Toward Better Conversations: Assessing Caregiver–Child Communication in Pediatric Oncology

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Skeens, Mariam Kochashvili, Anna Olsavsky, Nadeen Alshakhshir, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7776804/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Feb, 2026 Read the published version in Supportive Care in Cancer → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Effective parent–child communication is central to coping with the psychosocial challenges of pediatric cancer, yet few studies have examined how caregivers and children perceive their communication. This study investigated congruence and discrepancies between caregiver and child reports of communication and associations with family relationship quality. Methods Seventy-six caregiver–child dyads (N=152) were recruited from two Midwestern pediatric hospitals. Children aged 8–17 with cancer and their caregivers independently completed measures of parent–child communication (PCCS) and family relationships (PROMIS). Descriptive statistics, correlations, and paired- and independent-samples t-tests were used to examine differences and associations across dyads, with attention to demographic and clinical factors. Results Both caregivers (M=3.95, SD=0.58) and children (M=4.15, SD=0.61) reported generally high-quality communication. However, significant discrepancies emerged: children rated caregivers as more attentive listeners (t(74)=2.53, p=.01), emotionally open (t(74)=2.30, p=.02), and willing to discuss problems (t(74)=2.86, p=.005) than caregivers reported their children. Child-reported communication correlated strongly with child-reported family relationships (r(75)=.75, p<.001), while caregiver reports were moderately associated with both their own and children’s assessments of family relationships. Age effects were observed, with older parent and child age linked to lower communication scores, and non-Hispanic caregivers reporting higher-quality communication than Hispanic. Conclusions Systematic discrepancies in caregiver and child perceptions of communication represent an underrecognized factor influencing family functioning in pediatric cancer. Findings underscore the importance of routine communication assessment and highlight the need for developmentally and culturally tailored interventions. Supporting families in bridging perception gaps may enhance psychosocial adjustment, strengthen family resilience, and improve treatment adherence. pediatric cancer communication symptom science caregivers family functioning Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Communication within families is a central mechanism through which children and caregivers cope with the stress of pediatric cancer treatment. Effective caregiver–child communication is particularly vital in navigating the complex psychosocial challenges of pediatric oncology.[ 1 ] Childhood cancer disrupts family routines and dynamics, placing considerable emotional, logistical, and financial demands on both children and caregivers. [ 2 , 3 ] The quality and openness of communication within these families directly influence psychological well-being, treatment adherence, and overall family functioning. [ 4 , 5 ] Yet despite its importance, limited research has systematically examined how caregiver and child perceptions of their communication align, or diverge, during cancer treatment. Cancer diagnosis and therapy are profoundly stressful, often requiring prolonged interventions that affect children’s physical, emotional, and social development.[ 6 ] Caregivers must simultaneously manage the child’s treatment demands and maintain family stability, compounding their own distress.[ 7 , 8 ] Family communication has been identified as a key protective factor in this context: open, supportive exchanges reduce psychological distress, foster adaptive coping, and improve adherence to treatment.[ 9 ] [ 10 ] Research in other chronic pediatric illnesses, such as cystic fibrosis and juvenile diabetes, similarly demonstrates that effective communication reduces behavioral and emotional problems while promoting resilience.[ 11 – 14 ] While these findings underscore the general value of communication, the dynamics of caregiver–child interaction in pediatric oncology are uniquely complex. Factors such as developmental stage, family structure, cultural background, and socioeconomic status shape how children and caregivers communicate about illness. [ 15 – 17 ] Younger children often require simplified, reassuring explanations to manage fear and uncertainty, whereas adolescents seek autonomy and involvement in decision-making.[ 18 – 20 ] These developmental differences highlight the need for tailored communication approaches that respect children’s evolving capacities while preserving family cohesion. This study addresses a current gap by examining both caregiver and child perspectives on communication in the context of pediatric cancer treatment. Specifically, it explores the degree of congruence and discrepancy in their perceptions of these interactions. By clarifying how families experience and interpret communication, the study aims to inform the development of targeted strategies that support psychosocial adjustment, strengthen family functioning, and enhance the delivery of pediatric cancer care. Methods Procedures Eligible caregiver–child dyads were recruited from two Midwestern children’s hospitals between October 2023 and March 2024. Participants were recruited during either outpatient oncology visits or inpatient chemotherapy admissions. Caregivers provided informed consent for both themselves and their child, while children gave verbal assent. Participants Eligible children met the following criteria: 1) aged 8–17, 2) diagnosed with any form of cancer, 3) undergoing adjuvant cancer treatment for at least two months or had completed treatment within the past six months, and 4) able to read and understand English. Caregivers were eligible if they: 1) were 18 or older, 2) played a role in caring for the participating child, and 3) could read and understand English. Dyads were excluded if any condition prevented them from completing the research questionnaires, or if the child was only receiving radiation treatment for cancer. Data Collection Once consent was obtained, dyads had the option to complete the surveys during their visit or remotely. If they chose to complete surveys remotely, the study team sent a text or email containing a unique URL generated by REDCap. Each URL linked to the appropriate surveys for each participant (child or caregiver). Participants had 30 days (+ 3 business days) to complete the surveys independently. Upon successful completion, both the child and the caregiver received a $ 25 electronic gift card each, totaling $ 50 per dyad. Measures Demographic and Clinical Characteristics Caregivers reported on their own and their child’s demographic characteristics such as age, race, ethnicity, education, and income. Clinical characteristics of the children, such as diagnosis, disease and treatment status, were abstracted from the electronic medical records (EMR) by the study team. Social Determinants of Health Participants’ addresses were used to classify rural and Appalachian residency, as well as medically underserved area (MUA) status. Rural-Urban Commuting Area (RUCA) codes were used to categorize families as rural or non-rural. RUCA scores range from 1 to 10, based on population density, urbanization, and commuting patterns at the census tract and ZIP code levels. Scores from 4 to 10 were classified as rural, while scores from 1 to 3 were classified as non-rural. [ 21 ]Appalachian residency was determined based on the counties served by the Appalachian Regional Commission (ARC) in 2021.[ 22 ] Participants residing in these counties were coded as 1 (Appalachian), and those residing outside these areas were coded as 0 (non-Appalachian). Medically Underserved Area (MUA) codes were used to assess access to primary care services.[ 23 ] Participants living in MUAs were coded as 1 (medically underserved), while those in non-MUA regions were coded as 0 (medically served). Parent–child Communication (PCCS) Child Version Children reported on their perceptions of their caregiver’s openness to communication. The child version of PCCS [ 24 ] included 10 questions, with responses rated on a 5-point Likert scale where 1 represented almost never and 5 almost always. Negatively worded items were reverse scored. Higher Mean scores indicated greater perceived openness to communication from caregivers and more frequent communication from the children. The Cronbach’s alpha of PCCS child version for this study was 0.73, which indicates acceptable internal consistency. Caregiver Version Similarly, caregivers reported on their perceptions of their openness to communicate with their child and their children’s communication skills with them. This version of PCCS includes 20 items, with responses on a 5-point Likert scale where 1 represented almost never and 5 almost always. Negatively worded items were reverse scored. Higher Mean scores indicate greater perceived openness to communication by the caregivers and stronger communication skills in children. Cronbach’s alpha of PCCS caregiver version for this study was 0.89, which indicates good internal consistency. Family Relationship Family relationships were assessed by both children and caregivers using