As we become more educated in the field of health and illness, it is hoped that we will be more receptive to health information provided through science breakthrough, health educators in various fields, the mass media, magazines and newspapers.

A plethora of information is available in health promotion, measures of prevention and coping with illness. With this increased knowledge, disseminated to the public, it provides the power in taking control and being responsible for one's body in health and illness.

Parents expressed their distress when their children with cancer were not assisted on return to school, from this concern a special program was developed. This program received an award from the PA. Division of the American Cancer Society in two categories, i.e., professional education and rehabilitation.

The program was designed and presented to school nurses. It brought to their attention available information that may be used to initiate, plan and implement a "program" to assist teachers, parents and their children when they return to class post-cancer therapy.

The setting for teachers is one of education and not medical. This makes a major difference. Consequently, the teacher is confronted with the following realization that enhances the stress factor.

The teacher:

1. now has a child with a long-term illness.
2. needs to set goals according to the child's perception in relation to what is demanded by the change, i.e., nutrition, and activities?
3. must make a realistic assessment, i.e., teaching and interacting with the child who has cancer.

The question arises - Is the teacher able to cope with this child?

This is why we need to consider the stress factor in teachers. They may or may not have had the opportunity to express feelings in relation to death. The medical and nursing personnel have witnessed death, since they are in more contact with patients. This transition for nurses did not come without having to cope with stress. However, in the Hospital it may still be perceived as death because of patients with terminal cancer. Whereas, clients treated in an outpatient department may be perceived as having a chronic or long-term illness. So there is a difference in one's perception.

The teacher's environment is primarily educational therefore, there is a possibility that they would more likely associate cancer with death. Consequently, a child with cancer may be viewed as one with a limited future. Unknowingly, teachers may be harboring negative feelings toward death, which may be sensed by the child as non-verbal communication and may threaten the child's feeling of support in the classroom.

Teachers need assistance in becoming more aware of general and specific attitudes and emotional responses to death. They need to share their perception of death with their peers, school nurse or other to gain a realization of how children of different ages perceive death.

These children are very sensitive as to how they will be seen and will easily pick up non-verbal cues in the classroom as to negative or positive feelings expressed.

 At one of the schools, a teacher was taken back when a student came to class after receiving chemotherapy. How to deal with this child was foreign to her and not without some stress. It was recommended that she preview a video about leukemia, "WHY CHARLEY BROWN, WHY?" She showed the video in class, the child responded to questions from her classmates, they understood that it was not a contagious disease. The child was accepted by her peers who were also supportive and helpful. This was an interesting and rewarding experience to witness in the classroom, i.e., the interaction of the teacher, the child with leukemia and her classmates.

Children need reinforcement, that there is hope in their lives and they have much to achieve. It is important to emphasize that these children with a long-term illness must continue to develop, and progress in regaining health.

Hope must be instilled in them, and cherished to the utmost, so that they may experience meaningful behavior in the continuance of life.

1. Child will have regular visits with the physician. (Child will be absent at times.)
2. Parents have been informed about the child's diagnosis and course of therapy.
3. Provide information regarding effects of chemotherapy. Specific chemotherapy the child has or will receive.
4. Aware of available personnel, the school nurse or medical and nursing personnel at the hospital to answer questions for clarification.

This information may assure the teacher that the medical needs of the child are being met, and allows them to concentrate on the learning process, which is within their educational domain and expertise.

Food for thought is Ake Mattisons' description of long-term or chronic illness. He states that --chronicity is a condition spaced in time which may be progressive and fatal (Negative aspect) or may follow a relative normal life in spite of changes that involve periods of recurrences and remissions. (Positive aspect)

During childhood, a chronic deviation affects the child's physical and emotional development. This may not occur in an acute illness because it is short-lived.

A long-term illness imposes many life-threatening experiences such as:

1. Changes in body functions -stressful. What is happening to their body? For Example: - hair loss, moon face and other.
2. Hospital admission - They are removed from their loved ones. Who are all these strange people? They may be experiencing some painful treatments.
3. Dependency vs. Independency. They are unable to meet their own basic needs.
4. Emotional climate - they may be overprotected or resented by the family.
5. Threat of recurrence -not again. Classes and activities are interrupted again.

These are the life-threatening experiences they have coped with and still do. It is rather heart-breaking for a child to undergo such an experience.

