Prosser, B., Reid, R. (1999). “Psychostimulant Use for Children with Attention Deficit Hyperactivity Disorder in Australia”. Journal of Emotional and Behavioral Disorders 7, 110-117

Psychostimulant Use for Children withAttention Deficit Hyperactivity Disorder in Australia

Brenton ProsserFlinders University of South Australia

Robert ReidUniversity of Nebraska

running head: medication use

ncrev v.1

medication usep. 2

AbstractThere has been a rapid growth in the use of medication for treatment

of ADHD in the last decade. This growth has often been explained as the recognition of a condition that affects up to five percent of all young people. The purpose of this study is to compare past medication trends and current usage in Australia with the United States. We present country-wide data from Australia on psychostimulant production and prescription rates. We also analyze data from one city on the numbers of children receiving medication. Results suggest that medication use in Australia is increasing at a rate similar to the United States and that in one city a relatively small proportion of practitioners accounted for the majority of prescriptions. Results also suggest that, in Australia, there may be differences in prescription rates by income and unemployment.

medication usep. 3

Psychostimulant Use for Children with Attention Deficit Hyperactivity Disorder in Australia

Attention Deficit Hyperactivity Disorder (ADHD) is now one of the most commonly diagnosed disorders of childhood. Although estimates vary greatly, the prevalence of ADHD is thought to be approximately 3-5% of the school-aged population (Barkley, 1998). In the United States, the most common form of treatment is psychostimulant medications (drugs which increase arousal of the central nervous system). The most frequently used psychostimulants are methylphenidate or dextroamphetamine (Pelham, 1993; Greenhill, 1992). For children who have been diagnosed as having ADHD by medical/health professionals, nine out of ten will receive medication for at least some period of time (Reid, Maag, Vasa, & Wright, 1994). Use of Psychostimulants in the United States

It is difficult to state exactly how many children in the U.S. receive medication. In 1980 it was estimated that up to 541,000 children received psychostimulants (Gadow, 1981); in 1987 estimates increased to 750,000 (Safer & Krager, 1988). In 1993 estimates rose to 1.7 million, and a 1995 estimate put the number at slightly over 2 million (Swanson, Lerner, & Williams, 1995). Because many of these estimates were based on extrapolations from local data there is room for error; however, they do strongly suggest that the number of children receiving medication is increasing rapidly. There is also empirical evidence to suggest that the rate of medication use is increasing.

Morrow and his colleagues (Morrow, Morrow, & Haslip, 1998) used Drug Enforcement Agency methylphenidate distribution data to compare national and regional patterns of medication use in the United States in

medication usep. 4

1990 and 1995. They found that average use increased nationally from 60 grams per 10,000 in the general population in 1990, to 168 grams per 10,000 in 1995. They also reported distinct variations among regions and across time. In 1990, differences in medication use across regions was quite small. Medication use was highest in the upper mid west and western regions of the United States. In 1995 all regions were well above 1990 rates, with the upper mid west and south exhibiting the highest rate of distribution.

In an extensive review of psychostimulant use, Gadow (1981) also found that rates of medication prescription varied greatly between the eastern, midwest, and western regions, and noted significant increases within these regions over time. He posited several reasons for this variation, some of which included: socioeconomic status, race, age of the students, time of year, or whether special education students were included in the sample. However, Gadow also cautioned that because of different data collection techniques and sampling procedures it was difficult to draw comparisons across regions. We should note that the documented proportion of increase in methylphenidate production does not directly equate to increased ADHD diagnosis. The increase in numbers of children medicated is less than the increase in amount of methylphenidate produced. Safer, Zito, and Fine (1996) reviewed data from large scale regional studies from 1990-1995 that suggests that child medication use has increased by a factor of 2.5 or less, in contrast to more than a six-fold increase in production. Although methylphenidate is used for other disorders such as narcolepsy, this accounts for a very small proportion of the total usage.