PROMIS Pediatric Short Form v1.0 - Family Relationships measure 8a[ 25 ]. This measure includes 8 items measuring responses on 1–5 Likert scale where 1 represented never and 5 represents always, with a 4 week recall period. In the U.S general population, the average score is 50 with a standard deviation of 10 with higher T-scores indicating a better family relationship. The child version measures child’s perceived family relationship (“I feel really important to my family”) and caregiver version assesses child’s family relationship from the caregiver perspective (“My child felt he/she was really important to our family”). Cronbach’s alpha of the child version of the measure for this study was 0.93 indicating excellent internal consistency. Cronbach’s alpha of the caregiver version of the measure for this study was 0.84 indicating good internal consistency. Statistical Analysis Data were analyzed using IBM SPSS, version 28 for Windows. Descriptive statistics, including means, percentages and standard deviations, were calculated to summarize the sample. Correlations assessed associations among caregiver–child communication, family relationships, and demographic and clinical characteristics. Independent samples t-tests were conducted to explore differences in caregiver–child communication based on demographic characteristics. Paired samples t-tests were conducted to explore differences between child and caregiver for 10 matched PCCS items. Results Demographic Characteristics Seventy-six child–caregiver dyads ( N = 152) participated. Most children and caregivers identified as White (children: n = 67, 88.2%; caregivers: n = 70, 92.1%) and non-Hispanic (children: n = 66, 86.8%; caregivers: n = 66, 86.8%). Female caregivers outnumbered male caregivers ( n = 53, 69.7% vs. n = 22, 28.9%), and there were more male children ( n = 49, 64.5%) compared to female children ( n = 26, 34.2%). The average age of the children was 13.4 years ( SD = 3.2). Most children were diagnosed with hematologic malignancies ( n = 40, 52.6%) and had active disease status (presence of any disease on previous blood, bone marrow, or imaging) within 10 days prior to enrollment ( n = 50, 65.8%) and had not reached remission. Most caregivers were biological parents of the child with cancer ( n = 69, 88.5%) and with an average of three children per household ( SD = 1.6). Most caregivers were employed ( n = 49, 62.8%). Full demographic and clinical characteristics are detailed in Table 1. Table I. Demographics Caregiver Demographic Characteristics Caregiver’s Age (Mean, SD)* 42.0 (7.3) Gender Male 22 (28.9%) Female 53 (69.7%) Missing 1 (1.3%) Relationship to the Child Biological Parent 69 (90.8%) Step-parent 2 (2.6%) Adoptive Parent 3 (3.9%) Grandparent 1 (1.3%) Other Caregiver 1 (1.3%) Number of Children in Household (Mean, SD) 3.01 (1.6) Highest Grade of School Less than High School 4 (5.3%) Completed High School 12 (15.8%) Post High School (Technical or Trade School) 26 (34.2%) College 16 (21.1%) Graduate/Professional 16 (21.1%) Don’t know 1 (1.3%) Missing 1 (1.3%) Work Status Working now 49 (64.5%) Only temporarily laid off, sick leave, or maternity leave 5 (6.6%) Looking for work, unemployed 3 (3.9%) Retired 1 (1.3%) Disabled, permanently, or temporary 2 (2.6%) Keeping house 7 (9.2%) Student 1 (1.3%) Other 6 (7.9%) Missing 2 (2.6%) Annual Family Income Under $ 25,000 5 (6.6%) $ 25,001 - $ 50,000 per year 9 (11.8%) $ 50,001 - $ 75,000 per year 15 (19.7%) $ 75,001 -100,000 per year 10 (13.2%) $ 100,001 - $ 150,000 per year 13 (17.1%) $ 150,001 or more 16 (21.1%) Prefer not to answer 6 (7.9%) Missing 2 (2.6%) Caregiver’s Race White 70 (92.1%) Black or African American 2 (2.6%) Vietnamese 1 (1.3%) Some other race 3 (3.9%) Caregiver’s Ethnicity Not of Hispanic, Latino or Spanish origin 66 (86.8%) Mexican, Mexican-American, Chicano 7 (9.2%) Another Hispanic Latino, or Spanish origin 1 (1.3%) Missing 2 (2.6%) Child Demographic characteristics Child’s Age (Mean, SD) 13.4 (3.2) Child’s Gender Male 49 (64.5%) Female 26 (34.2%) Missing 1 (1.3%) Child’s Race White 67 (88.2%) Black or African American 3 (3.9%) Vietnamese 1 (1.3%) Some other race 3 (3.9%) Missing 1 (1.3%) Child’s Ethnicity Not of Hispanic, Latino or Spanish origin 66 (86.8%) Mexican, Mexican-American, Chicano 6 (7.9%) Another Hispanic Latino, or Spanish origin 2 (2.6%) Missing 2 (2.6%) Child’s Diagnosis Hematologic Malignancy 40 (52.6%) Non-CNS solid tumor 22 (28.9%) CNS tumor 14 (18.4%) Disease Status 10 Days Prior Documented Remission 24 (31.6%) Active Disease Presence of previous blood, BM, or imaging 50 (65.8%) Cancer Directed Therapy 10 Yes 46 (59%) Days Prior No 30 (38.5%) *Note: 5 caregivers had missing age values Correlation analyses revealed that child-reported and caregiver-reported scores of caregiver–child communication were significantly correlated, r (75) = 0.43, p < .001. Child-reported caregiver–child communication was also significantly correlated with both child-reported family relationships, r (75) = 0.75, p < .001, and caregiver-reported family relationships, r (75) = 0.27, p < .05. Caregiver-reported caregiver–child communication was significantly correlated with child-reported family relationships, r (76)=-0.30, p < .001, as well as with parent-reported family relationships, r (76) = 0.58, p < .001. Caregiver age was significantly associated with child-reported caregiver–child communication, r (70)= -0.29, p < .05, indicating that children perceived lower quality communication as caregiver age increased. Similarly, child age was negatively correlated with caregiver-reported communication scores, r (76)=-0.30, p < .05, with caregivers reporting lower quality communication as children grew older. Caregiver age was not associated with caregiver-reported communication, similarly child age was not associated with child-reported communication. (Table 2) Table II. Correlations Measure N M SD 1 2 3 4 5 1. Child-Reported PCCS 75 4.15 0.61 - 2. Caregiver-Reported PCCS 76 3.94 0.58 0.44** - 3. Child-Reported Family Relationship 76 54.4 9.86 0.75** 0.41** - 4. Caregiver-Reported Family Relationship 76 52.9 8.38 0.27* 0.58** 0.35** - 5. Caregiver Age 71 42.2 7.44 -0.29* -0.15 -0.23 -0.64 6. Child Age 76 13.4 3.20 -0.02 -0.30** -0.2 -0.29** -0.42** Note: PCCS stands for Parent-Child Communication Scale. **p < .01; *p < .05. Independent samples t-tests revealed significant differences in caregiver–child communication based on ethnicity. Non-Hispanic caregivers reported significantly higher quality communication with their children ( M = 4.02, SD = 0.53) compared to Hispanic caregivers ( M = 3.58, SD = 0.63; t (72) = 2.17, p = .03) (Fig. 1 ). Similarly, caregivers reported significantly higher quality communication with non-Hispanic children ( M = 4.00, SD = 0.53) compared to Hispanic children ( M = 3.58, SD = 0.63; t (71) = 2.13, p = .04). Differences in communication scores based on caregiver and child gender, race, rurality, MUA and Appalachian residency were not significant. Both children ( M = 4.15, SD = 0.61) (Fig. 2 ) and caregivers ( M = 3.95, SD = 0.58) (Fig. 3 ) reported high overall quality of communication. However, paired samples t-tests revealed several significant differences between child and caregiver perceptions across specific dimensions of communication (Fig. 4 ). Children rated their caregivers as better listeners ( M = 4.36, SD = 0.94) than caregivers rated their children ( M = 3.97, SD = 1.03; t (74) = 2.53, p = .01). Similarly, children reported that their caregivers made more effort to understand what they were thinking ( M = 4.27, SD = 0.97) than caregivers perceived their children made to understand them ( M = 3.81, SD = 0.92; t (73) = 3.08, p = .003). There was also a significant difference in how often problems were reportedly discussed. Children indicated that they talked about problems with their caregiver more frequently ( M = 3.95, SD = 1.24) than caregivers reported discussing problems with their child ( M = 3.41, SD = 1.08; t (74) = 2.86, p = .005). When asked about insulting behavior during anger, children reported that their caregivers insulted them more often ( M = 4.57, SD = 1.04) than caregivers reported being insulted by their child ( M = 4.15, SD = 1.17; t (74) = 2.81, p = .006). Children also reported greater emotional openness. They indicated a significantly higher ability to express their true feelings to their caregiver ( M = 4.23, SD = 1.10) compared to caregivers’ reports of being able to express their feelings to their child ( M = 3.89, SD = 0.97; t (74) = 2.30, p = .02). Additionally, children rated themselves as significantly more able to let their caregiver know what is bothering them ( M = 4.37, SD = 0.92) than caregivers believed their child could let them know what is bothering him/her ( M = 3.80, SD = 1.05), t (75) = 4.30, p < .001. Discussion Systematic discrepancies emerged between caregiver and child perceptions of communication, highlighting an underrecognized factor influencing psychosocial outcomes in pediatric cancer care. Children reported higher levels of communication quality than caregivers recognized in them, suggesting that caregivers may underestimate children’s communication abilities. It is important to further investigate how to improve caregivers’ perceptions of communication quality with their child given that both caregiver and child reports of communication quality were significantly associated with overall family relationship quality, underscoring the interdependence of communication and family functioning in the oncology context. This extends evidence that effective communication is not only protective but also relationally dynamic, whereby multiple domains of family well-being may be associated.