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ARTICLE

Parents Use of Praise and


Criticism in a Sample of
Young Children Seeking
Mental Health Services
Stephanie Swenson, BSN, RN, Grace W. K. Ho, PhD, RN,
Chakra Budhathoki, PhD, Harolyn M. E. Belcher, MD, MHS,
Sharon Tucker, PhD, RN, FAAN, Kellie Miller, &
Deborah Gross, DNSc, RN, FAAN
Stephanie Swenson, Registered Nurse, Childrens National
Medical Center, Washington, DC.
Grace W. K. Ho, Morton and Jane Blaustein Postdoctoral Fellow in ABSTRACT
Mental Health & Psychiatric Nursing, School of Nursing, Johns Parents use of praise and criticism are common indicators
Hopkins University, Baltimore, MD.
of parent-child interaction quality and are intervention tar-
Chakra Budhathoki, Assistant Professor, School of Nursing, Johns gets for mental health treatment. Clinicians and researchers
Hopkins University, Baltimore, MD. often rely on parents self-reports of parenting behavior,
Harolyn M.E. Belcher, Director of Research, Center for Child and although studies about the correlation of parents self-
Family Traumatic Stress at Kennedy Krieger Institute, and reports and actual behavior are rare. We examined the
Associate Professor of Pediatrics, Johns Hopkins School of concordance between parents self-reports of praise and
Medicine, Baltimore, MD. criticism of their children and observed use of these behav-
Sharon Tucker, Director of Nursing Research, Evidence-Based iors during a brief parent-child play session. Parent self-
Practice & Quality, University of Iowa Hospitals & Clinics, Iowa City, IA. report and observational data were collected from 128
parent-child dyads referred for child mental health treat-
Kellie Miller, Research Coordinator, School of Nursing, Johns
ment. Most parents reported praising their children often
Hopkins University, Baltimore, MD.
and criticizing their children rarely. However, parents
Deborah Gross, Leonard and Helen Stulman Professor in Mental were observed to criticize their children nearly three times
Health & Psychiatric Nursing, School of Nursing, Johns Hopkins more often than they praised them. Self-reported and
University, Baltimore, MD. observed praise were positively correlated (rs = 0.32,
This study was conducted as part of the first authors research p < .01), whereas self-reported and observed criticisms
honors project while she was a student at Johns Hopkins were negatively correlated (rs = 0.21, p < .05). Parents ten-
University School of Nursing. Data are from a larger study dencies to overestimate their use of praise and underesti-
supported by a grant from the National Institute for Nursing mate their use of criticism are discussed. J Pediatr Health
Research (R01 NR012444) to Drs. Gross and Belcher.
Care. (2016) 30, 49-56.
Conflicts of interest: None to report.
Correspondence: Stephanie Swenson, BSN, RN, c/o Deborah KEY WORDS
Gross, DNSc, RN, FAAN, School of Nursing, Johns Hopkins Parenting, young children, praise, critical statements, parent
University, Ste 531, 525 N Wolfe St, Baltimore, MD 21205; e-mail: self-report
stephswenson@gmail.com.
Parents are a powerful source of feedback in shaping
0891-5245/$36.00
their young childrens behavior and sense of self. It
Copyright Q 2016 by the National Association of Pediatric is within these earliest relationships that children first
Nurse Practitioners. Published by Elsevier Inc. All rights
reserved.
begin to acquire a sense of themselves as capable,
competent, and loved (Bohlin, Hagekull, & Rydell,
Published online October 30, 2015.
2000; Bowlby, 1988; Cassidy, 1988). Two common
http://dx.doi.org/10.1016/j.pedhc.2015.09.010 sources of parental feedback used to shape young

