May 2006: Talking with Kids About Breast Cancer

No nipple construction negatively affects daughter?

Question from Serfi: I am a 34-year-old breast cancer survivor with a 5-year-old daughter. I have had mastectomy on both breasts and breast reconstruction, but I did not have the nipples constructed. I am pretty comfortable like this but my daughter is asking when I will have them back. Should I have them made just for her if she is negatively affected by this?

Answers —Paula Rauch, M.D.: What's important is that you yourself feel comfortable with your body and that you help your daughter to feel comfortable with your body too. Five-year-olds often have questions about people's differences—the color of their skin, the shapes of their bodies—so curiosity may be playing a part. I would recommend that you help her get comfortable with your breasts as they are now and as you feel comfortable with them.

Tamara Shulman, Ph.D., F.A.A.C.P.: I think children take a lot of cues from their parents and if the mom is comfortable with her decision, that will ultimately be conveyed to the child. As your child gets older, you may give explanations about what has happened and that would be appropriate for an older child. But a 5-year-old will respond to your comfort with your body. Questions are very normal.

8-year-old concerned about breast cancer?

Question from Marg: I have an 8-year-old daughter who worries that she too will have breast cancer. My mother is a 7-year survivor and I just completed chemotherapy two months ago. We both had mastectomies and she also worries that she will have to have her breast removed.

Answers —Tamara Shulman, Ph.D., F.A.A.C.P.: When there's a family history—a grandmother and a mother with breast cancer—it's normal for a child to ask questions. It's also pretty likely that you are worried about your daughter's risk. One of the best things you can do is reassure her that children do not get breast cancer. It's nothing she needs to worry about for herself now. Another thing that can be encouraging is to point out that the grownups have been taking good care of themselves and are getting well. Also let her know that the doctors are working on newer medicines and more ways to help women with breast cancer so it's not likely she will be affected by this. When she's older, there may be many other options to prevent and/or treat breast cancer.

Paula Rauch, M.D.: It may also be helpful to think about how you might answer another concern or worry that your child expresses that would affect her in adulthood. For example: worrying about wanting to live at home when she's in college, or worrying that she won't find the perfect partner. Sometimes when parents think about similar future-oriented questions but ones that aren't about cancer, it helps them think about how they might want to answer a question about cancer that might affect the child in the distant future.

Tamara Shulman, Ph.D., F.A.A.C.P.: That's a wonderful point. So often women with breast cancer can be concerned with questions their kids have, or nightmares due to the breast cancer situation. Sometimes things are a reaction to the parent being ill, but sometimes other children of similar age are having similar anxieties and as Dr. Rauch suggested, it's not only about breast cancer. There are many other things children can worry about.

Paula Rauch, M.D.: It's important that parents welcome their children's questions and worries so that a child isn't worrying alone. But at the same time, it may be important for the child to focus on current issues by reminding them that luckily they don't have to worry about breast cancer now, but it might be important to go to sleep on time because there's a spelling test tomorrow.

Tamara Shulman, Ph.D., F.A.A.C.P.: Sometimes if there is cancer in the family, there can be a conception with children that it can be "caught" and it can be a good time to clarify for a child that it's not something you can catch from someone and that nobody caught it from someone else in the family.

How to explain chemo, hair loss to daughter?

Question from Website Question: How can I explain chemotherapy to my 7-year-old daughter? What should I tell her about losing my hair?

Answer —Paula Rauch, M.D.: Often parents describe chemotherapy as a "special strong medicine" that kills the breast cancer cells. Because breast cancer cells can be fast growing cells, the same medicine can affect other fast growing cells, like the cells that make Mom's hair grow. One way to think about losing hair is that it's a reminder of what a good job the chemotherapy is doing.

Tell the kids without scaring them?

Question from ChelleL 37: I just found out I have Stage III breast cancer. My kids, age 2 and 5, sense something is really wrong, but I haven't found the words to tell them yet. How can I let them know without frightening them?