[ 9 , 10 ] Our findings also extend previous research documenting communication gaps in pediatric oncology. For example, Wiener et al. (2015) identified mismatches in caregiver and child understanding of emotional needs; our study expands this work by quantifying specific domains of discrepancy and linking them to family functioning outcomes. Consistent with earlier literature, open and supportive communication was associated with greater cohesion and reduced distress within families facing cancer.[ 1 ] Studies in other chronic pediatric conditions such as cystic fibrosis, type 1 diabetes, and juvenile idiopathic arthritis have similarly highlighted communication as a central determinant of adherence, emotional adjustment, and family cohesion.[ 13 , 26 ] However, while most prior research has evaluated caregiver or child perspectives separately, relatively few have systematically examined congruence and discrepancy between the two. This study therefore adds important nuance by showing that even when families report generally “good” communication, misalignments in perception can still exist and these misalignments carry implications for family functioning. Beyond overall discrepancies, developmental and cultural factors influenced perceptions of communication. Younger children and caregivers reported higher communication quality, while adolescents reflected the challenges of balancing autonomy with parental guidance. These developmental differences mirror prior research indicating that younger children are more reliant on parental reassurance and may respond positively to clear, consistent explanations.[ 27 ] In contrast, adolescents often seek greater independence in medical decision-making and may withhold information if they perceive parental control as limiting. This aligns with broader adolescent development literature showing that autonomy-supportive communication fosters resilience, whereas controlling communication can provoke resistance and conflict. [ 28 , 29 ] , [ 30 ] Cultural differences also emerged, with non-Hispanic families reporting higher communication quality than Hispanic families. Although exploratory due to the small Hispanic subsample, these findings echo studies demonstrating that Latino families often face barriers in healthcare communication, including language proficiency, interpreter availability, and culturally specific norms around caregiver–child dialogue.[ 31 , 32 ] For instance, Spanish-speaking caregivers have reported less partnership and lower respect from providers than English-speaking white caregivers.[ 33 ] While our findings cannot fully disentangle these influences, they highlight the importance of considering both structural and cultural factors in understanding communication quality. The findings have clear relevance for pediatric oncology practice. Oncologists and nurses are in a key position to coach families, by observing interactions during clinic visits and gently offering guidance. In line with this, the American Academy of Pediatrics and psychosocial oncology standards have called for evidence-based guidelines to improve communication in pediatric cancer care.[ 34 ] Therefore, routine assessment of family communication should be integrated into care through brief screening tools or structured discussions, allowing early identification of families struggling to maintain open dialogue. Communication-focused assessments have been recommended in psychosocial oncology guidelines[ 35 ] but are not consistently implemented. Our results support their integration as a standard component of pediatric cancer care. Second, interventions must be developmentally tailored. For younger children, caregivers may need support in providing clear, age-appropriate explanations and opportunities for expressive outlets such as play or drawing.[ 36 , 37 ] For adolescents, clinicians should facilitate open conversations that respect autonomy, including opportunities for private consultations and involvement in treatment decisions. This echoes evidence that autonomy-supportive care strengthens adherence and emotional regulation in adolescent patients.[ 12 , 38 ] Third, culturally responsive practices are essential. Studies have shown that culturally adapted interventions in pediatric chronic illness management improve adherence and family engagement.[ 39 ] In oncology, this may include interpreter services, linguistically appropriate educational materials, and collaborations with cultural liaisons or community health workers to ensure families feel empowered to participate in open dialogue. Such approaches are critical for reducing disparities and ensuring equitable psychosocial support. Together, these implications highlight that strengthening communication is not only a psychosocial priority but also a pathway to enhancing adherence, emotional well-being, and family resilience during treatment. This study is not without limitations. The cross-sectional design prevents causal inference, limiting conclusions about how communication discrepancies influence outcomes over time. The study relied on self-reported perceptions, which may be subject to social desirability or recall bias. Additionally, the measure of communication included items for caregivers that may not actually indicate better quality communication with their child, despite contributing to better overall scores. For example, higher scores on the item “do you discuss child-related problems with your child?” and lower scores on the item “are there things you avoid discussing with your child?” were interpreted as higher quality communication. These items may instead tap into the concept of parentification, whereby a caregiver chooses to allow their children to assume an adult or parental role in the family.[ 40 ] Better measures of caregiver–child communication should be developed to avoid this issue. In addition, the small number of Hispanic participants restricts generalizability. These limitations underscore the need for replication in larger, more diverse samples and through multimethod approaches, including observational data. Future studies should explore the origins of caregiver–child perception gaps, investigating whether discrepancies arise from caregiver underestimation, child overestimation, or both. Longitudinal research is needed to examine how communication and perceptions evolve across the treatment trajectory, from diagnosis through survivorship, and to identify periods when interventions may be most impactful. Expanding work in underrepresented and non–English-speaking populations is essential to ensure findings are generalizable and to inform culturally tailored interventions. Finally, linking communication discrepancies directly to outcomes such as child anxiety, treatment adherence, and family functioning will provide stronger evidence for integrating communication-focused interventions into standard care. Conclusion This study highlights significant discrepancies between caregiver and child perceptions of communication in the pediatric cancer context, with important implications for family functioning and psychosocial outcomes. While both groups reported generally high communication quality, children consistently rated communication more positively than their caregivers did. These mismatches, shaped in part by developmental and cultural factors, underscore the need for routine communication assessment and the development of targeted, developmentally appropriate, and culturally responsive interventions. Strengthening caregiver–child communication may serve as a critical pathway to enhancing psychosocial well-being and overall family resilience during pediatric cancer care. Declarations Funding This work was supported in part by an award from the William F. Vilas Trust Estate. Competing Interests The authors declare no relevant financial or non-financial interests to disclose. Author Contributions Micah Skeens and Kitty Montgomery contributed to the study conception and design. Material preparation, data collection and analysis were performed by Mariam Kochashvili and Anna Olsavsky. The first draft of the manuscript was written by Micah Skeens and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript . Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committees of University of Wisconsin-Madison (#2023-0921) and Nationwide Children’s Hospital (IRB#00003499; approved 10/20/2023). Consent to participate Informed consent was obtained from all individual participants included in the study and written informed consent was obtained from the caregivers of children under the age of 18 and verbal assent was obtained from the children. Consent to publish This manuscript does not contain any individual person’s data in any form. Data Availability The datasets generated and analyzed during the current study are not publicly available but will be made available from the corresponding author on reasonable request. References H. 