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Effective Behavioral Health Programming for Transition-Age Youth

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1 Effective Behavioral Health Programming for Transition-Age Youth
Image: Young male, arms on knees, covering his face. Effective Behavioral Health Programming for Transition-Age Youth The views, opinions, and content of this presentation are those of the presenters and do not necessarily reflect the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services. Charles E. Lewis, Jr., Ph.D., Facilitator Minority Fellowship Program Coordinating Center

2 Presenters Charles E Lewis, Jr., PhD, MSW Hewitt B. “Rusty” Clark, PhD
Principal Associate and Training Director for the Development Services Group (DSG) Minority Fellowship Program Coordinating Center (MFPCC); former CSWE MFP Fellow, Columbia University 2000–01. Hewitt B. “Rusty” Clark, PhD Director of the National Network on Youth Transition for Behavioral Health (NNYT); Professor Emeritus at the Department of Child & Family Studies, Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida. Gloria Reeves, MD Director of Maryland’s Strive for Wellness program and an Associate Professor in the Department of Psychiatry at the University of Maryland.

3 Transition-Age Youth This Webinar will focus on the behavioral health needs of youth and young adults between the ages of 16 and 25 years who are transitioning into adulthood. Some are living at home with parents, aging out of foster care, and may or may not be working or in school. Transition-age youth are particularly at risk for first episodes of mental illness and substance abuse.

4 Transition-Age Youth Image: Group of young people representing transition-age youth, 16–24 years old. There are 38.6 million noninstitutionalized individuals in the U.S. between the ages of 16 and 24 years1 This represents about 15 percent of the U.S. population 12.7 million (33 percent) were enrolled in school 20.3 million (52.7 percent) were working 1U.S. Bureau of Labor Statistics

5 Transition Age Youth The years of transitioning from adolescence to adulthood have challenges Particularly for youth aging out of foster care or leaving the juvenile justice system As they move into the adult system, they are covered by new laws and regulations This transition poses enormous hurdles for youth with behavioral health problems

6 Disconnected Youth Estimated 6.5 million disconnected youth—out of school and out of work—ages 16–24 in the United States in Image: Chart with percentages and numbers of 16 to 24 year olds out of school and out of work 1Annie E. Casey Foundation “Youth and Work” Report

7 Aging Out of Foster Care
According to HHS, about 500,000 children are in foster care on a given day About 26,000 “age out” each year Most states set 18 years old as the beginning of adulthood, however many states extend foster care until 21 years under certain circumstances (being enrolled in school) Image: Young male student, foreground; group of students in background.

8 Aging Out of Foster Care
At the age of 24, only half are employed1 More than one in 5 will become homeless after age 18 Only 58 percent will graduate high school by age 19 (compared to 87 percent of all 19 year olds) Fewer than 3 percent will earn a college degree by age 25 (compared to 28 percent of all 25 year olds) One in four will be involved in the criminal justice system within two years of leaving foster care 1Annie E. Casey Foundation

9 Transition-Age Youth According a 2012 Mathematica study (using 2009 data): About 6.3 percent of transition-age youth have a disability (about 2.5 million). The incidence of disability for the 500,000 youth in institutional settings is about 24 percent. Research shows that transition-age youth with mental health problems compared to those without are less likely to finish high school, less likely to be employed, more likely to become pregnant, and more likely to be involved in criminal activity.

10 Transition-Age Youth The most common primary diagnosis among transition age youth is depression (21.6 percent), followed by bipolar (14.6 percent), disruptive (14.2 percent), and anxiety (12.9 percent) disorders Image: Young female holding her head. Comorbidity is common, with approximately 60 percent of those with a disability having more than one diagnosis, 41.0 percent having a co-occurring medical problem, and 20.3 percent a substance use problem

11 Transition-Age Youth Some adolescents enter the transition-age period with pre- existing mental health problems and have received services from child-serving systems, while others do not develop mental health problems until the transition period and thus have no prior service system involvement. Adult systems often focus exclusively on providing services for the needs of persons with serious and persistent mental illnesses. Thus, the expertise of clinical personnel and ancillary services offered in adult systems may not be well matched to the clinical profiles of transition-age youth.

