[HOW HAVE WE DEVELOPED? THE HISTORY OF DEVELOPMENTAL AND REHABILITATION SERVICES FOR CHILDREN IN ISRAEL].

INTRODUCTION: Public health and welfare organizations, as well as governmental agencies in Israel, charged with the provision of services for children with special needs and their families, have reached a timely watershed. This large network finds its roots at the dawn of the last century in the history of the notable efforts made by idealistic individuals who immigrated to the country and in the many Jewish philanthropic community organizations, charged with helping others less fortunate. Beginning with services for the handicapped, who were either victims of polio or suffering from cerebral palsy, the gamut of providers blossomed to encompass many others in need, which today number in the hundreds of thousands each year, suffering from a wide range of impairments, and with a multitude of needs. We found it incumbent upon us to undertake a prodigious review of those pioneering individuals and organizations, contributing to the current wealth of services available to the public.

The contribution of the Neurobehavioral Screening Tool to identifying fetal alcohol spectrum disorders in children at high risk of prenatal alcohol exposure and neurobehavioral deficits.

BACKGROUND: Fetal alcohol spectrum disorders (FASD) describe various conditions resulting from prenatal alcohol exposure. The diagnosis of FASD can be challenging and complex. The Neurobehavioral Screening Tool (NST), derived from Achenbach's Child Behavior Checklist, has been suggested as a tool for identifying FASD. AIMS: To assess the external validity of the NST and to identify additional characteristics of FASD in a cohort of Israeli children and young adults referred to a neurology and child developmental clinic at a tertiary pediatric medical center in Israel. STUDY DESIGN: An observational study based on medical records. SUBJECTS: 151 children and young adults, of whom 40 were diagnosed with FASD according to updated clinical guidelines. OUTCOME MEASURES: NST results, as well as demographic and neurobehavioral variables, were compared between those who were and were not diagnosed with FASD. RESULTS: The NST demonstrated 72 % to 73 % sensitivity, and 34 % to 36 % specificity, in identifying FASD. Items 4 and 5 ('Lies or cheats', 'Lacks guilt after misbehaving') were the most predictive items in the NST. Other variables that were characteristic of the FASD group included: emotional regulation difficulties (p value <0.01), being born and adopted in Israel (vs. other countries) (p value <0.01) and younger age at the first visit to the clinic (p value <0.01). CONCLUSIONS: Our findings regarding the screening capabilities of the NST were less promising than those of most previous studies. Further research is needed to establish a valid neurobehavioral tool with the possible focus on antisocial behaviors and emotional regulation problems.

Nutritionists' Practices and Knowledge about the Risks of Alcohol Consumption during Pregnancy: An Israeli Survey.

Fetal alcohol spectrum disorders (FASDs) are lifelong disabilities and the leading preventable cause of developmental disabilities. Antenatal care providers may influence pregnant women's dietary practices and their awareness of the risks of alcohol consumption during pregnancy. This study aimed to assess nutritionists' self-reported knowledge about the risks of drinking alcohol during pregnancy, professional practices in this respect, and self-perceived competence to assess and guide women about alcohol consumption during pregnancy in Israel. A sample of 526 professional nutritionists completed an anonymous online questionnaire. Results showed significant differences between the nutritionists' knowledge and professional practices scores. About 349 (66.3%) of the sample agreed (to any degree) that they did not have enough knowledge to guide pregnant women regarding drinking alcohol. The number of years of experience, combined with self-perceived competence and the mean knowledge score, explained 18% of the variance in professional practices. Nutritionists and other health professionals may have a crucial role in preventing FASD and should prioritize appropriate screening for prenatal alcohol use. Eliminating alcohol consumption at any point in pregnancy would reduce the risk for FASDs.

Pregnant women's alcohol consumption and knowledge about its risks: An Israeli survey.

BACKGROUND: Alcohol consumption is found in a significant proportion of women during their pregnancies. The only study on the prevalence of alcohol consumption during pregnancy in Israel was conducted over a decade ago. Thus, our study aimed to assess alcohol consumption before and during pregnancy, associations with demographic characteristics, knowledge of possible risks of prenatal alcohol exposure, and relations among such knowledge, sociodemographic characteristics, and drinking habits. METHODS: A convenience sample of 802 pregnant Israeli women completed an anonymous online questionnaire regarding their alcohol consumption during pregnancy, recommendations received, and knowledge of possible risks. RESULTS: Of the sample, 539 (67.2 %) women self-reported drinking alcohol in the 2 months prior to learning they were pregnant, and 96 (12 %) during their pregnancy. Twice as many (28.1 %) reported knowing other women who had consumed alcohol during pregnancy. Women with higher education, in their first pregnancies, ethnically Jewish, and secular reported the highest pre-pregnancy rates of alcohol consumption. About 40 % reported receiving no education about the dangers of alcohol consumption during pregnancy. CONCLUSIONS: A concerning percentage of pregnant women in Israel acknowledge drinking alcohol near and after conception. Although most participants reported discontinuing use after realizing they were pregnant, a worrying percentage continued consumption with little knowledge of the dangers. Actual rates may be higher. Information about risks of prenatal alcohol exposure is not widely disseminated, emphasizing the need to increase public awareness.

