JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY

Volume XX, Number XX, 2018

ª Mary Ann Liebert, Inc.
Pp. 1–8
DOI: 10.1089/cap.2018.0095

Prevalence and Predictors of Medication Use in Children

with Attention-Deficit/Hyperactivity Disorder:
Evidence from a Community-Based Longitudinal Study

Daryl Efron, MBBS, FRACP, MD,1–3 Alisha Gulenc, BPsychSc (Hons),2,3 Emma Sciberras, (DPsych),1,3,4
Obioha C. Ukoumunne, MSc, PhD,5 Philip Hazell, FRANZCP, PhD,6
Vicki Anderson, PhD,1–3 Timothy J. Silk, PhD,1,3,4 and Jan M. Nicholson, PhD3,7
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Abstract
Objectives: To determine, in a community-based sample of primary school-aged children meeting diagnostic criteria for
attention-deficit/hyperactivity disorder (ADHD), (1) the proportion of children with ADHD treated with medication; (2)
predictors of medication use; and (3) the association between medication use and psychological service utilization.
Methods: Grade 1 children with ADHD were recruited through 43 schools in Melbourne, Australia, using a two-stage
screening and case confirmation procedure. Parent report of medication treatment, clinician diagnosis, and psychological
service use were collected at ages 7 and 10 years. Medication use was analyzed by ADHD subtype. Predictors of medication
treatment examined included ADHD symptom severity and persistence, externalizing comorbidities, poor academic per-
formance, and social disadvantage. Unadjusted and adjusted logistic regression were used to identify the predictors of
medication status.
Results: One hundred seventy-nine children with ADHD were recruited. At baseline, 17.3% had been clinically diagnosed
with ADHD, increasing to 37.7% at age 10 years. At baseline, 13.6% were taking ADHD medications, increasing to 25.6% at
age 10. Children with the combined and hyperactive-impulsive subtypes were more likely to be taking medication than those
with inattentive subtype (age 7: p = 0.002; age 10: p = 0.03). ADHD symptom severity (Conners 3 ADHD Index) at baseline
was concurrently and prospectively associated with medication use at both ages (both p = 0.01), and ADHD symptom severity
at age 10 was also associated with medication use at age 10 ( p = 0.01). Baseline area-level disadvantage was associated with
medication use at age 7 ( p = 0.04). At 10 years, children receiving medication were more likely, compared with those who
were not, to be receiving psychological services ( p = 0.001).
Conclusions: In this study, only a minority of children meeting diagnostic criteria for ADHD were diagnosed clinically or
treated with ADHD medication by age 10. The strongest predictors of medication treatment were ADHD symptom severity
and area disadvantage.

Keywords: ADHD, stimulant medication, psychological services

1
Department of Paediatrics, The University of Melbourne, Parkville, Australia.
2
The Royal Children’s Hospital, Parkville, Australia.
3
Department of Health Services, Murdoch Children’s Research Institute, Parkville, Australia.
4
School of Psychology, Deakin University, Geelong, Australia.
5
NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, United Kingdom.
6
Discipline of Psychiatry, Sydney Medical School, Sydney, Australia.
7
Judith Lumley Centre, La Trobe University, Melbourne, Australia.
Funding: The Children’s Attention Project was funded by an Australian National Health and Medical Research Council (NHMRC) project grant
(100852). This project has also received funding from the Collier Foundation and Murdoch Children’s Research Institute (MCRI). A/Prof Efron’s
position is funded by a Clinician Scientist Fellowship from MCRI. Dr Sciberras is funded by an NHMRC Early Career Research Fellowship (1037159)
and an NHMRC Career Development Fellowship (1110688; 2016–19). Professor Anderson is supported by an NHMRC Senior Practitioner Fellowship.
A/Prof Ukoumunne is funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care
(CLAHRC) for the South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust. The views expressed in this publication are those of the
authors and not necessarily those of the NHS and the NIHR or the Department of Health and Social Care in England. MCRI is supported by the Victorian
Government’s Operational Infrastructure Support Program.

