Israel Grapples With Diagnosing Attention Deficit Disorder in Children

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An Israeli classroom.Credit: Nir Kafri

Teachers lack the training to spot symptoms and doctors sometimes make misdiagnoses because they lack information about a child’s performance in school. Either way, diagnosing attention deficit disorders can be thorny.

Between 5 percent and 10 percent of Israeli children are thought to have received a diagnosis of ADD or attention deficit hyperactivity disorder – a popular explanation for poor academic performance, behavior issues and impaired social skills. Last year, more than 70,000 prescriptions to treat attention disorders were written in Israel every month, a number that’s constantly rising.

While the jury is still out over the benefits and drawbacks of giving children Ritalin and similar drugs for the condition, Israel’s education and health ministries — which share the burden of addressing these disorders — are still grappling with the more basic issue of diagnosis. Many experts point to a lack of coordination that they say has caused many errors.

“The diagnosis of ADD is a complex process that requires, in addition to a professional medical opinion, a reliable and detailed report on the child’s performance in various areas of life. Without seeing the entire picture, it’s very easy to make a misdiagnosis,” says Dr. Itai Berger, a pediatric neurologist and the head of the Neuro-Cognitive Center, Division of Pediatrics, at Jerusalem’s Hadassah Medical Center.

According to the American Academy of Pediatrics, whose guidelines Israel has adopted, a clinical diagnosis of ADD or ADHD requires detailed information from at least two sources, such as the child’s school, parents, after-school programs, remedial teachers or a psychologist. In Israel, diagnosis may be made by child psychiatrists, pediatric neurologists, specially trained pediatricians and child psychologists (but only if the diagnosis is also supported by a physician).

Many children must wait long periods before being evaluated, and even then there is a lack of critical information for diagnosis. In the best case parents are told to complete their kids’ files before an evaluation, but sometimes there is a diagnosis based on partial information.

Usually it’s the child’s teachers who attribute academic and behavioral issues to ADD or ADHD, at which point the parents are notified and the diagnostic process is launched. Berger and a number of his colleagues argue that very few Israeli teachers are trained to recognize attention disorders and often the diagnostic process is faulty.

Berger notes that not every child who is disruptive in class has ADHD, while girls with attention disorders are often not diagnosed because they are not disruptive, tending more often to have ADD Inattentive Type. “Naturally, teachers notice children who attract negative attention and are disruptive. That’s important but it misses part of the population,” he says.

At the annual conference of the Israeli Association of Child Development and Rehabilitation last week, Berger presented a survey of 430 teachers from the Tel Aviv area with an average of 14 years’ experience. Berger says the findings reflect a cry for help from teachers.

Of the teachers surveyed, 69 percent said physicians make their ADD/ADHD diagnoses without a full picture of the child’s performance in school, 75 percent said they had seen cases in which the diagnosis and treatment decisions were inaccurate, and 95 percent said coordination between teachers and physicians over ADD/ADHD diagnoses was poor.

Of the respondents, 88 percent said teachers should receive more instruction in recognizing signs of attention disorders, and 94 percent said they would be willing to attend such training sessions, on their own time and at their own expense. Berger stresses that no one expects teachers to diagnose the disorder, but they should have the basic tools to refer a child for evaluation.

Dr. Yael Leitner is a pediatric neurologist, specialist in child development and head of the Child Development Center and ADHD Clinic at Tel Aviv’s Sourasky Medical Center. She notes that children are sometimes referred for an evaluation by teachers who recommend Ritalin or the Test of Variables of Attention, a computerized diagnostic tool for attention disorders.

“But the computerized test is only a tool that can give an additional indication, and by international consensus it’s not considered a necessary part of the diagnostic process,” Leitner says. This is a complex evaluation that includes a plethora of details about the child’s behavior and performance.

“The parents sit with us in the room, not the teacher, so we need enormous amounts of information about the child’s activity and performance in the classroom. For this purpose there are specific tools such as behavioral questionnaires,” Leitner says. She says a major problem is that there is no protocol in Israeli schools about the questionnaires and other forms that must be filled out ahead of a medical evaluation for attention disorders.

“So parents come without the information, and I have to send them back for another round,” Leitner says, adding that while teachers play a critical role in both the diagnostic process and later treatment, there is no protocol for monitoring each child’s progress. “I don’t know who the contact person is at the school — who’s responsible and can help. There’s a disconnect that could be repaired using incredibly simple means.”

The Health Ministry’s department for child development and rehabilitation is aware of the problem. “I try to promote meetings at the Education Ministry, so far without success. I hope to make it happen,” says Dr. Hadar Yardeni, a pediatrician who heads the department.

She says the lack of coordination between the ministries can be catastrophic, as in cases where teachers tell parents their child will be expelled unless he or she undergoes a computerized evaluation, “which is only a diagnostic tool,” Yardeni says, echoing Leitner.

Education Ministry officials concede that improvements could be made, but they reject claims of a lack of communication with the Health Ministry

“Everyone’s confused — parents, teachers,” says Dr. Dani Giorno, deputy director of the Education Ministry’s psychology department. “We were aware of what was happening long before the findings of [Berger’s] survey were presented to us,” she says, noting that the ministry has been training teachers for children at all levels with learning disabilities and attention disorders.

“I agree that we need greater synergies between the ministries, but no less important among the local governments, the health insurance providers and the educational institutions,” Giorno says, adding that the education system cannot fix every problem and that diagnosis is only the start of the process.

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