Health Disparities Working Group Meeting: Cognitive and Emotional Health
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Health Disparities Working Group Meeting: Cognitive and Emotional Health In Minority Children
July 23-24, 2001
Hyatt Regency Hotel, Bethesda MD
Sponsored by the National Institute of Neurological Disorders and Stroke:
Systems and Cognitive Neuroscience Cluster
Office of Minority Health and Research
I. INTRODUCTION
Health disparities, as defined by the NIH, refers to differences in the incidence, prevalence, mortality, and burden of disease
among specific racial and ethnic minority populations in the United States. Some of the factors that contribute to these disparities
include increased risk of illness due to underlying biological or socioeconomic factors, increased exposure to environmental
pollutants, or reduced access to health care. To address some of these issues, the NIH has focused attention on additional
basic research, building research infrastructure at minority institutions, and improving public information and community
outreach.
Cognitive and emotional health of children is one of 10 areas that NINDS has included in its strategic plan to reduce health
disparities (Stroke, HIV, Neurological Complications of Diabetes, Epilepsy, Injury to the Developing Brain, Management of
Chronic Pain, Research Capacity Building, Outreach Activities and Inclusion Policies of Minorities in Research). This workshop
brought together experts from a wide variety of disciplines to discuss health disparities in the cognitive and emotional health
of minority children, identify unmet scientific needs, prioritize research opportunities and develop a plan of action.
Following 6 brief presentations, the participants were divided into 2 working groups. One group discussed the effects of environmental
and pharmacological pollutants on cognitive and emotional health in minority children, while the second group discussed the
impact of psychological stressors on the same parameters. On the second day, a joint session of both groups consolidated major
discussion points.
II. BACKGROUND
There are health disparity issues in many minority children irrespective of socioeconomic status, gender, race or ethnicity.
One major obstacle to approaching health disparities is the lack of articulated, consensual definitions of cognitive and emotional
health. Therefore, there are major gaps in our knowledge about the incidence and prevalence of health disparities in minority
children. Within that context, an added difficulty is the broad domain of questions that lie at the interface of biomedical
sciences, social and behavioral sciences. The 2001 National Research Council report titled: "New Horizons in Health - An Integrative
Approach", provides an excellent framework for the development of research initiatives that address the issues of health disparities
in cognitive and emotional health of minority children. The success of such initiatives is highly correlated to the integration
of information from the molecular and cellular level with psychosocial and community levels. This concept was emphasized at
the NINDS Working Group Meeting on Health Disparities in Cognitive and Emotional Health in Minority Children with the guidance
and expertise of Bruce McEwen (Rockefeller University), a member of the Committee on Future Directions for Behavioral and
Social Sciences Research at the National Institutes of Health and participant to the present working group meeting.
III. SCIENTIFIC PRESENTATIONS
III.A. ENVIRONMENTAL FACTORS AND BRAIN PLASTICITY
Ellen Silbergeld (University of Maryland) presented an overview of the effects of environmental pollutants, using lead as an example. The talk focused on the disparities in the sources and pathways of lead exposure resulting in unequal distribution of exposure and the non- optimal outcomes associated with that exposure. Lead poisoning is closely associated with other risk factors, such as low birth weight, in utero exposure to drugs of abuse and adverse early life experience. Lead exposure comes primarily from lead-based paint; children are particularly at risk due to the ingestion of paint chips and dust through
normal hand and mouth activity between the ages of 6-18 months. Lead is also found in garden soil in high traffic areas due
to the use of leaded gasoline, in dumping sites with lead contamination, and in lead smelters and recycling facilities that
are disproportionately located in minority neighborhoods. Lead crosses the placenta, as does mercury, polychlorinated biphenyl
compounds (PCBs) and dioxins. Therefore, immediate effects of exposure to lead can be seen in the development of the nervous
system, skeletal system, and cardiovascular system. Long- term effects can be seen in cognitive function and behavior. Epidemiology
studies have shown an association between early exposure to lead and aggressive behavior patterns and deficits in performance
in intelligence tests. Moreover, long- term effects of lead exposure are correlated with a three fold increased risk of hypertension
or cerebral cardiovascular incidents in adulthood. Research on the basic biological mechanisms of lead poisoning has pinpointed
the interaction of lead with several neurotransmitter systems, but the mechanisms by which specific deficits develop is still
not understood. Intervention strategies are few; a trial utilizing the lead chelator Succimer demonstrated a decrease in lead
blood levels but failed to show a reversal of the effects of lead on cognition. However other studies are testing the hypothesis
that nutritional supplements may lessen or reverse the effects of lead. It is clear that the prevention, and elimination of
the various sources of lead are a very high priority.
