Clinical trials in children raise methodological problems, such as the forming of homogeneous groups due to the difficulty in defining diagnostic criteria and the measurement of the changes that the treatment has caused [3]. Additionally, they raise clinical, moral and legal dilemmas – and as a consequence controlled, double-blind studies and obliging child psychiatrists to draw information from them concerning the efficacy and safety of medication from open studies remain few and far between in child psychiatry[4]. The result of the aforementioned difficulties is the rarity of data concerning pharmacokinetics and pharmacodynamics of psychotropic agents in children, even though there are different characteristics of metabolism (e.g. faster absorption, shorter duration of therapeutic blood levels).

In some countries, including our own [5], the lack of research on the efficacy of psychotropic medication on mental disorders of childhood contributes to the child psychiatrist's hesitation to suggest drug treatment. The deficit of studies poses a real dilemma for the child psychiatrist; whether to refuse to administer a treatment that might prove beneficial, or to accept responsibility for safety. Child psychiatrists are also affected by the existing negative attitudes of the public, and their hesitation, in turn, affects the acceptance of drug treatment by the parents.

In an earlier French study [1], it was reported that 70% of child psychiatrists were reluctant to prescribe psychotropic medication. More recent data however, show that the use of psychotropic medication in children has significantly increased during the past few years [6]. In the United States, the consumption of antipsychotic drugs nearly doubled between 1996 and 2001 in patients aged 2–18 years, with an increase of 61% for preschool ages, 93% for the ages between 6 and 12, and 116% between 13 and 18 years of age [7]. More recent studies [8,9] confirm that the frequency of psychotropic prescribing in child psychiatry continues to increase. Antipsychotics, in particular the atypical ones, have been used at an increasing rate over the past few years, and they have frequently been used to treat externalized, non-psychotic disorders [8,10]. Polypharmacy is also on the rise. Multiple psychotropic medication use occurred in nearly one third of youths with any psychotropic treatment [11,12].

While the provision of medication is often determined by ideological, political and social factors, it has been claimed that the mistaken perceptions on the acting mechanisms of psychotropic medication is not related to the socio-economic status or education level of the families. An important factor that may change the attitude of the parents is whether they themselves would accept medication [13,14].

In the literature there are only a few reports regarding the attitudes and opinions of the general public and the medical community about psychotropic medication. An earlier Greek study of a general population sample and non-psychiatric physicians illustrates a negative view of psychotropic drugs and psychiatric treatment regarding safety and efficacy, which affects the scientific evaluation of psychotropic medication and may have negative consequences on their therapeutic application. The opinion that psychotropic medications cause dependency and physical damage, when administered over a long period of time, and that they cause alterations of personality, are just some among the views expressed [15].

Additionally, the majority of parents (99; 74%) believe that psychotropic drugs are dangerous, but a clear differentiation exists among them. Only 18 (13%) believed that all psychotropic drugs are dangerous, while 81 (61%) limit the danger to just some categories. Two-thirds of the participants believe that psychotropic medication cause addiction (92 (69%) for antipsychotics, 99 (74%) for antidepressants, 76 (57%) for anxiolytics and 110 (82%) for hypnotics), while 23% did not express any opinion.

Statistical analyses reveal that significantly different responses were found between men and women on the question of whether they believe that there are different categories for psychotropic medication (Fisher's exact test, p = 0.042). The proportion of men (18.2%) who gave negative answers was greater than the same proportion of women (1.9%). No significant differences concerning parental opinion were found according to the gender of the child.

Possible differences in parental opinion according to the age of the child were also investigated. It was found that the proportion of parents who agree with the limitation to administrate psychotropics under special medical prescription increases as the age of the child increases. Specifically, 20% of the parents with children aged 2–7 years, 50% with children aged 7–12 years, and 75% with children aged older than 12 years responded that they agree with this limitation (Fisher's exact test, p = 0.008).

Additionally, a significantly lower proportion of the parents who were opposite to psychotropic medication take medication frequently themselves (4.3% vs. 21.1%). Furthermore, the responses to the question of whether psychotropic medication causes addiction differed between those who take medication frequently and those who do not (Fisher's exact test, p = 0.039). The proportion of positive responses was greater for those who take medication frequently (70% vs. 33.3%).

