There is a substantial and growing interest in approaches which could deliver better outcomes for looked after children, with current research into the effectiveness of a variety of therapeutic packages that include multi-systemic therapy and multi-dimensional treatment foster care. This is within the context of it being well known that the prevalence of mental health problems among looked after children across the lifespan is substantially higher than in the general population (see McCann et al, 1996; Phillips, 1997; Saunders and Broad, 1997). In addition, looked after children are at greater risk (in childhood and later life) of offending behaviour, unemployment, self-harm, domestic violence, drug and alcohol misuse, and having their own children eventually removed into local authority care (see Social Services Inspectorate, 1997; Richardson and Lelliott, 2003).
With this population of children and the problems they present, repeated placement breakdown and educational exclusion are common and a variety of specialist services has been constructed to address these issues (Racusin et al, 2005; Biggins, 2006; Roberts, 2006). In practice models, attachment theory (Bowlby, 1988) has been drawn upon extensively as it emphasises the importance of helping looked after children to make meaningful attachments to establish the safety and facilitate the developmental progress upon which future healthy behaviour and relationships are based. Placement stability is not sufficient on its own, but it is certainly part of what is necessary in order to achieve such vital attachments, as is inclusion in education. However, the maintenance of both is fraught with difficulties, not just because of adolescent behaviour but also in the professional systems established to meet the needs of these young people. For example, the recruitment and retention of foster carers who can care for troubled adolescents is difficult, resulting in adolescents being placed in residential units, often with highly questionable benefits for the young people. The evidence suggests that multiple fractured placements and institutional care have poor consequences for young people and for society, and it poses us a challenge to improve.
MIST: a specialist service
MIST is a multidisciplinary team hosted by the charity Action for Children (formerly National Children's Homes) and funded by social services, education and the local health board in Torfaen, in south-east Wales, and Action for Children. MIST works with young people aged 11-21 who are looked after and who present significant challenging and risk-taking behaviour, such that their placement stability is considerably threatened. Indeed, placement disruptions commonly run to figures of over 30 for young people accessing MIST. These are young people with complex needs requiring considerable resources to manage them and maintain their safety together, hopefully, with aiding their personal development. In addition to having experienced multiple placement breakdowns, they are likely to have been admitted to residential provision, to have been excluded from education, and to have frustrated the services of the usual range of child and adolescent services, including those of the National Health Service (NHS).
The MIST team incorporates four project workers from different professional backgrounds and experience, combining youth and community work, youth offending, social work, teaching, mental health nursing, family therapy, occupational therapy and play therapy. There is also a community support worker with experience in youth offending. The team is led by a manager who is a mental health nurse with a background in therapeutic communities, youth offending and psychotherapy, and a clinical lead who is a consultant clinical psychologist with a background in Child and Adolescent Mental Health Services (CAMHS) and social services liaison.
MIST was developed in 2004 by a multi-agency CAMHS strategy group in Torfaen, which continues to act as its management group. Initially, its remit was to bring young people in out-of-authority residential care back to kinship or foster care placements in their home communities. With this aim met, it has evolved to work more proactively to prevent young people from being moved to residential care.
In accordance with other services for adolescents with complex needs in 'wraparound' foster care, MIST takes an approach that is multi-dimensional and multi-systemic; multiple interventions drawing upon different psychological approaches are carried out concurrently with different configurations of the young person and their network. This work spans various contexts including foster home, family home, school and community. The service does not view young people in diagnostic terms. Instead, psychological formulations are thought to be more useful in understanding young people's needs and selecting appropriate interventions. Even though MIST attempts to integrate a range of different psychological interventions, attachment-based approaches are privileged, as a safe and meaningful attachment is considered to be vital to the young person's development.
The service works therapeutically with the adolescents themselves, utilising a variety of individual psychological therapies and activity-based inputs such as drama, music and art, as well as practical support, befriending and learning support. This work with the young person involves regular meetings throughout the week in a variety of locations. Clinical features of the programme involve attempts to promote trust, self-esteem, self-value, autonomy and emotional literacy.
In partnership with the local authority's family placement team, MIST jointly selects and manages four therapeutic foster care placements. It trains, supervises and supports these foster carers and provides 24-hour on-call support. In addition to therapeutic foster care placements, and intensive kinship placements, MIST also supports a small number of 'ordinary' foster care placements where a young person lived for some time and formed attachments to carers who display commitment, skills and orientation towards multi-agency...