Diagnosis of ADHD in Israel, A Guide to the Perplexed

Any new immigrant in Israel knows that life here can take some getting used to. The “next” person in line is usually the one standing beside you, stopping at a cross walk is optional for drivers, and you shouldn’t hold your breath for a “thank you” if you open the door for someone. Getting comfortable with the medical system here can take some time as well; it can often seem
fragmented, overly specialized and bureaucratic. In particular, getting assessed for ADHD can be challenging and confusing.

Having ADHD diagnosed in Israel often means dealing with long waiting times to see a neurologist, batteries of sometimes unnecessary specialized testing (psycho didactic evaluation,MOXO, TOVA), and tiring bureaucracy required by developmental centers. Choosing between an abundance of therapists from an ever expanding list of non-medical backgrounds (many of whom
are excellent and invaluable) adds to the confusion. Understanding who is certified to diagnose ADHD in Israel, what the ancillary tests are, when they are indicated (and when not!) can help save a lot of frustration, time and money.

COMPUTERIZED TESTING

Computerized tests such as the TOVA and MOXO provide objective information about distractibility, inattentiveness and impulsiveness. They are tools that can help the doctor collect further evidence to support or rule out the suspected diagnosis of ADHD. The tests in and of themselves, however are not diagnostic and need to be interpreted within the context of the entire evaluation. While the tests can be of value, the general consensus currently is that in the vast majority of cases, accurate diagnosis of ADHD does not require computerized testing. Their use should be limited to cases where the diagnosis is not clear and further objective information is needed. (As an analogy, a doctor can often diagnose pneumonia without a chest x-ray through careful clinical evaluation. In certain cases, a doctor might order a chest x-ray to help with diagnosis, but ultimately the diagnosis is made by the doctor after taking into account all of the clinical information. Valuable time and money would be wasted and patients would be unnecessarily exposed to radiation if everyone with symptoms of cough and fever went directly to do a chest x-ray!) In fact, some of the HMO’s in Israel have recently prohibited computerized testing without a referral from a doctor certified in diagnosis and treatment of ADHD. This policy will most probably be effective in preventing unnecessary testing and save time and money for patients. Self referral or direct referral by educational staff should be discouraged.

PSYCHO DIDACTIC EVALUATION

Psycho didactic evaluation is used to assess cognitive ability, detect learning disorders and emotional problems. Aspects of the evaluation are directed towards detecting deficiencies inattention and concentration as well. Psycho didactic evaluation, however, is not necessary when the only concern is ADHD. Thorough evaluation for ADHD requires consideration of common cooccurring conditions, and a high percentage of children with ADHD indeed suffer from learning disorders and emotional problems. When concern regarding these co-occurring conditions is raised during the evaluation for ADHD, referral for psycho didactic or other psychological evaluation might well be warranted. If however, the doctor evaluating for ADHD is comfortable (based on reports from teachers/parental input/screening tests etc.) that there is no concern for a learning disorder or significant emotional problem, then psycho didactic evaluation will not be necessary. Correspondingly, if concern is raised for possible ADHD by a child who has undergone psycho didactic evaluation for suspected learning disorder or emotional problems, they should be referred for formal diagnosis of ADHD by a doctor certified to do so.

WHO IS QUALIFIED TO DIAGNOSE AND TREAT ADHD IN ISRAEL?

For starters, it is important to point out that while psychologists, social workers and other therapists have an important role to play, in all cases, formal diagnosis in Israel can be made only by a medical doctor. Until recently, neurologists, psychiatrists and physicians specializing in development had been the only ones licensed to formally diagnose ADHD. Long waiting times to see overburdened sub-specialists, however, and a shift towards more holistic primary care, have led to a change in policy. Specially trained primary care doctors such as pediatricians and family doctors can now be certified in diagnosis and treatment of ADHD in Israel after completing a course run by the Ministry of Health. The evaluation should begin with a detailed review of the patient’s personal, medical and developmental history. A physical examination, including a neurological examination, is performed to rule out conditions that can imitate symptoms of ADHD. Detailed questionnaires are used to gather information about symptoms and gauge the severity of impairment. Often, much leg work is needed, by speaking with family members, teachers or co-workers to obtain a complete and accurate picture. Doctors use criteria set out by experts in the Diagnostic and Statistical Manual of Mental Disorders (DSM) to determine if a diagnosis of ADHD can be made or not. In most cases, accurate diagnosis can be made without need for additional ancillary testing.

SUMMARY OF RECOMMENDATIONS

In Israel many people, both children and adults, seek evaluation for ADHD. Undergoing thorough evaluation by a doctor certified in diagnosis and treatment of ADHD is recommended and often all that is needed. The need for ancillary tests such as computerised tests or psycho didactic evaluation should be determined on a case by case basis.