1
 2 EFRON ET AL.
Introduction
A ttention-deficit/hyperactivity disorder (ADHD) is the
most common neurodevelopmental disorder of childhood,
with an estimated prevalence in the order of 6%–7% (Polanczyk
et al. 2014). While stimulant medication is the most effective
symptomatic treatment ( Jensen 1999), and is recommended for
children with significant ADHD (American Academy of Pediatrics
2011), which persists after non-pharmacological approaches have
been offered (NICE 2018), the prescription of stimulant medication
for children with ADHD remains a controversial subject (Dunlop
and Newman 2016).
The important question of whether stimulant medications are
overprescribed has been of concern to the community and researchers
since prescription for ADHD became widespread in the United
States in the 1970s. In the United States the proportion of children for
whom ADHD medications are prescribed has increased incremen-
tally, and was estimated at 6.1% in 2011 (Visser et al. 2014). Factors
suggested to have contributed to increased rates of prescription in-
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clude changes in diagnostic criteria, increasing awareness, and better
access to services, particularly for low-income families (Garfield et al.
2012). Safer (2000) has discussed some practice changes needed to
improve the reliability of diagnosis and inform sound prescribing
decisions, such as multi-source data collection and greater commu-
nication between physicians and teachers.
However, to address the question of overprescribing at a popu-
lation level, the prevalence of ADHD and rate of medication pre-
scription needs to be examined in samples that include non-referred
children. Using epidemiological survey data from four U.S. com-
munities, Jensen et al. (1999) found that only 12.5% of children
meeting DSM-3-R ADHD diagnostic criteria had been treated with
stimulant medications in the preceding 12 months. While this
finding suggests undertreatment rather than overtreatment, more
current data are needed, including from countries outside the
United States.
Various methods have been used to measure the extent of
stimulant medication prescription in Australia. Studies using data
derived from state government regulatory authorities (Salmelainen
2002) and Pharmaceutical Benefits Scheme databases (Holling-
worth et al. 2011) have found the prevalence of prescription of
stimulant medication to be approximately 1%–2% of the childhood
population, and a recent study of a nationally representative sample
of children and adolescents obtained a similar result (Sawyer et al.
2017). Although there is considerable regional variation in pre-
scription of stimulant medications in Australia (Berbatis et al.
2002), overall the percentage receiving stimulant medication in
Australia has been estimated to be between those of North America
and Europe (Berbatis et al. 2002). However, population-level es-
timates are not able to inform about variation across sub-groups of
patients, nor about predictors of medication use, as they lack the
patient-level data required for such analysis.
The variables associated with the prescription of ADHD medi-
cation are not well understood. Studies examining this question are
either dated or restricted to children who are being managed by a
pediatrician. An Australian study conducted in 1998 identified
three factors associated with stimulant medication use in the gen-
eral population (Sawyer et al. 2002). In this study 1.8% of children
were prescribed stimulant medication, and only one in eight chil-
dren with ADHD was taking stimulants. The main predictors of
medication use were male sex, attending a pediatrician, and having
high levels of inattention or aggression (Sawyer et al. 2002). In a
recent audit of Australian pediatricians’ practice, 80% of children
with ADHD were treated with medication (Efron et al. 2013), a
similar proportion to that reported in the United States (Visser et al.
2014). Medication prescription in these children was predicted by
age, but not by sex or socioeconomic status (SES) (Efron et al.
2013). There has been little investigation of other potential child-
(e.g., ADHD symptom severity, academic and social function) and
family-level (e.g., parent mental health) predictors of medication
use in children with ADHD. Additionally, it is unknown whether
children who receive medication have different patterns of use of
recommended non-pharmacological management, for example,
psychological services.
Therefore, we investigated these issues using a community-
based sample of primary school-aged children meeting Diagnostic
and Statistical Manual of Mental Disorders, 4th edition (DSM-4),
criteria for ADHD (including cross-situational impairment). Spe-
cifically, we aimed to determine:
(1) proportion of children with ADHD treated with ADHD
medication (stimulant or non-stimulant) at ages 7 and 10
years in a community sample of children with ADHD