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S5, pp. S426–S459, 2015. G. Giuliani, J. Longhini, F. Ceni, G. Marini, E. Ambrosi, and F. Canzan, "Nurses' perspectives for the role of play with children in an onco-hematology department: A qualitative study," Journal of pediatric nursing, vol. 79, pp. e255–e261, 2024. K. Zhang, J. Ma, J. Chen, L. Xu, and C. Gu, "Effects of drawing therapy on pediatric oncology patients: a systematic review," Cancer nursing, vol. 45, no. 2, pp. E397–E406, 2022. A. van Dijk, E. Brummelman, and B. O. de Castro, "“I'm not here to push you:” raising adolescents' treatment engagement via autonomy support," Behaviour research and therapy, vol. 164, p. 104304, 2023. S. A. Carreon et al. , "Systematic review of culturally targeted behavioral and psychosocial interventions among children from racially and ethnically minoritized backgrounds with chronic health conditions in the United States," Journal of pediatric psychology, vol. 50, no. 7, pp. 552–560, 2025. R. Masiran, N. Ibrahim, H. Awang, and P. Y. Lim, "The positive and negative aspects of parentification: An integrated review," Children and youth services review, vol. 144, p. 106709, 2023. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 Feb, 2026 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 01 Dec, 2025 Reviews received at journal 01 Dec, 2025 Reviews received at journal 01 Dec, 2025 Reviewers agreed at journal 12 Nov, 2025 Reviewers agreed at journal 05 Nov, 2025 Reviewers invited by journal 05 Nov, 2025 Editor assigned by journal 05 Nov, 2025 Submission checks completed at journal 07 Oct, 2025 First submitted to journal 03 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7776804","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":545659469,"identity":"8da1ca08-065d-4c3f-8b98-099e1e9c1f40","order_by":0,"name":"Micah A. Skeens","email":"data:image/png;base64,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","orcid":"","institution":"The Abigail Wexner Research Institute at Nationwide Children’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Micah","middleName":"A.","lastName":"Skeens","suffix":""},{"id":545659470,"identity":"62e84fd2-522b-441c-aa62-c1dc52965344","order_by":1,"name":"Mariam Kochashvili","email":"","orcid":"","institution":"The Abigail Wexner Research Institute at Nationwide Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mariam","middleName":"","lastName":"Kochashvili","suffix":""},{"id":545659472,"identity":"e1f2e25c-de96-4beb-9ab3-49660de9e8df","order_by":2,"name":"Anna Olsavsky","email":"","orcid":"","institution":"The Abigail Wexner Research Institute at Nationwide Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Olsavsky","suffix":""},{"id":545659473,"identity":"23a33659-07df-48c7-a24d-8bfd45374d0b","order_by":3,"name":"Nadeen Alshakhshir","email":"","orcid":"","institution":"University of Minnesota","correspondingAuthor":false,"prefix":"","firstName":"Nadeen","middleName":"","lastName":"Alshakhshir","suffix":""},{"id":545659474,"identity":"7e6b7972-7a31-4eac-8f65-f1c076e01949","order_by":4,"name":"Mays Basha","email":"","orcid":"","institution":"Emory University","correspondingAuthor":false,"prefix":"","firstName":"Mays","middleName":"","lastName":"Basha","suffix":""},{"id":545659475,"identity":"43fe1df0-6cc2-4de6-9f4a-38f8998a84b1","order_by":5,"name":"Amy R. 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06:39:47","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":126507,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7776804/v1/51fdd780c818617946df1ab7.html"},{"id":96050977,"identity":"d6199d35-3870-4832-9c5d-fbbeacd715e8","added_by":"auto","created_at":"2025-11-17 06:39:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23386,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDifferences in caregiver-reported PCCS based on child and caregiver ethnicity\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7776804/v1/e82408fa9540229720d79542.png"},{"id":96051180,"identity":"79ec8952-ff4b-41ad-a006-527c1abe7d49","added_by":"auto","created_at":"2025-11-17 06:39:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":95392,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eChild’s reports of caregiver-child communication\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7776804/v1/a75b6361a1bba11ff4254004.png"},{"id":96050978,"identity":"61de596c-d1f3-40b7-95c8-a18988a245b7","added_by":"auto","created_at":"2025-11-17 06:39:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":94667,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCaregiver’s reports of caregiver-child communication\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7776804/v1/7d624c8d91939dba2db527e1.png"},{"id":96051179,"identity":"ace5ff8b-1419-4c7e-b256-59ecbc8f580a","added_by":"auto","created_at":"2025-11-17 06:39:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":83708,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMean child and caregiver’s report of caregiver-child communication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: ***p\u0026lt;.001; **p\u0026lt;.01; *p\u0026lt;.05\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7776804/v1/89bf790c23c7ed6ea309bbde.png"},{"id":103251138,"identity":"0030251d-727f-47dc-b4ae-e17734e97790","added_by":"auto","created_at":"2026-02-23 16:04:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1222044,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7776804/v1/ec1bf963-0c68-446f-8022-6173a57cfbf9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Toward Better Conversations: Assessing Caregiver–Child Communication in Pediatric Oncology","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCommunication within families is a central mechanism through which children and caregivers cope with the stress of pediatric cancer treatment. Effective caregiver\u0026ndash;child communication is particularly vital in navigating the complex psychosocial challenges of pediatric oncology.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Childhood cancer disrupts family routines and dynamics, placing considerable emotional, logistical, and financial demands on both children and caregivers. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The quality and openness of communication within these families directly influence psychological well-being, treatment adherence, and overall family functioning. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Yet despite its importance, limited research has systematically examined how caregiver and child perceptions of their communication align, or diverge, during cancer treatment.\u003c/p\u003e\u003cp\u003eCancer diagnosis and therapy are profoundly stressful, often requiring prolonged interventions that affect children\u0026rsquo;s physical, emotional, and social development.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Caregivers must simultaneously manage the child\u0026rsquo;s treatment demands and maintain family stability, compounding their own distress.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Family communication has been identified as a key protective factor in this context: open, supportive exchanges reduce psychological distress, foster adaptive coping, and improve adherence to treatment.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Research in other chronic pediatric illnesses, such as cystic fibrosis and juvenile diabetes, similarly demonstrates that effective communication reduces behavioral and emotional problems while promoting resilience.[\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eWhile these findings underscore the general value of communication, the dynamics of caregiver\u0026ndash;child interaction in pediatric oncology are uniquely complex. Factors such as developmental stage, family structure, cultural background, and socioeconomic status shape how children and caregivers communicate about illness. [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Younger children often require simplified, reassuring explanations to manage fear and uncertainty, whereas adolescents seek autonomy and involvement in decision-making.[\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] These developmental differences highlight the need for tailored communication approaches that respect children\u0026rsquo;s evolving capacities while preserving family cohesion.\u003c/p\u003e\u003cp\u003eThis study addresses a current gap by examining both caregiver and child perspectives on communication in the context of pediatric cancer treatment. Specifically, it explores the degree of congruence and discrepancy in their perceptions of these interactions. By clarifying how families experience and interpret communication, the study aims to inform the development of targeted strategies that support psychosocial adjustment, strengthen family functioning, and enhance the delivery of pediatric cancer care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eProcedures\u003c/h2\u003e\u003cp\u003eEligible caregiver\u0026ndash;child dyads were recruited from two Midwestern children\u0026rsquo;s hospitals between October 2023 and March 2024. Participants were recruited during either outpatient oncology visits or inpatient chemotherapy admissions. Caregivers provided informed consent for both themselves and their child, while children gave verbal assent.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eEligible children met the following criteria: 1) aged 8\u0026ndash;17, 2) diagnosed with any form of cancer, 3) undergoing adjuvant cancer treatment for at least two months or had completed treatment within the past six months, and 4) able to read and understand English. Caregivers were eligible if they: 1) were 18 or older, 2) played a role in caring for the participating child, and 3) could read and understand English. Dyads were excluded if any condition prevented them from completing the research questionnaires, or if the child was only receiving radiation treatment for cancer.