Social Work Practices for Young People with Complex Needs: An Integrative Review

The aim of this integrative review is to investigate research of social work practices for adolescents and young adults with complex needs. The research questions are: What are the major themes in studies of practices for young people with complex needs? How do studies suggest that complex needs can be met in ways that are beneficial for young people? A young person with complex needs is in this review defined as an adolescent or young adult who, due to mental ill-health in combination with different types of social vulnerabilities, is receiving assistance from multiple welfare services. Searches were conducted in seven databases. These searches resulted in a sample of 1677 records, published 2007–2016, which in the screening process were reduced to 24 publications, all peer-reviewed articles. The participants in the studies in the articles consisted of young people, parents and professionals from mainly Anglo-Saxon countries. The articles were analyzed with qualitative summative content analysis. Three empirically generated themes were found in studies of work practices targeting young people with complex needs: collaboration-, relationship- and empowerment-oriented practices. In conclusion, the practices contain a wide variety of features, but with the joint aim of acknowledging young people’s needs. The results can be used by practitioners and policymakers to further the development of services for youth with mental ill-health and social vulnerabilities, who use multiple welfare services.


Introduction
An extensive number of young people in Western countries are facing severe difficulties, due to mental ill-health (Hagqvist, 2011;Palmer, 2012) in combination with social vulnerability. These young people are often referred to as having "complex needs". Complex needs is an elusive concept (Hood, 2015) and there are large variations in what kind of problems and needs someone labeled as a person with complex needs may have. This concerns young people having mental ill-health with or without a psychiatric diagnosis, who are also exposed to various and multiple risk factors such as difficulties in completing education (De Ridder et al., 2013), unemployment (Egan, Daley & Delaney, 2015;Lager & Bremberg, 2009, Ose & Jensen, 2017, out-of-home care (Roesch-Marsh, 2014;Vinnerljung & Sallnäs, 2008) substance abuse and juvenile delinquency (Shook et al., 2011). The concept complex needs is applied to a fairly heterogeneous group, often recipients of long-term, but not very successful support within the welfare system.
According to Valentine (2016, p. 241), the concept of complex needs is used to categorize "especially disadvantaged people" or people presenting "challenges to services", and is also becoming increasingly common in social work research and practice. Searches in the database Web of Science show an increase in the occurrence of the term complex needs, in articles related to social work, from only one occurrence in 1990 to 65 in 2013 (Valentine, 2016). The concept of complex needs is often ascribed to persons who are considered to have "multiple interconnected needs that span medical and social issues" (Rankin & Regan in Valentine, 2016, p. 241). The heterogeneity of the possible problems that persons who are labeled this way might face makes it difficult to reach a clear definition of the group. Malvaso, Delfabbro, Hackett and Mills (2016, p. 129) define complex needs among youth as "situations where young people are burdened by multiple and co-occurring problems," problems that may be related to mental health issues and/or social problems that often lead to multiple forms of assistance. Ungar, Liebenberg and Ikeda (2014) use the categorization multiple service-using youth interchangeably with youth with complex needs based on the notion that it concerns young people who use multiple forms of services. This brings attention to the fact that a part of the problem might be the organization of services, placing complex care systems rather than individual needs in focus. Any definition must therefore be flexible enough to encompass a large variation in type of problems and needs, and take into account that complex needs might be a consequence of the complexity in how the care system is organized rather than of the young person in need of assistance. Since this is a vulnerable group, facing several negative outcomes, it is of utmost importance that researchers help professionals find practices, from among the measures provided by different social agencies, that are effective in helping this group to have higher quality of life and greater independence. Otherwise professionals may continue to engage with youth using measures lacking empirical evidence of their actual effectiveness, as is also argued by Naccarato and DeLorenzo (2008).
The review is part of a larger Swedish project, conducted between 2016 and 2017, with the overall aim to improve work practices for those labeled young people with complex needs. A reference group consisting of six professionals in leading positions in psychiatric child and youth care and social services at regional and municipal level was formed. From the start, the researchers and the reference group have met in bimonthly meetings. For this review, the reference group were consulted particularly when identifying the problem. Another purpose with the discussions was to retrieve and synthesize knowledge regarding work practices to develop and improve psychosocial services that benefit young people whose needs are considered to be complex. In accordance with the consulting discussions, the following research questions were developed: What are the major themes in studies of practices for young people with complex needs? How do studies suggest that complex needs can be met in ways that are beneficial for young people?