12 Federal Laws/Programs
The Child Abuse Prevention and Treatment Act (CAPTA) Signed into law in 1974 Reauthorized in 1978, 1984, 1988, 1992, 1996, and 2003 Funds states to prevent and address child abuse The Adoptions and Safe Families Act of 1997 Made the well-being of children paramount to the rights of biological parents Aimed to increase the number of children in foster care placed in permanent homes

13 Federal Laws/Programs
The Comprehensive Community Mental Health Services for Children and Their Families Program Launched by SAMHSA’s Center for Mental Health Services (CMHS) in 1992, the program promotes a coordinated, community-based approach to care for children and adolescents with serious mental health challenges and their families (Systems of Care) The Foster Care Independence Act of 1999 Established the John H. Chafee Foster Care Independence Program (CFCIP) Required ACF to develop a data collection/tracking system

14 Federal Laws/Programs
Fostering Connections to Success and Increasing Adoptions Act of 2008 Created an option for state and tribal agencies to provide kinship guardianship assistance payments Patient Protection and Affordable Care Act Extended Medicaid coverage to former foster care children younger than age 26 Eligible for benefits from the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) provisions of Medicaid until age 21

15 Now Is The Time (NITT) Substance Abuse and Mental Health Services Administration (SAMHSA) created two programs to address the behavioral health needs of transition age youth: Now Is The Time MFP—Addiction Counselors Now Is The Time MFP—Youth Train master’s level practitioners to work with transition age youth in unserved and underserved communities

16 Transition to Independence Process
Transition-Age Youth Today’s Webinar will focus on a successful program designed to move transition-age youth with behavioral health problems into independence Transition to Independence Process The Webinar will also examine best practices for the use of psychotropic medications with transition-age youth Image: Various pills and capsules spread across a tabletop.

17 Hewitt “Rusty” Clark Ph.D., BCBA
Image: Lighthouse atop rocky ledge above water Navigating Rough Waters: TIP Model™: Improving Outcomes for Youth and Young Adults with EBD Hewitt “Rusty” Clark Ph.D., BCBA © Copyright 2012– All rights reserved – Stars Behavioral Health Group

18 SBHG / NNYT Mission To improve the progress and outcomes for:
Youth and young adults (14–29 years of age) with emotional/behavioral difficulties (EBD) Through system development, program implementation, research, and dissemination in collaboration with provider agencies, communities, states, and national/federal entities. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

19 Comparison of Transition Domains Between the General Population and Young People (YP) with EBD
Blackorby J., Wagner M. Longitudinal postschool outcomes of youth with disabilities: Findings from the National Longitudinal Transition Study. Except Child 1996; 62: Clark, H.B. & Davis, M. (Eds.) (2000): Transition to adulthood: A resource for assisting young people with emotional or behavioral difficulties. Baltimore: Brookes Publishing. Karpur, A., Clark, H.B., Caproni, P., & Sterner, H. (2005).  Transition to adult roles for students with emotional/behavioral disturbances:  A follow-up study of student exiters from a transition program. Career Development for Exceptional Individuals, 28(1), Vander Stoep, A., Davis, M., & Collins, D. (2000). Transition: A time of developmental and institutional clashes. In H.B.Clark & M. Davis (Eds.) Transition of Youth and Young Adults with Emotional/Behavioral Disturbances in Adulthood: Recommended Practices, Research Findings and Policy Implications (pp. 3-28). Baltimore, MD: Brookes Publishing Company. Vander Stoep, A., Beresford, S.A.A., Weiss, N.S., McKnight, B., Cauce, A. M., & Cohen, P. (2000). Community-based study of transition to adulthood for adolescents with psychiatric disorders. American Journal of Epidemiology, 152, © Copyright 2012– All rights reserved – Stars Behavioral Health Group