Prevalence of epilepsy and attention-deficit hyperactivity (ADHD) disorder: a population-based study.

Epilepsy and attention-deficit hyperactivity disorder (ADHD) were reported to co-occur at rates higher than expected for coincidental findings. This study investigated the prevalence of both disorders in community-based primary care practice. The central database of the second-largest health maintenance organization in Israel was searched for all children aged 6 to 13 years (n = 284 419; 51.5% males) diagnosed as having ADHD according to the physicians' records and/or the filling of at least 10 prescriptions for antiepileptic medications according to pharmacy records. The prevalence of epilepsy in the total population was 5 out of 1000 children, and the prevalence of ADHD was 12.6%. More than one-fourth (27.7%) of the epileptic children were also diagnosed as having ADHD. On multivariate analysis, children with ADHD had almost twice the risk of epilepsy than children without ADHD. This study supports hospital-based findings of a strong interrelationship between ADHD and epilepsy. The high rate of ADHD in Israeli children warrants further investigation.

Anemia associated with acute infection in children.

BACKGROUND: The pathogenesis of anemia associated with acute infection in children has not been well delineated. OBJECTIVES: To characterize this type of anemia in children with acute infection, mainly in relation to iron status. METHODS: These two cross-sectional studies compared the prevalence and severity of anemia between outpatient febrile children and age-matched non-febrile controls. RESULTS: In part 1 of the study, children with acute infection (n = 58) had a significant decrease in hemoglobin levels compared with 54 non-febrile controls. Mean corpuscular volume (MCV) did not change this association. Moreover, there was no significant difference in MCV, mean cell hemoglobin or red cell distribution width values between the two groups. Regarding part 2, of the 6534 blood counts obtained in community clinics, 229 were defined as "bacterial infection." Chart survey confirmed this diagnosis. White blood cell level was significantly inversely associated with hemoglobin level (r = -0.36, P < 0.0001). Anemia was significantly more prevalent among children with bacterial infection compared to those without: 21.4% vs. 14.1% (P = 0.002). Mean values of iron status parameters were all within normal limits. CONCLUSIONS: Acute illness is associated with anemia. The pathogenesis of this anemia does not appear to be associated with disruption of iron metabolism.

Alcohol consumption during pregnancy among women in Israel.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is a range of disabilities caused by gestational exposure of the fetus to alcohol. Alcohol consumption in Israel has increased dramatically in the last decades. Our previous study revealed limited knowledge among Israeli medical professionals of the risks and potential long-term effects of FASD. OBJECTIVES: To evaluate the awareness and knowledge of women regarding the current recommendations on alcohol consumption during pregnancy, evaluate how many of the women received information regarding alcohol consumption during pregnancy from medical professionals, and their personal drinking habits during pregnancy. METHODS: A cross-sectional sample of new mothers in 3 large hospitals in Israel were asked to complete an ad hoc questionnaire on aspects of alcohol consumption during pregnancy. RESULTS: A total of 3815 women of mean age 30.4 years participated in the study; 82% were Jewish. Alcohol consumption during pregnancy was reported by 14.1%, including more than 17% of the Jewish women, 11.1% of the Christian women, and none of the Muslim women. Rates were higher among nonsecular and younger women and first-time mothers. 71.6% of the sample claimed that women should not drink alcohol at all during pregnancy, and 21.4% thought that it was permissible if limited to 2 drinks per week. Seventy-five percent had received no formal information from medical professionals regarding alcohol consumption during pregnancy. CONCLUSIONS: Alcohol consumption is frequent among pregnant women in Israel, especially young secular Jewish women with first pregnancies. Improved educational programs on the dangers of FASD are needed for both professionals and the general public.

Anemia of acute infection in hospitalized children-no evidence of hemolysis.