Mary Blue (John Hopkins University) discussed the specific effects of lead on cortical development. Although a number of studies
have demonstrated that a decline in intelligence is closely correlated with lead levels in two-year-old children, the neurobiological
mechanisms mediating this decline are largely unknown. In animal studies, low levels of lead exposure in the first postnatal
month, cause changes in long-term potentiation (LTP). Lead increases spontaneous electrical activity and receptor-dependent
signaling in neurons. This activity in turn influences the development of neural circuitry, and ultimately higher brain function.
Dr. Blue and colleagues hypothesized that neonatal lead exposure in rodents would alter the development and plasticity of
the cortical barrel field, a part of the somatosensory cortex. The cortical barrel field has proven to be a very useful animal
model system for brain plasticity and it allows the study of cortical development during critical periods of development.
Exposure of rat dams to lead acetate (0.5-2.0 g/L) in their drinking water from P1-P10 led to pups with significantly smaller
barrel sizes. A dose dependent decline in the barrel field size was correlated with exposure to increasing levels of lead
and an increase in glutamate receptor activity. In a second experiment, when rat dams were given 0.2% lead acetate in drinking
water from P1-P10, changes in brain plasticity were evident in the pups, following denervation of specific rows of the cortical
barrel field. These findings suggest that exposure to lead disrupts the normal competitive interactions that are involved
in cortical plasticity.
Bertram Payne (Boston University) provided a second perspective on brain plasticity and brain adaptability. His presentation
focused on lesions of the cat primary visual cortex as a model system for understanding how the brain changes with insult.
Dr. Payne and colleagues assess the types of neural processes and behaviors that are spared and those that are permanently
impaired, after injury. The parietal-visual cortex is a part of the brain involved in motion and spatial processing, while
the temporal-visual cortex is involved in pattern recognition. These areas of the brain are considered part of the secondary
visual cortex. In the adult cat, the secondary visual cortex suffers major losses after lesions to the primary visual cortex.
However, if the lesions are performed in the neonate, the resulting deficits are not as severe. Lesions of the primary visual
cortex on P1 or P28, results in an overall degeneration seen in all areas of visual cortex, but expansion and rewiring also
occurred in secondary visual cortex. Thus some functions are spared after insult to the brain early in life, and regrowth
and repair can also take place. Specific functions of the normal cerebral cortex can be remapped across the cortical surface
and the response of a young brain to an insult is unique because of the enormous potential to modify connections and rewiring
contributing to neural compensations and behavioral outcomes.
III.B. PSYCHOSOCIAL FACTORS
Cheryl Boyce (NIMH) gave an overview of the effects of psychosocial stressors on cognitive and emotional health. As the chair
of the NIH Child Abuse Neglect Workgroup, she emphasized the problem of inadequate definitions in the field of neglect. Classification
of neglect and abuse are not standardized, and coding of severity is a particularly sensitive issue. In recognition of the
problem, the Child Abuse Neglect Workgroup held technical assistance workshops to develop a uniform coding system for physical
injuries. In addition, the Workgroup has also held technical assistance workshops to encourage researchers to initiate research
programs in the area of neglect through career development awards in child abuse and neglect. An RFA on child neglect has
awarded 15 grants, ranging from the use of different models to test the reasons for the disparity in reports of child abuse
and neglect, to investigations on the neural basis of the parental response to infant crying. The hope for the future is in
developing good definitions and assessments, and applying them in longitudinal studies with good clear methodology.
Juanita Dimas (Alameda Alliance for Health) discussed the potential causes of health disparities, and the role of various
social and cultural factors. In examining psychological adjustment among Latino adolescents, she assessed basic demographic
variables for their predictive value, as well as cultural variables such as acculturation and ethnic identity. Both acculturation
and ethnic identity were highly predictive, and were correlated with a variable coined "public identifiers", which in this
case were last name (Spanish or English) and appearance (Latino or not). In other studies that examined outcome within the
same ethnic group, or within the same socioeconomic stratum, acculturative stress and minority status stress (experience with
discrimination) were predictive. Dr. Dimas proposes some ways to address the causes of health disparity. For example, she
recommends that medical care be provided in the native language of the patient, that doctors be trained in cultural competency,
and to simply preserve ethnicity information on medical forms so that the existence (or not) of disparities can be tracked.