Method
We had two major methodological challenges: first, there is a large variation in what kinds of problems and needs that might be connected to complex needs in searches, and second, we wanted to find and summarize research which could benefit practitioners as well as policymakers.
After deliberations we decided to use integrative review as method (Foster et al., 2016;Whittemore, 2005). Alternatives could be to present findings based on a meta-synthesis (Sandelowski and Barroso, 2007) or a meta-analysis (Cooper, 2010), but these methods might not provide such an encompassing information for practitioners and policy makers. The aim of an integrative review is to summarize empirical or theoretical literature in order to gain in-depth understanding of a phenomenon or to further develop the understanding of a problem or a concept (Broome, 1993;Whittemore & Knafl, 2005). An integrative review bears some resemblance to a critical review, the latter having a wider scope, dealing with issues of theoretical and methodological analysis (Broome, 1993). The integrative review method is the broadest type of research reviews, as it allows the researcher to combine diverse methodologies in the sample and may also combine empirical and theoretical papers (Whittemore & Knafl, 2005). This is both an advantage and a disadvantage. It can show variations in a phenomenon, but it also gives the researcher "a large repertoire of varied data" to handle (Whittemore & Knafl, 2005, p. 547). Integrative review method is also motivated by the aim to gain in-depth understanding of a phenomenon or to further develop the understanding of a problem or a concept. The scope of the review is work practices in a broader sense rather than to cover advices and suggestions on practices and interventions for particular problems or diagnoses. The concept complex needs necessitates a broader scope since there are large variations in what types of problems and needs these young people may have. We have followed five different stages for performing an integrative review; (1) problem identification stage, (2) literature search stage, (3) data evaluation stage, (4) data analysis stage and (5) presentation stage (Whittemore & Knafl, 2005).

Problem Identification
An important step of the problem identification stage was to reach a definition of the target group (cf. Whittemore & Knafl, 2005, p. 548). We discussed with the reference group, to reach a definition of the target group that would fit the overall aim, thus defining a young person with complex needs as a young person who due to mental ill-health in combination with different types of social vulnerabilities, is receiving assistance from multiple welfare services. Another question was the need to define young people with regard to age. In discussions with the reference group, we decided to limit the age range to comprise adolescents and young adults. This period of life entails important transitions, from childhood to adolescence and further to adulthood. This means that the young person faces certain expectations and demands. The transition towards becoming an adult, for instance, involves demands of increased independence which also encompass the young person's own expectations about life as an adult, for example regarding studies, work and relationships (see e.g. Mitchell, Jones, & Renema, 2015). The official care system is usually organized as to offer different kinds of service and care to those under and over the age of majority, 18 years old, being common in many countries. This may also necessitate transitions for young people when shifting from one agency to another, and create specific challenges for them. Part of the problem identification stage concerned what work practices and interventions we should focus on as specific for the category of young people with a variety of problems and needs. For instance, some youth categorized as young people with complex needs may have problems with addiction, but this is not representative of or applicable to the group as a whole. Some may have a psychiatric diagnosis and others may not. Some may live in residential care and others may live with their families. Our aim was to include studies that focused on what this category of youth might share. Thus, in collaboration with the project's reference group, we decided to focus on research targeting practices that-in a broader sense-were related to assisting young people considered to have complex needs.

Inclusion and Exclusion Criteria
The final task of the problem identification stage was to formulate inclusion and exclusion criteria. The primary criterion for being included was that the study should have been published within the last 10 years; we therefore decided to delimit the search to peer-reviewed records published between 2007 and 2016. Another criterion was that the studies as well as the journals should have an international scope. As mentioned, we define young people as adolescents and young adults, and therefore studies of practices relating to these age groups were included. For adolescents we decided upon an age range between 13 and 18 years and for young adults 18-25 years, since we were particularly interested in research covering the transition period from being a child to becoming an adult in the eyes of the law. A further criterion was that the publication's content should be based on experiences of practically assisting young people with complex needs, thereby excluding publications whose focus was not on work practices. Only publications based on empirical qualitative and quantitative research were included, and literature reviews and theoretical articles were excluded. Empirical studies about practices that were related to youth more generally but did not address complex needs were excluded, as were studies about young people with complex needs that did not focus on interventions or practices. Since our focus was on mental ill-health, studies about young people with other types of ill-health, such as severe somatic diseases or physical disability were excluded. The young person's needs were in focus, therefore studies on how parents cope, and on parental needs were excluded. Studies on juvenile delinquency and interventions within the criminal justice systems as well as the educational system were also excluded. The final inclusion and exclusion criterion concerned the quality in terms of transparency. A publication was excluded if there was not sufficient information about the methodology.