www.jpedhc.org January/February 2016 49


childrens behavior Parents are a where parents might be highly sensitive to feeling
and self-esteem are blamed for their childs illness or to the stigma of
praise (i.e., positive
powerful source of engaging the mental health system (Meltzer, Ford,
statements designed feedback in Goodman, & Vostanis, 2011; Angold, et al., 1998).
to reinforce desirable shaping their young This study examines the extent to which parents self-
behaviors in children reports of praise and criticism are reflected in their
or communicate plea-
childrens behavior observed behavior in a sample of parents of preschool
sure with the child) and sense of self. children referred for mental health treatment. We also
and criticism (i.e., explore whether two indicators of parents tendency
negative statements designed to stop or change to hold negative attributions about themselves and their
childrens undesirable behavior or communicate children, depressive symptoms and perceptions of their
displeasure with the child). children as being more behaviorally difficult, moderate
Praise from parents has been used as a marker of the relationship between self-report and observed use
positive parenting behaviors in numerous studies of praise and critical statements. Consistent with cogni-
(Breitenstein et al., 2012; Chorpita, Caleiden, & Weisz, tive attribution theory, depressed parents may develop
2005; Wahler & Meginnis, 1997). Praise is often biases that their childrens misbehavior is intentional
accompanied by other parenting behaviors indicative and within their control, leading them to be less positive
of parental warmth, responsiveness, and nurturance and more critical in their interactions (Dix, Ruble,
(Furlong et al., 2013). Although the question of whether Grusec, & Nixon, 1986; Leung & Slep, 2006; Scott &
excessive use of praise can negatively influence Dadds, 2009).
childrens intrinsic motivation has been debated Using a descriptive, cross-sectional design, we posed
(Owens, Slep, & Heyman, 2012), substantial research the following research questions:
now shows that praise, used strategically, can boost
 What is the relationship between parents self-
childrens feelings of competence and confidence.
reported and observed use of praise based on
Therefore, praise remains an important indicator of
(a) frequency and (b) the proportion of statements
positive parenting behavior (Brummelman, Thomaes,
to their child that are praise during a 15-minute free
Orobio de Castro, Overbeek, & Bushman, 2014;
play session?
Cimpian, 2010; Henderlong & Lepper, 2002; Mueller
 What is the relationship between parents self-
& Dweck, 1998; Zentall & Morris, 2010).
reported and observed use of criticism based
Parents may use critical statements to express disap-
on (a) number and (b) the proportion of state-
proval with their childrens behavior or attitude.
ments to their child that are criticisms during a
However, using criticism can undermine their
15-minute free play session?
self-esteem, lead to greater child defiance and aggres-
 Do parents depressive symptoms moderate the
sion, and increase the likelihood of their developing
association between their self-reported and
behavioral problems (Barnett & Scaramella, 2013;
observed use of praise and critical statements?
Lorber & Egeland, 2011; Tung, Li, & Lee, 2012;
 Do parents perception of the severity of their
Webster-Stratton & Hammond, 1998). Thus, contrary
childrens behavior problems affect the association
to parents expectations, using critical statements
between their self-reported and observed used of
to shape child behavior actually may be
praise and critical statements?
counterproductive. In clinical studies of young
children in mental health treatment, parents who The goals of this study are to (a) understand the extent
directed more critical statements at their children to which parents self-reported use of praise and criti-
were also more likely to drop out of treatment cism accurately reflect the appraisals of their observed
(Fernandez & Eyberg, 2009). behavior and (b) offer guidance to practitioners on
Given their salience in child development research, how to address these two important parenting practices
parent training interventions have been designed to in pediatric primary care with parents of young children
increase parents use of praise and reduce their use of at risk for mental health problems.
criticisms with their children (Breitenstein et al., 2012;
Brotman et al., 2009; Eyberg et al., 2001; Gross et al., METHODS
2009). In clinical practice and research, parents use of This study is a secondary analysis of baseline parent-
praise and criticism is often assessed using parent self- report and observation data collected as part of a larger
report. However, some investigators have questioned clinical trial comparing two evidence-based parent
the accuracy of using self-reports to measure actual training programs. The larger clinical trial was conduct-
parenting behaviors, particularly when those behaviors ed in an urban mental health clinic serving low-income
are susceptible to recall or social desirability biases families with preschool children (Gross et al., 2014) and
(Morsbach & Prinz, 2006). These biases may be partic- was approved by the Johns Hopkins University Medical
ularly heightened in a child mental health population, Institutions Institutional Review Board.

