Part 4: Working together to meet the needs of at-risk groups of young people
4.1
Effective communication and collaboration between government agencies is important for providing mental health services and support to all young people. This is particularly critical for at-risk groups of young people because they are more likely than other young people to have a range of health and social needs.66
4.2
In this Part, we discuss how well government agencies are working together to understand and meet the needs of three groups of young people who experience a greater risk of mental health concerns.
4.3
These three at-risk groups of young people are:
- young people in care;
- young people not in education, employment, or training; and
- young people in prison.67
4.4
We expected agencies to:
- clearly understand their own and others' respective roles and responsibilities in relation to the mental health and well-being needs of at-risk groups of young people; and
- communicate clearly, share information, and work together in a co-ordinated way to ensure that the multiple, holistic needs of at-risk groups of young people are met.
Summary of findings
4.5
Young people in care, not in education, employment, or training, or in prison are all at significant risk of experiencing mental health issues. However, the agencies involved in supporting them might have little understanding of their mental health needs or barriers to accessing mental health care.
4.6
In our view, there is a lack of clear and integrated care pathways through the mental health system for at-risk groups of young people to access mental health support. Without these pathways, some of our most at-risk young people could miss out on the support they need to address their mental health needs.
Cross-agency support is needed for young people in care
4.7
Young people in care or who have been involved with Oranga Tamariki are at high risk of experiencing mental health issues. Compared with other young people, those who have been involved with Oranga Tamariki are more than twice as likely to report symptoms of depression and more than four times as likely to have attempted suicide in the past year.68
4.8
Māori, Pacific, disabled, and Rainbow young people are over-represented in the numbers of young people with past or current Oranga Tamariki involvement and young people in care.69
Oranga Tamariki does not know whether it meets the mental health needs of young people in its care
4.9
Oranga Tamariki is required to assess, and take all reasonable steps to meet, the health and mental health needs of the children and young people in its care.70
4.10
Oranga Tamariki is aware that young people involved with Oranga Tamariki are disproportionately at risk of developing mental health concerns. In a recent needs assessment, Oranga Tamariki acknowledges that such young people "often have high mental health and wellbeing support needs, including depression and suicidal ideation, anxiety, mood disorders and substance use".
4.11
Although information on the mental health needs of young people in care might be recorded in individual client casefiles, this information is not available to Oranga Tamariki at a system level through its national client management system.
4.12
The Independent Children's Monitor has a statutory role to monitor Oranga Tamariki's performance. Recently, the Independent Children's Monitor found that Oranga Tamariki does not collect enough data to know whether it meets its obligations to assess and meet the mental health needs of children and young people in its care.71
4.13
Oranga Tamariki uses several general screening tools to assess the needs of children and young people in its care, including:
- Tuituia, a needs assessment across multiple domains of well-being; and
- the Gateway Assessment, an interagency health and education needs assessment carried out when young people enter into care.
4.14
Oranga Tamariki informed us that the Gateway Assessment is under review and that it plans to discontinue Tuituia and introduce a new holistic needs assessment tool in its place.
4.15
Although Oranga Tamariki is required to assess the health needs of children and young people in its care (see paragraph 4.9), specific screening tools for mental health or alcohol and drugs are rarely used. Often these tools are used only when a young person is in crisis or has previously been diagnosed with a mental health condition. Oranga Tamariki's 2021/22 review of 756 casefiles found that only 21 children and young people had been specifically screened for mental health, substance use, and suicide risk, while a further 18 had received suicide risk screening only.72
4.16
Some Oranga Tamariki staff and young people with lived experience of the care system consider that mental health screening and support should be universal for children and young people in care. This is because of the high levels of trauma these children and young people are likely to have experienced.
4.17
However, improved screening for mental health conditions among young people in care and at-risk groups is only likely to be beneficial if it is followed by timely access to appropriate services. Without clear care pathways, young people might have expectations for support that are not met.
Young people in care are often unable to get the mental health support they need
4.18
Oranga Tamariki social workers receive basic mental health training but might lack the specialist knowledge of mental health and trauma to cope with the level of mental health need experienced by young people involved with Oranga Tamariki.
4.19
Oranga Tamariki provides a mixture of in-house and contracted services to support the mental health needs of children and young people involved with Oranga Tamariki.