As yet there is no generally accepted rationale behind the pronounced variations in medication use across region. One possible factor may be the

medication usep. 5

rise in specialized ADHD clinics. These clinics advertise ADHD assessment services and appear to diagnose an extremely high percent of referrals as ADHD (Diller, 1998). Changes in accepted practices may also affect medication use. Until recently, medication treatment for ADHD was relatively short term with most children receiving medication for 2 years or less (Swanson, Cantwell, Lerner, McBurnett, Pfiffner, & Kotkin, 1992). However, researchers suggest that this pattern is changing and that students now remain on medication for longer periods of time (Safer & Krager, 1994). It is also possible that physicians no longer recommend drug free periods or drug holidays which were used previously (Gadow, 1981). Prescribing practices of individual physicians may also be a factor. Some physicians will issue many times more prescriptions than comparable peers (Diller, 1998). There are documented instances where the prescribing practices of a single physician have materially affected the proportion of children medicated locally. For example, in Grand Junction, Colorado, a school district experienced an increase in the number of children receiving medication of over 500% in less than two years (Lofholm, 1994). This increase was due nearly entirely to one physician.

The role of socioeconomic status (SES) in the prescription of medication may also be important. Low SES has been implicated as a risk factor for ADHD and would therefore have an effect on medication use (Biederman, Milberger, Faraone, et al., 1995). Gadow (1981) noted that many studies have investigated the allegation that drug treatment is higher among poor and minority groups because medication is a means of social control. However, there are few data on this topic. One notable exception is the work of Sager and Krager who have systematically surveyed medication use among students in Baltimore County Maryland using public-school

medication usep. 6

medication records. Interestingly, Safer and Krager (1988) found that in the 1970Õs, families earning above the median income were more likely to have children who received psychostimulant medication. However, by the mid 1980Õs the situation had reversed. While uncertain of the cause of the shift, the authors attributed much of it to the prominent increase in publicly financed hyperkinetic child clinics which were primarily located in low-income areas and may have increased the availability of medication for low income students.

In summary, research to date indicates that medication use in the United States is increasing and that there is variation in the patterns of prescription of medication for ADHD. Primarily this variation has involved regional and socioeconomic factors.Use of Psychostimulants in Other Nations

There is also reason to believe that the nature of medical responses has varied from country to country. For example, Diller (1998) suggested that increased psychostimulant usage is largely an American phenomenon. In the only major international study conducted to date, Safer and Krager (1984) sent questionnaires to 195 medical professionals in 60 countries. They found that the trend toward psychostimulant treatment for hyperactive behavior was most pronounced in the United States, and relatively uncommon outside of the United States. Drug therapy was uncommon in Europe, and there was some evidence that Asian children exhibited less hyperactive behavior and hence were medicated less. Further, increases in stimulant treatment tended to follow the influx of American-trained physicians. However, this study was limited by a relatively low return rate (27%), and by only a few physicians within a country being sampled. These limitations, along with the fact that the data are now over

medication usep. 7

15 years old, casts doubts as to whether these findings reflect current practices.

Australia appears to be the only nation that has experienced a documented increase in psychostimulant use that parallels that which has occurred in the United States (Diller, 1998). Like the United States, Australia has recently experienced a five fold increase in medication use for ADHD (Hazell, McDowell, & Walton, 1996). Rates and growth of prescription appeared to vary among Australian states (Valentine, Zubrick, & Sly, 1996), possibly due to differing recording procedures. For example, Victoria recorded a twenty-fold growth in prescription between 1988 and 1994, and a seven-fold growth between 1993 and 1995. New South Wales recorded a six-fold, and then two-fold, growth over the same periods (National Health & Medical Research Council, 1997). Between 1991 and 1997, there was an estimated fifty fold increase in psychostimulant prescriptions in South Australia for children with ADHD (Atkinson, Robinson, Shute, 1997).

The rise in medication use may be the result of increased awareness of ADHD; however, the fact that there are marked regional differences in medication use (Morrow et al., 1998) suggests the possibility that other factors may also play a role. Analysis of social variables which may be related to medication use may prove valuable in understanding the underlying reasons for the increases in medication use.