(overall and by subtype);
(2) predictors of prescription, including ADHD symptom se-
verity, ADHD persistence, presence of comorbidities, sex,
academic performance, social functioning, primary care-
giver mental health, and family- and area-level indicators of
SES; and
(3) whether receipt of ADHD medication was associated with
different patterns of use of psychological services.
We hypothesized that, contrary to popular belief, only a minority
of children meeting criteria for ADHD would be treated with
medication. We further hypothesized that those factors that are
most strongly indicative of functional impairment in children with
ADHD—namely ADHD symptom severity and persistence, the
presence of externalizing comorbidities, and poor academic per-
formance—would be the strongest predictors of medication pre-
scription. In the absence of prior data, we offered no hypotheses
regarding the prevalence of use of psychological services by chil-
dren who were and were not receiving ADHD medication.
Methods
We analyzed data from the Children’s Attention Project (CAP),
a longitudinal community-based cohort study of children with
ADHD and non-ADHD controls (Sciberras et al. 2013). Only those
children who were identified as having ADHD at baseline were
included for the current article (i.e., non-ADHD controls were
excluded). Participants were recruited from 43 government primary
schools in metropolitan Melbourne, Australia. Schools were re-
cruited via Victorian Department of Education and Training re-
gions selected for representation of diverse socioeconomic
communities. Participants were recruited via a two-stage screening
and case-confirmation procedure. The first stage involved parent
and teacher Conners 3 ADHD Index score (Conners 2008)
completed for all grade 1 children in participating schools. Those
children who screened positive by both parent and teacher ratings,
and/or whose parents reported previous ADHD diagnosis, were
invited into the longitudinal study. A structured diagnostic inter-
view (National Institute of Mental Health Diagnostic Interview
Schedule for Children Version IV [DISC-IV]) (Shaffer et al. 2000)
was then completed with parents who consented to confirm or re-
fute ADHD caseness and to identify comorbid disorders. Children
who met criteria for ADHD on the DISC-IV made up the ADHD
 MEDICATION USE IN CHILDREN WITH ADHD
cohort for this study. Exclusion criteria were intellectual disability,
severe medical conditions, genetic disorders, moderate–severe
sensory impairment, neurological problems, and parents with in-
sufficient English to complete the interviews or questionnaires (for
details of participant flow, see Efron et al. 2014). Measures were
collected via detailed parent surveys at baseline (age 7 years) and
3-year follow-up (age 10 years). An additional report of medication
status was also collected by parent survey midway (at 18 months)
between the main data collections.
Study approval was granted by the Human Research Ethics Com-
mittees of the Royal Children’s Hospital, Melbourne (#31056) and
the Victorian Department of Education and Training (#2011_001095).
Measures
Medication status (yes/no) was determined by parent response to
the survey question ‘‘Is your child currently taking medication to
assist with learning, behaviour or emotional difficulties?’’ If they
responded yes, the parent was asked to indicate which medica-
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tion(s) their child was taking from a list, which included both ge-
neric and trade names for all available methylphenidate and
dexamphetamine products, and atomoxetine, as well as ‘‘other
please specify.’’ Other medications that may have been used to treat
ADHD but which can also be used for other indications (e.g.,
clonidine, tricyclic antidepressants) were excluded from the ADHD
medication category, as we did not have data on indication for use
and so could not say whether these medications were being used to
treat ADHD.
Clinical diagnosis of ADHD (independent of the study) and use
of psychology services were ascertained in the parent survey with
the questions ‘‘Has your child ever been diagnosed with ADHD by
a health professional?’’ and ‘‘Have you sought professional help
from a psychologist for any concerns about your child’s learning,
behaviour or emotions in the last 12 months?’’
ADHD subtype and persistence were ascertained using the
DISC-IV (Shaffer et al. 2000) conducted face-to-face with parents.
Persistence was defined as meeting diagnostic criteria for ADHD at
both ages. ADHD symptom severity was measured using the parent-
reported 10-item Conners 3 ADHD Index (Conners 2008). Items
are rated from ‘‘0: not true at all (never, seldom)’’ to ‘‘3: very much
true (very often, very frequent).’’ Scores are transposed from 0–3 to
0–2 as follows: the two less severe responses (0 + 1) are combined