4.20
Towards Wellbeing, one of the contracted services, provides social workers with clinical advice on suicide risk. Oranga Tamariki told us that about 600 tamariki and young people nationally are monitored under Towards Wellbeing each year.
4.21
The in-house specialist clinical services in Oranga Tamariki are tailored to the specific mental health needs of young people in care, who have often experienced trauma. Oranga Tamariki told us that this service is available in 11 of 12 Oranga Tamariki regions. However, the agency described its in-house services to us as severely over-subscribed and unable to keep up with high demand.73
4.22
Where appropriate, Oranga Tamariki refers children and young people to Te Whatu Ora mental health services. However, Oranga Tamariki staff told us that they often struggled to get referrals of children and young people accepted by ICAMHS.
4.23
When young people in Oranga Tamariki care cannot access timely support from publicly funded services, the agency might purchase private services. However, the private services it uses often have waiting lists. Oranga Tamariki told us that it spent about $2.4 million on private mental health services in 2021/22.74
4.24
Children and young people in care could change care placement multiple times. On average, children and young people in care will have four caregivers over the course of their time in care. Some will have many more.
4.25
We heard that meeting the mental health needs of young people in unstable or unsuitable living situations is often a source of tension between health agencies and Oranga Tamariki. ICAMHS staff told us that Oranga Tamariki is responsible for ensuring that young people in its care have a stable placement. ICAMHS staff also told us that the therapies they provide are only effective if young people have stable relationships with whānau or caregivers.
4.26
However, underlying mental health or substance-use concerns can be a factor in why young peoples' placements break down in the first place.
4.27
We heard that, in some regions, Oranga Tamariki's care and protection residences house young people with a severe level of mental health need who might require specialist support that staff in residences do not have the experience or training to provide.
4.28
In some regions, Oranga Tamariki and ICAMHS have established ways of working together to meet the specific needs of children and young people in care. There is, for example, a dedicated Children in Care Team working in the Canterbury ICAMHS service.
4.29
However, these types of arrangements appear to vary throughout the country. Health services do not have access to Oranga Tamariki data and therefore cannot routinely identify if young people are in care unless this information is shared by the young person being treated.
4.30
In addition, health records might not be accessible if a young person changes locations, which disproportionately affects young people in care who could have frequent changes in placement and caregiver.
Government agencies recognise improved co-ordination between agencies is needed to meet the needs of young people in care
4.31
Health agencies and Oranga Tamariki recognise the need for greater cross-agency collaboration to meet the mental health and well-being needs of young people in care. They described to us a range of joint initiatives they are carrying out to improve the mental health and well-being of children and young people involved with Oranga Tamariki.
4.32
These include joint actions under the Child and Youth Wellbeing Strategy and the 2022 Oranga Tamariki Action Plan. The 2022 Oranga Tamariki Action Plan is a joint plan by children's agencies75 to ensure that the holistic well-being needs of children and young people in "core populations of interest" to Oranga Tamariki are met.76
4.33
Specific cross-agency initiatives include:
- the 2023 publication of a specific needs assessment on the mental health needs of children and young people in care;
- the establishment of a cross-agency data and insights group to improve data sharing between Oranga Tamariki and health agencies; and
- "ring-fenced" 2022 Budget funding for ICAMHS focused on meeting the needs of young people with mental health concerns who are under the care of Oranga Tamariki.77
4.34
The health agencies and Oranga Tamariki also plan to review the specialist mental health support available to children and young people involved with Oranga Tamariki. This is to better understand barriers to mental health care for this group and why agencies "are not reliably connecting around individual children and young people", with the aim of developing a new integrated service model to meet the needs of this group.78
4.35
This acknowledgement from health agencies and Oranga Tamariki that the existing approach is not working well for many young people in care is important.
4.36
We support the commitment of health agencies and Oranga Tamariki to work together to improve the pathways for young people in care to receive mental health support. We will look to see if prioritisation of this work continues when we review how agencies have responded to our report.
