Showing papers in "Journal of Child and Adolescent Psychiatric Nursing in 2012"

Sources of stress and coping in American college students who have been diagnosed with depression.

Abstract: PURPOSE: The study aims to explore the sources of stress in American college students who had been treated for depression and to discern their coping mechanisms. ORGANIZING FRAMEWORK: A phenomenological approach using Seidman's guide to in-depth qualitative interviews using a three-part approach was used in the study. METHOD: Online in-depth interviews utilizing e-mail with asynchronous communication were used. FINDINGS: Sources of stress included roommate issues, academic problems, financial and career concerns, and pressure from family. Exercise, talking to friends, self-talk, deep breathing, journaling, marijuana use, and listening to music were common coping mechanisms. CONCLUSIONS: College students who have been treated for depression are under increasing stress today from a variety of sources. Nonmedical methods of coping were often cited as more effective than medication therapy.

Personality traits as predictors of adherence in adolescents with type I diabetes.

Abstract: TOPIC: Diabetes is a serious, chronic illness with long-term implications for health and lifestyle. Significant differences in health outcome may be achieved as a result of the degree of adherence to recommended diabetes management regimens. Adherence is a particularly challenging issue with adolescents with diabetes. PURPOSE: The present study examined the association between primary personality traits and adolescent adherence to prescribed diabetes management regimens. SOURCES: A measure of the five-factor model of personality was administered to a sample of adolescents with insulin-dependent diabetes mellitus. Five self-reported indicators of adherence were assessed: blood glucose monitoring, insulin administration, diet, exercise, and most recent glycosylated hemoglobin (HbA1c) level. CONCLUSIONS: Results revealed a pattern of significant correlations between the Conscientiousness and Neuroticism personality domains and one or more self-reported adherence behaviors. In addition, correlations were also found between one facet of Extraversion and one facet of Agreeableness. These suggestive results, if replicated in larger studies, provide useful information to clinicians as they design and monitor individualized diabetes management regimens for adolescents.

Investigation of autism comorbidities and associations in a school-based community sample.

Abstract: PROBLEM: Individuals with autism spectrum disorders (ASDs) have at least as many comorbidities as individuals with typical development may show, but sometimes with different presentations. METHODS: The study used a school-based health survey related to children diagnosed with ASD in Tehran to determine the possibility of comorbid conditions. Ninety-one children and adolescents with ASD between the ages of 6 and 14 years were included in the study, all from five schools of different districts of the city, using stratified random sampling. All of the subjects had received a clinical diagnosis of ASD (autism, Asperger, and pervasive developmental disorder-not otherwise specified) by a child neurologist or psychiatrist. All of the schools had registered the subjects and were restricted to those with high-functioning forms of ASD, and none were identified with co-occurring mental retardation. FINDINGS: Results indicated that 72.5% had at least one comorbid condition. There was a trend of higher severity in autism symptoms in subjects with comorbidity. Results showed that attention-deficit/hyperactivity disorder and epileptic disorders were the leading comorbidity in respective categories. CONCLUSION: Autistic individuals should be monitored regarding their comorbid profiles, with an emphasis on female subjects and those with more severe symptoms. Clinically, the current study has implications for school healthcare providers, including nurses, in addition to researchers and practitioners working with children diagnosed with ASDs.

Contingency management in community programs treating adolescent substance abuse: a feasibility study.

