It is useful to understand the relationship between family difficulties and child wellbeing. Yet it is also important to keep in mind that this relationship is not a straightforward one. In some families, parents are able to adequately care for their children despite managing multiple interrelated life difficulties. In other families, those same difficulties completely overwhelm parents’ capacities to provide a safe and nurturing environment for their children. Children too differ significantly in their levels of resilience in the face of adversity (Hunter, 2012).

Practice tips

The following section provides general guidance on building your confidence to support children in families with complex needs. It is a starting point, designed to help you to find ways of working with families that reduce your sense of feeling overwhelmed or out of your depth. This paper is not intended to provide you with all of the knowledge you will need in order to work effectively with families with complex needs. Such knowledge develops gradually through a combination of on-the-ground experience, professional training, reflective supervision, conversations with colleagues, and reading documents such as those outlined in the ‘Further Resources’ section of this paper.

While it is important to understand the many difficulties that families can face (e.g. mental health difficulties, substance use, domestic and family violence), it is equally important to accept that you are never going to have all of the answers. They are called ‘complex’ needs because they are just that: complicated and often challenging to work with. Putting pressure on yourself to always come up with immediate solutions to families’ problems is a recipe for anxiety.

Indeed, some practitioners actively work at developing a ‘beginner’s mind’ or a stance of ‘not knowing’. For example, Staemmler (1997) sees ‘cultivated uncertainty’ as an essential attitude to hold when working with clients. Cultivating uncertainty does not mean that you stop working to develop your knowledge and skills, or that you let your own uncertainty contribute to a family’s sense of chaos or helplessness. Rather, it means that you approach families with an appropriate sense of humility and openness in the face of complexity and change. It means that you are always ready to learn, ‘to throw any impression of [your] clients out of the window again, if necessary right after you’ve had it, so that you are open to form new pictures again and again’ (Staemmler, 1997, pg. 47, italics in original).

Accepting that it is okay not to know all the answers can provide space for families to develop their own expertise. If you are struggling to understand something about a family’s situation, you could ask them about their own understanding, which would validate them as the experts on their own lives.  If you do not know the answer to a question a family member has, you might say something like, ‘I don’t know the answer to that. Why don’t we look it up together?’ In this way, rather than presenting yourself as an expert, you will be collaborating with them in developing their own knowledge.

We live in an era of increasing specialisation in health and welfare services (Nancarrow & Borthwick, 2005). It is possible to find professionals with expertise in any number of topics relevant to families with complex needs: from childhood trauma, to financial counselling, to parenting education for people with substance use issues…the list of specialisations could go on and on.

Given the obvious importance of specialised services and skills, it can be easy to fall into the trap of thinking that if you cannot offer specialised assistance to families, then you have nothing to offer them at all. It is important to resist this kind of thinking by reminding yourself that it is often the simple things that matter most to families. Do not underestimate the importance of skills and attributes that you may already have, such as the ability to demonstrate empathy, to build an effective working relationship with parents, and to deeply listen to families’ hopes and fears.

A good example of the importance of generalist skills comes from ‘common factors’ research in the field of psychotherapy. For a long time, people assumed that the success of psychotherapy depended on the unique methods and procedures used in different psychotherapeutic approaches (e.g. cognitive-behavioural therapy [CBT], acceptance and commitment therapy [ACT]). However, a large body of research now demonstrates that most of the effectiveness of psychotherapy can actually be attributed to ‘common factors’ that cut across all major forms of psychotherapy, such as building a good therapeutic relationship and consistently demonstrating empathy (e.g. Messer & Wampold, 2002). For all of the specialised terms, models and theories used in psychotherapy, it is often the simple things that really make a difference.

The lives of families with complex needs can seem disorganised and chaotic. It is easy to feel overwhelmed in the face of such chaos, especially when families themselves are struggling to make sense of things. Developing a sense of clarity about a family’s life situation is important not only because it can help you feel more confident in your work, but also because it allows you to offer the family new ways of understanding their difficulties.

There are many tools and techniques that can help you to break down the complexities of family life, including eco maps, genograms and biopsychosocial case conceptualisation tools. Genograms, for instance, visually summarise information about a family’s relationships, as well as their history of medical problems, abuse and neglect, and other major life events. Similarly, ecomaps provide a visual map of a family’s connections to each other and the external world. They give you a picture of family dynamics, individual family members’ connections to social and community supports, the whole family’s level of connectedness to the external world, and areas where service support may need to be brought into play or strengthened. You can also use ecomaps as a baseline for ongoing discussions with families.

It is likely that your organisation already offers tools or techniques that can help you to think more clearly about the complexities of family life. It is best to see these not simply as another task that needs to be ticked off, but rather as powerful strategies for helping you feel less overwhelmed by the complexity of your work.