Literature Search and Data Evaluation
For these stages, a librarian was consulted. We made searches in seven databases: Social Services Abstracts, Sociological Abstracts, PsycINFO, CINAHL Plus, Social Care Online, Social Science Citation Index, and PubMed. The search was limited to peer-reviewed publications (written in English) published between 2007 and 2016. We used different combinations of search terms in order to cover our topic of interest. For an overview of search terms, see Table 1.
In high-recall searches, most or all documents are relevant and in high-precision searches, fewer items are found but most, if not all, are relevant (Sandelowski & Barroso, 2007). Different combinations of search terms were used, until we reached a balance in precision and recall rates. We set a benchmark for a balance between precision and recall rate at 100-200 records for one search, and 2-3 such searches per database were saved as samples. The saved searches in the above mentioned databases resulted in a sample of 1677 records, see Table 2.
In the first screening, the records were assessed based on a reading of title and abstract in relation to our inclusion and exclusion criteria. After excluding doublets, this screening reduced the number of records to 165. In the next phase, we divided the 165 articles between us and did a brief reading of the selected articles. To strengthen the validity of the selection we carried out the following procedure. We put the articles we thought should be included in one folder, those we thought should be excluded in another folder, and those we were uncertain about in a third folder. During this phase we continuously discussed exclusion and inclusion criteria in relation to the articles, particularly those we had decided to exclude or were uncertain about. One such topic of discussion concerned when there were uncertainties regarding the age criterion. We had decided to include studies with both professionals and young people. The studies with professionals did not always specify the age range. Some of these studies just referred to the professionals as working with youth. After a more thorough reading, we could eliminate studies that targeted younger children.
We read and discussed how specific criteria should be interpreted in relation to specific articles, with the aim to strengthen the internal reliability. This procedure validated the grounds for whether or not a record should be included, in which we also evaluated the quality of the studies in terms of methodological transparency. Articles with insufficient or unreliable information about how the study was conducted were excluded. The result of the third screening, after the uncertain articles had been mutually assessed and validated, was a reduction of the sample to 24 articles, which is the final number of articles included in the review. For an overview of the articles included in the sample, see Table 3.

Data Analysis
Qualitative data analysis has the potential to reveal the complexity and richness of a phenomenon. However, this richness is something that must be reduced (Miles & Huberman, 1994, p. 55). We summarized the content of each article, using qualitative summative content analysis (Hsieh & Shannon, 2005, p. 1281Morgan, 1993). We divided the articles between us and did a thorough reading of the 24 articles. We summarized important features in each article. Then we constructed a case-level display for partially ordered metamatrix to compare and contrast the contents of the articles with each other (cf. Miles & Huberman, 1994, p. 179). In this process of the analysis we were guided by our research questions: What are the major themes in studies of practices for young people with complex needs? and How do studies suggest that complex needs can be met in ways that is beneficial for young people? In the summative content analysis we identified a wide variety of different features in each article.
We compared them by displaying them in the meta-matrix, and identified three major themes. The first theme we identified in several of the articles was collaboration-oriented practices. Many different services and welfare agencies are involved in the care of young people with complex needs, and a recurring subject in several of the articles was different types of collaborative strategies between different welfare agents in order to mitigate a fragmentation of care. The second theme was relationship-oriented practices. This theme highlights the importance of creating a good relationship between the client and the professional, in order for treatment of youth with complex needs to be successful. The third theme was empowerment-oriented practices. This theme highlights practices emphasizing the importance of youth involvement for successful treatment. In the third step of the analysis we used the three themes of collaboration-, relationship-and empowerment-oriented practices to do a second and more structured reading of the articles, and the presentation of the findings are structured according to these three themes.

Presentation of Findings
In this section, we will present the results from the summative content analysis, which generated the three themes described above: collaboration-oriented practices, relationship-oriented practices and empowerment-oriented practices. The findings answer both research questions: What are the major themes in studies of practices for young people with complex needs? How do studies suggest that complex needs can be met in ways that are beneficial for young people?