However, many studies on long-term childhood illness reveal that with adequate assistance, support from their parents and others these children show a positive adjustment.

These children have functioned effectively at home, in school and with their peers with few limitations other than those imposed by the illness. Also they accept limitations, assume responsibility for their care and even assist in their medical management.

Any negative expression during recurrence or optimism during remission is a healthy balance showing control for both these feelings and earmarks well-adapted children with a chronic illness. This healthy balance is considered to be a sign of successful coping behavior, which results in adaptation, implying the person is functioning effectively. There is great hope for these children.

Following are some of the basic concerns at the Elementary, Jr. and H. S. Level.

Elementary and Jr. H.S.Level of School - It is essential for these children, when they return to the classroom, to be treated as students and not patients. In so doing, it will assist them to grow and develop with future goals in an educational environment, the same as their peers. Attendance and participation in class, allows the children some control over one phase of their lives.

This may be controversial, but it is believed that absenteeism and physical changes may be better explained by the children, provided they have been adequately prepared as to their condition by the health team. Rather than have the school nurse come to class and give a medical explanation, which then focuses on the children as patients. These students may change classes, have different teachers who need to know about their condition in order to assist them.

High School Level - At this level one is now dealing with teenagers who are more sensitive to social and peer pressures. Academic expectations are increased at this time. It is also a period when they are developing a sense of independence and responsibility and tend to challenge life in general. They are at a point where they are attempting to establish their self-identity only to find that they are more in need of their parents, which interferes with their independence and ability to grow and develop in the course of events and time. They need to be brought into the process of decision-making in relation to their program of studies, assignments and graduation, treated the same as their peers.

These are some thoughts on the family as expressed by Richard Burnham Jones.

For many years the family has established a pattern whereas each member shares responsibility as part of a whole unit. When a disruption of the family pattern occurs, stress invades each member which is expressed in different ways for each individual. Thomas Carlyle once said "Endurance is patience concentrated." These are some of the experiences the family has to endure and how much patience they need to cope with this long-term illness.

1. Other siblings may feel neglected and demand negative attention such as nightmares, bed wetting and poor school performance.
2. The sick child may misinterpret the illness and blame self for being disobedient or blame one of the other siblings if they had an argument. Because of these distorted ideas about body changes, they may hesitate to ask questions and continue their irrational fears as to their illness.
3. The family has difficulty in feeling comfortable and show concern in a long-term illness. Additional responsibility is imposed on each member. Robert Lewis Stevenson once wrote, "Life is not a matter of holding good cards, but of playing a poor hand well."

Parents need to understand the course of cancer and its implications, i.e., physical and emotional changes the child is experiencing and the therapy prescribed. An atmosphere of open communication and frank discussion of the illness hastens the coping process, consequently, they should be better able to mediate in the child's struggle during a long-term illness.

1. How to cope and deal with a long-term illness. Joining a support group would be helpful. In one situation, a child's mother was devastated and her husband withdrew when they learned of the diagnosis for their son.
2. Aware of the reaction of family members who become depressed, angry or anxious. These are normal responses which need to be dealt with.
3. Discuss with each family member, preparation for living with a sibling that has cancer.
4. Maintain a balance between the needs of the sick child and other siblings. The needs of one should not be continuously sacrificed for the needs of the others. For example, David's brother felt like a bag lady, every time David went to the hospital for treatment, his mother packed a bag and dropped him off.
5. Set up lines of communication with the school and the hospital as soon as possible for the following:

Plan a conference with the school nurse to share information.

Provide the school nurse with the following information, child's condition, therapy and period of absences.

Try to check with them, their knowledge of the disease and their feelings about it.

Maintain periodic conferences.

May request school to provide "Individualized Education Program."

In summary, one cannot overemphasize the value of communication. It is of the utmost importance that lines of communication be established for the interaction of the medical and nursing personnel, the teachers, the children with cancer and their parents.

The school nurse would be most helpful in the role of liaison in assisting these different groups especially, in helping the teachers so that they may feel comfortable and at ease in providing an educational environment for the children with cancer and enable them to participate in class as students on par with peers.

Also that parents share in this educational experience by providing the essential medical information to assist the school nurse and teachers for planning current and future conferences for the purpose of providing a forum to express and share their feelings as to the progress of these children with cancer.

" Every great man is always being helped by everybody, for his gift is to get good out of all things and all persons." -John Ruskin

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