Editor's Note: Mental health policymakers, planners and practitioners have become increasingly aware of the importance of cultural competence in the development and delivery of high-quality mental health services for children and adults alike. This issue of networks focuses specifically on the role of cultural competence in providing mental health services to minority children, adolescents and their families and provides strategies for developing culturally competent mental health systems.
America's young people are becoming increasingly ethnically diverse. It is predicted that early in the 21st century minority children and adolescents, including African Americans, Asian Americans, Hispanics/Latinos and Native Americans, will make up as much as 40 percent of the nation's child and youth population.
This demographic diversity is reflected in the growing proportion of youth of color being identified with mental health problems within public education, juvenile justice and child welfare systems. The trend has prompted many in the mental health field to focus on the importance of cultural competence in designing and delivering high-quality services that enhance the lives of minority children and adolescents with serious emotional disturbances and their families.
Proponents of cultural competence contend that the nation's increasing cultural diversity makes it incumbent on the public mental health system to develop and deliver services to equitably respond to children, adolescents and families from a wide range of cultural and ethnic backgrounds. Experts also raise concerns about indications that many minority youth with mental health needs are overrepresented in the juvenile justice system and are not being served by the mental health system.
These experts assert that ensuring that mental health service providers have the skills, attitudes and attributes needed to effectively deliver culturally competent services to children and adolescents of color and their families increases the likelihood of appropriate communications, interventions and outcomes and reduces the chances of service underutilization, inappropriate services and negative treatment outcomes. Delivering culturally competent mental health services strengthens the voices of children, adolescents, their families and communities.
What Is Cultural Competence and Why Is It Important?
Velva Taylor-Spriggs, a project officer with the Child, Adolescent and Family Branch of the federal Center for Mental Health Services (CMHS), points out that the issue of cultural competence is "on the table" in most State Mental Health Agencies and that many states have developed positive initiatives in this area. Nonetheless, Ms. Taylor-Spriggs laments that there has been "very limited" progress during the past decade in developing culturally competent mental health systems of care for minority children, adolescents and their families. She emphasizes that mental health agencies need to move from viewing cultural competence as an optional "add on" to recognizing it as an integral element in the provision of effective mental health services to children and adolescents of color and their families.
Cultural competence can be defined as a "set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals, enabling them to work effectively in cross-cultural situations....the word culture is used because it implies the integrated patterns of human behavior that include thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups. The word competence is used because it implies having the capacity to function within the context of culturally integrated patterns of human behavior defined by the group." (Isaacs, M.R. and Benjamin, M.P., 1991).
Marva Benjamin, A.C.S.W., director of the Cultural Competence Initiative of the National Technical Assistance Center for Children's Mental Health at the Georgetown University Child Development Center, explains that cultural competence is developmental in nature and that the cultural competence approach to service delivery and policy development provides an opportunity for practitioners, agencies and systems to respond appropriately to the unique needs of populations whose cultures may be different from the "mainstream" culture in America. She lists essential elements and values that contribute to the ability of an individual, agency or system to become more culturally competent: (1) valuing diversity, (2) having the capacity for cultural self-assessment, (3) respecting the "dynamics of difference" (a reciprocal process that occurs when individuals of different cultures interact), (4) institutionalizing cultural knowledge and (5) adapting to diversity.
According to Ms. Benjamin service providers and policymakers need to recognize that many children and adolescents of color are "disproportionately and adversely" affected by societal conditions such as poverty, poor nutrition, lack of health insurance, geographic isolation and institutionalized discrimination. Many of these conditions impact and influence the emotional and psychological well-being of minority children and adolescents.
Ms. Benjamin emphasizes that cultural competence requires doing more than providing equal and nondiscriminatory services. It also requires providing services that respond to the culturally defined needs of children, their families and communities. For example, the K'e Project in New Mexico, a child and adolescent mental health services program of the Navaho Nation funded by the federal Center for Mental Health Services and a state matching grant, combines conventional mental health assessment and intervention strategies with traditional Navaho values, principles and healing approaches that have a strong spiritual and communal focus. This program employs clinical social workers and traditional healers to provide mental health services to Navaho children and adolescents within their family and community setting.