The objective of the study is to examine the assumption that a process of hemolysis plays a role in anemia of acute infection in children. The study was comprised of febrile pediatric patients, who had a positive blood or urine culture. Complete blood count measures were compared between hospitalization and prehospitalization or posthospitalization values. Children admitted to the hospital for elective surgical procedures served as controls. Blood parameters of hemolysis were investigated in some of the patients. Of the 70 patients studied, 49 (70%) were diagnosed with pyelonephritis and 21 (30%) had bacteremia. Mean (+/-SD) hemoglobin (Hgb) on hospital admission was 10.9+/-1.27 g/L as compared with 12.1+/-1.03 g/L of the controls, P<0.0001. Compared with normal-for-age Hgb values as a standard, 42 (60%) cases were identified as anemic. Compared with hospitalization values, Hgb and hematocrit (Hct) were significantly higher in prehospitalization or posthospitalization, whereas WBC values were significantly lower. All parameters of hemolysis, namely reticulocytes, bilirubin, lactate dehydrogenase (LDH), and haptoglobin, were normal. Bacteremia and pyelonephritis are accompanied by a significant drop in Hgb level. There is no evidence of hemolytic anemia in these patients.

Time trends in reported autistic spectrum disorders in Israel, 1972-2004.

BACKGROUND: Studies from many countries have reported an increasing prevalence of autistic spectrum disorder in childhood. No comprehensive epidemiological studies of ASD have been performed in Israel. OBJECTIVES: To describe time trends in the reported number of patients with ASD in Israel and to characterize the demographic features of the reported patients. METHODS: We reviewed the charts of the National Insurance Institute of Israel from 1972 to 2004 for all children with a diagnosis of ASD receiving disability benefits. RESULTS: A total of 3509 children met the study criteria. Eighty percent were boys and 98% were Jewish. The incidence data showed an increase in the number of cases from zero in 1982-84 and 2 (1.2 per million capita under 18 years) in 1985 to a high of 428 cases in 2004 (190 per million). CONCLUSIONS: This is the first comprehensive study of the incidence of ASD in Israel. According to data derived from official health records, the rate of occurrence of ASD has substantially increased in the last 20 years. Further studies are needed to determine if this is a true increase or if the findings were confounded by external factors, such as recent improvements in diagnostic measures and social stigmas.

Fetal alcohol spectrum disorder in Israel.

BACKGROUND: Fetal alcohol spectrum disorder is a range of disabilities caused by gestational exposure to alcohol. FASD is the leading cause of preventable mental retardation and developmental disability in the United States, with an incidence of 1-10 per 1000 live births. FASD in Israel has yet to be examined systematically. OBJECTIVES: To evaluate professionals' experience, awareness and knowledge of FASD in Israel and their awareness of maternal consumption of alcohol, and to collect epidemiological data on the syndrome in Israel. METHODS: A short questionnaire was sent to all 43 program directors of genetic institutes (n = 14) and child developmental centers in Israel (n = 29). Four questions related to their experience and knowledge of FASD. The epidemiological survey included data from all 17 hospitals in Israel and from the two main health management organizations within the public health care system. RESULTS: The response rate was 98% (n = 42). A total of 38.1% of respondents reported having diagnosed at least one case of FASD and fewer than 10% of respondents stated that the knowledge regarding FASD among physicians in Israel was adequate. Developmental pediatricians were more likely to have diagnosed at least one case as compared to geneticists. During the period 1998-2007 the diagnosis of FASD appeared in the records of only 4 patients from the total number of 17 hospitals in Israel. During the same period only six patients were diagnosed at the HMO within the public health care system. CONCLUSIONS: Despite the accumulated knowledge on FASD in many countries and the increase in alcohol consumption in Israel, professionals' awareness of its potential damage is limited. Educational programs to increase physician awareness should accompany publicity campaigns warning the public of the dangers associated with alcohol consumption during pregnancy.

Post-adoption depression among adoptive mothers.

OBJECTIVE: To evaluate the rate of depressive symptomatology and possible underlying factors in adoptive mothers during the transition to motherhood. DESIGN: Cohort survey. SETTING: General Community. PARTICIPANTS: Thirty-nine adoptive mothers of reproductive age registered with international adoption agencies. INTERVENTIONS: All women completed the Edinburgh Postnatal Depression Scale (EPDS), the Beck Depression Inventory (BDI), and the Brief Symptom Inventory (BSI) before and 6 weeks after the adoption. MAIN OUTCOME MEASURES: Responses were compared between the study group and published findings for biological mothers in the general population, and within the study group, before and after adoption. RESULTS: Symptoms of depression were found in 15.4% of the study group. This rate was similar to that for postpartum depression in the general population, and lower than the rate recorded in the study group before adoption (25.6%). All women with symptoms of depression after the adoption had also shown evidence of depressive features before the adoption. Similar findings were noted for other psychopathologies as well. CONCLUSION: Adopting a child does not cause new-onset, reactive depression among adoptive mothers. It may even lead to a decrease in depressive features, perhaps in response to relief from other adjustment difficulties.

Pediatricians' satisfaction with their abilities to care for children with developmental, behavioral and psychosocial problems.