Answers —Tamara Shulman, Ph.D., F.A.A.C.P.: I think that children have a kind of emotional radar and of course they sense that the parent is upset. Young children may not even be able to verbalize what they're feeling, but they know there is something wrong. In this situation, it would be very important for you to get some emotional support for yourself to help you clarify and cope with your own feelings so that you can communicate more clearly and effectively with your young children. The 2-year-old may not have the complex language to understand a lot of verbal explanations, but can understand a simple explanation. I think it's important to use the word "cancer" when you're feeling a little calmer yourself. Talk to them about you having cancer, and that you have very good doctors and that you are going to have treatment for this. With children this age, the emotional tone is so important, as the complexities of diagnosis and treatment are not what they need. Kids are often very concerned about who will take care of them while Mom is having treatment. So let them know how Mom will get through the treatment and who will be taking care of them—taking them to school, making their meals, etc. It will help the children thrive to know their needs will be met. That will be reassuring for them. I see it as very important in this situation for you to get a lot of emotional support as well.

Paula Rauch, M.D.: One of the things that helps young children to feel their life continues to be safe and secure is maintaining regular routines and schedules. It's easy to make errors of kindness at times like these and let young children stay up later, have too many choices at meals, or offer them lots of toys and treats. But actually young children feel reassured by predictable and structured environments. Paying attention to regular mealtime and bedtime and organizing a familiar support system is really important.

No energy, attention to give to children?

Question from Franco's Mom: I'm going through chemotherapy and the fatigue makes it a struggle to always be there for my children. My 10-year-old son is going through a hard time in his math class right now. I don't have the energy to help him or give him attention. What can I do?

Answers —Tamara Shulman, Ph.D., F.A.A.C.P.: It's a healthy sign that your son is worrying about math and wanting to do well in his math class! One way to deal with the natural fatigue that comes with chemotherapy is to think of a good support system for the child which in this case might be concrete help in math from a family member or friend or a student from the local high school who can be energetic and enthusiastic about math. What you can offer Franco is your support and interest in his progress in math and his accomplishments, to let him know you're glad he's trying so hard and asking him perhaps to show you when he's completed a set of problems. That way, you can be supportive of his work in math without having to be the hands-on person who's actually helping him master the material.

Paula Rauch, M.D.: One of the signs of a good parent is getting help. None of us can support every part of our child's healthy development, and some of us may be able to manage grade school math but not junior high or high school math. It's important to see if there's someone in your support system who can help you think about which of the caring adults in your life and the life of your child can be helpful with different particular challenges that you're facing as a family. We sometimes talk about the person who organizes the different ways that friends can be helpful as a "Captain of Kindnesses." That person can be someone to whom you can say, "Gee, it would be great if there was someone to help my son with math" and there may be a friend or a friend's kid who might sit with your child at a helpful website that can assist with math, for instance. It's just one example of the people and practical resources that brainstorming in a community can provide.

Home busy with support frustrating kids?

Question from Lorraine NY: Our house is like Grand Central Station since I had surgery. Friends call or come over for several hours during the day, etc. I need my friends' support but sometimes it almost seems like my children don't appreciate it. I would think they'd be glad Mom is getting some outside support, but maybe my kids are trying to tell me that they want to be the ones taking on this role? Please help me understand this; thanks.

Answers —Tamara Shulman, Ph.D., F.A.A.C.P.: It can certainly feel busy with family and friends visiting. Part of the issue for children is that it's very disruptive of the family routine and children thrive on routine. They're giving you a strong message that they need things to quiet down for them. They may also need more family time to talk and relax with their parents when they're not surrounded by people. A nice way to handle this situation is to think in terms of scheduling the visits etc. in a way that's more manageable. Choosing one weekend day as a family day, and perhaps a couple of evenings during the week as family time, and making the kids aware of this, can be very helpful. Of course, if someone is coordinating things, they can let people know when company is welcome and when the family needs some close quiet family time.

