Israel has a three-tiered diagnostic and treatment system for children with developmental difficulties, headed by child development institutes. The institute staff includes physicians from various disciplines and health practitioners such as physio- speech-, and occupational therapists. Some institutes are affiliated with the Ministry of Health and government hospitals. Most are affiliated with the health plans. The second tier consists of child development units run (in general) by the health plans, the Israel Association of Community Centers, or NGOs; the third tier consists of private therapists.
The institutes carry a heavy workload and waiting times for appointments are long. The 2017 State Comptroller’s Report noted that the waiting times for diagnosis and treatment greatly exceed Ministry of Health stipulations (up to three months) and may be as much as a year or more.
Consequently, the National Institute for Health Policy Research and the Israel Pediatric Association commissioned a study from the Myers-JDC-Brookdale Institute (MJB) on the potential involvement of community pediatricians in this area to help advance the treatment of children with developmental difficulties.
The goal of the study was to examine the perceptions of child development institute directors of the role of community pediatricians at the time of writing, and the extent that they could be more involved in this area and contribute to advancing the treatment of children with developmental difficulties. The specific study questions were:
■ What is the actual involvement of community pediatricians in the area of child development, and what should it be?
■ To what extent are community pediatricians able to avoid unnecessary referrals to child development institutes?
■ If greater involvement of community pediatricians is desirable, what training and additional resources are required to that end?
The study employed semi-structured interviews. In the first stage, preliminary interviews were conducted with seven child development institute directors and pediatricians from the four health plans, hospitals, and the Ministry of Health. In the second stage, 15 child development institute directors were interviewed, 12 from the health plans and three from the ministry.
Content analysis was performed to identify the main topics. The first-stage interviews were analyzed separately by three members of MJB’s research team, followed by discussion to arrive at a consensus on categorization.
The study was approved by the MJB ethics committee.
Involvement of community pediatricians in the area of child development
There was broad agreement among the interviewees that the involvement of community pediatricians in the area of child development is currently very limited, and the directors would like to see their role increase substantially, particularly as follows:
a. Conduct a preliminary medical examination, referring children to relevant tests.
b. Transmit all relevant information to the institutes in a written referral that would include the child’s condition, prior illnesses, prior hospitalizations if any, illnesses in the family, developmental information, growth curve, head circumference, and the course of pregnancy prior to birth.
c. Serve as the contact person for concerned parents, providing guidance and consultation in the case of minor behavioral and developmental problems.
d. Exercise greater discretion to ascertain that child development institutes are in fact the right place to treat their patients before referring children to them or succumbing to pressure to do so from parents, preschool teachers or nurses at well-baby clinics. A minority view contended that pediatricians should not decide which children should or should not be referred since they do not have sufficient knowledge and may inadvertently cause damage.
e. In mild to moderate cases, refer directly to therapists, e.g., to a speech therapist from or through the health plan. Currently, pediatricians are restricted by the health plans from directly referring children to therapists.
The involvement of additional parties in identifying children with developmental delays
It was evident from the interviews that in most cases, pediatricians are not the first party to detect developmental delays in the children in their care. They are preceded mainly by nurses at wellbaby clinics and preschool teachers (apart from parents). To enhance detection child development professionals can be introduced into the clinics.
Problems that exacerbate the workload of child development institutes
Among the factors that exacerbate the workload of the institutes are unsuitable referrals and problems of other systems, such as education, which rely unduly on child development services due to lack of manpower (e.g., of teachers and teacher aides).
Barriers to the expansion of pediatrician involvement in diagnosis and treatment in the area of child development
The interviewees mentioned several barriers to the involvement of community pediatricians:
1. Lack of time – the most significant barrier according to the interviewees
2. Lack of adequate compensation for considerably greater involvement
3. Insufficient clinical experience
Possible ways to enhance pediatrician involvement
1. Introduction of the area of child development into the pediatrics specialization and/or the training of physicians interested in the area
2. Virtual consultation with specialists for family physicians, as needed
3. Incentives for pediatricians to perform screening tests
The interviewees would like to see pediatricians more involved in the area of child development. They would like the care system to include a community-based clinician who would refer a child to the institutes after having exercised their best judgment about the nature of the problem and the necessity of referral, and after having referred the child for relevant tests. The community pediatricians themselves would treat mild to moderate cases by guiding parents on how to address a problem.
Concomitantly, in the perception of the interviewees, the main barriers deterring pediatricians from a more active role in the area of child development are lack of time, inadequate compensation, and lack of knowledge. These problems were cited as critical.
The interviewees were critical of the inadequate exposure of physicians specializing in pediatrics to both the community and the area of child development. They made it clear that they do not expect community pediatricians to fill the role of developmental pediatricians. They do expect them, as pediatricians, to relate to child development problems as they do to other problems.
■ The area of child development should be part of the pediatrics residency training programs. Similarly, ways should be found to impart knowledge and to expose the area to pediatricians who have completed their residencies.
■ Pediatricians should be allowed to have longer visits with children suspected of developmental delay, and with their parents, and they should be compensated for the added time.
■ The possibility of periodic “well-child visits” to pediatricians should be explored. Such visits would enable the pediatricians to observe the children when they are well and calm. They should have the authority to refer the children to screening tests and monitor their development. This last point is contingent on the health plans allocating appropriate funding. In addition, consideration should be given to the involvement of nurses and other child development professionals to assist with
screening tests and enhance detection.
■ Consultation channels should be strengthened at the health plans (e.g., online) for pediatricians to be able to seek the advice of developmental specialists without having to turn to the institutes.
■ The information gleaned in this study about pediatrician involvement in child development should be rounded off with a study to examine the perceptions of the pediatricians themselves, and of the managers in charge of pediatrics at the health plans