20 Likelihood of Youth With EBD Being Incarcerated
Prange, M. (1993). A longitudinal perspective of youth with conduct disorder problems. Paper presented at the Rehabilitation of Children, Youth, and Adults with Psychiatric Disabilities Conference, Tampa, FL. Waves 1-7; N=497 © Copyright 2012– All rights reserved – Stars Behavioral Health Group

21 Barriers Youth and Young Adult Level Family Level
Community/ System Level Image: Three individuals climbing rocks.   © Copyright 2012– All rights reserved – Stars Behavioral Health Group

22 © Copyright 2012– All rights reserved – Stars Behavioral Health Group
Image: Cartoon with two prehistoric men.   © Copyright 2012– All rights reserved – Stars Behavioral Health Group

23 Transition to Independence Process TIP Model
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

24 What is the TIP Model™? Transition to Independence Process (TIP) system: Engage youth and young adults (14–29 years old) in their own futures planning process. Provide them with developmentally appropriate services and supports. Involve them and their families and other informal key players. In a process that prepares and facilitates them in their movement toward Greater self-sufficiency Successful achievement of their goals © Copyright 2012– All rights reserved – Stars Behavioral Health Group

25 TIP Model™ Guidelines Practice Level Program Level
Young Person Informal Key Players (e.g., family members, friends) Formal Key Players (e.g., therapist, teacher, probation officer) Program Level Community System Level State and Federal Policy Level The TIP Model Guidelines At the practice level, these guide the Transition Facilitator’s moment to moment, day to day, week to week work with a young person (and those around him or her). The extent to which the program, community system, and policy levels are aligned with these guidelines, the more seamless and effective the transition program. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

26 TIP Model™ Guidelines Engage young people through relationship development, person-centered planning, and a focus on their futures. Tailor services and supports to be accessible, coordinated, appealing, nonstigmatizing, and developmentally appropriate—building on strengths to enable the young people to pursue their goals across relevant transition domains. Engage young people through relationship development, person-centered planning, and a focus on their futures. 2. Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains. 3. Acknowledge and develop personal choice and social responsibility with young people. Background Image: Young people seated © Copyright 2012– All rights reserved – Stars Behavioral Health Group

27 Educational Opportunity Personal Effectiveness & Well-Being
Transition Domains Employment & Career Living Situation Educational Opportunity Community Life Functioning Personal Effectiveness & Well-Being Talk about how impairments occur in each domain May elaborate briefly on each with examples This domain graph is good to show YP because they are visual It maps for them what they need to focus on and what to do to take independence to next level © Copyright 2012– All rights reserved – Stars Behavioral Health Group

28 Transition Domains: Subdomains
Personal Effectiveness and Well-Being Interpersonal Relationships Emotional and Behavioral Well-Being Self-Determination Communications Physical Health and Well-Being Parenting Community-Life Functioning Daily Living Skills Leisure Activities Community Participation © Copyright 2012– All rights reserved – Stars Behavioral Health Group

29 TIP Model™ Guidelines Acknowledge and develop personal choice and social responsibility with young people. Ensure a safety net of support by involving a young person’s parents, family members, and other informal and formal key players. Engage young people through relationship development, person-centered planning, and a focus on their futures. 2. Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains. 3. Acknowledge and develop personal choice and social responsibility with young people. Background Image: Young people seated © Copyright 2012– All rights reserved – Stars Behavioral Health Group

30 Futures Planning with YP: Planning Partners and Necessary Connections
Planning partners are selected by YP. YP might choose different key players to serve as planning partners for different topics, needs, or goals. Often a YP may want to only involve him/herself and one or two key players (e.g., transition facilitator, parent, friend) to serve as planning partner(s). NOTE: With older youth and young adults, typically over 95 percent of the planning meetings are with just the YP and TF. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

31 Futures Planning with YP: Planning Partners and Necessary Connections
YP’s topic/need/goal determines who is a necessary connection(s) (e.g., probation officer, vocational rehabilitation counselor, community college instructor) for him/her to make progress on this topic, need, or goal. YP and transition facilitator or other planning partner would contact, plan, and/or negotiate with necessary connection(s) regarding a particular topic, need, or goal. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

