This is a normal phase that children will, in time, grow out of. In the meantime, it can take time for them to learn to be comfortable in a hospital or clinic.

You as a parent face a challenge. At a time when your normal instinct is to protect and nurture your sick child, you need to guard against letting him or her become too reliant.

This is a hard thing for many parents, because in the midst of a very upsetting time, caring for a child represents one of the few things over which you still have control. You can't control the cancer, or the cancer treatment, but you can control caring for your daughter or son.

You'll need to walk a fine line between giving and giving in. It's important to give a child options and choices, which promotes independence, yet resist the temptation to give in to every whim or demand, which emotionally hinders him or her.

Teenagers require special sensitivity, because this is a time of life when they're starting to exert their independence. While you naturally view your teenager as the infant you reared from birth and so your protective instinct is powerful, you may need to remind yourself to back off and give him or her time and space.

Your goals are to:

• call for help if it is needed
• prevent children from becoming over-dependent on you
• encourage children to develop a healthy independence as they work their way through treatment.

When To Get Professional Help

You should seek help from the doctor, nurse, hospital social worker, or counselor if any of the following is true:

• If a child becomes uncooperative with treatment. Usually, you or the medical staff will notice signs that a child is growing more reluctant. If your child is having a harder and harder time accepting something, ask the medical staff if some other method or medicine can be substituted. If you're beyond that point, however, and your child refuses to cooperate, you need to tell the doctor or nurse right away.
  
• If you see a sharp change in the child's personality and he or she doesn't snap out of this change. If a child who is usually outgoing and friendly becomes withdrawn, or if a child who is usually quiet becomes angry and lashes out, that's no cause for immediate alarm. If the change persists, however, and the child seems to be unable to shake off that change, talk to the doctor or nurse.
  
• If you as the caregiver feel as if you've lost control or lost the support you need. If you or your child are extremely upset, get help now before it grows into a pattern. One way you can tell if you're at this point is if something that always worked before in dealing with your child no longer works. If you let the situation go, you'll be frazzled and burnt out, and will be unable to give the child your best care. The homecare plan for Parents' Anxiety contains some ideas on how to deal with stress, both for you and for your child.

What You Can Do To Help

• Preventing problems of over-dependency
• Dealing with dependency

Preventing problems of over-dependency

You can take several steps to promote independence and avoid a child's becoming too reliant on you.

• Treat your child as normally as possible under the circumstances. This is the single most effective way to foster a healthy attitude and self-image in a child undergoing cancer treatment. Of course, it's impossible to go back to the way things were before the diagnosis or the treatments, but maintaining a kind of normalcy isn't out of reach. If you suddenly change all the rules, your child may ask why and conclude that you know something very serious. He or she may think: "Why don't I have to do the dishes anymore? If they're being so nice to me, I must be going to die." If there's no physical reason a child can't keep doing chores around the house, insist that he or she continue to do them. If the child physically can't do so, find an alternative task.
  
  Keep this phrase in mind: Independence equals hope. If you encourage your child to keep doing the same things as before, it inspires hope. You are sending a message that life will go on, that treatment does end at a certain time-whether the child is "well" or just well for a period of time followed by a relapse-and that there's reason for hope.
  
  This issue extends to scheduling and daily routines as well. At certain times, children with cancer are vulnerable to viruses and it's advisable to limit exposure to other children or large groups of the public. But don't carry this to an extreme-if the doctor says it's OK for your child to return to school, don't hold him or her back out of misplaced fears over any cough, cold or flu that might come along. Being with friends and continuing or resuming a normal school routine promotes not only educational progress, but emotional and social development as well. If you're in doubt, ask the doctor.
  
  Another reason is simply a quality-of-life issue-children who are spoiled really do not enjoy it.
  
• Set limits on behavior. Closely related to treating a child normally is setting or maintaining limits on behavior. If it wasn't OK for your child to hit her baby brother before she was diagnosed with cancer, it shouldn't be OK now. Impose the same consequences for unacceptable behavior as before. Ask yourself: How would I respond in this situation to my child if my child didn't have cancer? And then respond in that way.
  
• Stay calm and avoid imposing your frustrations on your child. At all costs, avoid threatening your child, such as by saying, "If you don't take this medicine, I'm going to leave," or worse, "If you don't take this medicine, you know you could die." The child may already be upset (for example, about taking an unpleasant medicine or sitting still for a painful procedure), so it's pointless to frighten him or her by introducing a new fear. A child can't focus on more than one crisis at a time. Reassure your child that your love doesn't depend on behavior.
  
• Be honest. It's very difficult for a parent to have to tell a child that he or she will undergo a painful procedure. But it's worse to deceive the child by pretending you don't know, or by saying it won't hurt much when you know (and the child will find out) that it hurts a lot. If you don't know the answer to a child's question about, for example, what's going to happen at the hospital today, say so. Or promise that as soon as you find out, you'll tell him or her. Broken promises and dishonesty will only increase a child's sense of frustration and feeling alone. Trust and confidence, on the other hand, will help a child mature far beyond his or her years in emotional and mental development.
  
