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\begin{document}

\title{Effect of Time on Quality of Parent-Child Communication in Pediatric
Cancer}



\author[1]{Brittany Cowfer}%
\author[2]{Mary Dietrich}%
\author[2]{Terrah Akard}%
\affil[1]{Vanderbilt University Medical Center}%
\affil[2]{Vanderbilt University School of Nursing}%


\vspace{-1em}



  
  \date{May 08, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Background A diagnosis of childhood cancer results in new parent-child
communication challenges. Little is known about how communication
changes over time after diagnosis or relapse. The objective of this
study was to determine the effect of time since diagnosis and relapse on
quality of parent-child communication. We hypothesized that there would
be a positive correlation between time and quality of parent-child
communication. Methods Cross-sectional study in children (7 to 17 years)
with relapsed/refractory cancer and their caregivers, who spoke English,
were not cognitively impaired, and had internet access. Parents were
recruited through Facebook ads. Parents and children completed the
Parent-Adolescent Communication Scale (PACS), a 20-item measure of
communication quality, with openness and problem subscales. Spearman's
Rho coefficients assessed correlations between PACS scores and time
since diagnosis/relapse. Results There was a statistically significant
negative correlation between parent PACS scores and time since child's
cancer diagnosis (Spearman's Rho = - 0.21, p = 0.02), indicating a
tendency for overall worsening communication as time since diagnosis
increased. There was a positive correlation between the parent PACS
problem scores and time since diagnosis (Spearman's Rho = + 0.22, p =
0.01), indicating more problematic communication as time since diagnosis
increased. Correlations of time since relapse and PACS scores were small
and not statistically significant. Conclusion Parent-child communication
worsens over time following a child's cancer diagnosis with more
communication problems, contrary to our hypothesis. Future studies are
needed to evaluate intervention timing to best support parent-child
communication beyond the new diagnosis period.%
\end{abstract}%



\sloppy


\textbf{Effect of Time on Quality of Parent-Child Communication in
Pediatric Cancer}

Brittany A. Cowfer\textsuperscript{a}, MD, Mary S.
Dietrich\textsuperscript{b}, MS, PhD, Terrah Foster
Akard\textsuperscript{b}, PhD, RN, CPNP, FAAN

\textbf{Affiliations} : \textsuperscript{a}Vanderbilt University Medical
Center and Monroe Carell Jr. Children's Hospital at Vanderbilt,
Nashville, TN; and \textsuperscript{b}Vanderbilt University Schools of
Nursing and Medicine, Nashville, TN

\textbf{Address Correspondence to:} Brittany Cowfer, MD, Monroe Carell
Jr. Children's Hospital at Vanderbilt, Pediatric Hematology/Oncology,
2220 Pierce Ave., PRB 397, Nashville, TN 37232.
Brittany.cowfer@vumc.org. Phone: 615-943-2908. Fax: 615-875-1478.

\textbf{Abstract word count:} 247

\textbf{Main text word count:} 2224

\textbf{Additional files:} 2 tables

\textbf{Short title:} Parent-Child Communication in Pediatric Cancer

\textbf{Key words:} Pediatric oncology, psychosocial, palliative care,
parent-child communication

\textbf{Abbreviations} :\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
NIH & \emph{National Institutes of Health}\tabularnewline
\midrule
\endhead
PACS & Parent-Adolescent Communication Scale\tabularnewline
IQR & Interquartile Range\tabularnewline
IRB & Institutional Review Board\tabularnewline
\emph{r\textsubscript{s}} & Spearman's rho\tabularnewline
\bottomrule
\end{longtable}

\textbf{Abstract}

\textbf{Background}

A diagnosis of childhood cancer results in new parent-child
communication challenges. Little is known about how communication
changes over time after diagnosis or relapse. The objective of this
study was to determine the effect of time since diagnosis and relapse on
quality of parent-child communication. We hypothesized that there would
be a positive correlation between time and quality of parent-child
communication.