Collaboration-Oriented Practices
Several of the articles mention the importance of collaboration, as a way to improve treatment of young people with complex needs. Collaboration is regarded as an important tool to avoid fragmentation, which is a serious challenge for

Journal of Social Service Research
Survey data from different professionals employed in the child welfare system and consumers (caregivers and parents), n = 1428 To explore barriers between different systems within the system of care

Journal of Children's Services
Self-report questionnaire and interviews in with youth, n = 9 and staff, n = 29 To evaluate a yoga program in a residential home regarding the effects on relationship building and well-being for youth and staff

Child and Adolescent Mental Health
Focused ethnography (field notes, interviews and conversations) over a period of 2 years with participants in intervention. Core participants (15) Formative evaluation of an intervention for excluded young people with complex unmet needs Ådnanes and Steihaug (2016) Norway

International Journal of Integrated Care
Qualitative interviews young adults, n = 32 To capture how young adults with mental health illness and complex needs experience treatment and care human service delivery systems. If coordination of care is not done actively, young people are at risk of receiving fragmented care that fails to address their overall needs. In this section we address the problem of fragmentation and work practices that are proposed as solutions to this problem. In their study of mental health care for children, Pavkov et al., (2012) investigate attitudes among professionals towards other professionals within the system of care. They identify obstacles to collaboration among different stakeholders. For example, each stakeholder group may be defined by the source of their funding, also referred to as "funding silos" (Pavkov et al., 2012, p. 673, see also;Miller, Blau, Christopher, & Jordan, 2012). According to Pavkov et al., funding silos make service providers act in ways that protect their own organizations, thus creating "competing interests across child-serving systems" (ibid.). In their study, they find a tendency toward "finger pointing" (Pavkov et al., 2012, p. 681) among professionals. This means that stakeholders from different systems show a lack of understanding of each system's role which creates a tendency to blame failures on other professionals. According to Pavkov et al., broad systemic changes are necessary in order to make different stakeholder groups to work towards a common goal. Bunger (2010) found that difficulties may arise when social workers collaborate with, for instance, medical providers or psychiatrists, because the different providers lack a shared theoretical framework and may also be at different levels in the hierarchy. She suggests two strategies to address these potential conflicts. One is to negotiate procedures for working together. The other involves matching or aligning treatment approaches. According to Bunger, using or having consistent, congruent or complementary treatment philosophies may be a way to reduce potential conflicts and enhance coordination, if providers approach treatment from a similar framework. Personal relationships that professionals form with each other also have an important impact on collaboration; they facilitate the exchange of information and referrals, which benefits service coordination, particularly over time. Personal relationships between providers are therefore, according to Bunger, a key driver of successful service coordination.
Inspired by Thompson (1967), Bunger (2010) mentions three different ways that collaboration and interdependencies can be expressed: they can be pooled, sequential or reciprocal. Bunger argues that pooled interdependency requires the least intense interaction; it develops when each service provider works independently, but the joint sum of their work contributes to the outcome. Sequential interdependencies occur when separate providers are responsible for screening and treatment. The third, reciprocal interdependency, is when the final outcome of collaborative work depends on providers being able to adjust services in response to the resources that are received or given. Case management is described in Bunger (2010) as a method to enhance service coordination of care when care is provided by multiple disciplines or in multiple settings. It can be used to link a client to multiple forms of services, meaning it functions as a bridge to move clients from one type of service to another. Coordination of care can be delivered via case managers in connection with discharge planning and other service transitions. Case management involves pooling resources, whereas wraparound is defined as a process which integrates assessment and planning and knits together services from all involved providers in order to address the needs of the child and family. Wraparound and integration of care are, thus, expressions of more progressively coordinated mechanisms that involve planning and reciprocal or mutual adjustment (Bunger, 2010). Bunger et al., (2014) also emphasize the importance of collaboration between organizations. Referral partnerships make it possible for agencies to reinforce trustworthiness, and establish a foundation for other collaborative activities, including the sharing of staff expertise. Therefore, referral partnerships can mediate the process in which possible partners trust one another and develop multiple service delivery partnership.
Management control systems for inter-agency collaboration for persons with "highly complex needs" (Alam & Griffiths, 2016, p. 295) handle problems like fragmentation. When many agencies are involved there is a lack of overall control of the different services provided and whether or not they are leading to a desired result for the client. Therefore, in addition to each agency monitoring its own contribution, a coordinator controls the overall result from the perspective of the client's interests. This coordinator "engages with all participating agencies for delivering support and services to clients" (Alam & Griffiths, 2016, p. 294) and the coordinator is also connected with a committee tasked with finding resources and producing care plans for the client.

