Visitor Spotlight: Gal Shoval

Friday, Jul 23, 2021
by Aimee Bronfeld, Center for Health and Wellbeing

Gal Shoval, M.D. has always been fascinated by the human body, particularly the brain, which he regards as the “greatest enigma by far.” While his aspirations of becoming a psychiatrist emerged early, it wasn’t until he worked for an underprivileged high school in South Tel Aviv that the Israeli native found his calling. There, as a medical student and mentor, he discovered an affinity for helping young people and grew to appreciate the intrinsic connection between education, science and clinical practice.

Dr. Shoval, director of the Child and Adolescent Division of Geha Mental Health Center and associate professor at Tel Aviv University, is currently on sabbatical to engage in collaborative research at the Center for Health and Wellbeing (CHW) and Princeton Neuroscience Institute (PNI). In this Spotlight, he discusses the five-year, international project behind his visit, his longstanding curiosity about the developing brain, and his ambitions for promoting stronger children, families and communities.

Q. You served three years in the Israeli army before attending medical school. Did this service guide your career and specialization in mental health?

A. I was interested in biology, medicine and neuroscience long before my army service. Even as an adolescent, I wanted to know how the brain works… why individuals fall in love with certain people or make different decisions in their lives, such as repeating the same mistakes or taking risks. While I decided to attend medical school around the age of 16, the mandatory army service after high school strengthened my resolve and influenced my focus on children and adolescents.

I was chosen to be a mentor for new, uniquely-talented trainees during a significant portion of my army service. This was the first time that I worked with youngsters and when I realized that being a teacher and being a therapist are not two different things. On the contrary, they go hand in hand and support one another. This experience led to my involvement in a project in civil life that profoundly impacted my career.

Q. Can you tell me about this project?

A. During medical school, I joined with some of the veterans of that army unit to help kids in a socially and economically disadvantaged community. We launched a school-based project that was originally designed to share better teaching methods in certain key areas, like math and Arabic, but it quickly transformed into a program that emphasized personal mentoring and encouragement of curiosity. This training paved the way for individual growth while promoting societal values. 

I remained at that school for nine consecutive years – even after I graduated from medical school and started my residencies. I’m still in touch with many of the students, 20 or 30 years later, who tell me that it wasn’t the teaching that made the biggest difference in their lives but the relationships and the many guests we brought in, such as university professors or figures with impressive vision. These guests exposed the kids to opportunities beyond high school, broadening their horizons and opening doors to a whole new world.

Q. How did this high school project affect your perspective and the trajectory of your career?

A. I learned that you cannot see children one-dimensionally. A child with depression, for example, probably has additional problems, such as learning disabilities, behavioral issues or health concerns that may not be sufficiently addressed. You need to target all of them to help the child comprehensively.

I remember an important, defining moment when one of the students in my class suddenly fainted. We rushed her to a nearby hospital, where we learned something that was obvious to the doctors but not to the teachers or to me. This young girl who was excelling in everything, from her studies to sports, was also suffering from anorexia nervosa and bulimia nervosa – which she had developed right before our eyes. In retrospect, there were many alarming signs that nobody recognized. This experience clarified, for me, the value of integrating school and medicine and led to an interest in the prevention, early detection and treatment of psychiatric disorders in youngsters.

Notably, I’m one of only a few professionals known to work as both a teacher and a psychiatrist for adolescents and children.

Q. What did you do immediately following your medical training?

A. After graduating from Tel Aviv University’s Sackler School of Medicine, I completed two residencies – one in psychiatry and the other in child and adolescent psychiatry – at Geha Mental Health Center, where I later assumed management roles in the Child and Adolescent Emergency Unit and Adolescent Day Ward. This well-known institution was the first mental health center in Israel, established in the 1940’s before Israel was an independent state.

