Parents’ Use of Praise and Criticism in a Sample of Young Children Seeking Mental Health Services

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, Children’s National

Medical Center, Washington, DC.

GraceW. K. Ho,Morton and Jane Blaustein Postdoctoral Fellow in

Mental Health & Psychiatric Nursing, School of Nursing, Johns

Hopkins University, Baltimore, MD.

Chakra Budhathoki, Assistant Professor, School of Nursing, Johns

Hopkins University, Baltimore, MD.

Harolyn M.E. Belcher, Director of Research, Center for Child and

Family Traumatic Stress at Kennedy Krieger Institute, and Associate Professor of Pediatrics, Johns Hopkins School of

Medicine, Baltimore, MD.

Sharon Tucker, Director of Nursing Research, Evidence-Based Practice&Quality,Universityof IowaHospitals&Clinics, IowaCity, IA.

Kellie Miller, Research Coordinator, School of Nursing, Johns

Hopkins University, Baltimore, MD.

Deborah Gross, Leonard and Helen Stulman Professor in Mental

Health & Psychiatric Nursing, School of Nursing, Johns Hopkins

University, Baltimore, MD.

This study was conducted as part of the first author’s research

honors project while she was a student at Johns Hopkins

University School of Nursing. Data are from a larger study supported by a grant from the National Institute for Nursing

Research (R01 NR012444) to Drs. Gross and Belcher.

Conflicts of interest: None to report.

Correspondence: Stephanie Swenson, BSN, RN, c/o Deborah

Gross, DNSc, RN, FAAN, School of Nursing, Johns Hopkins

University, Ste 531, 525 N Wolfe St, Baltimore, MD 21205; e-mail:

stephswenson@gmail.com.

0891-5245/$36.00

Copyright Q 2016 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights

reserved.

Published online October 30, 2015.

http://dx.doi.org/10.1016/j.pedhc.2015.09.010

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ABSTRACT Parents’ use of praise and criticism are common indicators of parent-child interaction quality and are intervention tar- gets for mental health treatment. Clinicians and researchers often rely on parents’ self-reports of parenting behavior, although studies about the correlation of parents’ self- reports and actual behavior are rare. We examined the concordance between parents’ self-reports of praise and criticism of their children and observed use of these behav- iors during a brief parent-child play session. Parent self- report and observational data were collected from 128 parent-child dyads referred for child mental health treat- ment. Most parents reported praising their children often and criticizing their children rarely. However, parents were observed to criticize their children nearly three times more often than they praised them. Self-reported and observed praise were positively correlated (rs = 0.32, p < .01), whereas self-reported and observed criticisms were negatively correlated (rs =�0.21, p < .05). Parents’ ten- dencies to overestimate their use of praise and underesti- mate their use of criticism are discussed. J Pediatr Health Care. (2016) 30, 49-56.

KEY WORDS Parenting, young children, praise, critical statements, parent self-report

Parents are a powerful source of feedback in shaping their young children’s behavior and sense of self. It is within these earliest relationships that children first begin to acquire a sense of themselves as capable, competent, and loved (Bohlin, Hagekull, & Rydell, 2000; Bowlby, 1988; Cassidy, 1988). Two common sources of parental feedback used to shape young

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Parents are a powerful source of feedback in shaping their young children’s behavior and sense of self.

children’s behavior and self-esteem are praise (i.e., positive statements designed to reinforce desirable behaviors in children or communicate plea- sure with the child) and criticism (i.e.,

negative statements designed to stop or change children’s undesirable behavior or communicate displeasure with the child). 

Praise from parents has been used as a marker of positive parenting behaviors in numerous studies (Breitenstein et al., 2012; Chorpita, Caleiden, & Weisz, 2005; Wahler & Meginnis, 1997). Praise is often accompanied by other parenting behaviors indicative of parental warmth, responsiveness, and nurturance (Furlong et al., 2013). Although the question ofwhether excessive use of praise can negatively influence children’s intrinsic motivation has been debated (Owens, Slep, & Heyman, 2012), substantial research now shows that praise, used strategically, can boost children’s feelings of competence and confidence. Therefore, praise remains an important indicator of positive parenting behavior (Brummelman, Thomaes, Orobio de Castro, Overbeek, & Bushman, 2014; Cimpian, 2010; Henderlong & Lepper, 2002; Mueller & Dweck, 1998; Zentall & Morris, 2010).