Gayle Porter (American Institutes for Research) provided some data that identify the highest rates of traumatic experiences,
negative experiences, conduct disorders, and levels of abuse and neglect in African-American girls as compared to Hispanic,
Asian, and Caucasian girls in a study of children referred for mental health services. African-American girls also were more
likely to be the victims of repeat rape, and homicide was their leading cause of death. For the most part these negative exposures
were also true for African-American males. Higher rates of exposure to these negative factors affected not only mental and
emotional health, but also seemed to correlate with higher rates of diseases such as stroke, emphysema, diabetes, or heart
disease in adulthood.
IV. DISCUSSION
Overall, the two working groups, regardless of whether they were discussing the impact of environmental or psychological stressors,
reached consensus on many issues independently. Brief summaries of major discussion points are given below. If a particular
item was brought forward primarily by one working group, it is so indicated.
IV.A. DATA COLLECTION:
All meeting participants recognized that a reliable baseline data on the cognitive and emotional health of minority children is incomplete, and longitudinal studies that follow children for more than a few years are rare. Information on the health status of different demographic groups needs to be gathered. To be maximally useful, this data should
disaggregate race, gender, and socioeconomic status. Comprehensive longitudinal studies were recommended, with the following
variables to be considered:
- Culture-specific, culture-universal, and cultural process variables (to understand the nature of ethnic disparities)
- Nutrition
- Biological sampling
- Biomarkers (exposure variables; imaging)
- Social environment
- Educational experience
- Legal, political, and ethical issues in data collection from children
- Consideration of other socio-demographic factors (SES, gender, rural vs. urban, language and literacy)
- Involvement of community and family members.
Retrospective studies to link early childhood exposure with adult onset dementias and other disorders found predominantly
in minority populations were considered important, as were studies to investigate the effect of exposure to various contaminants
at different developmental periods in humans.
Group 2 (psychosocial factors) discussed some of the barriers to obtaining good data, including a lack of definitions and
common terms among workers in the field and a general lack of trust within the community being studied. Many examples were
provided that illustrated the importance of involving the community at risk in both the research and the subsequent steps
taken to ameliorate a risk situation.
IV.B. ASSESSMENT
In general the development of research programs on health disparities is hampered by a lack of correct definitions and appropriate
assessments. Specifically, researchers need to adopt standardized definitions for the emotional and cognitive domains that
are evaluated. Many of the issues, as well as the terms used to describe them, are highly sensitive. As one of the working
group participant, Kathleen Westcott pointed out, "There has got to be a way to talk about this without supporting stereotypes..."
Group 2 (psychosocial stressors) highlighted misdiagnosis as a pervasive problem. Behavioral or psychological symptoms in
minority children are not always probed to find out if there are underlying cultural issues such as language, self-image,
or other culture-specific stresses. Thus these children may be over-medicated while the root problems persist.
There was overwhelming consensus that new assessment tools need to be developed. These assessment tools should be at least
culture-neutral, since many of the tests currently used are biased against ethnic populations. Multiple indices of learning
and memory should be assessed, as well as spatial and non-spatial learning. Functional brain imaging might be very informative,
and ought to be exploited especially in the case of children with brain injury or children exposed to environmental contaminants.
Outcome measures need to be tailored to the group being studied, since what is relevant for one group of children may not
be relevant to another. For example, in some Native American populations a highly relevant measure is the percent of children
in satanic cults, a question that is not usually asked on most tests.
Group 2 (psychosocial factors) also discussed the alarming homicide rates in minority youths and the potential contributing
psychological stressors. The group recognized the importance of various factors, such as strong support networks, physical
activity and spirituality, which lead to resilience as compared to vulnerabilities to these stressors.
IV.C. BASIC SCIENCE
Several areas of neuroscience research were considered especially relevant for understanding differences in cognitive and emotional health in minority children.