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eOnce consent was obtained, dyads had the option to complete the surveys during their visit or remotely. If they chose to complete surveys remotely, the study team sent a text or email containing a unique URL generated by REDCap. Each URL linked to the appropriate surveys for each participant (child or caregiver). Participants had 30 days (+\u0026thinsp;3 business days) to complete the surveys independently. Upon successful completion, both the child and the caregiver received a \u003cspan\u003e$\u003c/span\u003e25 electronic gift card each, totaling \u003cspan\u003e$\u003c/span\u003e50 per dyad.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eDemographic and Clinical Characteristics\u003c/h2\u003e\u003cp\u003eCaregivers reported on their own and their child\u0026rsquo;s demographic characteristics such as age, race, ethnicity, education, and income. Clinical characteristics of the children, such as diagnosis, disease and treatment status, were abstracted from the electronic medical records (EMR) by the study team.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eSocial Determinants of Health\u003c/h2\u003e\u003cp\u003eParticipants\u0026rsquo; addresses were used to classify rural and Appalachian residency, as well as medically underserved area (MUA) status. Rural-Urban Commuting Area (RUCA) codes were used to categorize families as rural or non-rural. RUCA scores range from 1 to 10, based on population density, urbanization, and commuting patterns at the census tract and ZIP code levels. Scores from 4 to 10 were classified as rural, while scores from 1 to 3 were classified as non-rural. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]Appalachian residency was determined based on the counties served by the Appalachian Regional Commission (ARC) in 2021.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Participants residing in these counties were coded as 1 (Appalachian), and those residing outside these areas were coded as 0 (non-Appalachian). Medically Underserved Area (MUA) codes were used to assess access to primary care services.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Participants living in MUAs were coded as 1 (medically underserved), while those in non-MUA regions were coded as 0 (medically served).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParent–child Communication (PCCS)\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eChild Version\u003c/h2\u003e\u003cp\u003e Children reported on their perceptions of their caregiver\u0026rsquo;s openness to communication. The child version of PCCS [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] included 10 questions, with responses rated on a 5-point Likert scale where 1 represented almost never and 5 almost always. Negatively worded items were reverse scored. Higher Mean scores indicated greater perceived openness to communication from caregivers and more frequent communication from the children. The Cronbach\u0026rsquo;s alpha of PCCS child version for this study was 0.73, which indicates acceptable internal consistency.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eCaregiver Version\u003c/h2\u003e\u003cp\u003eSimilarly, caregivers reported on their perceptions of their openness to communicate with their child and their children\u0026rsquo;s communication skills with them. This version of PCCS includes 20 items, with responses on a 5-point Likert scale where 1 represented almost never and 5 almost always. Negatively worded items were reverse scored. Higher Mean scores indicate greater perceived openness to communication by the caregivers and stronger communication skills in children. Cronbach\u0026rsquo;s alpha of PCCS caregiver version for this study was 0.89, which indicates good internal consistency.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eFamily Relationship\u003c/h2\u003e\u003cp\u003eFamily relationships were assessed by both children and caregivers using PROMIS Pediatric Short Form v1.0 - Family Relationships measure 8a[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This measure includes 8 items measuring responses on 1\u0026ndash;5 Likert scale where 1 represented never and 5 represents always, with a 4 week recall period. In the U.S general population, the average score is 50 with a standard deviation of 10 with higher T-scores indicating a better family relationship. The child version measures child\u0026rsquo;s perceived family relationship (\u0026ldquo;I feel really important to my family\u0026rdquo;) and caregiver version assesses child\u0026rsquo;s family relationship from the caregiver perspective (\u0026ldquo;My child felt he/she was really important to our family\u0026rdquo;). Cronbach\u0026rsquo;s alpha of the child version of the measure for this study was 0.93 indicating excellent internal consistency. Cronbach\u0026rsquo;s alpha of the caregiver version of the measure for this study was 0.84 indicating good internal consistency.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using IBM SPSS, version 28 for Windows. Descriptive statistics, including means, percentages and standard deviations, were calculated to summarize the sample. Correlations assessed associations among caregiver\u0026ndash;child communication, family relationships, and demographic and clinical characteristics. Independent samples t-tests were conducted to explore differences in caregiver\u0026ndash;child communication based on demographic characteristics. Paired samples t-tests were conducted to explore differences between child and caregiver for 10 matched PCCS items.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eDemographic Characteristics\u003c/h2\u003e\u003cp\u003eSeventy-six child\u0026ndash;caregiver dyads (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;152) participated. Most children and caregivers identified as White (children: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;67, 88.2%; caregivers: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;70, 92.1%) and non-Hispanic (children: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;66, 86.8%; caregivers: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;66, 86.8%). Female caregivers outnumbered male caregivers (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53, 69.7% vs. \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22, 28.9%), and there were more male children (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;49, 64.5%) compared to female children (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;26, 34.2%). The average age of the children was 13.4 years (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.2). Most children were diagnosed with hematologic malignancies (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40, 52.6%) and had active disease status (presence of any disease on previous blood, bone marrow, or imaging) within 10 days prior to enrollment (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;50, 65.8%) and had not reached remission. Most caregivers were biological parents of the child with cancer (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;69, 88.5%) and with an average of three children per household (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.6). Most caregivers were employed (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;49, 62.8%). Full demographic and clinical characteristics are detailed in Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003e\u003cem\u003eTable I. Demographics\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCaregiver Demographic Characteristics\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCaregiver\u0026rsquo;s Age (Mean, SD)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.0 (7.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (28.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (69.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRelationship to the Child\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBiological Parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69 (90.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStep-parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdoptive Parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrandparent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther Caregiver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of Children in Household (Mean, SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.01 (1.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHighest Grade of School\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLess than High School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCompleted\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (15.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost High School (Technical or Trade School)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (34.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCollege\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (21.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGraduate/Professional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (21.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWork Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWorking now\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (64.