I was not so fascinated with research when I started but soon understood that in order to be a good clinician, you also need to be engaged in research. I realized that if you don’t read the scientific papers and conduct research of your own, then you cannot be a leader who makes an impact on the field. Over the years, Geha has helped me progress in both the clinical world and with my research. I’ve been heading the center’s Division of Child and Adolescent Psychiatry for the past three years and have published more than 90 papers and book chapters.

Importantly, I’ve learned that medicine, particularly psychiatry, is also a social occupation. The field is greatly affected by stressors, like wars or pandemics, and can deeply impact many aspects of people’s lives. With this in mind, I have been allowed and encouraged to pursue roles on a national level and to lead activities aimed at making changes in society.

Q. To that point, your CV highlights several community outreach initiatives addressing teen addiction and other risk behaviors. Were any of these endeavors especially noteworthy or consequential?

A. In 2007, I led a national suicide prevention program for Israeli boarding schools, which had contacted the Geha Mental Health Center because they had an epidemic of teen suicides among Ethiopian immigrants. Our team responded by creating a simple yet highly successful intervention. We trained the school’s personnel to recognize signs of depression in youngsters and to intervene quickly if they sensed that someone may be in trouble. We emphasized that there is no doubt when it comes to mental health, urging them to refer these students to a psychiatrist or psychologist without hesitation or fear of stigma. Within one year, the suicide rate for this population dropped to zero.

We learned that although the heads of these schools were outstanding educators and administrators, they barely knew anything about mental health. With the proper tools and collaboration, it is often easy to diagnose and treat early symptoms of mental illness, which not only prevents suicide but also stress and suffering.

Q.  In addition to your clinical practice at Geha Mental Health Center, you teach at Tel Aviv University, Sackler School of Medicine. Why did you incorporate this role into your career?

A. It is nice to make scientific discoveries, but it’s also nice to share them – and not just within a university setting. I enjoy teaching beyond the classroom. My vision is that science should be more accessible to everybody. In psychiatry, we often help families by educating them about mental health and ways to improve the quality of life for both parents and children.

A good example of this impact, over the last decade, is the de-stigmatization of psychiatric disorders. An increase in awareness and education has freed parents from the guilt associated with a mental health diagnosis while more youngers are receiving proper therapy, which may be life-changing or even life-saving. I recently authored a paper, published by JAMA Network journal, showing a link between ADHD therapy and decreased suicidal behaviors in children with ADHD-related symptoms.

I consider teaching, on campus and in the community, a part of my mission here at Princeton during this two-year sabbatical.

Q.  You first came to Princeton in 2017, when you spent two months working with another CHW affiliate, Yael Niv. What inspired that visit and then brought you back in 2021 as a CHW visiting research scholar and C.V. Starr Fellow at PNI?

A. Princeton has amazing neuroscientists doing cutting edge research, but it does not have a medical school or psychiatrists. As a practicing physician, I bring clinical expertise and a different perspective, enabling us to pool our resources and forge a valuable partnership between the two institutions and disciplines.

Over the years, Dr. Niv and I have developed a strong, collaborative relationship. I was captivated by her research exploring decision-making processes, which prompted my initial visit. Her work was originally focused on healthy adults, but I was fascinated by the possibility of expanding the study to also include youngsters and individuals with psychiatric disorders.

We have received a large research grant of almost $2 million [from the National Institutes of Health and the U.S.-Israeli Binational Science Foundation, BSF] for a five-year, multi-center study to explore the subject further. This funding allowed us to build an international group of researchers, which also includes Dr. Catherine Hartely from New York University and Dr. Eran Eldar from the Hebrew University in Jerusalem, to characterize – computationally, cognitively and neurally – the decision-making phenotype of adolescents and then relate this phenotype to psychopathology. This is one of the main projects that I’ll be working on during my 2021 visit to Princeton.

