Coping is universal. Life brings all kinds of stresses that must be managed in order to survive, grow, and thrive. Day-to-day living involves coping with numerous stresses and hassles. While there have been many ways to describe coping, perhaps the most comprehensive definition is that of Richard Lazarus, whose theory and research have guided much of the coping field. Coping means “cognitive and behavioral efforts to manage specific external or internal demands (and conflicts between them) that are appraised as taxing or exceeding the resources of the person” (Lazarus and Folkman 1984). Coping is essential when we are faced with a situation or condition that is both potentially stressful and meaningful. Coping is a fluid process that is a transaction between the person and the environment affected by one’s age, personality, experiences, and situational demands.

Coping in the context of cancer describes a method of integrating the cancer experience into the existing personality of the patient or family member. This requires acknowledging the threat cancer poses and the demands of cancer treatment while, at the same time, managing emotional reactions and maintaining essential aspects of the child’s or family member’s identity and role in the family and community.

Every cancer patient and every family member must find ways to cope with the disease, its treatment, and sequelae, each of which presents an unfamiliar set of stressful situations. From the initial difficult diagnosis discussion, to the challenges of survivorship or the heartbreak of a child’s death from cancer, coping defines the interaction of the person with the cancer experience. In describing the intense emotional reactions children and families exhibit, Simms et al. (2002) referred to “clinically relevant distress” as distinguished from psychopathology, pointing out the inevitability of distress in the context of a cancer diagnosis. He noted that high-level distress in the context of a high-level threat like cancer represents an appropriate, not a pathological, response. This is true at diagnosis and also at points of potential or actual medical exacerbation, such as entry into stem cell transplantation or relapse. Sensitive experienced clinicians can distinguish appropriate reactions at such a point from reactions indicative of poor coping and unstable emotional status.

Anger is not uncommon at these times, but sometimes it is so intense and unrelenting that it signals deeper problems and requires more attention.

As treatment continues, stressful situations continue to present themselves and it is important to understand the specific stressors with which the person must cope, as coping depends on context. We have outlined many of the stressors that children and families have to face throughout and after treatment (Patenaude and Kupst 2011). For example, after diagnosis and in early treatment, parents must try to absorb all of the medical and treatment information they receive in order to make rapid decisions about their child’s treatment. At the same time, they seek to support their child, manage their own emotions, and begin to integrate hospital demands with home, work, and family needs. Children must deal with unfamiliar, invasive, and painful procedures, side effects of treatment, and interruptions of school, peer, and social activities. They must often cope with separation from their families and friends and with adjustment to the hospital environment. Even when treatment ends, children and parents must try to balance their happiness and relief that treatment is over with the loss of the support they relied upon from treatment and staff. After so much time focusing on cancer and treatment, it is challenging to reorganize family, work, school, and social lives while maintaining optimism about future health, knowing there is the lurking possibility of recurrence or relapse.

Survivorship can mean the end of cancer, but the need to cope persists as children and parents manage the physical, neurocognitive, and/or psychosocial late effects of treatment. In some cases this involves coping with diminished cognitive functioning and changes in academic and vocational plans. Late effects may require children to cope with general medical and/or psychosocial follow-up, repeated assessments, and ongoing care for posttreatment conditions (see Chap. 15 on Survivorship).

Clinical work with children with cancer makes us aware that, in addition to the burdens and fears associated with the diagnosis of a child with cancer and the treatment and uncertainty which follow, cancer is often not the only major stressor families are experiencing. We detail here several examples of family experiences, which may further burden the coping resources of families where a child has cancer. Some relevant concurrent stressors can be serious illness in a parent themselves or in another family member (see section on the stress of hereditary cancer); chronic illness of a sibling requiring special education or home care; economic problems including work, insurance, and housing; and low levels of social support.