• Give choices. Both at home and in the hospital setting, negotiating for a child to do something he or she hates to do can be a trying experience. Be creative by setting up choices rather than throwing down orders or ultimatums. Try some of these approaches, which have been used by parents and medical staff:
  
  "You have to take the medicine. I know you don't like to do it this way, so what about another way? Can we coat the pill with applesauce or chocolate syrup? If you don't like taking a pill, how about a liquid?"
  
  "We need to take this medicine by 2 o'clock-do you want to do it now or five minutes from now?" Or give the child a timer and say, "By the time this rings, you need to take the pills." Or: "By the time your favorite cartoon is over, you need to take these pills."
  
  "Here are the three pills you need to take. Which one do you want to take first?"
  
  This is true for older children and teenagers, as well. If your 17-year-old son wants to rearrange his chemotherapy treatment schedule to allow him to spend a long weekend at the beach with friends, there's nothing wrong with that.
  
• Be liberal with praise. It's easy to focus on the negative things, so make sure your child hears praise and positive comments as well. If a child has handled a couple of difficult procedures particularly well, make sure you say that you noticed. It will set the tone for helping your child cope with the same or other procedures later. Also, praise them for doing the normal things that have nothing to do with cancer treatment, as in, for example, "You did a good job helping with the dishes. Thank you."
  
• Carefully plan a hospital stay. Especially for younger children, a stay in a hospital can be scary. It may be the first time he or she is separated from parents. Try to ease into it by bringing familiar things from home, and photos of the family.
  
  Get children involved with other activities in the hospital and establish a routine so they know what's going to happen and when. Some children have difficulty being apart from parents, so if it's necessary, you can gradually increase your time away from the child, building up to an overnight separation. Remind your child that he or she can call you on the phone. Arranging for other relatives or friends to visit when you can't will help provide some security. Teenagers, on the other hand, take a different approach. They won't want you to hover (see "Give Teenagers Space and Time," next page).
  
• Phrase requests positively. Some treatment procedures will be unpleasant or painful. You may need to help get your child to do something he or she doesn't want to do. Rather than threaten by saying: "If you don't hold still, I'm going to have to hold you down," rephrase the identical message in a kinder way: "You need to hold still and if you can't hold still, I'll help you."
  
• Recall what worked in the past. Try to recall how your child coped with stressful events in the past-a school play or sports competition, for example, or a previous hospitalization. If medical staff members haven't already asked, let them know how your child normally handles stress or new situations, so they know what to expect and how to best talk with your child.
  
• Encourage your child, especially a teenager, to learn about his or her condition and participate in decisions about care and treatment. Make your child a central part of the planning and decision-making for treatment and care. When the doctor comes in, encourage your child to ask the questions rather than you posing them for him or her. Instead of saying, "This is what Michael wanted to know," say: "Michael, what did you want to ask the doctor?" Encouraging the child to respond directly and take part will help restore his or her sense of control.
  
  For older children-that is, from school age on, and especially for teenagers-encourage them to learn about their disease and to talk with others their age who have cancer, so that they hear how others have dealt with it. Ask the staff if any other current patient in the clinic or hospital has had a similar problem, and find out if a meeting can be arranged.
  
  It's common for teenagers to withdraw and feel that they're facing this all alone. In addition, they understand more than young children and have a concept of the finality of death.
  
  In any case, this principle holds true: A child who is better informed will respond to treatment better.
  
• Give teenagers space and time to be alone, and encourage them to maintain friendships. Don't suffocate your teenager with 24-hour round-the-clock vigils. He or she needs time alone. Before the diagnosis, you didn't spend every single moment with your teenager, so it's unnatural to do so now.
  
  Cancer and cancer treatments represent an intrusion into a teenager's life. Just at the point when they're preparing to take greater control and become independent by growing toward adulthood, a cancer diagnosis rips control from them. This is why it's helpful to keep conditions as normal as possible.
  
  Encourage friends to visit. Consider rounding up your teenager's friends (especially those who can't yet drive) and driving them to the hospital for a day-long Saturday visit. While they spend time together in the lounge, for example, you and a spouse, family member, or friend might visit in the room, in the cafeteria, or in another area. This achieves several goals-you're keeping a presence without intruding; you're demonstrating to your teenager that you take seriously his or her need for friends and are willing to help, and you're also serving your own need to be near (if not right beside) your teenager. Keep things in perspective-you can visit one-on-one on another day; your teenager's friends, who, unless it's summer, probably have school obligations, may not have that opportunity.

Dealing With Dependency

If your child has already slipped into a type of dependency, or his or her behavior shows backsliding to an earlier period of development, you can take steps to steer the child back toward independence.

• Be patient. Understand that this is a normal pattern and that putting added pressure or stress on yourself or your child may only prolong the behavior. Try to hold reasonable expectations of the child. If a child has just gotten off bottle feeding and has to begin the unfamiliar routine of cancer treatment, he or she may want the bottle again. That's OK-in time, the child will get back on track and resume normal feeding.
  
