Complex Needs Planning for Children and Youth Through Age 21

The Department of Human Services (DHS) seeks to provide a comprehensive approach to serving children, youth, and young adults — birth to 21 years of age — through programs that focus on early intervention, long-term prevention, and services that support family stability, safety, community protection and the child/youth's healthy development and permanent connections.

In order to meet the needs of children, youth, and families with complex challenges, clear structures are necessary at the county, regional and state levels so that resources, expertise and collaboration can be maximized. 

A comprehensive and effective system of care recognizes that children and youth with social, emotional, behavioral, and/or physical health needs often require services from more than one child-serving system. Effective planning takes into account the strengths of the child and family, the multitude of needs, and engages the various human service agencies responsible for assisting the child and family.

Understanding that each youth with complex needs and their families are unique, there are several characteristics that can help identify them.  The following are the most frequently encountered characteristics of youth with complex needs; often, the combinations and acuity of these characteristics vary significantly: 

• Complex trauma including abuse, neglect, developmental and institutional trauma;  
• Multiple and complex diagnoses across the developmental, physical, behavioral and /or mental health domains;  
• Complex communication needs;  
• Inconsistent presentation of behaviors and symptoms across settings;  
  
• Diagnostic overshadowing due to an intellectual disability and/or autism diagnosis;  
• Lack of diagnostic clarity;  
• Disrupted education;  
• Limited, strained, or no natural supports;  
  
• Multiple system involvement, including justice systems; or  
• An extensive history of out-of-home care, including multiple disrupted placements.  

When considering a specific youth, not all of the characteristics listed above are required, though it is often a combination of several and sometimes all of these characteristics.  Additionally, a youth may not have emergent acuity but could still be considered as having complex needs.   

Services should be planned to meet the individual needs of the youth and the family and/or caregiver(s).  These services should be developmentally appropriate and child specific, they should consider the youth’s family and community structure, build on the strengths of the youth and family and/or caregiver(s) to meet the developmental, social, cultural, physical and behavioral health needs of the child.  Representatives from all child-serving systems should collaborate with the family and/or caregiver(s) and involve the youth as much as developmentally appropriate when defining goals for the youth, developing a service plan, developing the necessary resources to implement the plan, providing appropriate support to the youth and family and/or caregiver(s), and evaluating progress.  Service planning is not a static activity, rather, it is an ongoing process as needs, goals, and circumstances change.

Complex needs planning is a multi-agency effort spanning multiple child-serving systems and multiple disciplines, all of which requires significant coordination, communication, and shared goals.  County planning teams often experience many different challenges in their efforts to support youth with complex needs and their families. 

To effectively and efficiently support county planning teams, the Department established a referral process for counties to request technical assistance from the DHS Complex Needs Planning Team.  The Department’s technical assistance includes guidance related to licensed settings, funding, clinical and medical resources, and successful strategies from other counties and regions in the Commonwealth. 

To learn more about the Complex Needs Planning Referral Process or to submit a referral, please read the Complex Needs Planning Bulletin.