to 0, 2 to 1, and 3 to 2. Transposed scores are then added to create
summary scores (range 0–20), with higher scores indicating greater
ADHD symptom severity. This measure has excellent test-retest
reliability (Pearson’s r = 0.71–0.98) and internal consistency (par-
ent a = 0.92) (Conners 2008).
Mental health comorbidities were assessed using the DISC-IV
(Shaffer et al. 2000). Children were classified as having an inter-
nalizing disorder if they met criteria for separation anxiety disor-
der, social phobia, generalized anxiety disorder, posttraumatic
stress disorder, obsessive-compulsive disorder, major depressive
disorder, dysthymia, hypomania, or manic episode, and an exter-
nalizing disorder if they met criteria for oppositional defiant dis-
order (ODD) or conduct disorder.
Academic achievement was assessed using the word reading and
math computation subtests of the Wide Range Achievement Test 4
(Wilkinson and Robertson 2006). Age-based standard scores were
derived for all measures (normative mean [SD] = 100 [15]).
Social functioning was assessed using the five-item parent-
reported peer problems scale of the Strengths and Difficulties
Questionnaire (Goodman 1997). Items are rated from ‘‘not true’’
3
(0) to ‘‘certainly true’’ (2), and summed to give scores with a range
of 0–10. Higher scores indicate poorer functioning.
Primary caregiver variables were ascertained by parent survey.
Primary caregiver ADHD symptoms were measured using the 12-
item Conners Adult ADHD Rating Scale (CAARS; internal con-
sistency a = 0.76) (Conners et al. 1999). Respondents indicate how
much/frequent each statement applies to them recently from ‘‘not at
all’’ (0) to ‘‘very much, very frequently’’ (3), and scores are sum-
med to derive a total score. Primary caregiver mental health
problems were measured using the Kessler 6, a six-item validated
and widely used self-report screen for psychological symptoms.
Responses range from ‘‘none of the time’’ (0) to ‘‘all of the time’’
(4), and scores are summed to derive a total score (Furukawa et al.
2003). Family demographic characteristics, collected by parent
report, included highest primary caregiver educational level, family
income, and area-level SES, measured by the Socioeconomic In-
dexes for Areas Disadvantage Index (SEIFA) for the child’s post-
code of residence (mean [SD] = 1000 [100]); higher scores reflect
less disadvantage (Australian Bureau of Statistics 2011).
Statistical analyses
Descriptive statistics were used to describe sample characteristics
and frequency of medication use (Aim 1). Logistic regression ana-
lyses were conducted at each time point to examine the relationships
between medication use (outcome) and the following a priori iden-
tified potential predictors: child sex, ADHD symptom severity and
persistence, internalizing and externalizing comorbidities, academic
performance, peer problems, primary caregiver ADHD and mental
health, parent level of education, family income, and area-level SES
(Aim 2). Crude (unadjusted) models with one predictor only and
adjusted models with only predictors that were statistically significant
at 5% level in the crude model were fitted. Baseline predictors were
considered in models fitted to medication status at 7 years of age, and
both baseline and follow-up predictors were considered in models
fitted to medication status at 10 years. The squared Pearson correla-
tion measure was reported to quantify explained variation (R squared)
for the adjusted models (Hosmer and Lemeshow 2000). All regres-
sion analyses allowed for clustering within schools using multilevel
(mixed-effects) logistic regression. Chi-squared tests were conducted
to compare medication use and psychology service utilization by
ADHD subtype (Aim 3). For comparison, all continuous predictors in
the logistic regression models were converted to standardized scores
to have a mean of 0 and a standard deviation of 1. Analyses were
performed using Stata 15.0 (Stata Corp, College Station, TX).
Results
The cohort characteristics and baseline functional status have
been reported previously (Efron et al. 2014). There were 179
children with ADHD in the cohort at baseline, of which 144
(80.4%) participated in the 3-year follow-up. Compared with those
who participated in the 3-year follow-up, parents who did not
participate were less likely to have completed high school (41.9%
[13/31] vs. 67.6% [92/136]) or university (6.5% [2/31] vs. 28.7%
[39/136]). There were no differences in income between partici-
pants and non-participants at the 3-year follow-up.
Almost one-third (45/144; 31%) did not meet diagnostic criteria
for ADHD on the DISC-IV at follow-up (‘‘remitted’’). At baseline,
17.3% (31/179) had received an independent clinical diagnosis of
ADHD, which increased to 37.7% (49/130) at 3-year follow-up
(Table 1). At baseline, 13.6% (23/169) of children were taking
ADHD medications. This increased to 25.6% (35/137) at follow-up
 4 EFRON ET AL.