Q. Can you give us a general overview of the study and why it is unique?

A. Our research team will integrate computational models, a set of reinforcement learning tasks, and functional imaging to better understand how children and adolescents learn from the environment and make decisions. The experiment includes both healthy children and adolescents as well as youngsters with common psychopathology, such as anxiety, depression and ADHD. No other study has incorporated all four of these criteria. 

Our goal is to create a set of observable traits and characteristics for learning and decision-making processes. This will involve a set of task-oriented computer “games” that investigate how participants learn from experience. Additionally, we will conduct functional MRI scans to shed light on the involved brain areas and circuits activation, allowing us to dynamically see what happens in the brain when people study or take risks. We’ll also be using computer modeling to predict behavior, such as which patients with depression may relapse or which patients will respond better to a particular therapy. 

Q. How will this information contribute to the field of adolescent and child psychiatry?

A. As a psychiatrist with two board certifications and 20 years of experience, I can confidently, sadly say that we know very little about how children and adolescents make their decisions. This matters tremendously because serious and long-term consequences may be at stake when they make decisions about relationships, experimenting with alcohol or drugs, or choosing any of the numerous “roads” offered by the modern world – which are undoubtedly more variable and confusing than ever in history.

Understanding these processes is relevant for every individual but especially critical for youngsters, whose personalities and behaviors are just crystalizing. Their brain mechanisms are occasionally immature enough to cope efficiently with the increasingly challenging turmoil and adversities of adolescence, but there is more we can do. Adapting age-tailored interventions for adolescents in family or school contexts should focus on the particular “weak spots” indicated by the results of our research. For instance, a tendency to ignore certain knowledge when making decisions could be a target for change by parents and teachers. With this strategy, a child’s vulnerability could be superseded by resilience. 

We hope our findings will offer groundbreaking insights for both science and medicine. Importantly, we hope the study will enable us to measure and quantify cognitive variables and lead to improved methods for diagnosing, treating and even preventing mental health disorders. Addressing the underlying pathology when the brain is extremely plastic and amenable could dramatically affect a patient’s prognosis.

Q. How are you advancing the project at Princeton?

A. In the Niv Lab, we are developing the reinforcement learning tasks and modeling that will be used for the experiment. I am learning more about the computational and cognitive-science aspects of the project from her team, while I contribute the clinical expertise and emphasis.

At the same time, I am heading my research team in Israel and working with my team at Geha Mental Health Center to recruit a total of 150 subjects, adolescent patients and controls, for the study. We have almost completed the pilot phase, which also includes training our research assistant, obtaining Institutional Review Board approval, compensating participants, and other technicalities. Because of our curiosity and eagerness to move forward, we are about two years ahead of schedule.

Q. What else do you have planned during your Princeton visit? Will you be teaching or working on other projects?

A. I will be teaching a computational psychiatry course with Professors Yael Liv and Nathaniel Daw and lecturing in different forums through the Center for Health and Wellbeing and Princeton Neuroscience Institute. As part of my desire to make science more accessible, I’d like to talk to students, faculty, school counselors, parents, clinicians, and the general public. I also hope to develop a guide or academy for the layperson – anybody who is connected to kids – to share key information about child development, mental health, and parenthood.

Furthermore, one of my personal goals during this sabbatical is to study as much as I can in all areas that are relevant to child and adolescent psychiatry. I’m looking forward to participating in many conferences, seminars, and other enrichments.

I want to underscore my thankfulness to Princeton for this amazing opportunity to float knowledge, exchange ideas, and pursue discoveries in collaboration with other researchers. That’s a great basis for making progress.

Q. On a grander scale, what is your greatest ambition when it comes to impacting the mental health and wellbeing of children, adolescents and families?

A. I would like to contribute to both science and medicine in a way that is intertwined, as you cannot impact one without impacting the other. I hope that my work plays a role in providing children with a stronger foundation – one that supports their emotional, cognitive and behavioral development while promoting better resilience and quality of life. By helping them as individuals, we also build a healthier, more robust society.