The purpose of this paper is to report data on this increase in Australia, and to assess factors which may have contributed to the rise in medication use. First we will present descriptive data on the rate of increase in psychostimulant use and new prescriptions. Next, we compare use patterns and variations to that of the United States. Finally, we investigate

medication usep. 8

whether the recent growth in medical treatment varies according to socioeconomic factors.

MethodWe collected data on the growth and demographic distribution of

psychostimulant prescription for children with ADHD within Australia from a number of official bodies. Sources included the Commonwealth of Australia Department of Human Services (DHS), the Australian Bureau of Statistics (ABS) 1996 National Census, and the South Australian Health Commission (SAHC).Demographic Data

Demographic data were taken from the 1996 Commonwealth of Australia national census. From these data we used population figures for 121 postcodes (equivalent to American zipcodes) for children aged 4 to 18 years in the city of Adelaide, South Australia. These figures represented the approximate population of each Adelaide postcode at the time initial data were collected on distribution of medication (April, 1997). In November, 1997, the ABS also published a social atlas for Adelaide which detailed further demographic information from the 1996 census. This atlas provided information on socioeconomic status and unemployment by postcode, and changes in population of the 4 to18 year-old group since 1996. This information indicated an overall decline in the 4 to 18 population of approximately 1.25% over the period 1997-8. This rate of decline was used to estimate the approximate population of each Adelaide postcode at the time of the second data collection (September, 1998).Psychostimulant Use

The DHS supplied data on annual prescriptions for methylphenidate and dextroamphetamine filled by pharmacies in Australia over the period

medication usep. 9

1990 to 1997. Both drugs also have approval for the treatment of narcolepsy, but prescriptions for this disorder are negligible.

The SAHC Drug Dependence Unit provided general data from South Australia as well as specific data from Adelaide. Because methylphenidate and dextroamphetamine are classified as Òdrugs of dependenceÓ, all medical practitioners are required to gain authorization from the SAHC to treat a patient with either psychostimulant for any period greater than two months. The SAHC provided data on the number of patients authorized to obtain methylphenidate and dextroamphetamine by Adelaide postcode, as of April, 1997, and September, 1998. The SAHC also made available: the number of authorized patients for the years 1987 to 1997; the number of approved dextroamphetamine and methylphenidate prescriptions for the same period; and records of distribution of prescriptions by practitioner for the years 1993 and 1996. This accounts for every reported child prescribed a psychostimulant to treat ADHD for a period greater than two months. To estimate the extent of psychostimulant use by postcode, we computed the proportion of children receiving a psychostimulant by dividing the number of authorized patients by the 4 to 18 year-old population of each postcode. Socioeconomic Status

Income. Based on the criteria used by the ABS, a postcode was defined as high income if over 40% of the population earned more than $590 per week (AUS $1,000 per week). A postcode was low income if over 40% of its population earned less than $177 per week (AUS $300). Middle income status postcodes were those that did not qualify under either of the previous criteria.

Unemployment. Again following the ABS criteria, three levels of unemployment were defined by postcode. High unemployment was defined

medication usep. 10

as postcodes with 15% unemployment or more, middle as postcodes with 10-14% unemployment, and low as 9% or less unemployment. The overall rate of unemployment within Adelaide at the time of the census was 10.6% of the labor force.

ResultsTrends in Psychostimulant Use

The growth in the number of psychostimulant prescriptions dispensed by pharmacies in Australia over the period of 1990-1997 is shown in Figure 1. In comparison, United States records of methylphenidate production for the same period show a similar pattern of growth, from 1,768 kg to 13,824 kg (DEA, 1998). We would caution that, because United States data are kilograms produced and Australian data are number of prescriptions, rates can not be directly equated. However, the growth in Australian psychostimulant prescriptions is strikingly similar to that of production in the United States in terms of time frame (both rates accelerated after 1990) and rate of increase.