Parents may use critical statements to express disap- proval with their children’s behavior or attitude. However, using criticism can undermine their self-esteem, lead to greater child defiance and aggres- sion, and increase the likelihood of their developing behavioral problems (Barnett & Scaramella, 2013; Lorber & Egeland, 2011; Tung, Li, & Lee, 2012; Webster-Stratton & Hammond, 1998). Thus, contrary to parents’ expectations, using critical statements to shape child behavior actually may be counterproductive. In clinical studies of young children in mental health treatment, parents who directed more critical statements at their children were also more likely to drop out of treatment (Fernandez & Eyberg, 2009).

Given their salience in child development research, parent training interventions have been designed to increase parents’ use of praise and reduce their use of criticisms with their children (Breitenstein et al., 2012; Brotman et al., 2009; Eyberg et al., 2001; Gross et al., 2009). In clinical practice and research, parents’ use of praise and criticism is often assessed using parent self- report. However, some investigators have questioned the accuracy of using self-reports to measure actual parenting behaviors, particularlywhen those behaviors are susceptible to recall or social desirability biases (Morsbach & Prinz, 2006). These biases may be partic- ularly heightened in a child mental health population,

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where parents might be highly sensitive to feeling ‘‘blamed’’ for their child’s illness or to the stigma of engaging the mental health system (Meltzer, Ford, Goodman, & Vostanis, 2011; Angold, et al., 1998). This study examines the extent towhich parents’ self-

reports of praise and criticism are reflected in their observed behavior in a sample of parents of preschool children referred for mental health treatment. We also explore whether two indicators of parents’ tendency to hold negative attributions about themselves and their children, depressive symptoms andperceptions of their children as being more behaviorally difficult, moderate the relationship between self-report and observed use of praise and critical statements. Consistent with cogni- tive attribution theory, depressed parents may develop biases that their children’s misbehavior is intentional andwithin their control, leading them tobe less positive and more critical in their interactions (Dix, Ruble, Grusec, & Nixon, 1986; Leung & Slep, 2006; Scott & Dadds, 2009). Using a descriptive, cross-sectional design,we posed

the following research questions:

� What is the relationship between parents’ self- reported and observed use of praise based on (a) frequency and (b) the proportion of statements to their child that are praise during a 15-minute free play session?

� What is the relationship between parents’ self- reported and observed use of criticism based on (a) number and (b) the proportion of state- ments to their child that are criticisms during a 15-minute free play session?

� Do parents’ depressive symptoms moderate the association between their self-reported and observed use of praise and critical statements?

� Do parents’ perception of the severity of their children’s behavior problems affect the association between their self-reported and observed used of praise and critical statements?

Thegoals of this study are to (a) understand the extent to which parents’ self-reported use of praise and criti- cism accurately reflect the appraisals of their observed behavior and (b) offer guidance to practitioners on how to address these two important parenting practices in pediatric primary care with parents of young children at risk for mental health problems.

METHODS This study is a secondary analysis of baseline parent- report and observation data collected as part of a larger clinical trial comparing two evidence-based parent training programs. The larger clinical trial was conduct- ed in an urban mental health clinic serving low-income familieswith preschool children (Gross et al., 2014) and was approved by the JohnsHopkins UniversityMedical Institutions Institutional Review Board.

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Sampling Design Data were drawn from a convenience sample of 128 parents seeking treatment at an urban child mental health clinic serving families of young children, birth to 5 years old,whowere recruited into the larger clinical trial. Approximately 80% of the clinic population is African American or multiracial, and more than 95% of families receive Medicaid. Criteria for inclusion were that the parent is (a) the biological or adoptive parent or legal guardian for a 2- to 5-year-old child and (b) seekingmental health treatment for their child’s behavior problems. Parentswere excluded if they had a severe mental illness, substance use disorder, or cogni- tive impairment that would interfere with their child’s treatment. Childrenwere excluded if theywere actively suicidal or psychotic, had a diagnosis of autism or pervasive developmental disorder, or had a congenital or genetic anomaly that would interferewith treatment. Parents who met the inclusion criteria and consented to participate in the clinical trial completed a set of baseline measures and were video recorded with their child during a 15-minute free-play session (see the Procedures section).