The way people cope and the effectiveness of their coping strategies determine how well they adapt to the series of stressful situations that are part of cancer diagnosis, treatment, and survivorship. Knowing a person’s typical coping style can help a clinician select optimal ways to approach children and families. Some people prefer to have a great deal of information (“monitors”), while for others a large amount of detailed information can increase anxiety (“blunters”) (Miller 1995). For those who prefer the monitoring style, seeking and receiving information is a way of coping that helps them to adapt to the situation through perceived control. For those who have a blunting style, presenting an overview followed by several small increments of information may reduce anxiety. Similarly, it is often assumed that talking with others helps people cope with stress, and for some people this is true. However, others may prefer to be alone in order to process their thoughts and manage their emotions before talking with others. Knowing which way people typically cope can help in providing effective interventions. This information can also be usefully shared with the medical team to help guide their interactions with the patient and family.

It used to be that a “defensive” style was considered negative, but more recent work has tempered that belief somewhat (Phipps et al. 2006; Harper et al. 2014). In several studies, children and adolescents with cancer showed lower levels of anxiety and reported fewer psychological problems than children in the general population or those with other medical conditions. A possible explanation offered was that such reports represented denial or repression. However, a “repressive adaptational” style (Phipps et al. 2001) is not necessarily problematic and can be adaptive, especially early in the cancer experience when the volume of emotionally upsetting information received can approach unbearable levels. Finding a good fit between style or disposition to cope and the demands of the situation can enable the clinician to help improve patient or parent coping and/or to offer reassurance that the approach will not prove detrimental. Past research has helped us define successful adaptation to cancer as coping which allows the child to tolerate bad news and unpleasant treatment and to express appropriate emotions, yet to remain in reasonable interpersonal connection with others in the hospital or home setting and to continue to experience themselves as whole and cared for. For parents, coping means being able to understand the realities and implications of the medical information about diagnosis and treatment, to regulate strong emotional reactions and maintain equilibrium, and to do what is necessary to participate in care of the child and attend to other responsibilities.

The stress and coping framework suggests that when a person is presented with a stressful situation, they must determine if it represents a significant threat or stressor. If it does, the next question they need (often unconsciously) to ask is, “Can I change or affect it in some way?” This second question involves the potential use of a range of different coping strategies. Several schools of thought (see reviews by Aldridge and Roesch 2007; Skinner and Zimmer-Gembeck 2007) suggest that, in cases where something can be changed, an active, problem-focused coping “approach” can be most helpful. These would be efforts such as seeking information, problem-solving, or confronting the stressor. For a child with cancer who is going to miss school for treatment, it may mean getting information about alternative ways to keep current with schoolwork and peers. In cases where the stressor cannot be changed and the reality that cancer will mean stopping an activity such as sports may require emotion-focused coping strategies such as cognitive reappraisal or acceptance. When a situation is not changeable, a person can change how he or she thinks and feels about it and can utilize stress management techniques such as distraction, relaxation, etc., to manage the situation (see reviews by Compas et al. 2012; Vrijmoet-Wiersma et al. 2008). It is, however, always important to acknowledge that people may use many different strategies over time or even in response to the same stressor. There is no 1:1 algorithm that a particular stressor will always necessitate the use of a particular coping strategy, but rather that the circumstance and the person define the optimal approach. The solid research published in recent years by Bruce Compas and colleagues offers promise to better understand individual use of strategies in various situations, as well as development of interventions to teach or enhance coping (Compas et al. 2014).

An example of differences in coping is the way childhood cancer survivors deal with ongoing cancer activities. Some survivors become actively involved in volunteer efforts, such as camps for children with cancer, survivorship groups, fund raising for cancer-related causes, and mentoring newly diagnosed patients. It is not uncommon for survivors to pursue careers in nursing, medicine, social work, psychology, or child life and some express their desire to help others with cancer as they were helped. Others however consider their cancer experience “ancient history” as one young man put it, and they focus more on “getting on with the rest of my life.” This isn’t denial or repression. He freely spoke about having had cancer and his treatment, including late effects, and has kept in touch with staff and patients he met during his treatment, but his focus has shifted away from cancer. Both are ways of coping and demonstrate that individual approaches can be equally adaptive.