Childhood Disintegrative Childhood Disintegrative Disorder:Disorder:

An Overview and Guide for Early Childhood An Overview and Guide for Early Childhood ProfessionalsProfessionals

Ngoc T. Tang

Learner ObjectivesLearner Objectives

• Describe ways to help parents cope Describe ways to help parents cope when they learn their child has a when they learn their child has a disabilitydisability

• Note common symptoms of childhood Note common symptoms of childhood disintegrative disorder (CDD)disintegrative disorder (CDD)

• List and explain school services for List and explain school services for children with disabilities who meet the children with disabilities who meet the criteriacriteria

DefinitionDefinitionChildhood disintegrative disorder (CDD) is a rare conditionChildhood disintegrative disorder (CDD) is a rare conditionthat affects children most often around ages 3-4, but may that affects children most often around ages 3-4, but may

rangerangefrom ages 2-10from ages 2-1011. As written in the . As written in the Diagnostic and StatisticalDiagnostic and StatisticalManual of Mental Disorders IV-TR Manual of Mental Disorders IV-TR (DSM-IV-TR), there must (DSM-IV-TR), there must

be:be:““After at least 2 years of normal postnatal development, significant lossesAfter at least 2 years of normal postnatal development, significant losses

manifest in the following domains:manifest in the following domains:

1.1. Expressive or receptive languageExpressive or receptive language

2.2. Social or adaptive behaviorSocial or adaptive behavior

3.3. Bladder or bowel controlBladder or bowel control

4.4. PlayPlay

5.5. Motor skillsMotor skills

AND the development of features of autistic disorderAND the development of features of autistic disorder”5, 1”5, 1

8. Mayo Clinic Staff (2006)5. Findling, R., Leventhal, B., & Scahill, L. (2007)1. American Psychiatric Association (2000)1. American Psychiatric Association (2000)

BackgroundBackground• Originally reported as Originally reported as dementia infantilisdementia infantilis by by

Theodore Heller in 1908. Other known names are: Theodore Heller in 1908. Other known names are: Heller syndromeHeller syndrome

Progressive disintegrative psychosisProgressive disintegrative psychosis

Pervasive disintegrative disorderPervasive disintegrative disorder88

• Part of the umbrella group of Pervasive Part of the umbrella group of Pervasive Developmental Disorders (PDD)Developmental Disorders (PDD)

Asperger SyndromeAsperger Syndrome Autistic DisorderAutistic Disorder Childhood Disintegrative DisorderChildhood Disintegrative Disorder Rett SyndromeRett Syndrome Pervasive Developmental Disorder Not Otherwise Pervasive Developmental Disorder Not Otherwise

SpecifiedSpecified1010

8. Mayo Clinic Staff (2006)Mayo Clinic Staff (2006)10. Strock (2004)

BackgroundBackground• Similar to autism but is often distinguished by Similar to autism but is often distinguished by

its late age of onset and the severity of its late age of onset and the severity of regressionregression77

• Since CDD is rare, there is limited information Since CDD is rare, there is limited information available. Autism, which occurs more available. Autism, which occurs more frequently, should be used as a guide.frequently, should be used as a guide.

• Causes are unknownCauses are unknown

• Regression can occur abruptly from days to Regression can occur abruptly from days to weeks or gradually over an extended period of weeks or gradually over an extended period of timetime88

7. Mouridsen, S.E. (2003)Mouridsen, S.E. (2003)8. Mayo Clinic Staff (2006)

PrevalencePrevalence

• Childhood disintegrative disorder is Childhood disintegrative disorder is quite rarequite rare 1.7 per 100,000 children (avg. of four 1.7 per 100,000 children (avg. of four

studies)studies)66

• rates have a wide rangerates have a wide range Occurs more in males than femalesOccurs more in males than females4 4

6. Fombonne (2002)4. Childhood Disintegrative Disorder

Identifying CDDIdentifying CDD• Warning signs and symptomsWarning signs and symptoms

Loss of social skills Loss of social skills Loss of bowel and bladder control Loss of bowel and bladder control Loss of expressive or receptive language Loss of expressive or receptive language Loss of motor skills Loss of motor skills Lack of play Lack of play Failure to develop peer relationships Failure to develop peer relationships Impairment in nonverbal behaviors Impairment in nonverbal behaviors Delay or lack of spoken language Delay or lack of spoken language Inability to start or sustain a conversationInability to start or sustain a conversation

11. Voorhees (2006)Voorhees (2006)

Identifying CDDIdentifying CDD

• What What parentsparents should do: should do: Stage 1- Schedule a check-upStage 1- Schedule a check-up

• Take child routinely for well-child checkups at his Take child routinely for well-child checkups at his primary care provider. primary care provider.