Table 1. Sample Characteristics

Baseline (N = 179) 3-year follow-up (N = 144)

Outcome variables
ADHD medication, n (%) 23 (13.6) 35 (25.6)
Methylphenidate 23 (13.6) 32 (23.4)
Dexamphetamine 0 (0) 1 (0.7)
Atomoxetine 0 (0) 2 (1.5)
Use of psychology services, n (%) 69 (38.6) 43 (33.3)
ADHD medication 13 (56.5) 19 (55.9)
No medication 54 (37.0) 24 (25.3)
Child characteristics
Age in years, mean (SD) 7.3 (0.4) 10.5 (0.6)
Male, n (%) 124 (69.3) 100 (70.9)
Clinical diagnosis of ADHD, n (%) 31 (17.3) 49 (37.7)
Met DISC-IV ADHD criteria, n (%) 179 (100) 91 (66.4)
ADHD subtype
Combined 93 (52.0) 40 (44.0)
Inattentive 64 (35.8) 45 (49.5)
Hyperactive 22 (12.3) 6 (6.6)
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ADHD symptom severity, mean (SD) 13.7 (4.0) 10.3 (6.4)

Comorbidities
Internalizing disorder, n (%) 47 (26.3) 34 (26.4)
Externalizing disorder, n (%) 97 (54.2) 66 (51.2)
Primary caregiver and family characteristics
Age in years, mean (SD) 37.2 (5.8) 40.5 (6.1)
Caregiver completing survey, n (%)
Biological mother 154 (92.8) 112 (92.6)
Biological father 8 (4.8) 6 (5.0)
Other parent/guardian 4 (2.4) 3 (2.5)
Psychological distress, Kessler 6—clinical range, n (%) 14 (8.4) 12 (9.8)
Primary caregiver ADHD symptoms, CAARS—mean (SD) 51.5 (9.9)a 52.0 (10.2)
Highest educational level, n (%)
Did not complete high school 62 (37.1) 31 (25.4)
Completed high school 64 (38.3) 48 (39.3)
Completed university degree 41 (24.6) 43 (35.3)
Family income, n (%)
<$30,000 per year 28 (17.1) 22 (18.0)
$30,001–$60,000 per year 44 (26.8) 26 (21.3)
$60,001–$90,000 per year 45 (27.4) 23 (18.9)
>$90,000 per year 47 (28.7) 51 (41.8)
SEIFA, mean (SD) 1011.3 (43.2) 1011.8 (44.8)
a
Measured at 18-month follow-up wave.
ADHD, attention-deficit/hyperactivity disorder; DISC-IV, Diagnostic Interview Schedule for Children Version IV; CAARS, Conners Adult ADHD
Rating Scale; SD, standard deviation; SEIFA, Socioeconomic Index for Areas.

and included 6 of the 46 children (13%) who no longer met ADHD years ( p = 0.03) (Table 2). These children were also more likely to
diagnostic criteria. Methylphenidate represented all of the ADHD access psychology services at age 7 ( p = 0.04), but not age 10 years,
medication at age 7, and 91.4% at age 10. compared with children with the inattentive subtype.

ADHD medication continuity

Data on medications were collected at three time points (base-
line, 18 months, and 3-year follow-up), with complete data avail-
able for 104 children. Eight (7.7%) children were taking ADHD
medication at one time point, 9 (8.7%) at two time points (8 of
whom were taking ADHD medication at both 18 months and 3-year
follow-up), and 10 (9.6%) at all three time points.
Medication and psychology service use by subtype
Children with either the combined or the hyperactive-impulsive
ADHD subtype were more likely to be taking medication than
those with inattentive subtype at both 7 years ( p = 0.002) and 10
Predictors of ADHD medication
use at ages 7 and 10 years
ADHD symptom severity at age 7 was associated with medi-
cation use at both ages 7 and 10, and ADHD symptom severity at
age 10 was also associated with medication use at age 10 (all
p = 0.01) (Tables 3 and 4). Low area-level SES at age 7 was also
associated with medication use at age 7 ( p = 0.04) but not at age
10 in cross-sectional ( p = 0.40) or prospective ( p = 0.06) analyses.
Household income below $30,000 was associated with medica-
tion use at age 7 in the unadjusted analysis, but this association
was no longer statistically significant at the 5% level in the ad-
justed analysis ( p = 0.43).
 MEDICATION USE IN CHILDREN WITH ADHD 5