Relationship-Oriented Practices
Another important feature that is highlighted as crucial in studies of interventions targeting young people with complex needs is the quality of the relationship between the professional and the young person. Findings by Ungar et al., (2012) and Ungar et al., (2014) on service satisfaction among young people with complex needs emphasize the correlation between young people's experiences of the good quality in relationships with professionals and treatment outcomes. Young people refer to good quality in relationships as feeling that professionals relate to them in an authentic manner, meaning genuinely caring (Cahill et al., 2015;Ungar et al., 2012Ungar et al., , 2014 and relate to them in ways that are non-judgemental (Zlotowitz et al., 2016). A good quality in relations to parents is also an important factor that can smooth the process of supporting youth, as good 1 3 interpersonal skills may reduce the likelihood of professionals alienating parents and other professionals (Devaney, 2008). Harder et al., (2013) identify several crucial factors associated with a positive client-staff relationship in secure residential care for young people. Treatment skills among care workers that are identified as promoting positive adolescent-staff relationships are those that cause the professional to be perceived as someone who shows commitment, stands beside the client, is reliable, fits in with the client, is respectful of the client, has good contact with the client, and gives positive feed-back. Malvaso et al., (2016) emphasize the importance of professionals' interaction style and relationship building skills, and state that professionals working with young people with complex needs should have an interaction style that is informal, based on outreach rather than in-office meetings, indirect, and characterized by persistency. Malvaso et al., (2016, p. 134) also argue that in some cases, the young person's behavior makes it difficult for professionals to create good relationships with the young person. Here the problem is localized to the young person, who is described as more difficult to engage with because he or she has "problems with aggression" or "anti-social behavior". Solutions to this challenge, according to Malvaso et al., can be achieved through increased collaboration between professions with different areas of expertise, and on the micro-level through the professionals' personal interaction styles and relationship building skills. Interactional skills such as interpersonal warmth and non-authoritarian interaction style are highlighted in the study as important factors for successful treatment outcomes when a young person is categorized as having anti-social behavior.
A certain kind of relationship-oriented practices comprises practices based on specific therapies, such as traumaoriented therapy. The professional's ability to create relations with young people based on trust is described as particularly important in trauma-informed treatment models (Lanktree et al., 2012;Purvis et al., 2014). Purvis et al., (2014) evaluate a trauma-specific multimodal intervention, Trust Based Relational Intervention, for young people in psychiatric residential care suffering from severe trauma due to recurrent neglect in early childhood years. This treatment model is guided by three principles, empowerment, connection and correction. From a theoretical standpoint, the intervention is guided by attachment theory, and it aims to reduce trauma by creating a trusting relationship between client and therapist. Lanktree et al. (2012) evaluate and propose a specific trauma-informed model, Integrative Treatment of Complex Trauma (ITCT), for socially marginalized youth with multiple psycho social trauma that have a history of being victims of abuse, neglect and maltreatment. According to Lanktree et al., young people with complex trauma are at risk of not getting evidence-based treatment according to their needs since most treatments that are classified as evidence based, focus on one diagnosis only and therefore they are not constructed to handle complex traumas. A model such as ITCT is, according to Lanktree et al., more preferable as it can adjust treatment to complex, individual and changing needs. ITCT uses various instruments to handle variability across different individuals, changes in the social and physical environment, and changes over time due to new stressors in the young person's life or changes in symptomatology or problems.
Relationships between the young people receiving therapy and their therapists have both affective and collaborative aspects that are referred to by Lamers and Vermeiren (2015) as Therapeutic Alliances (TA). In their study of practices among case managers and parent counselors, Lamers and Vermeiren (2015, p. 651) identify different types of TA that are formed between the multidisciplinary team, young people and their parents such as "youth personal alliances," "youth task alliances," and "parent alliances". They also found that strong youth-personnel alliances correlated with a more positive functioning of the youth, and that a strong parental alliance could also play an important role for the outcome of the therapy. Lamers and Vermeiren interpret this as being connected to improved parenting skills, which may be a possible effect of the parents' strong alliance with the therapist. The importance of the therapeutic relationship was also found by Ryall et al. (2008) in a study of Intensive Mobile Youth Outreach Service (IMYOS). The strength of IMYOS interventions, according to Ryall et al., was its focus on three levels: the individual level, the family level, and the system level, i.e. the professionals involved in the care.
Continuity has been argued to be an important factor for the development of a good relationship between caregiver and client (Cahill et al., 2015;Greeson et al., 2009;Ådanes & Steihaug, 2016). According to the study by Greeson et al., (2009), there is a positive correlation between continuity in relations and desirable outcomes of therapy. Ådanes and Steihaug's (2016, p. 2) study of young adult service users "with mental health illnesses and complex needs" explores the issue of continuity from a patient perspective. The young adults in Ådanes and Steihaug's study stress the importance of a good and stable relationship between service-user and care-provider to mitigate the fragmentation of care. Further, the young adults describe that they need more information about adequate treatment and progress from the care providers, young adults describe this as hard to get. Besides continuity, Greeson et al., (2009) show that the therapist's gender may also be important for treatment outcome. The impact of gender when it comes to building relationships, and gendered obstacles to forming good relations, are also highlighted by Cahill et al., (2015), who found that having a therapist of the opposite sex could, on some occasions, be experienced by the young person as creating difficulties in communication and trust in the relationship between the caregiver and the young person.