Variables and Measures

Self-reported praise and criticism Parents’ self-reported use of praise and criticism was measured using two survey items from the Parenting Questionnaire (Gross, Fogg, Garvey, & Julion, 2004; McCabe, Clark, & Barnett, 1999), a 40-item Likert-type measure of parent discipline strategies. One item asks parents to circle the frequency with which they praise their child along a 5-point scale of 1 (almost never) to 5 (very often). Another itemasksparents to circle the fre- quency with which they criticize their child, using the same 5-point scale of 1 (almost never) to 5 (very often).

Parent depressive symptoms The 20-item Center for Epidemiologic Studies Depres- sion Scale–Revised (CESD-R) was used to measure parent depressive symptoms. This version of the CESD was created to better reflect the range of symp- toms indicative of major depression (Eaton, Muntaner, Smith, Tien, & Ybarra, 2004). Validity of the CESD-R has been supported by confirmatory factor analysis and positive correlations with other measures of depression and anxiety (Van Dam & Earleywine, 2011). Higher scores are indicative of more depressive symptoms; a score of 16 or higher indicates depressive symptomatology within the clinical range. The Cron- bach a for the CESD-R in this sample was 0.92.

Child behavior problems Parents’ reports of their child’s behavior problemswere measured using the Child Behavior Checklist for ages 1½ to 5 years (CBCL; Achenbach & Rescorla, 2000).

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The CBCL measures two dimensions of child behavior problems: externalizing behavior (e.g., aggression, noncompliance, and inattention) and internalizing behavior (e.g., anxiety, depression, and withdrawal). Parents rate their child’s behavior problems on a scale of 0 (behavior is not true) to 2 (behavior is very true or often true); higher scores are indicative of more behavior problems. In the current study, only external- izing behavior problems were examined because these behaviors tend to be more aversive to parents. The CBCL externalizing scale contains 24 items, and scores range from 0 to 48. Standardized T scores are used to identify children with externalizing behavior problems in the borderline clinical (93rd percentile) and clinical (98th percentile) range. In low-income racial and ethnic minority populations, a reliabilities for the external- izing scale range from 0.88 to 0.91 (Gross et al., 2006), and validity has been supported (Gross et al., 2007; Sivan, Ridge, Gross, Richardson, & Cowell, 2008).

Observed use of praise and criticism Frequencies of observed praise and criticism were measured from 15-minute video recorded parent- child free play interactions using a modified version of the Dyadic Parent-Child Interaction Coding System (DPICS; Eyberg & Robinson, 1992). The DPICS mea- sures frequencies of select observed parent and child verbalizations and behavior. Observed parent verbal- izations collected in this study include numbers of crit- ical statements, encouraging statements, praise statements, and commands. Parents’ use of praise and criticism were estimated in two ways; (a) the frequency of observed praise statements or critical statements and (b) the proportion of praise statements or critical state- ments to all observed parent verbalizations during the 15-minute free play session. Praise statements includeboth labeled andunlabeled

praise. Labeled praise is operationalized as any specific statement by a parent expressing their favorable judg- ment of an activity, product, or attribute of the child, such as ‘‘That’s a terrific house you made.’’ Unlabeled praise is operationalized as a nonspecific verbal comment by the parent expressing a favorable judg- ment of an activity or attribute of the child, such as ‘‘Great’’ or ‘‘Good job.’’ In this analysis, these two types of praise were summed to form a single estimate of parents’ total use of praise. Critical statements are operationally defined as

parent verbalizations that find fault with the activities, products, or attributes of the child. Blame statements and guilt-inducing statements are also considered to be critical statements. Examples include, ‘‘You’re being naughty’’ and ‘‘I don’t like your attitude.’’

Procedures After completing the self-report measures, parents were asked to play with their child for 15 minutes

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TABLE 1. Sample characteristics

Characteristic Mean (SD) n (%)

Parent characteristics (n = 128) Age, year 34 (10.3) Relationship to child Mother 97 (75.8) Other 31 (24.2)

Race/ethnicity African American 86 (67.2) White 30 (23.4) Hispanic/Latino 6 (4.7)

Education level High school graduate or less 79 (61.7) Some college 28 (21.9) College graduate or higher 11 (8.6)

Household income < $20,000 or receive Medicaid

121 (95.3)

Unemployed 82 (64.1) CESD-R score 17.8 (15.6) Score $ 16 59 (46.1)