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOnly temporarily laid off, sick leave, or maternity leave\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (6.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLooking for work, unemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetired\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDisabled, permanently, or temporary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKeeping house\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (9.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (7.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnnual Family Income\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnder \u003cspan\u003e$\u003c/span\u003e25,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (6.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e25,001 - \u003cspan\u003e$\u003c/span\u003e50,000 per year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (11.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50,001 - \u003cspan\u003e$\u003c/span\u003e75,000 per year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (19.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e75,001 -100,000 per year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (13.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e100,001 - \u003cspan\u003e$\u003c/span\u003e150,000 per year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (17.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e150,001 or more\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (21.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrefer not to answer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (7.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCaregiver\u0026rsquo;s Race\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70 (92.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlack or African American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVietnamese\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSome other race\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCaregiver\u0026rsquo;s Ethnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot of Hispanic, Latino or Spanish origin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66 (86.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMexican, Mexican-American, Chicano\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (9.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnother Hispanic Latino, or Spanish origin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"BoldItalicUnderline\" class=\"BoldItalicUnderline\" name=\"Emphasis\"\u003eChild Demographic characteristics\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChild\u0026rsquo;s Age (Mean, SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.4 (3.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChild\u0026rsquo;s Gender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (64.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (34.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChild\u0026rsquo;s Race\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67 (88.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlack or African American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVietnamese\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSome other race\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChild\u0026rsquo;s Ethnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot of Hispanic, Latino or Spanish origin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66 (86.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMexican, Mexican-American, Chicano\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (7.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnother Hispanic Latino, or Spanish origin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChild\u0026rsquo;s Diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHematologic Malignancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (52.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-CNS solid tumor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (28.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCNS tumor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (18.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDisease Status 10 Days Prior\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDocumented Remission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (31.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eActive Disease Presence of previous blood, BM, or imaging\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (65.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCancer Directed Therapy 10\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (59%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDays Prior\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (38.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e*Note: 5 caregivers had missing age values\u003c/h2\u003e\u003cp\u003eCorrelation analyses revealed that child-reported and caregiver-reported scores of caregiver\u0026ndash;child communication were significantly correlated, \u003cem\u003er\u003c/em\u003e(75)\u0026thinsp;=\u0026thinsp;0.43, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Child-reported caregiver\u0026ndash;child communication was also significantly correlated with both child-reported family relationships, \u003cem\u003er\u003c/em\u003e(75)\u0026thinsp;=\u0026thinsp;0.75, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, and caregiver-reported family relationships, \u003cem\u003er\u003c/em\u003e(75)\u0026thinsp;=\u0026thinsp;0.27, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05. Caregiver-reported caregiver\u0026ndash;child communication was significantly correlated with child-reported family relationships, \u003cem\u003er\u003c/em\u003e(76)=-0.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, as well as with parent-reported family relationships, \u003cem\u003er\u003c/em\u003e(76)\u0026thinsp;=\u0026thinsp;0.58, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Caregiver age was significantly associated with child-reported caregiver\u0026ndash;child communication, \u003cem\u003er\u003c/em\u003e(70)= -0.29, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, indicating that children perceived lower quality communication as caregiver age increased. Similarly, child age was negatively correlated with caregiver-reported communication scores, \u003cem\u003er\u003c/em\u003e(76)=-0.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, with caregivers reporting lower quality communication as children grew older. Caregiver age was not associated with caregiver-reported communication, similarly child age was not associated with child-reported communication. (Table\u0026nbsp;2)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTable II. Correlations\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeasure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Child-Reported PCCS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Caregiver-Reported PCCS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.44**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Child-Reported Family Relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.75**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.41**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Caregiver-Reported Family Relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.27*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.58**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.35**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Caregiver Age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.29*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Child Age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.30**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.29**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.42**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eNote: PCCS stands for Parent-Child Communication Scale. **p\u0026thinsp;\u0026lt;\u0026thinsp;.01; *p\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e Independent samples t-tests revealed significant differences in caregiver\u0026ndash;child communication based on ethnicity. Non-Hispanic caregivers reported significantly higher quality communication with their children (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.02, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.53) compared to Hispanic caregivers (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.58, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.63; \u003cem\u003et\u003c/em\u003e(72)\u0026thinsp;=\u0026thinsp;2.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.03) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Similarly, caregivers reported significantly higher quality communication with non-Hispanic children (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.00, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.53) compared to Hispanic children (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.58, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.63; \u003cem\u003et\u003c/em\u003e(71)\u0026thinsp;=\u0026thinsp;2.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.04). Differences in communication scores based on caregiver and child gender, race, rurality, MUA and Appalachian residency were not significant.