Empowerment-Oriented Practices
Empowerment-oriented practices address issues concerning the young person's involvement in decision making and services, and sometimes also include the young person's family or other resources in the surrounding community. Several studies address the problems with inequalities in power, where young people often are not sufficiently involved in decision making (Malvaso et al., 2016;Ungar et al., 2012Ungar et al., , 2014Ådanes & Steihaug, 2016). Ungar et al., (2013) identify a strong positive correlation between the perceived quality of service for young people who receive multiple psycho social interventions, and treatment outcome. Besides consistency in approach and easy access to services (Ungar et al., 2014), the best predictor of treatment success is if services are perceived of as engaging the client's personal agency (Ungar et al., 2013).
As mentioned earlier, Malvaso et al., (2016) advocate person-centered case management and the professional's personal interaction style as a key factor in empowering the young person (cf. previous section). Focusing on the young people's skills and strengths, giving them opportunities to articulate their views, making different options known to them, and giving them time to make a choice are interactional techniques that ought to be used by professionals to empower young people according to Malvaso et al., practices that promote empowerment must not, however, leave young people entirely on their own in the decision making process. According to Malvaso et al., it is also the duty of professionals to strongly advocate on behalf of the young people's best interests, and professionals should therefore take time to negotiate decisions with the young peopele if they appear to be making less constructive choices. Empowerment is also a matter of contributing to the young person's growth. Malvaso et al., found that services should offer individualized activities related to life skills. Mentorship by peers and professionals is another strategy described as crucial to strengthening necessary life skills.
Walk-in services (Malvaso et al., 2016) and outreachprograms (Edinburgh & Saewyc, 2009;Zlotowitz et al., 2016) are other practices that can be identified as empowerment oriented practices. The intention is to make services more centered round the young person's needs instead of requiring that young people attend fixed appointments in agency offices. Walk-in services is according to Malvaso et al., (2016) a way to make services less structured around bureaucratic principles of the organizations, more flexible and more accessible for young people. In a study by Barwick et al. (2013), client satisfaction in a walk-in treatment model for young people with psychosocial problems is compared with client satisfaction in service as usual treatment models. According to Barwick et al., there are no big differences in service satisfaction rates, the explanation being that walk-in treatment is a more attractive service option for specific segments of the client population. According to Barwick et al., walk-in services thus accommodate the needs of one segment of families or young people, but may not fit all of them, and therefore Barwick et al. suggest that walk-in services should be seen as a complement to, but not a replacement for service as usual. Zlotowitz et al., (2016) evaluate an outreach project that uses cultural activities, in this case music, to engage young people in what the authors refer to as a multicomponent intervention that also has an explicit empowerment orientation. The social care offered to the young people consists of activities where professionals engage locally with youth in their neighborhood and on their terms. Another sign that the interventions in the program explicitly work according to an empowerment perspective is that activities within the project are based on the idea of coproducing interventions with youth. Empowerment is also visible in the youth involvement; activities in the program are youth led, and the young people recruit others to the program and work together with professionals to create change for others in their peer group. Thus young people have opportunities to practice skills, cultivate strengths, and gain experience as volunteers and leaders. Another distinct empowerment perspective in this project is the way it does not only focus on individual change but also target contextual change, encouraging and helping young people to problematize the services they are offered and to work for change.
Resilience-building arts workshops can also, according to Macpherson et al., (2016), be used to emphasize young people's strengths, thereby empowering them. Other studies of outreach-oriented interventions that use creative activities as an informal vehicle to engage with young people are Coholic (2011) andPerez Vallejos et al., (2016). The study by Coholic describes a mindfulness and arts based method for increasing personal skills such as relaxation, coping and problem-solving. This is also, according to Coholic a way to help young people understand and tolerate emotions, and increase their self-awareness. If Coholic's study focuses on personal change in the young person, the Kundalini yoga program evaluated by Perez Vallejos et al., (2016) targets mutual and reciprocal improvement with well-being in both staff and children in care. Perez Vallejos et al., (2016) identify individual positive effects reported by the yoga program participants, such as improvement of quality and duration of sleep, reduced stress, increased sense of self-awareness, improved emotional regulation and ability to focus. They note that the enacting of togetherness through yoga resulted in social benefits by creating opportunities for positive peerrelations to evolve between the young people and for staff and young people to merge in a way that facilitated relational depth and openness towards others. Edinburgh and Saewyc's (2009) study is an evaluation of a client-centered intensive case management outreach program, aiming to reduce trauma and increase self-esteem among sexually exploited female adolescents. Alongside outreach strategies where professionals visit girls in their homes and at school, this program also works with therapeutic-empowerment group counseling. Empowerment oriented practices can to varying degrees include the young person's family in decisions and services provided. When analyzing patterns concerning the interaction between service providers, caregivers and adolescents, Ungar et al., (2012) found that the most well-functioning of these patterns were based on family empowerment. This refers to a pattern where the family is both directly involved with helping their child and places demands on system providers that reflect the family's priorities. It was experienced as protective, as helping the young people to meet their personal needs, and also as enhancing communication. The authors imply a therapist role that includes both being a clinician and striving for better services. A major aim with an outreach intervention studied by Rots-de Vries et al., (2011) is building bridges between the family and agencies that could offer assistance. The intervention consisted of team meetings in three locations, attended by the preventive child health care staff who delivered the intervention, their manager and their method supervisor. It resulted in shared care, a liaison between families and follow-up help. Significant main stages in the intervention process were case finding, making and sustaining contact with the families, developing a family plan, and arranging for the delivery of services. Providing practical support was a major activity and could take the form of helping with household chores, transport to school facilities, and applying for social benefits. Strong engagement from professionals was vital, as was knowledge about the health care and welfare system. Well-defined counseling tactics were used, such as solution-focused models (Rots-de Vries et al., 2011).

