Alan Apter - Academia.edu (original) (raw)

Papers by Alan Apter

Adolescent suicidal behavior is the most common reason adolescents present to the emergency depar... more Adolescent suicidal behavior is the most common reason adolescents present to the emergency department in pediatric hospitals. Recently, suicidal behavior has become more common in preadolescent children. It is important to understand the underlying nature of non-fatal suicidal behavior in children and how they may differ from adolescent to implicate unique prevention and management for this population. The current study aims to investigate the psychosocial characteristics associated with suicidal ideation and behaviors in an emergency department sample of 183 children and adolescents aged 7–18. All participants completed a diagnostic interview, self-report and parent-report questionnaire of psychosocial risk factors. Cross-sectional correlational and regression analyses were used to determine significant correlates of suicidal outcomes within the two age groups. The results indicated that among adolescents, suicidal thoughts and behavior were more common in females compared to male...

European Child & Adolescent Psychiatry, Jul 22, 2019

European Child & Adolescent Psychiatry, 2021

Current forms of parent training for childhood attention deficit hyperactivity disorder (ADHD) ar... more Current forms of parent training for childhood attention deficit hyperactivity disorder (ADHD) are often insufficient. Many families drop out of the training, and treatment gains are often not maintained. Nonviolent resistance parent training (NVR) focuses on helping parents resist the child's negative behaviors without escalating the problem. NVR helps parents to fulfill an anchoring function, supporting the child through presence, self-regulation, structure, and support network. This study is a randomized controlled trial designed to assess the efficacy of NVR in the treatment of childhood ADHD. Participants were Israeli parents of children with primary ADHD diagnosis (N = 101; 5–13 years old; 79% male participants) randomly assigned to either 12-session NVR (N = 50) or waiting list (N = 51). Measures were administered before and after treatment and at a 4-month follow-up. ADHD outcomes included the Conners and Child Behavior Checklist. Parenting outcomes included parental helplessness, emotional regulation, anchoring function, and family chaos. Participants in the NVR condition reported significant improvements in the child’s internalizing, externalizing, and ADHD symptoms, as well as improvement in paternal and maternal helplessness and anchoring. Participants in the control condition did not report changes in the child’s symptoms or the parents’ condition. The results at follow-up revealed maintenance of change in the child’s externalizing and internalizing symptoms, but failure to maintain gains in ADHD core symptoms. Maternal helplessness and anchoring, as well as family chaos continued to improve at follow-up. Dropout rates in the treatment group were low (5%), and fathers’ engagement was close to 100%. NVR is an efficient treatment for childhood ADHD, with benefits extending beyond the child’s symptoms to the entire family. NVR’s special focus on parental distress may have contributed to low dropout, high paternal engagement, and maintenance of change.

Frontiers in Psychiatry, 2020

In recent years, suicidal behaviors have shown substantial increase worldwide. This trend is also... more In recent years, suicidal behaviors have shown substantial increase worldwide. This trend is also prominent in Israel and has led to a dramatic increase in mental health treatment demand resulting in long wait times and low treatment acceptance rate. To address the critical need in crisis intervention for children and adolescents at suicidal risk we developed an ultra-brief acute crisis intervention, based on Interpersonal Psychotherapy (IPT). IPT is an evidence-based intervention for various psychopathologies among different age groups. The current adaptation of IPT-A is comprised of five weekly sessions, followed by monthly follow-up caring email contacts to the patients and their parents, over a period of 3 months. This paper aims to review the theoretical foundation of this intervention, describe the research design, and present preliminary results of a pilot study. Preliminary Results from our samples of 26 adolescents indicate meaningful trends for both the suicidal ideation (...