• In case of suspected problems, ask for a In case of suspected problems, ask for a developmental screening.developmental screening.

Stage 2- Evaluation and diagnosis by team of Stage 2- Evaluation and diagnosis by team of experts, which may include:experts, which may include:

• Psychologist, neurologist, psychiatrist, speech Psychologist, neurologist, psychiatrist, speech therapist, occupational therapist, physical therapisttherapist, occupational therapist, physical therapist

10. Strock (2004)

Getting HelpGetting Help Stage 3- DiagnosisStage 3- Diagnosis

• Get a notebook to write everything down. No one Get a notebook to write everything down. No one can remember everything.can remember everything.

• Gather information and contacts from specialists. Gather information and contacts from specialists. They will help you adjust and offer financial and They will help you adjust and offer financial and emotional help.emotional help.

• Join a support group or network.Join a support group or network. Stage 4- TreatmentStage 4- Treatment

• MedicationMedication• TherapyTherapy• Individualized program for your childIndividualized program for your child

10. Strock (2004)

ScreeningScreening• Stage 1- Developmental screeningStage 1- Developmental screening

Healthcare provider asks parents questions Healthcare provider asks parents questions related to normal development, focusing on related to normal development, focusing on social, emotional, and intellectual development. social, emotional, and intellectual development. Some questions are:Some questions are:

“ “Does your child… Does your child… • Not speak as well as other children her age?” Not speak as well as other children her age?” • Seems unable to tell you what she wants, and so takes your Seems unable to tell you what she wants, and so takes your

hand and leads you to it, or gets it herself?” hand and leads you to it, or gets it herself?” • Have trouble following simple directions?”Have trouble following simple directions?”• Prefer to play alone?”Prefer to play alone?”• Not play “make-believe” games?”Not play “make-believe” games?”• Not play with toys in a usual wayNot play with toys in a usual way• Act as if she is in her own world?” Act as if she is in her own world?” NICHDNICHD

Possible indicators should lead to further Possible indicators should lead to further evaluationevaluation

9. National Institute of Child Health and Human Development (2005)

EvaluationEvaluation

• Stage 2- Comprehensive evaluation:Stage 2- Comprehensive evaluation: Review of child’s:Review of child’s:

• Developmental historyDevelopmental history• Family historyFamily history• Medical historyMedical history

Physical examinationPhysical examination Auditory test- to rule out transient hearing lossAuditory test- to rule out transient hearing loss Lead exposure- children chew on objects Lead exposure- children chew on objects

during their oral-motor stage, a cause for during their oral-motor stage, a cause for mental retardationmental retardation

Language assessment- communication skillsLanguage assessment- communication skills

5. Findling, R., Leventhal, B., & Scahill, L. (2007)5. Findling, R., Leventhal, B., & Scahill, L. (2007)

EvaluationEvaluation Medical examination- Medical examination-

• Neurological exam- lesions or possible seizure disorderNeurological exam- lesions or possible seizure disorder• Genetics assessment- syndromesGenetics assessment- syndromes• Cognitive- general functionCognitive- general function1010

Specific measures:Specific measures:• Autism Diagnosis Interview- Revised (ADI-R)- determines Autism Diagnosis Interview- Revised (ADI-R)- determines

child’s social interaction, communication, repetitive behaviors, child’s social interaction, communication, repetitive behaviors, and age-of-onset symptomsand age-of-onset symptoms

• Autism Diagnostic Observation Schedule (ADOS-G)- contains Autism Diagnostic Observation Schedule (ADOS-G)- contains activities to observe patient’s social and communication activities to observe patient’s social and communication behaviorsbehaviors

• Vineland Adaptive Behavior Scale- measures child’s functional Vineland Adaptive Behavior Scale- measures child’s functional abilitiesabilities

• Aberrant Behavior Checklist (ABC)- evaluates behavior Aberrant Behavior Checklist (ABC)- evaluates behavior problemsproblems55

10. Strock (2004)5. Findling, R., Leventhal, B., & Scahill, L. (2007)5. Findling, R., Leventhal, B., & Scahill, L. (2007)

DiagnosisDiagnosis

• Stage 3- Communicating with Stage 3- Communicating with parentsparents Telling parents that their child may be Telling parents that their child may be

having problems and difficulties can be having problems and difficulties can be hard for anyone.hard for anyone.