You may have noticed that ‘strengths-based’ approaches are very popular across the health and welfare sectors. Such approaches employ strategies that emphasise people’s capabilities and resources, rather than the more traditional narrow focus on deficits. They are built on the idea that normal human development tends towards healthy growth and fulfilment, and that everyone has strengths that will aid them in this process. Of course, most strength-based approaches are not simply asking you to don a pair of ‘rose coloured glasses’: they acknowledge the need to identify and address risk factors and deficits alongside strengths, especially in situations where family members’ safety may be in question (Hunter, 2012).

Adopting a strengths-based approach can be tricky with families who are facing multiple and complex adversities. A family may be experiencing such difficult circumstances that even identifying basic strengths feels like a stretch. If risk factors for child maltreatment are present (e.g. substance use, parental mental illness), and especially if a family has had previous contact with child protection services, it can be difficult to establish the kind of openness and trust that allows for the identification of strengths.

Despite these difficulties, strengths-based approaches remain important. This is true not simply because research indicates that families benefit from them, but also because they can help you to maintain a sense of focus and optimism. If all you see when you look at a family are the multiple problems they face, it can be easy to lose hope in your ability to help them. On the other hand, if you broaden your focus to include the family’s strengths and capabilities—no matter how buried these qualities seem—you may be better able to develop a clear sense of the role you can play in helping them grow towards better health and wellbeing.

One of the features of families with complex needs is that their needs generally cannot be met by a single agency working in isolation (Superu, 2015). It is common for practitioners to refer such families to other agencies who have the expertise or resources necessary to work with their specific difficulties. Hopefully your organisation has up-to-date referral procedures and networks in place. If it does not, you may want to speak to your manager or supervisor about ways of developing a more formalised referral system.

In any case, it can also be helpful to work at continually developing your own network of colleagues. You will be able to draw on their expertise when you are feeling unsure in your own practice. And some of these colleagues will also be able to help you with referring families on. When you personally know practitioners in other organisations, you can feel more confident referring families to them, and you will already have a ‘foot in the door’ in cases where referral may prove challenging.

It is important to note that support and referral networks—be they formalised networks in an organisation, or informal personal networks—require constant maintenance. This is not least because many health and welfare sectors face high levels of staff turnover and ongoing restructuring. If at all possible, it is important to seize opportunities to develop your professional network, for example by participating in networking events, interagency case meetings, and training outside of your organisation. Maintaining networks also means taking the time to understand how different services or professional groups understand the problems that families face. A practitioner in a housing service, for example, may understand complexity in family life quite differently to a general practitioner.

It is likely that you will work with families from a variety of cultural, language and faith groups. Some of these families will probably have different understandings to you of things like family life, what it means to be a good parent, and the best ways to work with problems such as mental illness or family violence. If you work with Aboriginal and Torres Strait Islander and culturally and linguistically diverse (CALD) families, it is important that you continually develop your cultural competence.

Part of developing cultural competence is gaining knowledge of different cultural practices and worldviews (SNAICC, 2012). Cultural competence training will help you to develop such knowledge, as will remaining open to learning from the families you work with, which can be as simple as asking, ‘Are there any cultural practices in your home that I need to be aware of?’ Your expertise in working with families from different cultures will continue to develop if you remain open to learning. You cannot be expected to know everything about all cultural groups right away.

However, you can be expected to continually reflect on your own culture and the ways in which it informs your practice. As the Secretariat of National Aboriginal and Islander Child Care identified, cultural competence involves the ability to ‘identify and challenge one’s own cultural assumptions, values and beliefs, and to make a commitment to communicating at the cultural interface’ (SNAICC, 2012, pg. 1). Especially if you have an Anglo-Australian heritage, it is essential to remember that the word ‘culture’ is not simply a label for people who are different to you—it applies to you too. The complexities and difficulties of working across cultures are real, but they will be reduced if you can approach your work with a humility and openness that comes from understanding your own cultural position.

You have probably heard of, been trained in, or currently use some variety of ‘reflective practice’, ‘reflective supervision’ or ‘critical reflection’. These are forms of supervision or debriefing that allow you to step back from the immediate experience of hands-on work with families in order to understand your work more clearly. ‘What is really going on with this family?’ ‘Why do I feel the way I do around them?’ ‘Is what I’m doing working?’ ‘What kind of intervention would best support them?’ Such reflective questions can be invaluable in helping you to develop a sense of clarity and know-how in your work with families with complex needs.

Unfortunately, there are at least a couple of reasons why reflective practice can be less than effective. First, as Fook (2007, pg. 440) noted, reflective practice can ‘simply become a new, and uncritical, orthodoxy, possibly because it can be enacted in many and varied ways and is used so widely across many different professions and disciplines’. The potential of reflective practice is limited if it is seen as ‘just another thing to tick off’.