In addition to the values and principles noted above, a number of experts agree that culturally competent child and adolescent mental health systems share the following characteristics:
The family, however defined by the culture, is viewed as the primary focus of mental health services and a partner in the decisionmaking process. The family helps to decide what services are needed and how they are provided. Barbara Huff, executive director of the Federation of Families for Children's Mental Health explains, "The family includes the people who care about the child and who love and nurture the child." The Federation is collaborating with The Annie E. Casey Foundation to implement model child and adolescent mental health programs in a number of cities. Ms. Huff points out that extended families often play a pivotal role in the growth and development of children and adolescents in minority communities. For Native Americans, the entire tribe is often considered one's family, she adds.
Mental health services are provided based on a careful understanding of several key considerations. These considerations include children's and adolescents' needs and circumstances, their family and community context, their cultural norms and expectations and how their life experiences may affect their outlook and goals. For example, cultural competence experts note that while mental health services often focus on helping children and youth to develop a sense of independence from their families, this approach can undermine the close-knit structure of many minority families and communities.
Cultural diversity is viewed as a positive attribute. Service providers recognize and build on the cultural strengths of the child or adolescent and the family. Service providers demonstrate respect for the culture of the child and his or her family by involving them in decisionmaking and adhering to their cultural customs when visiting their homes or interacting with them in clinical settings.
Culturally competent principles and practices are incorporated at all levels of the mental health system. These principles are reflected in attitudes, structures, policies and services. Providing culturally competent mental health services is considered everyone's responsibility, not just that of one or two staff members.
Strategies for Developing Culturally Competent Child and Adolescent Mental Health Systems
Ensuring that cultural competence becomes an integral part of child and adolescent mental health systems requires ongoing commitment, self-assessment, planning and evaluation. Policymakers, administrators, consumers, service providers and advocates all play a role. Key strategies for effectively promoting cultural competence include:
Obtaining the Commitment of Key Leaders. Developing culturally competent mental health systems on a statewide basis requires leadership and commitment from governors and their senior-level staff, legislators, State Mental Health Agency officials and representatives of other child-serving state agencies and organizations, according to Mareasa Isaacs-Shockley, Ph.D., author of a forthcoming monograph on cultural competence in state mental health systems. [See column on page 5.] Dr. Isaacs-Shockley points out that this form of leadership is needed to commit the mental health system to incorporating cultural competence as an integral part of services for children, adolescents and their families and to broker successful partnerships among stakeholders to carry out policymaking, planning and service delivery activities. Several states, including Arkansas, Ohio and Washington, have enacted legislation mandating cultural competence in state mental health services.
Establishing a Multi-Ethnic Task Force. To ensure that state leadership and commitment are translated into policy and practice, a number of states have established multi-ethnic task forces to assist State Mental Health Agencies to conduct statewide needs assessments and to develop comprehensive plans for enhancing culturally competent systems of care. According to Dr. Isaacs-Shockley, essential task force members include representatives of family organizations and community groups; minority mental health practitioners; senior State Mental Health Agency officials; representatives of other state and local child-serving agencies; a representative of the governor; and other key stakeholders as determined by a state's needs, circumstances and goals.
States have addressed these developments in a number of ways. For example, Florida law now requires that all state advisory boards be culturally representative of the citizens they serve. In Arizona, state mental health officials hold monthly meetings with Tribal Council representatives.
Conducting a Statewide Needs Assessment. Task forces have found it useful to conduct statewide needs assessments that address both the mental health services needs of minority children, adolescents and their families and the level of cultural competence of mental health providers and staff. [See column on this page for resources containing assessment tools.] Needs assessments often address issues such as the accessibility of mental health services to minority communities, the extent to which children and adolescents of color and their families utilize the mental health system and overrepresentation of minority children and adolescents in the juvenile justice system.
A number of California counties have performed county-level needs assessments. For example, Santa Clara County recently completed a comprehensive assessment of the mental health services needs of Cambodian-, Laotian-, Chinese- and Mexican-American residents to address equitable distribution of mental health resources. Information about the mental health services needs of these groups was instrumental in creating a blueprint for mental health program planning and development. Anticipating a need for services for non-English-speaking individuals who experience mental health crises, the state of Washington conducted a feasibility study on the development of a multilingual, multicultural emergency telephone response system.