32 TIP Model™ Guidelines Enhance young persons’ competencies to assist them in achieving greater self-sufficiency and confidence. Engage young people through relationship development, person-centered planning, and a focus on their futures. Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains. Acknowledge and develop personal choice and social responsibility with young people. Background Image: Young people seated © Copyright 2012– All rights reserved – Stars Behavioral Health Group

33 TIP Model™ Core Practices
Strength Discovery and Needs Assessment Futures Planning Rationales In-vivo Teaching Problem Solving (SODAS) Prevention Planning Process on High Risk Behaviors Mediation with Young People and Other Key Players

34 TIP Model™ Guidelines Maintain an outcome focus in the TIP system at the young person, program, and community levels. Engage young people through relationship development, person-centered planning, and a focus on their futures. Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains. Acknowledge and develop personal choice and social responsibility with young people. Background Image: Young people seated © Copyright 2012– All rights reserved – Stars Behavioral Health Group

35 Research on the TIP Model: Progress and Outcome Studies
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

36 TIP Model Implementation and Progress/Outcomes Evaluation of Progress and Outcomes for Youth and Young Adults at a New TIP Model Implementation Site Presenter: If any questions regarding this TIP model / TAS team initial evaluation, please contact Kelly France or Hewitt B. “Rusty” Clark © Copyright 2012– All rights reserved – Stars Behavioral Health Group

37 TIP Model Implementation Progress and Outcome Indicators on Young People
Initial Implementation of TIP model in Muskegon County, Mich. Transition Age Services (TAS) team is the lead TIP model entity Building community collaborative across mental health, family court, probation, homeless/runaway, and child welfare: Muskegon County TIP Model Collaborative TIP Community Steering Committee Presenter: Some this information may be more than you need based on the goal of your presentation and your audience. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

38 TIP Model Implementation Progress and Outcome Indicators on Young People
First 12 months of TIP model supports and services TAS Transition Facilitators (TFs) working with 29 youth and young adults over first 12 months. Main referrals from court, juvenile justice, and probation. Age of YP: 14–26 years old. YP have serious mental health conditions (SMHC) and at risk of, or extensive histories of, out of home placements, co-occurring substance use (e.g., cannabis dependence, polysubstance dependence), developmental trauma, and/or multiple-system involvement. Presenter: Some this information may be more than you need based on the goal of your presentation and your audience. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

39 TIP Model Implementation: New Site Findings
Community Life and Living Situation Progress Indicators © Copyright 2012– All rights reserved – Stars Behavioral Health Group

40 TIP Model Implementation: New Site Findings
Education and Employment Progress Indicators Presenter: A note of clarification. Regarding the fourth set of bars “Graduated HS / GED”, three of the 29 participants had graduated prior to entering the Transition Age Service (TAS) Team TIP model services.

41 Research Findings on the TIP Model
Numerous published studies that demonstrate improvement in real-life outcomes for youth and young adults with EBD. Refer to Theory and Research section of the TIP model website. National Network on Youth Transition

42 TIP Model™ Guidelines Involve young people, parents, and other community partners in the TIP system at the practice, program, and community levels. Engage young people through relationship development, person-centered planning, and a focus on their futures. Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains. Acknowledge and develop personal choice and social responsibility with young people. Background Image: Young people seated © Copyright 2012– All rights reserved – Stars Behavioral Health Group

43 TIP Model™ Guidelines Maximize the involvement of young people, family members, informal and formal key players, and other community representatives. Tap the talents of peers and mentors: Hire young adults as peer associates (possible functions such as mentoring, counseling, and/or leadership development). Assist young people in creating peer support groups and youth leadership opportunities. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

44 TIP Model™ Guidelines Use paid and unpaid mentors (e.g., co-worker mentors, college mentors, apartment roommate mentors). Partner with young people, parents, and others in the TIP system governance and stewardship. Advocate for system development, expansion, and evaluation—and for reform of funding and policy to facilitate implementation of responsive, effective community transition systems for youth and young adults and their families. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

45 Developmental Markers: Rights of Passage into Adulthood
Completing schooling and training Developing a social network Obtaining/maintaining rewarding employment/career Image: Man and woman in coffee shop. Becoming financially self- supporting Participating in your community and being a good citizen © Copyright 2012– All rights reserved – Stars Behavioral Health Group Image: Young man holding plaque.