Journal of Affective Disorders, 2008

Comprehensive Psychiatry, 2001

Brain, Behavior, and Immunity, 2019

Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat anxiety and/or depress... more Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat anxiety and/or depression in pediatric populations. However, the response rates are low (approximately 50%). Moreover, SSRI use is frequently associated with adverse events (AE). Currently there are no available biomarkers for treatment response/AE. Identification of biomarkers predicting early response and/or AE could help maximize the benefitrisk ratio for the use of SSRIs, and accelerate matching of treatments to patients. Pro-inflammatory cytokines were proposed as potential biomarkers. Method: Ninety-two patients (35 boys and 57 girls) with major depressive disorder and/or anxiety disorders, aged 13.90 ± 2.41 years, were treated with fluoxetine (FLX) for 8 weeks. Plasma concentrations of TNFα, IL-6, and IL-1β were measured by enzyme linked immunosorbent assays before and after FLX treatment. Clinical response and AE were measured using several clinical scales, including the Clinical Global Impressionimprovement, Children's Depression Rating Scale-Revised, the Beck Depression Inventory, the Screen for Child Anxiety Related Emotional Disorders, the Columbia suicide severity rating scale, and the Suicide Ideation Questionnaire. Results: IL-6 levels increased after treatment only in the group of children who developed FLX-associated suicidality. Conclusion: An increase in IL-6 levels during treatment may be a risk factor for the emergence of FLX-associated suicidality (OR = 1.70). Further studies are necessary to clarify the role and mechanism(s) of this cytokine in the pathogenesis of this life-threatening AE.

International Journal of Environmental Research and Public Health

The COVID-19 pandemic and response, which included physical distancing and stay-at-home orders, d... more The COVID-19 pandemic and response, which included physical distancing and stay-at-home orders, disrupted the daily lives of children and adolescents, isolating them from their peers, school, and other meaningful contacts. The present study aims to add to the accumulating evidence on the pandemic’s impact on child and adolescent suicidal behavior. Data were extracted from Schneider Children’s Medical Center of Israel’s pediatric emergency room (ER) admissions for psychiatric consultation for suicidal-risk assessment between 1 January 2020, and 16 April 2022. We applied time-lagged cross-correlation analysis and a Granger causality test to assess the temporal relationships between COVID-19 infection waves and patterns of suicide-related ER admissions. The results revealed a significant lagged correlation between national COVID-19 infection rates and ER admission rates. The highest correlation was above 0.4 and was found with a lag of 80 to 100 days from infection rate to ER admission...

European Child & Adolescent Psychiatry

Early detection and intervention can counteract mental disorders and risk behaviours among adoles... more Early detection and intervention can counteract mental disorders and risk behaviours among adolescents. However, help-seeking rates are low. School-based screenings are a promising tool to detect adolescents at risk for mental problems and to improve help-seeking behaviour. We assessed associations between the intervention “Screening by Professionals” (ProfScreen) and the use of mental health services and at-risk state at 12 month follow-up compared to a control group. School students (aged 15 ± 0.9 years) from 11 European countries participating in the “Saving and Empowering Young Lives in Europe” (SEYLE) study completed a self-report questionnaire on mental health problems and risk behaviours. ProfScreen students considered “at-risk” for mental illness or risk behaviour based on the screening were invited for a clinical interview with a mental health professional and, if necessary, referred for subsequent treatment. At follow-up, students completed another self-report, additionall...

Neurology, 2021

Objective To examine prospectively the association between group A Streptococcus (GAS) pharyngeal... more Objective To examine prospectively the association between group A Streptococcus (GAS) pharyngeal exposures and exacerbations of tics in a large multicenter population of youth with chronic tic disorders (CTD) across Europe. Methods We followed up 715 children with CTD (age 10.7 ± 2.8 years, 76.8% boys), recruited by 16 specialist clinics from 9 countries, and followed up for 16 months on average. Tic, obsessive-compulsive symptom (OCS), and attention-deficit/hyperactivity disorder (ADHD) severity was assessed during 4-monthly study visits and telephone interviews. GAS exposures were analyzed using 4 possible combinations of measures based on pharyngeal swab and serologic testing. The associations between GAS exposures and tic exacerbations or changes of tic, OC, and ADHD symptom severity were measured, respectively, using multivariate logistic regression plus multiple failure time analyses and mixed effects linear regression. Results A total of 405 exacerbations occurred in 308 of ...

