Students with emotional and behavioral problems have poor academic and behavioral outcomes, both short- and long-term. Psychotropic medications are commonly used as an intervention with this population and their use has increased significantly. This study investigated adolescent and family variables associated with medication use among high school students with elevated emotional and behavioral problems, including those with a label of emotional and behavioral disorders. Participants included 548 adolescents from a larger randomized controlled trial, 184 (33.6%) of whom were receiving medication. Hierarchical linear modeling revealed that special education status, externalizing and internalizing behavior symptoms and participant race were significant student predictors of medication use. Parenting stress, family structure, positive parenting, and poor monitoring were significant family predictors of participants’ medication use. These findings have implications for current practices in schools pertaining to screening and access to interventions as well as future research focused on the parent and student decision making process for choice of interventions.