DISCUSSION

The literature on the specific coping mechanisms of children of parents with cancer is limited. Most of the studies address concerns about children's reactions to the parent's illness, the effect on their development, premorbid factors, and the impact of communication on their ability to cope. The major limitation of the present study was that it enrolled a consecutive group of children who were referred by clinicians at the parent's request and, therefore, were more likely to have problems.

A study by Waechter (1971) provides support for the belief that giving a child opportunities to discuss his fears does not heighten anxiety and, as reflected in our case studies, that providing the child with understanding and with acceptance of his feelings and conveyance of permission to discuss any aspect of the parent's illness can decrease feelings of isolation and alienation and dispel the sense that the illness is too terrible to discuss. Waechter points out the striking dichotomy between the child's degree of awareness of the prognosis, as inferred from his imaginative stories, and the parent's belief about the child's degree of awareness of the parent's prognosis (Waechter, 1971). This dichotomy suggests that knowledge is communicated to the child by the changes that he encounters in his total environment after the diagnosis is made and by his perceptiveness of various nonverbal clues. This disparity presages a deepening isolation that is exacerbated when the child becomes aware of the evasiveness that meets expressions of his concern.

As we found in our study, interventions before the death of a parent can also ease the ensuing period of bereavement. In a longitudinal study of 25 preadolescent children living on a kibbutz who had lost their fathers in the Arab Israeli War of 1973, Elizur and Kaffman (1983) found that pretraumatic family and environmental factors were significant determinants of the duration and severity of bereavement. The data from this study were drawn exclusively from semistructured interviews held separately with the widowed mothers and the children's teachers: There were no child self-reports. The results suggested that emotional restraint in the surviving parent made it difficult for the child to express feelings, which led to a sense of intensified loneliness and increased anxiety and confusion. Their findings demonstrated that childhood bereavement symptoms tend to become exacerbated when the stress of the loss is compounded by pertinent child, family, and situational factors. In most cases, the combination of several factors determined the intensity of the bereavement response rather than the exclusive influence of any single factor. The results suggested that the child's emotional response during the early months of bereavement is largely determined by pretraumatic antecedent variables, whereas posttraumatic factors became more influential during the years following bereavement. Our study supports these conclusions and the importance of the availability of a supportive, stable family environment as well as the accessibility of professional intervention.

Kranzler et al. (1990) found that the ability of bereaved children to report grieving emotions correlated significantly with improved functioning, which supports our study's conclusions. Their study reported on the acute bereavement reactions of a cohort of preschool-aged children who experienced the death of either their mother or father. The aims of the study were to describe the children's acute state, to examine developmental influences that might impact on their vulnerability, and to identify important outcome mediators. The study supported both the importance of preexisting relationships in the family and the effects of ongoing adversity, especially depression in the surviving parent. It also provided acute bereavement data that support the retrospectively determined findings of Harris et al. (1986) and Breier et al. (1988), who concluded that although the death of a parent creates a vulnerability, ongoing provoking agents, particularly inadequacy of parenting after the loss, mediate the child's risk. The surviving parent's ability to cope with his or her own grief and capacity to respond to the emotional and other needs of their young children is critical. The young child's sensitivity to deficits in parental caretaking may create a particular vulnerability to parental loss.

The conclusion of Bowlby (1980) and Furman (1974) that grieving is possible even in early childhood is supported. The authors conclude that additional study of the interaction between the grieving parent and child is needed.

Hilden et al. (2000) found that when given the opportunity to communicate, children can conquer their fears as well as express their love in the terminal phase of a parent's illness and that honesty is indeed the best policy with children of all ages. In this way, the reality of the situation, no matter how awful it is, can be shared in an open manner. Our case studies support this viewpoint. Trying to protect children from knowledge about what is really happening often confuses the child even more than circumstances alone and escalates concerns about events that are beyond their control. A study conducted by Pfeffer et al. (2000) reported that the children in their sample were likely either denying or reluctant to acknowledge problems in the emotional domains assessed, for reasons that were directly or indirectly related to the loss of their parent. For example, they may have been reluctant to acknowledge their own feelings of depression for fear that doing so would upset other family members. However, reports of bereaved parents regarding their children's psychological distress and symptoms of depression reported lower levels than found in the children's reports of their own distress and psychiatric symptomatology. Bereaved parents may be so overwhelmed by their own grief and mourning that they are not fully aware of the level of distress of their children, or they may not be able to cope with their children's psychologically distressed states.

Finally, the death of a parent can interrupt the process of internalization and the development of feelings of safety. The roots of separation anxiety and fear of loss are grounded in the Attachment Theory first espoused by Bowlby (1980) who, in groundbreaking research, demonstrated that when primates are separated from the mother early in life their reaction escalates from a state of protest to marasmus and death. Since then other researchers have confirmed the instinctual roots of attachment, which assures the safety of infants who use intuitive behaviors to engage their caretakers and to guarantee their caretaker's presence and attentiveness. Internalization of primary caretakers is a process that becomes established by the time the child is 2 or 3 years of age. Once this process of internalization is accomplished, the child can sustain prolonged separations yet retain the memory of the parent. For the child to be able to obtain optimal emotional, social, and psychosexual maturity, a predicable, caring environment is required. Separation from the primary caretaker produces anxiety, which is manifested differentially depending on the child's developmental stage and is exacerbated by a terminal illness, as in the children we studied.

In conclusion, several themes emerge from these studies that are relevant both to the short- and long-term care of children who experience the death of a parent from cancer: (1) Previous family history affects the child's bereavement process, (2) a child's increased anxiety is directly correlated with a lack of information about his parent's cancer diagnosis, (3) anxiety increases when information is available but there is no opportunity for discussion with the child, (4) children of parents with cancer are at a higher risk of psychological disturbance (Harris et al., 1986), (5) a large percentage of bereaved children experience a major depressive disorder in adulthood (Harris et al., 1986), and (6) meeting with a mental health professional provides an avenue for supportive discussions, which in turn model for the family how discussions can be conducted to clarify issues, dispel fears, bring people together, or plan for the future.

It is important to remember that making recommendations to families in such a situation is difficult. There is no clear-cut solution for dealing with a family's reaction to terminal cancer. When a parent is dying of cancer, discussions among parents, children, and all other adult caretakers is important. However, these discussions are part of a process that should begin when the patient is first aware of his or her terminal condition. This may coincide with his or her referral to a palliative care team. The mental health professional should contact the family at this entry point and establish a connection. An assessment of the parent's adaptation to the illness and of the family and other support systems is very important. The children should be assessed independently to determine developmental age, level of information, adaptation to the critical situation, understanding of facts, and wishes and fantasies about the future. Finally, the interventions have to take place before despair or resignation set in so there is enough motivation to accomplish a higher level of communication, and possibly resolution of conflicts, before death is imminent.