Dealing with Terminal Illness, Dying, and Death with Children at Their Level

by John M. Briley, MD, Pediatrics

Children need accurate information at their level of understanding.

If a child overhears adult snippets of conversation regarding a dying family member—worried whisperings or “secret” conversations that are cut off when the child enters the room—he or she may imagine all sorts of scenarios, most of them wrong and frightening. Children may also feel they are to blame for the death because they are left out.

Consider the child’s level of understanding:

0-2 years of age:

·       Can’t understand. Simply comfort and support them. Keep schedules the same and don’t introduce new routines such as toilet training, etc.

2-6 years of age:

·       Trouble differentiating alive from not alive. Their teddy bears, dolls, and many toys can be “alive” to them.

·       Magical thinking about cause and effect. That means they can think that by being mad at the person, being naughty, or wishing the person dead they caused the person to die.

·       May not understand death is permanent and think that “Grandpa” will come back.

7-11 years of age:

·       Most accept that death is permanent, are self-oriented, and may show concern about their own deaths.

·       Physically-oriented: they may be upset by physical changes in an ill or dying family member and may look for similar changes in their bodies.

·       Abstract concepts like “heaven” can be confusing.


Toddlers: Toddlers are very concrete.

·       Realize that their way of viewing, feeling, and expressing their grief at their level is very different from that of the older child or adult: not right or wrong, just different.

·       Let them take the lead by their questions. When answering, be honest but age appropriate:  “Is Grandma real sick?” –“Yes”; “Is Grandma gonna die?” –“We don’t know.”

·       Then, continue the conversation. “How do you feel about Grandma being sick?” And so on.

·       Watch for ways they express their grief and anger about the death:

o   The pictures they draw/color. Discussing them is a good segue to further discussion. Don’t make concrete observations because you might misinterpret the child’s view. Instead, ask open questions like, “What is this?” or make general observations like, “This person looks like they’re really feeling something. What is that person feeling?” Then, “Why do you think that person feels that way?” And so on. Also, the child’s choice of color can also reveal the child’s mood.

o   Acting out behavior such as hitting a favorite stuffed animal or throwing toys, etc. If you see this, rather than tiptoe out of the room gently ask why. Or if they cannot answer, guide them into a conversation.

·       Routine comforts kids, especially younger kids, as it suggests normalcy. Make certain their routines remain unchanged as much as possible. In a grieving household, there is often a change in priority of activities and the appearance of new ones. If a routine is about to change, even temporarily, explain this to the child.

 Children 5/6-11 years of age:  Though they are at a higher level of ability of understanding and functioning, some problems and management methods resemble those of the toddler.

o   Spend “quality” time with them. Shoot hoops, go for ice cream, play games, etc. If you cannot do it, enlist the help of an adult they trust

o   Make sure they spend time with their friends.

o   If they notice you grieving (crying, for example), let them know it is not their fault and share how you feel (be honest but don’t overload them with too much information).

o   If possible, ask the dying person to get involved. Perhaps the person could write a letter praising the child and saying how loved and treasured the child is; perhaps the person would be in a photo or video with the child or share an activity they had enjoyed.

The above is not a complete list, and a question may have more than one correct answer, depending on the child’s age and the family’s cultural beliefs.

Aloha nui and God bless.

You can send individual questions for Dr. Briley to:  For more personalized information, contact Nā Keiki O Emalia (808.214.9832) or Hospice Maui (808.244.5555).


John M. Briley, MD is a general pediatrician, husband, father of three, grandfather of five, and writer of middle grader fantasy fiction.

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