\textbf{Methods}

Cross-sectional study in children (7 to 17 years) with
relapsed/refractory cancer and their caregivers, who spoke English, were
not cognitively impaired, and had internet access. Parents were
recruited through Facebook ads. Parents and children completed the
Parent-Adolescent Communication Scale (PACS), a 20-item measure of
communication quality, with openness and problem subscales. Spearman's
Rho coefficients assessed correlations between PACS scores and time
since diagnosis/relapse.

\textbf{Results}

There was a statistically significant negative correlation between
parent PACS scores and time since child's cancer diagnosis (Spearman's
Rho = - 0.21, p = 0.02), indicating a tendency for overall worsening
communication as time since diagnosis increased. There was a positive
correlation between the parent PACS problem scores and time since
diagnosis (Spearman's Rho = + 0.22, p = 0.01), indicating more
problematic communication as time since diagnosis increased.
Correlations of time since relapse and PACS scores were small and not
statistically significant.

\textbf{Conclusion}

Parent-child communication worsens over time following a child's cancer
diagnosis with more communication problems, contrary to our hypothesis.
Future studies are needed to evaluate intervention timing to best
support parent-child communication beyond the new diagnosis period.

\textbf{Introduction}

Approximately 16 850 children and adolescents will be newly diagnosed
with cancer in 2020.\textsuperscript{1} While five-year childhood cancer
survival rates have improved to 85\%,\textsuperscript{1} cancer remains
the leading cause of disease-related death for children in the United
States, with 1730 deaths expected in 2020.\textsuperscript{1} The stress
of childhood cancer often challenges parents' decision-making, time
management, coping, and communication, resulting in burden on parental
mental health.\textsuperscript{2} Parental distress has been shown to
negatively impact parent-child communication,\textsuperscript{3--5} and
ineffective and harsh communication has been correlated with psychologic
problems in children with cancer.\textsuperscript{5,6}

Parents have identified barriers to open and honest
communication,\textsuperscript{7} including desires to protect ill
children from fear or other unpleasant
emotions,\textsuperscript{8--12}perceptions of inappropriately burdening
children,\textsuperscript{13,14} concerns that children would lose trust
in them,\textsuperscript{11} fear of children's
reactions,\textsuperscript{8,15} feeling too
overwhelmed,\textsuperscript{12,13} and lack of confidence in
communicating.\textsuperscript{8,13} Some parents have perceived that
children were too young to understand,\textsuperscript{8} already knew
so did not need to communicate,\textsuperscript{8} or lacked the desire
to communicate.\textsuperscript{8,14} Consequently, the majority of
parents of children terminally ill with cancer have avoided discussions
with their child about potential death.\textsuperscript{8,16} About a
quarter of those parents later regretted not telling their child, more
commonly if they sensed their child was aware of their impending
death.\textsuperscript{16} Despite ill children's frequent awareness,
many children avoid communicating about death to protect their
parents.\textsuperscript{10} Parents and children with cancer may also
engage in mutual pretense, when they both know the
difficult-to-acknowledge truth about the child's terminal prognosis but
pretend as though they do not.\textsuperscript{8,17} This means of
interacting is often set by parents' lack of openness in disease-related
communication with their child.

Despite these challenges, communication between parents and children
with cancer is crucial and has numerous benefits. The National Cancer
Institute recommends that parents communicate openly and honestly with
ill children about their cancer diagnosis.\textsuperscript{18} Young
children value their family in helping them communicate with providers
and often feel anxious when information about their disease is
withheld.\textsuperscript{19} Supportive rather than invalidating
parental communication has resulted in less pain and distress in
children undergoing procedures, such as port access or lumbar
puncture.\textsuperscript{20} In children with incurable cancer, parents
have cited that communicating with their child about death allowed for
parents to address fears, gave the child the opportunity to help plan
their funeral, and resulted in stronger family
relationships.\textsuperscript{8} Parents are motivated to communicate
openly with their child when they feel it helps protect their child from
fear,\textsuperscript{10} facilitates coping,\textsuperscript{14,21} or
allows their child to be involved in
decision-making.\textsuperscript{14,15} Many parents want to avoid lying
and maintain their child's
trust.\textsuperscript{9,12,15}Child-initiated conversations about their
disease or death have facilitated more open parent-child
communication.\textsuperscript{21,22}Studies have shown that parents may
communicate because they feel it is difficult to hide
information\textsuperscript{15} and are more likely to communicate with
older rather than younger children.\textsuperscript{12,15}