Developing a Comprehensive Plan. The multi-ethnic task force in partnership with the State Mental Health Agency may wish to develop a comprehensive cultural competence plan that includes action steps, training activities, timelines, performance indicators and outcome measures. This statewide plan should address all levels of the mental health system, including policymaking, administration and service provision. The South Carolina Department of Mental Health's plan contains specific recommendations regarding policy, administration, clinical services, human resources development, community relations, public education and research.
As an illustration of successful action steps at the policymaking level, key decisionmakers in the State Mental Health Agency can commit to supporting a cultural competence initiative and to establishing performance goals for local mental health agencies and service providers on these issues.
An effective administrative-level initiative is to develop and implement a plan for recruiting, hiring and training culturally competent and diverse mental health staff. Pennsylvania's CASSP Technical Assistance and Training Institute recently included an advertisement in its newsletter seeking job candidates with cultural competence skills.
Examples of strategies to ensure that mental health services are accessible to minority children, adolescents and their families include locating services in neighborhoods where consumers live and providing mental health services within established community institutions such as schools, community centers and public health centers. In addition, mental health providers have found it helpful to make information and services available in the child's or family's native language.
Providing Ongoing Training. Training forms the bridge between policy- and administrative-level commitment and implementation of culturally competent mental health services. Agencies that have initiated training activities recommend providing ongoing, structured programs rather than one-time activities. Pennsylvania is among the states that have developed formal, multifaceted training curricula. [See article on page 4.] Massachusetts holds an annual "Mental Health Professionals of Color Symposium," and Ohio and South Carolina jointly sponsor a yearly cultural diversity conference.
National Initiatives
Two national mental health initiatives that support child and adolescent mental health demonstration projects which incorporate culturally competent approaches are the Children's Mental Health Services Demonstration Program funded by the Center for Mental Health Services and the Mental Health Initiative for Urban Children funded by The Annie E. Casey Foundation. The CMHS initiative provides grants and technical assistance to support 22 programs for children, adolescents and young adults with serious emotional disturbances and their families. Under a cooperative agreement with CMHS, the Washington Business Group on Health has established a Network to assist the sites in developing community-based systems of care based on the CASSP principles, including culturally competence. The Federation of Families for Children's Mental Health works with the Network to ensure that families are full partners in the program.
The Annie E. Casey Foundation initiative supports neighborhood-based mental health services that emphasize prevention and early intervention, address the needs of the whole family and provide culturally competent services that build on the strengths of each community. Program sites are located in cities such as Boston, Houston, Denver, Miami and Richmond. The Federation of Families also works with this initiative.
The Future of Cultural Competence
The public mental health system is struggling to develop and articulate its approach to culturally competent child and adolescent mental health systems of care. In this period of rapid change and uncertainty, many public health systems are finding it is difficult to establish clear policies and expectations in this and other areas. Nonetheless, change often begets opportunities. As the nation grapples with a wide range of health care challenges while simultaneously experiencing an increasingly diverse population, the time is right to embrace cultural competence as a core component of mental health systems for children, adolescents and their families.
Note: For additional information and guidance in planning and implementing culturally competent mental health services for children, adolescents and their families, contact organizations listed on page 6.
With this issue of networks, NTAC addresses a topic of critical importance to service delivery in the public mental health system, particularly in the era of managed care—culturally competent mental health services for children, adolescents and their families. In some ways, service programs for children and adolescents have led the mental health field in developing culturally competent mental health services, and so we look to them for guidance.
It is heartening to note the number and variety of innovative programs that are delivering services to children and adolescents within a culturally competent environment. Nonetheless, the mental health field has a long way to go in developing a broad and integrated vision of culturally competent mental health services for children and adults alike. The progress being made now is a result of the willingness of staff, consumers and families who advocate for these programs to directly face the serious challenges presented by such a goal.
Recruiting, retaining and retraining a workforce that is respectful of and knowledgeable about cultural diversity in a competitive, cost-conscious environment can be accomplished if staff are supported in the belief that developing cultural competence is everybody's job. Strategies are available that increase the chances of attracting members of minority communities to employment in the public mental health system, but they require us to think a bit "out of the box."
Beyond that, the values of cultural competence can be integrated by policymakers, administrators and clinical staff into both attitude and action, irrespective of one's own cultural background. Placing a high value on the strength of diverse perspectives and approaches; appreciating cultural traditions, particularly those related to healthcare; exercising leadership that encourages and rewards innovation and success in serving culturally diverse communities; and understanding that providing culturally competent services can be cost effective even within a managed care environment—all of these are part of the framework necessary to construct a mental health service delivery system that is truly culturally competent.