The participants propose that NINDS encourage research on the impact of exposure and the critical period of susceptibility
to environmental contaminants on higher brain functions that underlie complex behaviors such as learning, memory, attention,
language, cognition, emotion, movement and response to pain. In addition, information about susceptibilities to environmental
agents should be investigated in order to better understand and ameliorate the excess risk of minority children. While environmental
contaminants are not the sole contributors for health disparities in cognitive and emotional health among minority children,
studies of gene-environment interactions are extremely important and such studies could be undertaken and completed in a reasonable
time period.
Other potential research questions include the effects of environmental and psychological insults on the physiological changes
associated with puberty. While it has been documented that African American girls exhibit a significant earlier onset of puberty,
there have been no systematic investigations of potential contributing factors and corresponding impact on brain function
and behavior. Moreover, there have been few investigations of brain changes associated with post-traumatic stress disorder,
attention deficit disorder and differences in drug metabolism in minority children. As the genes involved in various disease
processes are identified, the existence of allelic variants among different ethnic populations should be identified, and population
based studies of gene-environment interactions in disease etiology should be fostered.
The collection of biological samples from ethnic populations was discussed at length. While the participants of the meeting
fully recognized the difficulties and barriers to obtaining biological samples for biological and genetic markers in minority
children, the overwhelming consensus was that there was a pressing need to fully investigate the disparities in cognitive
and emotional health in this population. However, the participants recommended that a task force be established to fully address
the ethics, the type of sample and the ease with which it could be obtained, the cost, and the exact neuropsychological tests
that would be administered in these studies.
IV.D. RISK FACTORS
Some of the risk factors that contribute to health disparities in cognitive and emotional health in minority children were
identified as follows:
- Alcohol (considered to be the leading risk factor for poor health outcome)
- Autoimmune thyroid disease
- Substances of abuse (both physical dependence and effects of social labeling)
- Mercury poisoning (primarily through consumption of fish, for Native American populations exposure also as a result of extensive dental work)
- Polychlorinated Biphenyls (PCBs)
- Polycyclic aromatic hydrocarbons (PAHs), cadmium, lead
- Racism-related stress (important to consider as a risk factor, especially for minority populations)
The contribution of these factors, individually and in combination, should be studied. Since risk factors rarely occur alone,
there was particular interest in studying combinations of risk factors. For example, the cognitive effects of lead exposure
along with cocaine use would be very informative, since these two risk factors are frequently associated.
Working group 2 (psychosocial factors) stressed the existence of heterogeneity within minority groups. Even if a particular
minority population is at higher risk, some children are able to cope better than others. From this observation the idea of
resilience has developed, and it would be important to fully characterize successful coping strategies within the population
at risk.
IV.E. EDUCATION
Group 1 (environmental factors) emphasized the importance of educating the community about health risks, since so many environmental
risks are preventable simply by avoiding them. Community outreach programs are especially valuable. It was noted that early
interventions during key developmental periods were important; and that teaching parenting skills improved not only health
outcome but also a host of other factors.
A second educational goal is to increase and improve mentorship programs starting in the early elementary grades through college
level, with the goal of increasing the cultural diversity of practicing health professionals.
Third, training in cultural competency should be provided to health professionals, so that they have the knowledge and skills
to provide care in a culturally sensitive way. The effectiveness of this training should also be objectively measured to determine
if health outcomes are improved.
IV.F. MULTIDISCIPLINARY, MULTIAGENCY APPROACH THAT INVOLVES COMMUNITY
The meeting participants recognized that the complexity of the issues underlying health disparities would be best addressed
by a multidisciplinary, multiagency approach. For example, the McArthur networks were discussed as a possible model, where
experts from different disciplines are given the resources to meet over several years to discuss and brainstorm about how
to solve a problem. Some NIH Institutes have funded working groups that are similar in concept to the McArthur networks. These
groups are funded for several years, bringing investigators from different disciplines together to identify promising new
approaches, generate pilot data, and ultimately submit competitive multi-investigator as well as single investigator grants.
The participants strongly recommended that the NINDS develop similar models.
Involvement of the target community was considered extremely important. When community leaders joined with researchers, the
quality of the data was much better, and the measures that were developed to handle the risk situation were more appropriate.
The example of work with the Mohawk tribe was given. Community leaders were involved from the early stages of research design,
they approved the final procedures to be used, and they indicated what steps they wished to see implemented should the data
so indicate. The study was very successful, the researchers got the data they needed and the tribe learned how to help themselves,
having decided to follow-up and get more funding once the formal part of the study was completed.