Insert Fig 1Within Australia, dextroamphetamine is prescribed at more than twice

the rate of methylphenidate. Figure 2 shows the amount of dextroamphetamine and methylphenidate prescribed in South Australia over the period 1987-1997. The South Australia growth curve appears to closely parallel the national trend. However, the proportion of use of methylphenidate and dextroamphetamine differ. From 1987 to 1995 methylphenidate use predominated, but in 1996 the usage patterns changed to more closely reflect national use.

Insert Fig 2

medication usep. 11

Prescribing PracticesData on prescribing practices in South Australia came from SAHC

reviews of psychostimulant prescribers in 1993 and 1996. In September, 1993, the SAHC recorded 50 prescribers, of whom 26 were specialists (neurologist, psychiatrist, pediatrician), accounting for 1005 patients, and 24 general practitioners, accounting for 39 patients. In 1993, five prescribers were responsible for 56% of the patients receiving psychostimulants. In October, 1996, the SAHC recorded 195 prescribers, of whom 39 were specialists (2913 patients) and 156 were general practitioners (350 patients). In 1996, five prescribers accounted for 61% of patients. These data suggest that the growth in prescriptions in South Australia was primarily due to increases among specialists, and that a small proportion of practitioners account for the majority of prescriptions.Effect of Socioeconomic Status

Psychostimulant medication use for 4-18 year-olds by income and unemployment for 121 postcodes in Adelaide, South Australia, are shown in Tables 1 and 2. We also assessed changes in the percentage of medicated children by calculating the percent difference per postcode across the two periods (1998 percent medicated minus 1997 percent medicated). We conducted separate one-way ANOVAs using as dependent measures percentage of medicated children per postcode in April, 1997, and in September, 1998, as well as percent difference. Significant one-way ANOVA results were followed by Tukey HSD post hoc tests to assess which groups differed significantly.

Income. For 1997, there was a significant difference across income levels (F[2,118] = 4.14, p = .018). Follow up Tukey HSD tests showed that the percent of children medicated in the low-income group was significantly

medication usep. 12

higher than in both the middle and high-income groups. For 1998, a similar pattern emerged. There was a significant overall effect (F[2,118] = 6.52, p = .002). Follow up Tukey HSD tests also showed that the percent of children medicated in the low-income group was significantly higher than in the middle and high-income groups. Percent difference over time, however, was not significant (F[2,118] = 2.78, p = .066).

Unemployment. For 1997, there was a significant difference across unemployment levels (F[2,118] = 8.01, p < .001). Follow up Tukey HSD tests showed that the percent of children medicated in the high unemployment group was significantly higher than in the low unemployment group but not the middle unemployment group. For 1998, an identical pattern emerged. There was a significant difference across unemployment levels (F[2,118] = 9.71, p < .001). Follow up Tukey HSD tests showed that the percent of children medicated in the high unemployment group was significantly greater than the low unemployment group but not the middle group. Again, percent difference was not significant (F[2,118] = 1.46, p = .235).

DiscussionThe results of this study suggest that there are both similarities and

differences in the rate of increase in psychostimulant use and prescribing patterns across Australia as well as the United States. The results also suggest that, in Australia, factors related to socioeconomic status may affect the likelihood of a child being diagnosed with ADHD and receiving medication.Increased Psychostimulant Use

The growth of psychostimulant usage in Australia bears a striking resemblance to that of the United States in terms of both the time of onset

medication usep. 13

and rate of growth. In the early 1990s both nations experienced a marked increase in psychostimulant use. In the United States, the number of children receiving medication increased 250% between 1990 and 1995, with an estimated 2.8% of children 5-18 receiving medication (Safer et al., 1996). However, there were marked regional differences in rates (Morrow, et al., 1998; Safer et al., 1996). Nationally, Australia experienced a five-fold increase from 1993 to 1996 (Hazell, et al., 1996) with an equally marked regional variation (Valentine, et al., 1996).