• Maintain routines. As much as you might be tempted to feel sorry for your child and relieve him or her of household chores, you'll promote a sense of normalcy by keeping the same routine as before. If a child is physically unable to continue some task, such as washing dishes or taking out the trash, find a substitute activity, such as doing light dusting or sorting and opening the mail.
  
• Offer choices where possible. If your child is feeling no control over anything, try to give control back by offering choices, even in small things such as what to wear, when to eat, and when to exercise.
  
• Phrase requests in a positive way. Some treatment procedures will be unpleasant or painful. To gain ideas on how to deal with this, observe staff members who are successful in getting children to comply with their requests without being threatening. At home or in the hospital or clinic, you may be called upon to get your child to do something he or she doesn't want to do. Rather than threaten by saying: "If you don't hold still, I'm going to have to hold you down," rephrase the identical message in a kinder way: "You need to hold still and if you can't hold still, I'll help you."
  
• Praise a child for positive or constructive behavior. Just as with prevention, this technique can help you guide a child out of dependency by reinforcing good or acceptable behavior. If a child handles a procedure well, make a point of noticing it and telling him or her about it.
  
• Stay attuned to your child's emotional state. If your child isn't talking about what he or she is feeling, it may help for you to talk about it, such as by saying: "You're really scared about these things, and that's normal, you would react this way, being in the hospital is very scary, and it is upsetting." If you hit the nail right on the head, your child's probably going to think: "Oh, that's right, I do feel this way," and may go even further by explaining it. It also shows your child that you understand him or her.
  
• Recall what worked in the past. Try to recall how your child coped with stressful events before the cancer diagnosis or treatment, or with other hospitalizations. That may give you clues for how to get him or her to handle this situation.
  
• Remain open to staff members' advice, even if it is blunt. Parents usually know what's best for their children, but the blur of events surrounding a crisis illness can sometimes cloud their judgment. Don't be offended if a doctor, nurse, or hospital social worker takes you aside and says, "If you don't stop giving Jennifer everything she demands, she's going to become a spoiled brat." This observation very likely is based on years of experience with hundreds of parent-child relationships. If a staff member says this to you, chances are good that it's true.
  
• Understand that teenagers may seesaw back and forth between dependency and independence. For teenagers, before the diagnosis and treatment, they were increasingly making decisions themselves and becoming more independent. Now their parents may be giving them directions and orders, as if they were little children again, perhaps telling them they have to go to the clinic at a certain day and time. You may find that your teenager, seeking security, wants to be nurtured and comforted, or that he or she swings back and forth between wanting nurturing and wanting independence. Through all of this, your instinct will probably be to play nursemaid, but don't smother him or her. Encourage as much independence as you find is healthy for both of you. Remember that going back and forth is OK as long as your teenager doesn't get stuck in an attitude of dependency.
  
• Make sure you're meeting your own needs. It's so easy to get wrapped up in your child's situation that you neglect your own needs. Make sure you're getting time to rest and recover. Also, ask the medical staff about support groups or coffee hours, which some hospitals or clinics offer on a weekly or monthly basis. Some include participation by "veteran" parents whose children have undergone a regimen of medical care and are now off treatment.

Possible Obstacles

1. "In our family we've never told children about things like this. I just can't bear the thought of breaking the news to my daughter that she'll have to go through a very painful set of treatments."
   
   Response: Honesty is still the best course. Children will grow and mature emotionally and mentally if you treat them honestly. Care seems to go more easily and produce better results when a child knows in advance what's going to happen. If your family background, culture, or religion hasn't traditionally encouraged openness, talk it over with medical staff members. They may be able to direct you to a family with a similar background who has experienced this situation and could share how they handled it.
   
2. "My son may not make it and so I want to spend the time I have with him, and I don't want to feel guilty for having disciplined him."
   
   Response: Your son may indeed survive and if you spoil him now, you'll have far more work undoing this behavior in the future.
   
3. "I'm keeping things under control, but Melissa's grand-parents seem to want to give in to her all the time."
   
   Response: If you can't seem to get your relatives to treat your daughter normally, ask the staff to speak privately with the relatives to explain why giving in to your child's demands isn't healthy for her emotional growth. Hearing it from someone in authority may make an impact.

Carrying Out and Adjusting Your Plan

Is your child learning to do without your constant presence? If you've noticed behavior from an earlier age returning, is he or she gradually easing back to normal?

Consider medical staff members to be a resource, because they see children with cancer and parents interacting every day. The variety of personalities is endless, but they will have a good idea of what your child might need to help grow into a healthy state of emotional independence.

If your plan doesn't work

Review the sections When to get professional help and Dealing With Dependency to make sure you haven't overlooked anything. If your child still insists on behaving in a younger way, or if you feel that you've reached the end of your rope, call a doctor, nurse, hospital social worker, or counselor and get help.

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