Refocusing on Competencies: A "Yes AND Approach" to the Child Life Crisis 

The definition of a Certified Child Life Specialist (CCLS) in the simplest form is an individual that is proficient in the child life competencies. The competencies (see Table 1) provide the foundation for child life services that are individualized, developmentally grounded, trauma-informed, relationship-oriented, play-based, and resilience focused (Boles, et al. 2020). Child life competencies are applicable to diverse settings and populations (Lowry, et al., 2023), yet an overarching theme in the current pathway to the profession is that it is largely situated within healthcare settings. This creates incongruence. The authors recognize and value the historical roots child life has in healthcare settings and the services provided in these settings. However, it is time to equally recognize that child life services, rooted in the child life competencies, are not setting-specific, and therefore the pathway to child life must also reflect this reality. Once this is accomplished, the pathway becomes less restricted and services become more accessible to all children and families in need.

Refining the Current Pathway

Disrupting the current system of education and clinical experiences to include community settings brings many benefits and solves many crises currently in the field, including:

• Facilitates an expansion in pre-internship and internship opportunities providing much needed relief for healthcare settings.
• Supports diversity, equity, and inclusivity by expanding opportunities to be more accessible to all students pursuing child life.
• Increases sustainability by creating professional choice, decreasing burnout and increasing retention as child life specialists are afforded opportunities to learn and grow both the profession and professionally.
• Expands child life services to reach more children and families experiencing stressful circumstances.
• The child life field needs innovative solutions that support sustainability and growth throughout the entire pathway to the profession. 

Academic Training

The competitive nature of internship sites (currently centered in healthcare) forces academic programs to largely base their curriculum on “patients”, “illness, injury”, and “hospitalization.” This limits students’ application of the competencies in all settings. Courses should always be discussed in the context of diverse settings with diverse populations, not just in relation to healthcare settings and populations. Academic programs struggle to balance the required courses for certification, courses desirable to internship sites (e.g., medical terminology, anatomy and physiology), and additional courses (e.g., trauma-informed care, stress and coping) that prepare students to meet the ever-changing needs of children and families in diverse settings. Child life education and training should focus on the ability to apply theory to practice in all settings where families experience crisis. The competencies guide child life specialists to assess a child and family holistically using all their lived experiences to create meaningful interventions. Even courses focused on illness and disease should use an inclusive lens that recognizes illness does not just happen in a vacuum but in settings within and outside of traditional healthcare. 

Clinical Training

Pre-internship and internship training opportunities are extremely limited and grossly disproportionate to the students seeking them. Clinical sites have long reported regularly receiving 50-200 applications for 2-4 clinical positions. Most importantly, these limited clinical training opportunities are restricting the number of CCLSs entering the field and therefore also limiting the settings and populations of children and families receiving child life services who could greatly benefit.  As a profession, we must consider what is lost by restricting access to clinical training and limiting employment opportunities by arbitrarily defining the profession to be only situated in healthcare environments.

A shift needs to take place in which diverse training and clinical hours are not just tolerated but valued. Internship hours required for certification eligibility currently state that “some” of the hours must be completed in a hospital setting (CLCC, 2019). While there are no minimum hour requirements attached to this statement, it once again highlights the focus on training students in healthcare settings. Clinical training (pre-internship experiences and internships) should focus on gaining the competencies of a child life specialist, under the supervision of a CCLS, in any setting the child life specialist practices.

Certification Exam

In addition, the certification exam needs to be reflective and inclusive of child life competencies within all settings. Currently, the exam domains explicitly use language such as “healthcare”, “patients”, and “illness, injury, and healthcare” rather than “stress”, “trauma”, “crisis”, “children and families.” This is a direct result of the content being driven by the job analysis (conducted every 5 years) rather than the competencies. The job analysis “determines the tasks a CCLS performs as well as the knowledge, skills, and abilities needed to perform those tasks competently (CLCC, 2023).” While the latter sounds like competencies, it begs the question, “What drives the definition of a Certified Child Life Specialist?” Is it current practices or the Child Life Competencies? If we solely rely on current practices, the field is at risk of diminishing, or worse eliminating, the very value of the child life specialist outlined by Boles et al. (2020). In addition, the Child Life Certification Commission Clinical Experience Verification Form (2019) centers solely on the child life certification exam, not the child life competencies. Is best practice “teaching to the test” or should we be evaluating “competency” of the student in becoming a CCLS professional?

Adjusting the pathway to certification to be inclusive of community settings opens the door for students to enter the field in whatever setting fits their professional interests and personal needs. Expanding supervision of clinical experiences to community sites creates more diverse and accessible entries into the field for students unable to relocate or meet the requirements for work within a healthcare facility. It validates the role of CCLSs working outside of healthcare and helps them reclaim the title of CCLS in roles currently being identified under other job titles. It is imperative that we continuously reevaluate the requirements to become a CCLS and ground the academic and clinical training required in the core competencies of the profession, not a specific setting.

Valuing Diverse Settings

It is currently recommended that CCLSs complete 6,000 hours of work in healthcare before engaging as a CCLS in a community setting (ACLP, 2022b). The gross assumption here is that somehow healthcare experience provides competency in and for other settings, whereas community experiences do not provide learning that is useful to healthcare settings. In reality, each setting a CCLS works in requires “on the job” training and specialization. Whether you are a CCLS in the Emergency Department, a Hem/Onc unit, the prison system, or in disaster relief, setting and population-specific training is required to provide the most appropriate and effective services to those served. The same is true for other professionals as well (e.g., social workers, nurses, physical therapists, teachers). They obtain their credentials based on general competency, then gain on the job training specific to the setting and population being served. When the field is recentered on competencies, child life experiences gained in any setting will be applicable to any setting. Diversity of experiences actually adds value that deepens our understanding, assessment, and interventions with children and families enduring stressful situations. 

Implications & Conclusions

The current crisis puts the child life profession at risk of losing footholds in the field that have taken decades to establish. With vacant positions and limited opportunities to fill them, child life programs risk losing those positions in future budgets. Shrinking departments unable to provide internships lead to qualified students leaving the field before they get started. Further, the current crisis has exacerbated existing issues of diversity, equity, inclusion, and accessibility within the  field (ACLP, 2020).

Child life specialists have historically focused their role in healthcare settings. The goal is not to diminish the healthcare role but to make space for the child life profession in all settings. We must take a “Yes and’’ approach to child life. Yes, child life specialists play an important role in multidisciplinary teams in healthcare settings AND serve in community settings wherever children, youth, and families encounter stress. By accepting child life specialists in community settings as a “traditional” role of child life, we create a powerful circle of care. Child life services are not limited to those children and families that attain traditional healthcare services, but are expanded to the children who witness a medical emergency but do not require medical attention; to children who need help translating terminology in a court setting; to teens grappling with the effects of school shootings; to youth affected by the any losses that accompany disasters, and to so many more. By connecting and supporting child life specialists in all settings, we create a powerful network of collaboration and enhance  continuity of care.

Since the competencies are already inclusive, we must use them more directly to support opportunities for equity, sustainability, and growth in the field. The current ACLP 2022-2024 strategic plan supports the education and clinical training that leads to diversity in the field [3b] and promotes professional opportunities resulting in increased services for children and families[5b] (ACLP, 2022a). The competencies must be the consistent and firm foundation for the entire pathway to the profession - in academics, clinical training, and certification exam. This will “create a more diverse and equitable entry into the field” (Lowry, et al., 2023), mitigate many of the current crises, and ultimately benefit more children and families experiencing stress.

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