In 1996 approximately 1.2% of children aged 5-18 years in South Australia were receiving medication for ADHD (SAHC, 1997). Using estimates based on ABS (1997) and SAHC (1998) figures, this can be seen as part of a growth from approximately 0.2% in 1991, to the current level of about 1.6% of the South Australian 5-18 year population. Our data show that in 1997, 1.74% of children in Adelaide aged 4-18 received medication for ADHD, while in 1998, this had grown to 2.36%. Thus, medication use in Adelaide, and South Australia as a whole, has recently increased substantially.

One interesting aspect of psychostimulant use in Australia is the proportion of prescriptions for methylphenidate as compared to dextroamphetamine. In the United States, methylphenidate is much more commonly prescribed for ADHD than dextroamphetamine (Pelham, 1993; Greenhill, 1992). In Australia this pattern is reversed at the national level: the number of prescriptions for dextroamphetamine are approximately double those of methylphenidate. This may be due to differences in health care systems across the two countries. Australians of low income can obtain free consultations by general practitioners and significantly subsidised access to certain listed medications under the Pharmaceutical Benefits

medication usep. 14

Scheme. The fact that dextroamphetamine is listed while methylphenidate is not (Upfal, 1995; Valentine et. al., 1996) may explain the higher use of dextroamphetamine in Australia. In South Australia, until 1996 methylphenidate was prescribed more frequently than dextroamphetamine (see Figure 2). The change is probably due to the growth in prescribing by private practitioners, and the introduction by government hospitals of a payment subsidy plan similar to the Pharmaceutical Benefits Scheme (SAHC, 1998).Factors Affecting Medication Increases

It has been suggested that the increase in psychostimulant use in the United States is due to a combination of factors including special education laws, increased awareness and diagnosis of ADHD, an improved public image of medication treatment, and increased duration of treatment (Diller, 1998; Safer et al., 1996; Swanson et al., 1995). It appears that these factors may be at work in both nations.

In the United States, an ADHD diagnosis may qualify a child for special educational services under Section 504 or under the Other Health Impaired category within the Individuals with Disabilities Education Act (Reid & Katsiyannis, 1995). In Australia, there is a Commonwealth Disability Discrimination Act which recommends students with specific learning difficulties receive attention from their state education institution. In both countries many students with ADHD qualify under a learning difficulties category. This could lead to the perception that ADHD is a means to additional education services.

The use of medication for ADHD has received a great deal of attention from the media worldwide. This media attention can influence medication use in a number of ways. In the United States in the 1990s, while there has

medication usep. 15

been some controversy over medication, the general tenor of the mediaÕs reporting of psychostimulant use has been favorable (e.g. Wallis, 1994). Along with the media attention, national parent groups have also worked actively to disseminate information on ADHD in general and medication use in specific. Parent groups such as CHADD (Children and Adults with Attention Deficit Disorder) have grown rapidly during the 1990s and have promoted the use of medication for children with ADHD (Diller, 1998, Teeter, 1998). In Australia, ADHD has also been the subject of a great deal of media attention. However media reports on ADHD have been somewhat less supportive of the use of medication, with many expressing concern over the recent rapid growth in psychostimulant use (e.g. Archdall, 1998; Loane, 1998; Williams, 1998). Thus, it appears that while awareness of ADHD is high in both countries, there may be differences in acceptance of medication use and in the effectiveness of parent groups.

Another factor in increased use of psychostimulants is the trend toward longer duration of medication use. Safer and Krager (1994) found that the duration of medication treatment was increasing. Our data did not directly address duration of use. However, for the years 1993-1997, the total number of psychostimulant prescription authorizations continued to increase, while the number of new authorizations did not. One logical conclusion is that children must be remaining on medication for longer periods. Socioeconomic Factors

The results of this study suggest that more South Australian young people are diagnosed with ADHD and medicated in areas of high unemployment and low income. We caution that the nature of our data do not demonstrate that ADHD prevalence is higher in these areas. However,

medication usep. 16

results are consistent with previous research which demonstrated that low socioeconomic status was a risk factor for ADHD behavior (Biederman, et al., 1995). There are several reason why low socioeconomic status might be associated with increased ADHD incidence. Firstly, low socioeconomic status may be associated with other ADHD risk factors, such as severe marital discord, large family size, or foster care placement. Secondly, low socioeconomic status may expose children to environmental or psychosocial stressors. For example, Murphy and colleagues (1998) have found that hunger resulted in impaired functioning and higher hyperactivity scores. Finally, socioeconomic status may affect observersÕ perceptions of behavior. Stevens (1981) used a simulation study in which teachers viewed identical videotapes of children. Along with the video segments teachers were presented vignettes which described the children as either middle or low socioeconomic status. The low socioeconomic status description resulted in significantly higher hyperactivity ratings.