46 Implementation Sustainability
TIP Model™ Implementation Sustainability © Copyright 2012– All rights reserved – Stars Behavioral Health Group

47 TIP Training and Implementation Steps
TIP Model™ Implementation Site Readiness Assessment Sustaining TIP Implementation Agency Commitment/ Selection Technical Assistance Calls Planning and Preparation On-Site Training and Consultation TIP Cross-Site Forum © Copyright 2012– All rights reserved – Stars Behavioral Health Group

48 TIP Model Implementation
Improve progress and outcomes for transition-age young people (14–29 years of age) with EBD Implementation in collaboration with a provider agency, community collaboratives, counties, and states © Copyright 2012– All rights reserved – Stars Behavioral Health Group

49 SBHG Stars Training Academy
Serves as the Purveyor of the Transition to Independence Process (TIP) model Guided by Implementation Science Community and rural areas in over 25 states and regions across North America are implementing this evidence-supported practice. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

50 Focus on Implementation
Training and field-based supports for personnel – front-line and supervisory TIP Solutions Review process Supervisors mentored in coaching Strong youth and young adult voice YP, family, and partners in governance © Copyright 2012– All rights reserved – Stars Behavioral Health Group

51 From Day 1 An Eye Toward Sustainability
Building site capacity For example, Site-Based Trainers Local Fidelity QI Assessors Expanding community partnerships Building a TIP Model Community of Practice Access for housing or college © Copyright 2012– All rights reserved – Stars Behavioral Health Group

52 Meaningful Evaluation Systems
YP satisfaction with helpfulness services Progress and outcome indicators YP level Program aggregate data TIP Model Quality Improvement Fidelity © Copyright 2012– All rights reserved – Stars Behavioral Health Group

53 Sustainability of your site is facilitated by
Youth and Young Adult Voice Image: Mixed-race group of young people. © Copyright 2012– All rights reserved – Stars Behavioral Health Group

54 Hewitt B. “Rusty” Clark, Ph.D.,
The Transition Handbook Transition of Youth and Young Adults with Emotional or Behavioral Difficulties: An Evidence-Supported Handbook Hewitt B. “Rusty” Clark, Ph.D., and Deanne K. Unruh, Ph.D. Brookes Publishing, 2009 © Copyright 2012– All rights reserved – Stars Behavioral Health Group

55 Hewitt B. “Rusty” Clark, Ph.D., BCBA
If your organization is interested in implementation of the TIP model please contact us: Hewitt B. “Rusty” Clark, Ph.D., BCBA Joseph Solomita, MSW © Copyright 2012– All rights reserved – Stars Behavioral Health Group

56 Principles of Safe and Effective Medication Treatment of Transition-Age Youth/Young Adults
Gloria Reeves MD Associate Professor Division of Child and Adolescent Psychiatry University of Maryland, School of Medicine

57 Objectives Introduce general principles/strategies to support safe and effective medication treatment Discuss two examples of commonly prescribed medications (stimulant medications, antipsychotic medications) Introduce a resource for youth with early signs of serious mental illness

58 Principle #1 A comprehensive evaluation is needed to develop a safe and effective treatment plan Image: Comprehensive evaluation diagram.

59 Strategies: Evaluation
Multiple sources of information: parent/family, school/work Assess timeline/context of symptoms Screen for developmental high risk behaviors Assess physical health Image: Stethoscope with red heart ornament.

60 Principle #2 Use informed consent process as an opportunity to teach about treatment decision-making Image: Consent form.