Paula Rauch, M.D.: It's very common for children to complain about the well-wishers and adult support that comes to the house. It's a sensitive issue of how to balance the mom's need for support from her friends along with a child's wish to have things feel more familiar, which includes having fewer guests in the house. Some families, as Dr. Shulman said, will have, for example, Sundays and Tuesdays as family-only days. Others will designate the hours from after school until bedtime as times when they encourage friends not to call so the focus then can really be on the children. It's hard for a child to recognize the kind of support that a parent needs when she's sick because they may be accustomed to their mom needing less support and being more available to them during all the years she was well.

Help to convince kids to keep up chores?

Question from Dust Bunnies: Since I was diagnosed, the family chores have really hit the wall. It's hard to convince my young ones that their rooms still need to be picked up, trash emptied, etc. even though Mom is sick. How can I gently explain this without sounding harsh? Thanks.

Answers —Paula Rauch, M.D.: One of the most common complaints that parents have (and all the more so the older the children), is the feeling that in the context of Mom's illness, the children aren't stepping up to the plate to do more family household chores. It's good training to help kids to take responsibility, but many parents find it takes more energy to get the kids to do those chores than sometimes to do them yourself or have another grownup do them. Having charts and lists that your child can check off his/her daily chores can help some. But if it's any comfort, know that many parents, sick and well, are struggling with that same frustration—that it's hard to get kids to pay attention to dust bunnies.

Tamara Shulman, Ph.D., F.A.A.C.P.: Sometimes it can be really helpful to sit down in a family meeting format to talk about what's going on, what's the plan, what's expected, etc. Kids like to have choices inasmuch as they need structure. Picking up their own things might be a given, but maybe they could negotiate the other household chores so they have input into what they are choosing to do. That said, as Dr. Rauch said, many kids are sometimes forgetful or resistant to doing household chores. Sometimes if it's practical, this is an area where a family may try to get some additional help or support so children are not burdened at this time with a lot of additional chores they don't normally do. Hiring someone, or getting volunteers in the support community, may be a good idea. This may be a time when kids are reassured by normal expectations of taking care of their own things. It may also be a time for a mom who has always been neat and in control to find a way for things to slide a bit. The fatigue won't last forever.

Worried about kids' reactions toward treatment?

Question from Mom Of Two: Hello everyone. I just had a mastectomy for stage IIIB and am about to start chemo. I'm really a bit nervous. I'm also worried about my two kids. My son is 14 and really not saying much about any of it. Sometimes he even has an attitude, which I find shocking considering what's going on. My daughter is 12 and she's more open, but I feel like she talks about my situation to family friends more than she talks to me.

Answer —Paula Rauch, M.D.: It's important to check in and try to understand what's going on with each of your two different children. You may want to think about the time of the day or days of the week when each of them is most likely to have a good conversation with you. For some children that might be bedtime; for others, a drive in the car, or when the parent is cooking or doing dishes. Let both of your children know that you don't want them to worry alone and you're interested in what they're thinking if they want to share it with you. It's not uncommon for adolescent boys to be less comfortable talking about most anything. When it's something emotional they may be even more uncomfortable, and for many boys talking about their mother's breasts is especially uncomfortable for them. Sometimes other forms of communication—an email, note, responsive journal—can open the lines of communication. Be kind to yourself, too. No matter how hard we try, some children may really only listen and not talk very much. Even if your child isn't talking, it's important that he and she know that if they wanted to talk, you'd be interested in hearing what they're feeling.

Talking to kids about end of life?

Question from Carl H: My wife has Stage IV with bone metastases and we are preparing for the end of her life. She has worked amazingly hard to stay upbeat, but it's really tough for me to hide my own anguish and I'm very worried about our kids. They are 12 and 14, both boys. I just don't know what to do or say to help them. I can tell that it tears them apart to see me cry.