The results of our study do not support DillerÕs (1998) conclusion that medication use in the United States is more likely among the middle to upper middle class. However, given the apparent regional variation within each country and changes over time (e.g., Safer & KragerÕs [1988] finding that in Maryland use patterns changed by socioeconomic status from the 1970s to the 1980s), generalizations may be risky. Differences between the make-up of lower SES groups across countries also make comparisons difficult. There is no single minority group within Australia that makes up a similar proportion of the low socioeconomic status population as African-Americans do in the United States. This is an important consideration as there is evidence that ethnicity may be related to whether a child receives medication treatment. In a recent review of medication use, Zito, Safer,

medication usep. 17

dosReis, and Riddle (1998) found that Caucasian youths were 2.5 times more likely to receive treatment with stimulant medication than African-American youths. This disparity is all the more noteworthy when considering the fact that African-American youth consistently receive higher ratings on behavior rating scales designed to assess ADHD (Reid, 1995; Reid et al., 1998). Additionally, there is evidence that parental perceptions of ADHD differ depending on ethnicity and SES status (Bussing, Schoenberg, Zima, Rogers, & Angus, in press).

In this study we documented increases in medication use in Australia and compared it to the United States. While growth is indisputable, we would note that it is impossible to determine if it is the result of excessive prescription or simply the provision of necessary and effective treatment. We would note that the data did not directly assess the relation between medication, income, and unemployment at the level of the individual (only by areas [postcodes]). Additionally, the data did not allow for detailed exploration of social, cultural, economic, and health care systems on medication use.

Future research should attend to several critical issues. First, there is a need for nationwide studies which utilize epidemiological methods with the individual child as the unit of analysis. This would provide a more accurate picture of national medication use as well as allowing for potentially interesting regional comparisons in the diagnosis of ADHD and prescription of medication (see Morrow, et al, 1998). Second, researchers should carefully attend to socioeconomic status, ethnicity, medication use, and health care policy. Some evidence (e.g., Zito et al., 1998) suggests that there is a disparity in medication prescription rates across ethnic groups. Finally, researchers should focus on physiciansÕ diagnostic practices and

medication usep. 18

prescribing practices in relation to medication use and potential overuse (Diller, 1998). ) Few empirical studies exist that would help us examine whether increased medication use is an appropriate response to the problems of children with ADHD or an inappropriate reaction to mild behavior difficulties.

medication usep. 19

ReferencesArchdall, S. (1998, 6 June). Speed warning. The Advertiser, Adelaide.

p. 53.Atkinson, I., Robinson, J. A., & Shute, R. H. (1997). Between a rock and

a hard place: an Australian perspective on education of children with ADHD. Educational and Child Psychology, 14(1), 21-30.

Australian Bureau of Statistics, (1997). Adelaide... a social atlas. Belconnen: Commonwealth of Australia.

Barkley, R. A. (1998). Attention-Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment. (2nd ed.). New York: Guilford Press.

Biederman, J., Milberger, S., Faraone, S. V., Kiely, K., Guite, J., Mick, E., Ablon, S., Warburton, R., & Reed, E. (1995). Family-environment risk factors for attention-deficit hyperactivity disorder. Archives of General Psychiatry, 52, 464-470.

Bussing, R., Schoenberg, N. E., Rogers, K. M., Zima, B. T., & Angus, S. (in press). Explanatory Models of ADHD: do they differ by ethnicity, child gender, or treatment status? Journal of Emotional and Behavioral Disorders.