Abstract: Data from the 2009 National Survey on Drug Use and Health showed that current marijuana use in 12- to 17-year-olds increased from 6.7% in 2007 and 2008 to 7.3% in 2009 (Substance Abuse and Mental Health Services Administration, 2010). In the most recent Monitoring the Future report on adolescent drug use (Johnston, O’Malley, Bachman, & Schulenberg, 2011), there was a slight increase in past month marijuana use in 8th graders (8%), 10th graders (16.7%), and 12th graders (21.4%). Marijuana use prevalence is two to three times higher than any other drug category. Although evidence is growing to support behavioral interventions, there is still limited consensus on the best approaches for treating adolescents with substance use disorders. Effective treatments must retain adolescents in treatment long enough for them to benefit from cognitive and psychosocial strategies on which many treatments are based. Contingency management (CM), a procedure that uses tangible incentives to reinforce positive behavior change, has been shown to be efficacious in many difficult-to-treat substance-dependent populations. CM is rooted in behavioral modification operant conditioning. Behaviors that are reinforced are more likely to reoccur and behaviors that are punished are less likely to reoccur (Skinner, 1969). Drug use is a conditioned behavior with continued use being reinforced by the rewarding properties of the drug. This behavior is best altered by providing positive reinforcement for more adaptive behavior (i.e., abstinence) versus negative reinforcement of old (drug using) behaviors (Bigelow, Stitzer, Griffiths, & Liebson, 1981). Contingency management procedures, coupled with certain psychosocial interventions such as cognitive behavioral therapy (CBT), motivational enhancement therapy (MET), and family therapy, have been shown to increase retention in treatment and reduce drug use in adolescents and young adults with marijuana use disorders (Budney, Moore, Rocha, & Higgins, 2006; Carroll et al., 2006; Kadden, Litt, Kabela-Cormier, & Petry, 2007; Stanger, Budney, Kamon, & Thostensen, 2009). Henggeler et al. (2006) found that CM increased retention and abstinence rates when added to multisystemic family therapy and standard community treatment in an adolescent drug court population. Despite a body of evidence supporting the efficacy of CM in the treatment of substance-abusing populations, clinicians in frontline treatment settings have been reluctant to adopt CM into their usual practice and integration of CM into standard treatment in community programs among adolescents has not been well studied. Kirby, Benishek, Dugosh, and Kerwin (2006) explored beliefs regarding CM in a large sample of community treatment providers. Although approximately half of those surveyed said they would be open to using CM, the most commonly reported objections were the cost of incentives, incentives not addressing the underlying issues and incentives not targeting multiple behaviors or treatment goals. Other less common concerns included incentives being considered a “bribe,” causing discord among patients, and undermining the treatment process and internal motivation. The present study was intended to explore the feasibility of integrating a cost-effective CM procedure similar to the one developed by Petry, Martin, Cooney, and Kranzler (2000) into standard community treatment for adolescents with primary marijuana use disorders. This study differs from previous studies in that CM was not coupled with another evidence-based psychosocial treatment and exclusion criteria were minimized so that participants were more representative of those typically seen in community programs. It was hypothesized that participants randomized to the incentive group plus standard community treatment would be retained in treatment longer, have a greater percentage of urine drug screens (UDS) negative for marijuana, and have longer periods of sustained marijuana abstinence than those participants randomized to a control group plus standard community treatment. In order to encourage submission of UDS, participants in the control group were given a set number of draws for each UDS submission. They received two draws for each UDS submitted (regardless of results) throughout the intervention period. This was necessary to increase the likelihood that the control group would submit sufficient UDS for comparison with the experimental group.

Habit Reversal Training for Children With Tourette Syndrome: Update and Review

Abstract: Topic Habit reversal training (HRT) is emerging as an efficacious behavioral intervention for Tourette syndrome in children and adults. Purpose The purpose of this article is to review the recent literature investigating the efficacy of HRT for treating children with chronic tic disorders. Sources This review examines single-subject design studies and randomized, controlled trials of HRT conducted in children with chronic tic disorders since 2000. Conclusions Intervention built on HRT appears to be effective for decreasing tic severity in children and adolescents. Results from a recent multisite trial suggest that incorporation of functional analysis may enhance the effectiveness of traditional HRT.

Externalizing Metaphors: Anxiety and High-Functioning Autism

Abstract: TOPIC: The intent of this article is to explore the efficacy of both the literal and concrete externalization aspects within narrative therapy, and the implementation of interactive metaphors as a combined psychotherapeutic approach for decreasing anxiety with people who present with high-functioning autism. PURPOSE: The purpose of this exploratory article is to propose the use of externalizing metaphors as a treatment modality as a potentially useful way to engage clients. Specifically, a three-step process of change is described, which allows for concretizing affective states and experiences, and makes use of visual strengths of people presenting with an autism spectrum disorder. SOURCE: A selective review was conducted of significant works regarding the process of change in narrative therapy, with particular emphasis on metaphors. Works were selected based on their relevance to the current paper and included both published works (searched via Psyc-INFO) and materials from narrative training sessions. CONCLUSIONS: Further research is needed to address the testable hypotheses resulting from the current model. This line of research would not only establish best practices in a population for which there is no broadly accepted treatment paradigm, but would also contribute to the larger fields of abnormal psychology, emotion regulation, and cognitive psychology by further elucidating the complex ways these systems interact.

Pregnancy intentions, long-acting contraceptive use, and rapid subsequent pregnancies among adolescent and adult first-time mothers.