Answers —Paula Rauch, M.D.: Your boys are lucky to have a father who loves their mother so much. It is hard to hide sadness when someone you love is approaching the end of her life. Still, there may be a lot of important and life-affirming family time between now and the end of your wife's life. If your wife is still well enough to be engaged with your sons and be enjoying their accomplishments and activities, you want to work together to try to make this next period of time as meaningful as possible. You need to have optimism about the future for your sons and for yourself, including being able to carry the love that you all share for your wife in your hearts even after she's gone. If you are afraid about the future without her, it's important for you to get help now so that you can be the loving and life-affirming guide you want to be for your children into the future.

Tamara Shulman, Ph.D., F.A.A.C.P.: I concur that finding a way to spend time together if your wife is still up to it is very important. Letting the boys know that anything they would like to share with their mother about their feelings, their daily lives, their experiences and thoughts are things she would like to hear. Keeping a sense of family connectedness through this process can be very important. Each child is different in terms of their temperament and ability to be involved with a seriously ill parent who is dying. It's important to try to check in with each child in some way and find a place that is comfortable for that child. For example, one child may be comfortable with a bedside visit; another may wish to send a note or email or stay in touch in other ways. However, it's very important for each child to find a way to stay connected with their mother through this process and to plan ways to remember her so they know their feelings for their mother will live on even after she's gone.

Paula Rauch, M.D.: It's important that you not be afraid of expressing your honest and heartfelt emotion. It's not dangerous to your boys for them to see that you feel deeply sad about their mother's advancing illness and, to the extent that they fully understand it, her approaching death. What they do need to know is that the fact that you sometimes cry doesn't mean that you'll be crying forever and continuously, but rather that the feelings are so big that sometimes they overflow and that you feel better after you've cried. Or that there are times you let out your feelings in other ways—by exercising or cooking—so kids know feelings are strong at some times, and not so strong at others. What's most frightening for kids is the idea that a parent is just going to get more and more and more upset and that they could lose them in that sadness.

Tamara Shulman, Ph.D., F.A.A.C.P.: Seeing a range of feelings expressed by their father may indirectly allow the boys more freedom to express their own feelings about their mother's illness.

Worried children aren't asking questions?

Question from Karen: I told my children, ages 9 and 11, that I have breast cancer. They have never asked any questions since. I don't know if I should talk to them more or not?

Answers —Paula Rauch, M.D.: Parents are often worried when children aren't asking questions, and it is reasonable to wonder, "Does my child have questions that he/she is afraid to ask, or does my child feel comfortable and not have any additional questions that he/she wants to ask?" It can be helpful to check in at a quiet time with your children and ask them if they have any questions. Sometimes when a child says no, you can come at the question from another angle and say something like, "What do you notice that's different around here?" or "Have you overheard anyone talking about my cancer?" or "Did anyone say anything that was confusing?" Some parents of older children will ask, "What's the dumbest thing that anyone's said about my cancer?" Some children who won't talk otherwise will be quite free to answer this question, and that will begin a conversation. If after checking in with your children they don't express any concerns, think about how the rest of their lives are going. How is your child doing in school? How is he/she doing with friends? Are they eating and sleeping well? Do they seem themselves around the house? If the answer to all those questions is yes, you should feel good about how your child is doing and just reiterate one more time that if they have things they want to talk about, you have time to listen.

Tamara Shulman, Ph.D., F.A.A.C.P.: If the answer to those questions about how they're doing is no, and there's an indication that they're distressed, it may be an idea to seek an outside consultation with a mental health professional experienced in this area just to get an objective and professional look at what's going on. Adolescents and pre-adolescents have issues and concerns that express themselves in all sorts of ways, whether a parent is ill or not. This may have nothing to do with your illness, but it's reassuring to find out if there are areas of concern so that the children get help in those areas.

Should daughter know about diagnosis?

Question from MIL: I was diagnosed with DCIS. This may not sound like much, but my husband doesn't want to tell my daughter about it. I think it's important for her to know, but he says it'll just upset her. Any advice welcome. Thanks.