Department of Health Services (1998). Prescriptions of dextroamphetamine and methylphenidate in Australia (1990-1997). Canberra: Commonwealth Department of Human Services.

Diller, L. H. (1998). Running on Ritalin: a physician reflects on children, society and performance in a pill. New York: Bantam Books.

Drug Enforcement Agency, Office of Congressional and Public Affairs. (1998). Controlled Substances: aggregate production quotas (1989 - 1998) . Washington DC: U.S. Department of Justice.

Gadow, K. G. (1981). Prevalence of drug treatment for hyperactivity and other childhood behavior disorders. In K. G. Gadow & J. Loney (Eds.),

medication usep. 20

Psychosocial aspects of drug treatment for hyperactivity (pp. 13-76). Boulder: Westview Press.

Greenhill, L. (1992). Pharmacologic treatment of attention deficit hyperactivity disorder. Psychiatric Clinics of North America, 15, 1-25.

Hazell, P. L., McDowell, M. J., & Walton, J. M. (1996). Management of children prescribed psychostimulant medication for attention deficit hyperactivity disorder in the Hunter region of NSW. Medical Journal of Australia, 165(November), 477-480.

Loane, S. (1998, ). The parent trap. The age: Goodweekend magazine, Melbourne. pp. 14-18.

Lofholm, N. (1994, October 9). Attention-deficit disorders: "The number of kids on medication is high. It's very high". The Daily Sentinel, p. 1A.

Morrow, R. C., Morrow, A. L., & Haislip, G. (1998). Methylphenidate in the United States, 1990 through 1995. American Journal of Public Health, 88, 1121.

Murphy, J. M., Wehler, C., Pagano, M. A., Little, M., Kleinman, R. E., & Jellinek, M. S. (1998). Relationship between hunger and psychosocial functioning in low-income American children. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 163-170.

National Health & Medical Research Council (1997). Attention Deficit Hyperactivity Disorder (ADHD). Canberra: National Health and Medical Research Council.

Pelham, W. E. (1993). Pharmacotherapy for children with attention-deficit hyperactivity disorder. School Psychology Review, 22, 199-227.

Reid, R. (1995). Assessment of ADHD with culturally different groups: The use of behavior rating scales. School Psychology Review, 24, 537-560.

medication usep. 21

Reid, R., & Katsiyannis, A. (1995). Attention-Deficit/Hyperactivity Disorder and Section 504. Remedial and Special Education, 16, 44-52.

Reid, R., DuPaul, G. J., Power, T. J., Anastopoulos, A. D., Rogers-Adkinson, D., Noll, M. B., & Riccio, C. A. (1998). Assessing culturally different students for attention deficit hyperactivity disorder using behavior rating scales. Journal of Abnormal Child Psychology, 26, 187-198.

Reid, R., Maag, J. W., Vasa, S. F., & Wright, G. (1994) Who are the children with ADHD: A school-based survey. Journal of Special Education, 28, 117-137.

Safer, D. J., & Krager, J. M. (1984). Trends in medication therapy for hyperactivity: National and international perspectives. Advances in Learning and Behavioral Disabilities, 3, 125-149.

Safer, D. J., & Krager, J. M. (1988). A survey of medication treatment for hyperactive/inattentive students. Journal of the American Medical Association, 260, 2256-2258.

Safer, D. J., & Krager, J. M. (1994). The increased rate of stimulant treatment for hyperactive/inattentive students in secondary schools. Pediatrics, 94, 462-464.

Safer, D. J., Zito, J. M., & Fine, E. M. (1996). Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics, 98, 1084-1088.

South Australian Health Commission, Drug Dependence Unit (1997). Data in relation to amphetamine use under section 33 of Controlled Substances Act. Adelaide: SAHC.

South Australian Health Commission, Drug Dependence Unit (1998). Data in relation to amphetamine use under section 33 of Controlled Substances Act. Adelaide: SAHC.

medication usep. 22

Stevens, G. (1981). Bias in the attribution of hyperkinetic behavior as a function of ethnic identification and socioeconomic status. Psychology in the Schools, 18 (1), 99-106.