Despite these advances in research related to parent-child communication
in pediatric oncology, minimal data exist for how parent-child
communication changes over time throughout the illness trajectory.
Specifically, initial diagnosis or relapse may be milestone timepoints
that create challenges for parent-child communication. While parents may
communicate more openly with older children,\textsuperscript{12,15} and
children often prefer to know more about their disease over
time,\textsuperscript{23} children's communication preferences may vary
at different points in their illness
journey,\textsuperscript{12,23}which may affect the quality and amount
of information exchange between parents and children. The purpose of
this study was to determine the effect of time since childhood cancer
diagnosis and relapse on quality of parent-child communication. We
hypothesized that there would be a positive correlation between time and
quality of parent-child communication.

\textbf{Methods}

This study was a secondary analysis of data collected as a part of a
randomized controlled trial examining the effects of a legacy
intervention for children with advanced cancer and their
parents.\textsuperscript{24} After obtaining Institutional Review Board
approval, parents of children with cancer were recruited between 2015
and 2018 through the use of Facebook advertisements. Advertisements
targeted parents in the United States who had ``liked'' or ``followed''
other childhood cancer-related Facebook pages. Advertisements included a
REDCap (a secure online software for the development and analysis of
research data)\textsuperscript{25,26} survey link which described the
study and asked basic screening questions, followed by a prompt for
demographic and contact information. Study personnel contacted
interested individuals within a week to discuss the study further.
Eligibility criteria included children diagnosed with relapsed or
refractory cancer aged 7 to 17 years and their primary parent caregivers
(aged 18 or older) who were fluent in English, without cognitive
impairment, and had internet access. The study coordinator obtained
verbal parent consent and child assent. Written consent was waived per
the IRB. Child-parent dyads were randomized 1:1 to a usual care or
intervention group.

After consent, parents completed a demographic survey, including dates
of diagnosis and relapse, if applicable. In addition to baseline (T1)
and post-intervention (T2) measures of child quality of life and child
and parent coping, children and parents completed the Parent-Adolescent
Communication Scale (PACS)\textsuperscript{27} via REDCap to assess
parent-child communication. The 20-item PACS consists of two subscales,
openness of and problems in communication, prompting participants to
select their rating on a 5-point Likert scale from ``strongly disagree''
to ``strongly agree.'' Higher scores for the openness subscale and lower
scores for problem subscale suggested higher quality of communication.
An overall communication score is then derived, with higher scores
indicating better communication. Children were asked to complete the
measure twice -- once regarding communication with their mother and
again regarding communication with their father. Parent participants
completed the questionaire about communication with their child with
cancer. Cross-sectional baseline demographic and PACS data from T1 only
were included in this secondary analysis.

Data were analyzed using IBM SPSS Statistics Version 27. Frequency
distributions were used to summarize the nominal and ordinal variables.
Due to skewness, median and interquartile range (IQR) were used to
summarize the continuous variables of age, time since diagnosis/relapse,
and the PACS scores. Spearman's Rho coefficients assessed the
correlations between the PACS scores and time since diagnosis/relapse.
Statistical significance was determined by an alpha of 0.05 (p
\textless{} 0.05).

\textbf{Results}

Of 273 screened parent-child dyads, 150 dyads enrolled in the study.
Dyads that completed T1 with information for time since diagnosis were
included in the sample for this secondary analysis (\emph{N =} 132).
Summaries of the children and caregivers included in the analyses are
shown in Table I. Children were a median 10.0 years old (IQR = 8, 13). A
majority of the children and caregivers were White (85\% and 92\%
respectively). Approximately 54\% of the children were female and a
majority of the caregivers were female (92\%). Children were a median
4.1 years from diagnosis (IQR = 1.8, 6.2). Ninety-two (70\%) children
had experienced a disease relapse and 40 (30\%) had refractory disease.