Answers —Tamara Shulman, Ph.D., F.A.A.C.P.: DCIS is breast cancer. You are clearly feeling that you want your daughter to be aware of it in some way, not to upset her, but to inform her. You don't mention her age, and what children need to know varies enormously by their age. Give her a clear label for the disease: breast cancer, along with a reassuring explanation that this is a very treatable breast cancer and that Mom will have some treatment and in all probability will be fine. I think you are being very caring and concerned that your daughter hear what's going on directly from you. Dad isn't comfortable talking about it, and that's important because children pick up on the emotional tone of the home. While your husband may want to protect your daughter from this diagnosis, she will still sense that her parents are anxious and something is afoot, whether it's phone calls or whispering. What children imagine is going on is often more distressing than a simple age-appropriate explanation of what is actually going on. It may initially seem more stressful and difficult, but is ultimately more reassuring for the child, not only for the immediate situation, but also so they know that they can trust their parents.

Paula Rauch, M.D.: It's not uncommon for parents to disagree about how much or how little to tell a child. I encourage parents to approach talking about breast cancer as part of the family value of being honest, of hopefully making it a model in the family for sharing even difficult news with each other. I've learned from some families that when parents withhold difficult truths from their children, when their children are teenagers they feel they've been given permission not to share difficult truths with their parents, i.e., that there was no parent home at a party or that alcohol or drugs were involved. It's a complicated message in a family to say, "If this is too hard to hear, we cannot share this piece of information." If this is an unusual situation between you and your husband in terms of the approach that each of you would like to take about communicating this, even one visit with one of the social workers or psychologists or psychiatrists at the cancer center where you're being treated can help put the two of you on the same page. If this is an ongoing difference, the parents may benefit from ongoing support from a professional. It's so important to work hard on the communication between parents when there's the stress of illness in the family, and you and your children deserve the extra help.

Where to find support groups for children?

Question from Gaia: Are support groups for children of breast cancer patients a good idea? How would I find one?

Answers —Paula Rauch, M.D.: In the greater Boston area where I practice, there are opportunities for children whose parents have cancer to meet. Our experience has been that a surprisingly small number of children choose to attend these groups. It seems that most children don't identify themselves as being children of mothers with breast cancer; they identify themselves as being boys who like baseball, girls who like gymnastics, or kids who like to swim. No matter how interesting, engaging and wonderful the activities are at these groups, most kids are reluctant to give up after school or weekend time. Our experience has been that parents are much more eager to meet with each other and talk about their experiences as parents than kids are interested in attending support groups. But certainly there's no one-size-fits-all. Whatever the resources are in your community, you may be able to access them by contacting the nearest large cancer center and asking an oncology social worker about what is available.

Tamara Shulman, Ph.D., F.A.A.C.P.: An alternative to involving the child in a support group is sharing with your children the information that you are part of a support group for other women with breast cancer and that many of them have children around the ages of your own children. I think this can be useful in letting children know that other children are experiencing this because it's not something that kids typically talk about. They may confide in close friends, or they may not. They may feel they're the only child whose mother has breast cancer so it can sometimes be reassuring for the child to know they're not the only one and that there is a possibility of talking with other people the way their mom does, if that would be helpful. It also puts the idea forward that people can get support and help with problems by talking about them with other people, which is indirectly modeled for the children when the parents tell them they're getting support themselves. It's a non-pressure way to let the kids know they can get support if they need it, and that other kids are going through this as well.

Tell grandson in fragile condition about diagnosis?

Question from Treesa: I take care of my 7-year-old grandson. His 3-year-old sister is very sick and only may live for a few more years. How do I tell him I have breast cancer? He is so afraid something will happen to me, and his mother is at the hospital most of the time.

