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Ruth Steinman, MD, is a clinical associate professor of psychiatry at the Abramson Cancer Center. Here, Dr. Steinman discusses ways to tell children of all ages about a cancer diagnosis.

Many parents feel overwhelmed about their cancer diagnosis and how it affects their families, especially their children. They may wonder what they should tell their children, or how their children will react to their cancer diagnosis.

Each child copes with a parent’s cancer according to his or her phase of development and his or her coping style. Children can cope far better than parents imagine if there is an understanding of their developmental needs and how to maximize an important support system for their children.

Children old enough to speak should be told about a parent’s cancer diagnosis. Below are recommendations for how to tell children of any age group about a cancer diagnosis and what a parent can expect at certain ages and stages of development.

Infants (age 0 to 2)
Babies and very young children are sensitive to changes in their routine and may respond with increased fussiness to the change in emotional tone in the household. Increased difficulty with separation in not uncommon and sleep may become an issue.
Maintaining consistency in caregiving is very important.

Pre-school children (age 3 to 6)
Preschoolers do not need a lot of detailed information. Magical thinking is common: “My sister was born and then mommy got cancer so my sister caused mommy’s cancer” or “I made my mommy angry and that is what made her sick.” It’s important for parents to tell their children that they did not cause cancer.

Under stress, preschoolers can regress and problems can manifest around separation, toileting and bedtime. Maintaining routine is essential with familiar toys, sippy-cups, and a consistent bedtime routine. These routines may help lower anxiety and worry.

School-aged children (age 7 to 12)
School-aged kids can cope with more information, but they too need to be reminded that they are in no way are responsible for their parent’s cancer. These children often cope by fact-finding so they tend to ask a lot of questions. They worry about how the illness affects them socially. Support consistent engagement in school activities and friendships. Anger often shows before sadness.

Adolescents (age 13 to 20)
Adolescents can understand more abstract concepts about prognosis and uncertainty. Some may stay close and other’s may withdraw, show little emotion and become occupied with peer relationships and activities. Try to limit how much extra responsibility is given to teenagers and continue to maintain as much routine as possible. Support and foster relationships teenagers have with trustworthy adults.

What if they ask if I’m going to die?
If children ask about dying, tell them you are doing everything you can to get better. Reassure them you will be honest with them along the way and that when they have concerns, they should talk to you: “From what I’ve been told, I don’t expect to die from this cancer, but if there are any changes, I’ll talk to you about it.”

Help them learn the difference between when the treatment is making you sick and when symptoms are caused by cancer: “Many people are made better by these treatments but the cancer cells are pretty nasty and I need really strong medicine to make me better,” or “The treatment is making my hair fall out and making me so tired all the time—not the cancer.”

Learn more about talking to your child about your cancer diagnosis.

Ruth Steinman, MD, is a clinical associate professor of psychiatry at Penn’s Abramson Cancer Center. In this blog, Dr. Steinman discusses how to tell children about a cancer diagnosis and offers suggestions on how to make the conversation easier.

Children who are old enough to speak need to be told about a cancer diagnosis. Begin by identifying your illness by name without confusing euphemisms. Discuss how it will be treated and what will happen to you during treatment (losing your hair, feeling tired and so on). Tell them who will be taking them to soccer practice, cooking their meals and how their day-to-day lives may change.

Don’t let them overhear it
Prevent your children from hearing the news of your cancer by overhearing. Let them know what is happening and what to expect directly from you. Tell them you will let them know any new information that comes up.

Welcome all questions warmly
Your child needs to know they can talk to you about any topic. Be available to talk about what is on their minds at times when they are likely to talk to you such as in the car, while doing an activity or at bedtime.

Try to tease out the “real” question your child wants to ask
“What are you wondering about?”

Often the real worry is something much more concrete and readily addressed. For example, children may ask: “Will you be better by summertime?” Rather than a question about prognosis or a request for a guaranteed cure, they may be asking if they will go to summer camp as usual. Remember: not every question requires immediate or detailed answers. “That is a good question. Let me think about it/discuss it with daddy/ask my doctor/ and get back to you.”

Respect children who wish not to talk
You can still provide basic information in order to prevent confusion or surprises even with children who don’t want to talk. Check in from time to time and ask what they are hearing and make sure they are getting the right amount of information. Instead of asking: “How are you feeling about Mommy’s cancer?” ask: “How is it working out with Katie’s mom picking you up from practice?”

Don’t let your child worry alone
Kids often hear or read frightening information. Tell your children you understand that they may feel more comfortable talking about what is worrying them with someone else and that you will arrange this if that is the case.

Try to maintain your child’s usual schedule
Assign a point person for each child. Post schedules and calendars for caregivers. Keep the channels of communication open with key caregivers who provide appropriate emotional support and ensure your children’s routines are disrupted as little as possible.

Let your kid’s teachers know who they can go to if they are having a hard time. Make sure the teachers do not share the information with other children in the class. School should be free of cancer talk unless your children initiate the discussion. Ask the teachers not to share information about cancer or about someone else who went through a similar situation. This information, while given with well meaning, can be burdensome to children.

Carve out protected time for the family
Turn off telephones and tell friends and family not to visit during these times so that your children have your full attention without distractions. Ask about their day. Try to use this time to focus on the children and not on your illness.

Have support around hospital visits
Hospital visits often help children feel less worried. Have extra support people accompany your children to the hospital to allow you to adjust the length of the visit to what your children can comfortably manage. Younger children should have toys available. When visits are not possible, cards, drawings and such are helpful. Be sure to have an adult check in with each child after the visit to answer questions about what they saw or heard which might have been confusing or worrisome.

Be honest
Don’t lie, no matter how much you think a lie will protect them. Children are less anxious when they can trust that the information they get from you is true. We all want to promise our children that we will never die. It is important not to make promises you may not be able to keep.

Talking to children about end-of-life
Acknowledge that sometimes people die of cancer. Reinforce the plan for your treatment and the hope that it will keep the illness from getting worse. The most important worry for children is who will look after them if something happens to you. You need to assure them that no matter what happens, they will be cared for.

After Death
Children need to know they are loved and why they are loved. It is also important to:

• Maintain a routine for kids of all ages.
• Include children in rituals but explain beforehand what will happen: the coffin, people crying, that they can leave at any time and this is who will go with them (family or friend).
• As time goes on, demonstrate that it is ok to discuss good and bad memories. Help your children find a way to maintain an emotional, internal connection.

It can often be difficult to tell when children need professional intervention. Certainly if a child asks to speak with someone outside of the family, he or she should be helped to do so. Symptoms that may indicate a need for intervention include depressed mood or high anxiety for more than a couple of weeks, changes in appetite and/or sleep, risk-taking behavior, problems with school (academic or behavioral) and substance abuse. Any expression of suicidal thinking needs to be taken seriously and evaluated by a professional despite the resistance in doing so.

Read “Speaking with Children about Cancer”