Throughout this issue of networks, NTAC draws the reader's attention to important issues involved in developing a culturally competent system of care and identifies a number of recommendations made by mental health professionals, consumers and other mental health experts for achieving that goal. We are fortunate to have access to such experts. They gave generously of their time, and we thank them.
This brief foray into a complex topic can only touch upon some of the critical issues involved and perhaps provide readers with further direction concerning resources available for additional information and guidance. We invite you to contact the experts and organizations listed in this issue and to call on us—in writing, by telephone and fax or online—as you consider your next steps in responding to the growing challenge of planning, delivering and evaluating culturally competent mental health systems of care for children, adolescents and their families.
—Bruce D. Emery, M.S.W.
For nearly a decade Pennsylvania has been a leader in providing culturally competent mental health services to children, adolescents and their families. Even now as the state begins the transition to a managed care environment, it is developing procedures to ensure that managed care organizations provide culturally competent mental health services.
According to Lenora Stern, M.Sc., director of the Division of Research and Program Development in the Pennsylvania Office of Mental Health and Substance Abuse Services, one key to the state's ability to stay ahead of the curve has been the ongoing commitment to cultural competence by the State Mental Health Commissioner and other senior state mental health officials. This commitment, both in policy and funding, set the stage for the variety of successful statewide activities that have occurred.
In the mid-1980's the Bureau of Children's Services in the Pennsylvania Office of Mental Health and Substance Abuse Services initiated a statewide effort to improve mental health and other social services for children, adolescents and their families in partnership with other child-serving agencies including education, child welfare and juvenile justice. The partners found common ground in the Child and Adolescent Services System Program (CASSP), a well-defined set of principles for providing mental health services to children, adolescents and their families. Services delivered according to these principles are "child-centered, family-focused, community-based, multi-system, culturally competent" and delivered in the "least restrictive/least intrusive" manner.
During this period the State Mental Health Agency established the Minority Initiatives Subcommittee, one of four subcommittees of the state CASSP Advisory Committee. In cooperation with the State Mental Health Agency, the subcommittee in 1990 convened a statewide conference on cultural competence attended by about 200 mental health professionals, community representatives, parents and other individuals.
The success of these activities led to a statewide needs assessment focusing on the mental health service needs of minority children, adolescents and their families and the development of a concept paper titled "The Pennsylvania Model: Towards a Culturally Competent System of Care." In 1992, the state established the Pennsylvania CASSP Training and Technical Assistance Institute with a grant from the federal Center for Mental Health Services. During the next two years, the Institute worked cooperatively with the Minority Initiatives Subcommittee, State Mental Health Agency officials and cultural competence experts to develop a comprehensive 10-module "train-the-trainer" curriculum on cultural competence in mental health systems.1
Since 1995, the Institute has held several state-of-the-art, week-long cultural competence training activities using the curriculum. About 75 state and local mental health and other staff have participated in the "train-the-trainer" course. Individuals who participate in the course often go on to provide on-site technical assistance to local mental health organizations. In addition all of the Institute's training activities now incorporate cultural competence and other CASSP principles.
Marsali Hansen, Ph.D., clinical director of the Training and Technical Assistance Institute, points out that more than 2,000 state mental health agency and other staff take part in approximately 70 training activities held annually by the Institute. Participants can earn continuing education units (CEUs). Costs range from $60 for a one-day course to $400 for the week-long "train-the trainer" program, which includes the price of the comprehensive course manual.
Dr. Hansen notes that the Institute will become affiliated with Pennsylvania State University this summer, a partnership that she believes will help to ensure that cutting-edge research findings are put into practice in the provision of culturally competent mental health services.
Cultural competence is an essential element in child and adolescent mental health services "not because it's a nice idea but because it works," Dr. Hansen asserts. She notes that the Institute is recruiting staff with cultural competence skills to enhance its ability to provide culturally competent training and technical assistance.
According to Ms. Stern (of the Pennsylvania Office of Mental Health and Substance Abuse Services) the state has incorporated indicators of cultural competence and other CASSP principles in its request for proposals (RFPs) for managed care mental health services. "The private sector needs to understand more fully what the public sector wants," Ms. Stern points out.
