Being told that you have cancer is a frightening experience.
Throw young children into the equation, and navigating the life-threatening illness often becomes more complex.
Parents who have been hit by the disease said one of their topmost concerns following their diagnosis is: "Should I tell the children?"
Mr Kelvin Choo, 50, chose not to share the news with his four children when he was battling advanced colon cancer in 2012 and 2013. As part of his treatment, the primary school teacher had surgery to remove 15cm of his large intestine and underwent chemotherapy.
His reason: At just two to seven years old then, his children were too young to understand the gravity of the situation.
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"My wife and I just told them that I was not feeling too good and needed some time to recover," said Mr Choo.
How to break the news to children
Cover the following basics:
• The type of cancer.
•Where the cancer is in the body.
• What will happen with treatment.
• How your child's life is expected to change.
Depending on your child's age, consider different approaches.
• Use age-appropriate words and short sentences. For example, say "medicine" instead of "chemotherapy". You may use the word "cancer" to explain that it is something that makes Mummy or Daddy sick.
• Prepare your child before your treatment, particularly if there will be changes in your physical appearance during treatment.
• Talk about changes at home. For example, you could say "Mummy is sick and needs more rest, so I have less time to play with you."
• Tell your child while in a safe environment, for instance, when your spouse and other significant family members (such as grandparents whom the child is close to) are present.
Primary school age
• At this age, your child can comprehend simple medical terms, so provide more details to help him understand the disease better. For example, explain what cancer is by using a simple analogy of a battle between "good cells"and "bad cells", and how having treatment will help you beat the bad cells that are making you ill. Consider using children's books.
• Share the information in parts, over time, so that he has time to digest it.
• After sharing, ask him how he feels about the news and if he has any queries. Establishing open communication helps children feel safe.
• Try not to tell only the older children. This may place a huge emotional burden on them.
• Sources: No One Walks Alone cancer care kit by Singapore Cancer Society (SCS); Jayne Leong, manager of psychosocial services at SCS; and Travis Loh and Saryna Ong, principal medical social workers from the division of psychosocial oncology at National Cancer Centre Singapore.
Another parent, Janice (not her real name), kept her condition a secret until a few weeks before her death. In her 40s, she did so to protect her only child from the horrors of the disease, which could not be contained despite aggressive treatment. But when she called her 10-year-old son to her bedside in the last weeks of her life, he rejected her.
By then, she had physically deteriorated so much that she was a shadow of her former self, said Ms Jayne Leong, manager of psychosocial services at the Singapore Cancer Society (SCS), which provided home hospice support to Janice's family.
Nobody told the boy or prepared him for it. The dying mother wanted her son to be near her. "But to the child, witnessing his mother's physical change must have been frightening," said Ms Leong.
Despite parents' good intentions of protecting their children, counsellors said hiding the disease beneath a shroud of secrecy can backfire.
This is because children, even the really young, are able to observe what is happening around them, said Mr Travis Loh, principal medical social worker from the psychosocial oncology division at National Cancer Centre, Singapore (NCCS).
Ms Saryna Ong, another medical social worker from the psychosocial oncology division, said: "Children can recognise that something is not right when their parents are sick."
When children are not given the right information, they become more frightened. In addition, said Ms Leong, trust may be broken if the children hear about the diagnosis from another person other than the parent himself.
Sharing information about the illness early - in an age-appropriate manner - opens the door for communication between parent and children. It also addresses any misconceptions the children may develop when they are being kept in the dark, added Mr Loh.
Ms Leong said that parents who want to protect the children do not realise that the youngsters need help to make sense of reality.
A case in point is Janice's son. In his naive 10-year-old mind, he had blamed himself for his mother's cancer. "He thought his mother was very sick because he was naughty. Children may think their parent's illness is their fault, when not given information and assurance," said Ms Leong.
BEING UPFRONT ABOUT ILLNESS
Senior enrolled nurse Zulfa Anas, 47, has seen first-hand the lasting regret secrecy can cause. She was diagnosed with a rare bone cancer in 2006 and has suffered two cancer relapses since then.
A mother of two boys aged 12 and nine, she said: "My friend did not tell her teenage sons she had cervical cancer until it was too late. At her wake, her children were so angry that they were not informed about her illness earlier.
"They also had a lot of regrets about not spending more time with their mum."
NCCS' Ms Ong said giving children appropriate and timely updates on their parents' disease helps minimise the shock they may experience if bad news is broken to them suddenly.
For that reason, Madam Zulfa has openly shared and involved her sons in her cancer journey.
She has even informed them who will take care of them, in the event that she dies.
"I don't want my kids to blame me or feel lost if I'm no longer around," she said. She is currently on maintenance treatment, in stable condition, but the doctor has not given her the all-clear.
Similarly, being upfront about her illness was a necessity for Madam Sandar Myint, 45, who is battling stage three breast cancer. Her three children are aged 14, nine and five.
Her husband, Mr Nay Myo Hun, 38, said: "They realised very early on that their mother was seriously sick when we took them along to the hospital for her treatments because no one else could care for them."
The illness has also affected the couple's finances. They had to explain why they could not afford many things when the new school term started. "I felt embarrassed telling the kids about our financial struggles, but it was necessary for them to understand," said Mr Nay Myo Hun.
While it may not always be possible, maintaining normalcy in your child's schedules will help him feel more secure.
Despite having no domestic help at home, Mr Choo and his wife, a 42-year-old insurance agent, tried to stick to their children's regular routines as much as possible.
They formed a tag team, working out a schedule to manage the children's routines, their work and his treatments.
"The only setback was not being able to take them out during my treatments," Mr Choo said.
But they made up for it by watching movies or playing educational games together at home. Mr Choo is currently cancer-free and does not need further treatment.
He eventually told his children about his brush with cancer, when the topic of death came up after his father died from prostate cancer last year.
"They are now older and at an age where they would ask many questions. We explained what cancer is, and they have also found out more information about the condition through the media," he said.
While telling your children about your illness is important, so is offering them ample support.
But for parents struggling to cope with their disease, that can be a huge challenge, said counsellors.
Ms Leong advises parents to rope in professional help - available at SCS and all restructured hospitals with a team of medical social workers - if they are unable or do not know how to do this.
They should also watch for changes in their children's behaviour - it may affect their academic performance, regular activities and mood.
"The ways children cope with difficulties in their lives can be very different from that of adults. They do not necessarily always verbally share their feelings and struggles," she said.
Hence, Mr Loh added, engaging them through non-verbal means, such as through play and art, can be more effective at times.
SCS and NCCS currently have support programmes in place to help children cope. About 100 children have gone through NCCS' art therapy and bereavement programmes.
Its medical social workers also provide counselling and psychosocial support to children affected by their parent's illness.
At SCS, the Help the Children and Youth programme has educational financial assistance schemes, free home tuition, and activities such as camps and family engagement programmes.
Through these day trips and activities, the family is brought together and experience what life was probably like before cancer.
Said Ms Leong: "Very often, families affected by cancer focus on the treatment plan and forget the need to have fun too."
Madam Zulfa and Mr Nay Myo Hun said sharing information with their little ones has its silver lining.
Mr Nay Myo Hun said his oldest child seems to have "grown up".
"He has become more understanding and proactive. Previously, he left all the household chores to his mother but, now, he helps out at mealtimes. He has also been working harder in school," he said.
Madam Zulfa said her illness has drawn the family closer.
"Every day, the children, especially my older boy, still tell me they love me very much before I leave for work," she said.
"Through this cancer journey, we have learnt to really treasure the time we have together as a family."