Abstract: Understanding the risk factors for a rapid subsequent pregnancy, especially among adolescents, is of perpetual public health concern. Some of the negative consequences of teen motherhood can be lessened if the mother delays, or avoids having, a second child (Klerman, 2004). Rapid subsequent pregnancy is defined as a pregnancy occurring within 24 months of the last pregnancy, and experts recommend an interpregnancy interval of at least 24 months to help ensure maternal health and to benefit child development (Department of Health and Human Services, 2001). It is important also for clinicians to be sensitized to adolescents’ needs and desires regarding family planning, especially related to timing and intention of a subsequent pregnancy. Mistiming of pregnancies has been found to have more serious health consequences for adolescents than for older women, and most mistimed subsequent pregnancies occur within 24 months of the previous pregnancy (Pulley, Klerman, Tang, & Baker, 2002). Because of this body of research, intentions are often demarcated by whether or not the woman intends to get pregnant within or beyond 24 months. A review of the research on birth spacing, though, found that the most significant risk for adverse perinatal outcomes is an interpregnancy interval less than 18 months and greater than 59 months, such that a clinical recommendation of a 2–5 year window between pregnancies is advised (Conde-Agudelo, Rosas-Bermudez, & Kafury-Goeta, 2006).

Ambiguity and Violence in Adolescent Dating Relationships

Abstract: PROBLEM: Little is known about dyadic processes that lead to adolescent dating violence. The purpose of this study was to examine the phenomenon of relationship ambiguity in adolescent dating relationships to better understand how ambiguity contributes to violence and aggression between dating partners. METHODS: Data were drawn from 88 narratives of young adults who had participated in a study on adolescent dating violence. Interpretive phenomenology was used to produce an in-depth description of the phenomenon of relationship ambiguity. FINDINGS: Relationship ambiguity results in differing expectations between partners regarding closeness and intimacy, fidelity, and obligation. These differences lead to conflicts that set the stage for violence and aggression in adolescent dating relationships. CONCLUSIONS: A series of recommendations for clinicians working with adolescents are presented. Language: en

Biopsychosocial Model of Hypersexuality in Adolescent Girls With Bipolar Disorder: Strategies for Intervention

Abstract: TOPIC: Engagement in high-risk behaviors, impaired judgment, and hypersexuality present unique health challenges to adolescent girls with bipolar disorder (BD). Behavioral management of sexuality does not routinely fall under the purview of psychiatric care, but requires preventive measures. PURPOSE: This paper presents a biopsychosocial model of hypersexuality in girls with BD, describes factors that lead to high-risk sexual behaviors, and provides a framework for cognitive-behavioral intervention. SOURCES USED: The study used a review of empirically based clinical and research literature. CONCLUSIONS: Sexual health education, improved treatment adherence, symptom monitoring, interpersonal skills training, parental involvement, and clinician education can improve hypersexual behavior in girls with BD. Language: en

Adolescent Depression: Meeting Therapeutic Challenges Through an Integrated Narrative Approach

Abstract: Topic The adolescent period is a time of transition and change often associated with losses and adjustment issues at the family, school, and individual levels. When this normal developmental transition is interrupted and compounded by depressive illness, treatment needs and nursing therapeutic challenges can be daunting. Purpose This clinically based article explores the clinical process and progress in work with a 14-year-old adolescent boy who was diagnosed with a major depressive episode. Core clinical features, distinguishing characteristics of depression in youth, as well as specific therapeutic issues and challenges are discussed. The value of an integrated clinical approach with special emphasis on narrative methods both for achievement of clinical goals and for establishing a therapeutic alliance is highlighted. Sources Used The study used published literature and the author's professional and clinical experiences. Conclusion Nursing therapeutics with adolescents experiencing depression must embrace a holistic integrated approach to adolescent recovery with an emphasis on what works with each unique clinical situation. Special attention to the nurse–adolescent therapeutic alliance not only facilitates achievement of therapeutic goals related to the depressive illness, but in addition, supports the shaping of a new self-narrative, wholeness, and healthy adolescent development and well-being.

A pilot program to address healthy sexual behaviors among girls in juvenile detention.