Exit strategies should thus be incorporated into any research program where a community is involved, so that the community
will be empowered to continue after the researchers go home. This helps to ensure that a community, after a period of intense
study and debate, can continue to make positive changes instead of being forgotten after the study is completed.
The meeting participants also discussed the advantages of NINDS partnerships with various service federal agencies. The Substance
Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) have
existing programs to promote youth development, maternal and child health and community outreach. A working collaboration
with agencies with expertise and commitments to the health outcome of children would be beneficial in addressing the problems
of health disparities in minority children. Moreover, the meeting participants also exalted the NIH to foster partnerships
with non-profit foundations (e.g., Annie E Casey Foundation, New Horizons for Learning, George Lucas Educational Foundation,
etc.), that are devoted to the well-being of children and the promotion of innovative educational paradigms.
IV.D. RECOMMENDATIONS
In order for NINDS to further its goal of funding research pursuant to the improvement of cognitive and emotional health in minority children, a change in funding structure, education, and institutional culture was recommended to support integrative and multidisciplinary studies on the cognitive and emotional health in minority children.
The overarching need is for the support of research on the development of neutral and/or culturally sensitive assessment tools,
community based research, and multi-site longitudinal studies. The implementation of these objectives would be best served
by the continued activities of chartered working groups. The following recommendations were agreed upon by both Working Groups:
- Encourage the establishment of multidisciplinary working groups to help frame research questions and gather pilot data.
- Develop new assessment tools that would be sensitive to the following factors: culture, socioeconomic status, gender, rural vs. urban location, language, and literacy.
- Identify and implement the use of (appropriate) biological markers.
- Conduct longitudinal multi-site studies.
- Develop, implement, and provide access to multiple intervention strategies, which are preventative, remedial, culturally relevant and therapeutically effective.
- Establish a board of advisors to provide oversight for legal, political and ethical issues.
- Establish educational opportunities to increase cultural diversity of future health professionals, researchers, and their staff.
- Fund basic neuroscience research to study the effects of post-traumatic stress on the brain, the changes that occur in the brain with puberty (and early onset of puberty), and the impact of environmental contaminants on brain function.
- Encourage multi-NIH Institutes initiatives and multi-agency initiatives (including SAMHSA, HRSA).
Participants
Neuroscience Laboratory
The Kennedy Krieger Research Institute
707 N. Broadway
Baltimore, MD 21205
Phone 410-502-9795
Fax: 410-502-8093
Email: blue@kennedykrieger.org
Cheryl A. Boyce, Ph.D.
Division of Mental Disorders, Behavioral Research and AIDS
National Institute of Mental Health
National Institutes of Health
6001 Executive Boulevard, Room 6200
Bethesda, MD 20892-9617
(Rockville, MD 20852 for FED EX and delivery)
Phone: 301-443-5944
Fax: 301-480-4415
Email: cboyce@nih.gov
Joan M. Cranmer, Ph.D.
Department of Pediatrics
University of Arkansas for Medical Sciences
P.O. Box 24865
Little Rock, AR 72221
Phone: 501-320-2986
Fax: 501-224-1947
Email: CranmerJoanM@uams.edu
Martha B. Denckla, M.D.
Kennedy Krieger Institute
Johns Hopkins University School of Medicine
707 North Broadway
Baltimore, MD 21202
Phone: 410-502-9399
Fax: 410-502-9101
Email: denckla@kennedykrieger.org
Juanita M. Dimas, Ph.D.
Alameda Alliance for Health
1850 Fairway Drive
Alameda, CA 94577
Phone: 510-895-4530
Fax: 510-483-0566
Email: jdimas@alameda-alliance.com
Emmeline Edwards, Ph.D.
Systems and Cognitive Neuroscience
National Institute of Neurological Disorders and Stroke (NINDS)
Neuroscience Center, Room 2109
6001 Executive Boulevard
Bethesda, MD 20892-9521
Phone: 301-496-9964
Fax: 301-402-2060
E-mail: ee48r@nih.gov
Debra Garrett, Ph.D.
The College of New Jersey
Department of Communication Sciences
P.O. Box 7718
Ewing, NJ 08628-0718
Phone: 609-771-2806
Fax: 609-637-5192
Email: dgarrett@tcnj.edu
Darryl B. Hood, Ph.D.