Although parents may expect something Although parents may expect something is wrong, there is usually shock and loss is wrong, there is usually shock and loss associated with an affirmative diagnosisassociated with an affirmative diagnosis

5. Findling, R., Leventhal, B., & Scahill, L. 5. Findling, R., Leventhal, B., & Scahill, L. (2007)(2007)

DiagnosisDiagnosis

• Minimize stress for ParentsMinimize stress for Parents Include parents in the evaluation process as Include parents in the evaluation process as

much as possible so they understand what much as possible so they understand what their child can and cannot dotheir child can and cannot do

• Talk about both strengths and weaknessesTalk about both strengths and weaknesses Let parents know that negative reactions are Let parents know that negative reactions are

normal and acceptablenormal and acceptable• Grieving, anger, a sense of loss, shock, helplessnessGrieving, anger, a sense of loss, shock, helplessness• Parents may need to take a trip to unwindParents may need to take a trip to unwind5, 105, 10

5. Findling, R., Leventhal, B., & Scahill, L. (2007)5. Findling, R., Leventhal, B., & Scahill, L. (2007) 10. Strock (2004)

Diagnosis

Help prepare information and contactsHelp prepare information and contacts• Parents may not remember all the information you Parents may not remember all the information you

tell them during the first session. tell them during the first session. • Repeat information several times if necessaryRepeat information several times if necessary• Organize information and write it down so parents Organize information and write it down so parents

can look at it when they are more ready tocan look at it when they are more ready to5, 105, 10

5. Findling, R., Leventhal, B., & Scahill, L. 5. Findling, R., Leventhal, B., & Scahill, L. (2007)(2007) 10. Strock (2004)

TreatmentTreatment• Stage 4- Treatment is similar to children Stage 4- Treatment is similar to children

with autismwith autism Assemble treatment team, adding people Assemble treatment team, adding people

similar to the diagnostic team similar to the diagnostic team • Include parents and teachers Include parents and teachers

Review available community resourcesReview available community resources• SchoolsSchools• Parent groupsParent groups• State and private agenciesState and private agencies• Respite programsRespite programs

10. Strock (2004)

TreatmentTreatment

• Specialized MembersSpecialized Members Language therapy- Language therapy-

• Improve social interaction and Improve social interaction and communication with peerscommunication with peers

• Develop language skillsDevelop language skills• Using pictures to help communicate needsUsing pictures to help communicate needs

Physical therapy-Physical therapy-• Improve movement, posture, balanceImprove movement, posture, balance

Occupational therapy-Occupational therapy-• Adjusts environment to the child’s needsAdjusts environment to the child’s needs

5. Findling, R., Leventhal, B., & Scahill, L. Findling, R., Leventhal, B., & Scahill, L. (2007)(2007)

TreatmentTreatment

• Develop a highly structured and Develop a highly structured and individualized program created by the individualized program created by the health professional and parent team, health professional and parent team, that:that: Aims to develop areas of difficultyAims to develop areas of difficulty Builds on child’s strengths and interestsBuilds on child’s strengths and interests Offers a predictable routineOffers a predictable routine Teaches skills in simple stepsTeaches skills in simple steps Provides frequent and positive Provides frequent and positive

reinforcementreinforcement Suggests structured and attractive activitiesSuggests structured and attractive activities

10. Strock (2004)

TreatmentTreatment

• Behavior managementBehavior management Reinforce desirable behaviorsReinforce desirable behaviors Reduce/extinguish undesirable Reduce/extinguish undesirable

behaviorsbehaviors Educate parents on how to work with Educate parents on how to work with

their childtheir child

9. National Institute of Child Health and Human Development (2005)

TreatmentTreatment

• Medications-Medications- Anti-psychotics are used to treat behavior Anti-psychotics are used to treat behavior

problemsproblems• Typical: haloperidol, thioridazine, fluphenazine, Typical: haloperidol, thioridazine, fluphenazine,

chlorpromazinechlorpromazine• Atypical: risperidone, olanzapine, ziprasidoneAtypical: risperidone, olanzapine, ziprasidone