Second, some practitioners feel guarded or even defensive when asked to discuss things such as how they feel, whether or not a particular intervention is working, and where they think they could improve in their practice. If this is true for you, it might be useful to discuss your concerns about reflective practice with your supervisor or manager in an attempt to find a way of doing it that works for you.

One of the difficulties of working with families with complex needs is that it is not always clear exactly where the boundaries of your professional role lie. ‘Should this family have been referred to my service?’ ‘At what point do I need to refer them on?’ ‘Should some of the things that I am doing be picked up by other members of the multidisciplinary care team?’ ‘Is my manager asking too much of me?’ Many practitioners struggle with such questions.

One way to get answers to these questions is to develop a clear understanding of the nature and expectations of your professional role. Read over the position description for your role. Remind yourself of the key performance indicators (KPIs) used to evaluate your work. If these documents do not match the reality of the work you are actually doing on a day-to-day basis, then it is time to have a conversation with your supervisor or manager.

Another way to maintain clarity about the boundaries of your role is to clearly communicate these boundaries with families when you begin working with them. Outline the scope of the services that you provide. Explain to families the things you can do within your role, as well as the things you cannot. Clearly outline the types of events or situations that would require you to refer them to a different service or make a report to child protection services. When you can communicate your professional boundaries in this way, you will be less likely to find yourself feeling out of your professional depth.

If you feel unclear about how to work with a family, ask for help. If you feel overwhelmed by the complexity of the needs of a family, ask for help. If you feel overly stressed or burnt out, ask for help. Ask your colleagues for help. Ask your manager or supervisor for help. If your organisation has Human Resources staff, ask them for help. Get involved in peer supervision. Present a particularly challenging case presentation to a practice network or alliance. If you have access to an Employee Assistance Program (EAP), use it.

This advice could not be more straightforward, yet it is not always easy to follow. It can feel hard to show others that you do not know all the answers, that your training or expertise are limited, or that you are struggling to keep your head above water. Asking for help often requires bravery and a willingness to show vulnerability. If it does not feel appropriate or safe to display such vulnerability in your own organisation, then consider reaching out to colleagues from other organisations. Everybody needs help at different stages in their career, and receiving it is a necessary part of becoming a competent and safe practitioner.

Bromfield, L., Lamont, A., Parker, R., & Horsfall, B. (2010). Issues for the safety and wellbeing of children in families with multiple and complex problems: The co-occurrence of domestic violence, parental substance misuse, and mental health problems (NCPC Issues Paper 33). Melbourne: Australian Institute of Family Studies.

Bromfield, L., Sutherland, K., & Parker, R. (2012). Families with multiple and complex needs: Best interests case practice model. Retrieved from Melbourne: Victorian Government Department of Human Resources in collaboration with the Australian Institute of Family  Studies.

Katz, I., Spooner, C. and Valentine, K. (2006). What interventions are effective in improving outcomes for children of families with multiple and complex problems? Perth, Australia: Australian Research Alliance for Children and Youth (ARACY).

McDonald, M. (2010). Are disadvantaged families “hard to reach”? Engaging disadvantaged families in child and family services (CAFCA Practice Sheet). Melbourne: Australian Institute of Family Studies.

Network of Alcohol and Other Drugs Agencies (NADA)(n/d). Complex Needs Capable: A practice resource for drug and alcohol services: Practice tips for workers. Available online at: http://www.complexneedscapable.org.au/practice-tips.html

Shelter (2011). Working with families with complex needs: Guidance for housing professionals (Good Practice Briefing). London: Shelter.

Superu. (2015). Families with complex needs: International approaches. Wellington, New Zealand: Social Policy Evaluation and Research Unit (Superu).

Acknowledgements

For advice and feedback, thanks to Thy Meddick, Morwynne Carlow, Cathryn Hunter, Rebecca Armstrong, Nicole Paterson, Margaret Nixon, Daniel Moss, Rosie Schellen and Geneva Batten.

References

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Bromfield, L., & Miller, R. (2012). Cumulative harm: Best interests case practice model. Melbourne: Victorian Government Department of Human Resources in collaboration with the Australian Institute of Family Studies.

Bromfield, L., Sutherland, K., & Parker, R. (2012). Families with multiple and complex needs: Best interests case practice model. Retrieved from Melbourne: Victorian Government Department of Human Resources in collaboration with the Australian Institute of Family Studies.

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Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., McGuinn, L., . . . Wegner, L. M. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246.

SNAICC. (2012). Cultural competence in early childhood education and care services, SNAICC Consultation Overview. Melbourne: Secretariat of National Aboriginal and Islander Child Care (SNAICC).

Staemmler, F. (1997). Cultivated uncertainty: An attitude of gestalt therapists. British Gestalt Journal, 6(1), 40-48.

Superu. (2015). Families with complex needs: International appraoches. Wellington, New Zealand: Social Policy Evaluation and Research Unit (Superu).