61 Strategy Identify patient priorities/expectations/values for treatment
Help generate questions about medication and other treatment options Discuss pros and cons of treatments Support opportunities to seek additional info and consultation (e.g., trusted family advisor, consumer support program, accurate websites) Establish opportunities to revisit decisions

62 Prescribing Principle #3
Have a plan to track for medication benefits and side effects Image: Bottles of psychotropic medications.

63 Strategies: Outcomes-based Care
Assess baseline symptom severity and frequency at baseline Use observer rating scales to assess behavioral concerns and self report for internalizing symptoms (e.g., anxiety) Assess side effect issues at baseline (e.g., obtain baseline labs and weight/height) Optimize treatment to achieve recovery/remission

64 Prescribing Principle #4
Monitor adherence at each medication follow-up visit Image: Pill dispenser for medications.

65 Strategies: Universal Adherence Monitoring
Assess adherence at each medication visit Adherence may change over development (e.g. teenagers want to become independent) Free apps and other tools may be helpful Anticipate adherence concerns for complex regimens as well as complex family situations (e.g. child lives between 2 households) Reinforce accurate reporting, not “compliance” with medication

66 Building self-reliance for adherence
Smart Phone Apps (free) iPhone and Android MyMedSchedule MyMeds MedSimple PillManager Mymedschedule.com

67 Principle #5 All psychiatric treatment should involve universal screening for trauma Image: Checklist with hand holding red pencil.

68 Strategy: Assess Common Concerns
The ACE Study, 1995–97 17,000 adults undergoing a standardized physical through Kaiser Permanente Report of childhood: Emotional Abuse 10.6 percent Physical Abuse 28.3 percent Sexual Abuse 20.7 percent Emotional Neglect 14.8 percent Physical Neglect 9.9 percent Total population percentage 68

69 Pediatric Approved Antipsychotics
Irritability due to autism Risperdal (risperidone) 5-17 Abilify (aripiprazole) 6-17 Schizophrenia Bipolar I Risperdal (risperidone) 13– Abilify (aripiprazole) Zyprexa (olanzapine) Seroquel (quetiapine) Invega (paliperidone)* Saphris (asenapine)* 10-17 *Newest antipsychotic medications approved for pediatric treatment. Fewer data in youth available.

70 Overview Most pediatric treatment is for “off label” treatment of severe aggression and irritability Safety monitoring: weight/height, fasting labs (glucose, cholesterol/lipids, liver function) at baseline and follow up; ECG for some medications Risk of new onset diabetes Non-adherence is common Medication titration often necessary Watch for early onset side effects: sedation, constipation, dry mouth, movement disorders Medication trial usually 4–8 weeks to see greatest response

71 Stimulant Medications
Methylphenidate Ritalin Methylin Ritalin LA Ritalin SR Metadate CD Concerta Focalin Focalin XR Daytrana Patch Quillivant XR Mixed amphetamine salts Adderall Adderall XR Dextroamphetamine Dexedrine Dexedrine spansules Vyvanse

72 Stimulant Medications
Used to target both hyperactivity and inattention Benefit of a medication dose evident quickly: don’t need to wait weeks to see an effect Medication can be held abruptly without physical withdrawal Baseline: check weight, height, blood pressure Monitor: sleep/appetite, tics, irritability, increased blood pressure/pulse Refer to PCP: delays in growth, abnormal BP

73 Maryland Early Intervention Program
“A collaborative for the early identification and treatment of mental illness with psychosis”

74 Centralized Contact For Services
Website: Toll free numbers Phone: 877–277–MEIP (6347) Fax: 877–689–9185 Centralized Staffed by a trained specialist Master’s-level clinician. 9 a.m. to 5 p.m. Mondays through Fridays. For emergency situations, please call 911 or go to your nearest emergency room before contacting the EIP.

75 Dr. Hewitt “Rusty” Clark
Presenter Contact Information Dr. Hewitt “Rusty” Clark Dr. Gloria Reeves

76 Contact DSG If you have questions or need additional information
about this Webinar, contact Development Services Group, Inc. Dr. Charles E. Lewis Jr. Training Director for the Minority Fellowship Program Coordinating Center


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