Discussion
In this section we discuss the findings in relation to the research questions: What are the major themes in studies of practices for young people with complex needs? How do studies suggest that complex needs can be met in ways that are beneficial for young people? We will therefore discuss what conclusions can be drawn to furthering an understanding of work practices for youth with complex needs. Limitations of the study and possible implications for social work practices are also discussed.
We start with the first question: What are the major themes in studies of practices for young people with complex needs? Features that we identified in the content analysis formed three themes: collaboration-oriented practices, relationship-oriented practices, and empowerment-oriented practices. Features belonging to the collaboration-oriented practices address the risk of fragmentation of care. This problem is described as caused by there being many different agencies involved in the care of young people with complex needs. There are no simple solutions to the problem of fragmentation of care; it is a consequence of specialization, and has been highlighted in research as a recurrent dilemma in social work practices (cf. for instance Grell, 2016). The articles describe different practices aiming to increase collaboration and mitigate fragmentation of care for young people with complex needs (Alam & Griffiths, 2016;Bunger, 2010). Examples of work practices for coordination of care are for instance case management which, according to Bunger, involves pooling resources, in contrast with wraparound processes, which integrates assessment and planning. Wraparound and integration of care are thus expressions of more progressively coordinated mechanisms that involve planning and reciprocal or mutual adjustment (Bunger, 2010). Another feature of collaboration-oriented practices are work practices attempting to mitigate the problem of fragmentation through creating shared theoretical treatment philosophies (cf. Bunger, 2010;Pavkov et al., 2012). Professionals' lack of knowledge about other systems within care work may lead to improductive battles instead of collaboration for the young person's best interest (cf. Pavkov et al., 2012).
The second theme, relationship-oriented practices, consists of features expressing the importance of relationships, and addresses questions of how professionals relate to and interact with young people. Several studies argue that the quality of the relation between professionals and youth is crucial for a successful outcome of interventions. Young people feeling that professionals relate to them in an authentic way is of utmost importance to successful treatment outcome (Cahill et al., 2015;Ungar et al., 2012Ungar et al., , 2013Ungar et al., , 2014Zlotowitz et al., 2016). Skills such as empathy and being able to adopt another person's perspective are highlighted as crucial factors in building good relations, or therapeutic alliances between professionals, young people and their parents, which may increase the likelihood of successful intervention outcomes. Research stress how different professionals' interaction styles and interpersonal skills can positively affect the quality of the relationship (cf. Malvaso et al., 2016). To create a trusting relationship with youth with complex needs, work-practices should also be based on trauma-informed treatment (Lanktree et al., 2012;Purvis et al., 2014). Relationshiporiented practices address professionals' interaction skills at a micro level, but also concern managerial liability and policymaking. Policies that put relationships in the center of practice, and welfare organizations that give the right prerequisites for professionals to further develop relationship based work practices cannot be enough emphasized, is one conlusion we draw.
The third theme is based on what we identified as empowerment-oriented practices. They concern inequalities of power relations. Professionals seek ways to involve young people in decision making, thereby increasing their agency. This encompasses the young person's involvement in decision making and services, that may be accomplished through the professional's interactional style, techniques that according to Malvaso et al., (2016) are important tools that can be used in order to empower young people. Person-centered case management, as mentioned earlier, can also be seen as an empowerment-oriented practice, as it aims to make interventions more centered around the young person's needs (ibid.). Another feature we identified as a sign of empowerment was the existence of activities within the project which encouraged the young person's own agency, for instance by co-producing interventions together with the young person. Stressing skills and strengths in the young person, aiming to give the young person an opportunity to articulate his or her own views, or offering individualized and life skills related activities, are other examples of such features (cf. Malvaso et al., 2016;Zlotowitz et al., 2016). Some empowermentoriented practices target young people themselves, while others also may include their families or resources in the community (cf. Rots-de Vries et al., 2011). Other practices aim to interact with young people in more accessible and flexible manners, centered around young people's needs. Walk-in services or more outreached oriented practices that engage with youth locally or use creative activities as informal ways to involve youth exemplify this (Coholic, 2011;Zlotowitz et al., 2016).
Further to the second question: How do studies suggest that complex needs can be met in ways that are beneficial for young people? The findings indicate that the young person's satisfaction with interventions is an important predictor of successful treatment (cf. Ungar et al., 2013). Important factors for young people's satisfaction are services that are experienced by young people as consistent, coherent and accessible. (cf. Ungar et al., 2013Ungar et al., , 2014. This requires collaboration. Other factors that contribute to service satisfaction are related to relationship-oriented practices and interactional styles of the professionals, or concern empowerment-oriented practices, which enable services to be perceived as engaging the personal agency of the young person (Ungar et al., 2014).