Abstract: PURPOSE: This pilot study was designed to determine the effectiveness of an intervention on sexual behavior among girls in juvenile detention.; METHODS: The pre/posttest model assessed for changes in knowledge, attitudes, and reported behaviors. This program merged three curricula to create the unique Young Women Get Real Program with nursing student program facilitators.; FINDINGS: Despite high levels of satisfaction with the program, the data related to the final sample (n = 35) failed to reveal significant changes in measured variables.; CONCLUSIONS: The results may inform nurses as they pursue interventions to promote responsible sexual behavior in selected populations. 2012 Wiley Periodicals, Inc. KW: Juvenile justice; Juvenile delinquency;

Motivational Interviewing with Adolescents: An Advanced Practice Nursing Intervention for Psychiatric Settings

Abstract: TOPIC:The article focuses on the use of motivational interviewing (MI) as an intervention with adolescent patients in mental health treatment settings.PURPOSE:The aim of the study is to review MI theory and principles, and inform advanced practice nurses about the suitability of this intervention fo

Assessing the Educational Needs of Mental Health Nurses Working in an Adolescent Inpatient Psychiatric Ward in Japan

Abstract: PROBLEM: In Japan, preregistration education is not sufficient to prepare nurses to work as child adolescent mental health nurses. METHODS: Nominal group technique (NGT) using focus group discussions, and Knowles' Adult Learning Theory, were used to examine the continuing educational needs of nurses in a Japanese adolescent mental health unit. FINDINGS: Nurses caring for adolescent patients with mental health issues need continuing education. This research demonstrates the utility of nominal group technique in needs analysis in this context. CONCLUSIONS: Educational priorities include instruction on patients' developmental stage, promoting patient self-sufficiency, and strategies for meeting the needs of families. A family-centered care approach is recommended.

The impact of childhood sexual abuse on psychological distress among women in New Zealand

Abstract: PROBLEMS: In order to better understand the long-term impact of child sex abuse, this study examined the association between women's experience of abuse, health symptoms, and psychological distress in adulthood. There is limited information about child abuse outside the United States. METHODS: Nine hundred sixty-one women participated in a structured interview. RESULTS: Participants who had experienced abuse (13%) were significantly more vulnerable to psychological distress in adulthood if they were younger, less satisfied with their standard of living, and resided in urban areas. CONCLUSION: Dissemination and evaluation of therapies for the treatment of sex abuse in the New Zealand context is warranted. Language: en

Exploring the Relationship Among ADHD, Stimulants, and Substance Abuse

Abstract: TOPIC: There is an ongoing debate among prescribers concerning the risk of inadvertently contributing to the initiation of substance abuse (SA) in children and adolescents through the use of stimulants in the treatment of attention-deficit/hyperactivity disorder (ADHD). Psychiatric nurses at all levels of practice must be informed about this important discourse in order to provide accurate and timely interventions to clients and their families. PURPOSE: This literature review explores the current state of prescriptive stimulant use for ADHD and the possible links to SA. Developmental, genetic, and neuro-chemical theories of the disorder that may contribute to SA as well as the burden of comorbidity are considered. The impact of gender, cultural, legal, and ethical influences on diagnostic and treatment recommendations is also included. SOURCE: U.S. and other English language articles were identified through PubMed and the Cumulated Index of Nursing and Allied Health Literature. These sources were used to determine the current practice of stimulant prescription and the prevalence of SA as a comorbidity to other child psychiatric disorders including ADHD. Textbooks were consulted for information regarding relevant neurochemistry, genetics, and psychopharmacology. CONCLUSIONS: The authors conclude that the use of stimulants is appropriate for children and adolescents with ADHD when opportunities for screening, family and child education, and counseling concerning SA are consistently integrated into the ongoing treatment regimen.

A quality improvement project to decrease the length of stay on a psychiatric adolescent partial hospital program.

Abstract: Problem Clinicians are challenged to treat adolescents with life-threatening behaviors while accessing fewer mental health resources with increased utilization management pressures. Methods Dialectical behavior therapy (DBT) skills training groups were implemented as a quality improvement project to decrease the length of stay on an adolescent psychiatric partial hospital program by reducing potential life-threatening behaviors. Findings The average length of stay decreased nearly 5 days during the project. Potential life-threatening urges seemed to increase from pretreatment findings while life-threatening actions appeared to decrease. Conclusions While the findings were inconclusive regarding the actual effect on life-threatening urges and behaviors, dialectical behavior therapy skills training groups may have positive outcomes on an adolescent psychiatric partial hospital program.

Autism and the cognitive processing triad: a case for revising the criteria in the diagnostic and statistical manual.