Child characteristics (n = 128) Age, year 3.6 (1.0) Male 70 (54.7) Externalizing behavior $ borderline clinical range

53 (41.7)

Note. CESD-R, Center for Epidemiologic Studies Depression Scale–Revised; SD, standard deviation.

while the research assistant video recorded the inter- action. Parents were instructed to play with their child as they normally would, and the research assistant would let them know when the 15 minutes was over. Video recordings were then sent electronically to trained DPICS coders who were blinded to study hypotheses. Inter-rater reliability, assessed through intraclass correlation for 10% of DPICS assessments, was 0.98 for praise statements and 0.92 for critical statements.

Data were analyzed using SPSS version 22 (IBM Corp., Armonk, NY). Descriptive statistics were used to summarize parents’ self-reports of praise and criti- cism use and observed use of praise and criticism (as frequencies and as proportions of total verbalizations) in a 15-minute play session. Bivariate correlations between parents’ self-reported and observed uses of praise or criticism, as well as correlations between self-reported and observed uses of praise and criticism with parent depression and perceived child behavior problems, were calculated using Spearman’s rho. Multiple regression analyses were conducted to test the effects of parent depressive symptoms or perceived child behavior problems on parents’ self-reports of praise and criticism as predictors of their observed use. To address data skewness, outliers were removed using Mahalanobis distance, Cook’s distance, and centered leverage values.

RESULTS Sample characteristics are summarized in Table 1. A majority of the parents were mothers (75.8%), African American (67.2%), unemployed (64.1%), and economically disadvantaged (95.3% reported a household income less than $20,000 or received Medicaid). The mean parent age was 34 years (SD = 10.3). The mean CESD-R score was 17.8 (SD = 15.6); more than 46% of the parents had depressive symptom scores in the clinical range. The average age of the children was 3.64 years (SD = 1.04). More than half of the children were boys (54.7%). Although all of the children were referred for behavior problems, only 41.7% of the parents reported child externalizing behavior prob- lems in the clinical or borderline clinical range.

Parents’ Use of Praise and Criticism A majority of the parents (86.7%) reported using praise ‘‘often’’ or ‘‘very often,’’ and using criticism ‘‘rarely’’ or ‘‘almost never’’ (77.3%). During their observed parent-child play interactions, parents verbalized a median of three praise statements (range = 0-48) and eight critical statements (range = 0-38) in 15 minutes. A higher proportion of parents’ total verbalizations consisted of critical state- ments compared with praise statements (13.6% vs. 7.4%). These results are presented in Table 2.

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Relationships Between Parents’ Self-Reported and Observed Use of Praise and Criticism Tables 3 and 4 summarize bivariate correlations between pertinent variables for parent praise and criticism, respectively. We found a positive correlation between parents’ self-reported and observed use of praise based on absolute frequency of praise (rs=0.32,p< .01) andproportionofpraise to total parent verbalizations (rs = 0.23, p < .01). In contrast, a negative association was found between parents’ self-reported use of criticism and the observed frequency of critical statements (rs = �0.21, p < .05). No relationship was found between parents’ self-reports of their use of criticism with their child and the proportion of observed critical statements to total parent verbaliza- tions (rs = �0.05, not significant).

Moderating Effect of Parent Depressive Symptoms on the Relationship Between Parents’ Self-Reported and Observed Behaviors As shown in Table 3, parent depression scores were not significantly associated with parents’ use of praise based on self-report (r = �0.08, not significant) or observation (r = �0.05, not significant). Also based on regression analysis, parents’ depressive symptoms did not moderate the relationship between self-reported and observed use of praise (i.e., no significant interac- tion between depressive symptoms and self-reported use of praise was found; b =�0.10, p = not significant).

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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 also unrelated to frequency (r = �0.05, not significant) and proportion (r = 0.07, not significant) of observed critical statements. However, parents with higher depression scores self-reported using more criticism with their children (rs = 0.20, p < .05). Parents’ depres- sive symptoms did not moderate the relationship be- tween parents’ self-reported and observed use of critical statements (i.e., depressive symptoms and self- reported use of criticism did not interact significantly; b = �0.12, p = not significant).