Addictive Behaviors, 2021

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

European Child & Adolescent Psychiatry, 2020

Suicide is one of the leading causes of death in adolescents and help-seeking behaviour for suici... more Suicide is one of the leading causes of death in adolescents and help-seeking behaviour for suicidal behaviour is low. School-based screenings can identify adolescents at risk for suicidal behaviour and might have the potential to facilitate service use and reduce suicidal behaviour. The aim of this study was to assess associations of a two-stage school-based screening with service use and suicidality in adolescents (aged 15 ± 0.9 years) from 11 European countries after one year. Students participating in the ‘Saving and Empowering Young Lives in Europe’ (SEYLE) study completed a self-report questionnaire including items on suicidal behaviour. Those screening positive for current suicidality (first screening stage) were invited to an interview with a mental health professional (second stage) who referred them for treatment, if necessary. At 12-month follow-up, students completed the same self-report questionnaire including questions on service use within the past year. Of the N = 12...

Frontiers in Psychiatry, 2018

Background: Mental health professionals have a pivotal role in suicide prevention. However, they ... more Background: Mental health professionals have a pivotal role in suicide prevention. However, they also often have intense emotional responses, or countertransference, during encounters with suicidal patients. Previous studies of the Therapist Response Questionnaire-Suicide Form (TRQ-SF), a brief novel measure aimed at probing a distinct set of suicide-related emotional responses to patients found it to be predictive of nearterm suicidal behavior among high suicide-risk inpatients. The purpose of this study was to validate the TRQ-SF in a general outpatient clinic setting. Methods: Adult psychiatric outpatients (N = 346) and their treating mental health professionals (N = 48) completed self-report assessments following their first clinic meeting. Clinician measures included the TRQ-SF, general emotional states and traits, therapeutic alliance, and assessment of patient suicide risk. Patient suicidal outcomes and symptom severity were assessed at intake and one-month follow-up. Following confirmatory factor analysis of the TRQ-SF, factor scores were examined for relationships with clinician and patient measures and suicidal outcomes. results: Factor analysis of the TRQ-SF confirmed three dimensions: (1) affiliation, (2) distress, and (3) hope. The three factors also loaded onto a single general factor of negative emotional response toward the patient that demonstrated good internal reliability. The TRQ-SF scores were associated with measures of clinician state anger and anxiety and therapeutic alliance, independently of clinician personality traits after controlling for the state-and patient-specific measures. The total score and three subscales were associated in both concurrent and predictive ways with patient suicidal outcomes, depression severity, and clinicians' judgment of patient suicide risk, but not with global symptom severity, thus indicating specifically suicide-related responses.