50 Volume 30  Number 1 Journal of Pediatric Health Care


Sampling Design The CBCL measures two dimensions of child behavior
Data were drawn from a convenience sample of 128 problems: externalizing behavior (e.g., aggression,
parents seeking treatment at an urban child mental noncompliance, and inattention) and internalizing
health clinic serving families of young children, birth behavior (e.g., anxiety, depression, and withdrawal).
to 5 years old, who were recruited into the larger clinical Parents rate their childs behavior problems on a scale
trial. Approximately 80% of the clinic population is of 0 (behavior is not true) to 2 (behavior is very true
African American or multiracial, and more than 95% or often true); higher scores are indicative of more
of families receive Medicaid. Criteria for inclusion behavior problems. In the current study, only external-
were that the parent is (a) the biological or adoptive izing behavior problems were examined because these
parent or legal guardian for a 2- to 5-year-old child behaviors tend to be more aversive to parents. The
and (b) seeking mental health treatment for their childs CBCL externalizing scale contains 24 items, and scores
behavior problems. Parents were excluded if they had a range from 0 to 48. Standardized T scores are used to
severe mental illness, substance use disorder, or cogni- identify children with externalizing behavior problems
tive impairment that would interfere with their childs in the borderline clinical (93rd percentile) and clinical
treatment. Children were excluded if they were actively (98th percentile) range. In low-income racial and ethnic
suicidal or psychotic, had a diagnosis of autism or minority populations, a reliabilities for the external-
pervasive developmental disorder, or had a congenital izing scale range from 0.88 to 0.91 (Gross et al., 2006),
or genetic anomaly that would interfere with treatment. and validity has been supported (Gross et al., 2007;
Parents who met the inclusion criteria and consented Sivan, Ridge, Gross, Richardson, & Cowell, 2008).
to participate in the clinical trial completed a set of
baseline measures and were video recorded with their Observed use of praise and criticism
child during a 15-minute free-play session (see the Frequencies of observed praise and criticism were
Procedures section). measured from 15-minute video recorded parent-
child free play interactions using a modified version
Variables and Measures of the Dyadic Parent-Child Interaction Coding System
(DPICS; Eyberg & Robinson, 1992). The DPICS mea-
Self-reported praise and criticism sures frequencies of select observed parent and child
Parents self-reported use of praise and criticism was verbalizations and behavior. Observed parent verbal-
measured using two survey items from the Parenting izations collected in this study include numbers of crit-
Questionnaire (Gross, Fogg, Garvey, & Julion, 2004; ical statements, encouraging statements, praise
McCabe, Clark, & Barnett, 1999), a 40-item Likert-type statements, and commands. Parents use of praise and
measure of parent discipline strategies. One item asks criticism were estimated in two ways; (a) the frequency
parents to circle the frequency with which they praise of observed praise statements or critical statements and
their child along a 5-point scale of 1 (almost never) to (b) the proportion of praise statements or critical state-
5 (very often). Another item asks parents to circle the fre- ments to all observed parent verbalizations during the
quency with which they criticize their child, using the 15-minute free play session.
same 5-point scale of 1 (almost never) to 5 (very often). Praise statements include both labeled and unlabeled
praise. Labeled praise is operationalized as any specific
Parent depressive symptoms statement by a parent expressing their favorable judg-
The 20-item Center for Epidemiologic Studies Depres- ment of an activity, product, or attribute of the child,
sion ScaleRevised (CESD-R) was used to measure such as Thats a terrific house you made. Unlabeled
parent depressive symptoms. This version of the praise is operationalized as a nonspecific verbal
CESD was created to better reflect the range of symp- comment by the parent expressing a favorable judg-
toms indicative of major depression (Eaton, Muntaner, ment of an activity or attribute of the child, such as
Smith, Tien, & Ybarra, 2004). Validity of the CESD-R Great or Good job. In this analysis, these two types
has been supported by confirmatory factor analysis of praise were summed to form a single estimate of
and positive correlations with other measures of parents total use of praise.
depression and anxiety (Van Dam & Earleywine, Critical statements are operationally defined as
2011). Higher scores are indicative of more depressive parent verbalizations that find fault with the activities,
symptoms; a score of 16 or higher indicates depressive products, or attributes of the child. Blame statements
symptomatology within the clinical range. The Cron- and guilt-inducing statements are also considered to
bach a for the CESD-R in this sample was 0.92. be critical statements. Examples include, Youre being
naughty and I dont like your attitude.
Child behavior problems
Parents reports of their childs behavior problems were Procedures
measured using the Child Behavior Checklist for ages After completing the self-report measures, parents
1 to 5 years (CBCL; Achenbach & Rescorla, 2000). were asked to play with their child for 15 minutes