Anticonvulsants help treat seizuresAnticonvulsants help treat seizures• Carbamazepine, lamotrigine, topiramate, valproic Carbamazepine, lamotrigine, topiramate, valproic

acidacid Monitor effects closely to determine benefitMonitor effects closely to determine benefit Inform parents of potential side effectsInform parents of potential side effects8, 108, 10

8. Mayo Staff Clinic (2006)10. Strock (2004)

TreatmentTreatment

• Other interventionsOther interventions Dietary- some children with autism Dietary- some children with autism

benefit from certain dietsbenefit from certain diets• Casein free dietCasein free diet

A protein found in milk, wheat, oat, rye, barleyA protein found in milk, wheat, oat, rye, barley More expensive than regular foodsMore expensive than regular foods

• Vitamin B6 supplement with magnesiumVitamin B6 supplement with magnesium• Secretin- single dose onlySecretin- single dose only

May improve symptomsMay improve symptoms Sleep patterns, eye contact, language skills, Sleep patterns, eye contact, language skills,

alertnessalertness

10. Strock (2004)

TreatmentTreatment

• Key components for effective early Key components for effective early interventionintervention Provide services at earliest possible ageProvide services at earliest possible age At least 20 hours per weekAt least 20 hours per week Parental involvement, training, and supportParental involvement, training, and support Focused on social and communication skillsFocused on social and communication skills Instruction with individualized goalsInstruction with individualized goals Help child generalize skills to other settingsHelp child generalize skills to other settings

5. Findling, R., Leventhal, B., & Scahill, L. (2007)5. Findling, R., Leventhal, B., & Scahill, L. (2007)

Financial AssistanceFinancial Assistance

• Several types of Medical Assistance (MA)Several types of Medical Assistance (MA) Also known as Title 19Also known as Title 19 Available to parents of children with severe Available to parents of children with severe

disabilities under age 18disabilities under age 18 May cover therapeutic and other medical May cover therapeutic and other medical

costscosts Available funding varies by locationAvailable funding varies by location

For more information, contact For more information, contact

your state Department of Health and Human Services or your state Department of Health and Human Services or

Developmental Disabilities AdministrationDevelopmental Disabilities Administration

3. Autism Society of America (n.d.)

Legal Safeguards in Legal Safeguards in PennsylvaniaPennsylvania

• Individuals with Disabilities Education Act Individuals with Disabilities Education Act (IDEA)-(IDEA)- Must meet federal and state criteriaMust meet federal and state criteria Makes it possible for children with disabilities to Makes it possible for children with disabilities to

receive free educational services and devices to receive free educational services and devices to facilitate learningfacilitate learning

Available from age 3 through high school or age 21Available from age 3 through high school or age 21 Contact principal or special education coordinator Contact principal or special education coordinator

for qualification assessmentfor qualification assessment

9. National Institute of Child Health and Human Development (2005)

Legal Safeguards in Legal Safeguards in PennsylvaniaPennsylvania

• Individual education plan (IEP)- Individual education plan (IEP)- Qualification for IEP is easier to receive than IDEAQualification for IEP is easier to receive than IDEA Required by law for children with special education Required by law for children with special education

needsneeds Written document between the school and family, Written document between the school and family,

tailored to the child’s educational needstailored to the child’s educational needs States educational goals and environmental changesStates educational goals and environmental changes

• Addressing academic achievement, adaptive behavior goals, Addressing academic achievement, adaptive behavior goals, motor skills, communication skills, motor skills, communication skills,

• Adaptations to environment such as extending programs Adaptations to environment such as extending programs into the home, allowing more time on work, extending into the home, allowing more time on work, extending school yearschool year

9. National Institute of Child Health and Human Development (2005)

EducationEducation• School-based programsSchool-based programs

All public schools must provide services for All public schools must provide services for children with disabilities ages 3-21children with disabilities ages 3-21

Must have an educational evaluation provided Must have an educational evaluation provided by the public school to receive servicesby the public school to receive services

• Special education for childrenSpecial education for children Offer highly-structured settingOffer highly-structured setting Use visuals to accompany instructionUse visuals to accompany instruction Build on child’s interestsBuild on child’s interests Include specialists from treatment teamInclude specialists from treatment team