Table 2. Medication Use by Attention-Deficit/Hyperactivity Disorder Subtype

ADHD subtypea
Inattentive Combined Hyperactive p

Baselineb
Number 64 93 22 —
ADHD medication, n (%) 1 (1.6) 18 (19.4) 4 (18.2) 0.002
Use of psychology services, n (%) 17 (26.6) 41 (44.1) 11 (50.0) 0.04
3-year follow-upc
Number 45 40 6 —
ADHD medication, n (%) 9 (20.0) 16 (40.0) 4 (66.7) 0.03
Use of psychology services, n (%) 18 (40.0) 14 (35.0) 1 (16.7) 0.42
a
Baseline assessment (age 7).
b
N ranged from 169 to 179.
c
N ranged from 85 to 91.
ADHD, attention-deficit/hyperactivity disorder.

Psychology treatment by medication status Discussion

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Overall 39% of the ADHD cohort had sought help from a psy-
chologist in the previous 12 months at age 7, and 33% at age 10. At
both waves, just over half of those taking ADHD medication were
seeing a psychologist. Children who were taking ADHD medica-
tion were more likely to have seen a psychologist than those who
were not [at 7 years: 56.5% (13/23) vs. 37.0% (54/146); p = 0.08; at
age 10 years: 55.9% (19/34) vs. 25.3% (24/95); p = 0.001].
In this community study of children, all of whom met diagnostic
criteria for ADHD (including impairment criteria) at age 7 years,
we found that only one in six had received a clinical diagnosis by
age 7, and one in three by age 10. Approximately one in seven had
been prescribed ADHD medication at age 7, and one-quarter at
age 10. Six children continued to take medication at age 10 despite
no longer meeting criteria for ADHD. The main predictor of

Table 3. Unadjusted Predictors of Medication Use (y/n) at Baseline and 3-Year Follow-Up

Cross-sectional analyses Prospective analyses

3-year follow-up 3-year follow-up
Baseline medication usea,b medication usec,d medication usea,e
Predictor OR 95% CI p OR 95% CI p OR 95% CI p

Child variables
Male 2.19 0.69–6.93 0.18 1.95 0.70–5.41 0.20 — — —
ADHD
Persistence — — — 3.37 1.17–9.76 0.03 — — —
Symptom severity 2.68 1.48–4.9 0.001 3.05 1.74–5.34 <0.001 2.19 1.32–3.61 0.002
Comorbidities
Internalizing 1.54 0.59–4.02 0.38 1.85 0.71–4.87 0.21 1.76 0.69–4.46 0.24
Externalizing 2.67 0.99–7.22 0.05 4.39 1.67–11.55 0.003 3.06 1.23–7.62 0.02
Academic performance
Math computation 0.65 0.41–1.02 0.06 1.29 0.82–2.02 0.27 0.83 0.54–1.29 0.41
Word reading 0.71 0.44–1.14 0.15 0.91 0.58–1.43 0.68 0.91 0.58–1.43 0.69
Peer problems 1.34 0.87–2.08 0.19 1.78 1.14–2.76 0.01 1.56 1.03–2.37 0.04
Primary caregiver and family variables
Primary caregiver ADHD symptoms — — — 1.78 1.13–2.80 0.01 — — —
Primary caregiver mental health problems 1.37 0.90–2.10 0.14 1.49 1.00–2.24 0.053 1.36 0.90–2.05 0.14
Household incomef 0.03 0.11 0.05
$60,001–$90,000 2.20 0.38–12.62 2.94 0.82–10.60 2.30 0.64–8.20
$30,001–$60,000 4.26 0.83–21.74 1.93 0.55–6.77 4.14 1.23–13.91
<$30,000 9.00 1.75–46.24 4.54 1.30–15.92 5.53 1.45–21.13
Parent completed high school 0.49 0.19–1.23 0.13 0.71 0.27–1.91 0.50 0.64 0.27–1.51 0.31
Area-level socioeconomic status 0.54 0.34–0.84 0.01 0.63 0.41–0.97 0.04 0.59 0.38–0.91 0.02
a
Baseline predictors.
b
N ranged from 166 to 169.
c
Predictors of wave-three medication use.
d
N ranged from 122 to 137.
e
N ranged from 111 to 137.
f
Reference group: >$90,000 per year.
ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; OR, odds ratio.
 6 EFRON ET AL.