www.jpedhc.org January/February 2016 51


while the research assistant video recorded the inter-
TABLE 1. Sample characteristics
action. Parents were instructed to play with their child
as they normally would, and the research assistant Mean
would let them know when the 15 minutes was over. Characteristic (SD) n (%)
Video recordings were then sent electronically to Parent characteristics (n = 128)
trained DPICS coders who were blinded to study Age, year 34 (10.3)
hypotheses. Inter-rater reliability, assessed through Relationship to child
Mother 97 (75.8)
intraclass correlation for 10% of DPICS assessments,
Other 31 (24.2)
was 0.98 for praise statements and 0.92 for critical Race/ethnicity
statements. African American 86 (67.2)
Data were analyzed using SPSS version 22 (IBM White 30 (23.4)
Corp., Armonk, NY). Descriptive statistics were used Hispanic/Latino 6 (4.7)
Education level
to summarize parents self-reports of praise and criti-
High school graduate or less 79 (61.7)
cism use and observed use of praise and criticism (as Some college 28 (21.9)
frequencies and as proportions of total verbalizations) College graduate or higher 11 (8.6)
in a 15-minute play session. Bivariate correlations Household income < $20,000 121 (95.3)
between parents self-reported and observed uses of or receive Medicaid
Unemployed 82 (64.1)
praise or criticism, as well as correlations between
CESD-R score 17.8 (15.6)
self-reported and observed uses of praise and criticism Score $ 16 59 (46.1)
with parent depression and perceived child behavior Child characteristics (n = 128)
problems, were calculated using Spearmans rho. Age, year 3.6 (1.0)
Multiple regression analyses were conducted to test Male 70 (54.7)
Externalizing behavior $ borderline 53 (41.7)
the effects of parent depressive symptoms or perceived
clinical range
child behavior problems on parents self-reports of
praise and criticism as predictors of their observed Note. CESD-R, Center for Epidemiologic Studies Depression
ScaleRevised; SD, standard deviation.
use. To address data skewness, outliers were removed
using Mahalanobis distance, Cooks distance, and
centered leverage values. Relationships Between Parents Self-Reported
and Observed Use of Praise and Criticism
RESULTS Tables 3 and 4 summarize bivariate correlations
Sample characteristics are summarized in Table 1. between pertinent variables for parent praise and
A majority of the parents were mothers (75.8%), criticism, respectively. We found a positive correlation
African American (67.2%), unemployed (64.1%), between parents self-reported and observed use
and economically disadvantaged (95.3% reported a of praise based on absolute frequency of praise
household income less than $20,000 or received (rs = 0.32, p < .01) and proportion of praise to total parent
Medicaid). The mean parent age was 34 years verbalizations (rs = 0.23, p < .01). In contrast, a negative
(SD = 10.3). The mean CESD-R score was 17.8 association was found between parents self-reported
(SD = 15.6); more than 46% of the parents had use of criticism and the observed frequency of critical
depressive symptom scores in the clinical range. statements (rs = 0.21, p < .05). No relationship was
The average age of the children was 3.64 years found between parents self-reports of their use of
(SD = 1.04). More than half of the children were criticism with their child and the proportion of
boys (54.7%). Although all of the children were observed critical statements to total parent verbaliza-
referred for behavior problems, only 41.7% of the tions (rs = 0.05, not significant).
parents reported child externalizing behavior prob-
lems in the clinical or borderline clinical range. Moderating Effect of Parent Depressive
Symptoms on the Relationship Between
Parents Use of Praise and Criticism Parents Self-Reported and Observed
A majority of the parents (86.7%) reported using Behaviors
praise often or very often, and using criticism As shown in Table 3, parent depression scores were
rarely or almost never (77.3%). During their not significantly associated with parents use of praise
observed parent-child play interactions, parents based on self-report (r = 0.08, not significant) or
verbalized a median of three praise statements observation (r = 0.05, not significant). Also based on
(range = 0-48) and eight critical statements regression analysis, parents depressive symptoms did
(range = 0-38) in 15 minutes. A higher proportion of not moderate the relationship between self-reported
parents total verbalizations consisted of critical state- and observed use of praise (i.e., no significant interac-
ments compared with praise statements (13.6% vs. tion between depressive symptoms and self-reported
7.4%). These results are presented in Table 2. use of praise was found; b = 0.10, p = not significant).