Moderating Effect of Parents’ Perceptions of the Severity of Their Child’s Behavior Problems on the Relationship Between Their Self-Reported and Observed Behaviors As shown in Table 3, parents’ self-reports of their use of praise was inversely correlated with their perceptions

TABLE 3. Bivariate Spearman’s rank correlation coefficients for main variables related to parent praise

Variables 1 2 3 4 5

1 Self-reported praise 0.32† 0.23† �0.08 �0.18* 2 Observed praise 0.89† �0.05 �0.003 3 Praise as proportion �0.001 �0.02 4 Parent’s depressive symptoms

0.31†

5 Child’s externalizing behaviors

*Correlation coefficient significant at p < .05. †Correlation significant at p < .01.

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of their child’s externalizing behavior problems (rs = �0.18, p < .05)—that is, parents who rated their children as having more behavior problems were less likely to report praising their child. However, modera- tion analysis did not reveal a significant interaction be- tween the child’s externalizing behavior and parents’ self-reported use of praise in predicting their observed use (b =�0.03, p = not significant). Children’s external- izing behavior problemswere also unrelated to parents’ use of critical statements based on self-report and observation (see Table 4). Finally, there was no evi- dence that parents’ perceptions of the severity of their children’s externalizing behavior problems moderated the relationships between parents’ self-reported and observed use of critical statements (i.e., no significant interaction was found between perceived child exter- nalizing behavior problems and self-reported criticism use; b = �0.06, p = not significant).

TABLE 4. Bivariate Spearman’s rank correlation coefficients for main variables related to parent criticism

Variables 1 2 3 4 5

1 Self-reported criticism �0.21* �0.05 0.20* 0.15 2 Observed criticism 0.65† �0.05 0.13 3 Criticism as proportion 0.07 0.12 4 Parent depressive

symptoms 0.31†

5 Child externalizing behaviors

*Correlation coefficient significant at p < .05. †Correlation significant at p < .01.

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DISCUSSION Parents’ praise and criticism are powerful sources of feedback in shaping their young children’s behavior and development. These parenting behaviors

Data obtained from this clinic sample suggest that parents tend to overestimate their use of praise and underestimate their use of criticismwith their preschool children.

have been a key focus in child development research and serve as important indicators of positive or negative parenting in families of children with mental, emotional, and behavior disor- ders. Although many studies use parents’ self-reports of praise and criticism, the extent to which we can rely on parent

report as reliable indicators of their actual use remains unclear. Data obtained from this clinic sample suggest that parents tend to overestimate their use of praise and underestimate their use of criticism with their preschool children. 

Although parents who reported praising their child more often were observed to use more praise, the magnitude of the effect was small (rs = 0.32). This modest correlation is consistent with prior literature showing generally small correlations across methods, suggesting that self-report and observation capture different aspects of the same variable (i.e., perceived versus actual parenting behavior; Gardner, 2000).

Despite the positive correlation between self- reported and observed use of praise, praise was not frequently expressed. Parents verbalized a median of only three praise statements in the 15-minute observed play sessions. On average, only 7% of the parents’ state- ments counted from the parent-child interactions qual- ified as praise, though these sessions were intended to be a positive one. Yet, nearly 87% of parents reported praising their children ‘‘often’’ or ‘‘very often.’’

Parents’ self-reports of their use of criticism was modestly though negatively correlated with their actual use. Specifically, parents who reported using criticisms infrequently were actually more likely to criticize their children during the 15-minute play session. There are multiple plausible explanations for this finding. First, parents are aware that being critical is a socially undesir- able behavior and therefore may have reported a more socially acceptable answer. However, it is also possible that parents are truly unaware of how frequently they criticize their children. Indeed, the parents in this sam- ple criticized their children nearly three times more frequently than they praised them (i.e., eight criticisms versus three praise statements) despite their reports to the contrary (77% reported criticizing their children