1Isaacs-Shockley, M., and Pennsylvania Minority Initiatives Subcommittee. (1995). Pennsylvania Cultural Competence Train-the-Trainers Manual. Cost: $100.
For more information on the Institute, contact Marsali Hansen, Ph.D.; to order a copy of the "Train-the-Trainers" manual, contact Harriet Bicksler. Tel: 717-232-3125.
Garland, A. and Besinger, B. (1996). "Adolescents' Perceptions of Outpatient Mental Health Services," Journal of Child and Family Studies. 5(3):355-375.
Isaacs, M.R. and Benjamin, M.P. (1991). Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed, Volume II. Washington, DC: Georgetown University Child Development Center. (Cost: $15; contact the Center at 202-687-8635.)
Isaacs-Shockley, M. (In press). The State of the States: Responses to Cultural Competence and Diversity in Child Mental Health. Washington, DC: Georgetown University Child Development Center. (Contact the Center at 202-687-8635.)
Knitzer, J. (1982). Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Services. Washington, DC: Children's Defense Fund.
Munoz, Jr., R.H. and Sanchez, A.M. (In press). Developing Culturally Competent Systems of Care for State Mental Health Services. Boulder, CO: Western Interstate Commission for Higher Education. (Free; contact WICHE at 303-541-0250.)
Sanchez, M. and McGuirk, F. (eds.). (1995). Latino Children and Adolescents in the Mental Health System. Boulder, CO: Western Interstate Commission for Higher Education. (Cost: $15; contact WICHE at 303-541-0250.)
Stroul, B. (1994). A System of Care for Children and Youth with Severe Emotional Disturbances, Revised Edition. Washington, DC: National Technical Assistance Center for Children's Mental Health. (Cost: $15; contact the Center at 202-687-8635.)
Technical Assistance Center for the Evaluation of Children's Mental Health Systems, Judge Baker Children's Center. (1996). A Practical Guide for the Assessment of Cultural Competence in Children's Mental Health Organizations. Boston, MA: Judge Baker Children's Center. (Contact the Center at 617-232-8390.)
Vargas, L. (1992). Working with Culture: Psychotherapeutic Interventions with Ethnic Minority Children and Adolescents. San Francisco, CA: Jossey-Bass Publisher, Inc. (Cost: $34.95; call 415-433-1767.)
Annie E. Casey Foundation: Provides descriptions of Foundation-supported programs that foster public policies, human service reforms and community services to meet the needs of vulnerable children and families. Tel: 410-547-6600; Web site: http://www.aecf.org
Center for Mental Health Services' Caring for Every Child's Mental Health: Communities Together Campaign: Promotes awareness of children's mental health problems and of services that address their needs. Offers a wide range of information and resources. Tel: 800-784-2647; Web site: http://www.mentalhealth.org/child
Federation of Families for Children's Mental Health: Offers information on managed care and children's mental health, including principles of the system of care applied to managed behavioral health care. Tel: 703-684-7710; Web site: http://www.ffcmh.org
Judge David L. Bazelon Center for Mental Health Law: Offers information and advocacy resources on mental health services for adults and children under managed care. Also provides information on services and benefits for children with serious emotional disturbances. Tel: 202-467-5730; Web site: http://www.bazelon.org
National Technical Assistance Center for Children's Mental Health, Georgetown University: Provides information on research and initiatives to improve the quality of life for children with mental health needs and their families, including enhancing cultural competence in child mental health. Tel: 202-687-5000; Web site: http://www.dml.georgetown.edu/depts/pediatrics/gucdc/index.html
Research and Training Center on Family Support and Children's Mental Health, Portland (OR) State University: Offers information on research and training activities that focus on improving services to families whose children have emotional or behavioral disorders. Tel: 800-628-1696; Web site: http://www.adm.pdx.edu/user/rri/rtc
U.S. Department of Health and Human Services, Office of Minority Health: Provides information on a wide range of subjects related to cultural competence, including the provision of mental health and other services to minority children. Tel: 800-444-6742; Web site: http://www.os.dhhs.gov/progorg/ophs/omh
University of South Florida Department of Child and Family Studies, ResourceNet: Offers information on the Research and Training Center for Children's Mental Health and the System Accountability Project for Children's Mental Health—Florida Kids Count. Tel: 703-684-7710; Web site: http://resnet.fmhi.usf.edu/reg/homepage.html
Washington Business Group on Health/National Resource Network for Child and Family Mental Health Services: Provides information on programs involving organized systems of care, integrated benefits and services, performance, and market environments including those that impact children. Tel: 202-408-9320; Web site: http://www.wbgh.com
June 2: Syracuse University, Marriage and Family Program. Family Therapy Summer Institute: African American Families—Therapeutic Challenges and Strategies, Syracuse, NY. Contact Tracey Leszloffy at 315-443-3023.
