In a recent column entitled “To the limit,” I tried to make the case that the negative consequences of permissive parenting are numerous enough to warrant the attention of primary care pediatricians and family physicians. The evidence linking atypical sensory adaptation, behavior difficulties, sleep deprivation, and obesity to a permissive parenting style is just beginning to appear in the literature, but the numbers are in sync with the anecdotal observations of many experienced pediatricians like me. In that previous column, I offered to provide a more nuanced discussion of when and how clinicians might address the issue of permissive parenting with families in their practices.

First, let me make it clear that I don’t consider parenting style to be a topic that needs to occur on the checklist of every patient at every health maintenance visit. You already are overburdened with the demands of experts who have lobbied to have their favorite hot button issues included in your 15 minutes of face-to-face time with your young patients.

In the study linking atypical sensory adaptation and increased behavioral difficulties with parenting style, Mary Lauren Neel, MD, found that only 11% of the parents in her study group could be categorized as permissive (“ Parenting style link to atypical toddler sensory adaption ” by Tara Haelle ). Our target group would appear to be relatively small.

We also must accept our limited role as advisors. There are many ways to skin a cat and to raise a child. Homogeneity is not our goal. We must respect the cultural and philosophical differences that exist in our society. However, in my opinion, the unhealthy consequences of permissive parenting deserve a sensitive attempt at education and some gentle anticipatory guidance … hopefully without an aroma of condescension.

The opportunities for our input begin in the first few months of life when parents are faced with the difficult questions of whether it is safe and appropriate to allow their infant to cry himself to sleep and whether a mom must allow her infant to use her breast as a pacifier. With the transition to solid food comes the challenge of how to manage the inevitable rejection of new tastes, colors, and textures. Of course, most parents find these issues challenging, but to what degree a parent can internalize your reassurance and advice is a good reflection on where he or she sits on the permissive to authoritarian spectrum of parenting.

With an infant’s rapidly advancing motor skills comes the question of when, where, and how to create boundaries to keep the child safe … and to protect the environment from the surprisingly destructive power of an inquisitive toddler. Here the permissive parent will be continually challenged when he or she finds that simply saying “No” or “Don’t” doesn’t always work … to some extent because, up to this point, the child has never encountered a situation in which s/he hasn’t gotten what s/he wants.

It is possible that your advice on when and how to say “No” will meet immediate resistance from a parent who simply believes that every child will eventually self-correct herself. Or, you may encounter a parent who has been told that setting limits will stifle her young child’s creative impulses. Of course, this is hogwash because you know as well as I do that carefully considered age-appropriate limits can keep a child safe and still give him plenty of room to exercise his creativity.

This is not an issue in which we should allow ourselves to get bogged down in circuitous philosophical arguments. We must keep our advice practical and focused on issues of safety and health. I have found that a significant number of permissive parents can learn the difficult skill of saying “No” to their children. It takes time, but it is time well spent.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com .

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