Summaries of the PACS scores and their correlations with time since
diagnosis and relapse are shown in Table II. Most of the children
completed the PACS describing communication with their mothers (n = 129
of 132, 98\%), while only 61\% (n = 81 of 132) completed the respective
measures about their fathers.

There was a statistically significant inverse (negative) correlation
between the parental overall PACS scores and the number of years since
their child had been diagnosed with cancer (\emph{r\textsubscript{s}} =
- 0.21, p = 0.02, Table 2) describing a tendency for overall
communication scores to decrease as the time since diagnosis increased.
This overall correlation appeared to be largely explained by the
positive correlation between the PACS problems scores and time since
diagnosis (\emph{r\textsubscript{s}} = + 0.22, p = 0.01). The
correlation between the parental PACS communication openness and time
since diagnosis was considerably smaller than the other two and not
statistically significant (\emph{r\textsubscript{s}} = - 0.11, p =
0.23). None of the correlations between the child reports of
communication with either parent and the time since diagnosis were
statistically significant (\emph{r\textsubscript{s}} ranged from - 0.15
to + 0.16, p \textgreater{} 0.05). Finally, all the correlations of
either parent or child PACS scores with time since relapse were quite
small and not statistically significant (\emph{r\textsubscript{s}}ranged
from - 0.05 to + 0.06, p \textgreater{} 0.50).

\textbf{Discussion}

Due to the simultaneous importance and challenge of parent-child
communication in childhood cancer, research is needed to better
understand how time affects the quality of communication between parents
and children with cancer. Novel aspects of this study included the
analyses of parent-child communication from both parent and child
perspectives, while prior studies have evaluated communication based on
either parent or child report.\textsuperscript{28,29} Other strengths of
the study included the large sample size and inclusion of patients with
relapsed/refractory cancer, a population that is typically difficult to
access.

Contrary to our hypothesis, increased time since cancer diagnosis was
associated with more problematic communication and worse overall
communication based on parent reports. These results align with those of
prior studies in pediatric cancer survivors that showed more time from
diagnosis increased the likelihood of developing a struggling
parent-child relationship with poor
communication.\textsuperscript{29}Similarly, children newly diagnosed
with non-advanced cancer have shown an increase in parent-child conflict
and problematic communication over time.\textsuperscript{28,30} While
more parent-child communication problems over time may be expected as
children enter adolescence and strive for more
autonomy,\textsuperscript{31} we conducted a post-hoc analysis that
showed no statistically significant association between child age and
years since diagnosis. Thus, age is an unlikely mediator of the
correlation between time and problematic communication.

Our results also suggested that time from diagnosis did not impact
communication openness. This is in contrast to previous findings in
pediatric cancer patients, which showed a decrease in paternal openness
at one year after diagnosis compared to time of diagnosis in children
with non-advanced cancer.\textsuperscript{28} However, in studies
evaluating quality of communication between adults with cancer and their
adolescent children, parent-child communication openness and problems
were not impacted by time since diagnosis.\textsuperscript{32,33}

Interesting to note is that our results showed no statistically
significant association between time from most recent relapse and
quality of communication in the patients with relapsed disease. These
results are congruent with a prior study, which showed that parent-child
communication problems and openness were more stable in children with
advanced cancer, measured in the year following relapse, than in healthy
children or those with newly diagnosed non-advanced
cancer.\textsuperscript{28} Ethnographic data from families who
experienced childhood cancer relapse found that families strive to
maintain normalcy and avoid letting cancer dominate their lives after
relapse, distinct from the new-diagnosis period when the families' lives
are completely centered around the child's
treatment.\textsuperscript{34} This may explain why relapse appeared to
be a less important milestone than diagnosis in affecting parent-child
communication. While disease relapse has been associated with a closer,
more involved parent-child relationship,\textsuperscript{29} with few
studies evaluating communication change over time, more research is
needed to understand the continued impact of relapse on parent-child
communication.