Agencies need to work together better to assist young people into study or work
4.37
Young people who are not in education, employment, or training are at high risk of experiencing mental health concerns. A recent New Zealand study found that 70% of these young people had experienced "significant depressive symptoms" over the past 12 months, and almost one in three (29%) had attempted suicide in the past year.79
4.38
At the end of 2022, 11% of young New Zealanders aged 15 to 24 years were not in education, employment, or training.80 Māori, Pacific, and disabled young people are over-represented in this group; almost 20% of rangatahi Māori and almost 17% of young Pacific people are not in education, employment, or training. About a third of disabled young people are not in education, employment, or training.81
4.39
No government agency specifically collects data on the mental health needs of young people who are not in education, employment, or training.
Several government agencies offer services for young people who are not in education, employment, or training or are at risk of becoming so
4.40
The Ministry of Education and the Ministry of Social Development both fund or provide services for young people who are not in education, employment, or training or are at risk of becoming so.
4.41
None of these services are mental health services. However, a high proportion of young people who use these services experience mental health concerns. For many of these young people, their underlying mental health concerns could be a contributing factor to why they are not in education, training, or work.
4.42
The success of government programmes aimed at assisting young people into study or employment is likely to have beneficial flow-on effects for a young person's mental health. This is because being in work or education is a strong protective factor for young peoples' well-being.
There is no data on mental health as a factor in declining school attendance
4.43
Regular school attendance is strongly linked to students' mental health and well-being.82 Mental health can be an underlying factor in non-attendance, and lower school attendance is linked to poorer mental health outcomes.
4.44
School attendance in New Zealand has been declining since 2015 and is significantly lower than comparable countries, such as Australia. From 2015 to 2023, the percentage of New Zealand students regularly attending school fell from just under 70% to 46%. Only a third of Māori and Pacific students attend school regularly.83
4.45
Recording and monitoring student attendance and ensuring that students attend school regularly is a responsibility of individual schools, with support from the Ministry of Education. Although it is not mandatory for schools to submit attendance data to the Ministry of Education, about 90% of schools do.
4.46
The Ministry of Education contracts providers to deliver a national attendance service to support students aged 6 to 16 years who are either not enrolled in or attending school to return to school.
4.47
The Ministry of Education requires providers of Attendance Services to understand and address the "underlying root causes of poor or non-attendance". However, it does not require providers to report back data on the reasons for students' poor attendance.
4.48
The Education Review Office considers increasing mental health issues to be a key factor in falling school attendance over the past decade.84 Many submissions to a recent parliamentary inquiry into school attendance highlighted that mental health concerns are a significant contributor to student absences and that Covid-19 had exacerbated this problem for some students.
Alternative Education services are a common intervention for young people disengaged from school
4.49
A common intervention for young people who are chronically absent from (or who are suspended, expelled, or excluded from) school is enrolment in Ministry of Education-funded Alternative Education services.
4.50
Alternative Education services offer an alternative learning option for people aged 13 to 16 who are disengaged or at risk of disengaging from school, with the aim of assisting them to return to school or into further study or work.
4.51
A recent New Zealand study of students in Alternative Education found that almost three-quarters reported clinically significant symptoms of depression.85 The Education Review Office found that almost a third of students enrolled in Alternative Education had previously accessed specialist mental health services.86
4.52
Despite this high level of need, we heard that Alternative Education and Attendance providers can struggle to get students with mental health concerns the help they require from publicly funded mental health services.
The Ministry of Social Development also offers services for young people who are not in education, employment, or training
4.53
The Ministry of Social Development provides and funds services for young people who are not in education, employment, or training or at risk of becoming so. These services are:
- Youth Services, which supports young people aged 16-17 who apply for certain youth benefits, and young people aged 15-17 who self-refer to a Youth Service provider for support or are identified through an automated referrals system to be in high need of support.87
- He Poutama Rangatahi, which supports young people aged 15-24 (with a focus on rangatahi Māori) who are risk of long-term unemployment.88
4.54
Although there is no specific data on the mental health needs of young people who are not in education, employment, or training, Ministry of Social Development staff told us that mental health was among the top issues in youth service providers' reporting.
4.55
Youth service providers told us that although most young people they see would benefit from specialised mental health care and treatment, the providers often struggled to find timely or appropriate mental health services for the young people they support.
Improved co-ordination is required to meet the mental health needs of young people not in education, employment, or training
4.56
The interconnected nature of young peoples' mental health and well-being and their ability to participate in education or employment means that siloed approaches by government agencies are unlikely to work for at-risk groups of young people.