Abstract: TOPIC: The next iteration of the Diagnostic and Statistical Manual of Mental Disorders is due for release in May 2013. The current diagnostic criteria for autism are based on a behavioral triad of impairment, which has been helpful for diagnosis and identifying the need for intervention, but is not useful with regard to developing interventions. Revised diagnostic criteria are needed to better inform research and therapeutic intervention. PURPOSE: This article examines the research underpinning the behavioral triad of impairment to consider alternative explanations and a more useful framing for diagnosis and intervention. SOURCES: Contemporary research and literature on autism were used in this study. CONCLUSIONS: It is proposed that the cognitive processing triad of impaired abstraction, impaired theory of mind, and impaired linguistic processing become the triad of impairment for autism in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. These are investigable at the diagnostic level and can usefully inform intervention. Further, in addressing the debate on whether restrictive and repetitive behavior should remain central to diagnosis or be replaced by a deficit in imagination, the authors argue that both behavioral manifestations are underpinned by impaired abstraction.

Underaged patients' opinions toward different containment measures: a questionnaire survey in Finnish adolescent psychiatry.

Abstract: Problem The current literature does not provide an understanding of adolescent patients' opinions toward various containment measures and how these are related to the opinions of the staff who are caring for them. Methods The study population comprised 81 inpatients and 128 staff members in an inpatient setting in Finland. Their opinions were studied using the Attitude to Containment Measures Questionnaire. Findings The adolescents were more critical toward most containment measures compared to the staff. Exactly as reported in previous studies among adult service users, the containment measures most accepted by the adolescents were as-needed medication, intermittent observation, and time out. They were considered as helpful, safe, and respectful methods. Net bed, which has never been used in Finland, was most disapproved. It was considered as a distressing, inhuman, and cruel method. Opinions toward mechanical restraint, which is commonly used in Finnish adolescent psychiatry, were noticeable: adolescents rated mechanical restraint among the three least accepted, staff among the three most accepted containment methods. Adolescents considered it as distressing and not consistent of human dignity. Conclusions Adolescents disapprove of containment measures some of which are widely used in psychiatric practice. Their opinions differ significantly from those of the staff. New ways to manage crisis situations should be developed. Where containment cannot be avoided, information, explanation about the procedures involved, and debriefing should be offered to an underaged patient in a manner which takes account of his/her developmental level.

Changes in stress and coping during late childhood and preadolescence.

Abstract: PROBLEM: Little is known about what produces stress in preadolescents. METHODS: Secondary data analysis using hierarchical linear modeling was performed to determine how stressors and coping changed over time in 1,568 preadolescents (51% Hispanic) in 28 public schools. FINDINGS: Over time, participants experienced most stressors less intensely, but intensity varied by gender. Children in lower grades and girls found that coping strategies used were more effective compared with those in upper grades or boys. There were several interactions of grade level, sex, and ethnicity. CONCLUSION: Changes in stress and coping among preadolescents have implications for nurses concerned with mental health.

A Comparative Assessment of Early Adult Life Status of Graduates of the North Carolina Adolescent Parenting Program

Abstract: PROBLEM: What is the comparative impact of a second pregnancy prevention program for teen mothers on those who graduate from the program compared with a sample of young mothers of similar age and social circumstances who did not participate in the program? METHODS: Fifteen program graduates and 20 nonprogram cohorts were surveyed regarding a range of life domains. FINDINGS: Data indicated that program graduates were on a more positive life course: greater primary responsibility for housing and utilities, greater higher education enrollment, more job stability, and greater focus on career goals. CONCLUSION: The differences demonstrate the value of programs designed to assist teen mothers through the challenges of parenting and their own adolescent development. Teen mothers who received these resources became more capable, happier, and confident, which in turn will make them better parents and more empowered to pursue their own personal development.

Childhood predictors of adolescent competence and self-worth in rural youth.

Abstract: Studies of resilient children showed that despite the presence of numerous risk factors (e.g., poverty, psychopathology, stress, and disruptions in the family unit), many have become competent adults (Werner, 1989; 2003). Resilience theory suggests that these children have resources such as caring parents and other adults in their lives (Croll, Neumark-Sztainer, Story, & Ireland, 2002; Henrich, Brookmeyer, & Shahar, 2005). They also use adaptive coping strategies for dealing with environmental stressors (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001) Some may have a temperament high in task persistence (McClowry, 2003), which serves as a protective resource. Both intrapersonal and interpersonal risk factors and protective resources discernible in childhood may predict competence and self-worth in adolescence. Much of the research on risk and protective factors among adolescents has been done with urban samples in which the majority of the sample was white (Appleyard, Egeland, & Sroufe, 2007; Goodman, McEwen, Dolan, Schafer-Kalkhoff, & Adler, 2005). Do these same factors increase risk or offer protection to rural and Hispanic adolescents as well? The purpose of this study was to determine whether selected risk and protective factors measured in childhood predicted competence and self-worth during adolescence.