\u003c/p\u003e\u003cp\u003eBoth children (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.15, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.61) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and caregivers (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.95, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.58) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) reported high overall quality of communication. However, paired samples t-tests revealed several significant differences between child and caregiver perceptions across specific dimensions of communication (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Children rated their caregivers as better listeners (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.36, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.94) than caregivers rated their children (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.97, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.03; \u003cem\u003et\u003c/em\u003e(74)\u0026thinsp;=\u0026thinsp;2.53, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.01). Similarly, children reported that their caregivers made more effort to understand what they were thinking (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.27, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.97) than caregivers perceived their children made to understand them (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.81, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.92; \u003cem\u003et\u003c/em\u003e(73)\u0026thinsp;=\u0026thinsp;3.08, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003). There was also a significant difference in how often problems were reportedly discussed. Children indicated that they talked about problems with their caregiver more frequently (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.95, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.24) than caregivers reported discussing problems with their child (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.41, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.08; \u003cem\u003et\u003c/em\u003e(74)\u0026thinsp;=\u0026thinsp;2.86, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.005). When asked about insulting behavior during anger, children reported that their caregivers insulted them more often (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.57, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.04) than caregivers reported being insulted by their child (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.15, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.17; \u003cem\u003et\u003c/em\u003e(74)\u0026thinsp;=\u0026thinsp;2.81, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.006). Children also reported greater emotional openness. They indicated a significantly higher ability to express their true feelings to their caregiver (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.23, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.10) compared to caregivers\u0026rsquo; reports of being able to express their feelings to their child (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.89, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.97; \u003cem\u003et\u003c/em\u003e(74)\u0026thinsp;=\u0026thinsp;2.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.02). Additionally, children rated themselves as significantly more able to let their caregiver know what is bothering them (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.37, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.92) than caregivers believed their child could let them know what is bothering him/her (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.80, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.05), \u003cem\u003et\u003c/em\u003e(75)\u0026thinsp;=\u0026thinsp;4.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSystematic discrepancies emerged between caregiver and child perceptions of communication, highlighting an underrecognized factor influencing psychosocial outcomes in pediatric cancer care. Children reported higher levels of communication quality than caregivers recognized in them, suggesting that caregivers may underestimate children\u0026rsquo;s communication abilities. It is important to further investigate how to improve caregivers\u0026rsquo; perceptions of communication quality with their child given that both caregiver and child reports of communication quality were significantly associated with overall family relationship quality, underscoring the interdependence of communication and family functioning in the oncology context. This extends evidence that effective communication is not only protective but also relationally dynamic, whereby multiple domains of family well-being may be associated.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eOur findings also extend previous research documenting communication gaps in pediatric oncology. For example, Wiener et al. (2015) identified mismatches in caregiver and child understanding of emotional needs; our study expands this work by quantifying specific domains of discrepancy and linking them to family functioning outcomes. Consistent with earlier literature, open and supportive communication was associated with greater cohesion and reduced distress within families facing cancer.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Studies in other chronic pediatric conditions such as cystic fibrosis, type 1 diabetes, and juvenile idiopathic arthritis have similarly highlighted communication as a central determinant of adherence, emotional adjustment, and family cohesion.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] However, while most prior research has evaluated caregiver or child perspectives separately, relatively few have systematically examined congruence and discrepancy between the two. This study therefore adds important nuance by showing that even when families report generally \u0026ldquo;good\u0026rdquo; communication, misalignments in perception can still exist and these misalignments carry implications for family functioning.\u003c/p\u003e\u003cp\u003eBeyond overall discrepancies, developmental and cultural factors influenced perceptions of communication. Younger children and caregivers reported higher communication quality, while adolescents reflected the challenges of balancing autonomy with parental guidance. These developmental differences mirror prior research indicating that younger children are more reliant on parental reassurance and may respond positively to clear, consistent explanations.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] In contrast, adolescents often seek greater independence in medical decision-making and may withhold information if they perceive parental control as limiting. This aligns with broader adolescent development literature showing that autonomy-supportive communication fosters resilience, whereas controlling communication can provoke resistance and conflict. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eCultural differences also emerged, with non-Hispanic families reporting higher communication quality than Hispanic families. Although exploratory due to the small Hispanic subsample, these findings echo studies demonstrating that Latino families often face barriers in healthcare communication, including language proficiency, interpreter availability, and culturally specific norms around caregiver\u0026ndash;child dialogue.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] For instance, Spanish-speaking caregivers have reported less partnership and lower respect from providers than English-speaking white caregivers.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] While our findings cannot fully disentangle these influences, they highlight the importance of considering both structural and cultural factors in understanding communication quality.\u003c/p\u003e\u003cp\u003eThe findings have clear relevance for pediatric oncology practice. Oncologists and nurses are in a key position to coach families, by observing interactions during clinic visits and gently offering guidance. In line with this, the American Academy of Pediatrics and psychosocial oncology standards have called for evidence-based guidelines to improve communication in pediatric cancer care.[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Therefore, routine assessment of family communication should be integrated into care through brief screening tools or structured discussions, allowing early identification of families struggling to maintain open dialogue. Communication-focused assessments have been recommended in psychosocial oncology guidelines[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] but are not consistently implemented. Our results support their integration as a standard component of pediatric cancer care. Second, interventions must be developmentally tailored. For younger children, caregivers may need support in providing clear, age-appropriate explanations and opportunities for expressive outlets such as play or drawing.[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] For adolescents, clinicians should facilitate open conversations that respect autonomy, including opportunities for private consultations and involvement in treatment decisions. This echoes evidence that autonomy-supportive care strengthens adherence and emotional regulation in adolescent patients.