4.57
For example, a young person experiencing unresolved alcohol or drug concerns is unlikely to keep a job long-term, even if assisted into employment. The efforts of attendance services to help a student experiencing extreme social anxiety to return to school are less likely to succeed if no support is available for their underlying mental health concerns.
4.58
Receiving only part of the support needed increases the chances that at-risk young people will not benefit from services, making it more likely that they will experience negative outcomes or need more intensive and costly support later in life.
4.59
In our view, government agencies need to work more closely together to ensure that young people who are not in education, employment, or training (or at risk of becoming so) can access the mental health support and services they need to make a successful transition to school, study, or employment.
Agencies need to work together better to support young people in prison
4.60
The Department of Corrections (Corrections) is aware that mental health concerns are extremely common among people in prison. Over 60% of prisoners have experienced a mental health condition in the past 12 months, and 91% of prisoners have experienced a mental health condition in their lifetime.89
4.61
Today, people aged under 25 years make up less than 10% of the adult prison population, with most of these in the 20 to 24 year age group.90
4.62
Corrections operates specialised youth units for young men aged under 20. Corrections told us that in 2023, its youth units could accommodate up to 32 people. This means that most young people in prison aged under 25 are housed in adult units.
Screening is available for young people on entry to prison but might not detect all mental health concerns
4.63
Corrections told us that there are different points during a young person's stay in prison where potential mental health concerns could be detected.
4.64
When prisoners enter Corrections' custody, they undergo initial basic screening for mental health and substance use.91
4.65
Prisoners are not routinely re-screened for mental health concerns after the initial screening. However, they might be screened again if they are involved in an incident in prison or if their behaviour causes custodial staff to suspect they are experiencing mental health concerns.
4.66
Corrections is aware that the prison environment can create or exacerbate mental health concerns for prisoners after initial screening is complete.
4.67
Corrections told us that since 2021, 845 community corrections and custodial staff have completed "Mental Health 101" training to assist them in identifying signs of a potential mental health condition in prisoners.
Young people in prison face barriers accessing mental health and substance use services
4.68
Corrections recognises that addressing prisoner mental health and addiction is critical to achieving its goals of reducing reoffending and equipping prisoners to re-enter the community.
4.69
New Zealand's rates of imprisonment are high compared to comparable countries overseas and many people released from prison will offend again. Almost 55% of people released from prison are re-convicted within two years, and over 35% are reimprisoned. Rates of re-offending and re-conviction are higher among younger prisoners.92
4.70
Corrections funds several mental health and substance use services for adult prisoners. The Improving Mental Health Service, a primary mental health service provided by NGOs, is offered to remand and sentenced prisoners with a mild to moderate level of mental health need.93
4.71
For remand and sentenced prisoners with moderate to severe mental health needs, Corrections employs multi-disciplinary mental health teams at seven of the 17 sites it manages. Remand and sentenced prisoners at a further seven sites can access support from specialist mental health nurses.
4.72
Corrections offers 18 alcohol and other drug programmes at 14 sites. All but two of these programmes are restricted to sentenced prisoners. Corrections told us that brief alcohol and other drugs interventions have been available to remand and sentenced prisoners at two prison sites since 2023, and will be available at a further seven sites in 2024.
4.73
Corrections told us that for some prisoners, contact with mental health services in prison are the first time their underlying mental health or substance use concerns have been detected or treated.
Mental health services provided by the Department of Corrections might not be youth- or culturally appropriate
4.74
Corrections' youth units offer age-appropriate programmes and support aimed at meeting the needs of young male prisoners. However, as previously noted, most young people aged under 25 are accommodated in adult units.
4.75
Corrections staff told us that its mental health services in adult units are designed with older adults in mind and might not be well suited for young prisoners. However, Corrections told us that its mental health practitioners "consider each individual's needs and preferences when engaging with them".
4.76
Although Corrections did not previously collect data on the age of people accessing its mental health services, all mental health staff employed or contracted by Corrections now have access to a new data reporting system which will allow age-based reporting by early 2024.
4.77
Corrections told us that young people aged 18 to 24 years made up about 15% of people accessing its addiction services from 2017 to 2022.