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‘‘rarely’’ or ‘‘almost never’’). Another explanation re- lates to the artificial conditions under which the observed behavior sample was obtained. Parents with a stronger tendency to criticize their children may have consciously suppressed those comments during the 15-minute play session. Nonetheless, it should be noted that despite the possibility that parents may have modified their behavior while being observed, the proportion of parents’ critical statements were still nearly twice those of their praise statements (i.e., 13.6% vs. 7.6%).We also examinedwhether two indica- tors of parents’ tendency to hold negative attributions about themselves and their children (i.e., parents’ depressive symptoms and parents’ ratings of their chil- dren’s externalizing behaviors) affected concordance between self-report and observed behavior. Higher depressive symptom scores were associated with more self-reported use of critical statements. However, parents’ depression scores did not moderate the rela- tionships between self-reported and observed used of criticism or praise. In addition, parents who rated their children as having more externalizing behavior prob- lems also reported praising their children less often, but the severity of their child’s behavior problems did not moderate the association between self-reported and observed use of criticism or praise. These data suggest that parents’ negative attributions affect how they perceive their children and themselves, but these attributions do not appear to account for the lack of concordance between self-reported and observed behavior. Several study limitations should be noted. First,

parents’ self-reported use of praise and criticism were each measured from a single item extracted from a parent survey. A single item measure may not be an accurate indicator of parents’ perceptions of their use of praise or criticism. Second, the behavior sample used to measure observed parent behavior was derived from a video-recorded 15-minute play session. Parents’ behavior in this context may not have been representative of their typical behavior. However, being recorded while playing with one’s child would likely elicit more positive behavior than might be typical. Thus, the number of parent praises observed might have actually been higher and the number of critical statements observed lower than was typical for these participants. Finally, this second- ary analysis relied on an existing convenience sample of parents seeking mental health services for their children. As a result, the size of the sample, the study measures used, and the representativeness of the sample were all limited. Additional studies evaluating concordance between parents’ self-reports and observed behavior with their children using larger and more diverse samples in both mental health and community populations are warranted to better

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The challenge for clinicians is to support parents in preparing their children for life’s difficulties by building the self- esteem and resilience that their childrenwill need to grow and thrive despite the difficulties.

understand these discrepancies in measurement and best practices for guiding parents in using more positive parenting strategies with their preschool children.

IMPLICATIONS FOR PRACTICE Chronic mental health problems in children have now surpassed physical illnesses as one of the five most prevalent disabilities affecting children in the United States (Halfon, Houtrow, Larson, & Newacheck, 2012; Slomski, 2012). Their prevalence points to the importance of screening for behavioral and emotional problems in pediatric primary care and identifying appropriate resources for parents (Weitzman & Wegner, 2015).

Thoughtful discussions with parents in primary care settings about positive strategies for supporting their children’s behavioral health, supplemented with written materials on how and when to use these strategies, would be an initial step. For example, Bright Futures includes brief handouts on communi- cating with children in ways that support their self- esteem (www.brightfutures.org). These handouts, in conjunction with discussions on the importance of parents’ positive statements supporting their chil- dren’s efforts and behavior, would be an important addition to well-child visits. Referral to parent training programs that are available in many cities across the country would connect parents to interventions that strengthen parents’ use of positive skills, such as praise, and teach alternate strategies for discouraging misbehavior other than criticism. Parent training pro- grams that use brief video-recorded examples of par- ents using evidence-based parenting strategies to promote positive child behavior may be useful if par- ents have not previously been exposed to these strate- gies (e.g., the Chicago Parent Program, the Incredible Years). The National Registry of Evidence-Base Pro- grams and Practices, sponsored by the Substance Abuse andMental Health Services Administration, lists more than 70 different parent-training programs. The Web site also provides critical evaluations of each program’s evidence and readiness for dissemination along with program contact information for providers and consumers seeking additional information (www. nrepp.samhsa.gov).

It is important to note that although the parents in this sample were seeking help for their children’s behavior, these parents also represent a highly vulnerable population. Most were unemployed and economically disadvantaged, and more than 46% evi- denced high levels of depressive symptoms. It is possible that these parents have experienced little praise and a great deal of criticism in their lives. As a result, their perspective on what constitutes ‘‘a lot’’ of praise and ‘‘rare’’ criticism may be skewed. Moreover, parents raising young children in

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under-resourced com- munities may feel the need to ‘‘toughen’’ their children to the realities of life. Thus, critical statements may seem to some parents to be a more responsible and real- istic way to prepare their children for adulthood than using praise. The challenge for clinicians is to support parents in pre- paring their children for life’s difficulties by building the self- esteem and resilience

that their children will need to grow and thrive despite the difficulties. 

We gratefully acknowledge the support of Mirian Ofonedu, Ivonne Begue De Benzo, and Maria Cecelia Lairet-Michelena.

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Journal of Pediatric Health Care