52 Volume 30  Number 1 Journal of Pediatric Health Care


TABLE 2. Parents self-reported and observed use of praise and criticism
Variables f (%) Median Mean (SD) Range Proportion, %*
Parent self-reports
I praise my child.
Almost never 1 (0.8)
Rarely 0 (0)
Sometimes 16 (12.5)
Often 46 (35.9)
Very often 65 (50.8)
I criticize my child.
Almost never 69 (53.9)
Rarely 30 (23.4)
Sometimes 22 (17.2)
Often 7 (5.5)
Very often 0 (0)
Observed parent behaviors
Total praise statements 3 5.8 (7.7) 0-48 7.4
Labeled praise 0 0.3 (0.7) 0-4 0.3
Unlabeled praise 3 5.5 (7.3) 0-45 7.1
Critical statements 8 8.5 (6.6) 0-38 13.6
Other parent verbalizations 48.5 55.8 (35.7) 1-155 79.0
Total verbal behaviors 61 70.1 (43.4) 2-201 100
*Proportion of praise or critical statements to all parent verbalizations.

As shown in Table 4, parents depression scores were of their childs externalizing behavior problems
also unrelated to frequency (r = 0.05, not significant) (rs = 0.18, p < .05)that is, parents who rated their
and proportion (r = 0.07, not significant) of observed children as having more behavior problems were less
critical statements. However, parents with higher likely to report praising their child. However, modera-
depression scores self-reported using more criticism tion analysis did not reveal a significant interaction be-
with their children (rs = 0.20, p < .05). Parents depres- tween the childs externalizing behavior and parents
sive symptoms did not moderate the relationship be- self-reported use of praise in predicting their observed
tween parents self-reported and observed use of use (b = 0.03, p = not significant). Childrens external-
critical statements (i.e., depressive symptoms and self- izing behavior problems were also unrelated to parents
reported use of criticism did not interact significantly; use of critical statements based on self-report and
b = 0.12, p = not significant). observation (see Table 4). Finally, there was no evi-
dence that parents perceptions of the severity of their
Moderating Effect of Parents Perceptions childrens externalizing behavior problems moderated
of the Severity of Their Childs Behavior the relationships between parents self-reported and
Problems on the Relationship Between Their observed use of critical statements (i.e., no significant
Self-Reported and Observed Behaviors interaction was found between perceived child exter-
As shown in Table 3, parents self-reports of their use of nalizing behavior problems and self-reported criticism
praise was inversely correlated with their perceptions use; b = 0.06, p = not significant).

TABLE 3. Bivariate Spearmans rank TABLE 4. Bivariate Spearmans rank


correlation coefficients for main variables correlation coefficients for main variables
related to parent praise related to parent criticism
Variables 1 2 3 4 5 Variables 1 2 3 4 5
1 Self-reported praise 0.32 0.23 0.08 0.18* 1 Self-reported criticism 0.21* 0.05 0.20* 0.15
2 Observed praise 0.89 0.05 0.003 2 Observed criticism 0.65 0.05 0.13
3 Praise as proportion 0.001 0.02 3 Criticism as proportion 0.07 0.12
4 Parents depressive 0.31 4 Parent depressive 0.31
symptoms symptoms
5 Childs externalizing 5 Child externalizing
behaviors behaviors
*Correlation coefficient significant at p < .05. *Correlation coefficient significant at p < .05.
Correlation significant at p < .01. Correlation significant at p < .01.