4.78
Corrections told us it is currently reviewing its mental health services for prisoners and that this will include work to improve the collection of outcomes data and assess the suitability of existing outcomes tools for use in prison environments.94
4.79
Corrections aims to give Māori prisoners, who make up 52% of the adult prison population, access to culturally appropriate mental health and alcohol and other drugs programmes.
4.80
Corrections has made some progress in improving the cultural appropriateness of its services for Māori. For example, there are Māori mental health practitioner roles in all its seven in-house multi-disciplinary mental health teams. Nine of its 15 addiction service providers are kaupapa Māori services.
4.81
Corrections told us that it has more work to do "with respect to meeting the needs of Māori [prisoners]". It expects that the ongoing review of its mental health services in prisons will have a positive effect.
4.82
Te Whatu Ora also provides specialist (forensic) mental health services for prisoners with a severe level of need.
4.83
Corrections staff told us that lack of capacity in forensic mental health services often leaves prisons supporting prisoners whose needs are better aligned to a forensic service. Likewise, a provider of prison-based services told us that capacity constraints in forensic services means that their referrals of patients are often declined.
Young people in prison face many barriers to accessing mental health support
4.84
Young people can experience greater difficulty accessing mental health services in prisons than older age groups. Young people are often a transitory population in prisons and are more likely than older age groups to be in prison on remand or short sentences.
4.85
This increases the chance that young people might be screened for mental health and substance use concerns when they enter prison but be unable to access appropriate mental health support. In other cases, young people might begin mental health treatment in prison, only to have that service stop when they leave.
4.86
We heard that prisoners are sometimes transferred between prison sites despite them accessing mental health services. This can cause the trust and rapport they develop with a professional to be disrupted. Corrections told us it is aware that transfers can be disruptive to prisoners and whānau but are sometimes needed to safely manage the prison population.
4.87
Corrections told us it is reviewing its procedures to ensure that prisoner health needs and continuity of care are met when they are transferred between sites.
4.88
When prisoners want to access mental health care, custodial staff are required to facilitate their attendance at therapy sessions, such as by making referrals, escorting prisoners to therapy and remaining in sight (although not in hearing distance) during the session.
4.89
The role of custodial staff in facilitating access to prison-based services could be a barrier for young people who do not have a positive or trusting relationship with custodial staff.
4.90
Corrections confirmed to us that services needing custodial staff escorts or presence are currently curtailed in many of its sites due to staff shortages. This means that the mental health services that Corrections provides may not be currently available to many prisoners.
Agency roles and responsibilities for the mental health needs of young people reintegrating into the community lack clarity
4.91
On leaving prison, prisoners with ongoing mental health needs must transfer from the care of prison-based services to publicly funded health services.
4.92
As with any care transitions, prisoners who transfer between prison-based mental health services and services in the community require increased and co-ordinated support to ensure that their mental health needs can continue to be met after they leave prison.
4.93
However, we were told that essential information such as health notes and prescriptions are not always transferred between prison and community-based services in a timely way. This could mean that people with mental health conditions are released from prison without medication or ongoing care plans.95
4.94
Corrections told us that it is working on strengthening procedures for referrals, discharge, and transfer of care so that people with mental health needs who are being released from prison (or transferred to other areas) can access and transition effectively between services.
| Recommendation 7 |
|---|
| We recommend that Te Whatu Ora work with the Ministry of Health, the Ministry of Education, Oranga Tamariki, the Ministry for Social Development, and the Department of Corrections to ensure that integrated care pathways are in place so that at-risk groups of young people experiencing mental health concerns can access consistent and continuous care as they enter, move between, and leave the care of services. |
66: See New Zealand Productivity Commission (2015), More effective social services, page 2.
67: We note that there is a high degree of overlap between the three at-risk groups discussed in this Part.
68: Fleming, T et al (2022), Young people who have been involved with Oranga Tamariki: Mental and physical health and healthcare access, page 4.
69: See Oranga Tamariki (2023), Mental health and wellbeing needs of children and young people involved with Oranga Tamariki: In-depth assessment, pages 3-4, Oranga Tamariki (2020), Children and young people with impairments, page 8, and New Zealand Government (2022), Oranga Tamariki Action Plan, page 10.
70: Oranga Tamariki (National Care Standards and Related Matters) Regulations 2018, section 35.