Limitations of our study included potential selection bias based on the
opt-in recruitment approach. The limited range of scores of the PACS may
have reduced the ability to detect correlations with time. A small
number of fathers participated (n = 10; 7.7\%) as primary parent
caregivers; thus, the parent PACS data is biased towards maternal
impressions of communication with the ill child. Only 61\% of children
completed the PACS about their fathers (versus 98\% about their
mothers); this could be due in part to participation by single-parent
families, as half of participating parents report being married.
Regardless, limited father participation in pediatric research studies
has been a long-standing challenge.\textsuperscript{35--37} Social media
advertisements targeting fathers rather than gender-neutral ``parent''
strategies have recently been shown to improve recruitment in this
population.\textsuperscript{38} Additional research on and
implementation of paternal recruitment strategies may allow for a more
balanced representation of parental perspectives in future studies.

\textbf{Conclusion}

With evidence that parent-child communication worsens over time with
more problems in communication following the diagnosis of childhood
cancer, oncologists should continue to provide families with support in
communication throughout the child's illness journey rather than only in
the immediate new diagnosis period. Providers should consider continued
involvement of interdisciplinary teams, including psychologists, social
workers, child life specialists, and palliative care providers in order
to best support communication within the family over time. Furthermore,
providers can encourage high-quality communication within the family by
modeling open communication in the clinic, including sharing medical
information with both the parent and child while eliciting questions and
concerns from each, establishing the expectation for ongoing openness at
home.

Future studies are needed to determine if there is an optimal time for
intervention after a child's diagnosis or relapse to most effectively
prevent worsening parent-child communication. Additional prospective
studies evaluating parent-child communication over time from the child's
cancer diagnosis through relapse may better elucidate the impact of each
of these milestones on quality of communication. With many more mothers
than fathers participating in this and most other studies for parents of
children with cancer and other chronic childhood illnesses, further
research endeavors specifically targeting fathers would also be
valuable. Such research is critical to improving care and decreasing
suffering for vulnerable pediatric patients and their caregivers.

\textbf{Conflict of Interest Statement:} The authors have no conflicts
of interest to disclose.

\textbf{Data Sharing Statement:} The data that support the findings of
this study are available upon request from the Palliative Care Research
Cooperative Group.

\textbf{Acknowledgements:} We thank the children and parents who kindly
participated in this study.

\textbf{References}

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. \emph{CA
Cancer J Clin} . 2020;70(1):7-30. doi:10.3322/caac.21590

2. Price J, Kassam-Adams N, Alderfer MA, Christofferson J, Kazak AE.
Systematic Review: A Reevaluation and Update of the Integrative
(Trajectory) Model of Pediatric Medical Traumatic Stress. \emph{J
Pediatr Psychol} . 2016;41(1):86-97. doi:10.1093/jpepsy/jsv074

3. Rodriguez EM, Murphy L, Vannatta K, et al. Maternal Coping and
Depressive Symptoms as Predictors of Mother--Child Communication About a
Child's Cancer. \emph{J Pediatr Psychol} . 2016;41(3):329-339.
doi:10.1093/jpepsy/jsv106

4. Murphy LK, Preacher KJ, Rights JD, et al. Maternal Communication in
Childhood Cancer: Factor Analysis and Relation to Maternal
Distress.\emph{J Pediatr Psychol} . 2018;43(10):1114-1127.
doi:10.1093/jpepsy/jsy054

5. Murphy L, Rodriguez E, Gerhardt C, et al. Longitudinal Associations
Among Maternal Communication and Adolescent Posttraumatic Stress
Symptoms after Cancer Diagnosis. \emph{Psychooncology} .
2016;25(7):779-786. doi:10.1002/pon.3918

6. Adduci A, Jankovic M, Strazzer S, Massimino M, Clerici C, Poggi G.
Parent--child communication and psychological adjustment in children
with a brain tumor. \emph{Pediatr Blood Cancer} . 2012;59(2):290-294.
doi:10.1002/pbc.24165

7. Son H, Haase J, Docherty SL. Parent-Child Communication in a
Childhood Cancer Context: A Literature Review. \emph{Pediatr Nurs} .
45(3):13.