BACKGROUND: Developmental and behavioral pediatrics has emerged as an area of special interest and new responsibility for pediatricians. The aim of this study was to evaluate the impact of training, experience, and other factors on pediatricians' satisfaction with their abilities to care for children with developmental, behavioral and psychosocial problems. METHODS: A questionnaire was sent to 211 pediatricians working in primary care clinics in the community in Israel. Items included personal characteristics and experience, practice and satisfaction with the care of children with developmental, behavioral and psychosocial problems. Overall, pediatrician satisfaction with their personal abilities in this domain was defined as the dependent variable on multivariate analysis. RESULTS: The response rate was 76.3% (n = 161). Pediatricians' satisfaction with their overall professional ability to care for children with developmental, behavioral and psychosocial problems was significantly and positively associated with the following independent variables: (i) satisfaction with training received in the child development field; (ii) satisfaction with psychiatric updates; (iii) general satisfaction with the available child development services; (iv) prescription of methylphenidate to children with attention deficit/hyperactivity disorder; and (v) having completed their medical studies in a country in which the issue is emphasized. CONCLUSIONS: Imparting more knowledge and skills in child development and behavioral pediatrics in pediatric residency and continuing education programs will help improve the attitudes of primary care pediatricians towards developmental and behavioral problems, encourage them to treat these patients and their families, and better the quality of care.

Pre-placement screening in international adoption.

BACKGROUND: The number of child adoptions from abroad is increasing, but the adverse living conditions of these children prior to the adoption raise questions on their medical and neurodevelopmental status, particularly since there are no guidelines for pre- or post-adoption medical evaluation. OBJECTIVES: To describe the condition of a cohort of young children who were candidates for adoption in East European orphanages and foster homes, and to determine those attributes associated with a family's decision to adopt or refuse a particular child. METHODS: Eighty-two young children, median age 11 months, were evaluated by Israeli pediatricians in Eastern Europe between 3 weeks and 6 months prior to their adoption. The evaluation consisted of comprehensive medical and neurodevelopmental testing on site using a battery of standardized assessment tools, and observation of free play and social interactive behaviors recorded on videotape. Laboratory tests included complete blood count, chemistries, serology screening, and metabolic and genetic testing. RESULTS: The children were growth-retarded. Medical problems were classified as resolved (pneumonia and diarrhea) in 32.8%; or ongoing, such as hepatitis B and C, failure to thrive, organomegaly, and visual and hearing disorders, in 14.8%. Neuromotor status was grossly abnormal in 13.4%. Twenty-two percent of the children were rejected for adoption by families in Israel. Factors associated with the adoption decision were performance skills on developmental testing (P = 0.0001), present medical status (P = 0.002), and weight (P = 0.016). CONCLUSIONS: Pre-placement comprehensive screening of children eligible for foreign adoption, which includes developmental screening, helps to identify a wide variety of strengths and impairments in a child's background before the adoption procedure is finalized. A family's decision to adopt or not was associated with the child's performance on Bayley Scales, weight, and current medical status, but not with language delays, serious past medical history or suspect family background.

[Growth and development aspects of international adoption].

With the increase in the number of children being adopted by Israeli families from abroad, the medical system has to face heretofore unfamiliar medical and developmental challenges. Many of the biological mothers of these children were substance abusers and suffered from a variety of illnesses and nutritional deficiencies during their pregnancy. Their infants and young children were placed in orphanages at a very young age. The ensuing emotional and environmental deprivation in many cases impacted negatively on their neurological, physical and emotional development. Whereas our previous survey dealt with the purely medical aspects of international adoption, the current review deals with the growth and developmental issues involved in raising these children.

Isolated orofacial dyskinesia: a methylphenidate-induced movement disorder.

We report a case of orofacial dyskinesia in a 6-year-old female with attention-deficit-hyperactivity disorder who received a low dose of methylphenidate. The orofacial dyskinesia appeared immediately and subsided rapidly on the same day in an "on-off" fashion and on 3 separate days when methylphenidate was taken. To our knowledge this particular side effect has not been described previously and might represent an unusual type of brain response or sensitivity.

[Parenthood--medical aspects of international adoption].

The unavailability of significant numbers of native-born children for adoption by local families has led to an upsurge in international adoptions throughout the Western world, including Israel. The sudden appearance here of large numbers of babies and young children from countries with a variety of indigenous infectious diseases has focused concern on the issue. It has also induced the Ministry of Health to issue guidelines to protect the well-being of the public at large, as well as to aid adoptive families in maintaining their own, as well as their newly adopted children's health. The great majority of community based primary caregivers are unfamiliar with the health issues surrounding internationally adopted children. These children merit special care and consideration. One possible solution, in addition to educational campaigns, and already implemented abroad, is the specialized training of physicians caring for large numbers of such children. [International Adoption, HIV, Hepatitis B, Hepatitis C, Tuberculosis, Syphilis].