Researchers at the Departments of Psychiatry and Pediatrics, Children's Memorial Hospital, Chicago, conducted a randomized medication trial for ADHD involving 24 pediatric practices. Patients were randomly assigned to 2 groups, treatment as usual or a specialized care group in which physicians received 2 hours of ADHD medication management training plus training on a software program to monitor response. Parent and teacher reports were obtained before treatment and 4, 9, and 12 months after starting medication. Exclusion criteria included IQ < 70, history of intolerance to stimulants, and ADHD medication in previous 2 months. Of 270 children participating, 208 (77%) were boys and 62 (23%) girls, mean age 8.2 years. Comparisons between groups were made for the highest daily dose of medication, with stimulant medications converted to methylphenidate equivalents. Total daily medication dose did not differ significantly between groups: mean 27.1 mg/day for titration group and 27.9 mg/day for patients not adhering to dose titration. Children in both groups improved on the ADHD Rating Scales and SNAP-IV, with no group differences in rate of improvement. Starting on a short-acting versus long-acting stimulant showed no significant difference in benefit but significant effects were associated with progressing sequentially until symptoms were in the average range (P=0.039). Brief physician training alone was of no added benefit, but adherence to recommended titration procedures was followed by improvements in total and inattentive ADHD symptoms on the ADHD Rating Scales and SNAP-IV parent and teacher scales. Computer-assisted medication management may contribute to better treatment outcomes in pediatric primary care management of ADHD. 
COMMENT. Successful management of the child with ADHD is benefitted by computer-assisted titration of medications. Brief training periods for physicians are not sufficient to obtain a better outcome. Computer-assisted dose-response decision-making increases adherence to guidelines. The optimal dose is the lowest dose producing a clinically significant change and symptom rating in the average range. This is associated with significant improvements in classroom behavior. Practices that stress to the parents the importance of obtaining school reports are more likely to obtain optimal results.