Faculty Bibliography

To elucidate molecular, cellular, and circuit changes that occur in the brain during learning, we investigated the role of a glutamate receptor subtype in fear conditioning. In this form of learning, animals associate two stimuli, such as a tone and a shock. Here we report that fear conditioning drives AMPA-type glutamate receptors into the synapse of a large fraction of postsynaptic neurons in the lateral amygdala, a brain structure essential for this learning process. Furthermore, memory was reduced if AMPA receptor synaptic incorporation was blocked in as few as 10 to 20% of lateral amygdala neurons. Thus, the encoding of memories in the lateral amygdala is mediated by AMPA receptor trafficking, is widely distributed, and displays little redundancy

Evidence-based medicine (EBM) is defined as a set of processes that facilitate the conscientious, explicit, and judicious integration of individual clinical expertise with the best available external clinical evidence from systematic research in making decisions about the care of individual patients. EBM focuses not only on grading the strength of the evidence but also on the processes and tools that are necessary for clinicians to continually upgrade their knowledge and skills for those problems encountered in daily practice. This article, authored by members of the Duke Pediatric Psychiatry EBM Seminar Team, (1) describes EBM as applied to the training of child and adolescent psychiatrists in the Division of Child and Adolescent Psychiatry, Department of Psychiatry at Duke University Medical Center; (2) presents a simplified discussion of EBM as a technology for training and patient care; (3) discusses the basic principles and procedures for teaching EBM in the setting of a multidisciplinary training program; and (4) briefly mentions two training and research initiatives that are furthered by incorporating EBM.

With the emergence of postmodern models and critiques, the concept of symptom functionality has lost favor in the family therapy field. To be reconsidered as clinically valuable it must both demonstrate pragmatic utility and meet ethical and conceptual criteria. Functional hypotheses cannot be believed too strongly, used to blame, or employed without considerations of biology. Symptom functionality is considered in its strong and weak versions. Tempered by the more ecological weak sense, strong-sense functional hypotheses are presented as one form of description that can guide a therapist's actions

The aim of this paper was to discuss the arguments for and against the use of atypical antipsychotics in children and adolescents with aggression, and provide recommendations for future research. A MEDLINE search (1985-2004) was performed to identify key literature. Search terms included, but were not limited to, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, children, and adolescents. The search was limited to English-language literature and randomized controlled trials. The use of atypical antipsychotics in children and adolescents has increased significantly over the past few years. Atypical antipsychotics are associated with a more favorable side-effect profile, and growing evidence supports their efficacy for aggression in this population. However, the long-term effects of these agents are unknown. No head-to-head evidence exists to suggest whether pharmacological or nonpharmacological treatments are superior for managing aggression associated with childhood and adolescent psychiatric and behavioral conditions. Future research of atypical antipsychotics in children and adolescents needs to evaluate not only the efficacy but also the effectiveness. Examination of treatment mediators and moderators may help to optimize treatment regimens and improve patient outcomes. Finally, effective interventions require the development and implementation of evidence-based treatment strategies using a multidisciplinary approach.

OBJECTIVE: To assess the effect of escitalopram in the treatment of pervasive developmental disorders (PDDs). METHOD: This 10-week study had a forced titration, open-label design. Twenty-eight subjects (mean age 125.1 +/- 33.5 months) with a PDD received escitalopram at a dose that increased weekly to a maximum dose of 20 mg as tolerated. The Aberrant Behavior Checklist-Community Version (ABC-CV) and the Clinical Global Impression scale (CGI) were used to assess outcome. RESULTS: There was significant improvement in ABC-CV Irritability Subscale Scores (baseline mean 20.5 +/- 5.9 to final mean 10.9 +/- 7.2; p < or = .001) and in the other ABC-CV Subscales. Improvement on Clinical Global Improvement Scale severity rating was also significant (baseline mean 5.2 +/- 1.0 to final mean 4.6 +/- 1.2; p < or = .001). Twenty-five percent of the subjects responded at a dose less than 10 mg and did not tolerate the 10-mg dose, and an additional 36% responded at a dose greater than or equal to 10 mg. Final dose was unrelated to weight and only weakly correlated with age. CONCLUSIONS: This open-label study found escitalopram to be useful in treating some difficulties common in PDDs. A wide variability in dose was found that could not be accounted for by weight and only partially by age. The study provides information useful for the design of double-blind, placebo-controlled studies of escitalopram in PDDs