71: Independent Children's Monitor (2023), Experiences of Care in Aotearoa: Agency Compliance with the National Care Standards and Related Matters Regulations, pages 12-13.
72: Independent Children's Monitor (2022), Experiences of Care in Aotearoa: Agency Compliance with the National Care Standards and Related Matters Regulations, pages 84-85. Oranga Tamariki has excluded questions about the use of specific mental health screening tools from its 2022/23 casefile review as it lacks data on how many young people have mental health needs that would warrant such screening.
73: Although the focus of this section is Oranga Tamariki care and protection services, we note that Oranga Tamariki also works with Te Whatu Ora youth forensic teams and in-house staff to provide mental health support to young people in the custody of its youth justice residences.
74: This figure excludes Oranga Tamariki's expenditure on private services in related areas such as mentoring.
75: The children's agencies are Oranga Tamariki, New Zealand Police, the Ministry of Education, the Ministry of Social Development, the Ministry of Justice, and the Ministry of Health.
76: The "core populations" of interest to Oranga Tamariki are defined in the Children's Act 2014, section 5. They are children and young people with past or current involvement with care and protection and youth justice systems, or those at risk of becoming involved with these systems.
77: To date, this funding has been used to employ ICAMHS clinicians to work with young people in care in the Te Whatu Ora Southern District and in the Oranga Tamariki Care & Protection residence at Epuni.
78: Oranga Tamariki (2023), Prioritising mental health and wellbeing needs of children and young people involved with Oranga Tamariki: Cross-agency plan for implementation, page 4.
79: Clark, T et al (2022), Youth19 Rangatahi Smart Survey: The Health and Wellbeing of Youth who are Not in Education, Employment or Training (Y-NEETs), page 3.
80: Ministry of Business, Innovation, and Employment (2022), "Monthly Labour Market Fact Sheet – December 2022", page 1, at mbie.govt.nz.
81: Office of Disability Issues (2022), "Labour Market Statistics as at the June 2022 quarter", at odi.govt.nz.
82: The Ministry of Education defines regular school attendance as students who have attended more than 90% of the term. For the links between attendance and student well-being, see Education Review Office (2022), Missing Out: Why Aren't Our Children Going to School, pages 10-11.
83: The Ministry of Education (2023), "Education Counts: Attendance", at educationcounts.govt.nz.
84: Education Review Office (2022), Missing Out: Why Aren't Our Children Going to School?, pages 19 and 35-39.
85: Clark, T et al (2023), Youth19 Rangatahi Smart Survey: The Health and Wellbeing of Young People in Alternative Education, page 3.
86: Education Review Office (2023), An Alternative Education? Support for our most disengaged young people, page 29.
87: The automatic referrals system matches data from Ministry of Education, Oranga Tamariki, and the Ministry of Social Development to identify young people at high risk of needing support. Such young people typically have a range of risk factors, including previous Oranga Tamariki involvement, a history of past education interventions (such as a stand-down or suspension or enrolment in Alternative Education), and mental health factors such as "severe anxiety" or "suicide ideation".
88: For a description of He Poutama Rangatahi and how it is improving outcomes for rangatahi Māori, see Controller and Auditor-General (2023), Four initiatives supporting improved outcomes for Māori, at oag.parliament.nz.
89: Indig, D et al (2016), Comorbid substance use disorders and mental health disorders among New Zealand prisoners.
90: Very few young people aged 19 and under are in adult prisons. In 2023, prisoners aged under 20 made up 1.3% of the prison population (115 individuals).
91: Tools used are the Structured Dynamic Assessments, which collects data on prisoner need based on a range of protective and risk factors, and ASSIST, which focuses on prisoners' alcohol and drug use and its impact on their lives. Suicide risk for people starting community sentences is screened using the Columbia-Suicide Severity Rating Scale.
92: The Department of Corrections (2023), Annual Report 2022/2023, page 206.
93: Corrections received $129 million of new funding in the 2019 Budget to fund expanded mental health and addiction services for prisoners.
94: Corrections currently uses the Kessler-10 psychological distress scale as a self-report outcome measure for prisoners who access its Improving Mental Health Service.
95: Office of the Chief Coroner of New Zealand (2023), Recommendations Recap: A summary of coronial recommendations and comments made between 1 January and 31 March 2023, pages 84-85.