Answer —Paula Rauch, M.D.: Your family is living with an enormous amount of distress, and it's easy to understand why your grandson feels worried. It's probably still best to let him know that you're getting treatment if that's the case. Someone as sensitive as he is likely to guess, and it will be harder for him to discover this news. Overhearing bad news or learning it indirectly is the hardest way to learn it. You haven't shared with us your prognosis, but if your prognosis is good and you're going to be able to continue to provide care to him, though he is likely to be worried at the time of this news, demonstrating that you can continue to spend time with him and care about him is likely to help him to feel reassured. At the same time, you want to remind him of all the adults in his life who love him, and help him to feel that the group of adults who love him is broad and deep. You and his mom may need to sit down and discuss how to increase your support system so that your grandson feels more comfortable with some additional important adults.

Good idea to videotape feelings and wishes?

Question from Maggie J: I've heard about others videotaping their feelings and wishes for their children. Do you think that this is a good idea for the future?

Answers —Paula Rauch, M.D.: I hope that you will be around for a long time to tell your children all the things that you love about them. But for moms who may not be, what we learned from interviewing adults who had a parent die of cancer when they were 12 or younger is that they wish they had a communication—usually they spoke of letters—where the parents expressed both what they saw that was special in the child and what they loved best about parenting that child. Many parents that I've worked with over the years find talking into a video camera hard to do, whereas writing a letter is a bit easier, and videotaping family events is easier as well. Sometimes in the context of a family event—Thanksgiving, a child's birthday—you can ask the people assembled to answer those questions: what is special in each of the children, and what you love best about parenting him/her. Or, with no script at all, just provide the video or DVD record of those happy family events.

Tamara Shulman, Ph.D., F.A.A.C.P.: I've known parents who have left letters to be opened at milestones in the child's life—graduations, weddings. That way they can leave for children who may be too young now to understand, something that can be understood later on. I think the parents who have done this have described it as a valuable emotional experience for them, and while I have no way of knowing how the child feels when getting these letters later in life, a thoughtful letter from a parent who is no longer with them might well be something that would be treasured.

Paula Rauch, M.D.: Even if the parent is alive and well when the child reads such a letter, my guess is that it would still be wonderful and special.

Is anger about cancer affecting children?

Question from Kryton: I am so angry about having cancer that I could just scream, and sometimes I do just scream. It's usually in the car, away from the children, but I fear that some of this is getting through to them. What can I do about this?

Answer —Paula Rauch, M.D.: It's natural to have a wide range of feelings about having breast cancer and anger is certainly a very common and understandable one. If you feel like the anger is just too difficult for you to vent, and that it may be leaking out in other places and may be negatively affecting your children, it's important to get some help from a counselor and to think of activities and other outlets that help you to feel more comfortable in yourself. I admire you for being honest about this. It's often hard for people to be honest about anger, and being honest about those feelings is the first step to finding ways to feel more comfortable in your own skin.

Is it okay to bring kids to chemo session?

Question from Karen: Is it a good idea to take your children (ages 9 and 11) to a chemotherapy session or not?

Answers —Paula Rauch, M.D.: It depends on whether they want to go. If the child expresses an interest in visiting the hospital, and if it's even possible to do so, it may demystify the experience. Sometimes a chemotherapy visit is too long and you just may not feel up to having the children present for the entire time unless you have another adult present who can take them to do other activities. Some parents will take their children if they're having bloodwork or another short appointment. For others whose children are interested in the hospital but don't necessarily want to see an appointment, take photographs—nurses, your physician, the front desk people—and have a conversation using those illustrations.

Tamara Shulman, Ph.D., F.A.A.C.P.: When a child asks to attend a chemotherapy session, one thing I wonder about is what information they are actually seeking. It may be very helpful to ask what they're curious about. By demystifying the experience and giving them some information—what actually happens, how long it lasts, what it looks like, etc.—that may satisfy the natural curiosity those questions are expressing. Some children may wish to see the setting, and it might be an idea to take them to see the area of the hospital when you're not having chemotherapy. Very often when children ask if they can see a treatment, what they're really asking for is more information about the treatment. They're worried about what Mom does all day and then comes home and is tired. Giving that kind of information is helpful and reassuring.