Limitations
There are a number of limitations in the review. The studies have been conducted in different countries, and there may be differences regarding the organization of services to young people between these countries, or even between regions in the countries. The sample has a bias towards Anglo-Saxon countries. Besides one Norwegian study and three studies from the Netherlands, all other studies have been conducted in the US, Canada, the UK, Australia or Ireland. There may be differences between these countries which relate to culture, social norms and values, or differences due to type of welfare state regime or governmental system which may influence work practices. This is, however, beyond the article's scope. We found few studies from developing countries in our searches. Therefore, another limitation is a bias towards Western and primarily Anglo-Saxon studies, and a lack of studies from developing countries. The few studies we did find were eventually excluded since they did not fit with our research questions.
It was not possible to cover all aspects of societal life. Studies of work practices in areas such as education or juvenile delinquency were not included in the sample. Moreover, a concept such as complex needs necessitates a broader scope. Therefore, the review neither cover advices and suggestions for practitioners and policymakers on practices and interventions for particular problems or diagnoses, nor provide solutions to specific problems that youth may have.

Implications for Practice and Policy
The aim of this review was to investigate research of social work practices for adolescents and young adults with complex needs. On a societal level, the main purpose in terms of both practice and policy is to decrease the incidence of mental ill-health and social vulnerability among young people. On an individual level, the purpose is to stimulate reflections and discussions among practitioners and policymakers in mental health care services and social work services. Further, that they will be encouraged to reflect around work practices in a broader sense, and that collaboration-, relationship-and empowerment-oriented practices will be used as tools to promote young people's mental health and decrease their social vulnerability.