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Third, culturally responsive practices are essential. Studies have shown that culturally adapted interventions in pediatric chronic illness management improve adherence and family engagement.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] In oncology, this may include interpreter services, linguistically appropriate educational materials, and collaborations with cultural liaisons or community health workers to ensure families feel empowered to participate in open dialogue. Such approaches are critical for reducing disparities and ensuring equitable psychosocial support. Together, these implications highlight that strengthening communication is not only a psychosocial priority but also a pathway to enhancing adherence, emotional well-being, and family resilience during treatment.\u003c/p\u003e\u003cp\u003eThis study is not without limitations. The cross-sectional design prevents causal inference, limiting conclusions about how communication discrepancies influence outcomes over time. The study relied on self-reported perceptions, which may be subject to social desirability or recall bias. Additionally, the measure of communication included items for caregivers that may not actually indicate better quality communication with their child, despite contributing to better overall scores. For example, higher scores on the item \u0026ldquo;do you discuss child-related problems with your child?\u0026rdquo; and lower scores on the item \u0026ldquo;are there things you avoid discussing with your child?\u0026rdquo; were interpreted as higher quality communication. These items may instead tap into the concept of parentification, whereby a caregiver chooses to allow their children to assume an adult or parental role in the family.[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] Better measures of caregiver\u0026ndash;child communication should be developed to avoid this issue. In addition, the small number of Hispanic participants restricts generalizability. These limitations underscore the need for replication in larger, more diverse samples and through multimethod approaches, including observational data.\u003c/p\u003e\u003cp\u003eFuture studies should explore the origins of caregiver\u0026ndash;child perception gaps, investigating whether discrepancies arise from caregiver underestimation, child overestimation, or both. Longitudinal research is needed to examine how communication and perceptions evolve across the treatment trajectory, from diagnosis through survivorship, and to identify periods when interventions may be most impactful. Expanding work in underrepresented and non\u0026ndash;English-speaking populations is essential to ensure findings are generalizable and to inform culturally tailored interventions. Finally, linking communication discrepancies directly to outcomes such as child anxiety, treatment adherence, and family functioning will provide stronger evidence for integrating communication-focused interventions into standard care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights significant discrepancies between caregiver and child perceptions of communication in the pediatric cancer context, with important implications for family functioning and psychosocial outcomes. While both groups reported generally high communication quality, children consistently rated communication more positively than their caregivers did. These mismatches, shaped in part by developmental and cultural factors, underscore the need for routine communication assessment and the development of targeted, developmentally appropriate, and culturally responsive interventions. Strengthening caregiver\u0026ndash;child communication may serve as a critical pathway to enhancing psychosocial well-being and overall family resilience during pediatric cancer care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported in part by an award from the William F. Vilas Trust Estate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMicah Skeens and Kitty Montgomery contributed to the study conception and design. Material preparation, data collection and analysis were performed by Mariam Kochashvili and Anna Olsavsky. The first draft of the manuscript was written by Micah Skeens and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript\u003cstrong\u003e\u003cem\u003e.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committees of University of Wisconsin-Madison (#2023-0921)\u0026nbsp;and Nationwide Children\u0026rsquo;s Hospital (IRB#00003499; approved 10/20/2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study and written informed consent was obtained from the caregivers of children under the age of 18 and verbal assent was obtained from the children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript does not contain any individual person\u0026rsquo;s data in any form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available but will be made available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eH. 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Lim, \u0026quot;The positive and negative aspects of parentification: An integrated review,\u0026quot; \u003cem\u003eChildren and youth services review, \u003c/em\u003evol. 144, p. 106709, 2023.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"pediatric cancer, communication, symptom science, caregivers, family functioning","lastPublishedDoi":"10.21203/rs.3.rs-7776804/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7776804/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003cbr\u003e\nEffective parent–child communication is central to coping with the psychosocial challenges of pediatric cancer, yet few studies have examined how caregivers and children perceive their communication. This study investigated congruence and discrepancies between caregiver and child reports of communication and associations with family relationship quality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nSeventy-six caregiver–child dyads (N=152) were recruited from two Midwestern pediatric hospitals. Children aged 8–17 with cancer and their caregivers independently completed measures of parent–child communication (PCCS) and family relationships (PROMIS). Descriptive statistics, correlations, and paired- and independent-samples t-tests were used to examine differences and associations across dyads, with attention to demographic and clinical factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nBoth caregivers (M=3.95, SD=0.58) and children (M=4.15, SD=0.61) reported generally high-quality communication. However, significant discrepancies emerged: children rated caregivers as more attentive listeners (t(74)=2.53, p=.01), emotionally open (t(74)=2.30, p=.02), and willing to discuss problems (t(74)=2.86, p=.005) than caregivers reported their children. Child-reported communication correlated strongly with child-reported family relationships (r(75)=.75, p\u0026lt;.001), while caregiver reports were moderately associated with both their own and children’s assessments of family relationships. Age effects were observed, with older parent and child age linked to lower communication scores, and non-Hispanic caregivers reporting higher-quality communication than Hispanic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nSystematic discrepancies in caregiver and child perceptions of communication represent an underrecognized factor influencing family functioning in pediatric cancer. Findings underscore the importance of routine communication assessment and highlight the need for developmentally and culturally tailored interventions. Supporting families in bridging perception gaps may enhance psychosocial adjustment, strengthen family resilience, and improve treatment adherence.\u003c/p\u003e","manuscriptTitle":"Toward Better Conversations: Assessing Caregiver–Child Communication in Pediatric Oncology","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-17 06:38:51","doi":"10.21203/rs.3.rs-7776804/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-01T22:29:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-01T22:19:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-01T22:04:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24264010177038156651518913256574063819","date":"2025-11-12T17:00:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44601552982207958303473387960443946387","date":"2025-11-06T01:22:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-06T00:53:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-06T00:13:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-07T23:35:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2025-10-04T01:49:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7ea82e6c-32de-4d78-aecd-62eb441d13a6","owner":[],"postedDate":"November 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:01:28+00:00","versionOfRecord":{"articleIdentity":"rs-7776804","link":"https://doi.org/10.1007/s00520-026-10446-y","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2026-02-17 15:58:10","publishedOnDateReadable":"February 17th, 2026"},"versionCreatedAt":"2025-11-17 06:38:51","video":"","vorDoi":"10.1007/s00520-026-10446-y","vorDoiUrl":"https://doi.org/10.1007/s00520-026-10446-y","workflowStages":[]},"version":"v1","identity":"rs-7776804","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7776804","identity":"rs-7776804","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}