Beyond Survival: Anxiety, Depression, and Unspoken Fear of Death Among Children and Adolescents with Cancer in Saudi Arabia

When a child is diagnosed with cancer, the medical world focuses intensely on survival. Doctors and families work tirelessly to eradicate the disease, measuring success in years of life gained and tumors removed. In wealthy nations, the majority of children now survive their illness, shifting the medical conversation from mere survival to the quality of life that follows. Yet, the journey through cancer is not just a physical battle; it is a profound psychological ordeal. The fear of the unknown, the pain of treatment, and the disruption of a normal childhood can weigh heavily on a young mind. While it is well known that cancer causes emotional distress, the specific nature of this burden varies across different cultures and healthcare systems. In the Arab world, and specifically in Saudi Arabia, there has been a significant gap in understanding how children and teenagers experience this emotional toll. Without local data, doctors cannot fully tailor their support to the unique cultural and clinical realities of their patients.

A team of researchers in Saudi Arabia set out to fill this gap by listening directly to the children themselves. They conducted a study at a major hospital in Jeddah, inviting children and teenagers aged eight to eighteen who were currently fighting cancer to share their feelings. The researchers used a standard questionnaire, translated and tested for Arabic speakers, which asked the young patients about their worries, their sadness, and their general emotional state. The goal was not just to count how many children felt anxious or depressed, but to understand who was struggling the most and what factors in their treatment or lives might be making things harder. They looked at variables such as age, gender, the type of cancer, and the intensity of the medical treatment the children were receiving.

The study involved sixty-seven young participants, a group that reflected the typical mix of cancer cases seen in Saudi Arabia, with leukemia being the most common diagnosis. When the researchers analyzed the answers, they found a heavy emotional burden. Using established benchmarks to define what counts as a clinical level of distress, they discovered that one in four children met the threshold for significant anxiety, and nearly one in five met the threshold for depression. When looking at the combined picture of anxiety and depression, the number rose to nearly one in four. These rates were notably higher than what is typically seen in general populations of children, suggesting that the experience of cancer in this setting carries a unique psychological weight.

Certain groups within the study appeared to be at higher risk. The data showed that female participants reported significantly higher levels of distress than their male counterparts across all measures. Age also played a role; older children and teenagers tended to report higher levels of depression than the younger children in the study. This aligns with the understanding that adolescence is a time of intense identity formation and social pressure, which cancer can severely disrupt. Furthermore, the type of treatment mattered. Children receiving a combination of different therapies, such as chemotherapy alongside other intensive treatments, reported the highest levels of emotional distress. This suggests that the intensity of the medical regimen is directly linked to the psychological strain on the patient.

One of the most striking and unusual findings emerged from a single question on the survey: "Do you think about death?" While most children answered this question using the standard scale provided, a significant portion of the group—about twenty-one percent—did not. Some crossed the question out, drew a sad face, or simply left it blank while answering every other question on the form. The researchers interpreted this not as a mistake or a lack of attention, but as a deliberate act of avoidance. The rate of this specific avoidance was hundreds of times higher than for any other question on the survey. This behavior suggests that the topic of death is so emotionally overwhelming for these young patients that they instinctively shut down when confronted with it. Even among those who did answer, the frequency of thinking about death was strongly linked to higher scores of anxiety and depression, indicating that fear of mortality is a central, unspoken part of their experience.

Interestingly, the study found a paradoxical result regarding the use of steroid medications. Children who were taking steroids reported lower levels of distress than those who were not. The researchers noted that steroids are known to cause temporary mood elevation or euphoria, which might have masked the underlying anxiety at the time of the survey. This finding highlights the complexity of measuring emotions in a medical setting, where the very drugs used to treat the disease can temporarily alter how a patient feels and reports their mental state.

The study also addressed a critical limitation in how these emotions are measured. The questionnaire used was originally designed and tested on children in the United States. When the Saudi researchers applied the American standards to their local data, they found that the average Saudi child with cancer was already scoring at the very top end of the "normal" range before even reaching the threshold for clinical concern. This suggests that the American standards may not be sensitive enough to capture the true level of distress in Saudi children. The researchers argue that the local population likely experiences a higher baseline of psychological strain, and using foreign benchmarks risks underestimating the severity of the problem.

Ultimately, this research provides a clear, evidence-based picture of the emotional landscape for children with cancer in Saudi Arabia. It identifies adolescent girls and those undergoing intensive combined treatments as the most vulnerable groups. It also reveals a deep, often silent fear of death that many children are too overwhelmed to articulate directly. The findings call for a shift in how care is delivered, suggesting that psychological support needs to be integrated directly into cancer treatment plans. Rather than treating emotional health as a secondary concern, the study argues that addressing anxiety, depression, and the unspoken fear of death is essential for the holistic care of these young patients. The work underscores the urgent need to develop local standards for measuring mental health in the region, ensuring that future support systems are built on data that truly reflects the lives of Saudi children.