2. Autism Society of America (2006)

EducationEducation• ParentsParents

Regular communication between parents and Regular communication between parents and teachersteachers

• Utilize notebooks, e-mail, phone calls, meetingsUtilize notebooks, e-mail, phone calls, meetings Special education can offer:Special education can offer:

• Lower student to teacher ratioLower student to teacher ratio• Trained and experienced professionals who have Trained and experienced professionals who have

worked with children with disabilitiesworked with children with disabilities• Many environmental and educational adjustmentsMany environmental and educational adjustments• Special equipment and learning toolsSpecial equipment and learning tools• Respite servicesRespite services• Parent trainingParent training• Emergency careEmergency care• Resource referralResource referral

2. Autism Society of America (2006)

Information for ParentsInformation for Parents

• Refer to the brochure handoutRefer to the brochure handout Brief information about CDDBrief information about CDD Local and national support servicesLocal and national support services

• National Alliance on Mental Illness of Pennsylvania National Alliance on Mental Illness of Pennsylvania HelplineHelpline Provides information, referrals, emotional support- (800) 223-Provides information, referrals, emotional support- (800) 223-

05000500

• Autism Society of America (ASA)-Autism Society of America (ASA)- Information and support Information and support Led by parents of children on the autism spectrumLed by parents of children on the autism spectrum www.autism-society.orgwww.autism-society.org

• MayoClinicMayoClinic Information and educationInformation and education www.mayoclinic.com/health/childhood-disintegrative-www.mayoclinic.com/health/childhood-disintegrative-

disorder/DS00801disorder/DS00801

Information for ParentsInformation for Parents

• LiteratureLiterature Helpful Responses to Some of the Behaviors Helpful Responses to Some of the Behaviors

of Individuals with Autismof Individuals with Autism by Nancy by Nancy DalrympleDalrymple

Children with Autism: A Parents’ GuideChildren with Autism: A Parents’ Guide edited by Michael D. Powersedited by Michael D. Powers

The Complete IEP Guide: How to Advocate The Complete IEP Guide: How to Advocate for You Special Ed. Childfor You Special Ed. Child by Lawrence M. by Lawrence M. SiegelSiegel

Siblings of Children with Autism: A Guide for Siblings of Children with Autism: A Guide for FamiliesFamilies by Sandra L. Harris by Sandra L. Harris

For further informationFor further information• National Alliance on Mental Illness of Pennsylvania (NAMI)- National Alliance on Mental Illness of Pennsylvania (NAMI)-

Education and support to families with mental illnessesEducation and support to families with mental illnesses Education and information to mental health consumersEducation and information to mental health consumers namipa.nami.orgnamipa.nami.org

• National Information Center for Children and Youth with National Information Center for Children and Youth with DisabilitiesDisabilities Information and resourcesInformation and resources www.nichcy.orgwww.nichcy.org

• U.S. Department of Health and Human ResourcesU.S. Department of Health and Human Resources Information and financial aidInformation and financial aid www.hhs.gov/children/index.htmlwww.hhs.gov/children/index.html

• National Institute of Child Health and Human DevelopmentNational Institute of Child Health and Human Development Education and researchEducation and research www.nichd.nih.govwww.nichd.nih.gov

For further informationFor further information• LiteratureLiterature

Inclusion: 450 Strategies for Success: A Practical Inclusion: 450 Strategies for Success: A Practical Guide for All Educators Who Teach Students with Guide for All Educators Who Teach Students with DisabilitiesDisabilities by Peggy A. Hammeken by Peggy A. Hammeken

Teaching Children with Autism: Strategies for Teaching Children with Autism: Strategies for Initiating Positive Interactions and Improving Initiating Positive Interactions and Improving Learning OpportunitiesLearning Opportunities edited by Robert and Lynn edited by Robert and Lynn KoegelKoegel

Behavioral Interventions for Young Children with Behavioral Interventions for Young Children with Autism: A Manual for Parents and ProfessionalsAutism: A Manual for Parents and Professionals edited by Catherine Maurice, Gina Green, and edited by Catherine Maurice, Gina Green, and Stephen C. LuceStephen C. Luce

Learning and Cognition in AutismLearning and Cognition in Autism edited by Eric edited by Eric Schopler and Gary B. MesibovSchopler and Gary B. Mesibov

ReferencesReferences1. American Psychiatric Association (2000).1. American Psychiatric Association (2000). Diagnostic and Diagnostic and

statistical manual of statistical manual of mental disorders mental disorders (4th ed., text revision).(4th ed., text revision). Washington, DC: Author. Washington, DC: Author.