Deeper socio-cultural beliefs seem to affect the acceptance (or non-acceptance) of medication. In the study of Schnittker [17], it was shown that African-Americans are more reluctant to take or to accept psychotropic medication for their children in comparison to the Caucasian population. In a recent study [18] it was shown that Caucasian race is associated with higher proportions of medication use among children in the Child Welfare System. African-American and Latino races were associated with lower proportions of medication use. Our sample was homogeneous regarding race and ethnicity (Greek) and the opinions on psychotropic medication are not statistically differentiated with parental age. The only significant difference found between men and women concerned the question of whether they believe that there are different categories of psychotropic medication. Women seemed to be better informed than men about this issue. Educational level only influenced the fear of drug addiction. Where the educational level was higher, parents seem to be closer to the scientific point of view and they did not fear the risk of addiction as much.

Our results show that most parents have a greater fear concerning their children taking psychotropic medication than for other types of medication. This is consistent with the study of Pappaport and Chubinsky [19], who found that while parents easily give cough medicine or antibiotics, they are afraid to give medication that might alter the behaviour or thinking of their children. Parental hesitation to administer psychotropic medication to their children may intervene with the treatment and affect treatment compliance. The high percentage of children that discontinue pharmacotherapy confirms that assertion [20]

According to our results parents seem to be aware of the distinction of psychoagents into four categories, but the majority of the respondents seem to not be well informed about the safety of psychotropic drugs. This contradiction is probably due to the fact that the structure of the question, concerning the distinction of psychoagents, led to the correct answer. Most of them are afraid of potential dependency, and are affected by anti-drug public opinion. The prevalence of the belief that antipsychotics (69%) and antidepressants (74%) cause addiction is considerable. The use of psychostimulants during childhood in order to treat ADHD (attention deficit hyperactivity disorder) had been accused of causing dependence and predisposition to the use of controlled substances. More recent research has shown that their use does not increase the possibility of substance abuse later in life [21,22]. In fact, another study has found that children with ADHD who received pharmacotherapy (methylphenidate) were less likely to use alcohol or substances later in their life, in comparison to children that presented with hyperactivity but did not receive pharmaceutical treatment [23].

Most parents consider psychotherapy as the most effective treatment for mental disorders, including childhood schizophrenia (65%). According to Pappaport and Chubinsky [19], parents accept pharmacotherapy only when behavioural and psychological interventions have been exhausted. They then experience a process of grief and the acceptance of pharmacotherapy seems to coincide with the acceptance of the psychiatric diagnosis. It is the final proof of what they fear. They realize that their child is suffering from a serious mental illness that might accompany them into adulthood.

A considerable proportion of respondents believe that there is overuse of psychotropic medication during childhood. In a study [24] involving 302 parents whose children were hyperactive, the erroneous opinions about the disorders and the methods of treatment became apparent. A total of 75% of the parents expressed the view that sugar and diet affected hyperactivity, 55% were reluctant for their children to use medication and 33% believed that there is an overuse of drugs in children with hyperactivity disorder.

Even though antipsychotics today occupy a significant place in child psychiatry [25], there is a recorded reluctance by the mothers to accept them as a treatment option during their child's first psychotic episode [26]. Reluctance in accepting pharmacotherapy is also presented by fathers of hyperactive boys [27]. Through identification mechanisms, they consider that treatment with methylphenidate separates their children from their peers and makes them different and isolated.

A high percentage of American parents (57%) accept pharmacotherapy when their child has expressed suicidal ideas and a smaller percentage in the case of disruptive behaviour (34,2%) or hyperactivity (29.5%). These differences are not dependent on socio-economic factors or educational level but on the trust in the doctor [14]. Hyperactivity and hallucinations/delusions are the main problems for teachers that could lead to the use of pharmaceutical treatment [28]. In our sample, there was no correlation between the parental attitudes and the severity of the child's problem.

Child psychiatrists ought to scientifically inform the parents on the efficacy and safety of treatment, and then take into consideration the opinions and attitudes of the family. Only by paying attention to the desires, fears and beliefs of both parents and children will they be able to encourage and ensure compliance to treatment.