Department of Pharmacology
Meharry Medical College
1005 D. B. Todd Boulevard
Nashville, TN 37208
Phone: 615-327-6358
Fax: 615-327-6632
Email: dhood@mmc.edu
Gayathri Jeyarasasingam, Ph.D.
Office of Minority Health and Research
National Institute of Neurological Disorders and Stroke (NINDS)
Neuroscience Center, Room 2149
6001 Executive Boulevard
Bethesda, MD 20892
Phone: 301-496-3102
Fax: 301-594-5929
E-mail: gj62v@nih.gov
Jean A. King, Ph.D.
Behavioral Neuroscience Program
Department of Psychiatry
University of Massachusetts Medical School
55 Lake Avenue North, Room s7-830
Worcester, MA 01655-0002
Phone: 508-865-4979
Fax: 508-856-5990
Email: jean.king@umassmed.edu
George E. Locke, M.D.
Department of Neurosurgery and Neuroscience
King/Drew Medical Center
12021 South Wilmington Avenue
Los Angeles, CA 90059
Phone: 310-668-4523
Fax: 310-632-6748
Email: gelocke@cdrewu.edu
Bruce S. McEwen, Ph.D.
Laboratory of Neuroendocrinology
The Rockefeller University
1230 York Ave
New York, NY 10021
Phone: 212-327-8624
Fax: 212-327-8634
Email: mcewen@rockefeller.edu
Karin B. Nelson, M.D.
Neuroepidemiology Branch
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Building 10, Room 5S221
10 Center Drive
Bethesda, MD 20892-1447
Phone: 301-594-9486
Fax: 301-496-2358
Email: nelsonk@helix.nih.gov
Bertram R. Payne, Ph.D.
Department of Neurobiology
Boston University School of Medicine
700 Albany Street, W702
Boston, MA 02118
Phone: 617-638-4109
Fax: 617-638-4102
Email: bpayne@bu.edu
Audrey Penn, M.D.
National Institute of Neurological Disorders and Stroke (NINDS)
Building 31, Room 8A52
31 Center Drive
Bethesda, MD 20892
Phone: 301-496-3167
Fax: 301-496-0296
E-mail: penna@ninds.nih.gov
Paul M. Plotsky, Ph.D.
Department of Psychiatry & Behavioral Sciences
Emory University School of Medicine
1639 Pierce Drive, Suite 4000
Atlanta, GA 30322
Phone: 404-727-8258
Fax: 404-727-3233
Email: pplotsky@emory.edu
Gayle Porter, Psy.D.
Senior Mental Health Advisor
American Institutes for Research
5009 13th Street, NW
Washington, D.C. 20011
Phone: 202-298-2631
Fax: 202-298-5408
Email: gporter@air.org
J. Daniel Ragland, Ph.D.
Department of Neuropsychiatry and Psychiatry
University of Pennsylvania
10th Floor Gates Building, HUP
Philadelphia, PA 19104
Phone: 215-615-3609
Fax: 215-662-7903
Email: ragland@bbl.med.upenn.edu
Diane Scott-Jones, Ph.D.
Department of Psychology
Boston College
140 Commonwealth Avenue, McGuinn Hall.
Chestnut Hill, MA 02467-3807
Phone: 617-552-3972
Fax: 617-552-0523
Email: scottjon@bc.edu
Ellen Silbergeld, Ph.D.
Department of Epidemiology & Preventive Medicine
University of Maryland Medical School
10 South Pine Street
Baltimore, MD 21210
Phone: 410-706-8709
Fax: 410-706-0727
Email: esilbergeld@epi.umaryland.edu
Sonya K. Sobrian, Ph.D.
Department of Pharmacology
Howard University College of Medicine
520 W Street, NW
Washington, DC 20059
Phone: 202-806-7901
Fax: 202-806-4453
Email: ssobrian@fac.howard.edu
Ella Vallar, M.A.
Special Educator
David H. Hickman High School
Columbia Public Schools
Columbia, MO 65212
Phone: 573-214-3015
Email: vallare2000@yahoo.com
Kathleen D. Westcott, M.A., A.T.R.
Circle of Nations Residential School
3706 Round Lake Road
Brimson, MN 55602
Phone: 218-848-2622
Email: sangwinaria@hotmail.com
Last updated February 09, 2005
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