A total of 158 community physicians from 47 separate practices in Cincinnati, Ohio, participated in an ADHD Collaborative study designed to improve physician adherence to evidence-based AAP/ADHD treatment guidelines. Medical records of 785 children aged between 7 and 11 years were reviewed initially and every 3 months for 1 year to determine treatment outcome. Following treatment with medication alone, parent- and teacher-rated ADHD symptoms showed large improvements, but functional impairment was not significantly improved. Improvement of ADHD symptoms occurred mainly in the first 3 months of medication treatment and then remained improved and stable. The degree of improvement achieved in these community settings was comparable to that reported in the Multimodal MTA Cooperative Group, medication-only study phase. Community-based physicians can achieve improvement in ADHD symptoms, similar to university-based clinical trials, Symptom improvements are not associated with functional gains in academic performance and social and family relationships. An effective treatment program must be multimodal and include, in addition to medication, collaboration with educational and psychological services. 
COMMENT. Symptom improvements without significant functional gains in academic performance and social behavior may be expected in children with ADHD treated with medication alone in community-based settings. Educational, social and behavioral therapy are required to supplement medication for optimal management of ADHD.
The Multimodal Treatment Study of ADHD (MTA) was organized by the National Institute of Mental Health and collaborators to compare long-term effectiveness of various treatment strategies, 1994-1998. Patients were assigned to one of four groups: (1) medication alone, (2) combined medication/behavior modification, (3) behavior modification alone, and (4) routine community care. The medication alone group showed persisting superiority over behavior modification and community care for ADHD and ODD, but benefits at 24 months had diminished when compared to outcome at 10 months. Combination medication and behavior therapy was not superior to medical management alone, Results of behavior therapy were not significantly different from routine community care. The benefits of intensive medical management of ADHD symptoms extend 10 months beyond the two-year treatment phase, but the effects diminish over time. (NIMH, 2004). The AAP Committee on Quality Improvement concluded that: (1) ADHD should be managed as a chronic condition, (2) stimulant medications are beneficial and different medications are equally effective, (3) behavioral therapy is minimally effective but only in combination with medication, and (4) education and counseling of patient and family are necessary adjuncts to drug therapy. [2, 3]