Table 4. Adjusted Logistic Regression Analyses of Predictors of Medication

Use (y/n) at Baseline and 3-Year Follow-Up

Cross-sectional analyses Prospective analyses

Baseline 3-year follow-up 3-year follow-up
medication usea,b medication usec,d medication usea,e
Predictor OR 95% CI p OR 95% CI p OR 95% CI p

Child variables
ADHD
Persistence — — — 0.55 0.13–2.36 0.42 — — —
Symptom severity 2.29 1.21–4.36 0.01 2.83 1.35–5.94 0.01 1.97 1.14–3.39 0.01
Externalizing comorbidities 1.88 0.60–5.92 0.28 2.83 0.87–9.15 0.08 1.96 0.77–4.99 0.16
Peer problems — — — 1.29 0.73–2.26 0.38 1.16 0.71–1.87 0.56
Primary caregiver and family variables
Primary caregiver ADHD symptoms — — — 1.57 0.75–3.27 0.23 — — —
Primary caregiver mental health problems — — — 0.91 0.47–1.76 0.78 1.12 0.72–1.73 0.62
Household incomef 0.43 0.52 0.40
$60,001–$90,000 1.71 0.27–10.99 2.46 0.53–11.51 1.69 0.43–6.55
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$30,001–$60,000 2.35 0.42–13.10 1.81 0.36–9.08 2.75 0.77–9.80

<$30,000 3.96 0.67–23.26 3.39 0.61–18.76 2.66 0.64–11.01
Area-level socioeconomic status 0.58 0.34–0.97 0.04 0.77 0.42–1.42 0.40 0.63 0.39–1.02 0.06
R-squared 20.0% 27.6% 18.7%
a
Baseline predictors.
b
N = 161.
c
Predictors of wave-three medication use.
d
N = 115.
e
N = 131.
f
Reference group: >$90,000 per year.
ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; OR, odds ratio.