Israel Journal of Health Policy Research, 2019

Background: The Galilee Study is the first large epidemiological study to compare correlates of m... more Background: The Galilee Study is the first large epidemiological study to compare correlates of mental disorders between two Arab Palestinian minority groups of adolescents in Israel. Methods: A two-stage cross-sectional study, carried out between 2012 and 2014, included all 9th grade students from 5 Arab localities, representative of 77% of the Muslim and 100% of Druze citizens in Israel. During the screening stage, 1639 students completed the Strengths and Difficulties Questionnaire in the classroom (response rate = 69.3%). During the follow-up stage, 704 adolescent-mother dyads were interviewed at home; using the Development and Well-Being Assessment, the General Health Questionnaire (GHQ)-12, the Subjective Feeling of Discrimination Index (FDI), and socio-demographic questions (response rate = 84.4%). Results: Prevalence of any disorder, internalizing or externalizing disorders among Muslim adolescents were 19.2, 15.8 and 4.2%, respectively and among Druze adolescents 10.9, 5.9 and 5.5%, respectively. Muslim adolescents were 3.2 times more likely than Druze adolescents to have an internalizing disorder, while Druze were 2 times more likely than Muslim to have an externalizing disorder. Males were at higher risk than females for externalizing disorders in both populations, though among Druze the risk was more striking. Learning disabilities increased the likelihood of having an externalizing disorder in both populations. Risk factors for internalizing disorders among Muslim adolescents were female gender, a very low socioeconomic level, few siblings, LD, high maternal GHQ-12 score and high FDI; and for externalizing disorders, male gender, a relatively low socioeconomic level but not the lowest, learning disability and high maternal GHQ-12 score. Conclusions: We found an association between religion/ethnicity and internalizing and externalizing disorders as well as a strong correlation between religion/ethnicity and socioeconomic variables. Therefore, we tend to conclude that not religion per se but the multifaceted socio-cultural and economic factors that characterize religious groups are associated with mental disorders. Very low socioeconomic level and feeling discriminated which were traits connected only to Muslim adolescents, were associated with internalizing disorders. When preparing preventive measures aimed at furthering mental health among minority adolescents, authorities should focus on improving the socioeconomic status of minorities and reducing institutional and personal discrimination. The educational and mental health establishments could undertake measures to improve resilience and coping strategies of Muslim families living in the most adverse conditions, such as providing special support through the school counseling services and coordinating, at the ministerial levels, school and community health services in order to carry out joint preventive programs and referrals to specialist services when needed.

The American Journal of Clinical Nutrition, 1998

Background: Excessive weight in childhood is a serious public health concern because of its costl... more Background: Excessive weight in childhood is a serious public health concern because of its costly health consequences and its increasing prevalence. Objective: Our objective was to compare the efficacy of a family-based approach for the treatment of childhood obesity, in which the parents served as the exclusive agents of change, with that of the conventional approach, in which the children served as the agents of change. Design: This study had a randomized, longitudinal prospective design and lasted 1 y. Sixty obese children aged 6-11 y were randomly allocated to the experimental (parents as agents of change) or control (children as agents of change) group. Anthropometric and biochemical measurements were determined at the start and end of the study. A sociodemographic questionnaire and a family eating and activity habits questionnaire were completed by both parents. Hour-long support and educational sessions were conducted by a clinical dietitian: 14 sessions for the parents in the experimental group and 30 sessions for the children in the control group. Results: The dropout rate was nine times greater in the control group (n = 9) than in the experimental group (n = 1). Mean percentile weight reduction was significantly (P < 0.03) higher in children in the experimental group (14.6%) than in the control group (8.1%). Conclusions: Treatment of childhood obesity with parents as the exclusive agents of change was superior to the conventional approach, as indicated by the dropout rate and the percentage weight loss of the children during the 1-y intervention.

European child & adolescent psychiatry, Jan 14, 2018

Suicide is one of the leading causes of death among young people globally. In light of emerging e... more Suicide is one of the leading causes of death among young people globally. In light of emerging evidence supporting the effectiveness of school-based suicide prevention programmes, an analysis of cost-effectiveness is required. We aimed to conduct a full cost-effectiveness analysis (CEA) of the large pan-European school-based RCT, Saving and Empowering Young Lives in Europe (SEYLE). The health outcomes of interest were suicide attempt and severe suicidal ideation with suicide plans. Adopting a payer's perspective, three suicide prevention interventions were modelled with a Control over a 12-month time period. Incremental cost-effectiveness ratios (ICERs) indicate that the Youth Aware of Mental Health (YAM) programme has the lowest incremental cost per 1% point reduction in incident for both outcomes and per quality adjusted life year (QALY) gained versus the Control. The ICERs reported for YAM were €34.83 and €45.42 per 1% point reduction in incident suicide attempt and incident...