Children with Behavioral/Mental Health Disorders and School Mental Health Nurses in Australia

Abstract: TOPIC: This review of the literature addresses Australian school mental health nursing is an emergent field of practice. PURPOSE: Children with behavioral/mental health disorders present challenges to schools, teachers, and their families. They can be disruptive in class, inappropriate with their peers, and perform poorly academically. Often this group of children do not respond to the school's usual strategies to support appropriate behavior. When children with behavioral/mental health disorders do not receive specialized support based on their problems and needs, their problems can escalate over time and in adolescence their behavior may become more challenging, with increased aggression, substance use, contact with the criminal justice system, and school failure with or without dropout. CONCLUSION: Mental health nurses, working as case managers, could be effective in the support of children with behavioral/mental health disorders in schools. Mental health nurses, because of their professional education and clinical practice, work not only with the individual child but also with family members. They are well prepared to case manage in schools and support individual teachers and health and welfare services in their management of their clients with behavioral/mental health disorders. Language: en

Developing Schools' Capacities to Respond to Community Crisis: The Tennessee Initiative

Abstract: TOPIC: The development and implementation of a statewide initiative addressing mental health issues within schools postcrisis. PURPOSE: The potential for a community crisis occurs every day. After a crisis, schools are practical, logical, and effective places to help students recover from a tragedy. If crisis-related trauma is not addressed adequately, it can impact academic outcomes such as reading achievement, grade point average, and overall academic performance. For these reasons, it is imperative that school administrators support students in the aftermath of a crisis. CONCLUSIONS: This ongoing project continues in an effort to support students, faculty, and staff after a traumatic event within the Tennessee public school system.

Testing a Model of Depression Among Thai Adolescents

Abstract: Problem This predictive correlational study was designed to test a comprehensive model of depression for Thai adolescents. Methods This sample included 800 high school students in Chiang Mai, Thailand. Data were collected using self-reported measures of depression, negative automatic thoughts, effective social problem solving, ineffective social problem solving, rumination, parental care, parental overprotection, and negative life events. Findings Structural equation modeling revealed that negative automatic thoughts, effective and ineffective social problem solving mediated the effects of rumination, negative life events, and parental care and overprotection on adolescent depression. Conclusion These findings provide new knowledge about identified factors and the mechanisms of their influence on depression among Thai adolescents, which are appropriate for targeting preventive interventions.

Latest on Child Welfare Systems and Continued Call for White House Conference on Children

Abstract: Advocacy for children often takes second place in these stressed economic times. Nationally, the child welfare system faces immense challenges from agency workforce issues to disproportionality of available services for children living in poverty, of rural location, of incarcerated parents, with immigration problems, and members of tribal communities. Over the past decade,children have found permanent families, including dramatic increases in adoptions, from 38,913 in 1998 to more than 55,684 in 2009; reduction in the number of children in foster care, from more than 562,000 in 1999 to 423,773 in 2009; increased placement of children in kinship care; and the 58.4% of children reunified with their families. Taking a quick look at national child advocacy policy groups such as Child Welfare League of America (CWLA; cwla.org) helps bring the major issues to our attention in terms of the“5 Building Blocks.” Throughout a recent CWLA policy document, The Fundamental Building Blocks of a Successful System for Children and Families (CWLA, 2011), the call is made for Congress to include efforts that would encourage career paths in child welfare work. Advocates will find major shortand long-term policy recommendations to the Administration and Congress for the five populations listed earlier: children from poverty, rural, or tribal settings; those with incarcerated parents; and immigration issues. The overall theme of the discussion is challenges and disproportionality. Starting with the decreasing child welfare workforce and the looming loss of experienced workers due to retirement, states face the challenge of keeping good workers and competent supervisors on the job and fighting to reduce turnover. The current child welfare system that is not adequately staffed, trained, or supported leads to a system that makes it difficult to carry out its mission. Improvements require a workforce fully staffed, educated in best practices, and supported by proper supervision, equipment, and attention to worker safety. The U.S. General Accountability Office (GAO) documented the crisis in the child welfare workforce, finding that the child welfare system is seriously understaffed, undertrained, and undervalued (GAO, 2003). These workforce problems limit the states’ ability to meet the goals established in the federally mandated Child and Family Service Reviews.