2. Autism Society of America (2006). 2. Autism Society of America (2006). Building Our Future: Building Our Future: Educating Students on the Educating Students on the Autism SpectrumAutism Spectrum. n.d., 1-12.. n.d., 1-12.

3. Autism Society of America. (n.d.). 3. Autism Society of America. (n.d.). Next Steps: A Guide for Next Steps: A Guide for Families New to Families New to AutismAutism. n.d., 1-7.. n.d., 1-7.

4. Childhood disintegrative disorder4. Childhood disintegrative disorder. Retrieved September 15, . Retrieved September 15, 2007, from Yale 2007, from Yale Developmental Disabilities Clinic Web site: Developmental Disabilities Clinic Web site:

http://www.med.yale.edu/chldstdy/autism/cdd.htmlhttp://www.med.yale.edu/chldstdy/autism/cdd.html

5. Findling, R., Leventhal, B., & Scahill, L. (2007). Counseling 5. Findling, R., Leventhal, B., & Scahill, L. (2007). Counseling Points: Current Points: Current Concepts in the Diagnosis of Autism Concepts in the Diagnosis of Autism Spectrum Disorders. Spectrum Disorders. Autism Autism Counseling Points 1Counseling Points 1 (3), 3-11. (3), 3-11.

6. Fombonne, Eric (2002). Prevalence of childhood disintegrative 6. Fombonne, Eric (2002). Prevalence of childhood disintegrative disorder. disorder. SAGE Publications and The National Autistic SAGE Publications and The National Autistic Society, 6Society, 6 (2), 149-157. (2), 149-157.

ReferencesReferences7. Mouridsen, S.E. (2003). Childhood disintegrative disorder. 7. Mouridsen, S.E. (2003). Childhood disintegrative disorder. Brain Brain

and and Development: Official Journal of the Japanese Society of Development: Official Journal of the Japanese Society of Child Neurology, 25Child Neurology, 25, 225-, 225- 228. Retrieved September 21, 228. Retrieved September 21, 2007, from PsycInfo database.2007, from PsycInfo database.

8. Mayo Clinic Staff (2006). 8. Mayo Clinic Staff (2006). Childhood disintegrative disorderChildhood disintegrative disorder. . Retrieved September Retrieved September 15, 2007, from MayoClinic.com 15, 2007, from MayoClinic.com Website: Website:

http://www.mayoclinic.com/health/childhood-disintegrative-http://www.mayoclinic.com/health/childhood-disintegrative-disorder/DS00801/DSECTION=1disorder/DS00801/DSECTION=1

9. National Institute of Child Health and Human Development 9. National Institute of Child Health and Human Development (2005). (2005). Autism Autism Overview: What We KnowOverview: What We Know. n.d., 1-16.. n.d., 1-16.

10. Strock, Margaret (2004). 10. Strock, Margaret (2004). Autism Spectrum Disorders: Autism Spectrum Disorders: Pervasive Developmental Pervasive Developmental Disorders.Disorders. NIH Publication No. NIH Publication No. NIH-04-5511, National Institute of NIH-04-5511, National Institute of Mental Health, National Mental Health, National Institutes of Health, U.S. Department of Institutes of Health, U.S. Department of Health and Human Health and Human Services, Bethesda, MD, 40.Services, Bethesda, MD, 40.

11. Voorhees, Benjamin (2006). 11. Voorhees, Benjamin (2006). Childhood disintegrative disorderChildhood disintegrative disorder. . Retrieved Retrieved September 15, 2007, from Medline Plus Website: September 15, 2007, from Medline Plus Website:

http://www.nlm.nih.gov/medlineplus/ency/article/ 001535.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/ 001535.htm

Contact InformationContact Information

Ngoc T. TangNgoc T. Tang

Masters candidate in Psychology in Education Masters candidate in Psychology in Education

University of PittsburghUniversity of Pittsburgh

E-mail: E-mail: ntt2@pitt.edu

Replication of any materials requires prior approval. Replication of any materials requires prior approval.