Psychiatry Research, 2017

The present study evaluated the self-report version of the Inventory of Callous-Unemotional Trait... more The present study evaluated the self-report version of the Inventory of Callous-Unemotional Traits (ICU-SR) in terms of reliability, concurrent validity, and correlation with salivary oxytocin levels, a potential biomarker of CU traits. 67 socially at-risk male adolescents (mean 16.2 years) completed the ICU-SR, ICU teacher-version (ICU-TR), Strengths and Difficulties Questionnaire, and their medical files were coded for previous antisocial acts using Brown-Goodwin Lifetime Aggression Scale. Salivary samples were assayed for oxytocin. The reliability of ICU-SR was lower (α = 0.71) than ICU-TR (α = 0.86). ICU-SR mean score was significantly lower than ICU-TR (M = 25.29, SD = 8.02; M = 33.14, SD = 9.47). ICU-TR but not ICU-SR, significantly correlated with history of antisocial acts (r = 0.40). Two-way analysis of variance showed a significant effect of conduct disorder and oxytocin on ICU-TR but not ICU-SR [F(1,59) = 6.53; F(1,59) = 6.08], and a significant interaction only for ICU-TR [F(1,59) = 2.89]. Subjective self-reports of CU traits may be less reliable and valid than teachers' reports.

Psychiatric genetics, Oct 31, 2017

Inbreeding increases the probability of homozygosity of deleterious alleles. Inbreeding and runs ... more Inbreeding increases the probability of homozygosity of deleterious alleles. Inbreeding and runs of homozygosity (ROH) are associated with an increased risk for disease phenotypes, including schizophrenia and other psychiatric disorders. The effects of inbreeding, ROH, homozygous deletions, and other copy number variations (CNVs) on risk for depression and suicide attempt (SA) were quantified in an Arab Bedouin Kindred. We carried out genetic analyses of 439 individuals from an Arab kindred with high rates of depression and suicidal behavior. We obtained complete ascertainment of SAs and first-degree relatives of individuals who have attempted or died by suicide. We found extensive regions of ROH. On average, 5% of the genome is covered by ROH for these individuals, two-fold higher than ROH rates for individuals from populations of European ancestry. Inbreeding and total length of ROH were not associated with risk for depression or attempt. For CNVs, an increased number of duplicati...

International Journal of Environmental Research and Public Health, 2015

Reading books and watching films were investigated as protective factors for serious suicidal ide... more Reading books and watching films were investigated as protective factors for serious suicidal ideation (SSI) in young people with low perceived social belonging. Cross-sectional and longitudinal (12-month) analyses were performed using data from a representative European sample of 3256 students from the "Saving and Empowering Young Lives in Europe" study. Low

Neuropsychiatry, 2014

A history of past suicide attempt is the strongest and most consistent predictor of suicidal beha... more A history of past suicide attempt is the strongest and most consistent predictor of suicidal behavior and completion in mood disorders, and suicidal ideation is a proximal predictor for the short-term risk of suicidal behavior. Given the associations between severe, longstanding and recurrent depression and ongoing suicide risk, achieving complete remission in treatment is important. Clinical depressive symptoms of anhedonia, hopelessness, feeling worthless and excessive guilt are more important in assessing suicidal risk than reduced sleep, weight loss, concentration loss or psychomotor disturbance. Male gender, unmarried status, unemployment and low education or income is related to completed suicide in the general population; however, these factors have low prognostic utility in individuals with mood disorders. Given that mixed state of depression could be an important precursor of suicidal behavior, identifying hypomanic symptoms, such as irritability and psychomotor agitation, may reduce short-term risk of suicide attempt. Comorbid disorders characterized by agitation (e.g., post-traumatic stress disorder and generalized anxiety disorder) or impulse-control deficits (disruptive behavior disorders, substance use disorders or borderline personality disorder) may increase the likelihood of suicidal wish developing into suicidal act. Although clinicians cannot influence what has happened in the past history of their patients, collecting information about family history of suicidal behaviors and about past physical or sexual abuse is important in predicting suicide risk. Interpersonal problems, including bullying, may predict suicidal ideation during depressive episodes. Therefore, it is essential for clinicians to gain knowledge regarding social context, especially in young people. Impulsivity increases the likelihood of making a suicide attempt. Restriction of access to dangerous suicide means may often result in lower lethality attempts and long-term survival.