Cool Kids Don't Cry (Achtste-groepers huilen niet) (2012)

This page discusses the whole story, including the ending.

Akkie is eleven, in her final year of Dutch primary school, football-mad and quick to fight. Her chief enemy is Joep, a classmate she cannot stand. The film is adapted from Jacques Vriens's 1999 children's novel, and it was a considerable hit in the Netherlands.

After a playground scrap she is taken ill, and tests show leukemia, a cancer of the blood and bone marrow. Treatment pulls her out of school and into hospital. She loses her hair, is embarrassed by it, and is furious at being handled carefully. Her teacher keeps her place in the class, and she keeps insisting on being treated exactly as before.

On the school camping trip she gets stuck up a tree, and it is Joep who talks her down. The enmity turns into friendship and then into something like first love.

Then the disease comes back and spreads to her brain. She cannot play in the school football tournament she has been aiming at, so her classmates bring the match to her and play where she can watch from her hospital bed. She dies watching them. Her team plays the tournament with her name on their shirts.

This is a children's film, and it is unusually unsentimental about what a class of eleven-year-olds does with news like this.

It shows the awkwardness and the whispering. It shows a teacher who has to explain something he cannot explain to himself. It shows the friends who overcompensate and the ones who quietly stay away, and it does not condemn either group.

It also lets adults be visibly frightened in front of children, which most films for this age refuse to do. Children generally know when adults are pretending, and the pretending is often more frightening than the truth.

Akkie's fury at being treated as fragile is the truest thing in the film.

School-age patients describe this constantly. The illness changes how everyone speaks to them, what they are allowed to do, and whether anyone will still argue with them. Losing the right to be ordinary is often mourned more than the treatment itself.

The physical texture is shown rather than implied: hair loss, the central line (a thin tube placed in a large vein for treatment), isolation when the immune system is low, exhaustion, and the cycle of feeling better and then worse.

The relapse also arrives without warning, which is how relapse arrives. Spread to the central nervous system, meaning the brain and spinal cord, is a genuine complication of leukemia.

Diagnosis, remission, relapse, brain involvement and death all fall inside one school year. That is the film's largest liberty.

NCI puts typical treatment for childhood acute lymphoblastic leukemia at two to three years of chemotherapy. It runs through remission induction, then consolidation, then a long maintenance phase at lower doses. What the film compresses into montages is, in real life, most of a childhood.

Akkie's deterioration is also confined mostly to tiredness and hair loss. Leukemia in the central nervous system usually brings headaches, vomiting, and neurological changes. She is lucid, funny and comfortable in her last scene, which is a kindness to the audience rather than a description.

The other omission is the boring one. Childhood leukemia is mostly clinic visits, blood counts and tablets taken at home for years, and almost none of that reaches the screen.

The film says only "leukemia". In a child of eleven the most common form is acute lymphoblastic leukemia. It begins in the bone marrow, where abnormal immature white cells build up and crowd out healthy blood cells.

NCI lists these signs in children:

• Fever.
• Easy bruising or bleeding.
• Petechiae, which are flat pinpoint dark-red spots under the skin caused by bleeding.
• Weakness or fatigue.
• Pale skin, or looking pale.
• Bone or joint pain.
• Shortness of breath.
• Painless lumps in the neck, underarm, stomach or groin.
• Pain or a feeling of fullness below the ribs.
• Loss of appetite, and weight loss.
• Abdominal pain.
• Frequent infections, or infections that do not go away.

Read as a list this is alarming, and it should not be. Every item is far more often something ordinary. What matters is persistence and combination: a child who is pale and tired and bruising, or who has been unwell for several weeks without a clear reason.

The other point NCI makes is worth repeating to any parent who feels they are making a fuss. The only way to know is for the child to be seen.

Diagnosis uses a complete blood count with differential, a blood chemistry study, and a bone marrow aspiration and biopsy to confirm the type.

A lumbar puncture is also done. A needle draws a small amount of fluid from around the spinal cord so it can be examined for leukemia cells. That is not a formality. It is looking for exactly what happens to Akkie.

If leukemia is present in the central nervous system, treatment changes. It also explains a feature of the standard protocol that puzzles families: chemotherapy given directly into the spinal fluid, called intrathecal treatment. Most drugs given into a vein do not reach the brain and spinal cord well, so those areas can shelter leukemia cells. Intrathecal chemotherapy is given to prevent that, not because anything has gone wrong.

There is no screening test for childhood leukemia, and no health body recommends screening well children for it.

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This is a film for children about a child dying, and it does not soften the ending. It is well made and it will upset most viewers under about twelve, which is arguably the point.

If you are watching it with a child who knows someone with cancer, the honest framing is that Akkie's timeline is much faster than most, and that treatment for childhood leukemia usually lasts years and often works.

If you are here because your own child has been unwell for a few weeks, the practical step is small: ask about a complete blood count. See possible warning signs and screening.

This page discusses Cool Kids Don't Cry for education. It is not medical advice, and nothing here is a judgment of anyone's real medical care. Spotted an error? Please email corrections@cancerexplained.org.