www.jpedhc.org January/February 2016 53


DISCUSSION rarely or almost never). Another explanation re-
Parents praise and criticism are powerful sources of lates to the artificial conditions under which the
feedback in shaping their young childrens behavior observed behavior sample was obtained. Parents with
and development. These parenting behaviors a stronger tendency to criticize their children may
have been a key focus have consciously suppressed those comments during
in child development Data obtained from the 15-minute play session. Nonetheless, it should be
research and serve as this clinic sample noted that despite the possibility that parents may
important indicators have modified their behavior while being observed,
of positive or negative
suggest that the proportion of parents critical statements were still
parenting in families parents tend to nearly twice those of their praise statements (i.e.,
of children with overestimate their 13.6% vs. 7.6%). We also examined whether two indica-
mental, emotional, tors of parents tendency to hold negative attributions
and behavior disor-
use of praise and about themselves and their children (i.e., parents
ders. Although many underestimate their depressive symptoms and parents ratings of their chil-
studies use parents use of criticism with drens externalizing behaviors) affected concordance
self-reports of praise between self-report and observed behavior. Higher
and criticism, the
their preschool depressive symptom scores were associated with
extent to which we children. more self-reported use of critical statements. However,
can rely on parent parents depression scores did not moderate the rela-
report as reliable indicators of their actual use remains tionships between self-reported and observed used of
unclear. Data obtained from this clinic sample suggest criticism or praise. In addition, parents who rated their
that parents tend to overestimate their use of praise children as having more externalizing behavior prob-
and underestimate their use of criticism with their lems also reported praising their children less often,
preschool children. but the severity of their childs behavior problems did
Although parents who reported praising their child not moderate the association between self-reported
more often were observed to use more praise, the and observed use of criticism or praise. These data
magnitude of the effect was small (rs = 0.32). This suggest that parents negative attributions affect how
modest correlation is consistent with prior literature they perceive their children and themselves, but these
showing generally small correlations across methods, attributions do not appear to account for the lack of
suggesting that self-report and observation capture concordance between self-reported and observed
different aspects of the same variable (i.e., perceived behavior.
versus actual parenting behavior; Gardner, 2000). Several study limitations should be noted. First,
Despite the positive correlation between self- parents self-reported use of praise and criticism
reported and observed use of praise, praise was not were each measured from a single item extracted
frequently expressed. Parents verbalized a median of from a parent survey. A single item measure may not
only three praise statements in the 15-minute observed be an accurate indicator of parents perceptions of
play sessions. On average, only 7% of the parents state- their use of praise or criticism. Second, the behavior
ments counted from the parent-child interactions qual- sample used to measure observed parent behavior
ified as praise, though these sessions were intended to was derived from a video-recorded 15-minute play
be a positive one. Yet, nearly 87% of parents reported session. Parents behavior in this context may not
praising their children often or very often. have been representative of their typical behavior.
Parents self-reports of their use of criticism was However, being recorded while playing with ones
modestly though negatively correlated with their actual child would likely elicit more positive behavior than
use. Specifically, parents who reported using criticisms might be typical. Thus, the number of parent praises
infrequently were actually more likely to criticize their observed might have actually been higher and the
children during the 15-minute play session. There are number of critical statements observed lower than
multiple plausible explanations for this finding. First, was typical for these participants. Finally, this second-
parents are aware that being critical is a socially undesir- ary analysis relied on an existing convenience sample
able behavior and therefore may have reported a more of parents seeking mental health services for their
socially acceptable answer. However, it is also possible children. As a result, the size of the sample, the study
that parents are truly unaware of how frequently they measures used, and the representativeness of the
criticize their children. Indeed, the parents in this sam- sample were all limited. Additional studies evaluating
ple criticized their children nearly three times more concordance between parents self-reports and
frequently than they praised them (i.e., eight criticisms observed behavior with their children using larger
versus three praise statements) despite their reports to and more diverse samples in both mental health and
the contrary (77% reported criticizing their children community populations are warranted to better

54 Volume 30  Number 1 Journal of Pediatric Health Care


understand these discrepancies in measurement under-resourced com- The challenge for
and best practices for guiding parents in using more munities may feel the
positive parenting strategies with their preschool need to toughen
clinicians is to
children. their children to the support parents in
realities of life. Thus, preparing their
IMPLICATIONS FOR PRACTICE critical statements
Chronic mental health problems in children have may seem to some
children for lifes
now surpassed physical illnesses as one of the five parents to be a more difficulties by
most prevalent disabilities affecting children in responsible and real- building the self-
the United States (Halfon, Houtrow, Larson, & istic way to prepare
Newacheck, 2012; Slomski, 2012). Their prevalence their children for
esteem and
points to the importance of screening for behavioral adulthood than using resilience that their
and emotional problems in pediatric primary care and praise. The challenge children will need to
identifying appropriate resources for parents for clinicians is to
(Weitzman & Wegner, 2015). support parents in pre-
grow and thrive
Thoughtful discussions with parents in primary paring their children despite the
care settings about positive strategies for supporting for lifes difficulties by difficulties.
their childrens behavioral health, supplemented building the self-
with written materials on how and when to use these esteem and resilience
strategies, would be an initial step. For example, that their children will need to grow and thrive despite
Bright Futures includes brief handouts on communi- the difficulties.
cating with children in ways that support their self-
esteem (www.brightfutures.org). These handouts, in We gratefully acknowledge the support of Mirian
conjunction with discussions on the importance of Ofonedu, Ivonne Begue De Benzo, and Maria Cecelia
parents positive statements supporting their chil- Lairet-Michelena.
drens efforts and behavior, would be an important
addition to well-child visits. Referral to parent training REFERENCES
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