8. van der Geest IMM, van den Heuvel-Eibrink MM, van Vliet LM, et al.
Talking about Death with Children with Incurable Cancer: Perspectives
from Parents. \emph{J Pediatr} . 2015;167(6):1320-1326.
doi:10.1016/j.jpeds.2015.08.066

9. Wangmo T, Clercq ED, Ruhe KM, et al. Better to know than to imagine:
Including children in their health care. \emph{AJOB Empir Bioeth} .
2017;8(1):11-20. doi:10.1080/23294515.2016.1207724

10. Nuss SL. Redefining Parenthood: Surviving the Death of a
Child.\emph{Cancer Nurs} . 2014;37(1):E51-E60.
doi:10.1097/NCC.0b013e3182a0da1f

11. Arruda-Colli MNF, Perina EM, Santos MA. Experiences of Brazilian
children and family caregivers facing the recurrence of cancer.\emph{Eur
J Oncol Nurs} . 2015;19(5):458-464. doi:10.1016/j.ejon.2015.02.004

12. Coyne I, Amory A, Gibson F, Kiernan G. Information-sharing between
healthcare professionals, parents and children with cancer: more than a
matter of information exchange. \emph{Eur J Cancer Care (Engl)} .
2016;25(1):141-156. doi:10.1111/ecc.12411

13. Badarau DO, Wangmo T, Ruhe KM, et al. Parents' Challenges and
Physicians' Tasks in Disclosing Cancer to Children. A Qualitative
Interview Study and Reflections on Professional Duties in Pediatric
Oncology. \emph{Pediatr Blood Cancer} . 2015;62(12):2177-2182.
doi:10.1002/pbc.25680

14. Kars MC, Grypdonck MHF, de Bock LC, van Delden JJM. The parents'
ability to attend to the ``voice of their child'' with incurable cancer
during the palliative phase. \emph{Health Psychol} . 2015;34(4):446-452.
doi:10.1037/hea0000166

15. Watanabe A, Nunes T, Abreu G de. Japanese parents' perception of
disclosing the diagnosis of cancer to their children: \emph{Clin Child
Psychol Psychiatry} . Published online January 7, 2013.
doi:10.1177/1359104512470599

16. Kreicbergs U, Valdimarsd\selectlanguage{ngerman}óttir U, Onelöv E, Henter J-I, Steineck G.
Talking about Death with Children Who Have Severe Malignant
Disease.\emph{N Engl J Med} . 2004;351(12):1175-1186.
doi:10.1056/NEJMoa040366

17. Bluebond-Langner M. \emph{The Private Worlds of Dying Children} .
Princeton University Press; 1978.

18. Children with Cancer: A Guide for Parents - National Cancer
Institute. Published online September 2015. Accessed August 14, 2020.
https://www.cancer.gov/publications/patient-education/guide-for-parents

19. Mant J, Kirby A, Cox KJ, Burke A. Children's experiences of being
diagnosed with cancer at the early stages of treatment; an interpretive
phenomenological analysis. \emph{Clin Child Psychol Psychiatry} .
2019;24(1):3-18. doi:10.1177/1359104518788400

20. Cline RJW, Harper FWK, Penner LA, Peterson AM, Taub JW, Albrecht TL.
Parent communication and child pain and distress during painful
pediatric cancer treatments. \emph{Soc Sci Med} . 2006;63(4):883-898.
doi:10.1016/j.socscimed.2006.03.007

21. Clarke S-A, Sheppard L, Eiser C. Mothers' explanations of
communicating past health and future risks to survivors of childhood
cancer. \emph{Clin Child Psychol Psychiatry} . 2008;13(1):157-170.
doi:10.1177/1359104507080997

22. Jalmsell L, Kontio T, Stein M, Henter J-I, Kreicbergs U. On the
Child's Own Initiative: Parents Communicate with Their Dying Child About
Death. \emph{Death Stud} . 2015;39(2):111-117.
doi:10.1080/07481187.2014.913086

23. Kelly KP, Mowbray C, Pyke\selectlanguage{english}-Grimm K, Hinds PS. Identifying a
conceptual shift in child and adolescent-reported treatment decision
making: ``Having a say, as I need at this time.'' \emph{Pediatr Blood
Cancer} . 2017;64(4):e26262. doi:10.1002/pbc.26262

