Those who try to help severely troubled and troublesome children always run the risk that their interventions will make matters worse.

The therapy and and protection they are offered may help, but at a high cost: the resulting stigmatization, isolation and disruption to education and health care can seriously impair social, intellectual and emotional development.

So combating “status deterioration” is an important aspect of any prevention program. In complex cases, even when other problems persist, to have achieved even this much can be counted an achievement.

The risks are most extreme among adolescents who have been behaving violently or incomprehensibly at home, school or in the community. They are likely to experience repeated exclusions, leading to increasing social isolation and placements in controlling environments away from their homes.

Given this accumulation of risk and the high financial costs associated with it, it seems sensible to see how far the benefits of intensive help can be delivered in a way that minimizes the side effects.

With all these factors in mind, an experimental program called the Multidisciplinary Intervention Service, was set up in 2004 in Torfaen, a former mining district in the Welsh valleys.

MIST aims to provide a “wrap round” service for very troubled and troubling adolescents first by bringing into local foster and residential care, young people who have been placed far away from their homes, and then by preventing the need for such placements continuing.

Hosted by the UK charity, Action for Children, and joint funded by social services, education and local health boards, it serves young people in care between the ages of 11-21 whose behavior is such that their placement in a “standard” foster or residential home is likely to break down. Secure accommodation and prison are likely destinations.

The MIST team includes four workers from different backgrounds and experience, combining youth and community work, youth offending, social work, teaching, mental health nursing, family therapy and play therapy. There is also a community support worker with experience in youth offending. Their manager is a mental health nurse with a background in therapeutic communities, youth offending and psychotherapy. Clinical leadership is provided by a psychologist specialising in child and adolescent mental health.

The approach places the young people in multidimensional and multisystemic foster care. It is eclectic in the sense that the interventions draw on a mixture of psychological approaches carried out concurrently with different configurations of the young person and their family and social network.

There is an overarching humanistic perspective that focuses on the young person’s capacity to develop; psychological formulations are considered to be more useful in understanding young people’s needs and fashioning interventions that stress the importance of context, relationships and the co-construction of reality. This rationale is underpinned by a desire to establish safe and meaningful attachment-based relationships.

Among the therapies, arts activities, befriending support and outreach, three key components have been identified: therapeutic keyworking, the recruitment and training of specialist foster carers, and the formation of a multi-disciplinary team around the young person.

MIST is yet to be evaluated but it is attracting interest because it has been set up in a small local authority in an unfashionable area where it has already had a significant effect on the placement patterns of difficult young people.

In the first four years, it reduced the number of externally purchased residential placements from 14 to four, placement breakdowns have fallen to an average of one a year. Administratively, it is also significant that it is led by a voluntary agency (NGO), capable of taking up an autonomous position independent of agency dogmas.

The Torfaen experiment reports its share of problems and disappointments. Professionals do not always agree, foster carers find it difficult to work collaboratively, service structures (especially the move from children’s to adult services) hinder continuity of care and some young people are negatively influenced by local peers and relatives.

There is also an important ethical issue - whether it is right to ply any young person with an attachment-based relationship that is time-limited, especially one who has no other supportive ties. Some staff try to maintain these relationships informally, but it cannot be a satisfactory basis on which to develop a service.

See: Street S, Hill J and Welham J, “Delivering a therapeutic wrap-round service for troubled adolescents in care’”, Adoption and Fostering, 33 (2), pp 26-33, 2009.