medication use was ADHD symptom severity, and medication use
was associated with higher use of psychology services.
Children with combined or the hyperactive-impulsive ADHD
subtype were more likely to be taking medication than those with
inattentive subtype. This finding is consistent with an American study
that found that children with inattentive ADHD subtype [known as
‘‘presentation’’ in DSM-5 (American Psychiatric Association 2013)]
are less likely to receive medication treatment than those with com-
bined ADHD type (Weiss et al. 2003). It also aligns with our finding
that the effect of the child’s behavior on the family (generally related
to hyperactive-impulsive symptoms) is one of the main drivers of
parental help-seeking for children with ADHD (Efron et al. 2016).
The presence of comorbid externalizing disorders was a pre-
dictor of ADHD medication use in the unadjusted analysis, but not
in the adjusted analysis. This result suggests that, while the pres-
ence of externalizing disorders (predominantly ODD in this age
category) may bring children to clinical attention, the main driver
for medication prescription is the ADHD symptoms. This is con-
sistent with the evidence regarding the symptomatic efficacy of
ADHD medications ( Jensen 1999).
In this study, lower area-level SES at baseline was associated
with an increased likelihood of being prescribed ADHD medica-
tion. Similarly, in a nationally representative sample, Sawyer et al.
(2017) found the highest prevalence of stimulant prescription in the
lowest household income bracket, and Calver et al. (2007) found
the highest prevalence of stimulant prescription to Western Aus-
tralians in the lowest SES group. Reasons for the association be-
tween SES status and ADHD medication prescription are unknown.
We sampled across diverse communities, making systematic re-
ferral bias unlikely. Powers et al. (2008) proposed that children
from low SES groups are more likely to be recommended stimulant
treatment for their ADHD because they have less access to re-
sources commonly employed both within and outside of the home
by middle and high SES families to promote academic success.
This is unlikely to explain our findings as poor academic perfor-
mance was not a predictor of ADHD medication use in this study.
Alternatively, higher-SES-status parents may be more prepared to
wait to see if symptoms improve, or more inclined to seek non-
pharmacological management for their children’s ADHD. The
finding of an association between the area-level SES indicator and
medication use suggests that community service characteristics
may be important in determining whether children with ADHD are
assessed and treated. The 2015 Australian Atlas of Healthcare
Variation identified substantial variation by area in the prevalence
of prescription of psychotropic medications for children and ado-
lescents, suggesting a potential target for practice improvement
(Australian Commission on Safety and Quality in Health Care and
National Health Performance Authority 2015). Further research is
needed to better understand the factors influencing access to care
for Australian children with ADHD.
In relation to non-pharmacological management, at each data
collection point in this study, approximately one-third of children
with ADHD had seen a psychologist in the last year. Children were
more likely to have seen a psychologist if they had been treated
with ADHD medications. This suggests that parents who sought a
medical diagnosis were also more likely to seek psychology sup-
port, and/or that prescribers identified and addressed comorbidities
alongside medication treatment for ADHD, in accordance with
clinical practice recommendations (American Academy of Pedia-
trics 2011).
The finding of a higher prevalence of ADHD medication use in
our cohort at age 10 (26%) than at age 7 (13%) is consistent with
 MEDICATION USE IN CHILDREN WITH ADHD
previous Australian data showing the peak age for stimulant
medication use is 9–11 years (Salmelainen 2002). Sawyer et al.
(2017) reported that 14% of Australian children and adolescents
aged 4–17 years meeting DSM-4 criteria for ADHD had taken
stimulant medication in the previous 2 weeks. This figure reflects
an average prevalence across childhood, whereas our findings are
more specifically indicative of the prevalence of ADHD medication
use in early and mid-primary school. Sawyer et al. (2017) identified
some children in their cross-sectional study who did not meet di-
agnostic criteria for ADHD yet were receiving ADHD medication,
and discounted treatment response as the reason. In the present
study, the six children taking medication at age 10 years who did
not meet ADHD diagnostic criteria had all met criteria at age 7, and
remitted in the interim.
Our finding of substantial differences between the true preva-
lence (percentage of individuals in a representative sample meeting
research criteria) and ‘‘administrative prevalence’’ (rate of clinical
diagnosis) is consistent with previous research in childhood
ADHD. Large studies of representative samples in the United
Downloaded by Tulane University from www.liebertpub.com at 12/09/18. For personal use only.
States (Froehlich et al. 2007) and Europe (Ford et al. 2003) have
found that less than half of affected children are identified. Taylor
(2017) has postulated a range of factors that may underpin under-
diagnosis of ADHD, including concern about stigmatization from
use of diagnostic labels, lack of teacher training in recognition of
ADHD symptoms, concern that diagnosis will inevitably lead to
medication treatment, and underrecognition of ADHD by health
services who assess referred children.
This study had some limitations that need to be considered in the
interpretation of the findings. As with all cohort studies, we had
some participant attrition. Participants in the 3-year follow-up were
highly educated than non-participants, which may have biased
some findings. Our measure of medication use was parent-reported,
as we did not have an objective measure, such as prescription or
dispensing data. This may not always have been reliable. As sur-
veys were completed by the family’s nominated primary caregiver,
our data are predominantly from biological mothers, but only a
small percentage of biological fathers and other parents/guardians,
who may have reported some outcomes differently. Finally, some
analyses are likely to have lacked power, resulting in type 2 errors.
The confidence interval width informs the degree of precision of
our findings.
In summary, the majority of children in the Melbourne community
who meet ADHD criteria are not being medically diagnosed by age
10. Those who receive a clinical diagnosis are likely to be treated with
medication, and also likely to be referred for other interventions such
as psychology. These data suggest that overall children with ADHD
in this community are not being overmedicated.
Conclusion
This community-based study found that only a minority of
children meeting criteria for ADHD at age 7 were treated with
ADHD medication by age 10. The findings suggest that ADHD
medications are not overprescribed in Australia.
Clinical Significance
There is widespread concern that too many children are
treated with ADHD medications. The data from this study sug-
gest that, on the contrary, more children in the community with
impairing ADHD symptoms should be referred for assessment
and treatment.
7
Acknowledgments
We acknowledge all research assistants, students, and interns
who contributed to data collection for this study. We would also
like to thank the children, families, and schools for their partici-
pation in this study.
Disclosures
Prof Hazell or his employer has received payment from Shire
for participation in advisory boards; from Eli Lilly and Shire for
speaker’s bureau. All other authors declare that there are no conflicts
of interest.
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Address correspondence to:
Daryl Efron, MBBS, FRACP, MD
Department of Health Services
Murdoch Children’s Research Institute
Flemington Road
Parkville 3052
Australia
E-mail: daryl.efron@rch.org.au