24. Akard TF, Wray S, Friedman DL, et al. Transforming a Face-to-Face
Legacy Intervention to a Web-Based Legacy Intervention for Children With
Advanced Cancer: \emph{J Hosp Palliat Nurs} . 2020;22(1):49-60.
doi:10.1097/NJH.0000000000000614

25. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium:
Building an international community of software platform
partners.\emph{J Biomed Inform} . 2019;95:103208.
doi:10.1016/j.jbi.2019.103208

26. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG.
Research Electronic Data Capture (REDCap) - A metadata-driven
methodology and workflow process for providing translational research
informatics support. \emph{J Biomed Inform} . 2009;42(2):377-381.
doi:10.1016/j.jbi.2008.08.010

27. Barnes HL, Olson DH. Parent-Adolescent Communication and the
Circumplex Model. \emph{Child Dev} . 1985;56(2):438-447.
doi:10.2307/1129732

28. Keim MC, Lehmann V, Shultz EL, et al. Parent--Child Communication
and Adjustment Among Children With Advanced and Non-Advanced Cancer in
the First Year Following Diagnosis or Relapse. \emph{J Pediatr Psychol}
. 2017;42(8):871-881. doi:10.1093/jpepsy/jsx058

29. Tillery R, Willard VW, Sharp KMH, Klages KL, Long AM, Phipps S.
Impact of the parent-child relationship on psychological and social
resilience in pediatric cancer patients. \emph{Psychooncology} .
2020;29(2):339-346. doi:10.1002/pon.5258

30. Katz LF, Fladeboe K, Lavi I, et al. Trajectories of Marital,
Parent-Child and Sibling Conflict during Pediatric Cancer
Treatment.\emph{Health Psychol Off J Div Health Psychol Am Psychol
Assoc} . 2018;37(8):736-745. doi:10.1037/hea0000620

31. Remschmidt H. Psychosocial Milestones in Normal Puberty and
Adolescence. \emph{Horm Res} . 1994;41(2):19-29. doi:10.1159/000183955

32. Huizinga GA, Visser A, van der Graaf WTA, Hoekstra HJ,
Hoekstra-Weebers JEHM. The quality of communication between parents and
adolescent children in the case of parental cancer. \emph{Ann Oncol} .
2005;16(12):1956-1961. doi:10.1093/annonc/mdi395

33. Gazendam\selectlanguage{english}-Donofrio S, Hoekstra H, Graaf W van der, et al.
Parent-child communication patterns during the first year after a
parent's cancer diagnosis. \emph{Cancer} . 2009;115(18):4227-4237.
doi:10.1002/cncr.24502

34. De Graves S, Aranda S. Living with hope and fear--the uncertainty of
childhood cancer after relapse. \emph{Cancer Nurs} . 2008;31(4):292-301.
doi:10.1097/01.NCC.0000305745.41582.73

35. Phares V, Lopez E, Fields S, Kamboukos D, Duhig AM. Are Fathers
Involved in Pediatric Psychology Research and Treatment? \emph{J Pediatr
Psychol} . 2005;30(8):631-643. doi:10.1093/jpepsy/jsi050

36. Cabrera NJ, Volling BL, Barr R. Fathers Are Parents, Too! Widening
the Lens on Parenting for Children's Development. \emph{Child Dev
Perspect} . 2018;12(3):152-157. doi:10.1111/cdep.12275

37. Davison KK, Gicevic S, Aftosmes-Tobio A, et al. Fathers'
Representation in Observational Studies on Parenting and Childhood
Obesity: A Systematic Review and Content Analysis. \emph{Am J Public
Health} . 2016;106(11):e14-e21. doi:10.2105/AJPH.2016.303391

38. Leach LS, Bennetts SK, Giallo R, Cooklin AR. Recruiting fathers for
parenting research using online advertising campaigns: Evidence from an
Australian study. \emph{Child Care Health Dev} . 2019;45(6):871-876.
doi:10.1111/cch.12698

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