June 3: National Mental Health Consumers' Self-Help Clearinghouse and the National Mental Health Association. Third Annual National Mental Health Consumer/Survivor Public Policy Forum, Washington, DC. Call 800-553-4539, ext. 291.
June 4-7: National Mental Health Association. National Mental Health Conference, Washington, DC. Contact Diana Church at 703-838-7504.
June 5-7: Human Resources and Services Administration. National Health Care for the Homeless Conference, Washington, DC. Contact Polly Bullock at 615-226-2292.
June 9-13: International Association of Psychosocial Rehabilitation Services (IAPSRS). Beyond Boundaries, 22nd International Conference of IAPSRS, Vancouver, British Columbia. Call 604-872-3502.
June 27: Harvard Medical School, Department of Continuing Education. First Annual Course in Developmental Psychiatry and Psychology: A Primer for Clinicians Working with Children, Adolescents and Families, Cambridge, MA. Contact John O'Laughlen at 617-432-1525.
July 28-30: Council of State Community Development Agencies. Affordable Housing Conference, Washington, DC. Contact Vicki Watson or Kevin Kissinger at 202-624-3630.
August 11-15: Albert Einstein College of Medicine. Diagnosis and Treatment of Child and Adolescent Psychopathology in the Days of Managed Care and Empowering Parents: Almost Everything Child and Family Therapists Need to Know, Eastham, MA. Contact Dennis Cantwell or Ron Taffel at 718-430-2307.
September 18-19: National Technical Assistance Center for State Mental Health Planning and other federal and national organizations. National Executive Training Institute: Developing State-Level Partnerships between Housing and Mental Health Agencies, Arlington, VA. Contact Rebecca Crocker at 703-739-9333, ext. 12.
October 14-19: American Academy of Child and Adolescent Psychiatry. 44th Annual Meeting, Toronto, Canada. Contact Heidi Buttner at 202-966-7300.
November 20-23: Federation of Families for Children's Mental Health. Ninth Annual Conference, Washington, DC. Contact Scott Bryant-Comstock at 919-477-3677.
Behavioral health and human services vendors of color are invited to participate in "Success in a Changing Health Care Environment: A National Academy for Developing Child Behavioral Health Care Providers of Color," November 2-5, 1997, in Houston, Texas. The Academy will address economic and professional challenges encountered in the managed care arena. Participants will learn how to compete in the emerging behavioral health provider network serving children and adolescents of color and their families. Topics include understanding managed care, developing a business plan, implementing culturally competent mental health services, developing quality indicators and outcome measures, creating a strategic plan and understanding the procurement process (RFPs, contracts).
The Academy is sponsored jointly by the Child, Adolescent and Family Branch of the Center for Mental Health Services, the National Technical Assistance Center for Children's Mental Health and the National Resource Network for Child and Family Mental Health Services. For more information or an application form, contact Marva Benjamin, A.C.S.W., National Technical Assistance Center for Children's Mental Health, Georgetown University. Telephone: 202-687-5000, Fax: 202-687-8899.
networks is published quarterly by the National Technical Assistance Center (NTAC) for State Mental Health Planning (NTAC) and is supported under a Cooperative Agreement between the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration CMHS/SAMHSA) and the National Association of State Mental Health Program Directors (NASMHPD).
Spring 1997 Issue -
Cited reproductions, comments, and suggestions are encouraged. You may also be added to the mailing list for networks. Contact Christine Diaz at 703/739-9333, ext. 30, or send e-mail to: christine.diaz@nasmhpd.org. [Please include your name and return mailing address, email address and/or telephone number in the body of your message so we may respond to your inquiry].