Swanson, J. M., Cantwell, D., Lerner, M., McBurnett, K., Pfiffner, L., & Kotkin, R. (1992). Treatment of ADHD: Beyond medication. Beyond Behavior, 4, 13-22.

Swanson, J. M., Lerner, M., & Williams, L. (1995). More frequent diagnosis of attention deficit-hyperactivity disorder. The New England Journal of Medicine, 333, 944.

Teeter, P.A., (1998). Interventions for ADHD: Treatment in developmental context. New York: Guilford Press.

Upfal, J. (1995). The Australian drug guide. Melbourne: Bookman.Valentine, J., Zubrick, S., & Sly, P. (1996). National trends in the use of

stimulant medication for attention deficit hyperactivity disorder. Journal of Paediatrics and Child Health, 32, 223-227.

Wallis, C. (1994, July). Life in overdrive. Time, pp. 42-50. Williams, T. (1998, 29 April). Hyperkids on drugs up 4000: Health

commission alarmed over ÒpushoverÓ doctors, misdiagnosis. Guardian Messenger, Adelaide. pp. 1.

Zito, J. M., Safer, D. J., dosReis, S., & Riddle, M. A. (1998). Racial disparity in psychotropic medications prescribed for youths with medicaid insurance in Maryland. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 179-184.

medication usep. 23

Author NoteBrenton ProsserÕs participation was supported through the support of

the 1998 Flinders University of South Australia Overseas Fellowship, the Amy Forwood Travelling Award, the Bank SA Travelling Award, and the QueenÕs Trust for Young Australians Award.

medication usep. 24

Table 1: Psychostimulant medication use by income level among 4-18 year-olds in Adelaide1.

1997 1998Income Level(Number of Postcodes)

Children age 4Ñ18

Percent Medicated

(SD)Children age 4Ñ18

PercentMedicated

(SD)Low(24)

26,034 2.19(1.17)

25,708 3.02(1.43)

Middle(80)

99,138 1.67(.86)

97,891 2.23(.91)

High(17)

13,186 1.44(.70)

13,021 2.07(.64)

Total(121)

138,358 1.74(.93)

136,620 2.36(1.05)

1 Data are based on the months of April, 1997, and September, 1998. These were, respectively, the first month after the second author received research ethics clearance from his university and the last opportunity to collect data prior to leaving Australia.

medication usep. 25

Table 2: Psychostimulant medication use by unemployment level among 4-18 year-olds in Adelaide1.

1997 1998Unemployment

Level (Number of Postcodes)

Children age 4Ñ18

Percent Medicated

(SD)Children age 4Ñ18

PercentMedicated

(SD)Low(49)

44,793 1.42(.57)

44,229 1.95(.62)

Middle(44)

56,787 1.77(1.00)

56,074 2.42(1.01)

High(28)

36,778 2.26(1.11)

36,317 2.97(1.38)

Total(121)

138,358 1.74(.93)

136,620 2.36(1.05)

1 See note for Table 1.

medication usep. 26

Figure Captions

Figure 1. Psychostimulant prescriptions dispensed by Australian pharmacies, 1990Ñ1997 (DHS 1998).

Figure 2. Amount of psychostimulants prescribed, South Australia, 1987Ñ1997 (SAHC 1998).

medication usep. 27

Year

Psyc

host

imul

ant

Pres

crip

tion

s(t

hous

ands

)

0

50

100

150

200

250

1990 1991 1992 1993 1994 1995 1996 1997

10 1427

82

128

169

207

13 17 2331

4764

79 84

47

Dextroamphetamine Methylphenidate

medication usep. 28

Year

Psyc

host

imul

ants

Pre

scri

bed

(Kilo

gram

s)

0

5

10

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

0.1 0.1 0.1 0.1 0.1

1.1

2.1

3.1

4.7

7.8

10.5

0.6 0.6 0.7 0.9 1.2

2.1

3.6

5.5

6.5

7.4 7.7

Dextroamphetamine Methylphenidate