Communicate situation to kids, grandkids?

Question from Maryanne: Fortunately my kids are grown, but what should I be aware of so I can help them and my grandkids (8 and 13) deal with Grandma having breast cancer? We see them at least every week, so it's not something I can just pretend isn't happening.

Answers —Paula Rauch, M.D.: The same open communication that I would encourage between parents and children about a parent's cancer, I would encourage with respect to a grandmother's breast cancer. I do think your children need to be in the position to set the tone for the conversation they wish to have with their own children about your breast cancer. You can let your adult children know that you'd be comfortable answering any questions from your grandchildren, or facilitating conversation about it. But you don't want to set up tension between you and your adult children about how much and when to share information. Usually when your relationship is comfortable with your adult children and you're comfortable with them, they'll be the ones who want to have the first conversation with their own children and you can support those interactions. Your adult children will be in the best position to notice if their own children are having difficulties of any sort, including having worries, difficulties sleeping, problems at school, etc. My experience is that if the adult children are handling a grandmother's cancer with some comfort, the grandchildren will too.

Tamara Shulman, Ph.D., F.A.A.C.P.: With a parent, the children are seeing the parent daily and there is lot of contact. With grandchildren, the kids may feel they want to help and contribute something. If there is that kind of concern and interest on the part of the grandchildren, I think a simple suggestion that a drawing they've done might be cheerful for Grandma to hang in her room, or a story about what the child is involved in, or a phone call from the child about their baseball game or a movie they just saw—anything at all can be quite helpful in allowing the child to feel they can be connected with their grandmother in between their weekly visits at a time when they may be more concerned about her than usual.

Ex-wife's cancer causing son to be clingy?

Question from Jazzfan: My son has become really clingy since my ex-wife was diagnosed with breast cancer. We share custody, and he's saying he doesn't want to go back to her house when his weeks with me end. I want to do what's best for him and for my ex, but I just don't know what that is. Any advice?

Answer —Paula Rauch, M.D.: This is hard to answer without knowing more about your son's age and the issues surrounding his moving back and forth from home to home. If the transition of going from house to house was proceeding pretty easily and calmly prior to your ex-wife's diagnosis, it is reasonable to wonder whether the likely additional stress and distress in the house is being picked up by your son. If the environment at his mother's house continues to be calm and loving, it is important to support the continuing custody and living arrangements. If you and your child's mother are able to co-parent around this difficult issue, it would be great if you could brainstorm together about what he may be reacting to. For many divorced couples, this just doesn't feel possible to do without additional professional support. If that's the case, I would encourage you to seek help in order to support your son and his relationship with both his parents during this difficult time.

Wise to send kids off while recovering?

Question from JCH: My young kids, 5 and 8, did fine with my first two lumpectomies. Now that I need a mastectomy, I am considering sending them to Grandma's for the first few days to have fun while I deal with drains. Does this sound wise?

Answers —Tamara Shulman, Ph.D., F.A.A.C.P.: It sounds as if you shared the information about your lumpectomies with your children and they handled the information well. It's important to maintain the same open approach with your mastectomy and present it in an optimistic and positive way as something you do to take care of yourself at this point. However, while it's very important that they be informed and know what to expect, it may also be helpful for them to be in the most comfortable secure environment that you can provide if you're going to be in hospital for a few days. A visit to the grandparents may well be a realistic and helpful solution for the entire family. I would really separate the issue of what to communicate about the situation because I think letting children know what's going on is important, so give them permission to enjoy a visit with their grandparents while you recuperate. Doing fun things may work well for everyone depending on your particular family situation.

Paula Rauch, M.D.: It sounds like you and your children have had good preparation for this surgery by having experienced your two prior smaller surgeries. That may make it easier for your children and you to anticipate a good setting for your recuperation. Let your children know why you think it's a good idea, then be open to reconsider the plan if you're surprised by one of your children being upset by the plan or even after you explore what that concern might be about. But my guess is that your children will be happy with the plan you have in mind.