A Theoretical Vision for Child Life

ACLP Bulletin | Fall 2019 | VOL. 37 NO. 4

Donna Koller, PhD
Ryerson University, Toronto, ON, Canada
The child life profession is distinctive in the way it specializes in the psychosocial care of sick and dying children. The profession delivers exceptional psychosocial care to children and their families when they need it most. Because child life is uniquely valued and appreciated within pediatrics, progress and growth are necessary in order to maintain relevance in evolving healthcare environments. As per the Child Life Certification Commission (CLCC), part of this process involves a critical examination of theoretical paradigms to ensure currency and effective practices in the field (CLCC, 2019; Lookabaugh & Ballard, 2018; Woodhead, 2005).

The purpose of this article is to explore a way forward for the child life profession by drawing attention to some concerns regarding foundational theories in child life that derive from developmental psychology. In addition, I propose a more progressive theoretical stance that addresses present-day clinical needs and evolving views of childhood.

The Role of Theories in Practice

Essentially, theories are big ideas supported by strong explanations and evidence. Theories are especially powerful because they can influence everything we think and do, even when we may not know it. Despite substantial growth in the field of psychosocial care, there has been little to no attention paid to child life foundational theories. How can this be?

Developmental Stage Theories: Reasons to Think Differently

Theories are imperfect, but they should, for the most part, guide and support our work. If developmental theories do not always resonate with us, we should consider why. For too long, we have relied on a “developmentalist approach” that positions children according to age and stage (Burman, 2017). Piaget’s (1959) cognitive theory and Erikson’s (1963) psychosocial theory imply that all children evolve and grow at the same rate across cultures, and yet we know this not to be true (Deyhle & LeCompte, 1994; Freedman & DeBoer, 1979; Hughes, Devine, & Wang, 2018; Jordan & Tseris, 2018). These theories are largely informed by middle-class Eurocentric and colonialist perspectives that promote a singular and standard view of childhood (Callaghan, Andenæs, & Macleod, 2015; Miller & Scholnick, 2015; Pacini Ketchabaw & Taylor, 2015; Robinson & Jones Díaz, 2016; Woodhead, 2005).

Studies have found several inconsistencies with developmental stage theories. In particular, key concepts from developmental psychology have been refuted in cross-cultural research and other recent studies. For example, the process of language acquisition can differ greatly between children, as can the age at which children recognize their image in a mirror (Broesch, Callaghan, Henrich, Murphy, & Rochat, 2011; Kidd, Donnelly, & Christiansen, 2018). Research has also shown that sympathy arises in children as young as ten months, which is in opposition to Piaget’s claims that young children are predominantly egocentric (Kanakogi, Okumura, Inoue, Kitazaki, & Itakura, 2013; Oakley, 2004). Piaget’s research on conservation with preschoolers has been challenged in that children’s errors were found to be linked to how the questions were asked (Rose & Blank, 1974; Samuel & Bryant, 1984; Winer, Hemphill, & Craig, 1988). We should, therefore, be careful when applying developmental theories to all children and all situations.

For hospitalized children, developmental theories are particularly problematic. Developmental theories offer no guidance in terms of explaining or predicting behaviors in these children, and they do not tell us how to interpret the sequencing and timing of stages. These theories infer that “sick” children are aberrations from the norm because many of them do not fit neatly in a stage that aligns with an age (Black, 2013; James, 2004; James & Curtis, 2012). The “standardization” of the hospitalized child is often difficult to achieve because children’s abilities can vary tremendously across age groups (James, 2004; Koller, 2017). Furthermore, developmental theories applied to children in hospitals do not represent how these children perceive themselves and what they are experiencing (Alderson, Sutcliffe, & Curtis, 2006; James & Curtis, 2012). Finally, dominant theories of child development depict children as immature and passive objects, creating distance between adults and children that can inhibit active youth participation (Berman & MacNevin, 2017; Brady, Lowe, & Lauritzen, 2015; Burman, 2017; James & James, 2012; James & Prout, 1997; Koller, 2017). Despite all these concerns, the predominance of child development theories informed by developmental psychology has had a powerful and significant influence on policy, pedagogy, and practice (Robinson & Jones Díaz, 2016).

In the field of child life, we continue to revere developmental theories without any apparent critical appraisal. Questions regarding developmental theories are included on certification exams, and many child life textbooks focus almost exclusively on developmental frameworks as foundational to child life practice. While we may not need to entirely discard these theories from our teaching and practice, we must acknowledge their impenetrable stance and invite students to “problematize” the premise of stage theories (Blaisdell, 2019; James, 2004; James & James, 2012). Student engagement in the evaluation of theories promotes critical thinking and reflective practice over time—two essential skills for healthcare professionals. At the same time, educators in child life have an ethical responsibility to identify the benefits, risks, and limitations of all theories that inform practice. For child life pedagogy, this means that we must teach students how to think rather than just what to think.


The over-reliance on developmental theories has led to the practice of developmental assessments and the use of screening tools. While assessment tools can offer helpful information about a child’s abilities, we must be explicit about their benefits, risks, and limitations. These assessments impose power dynamics between the adult and child, predominantly because the child is forced to “perform” a range of skills required by the screening tool. For example, the Denver Developmental Screening Test appraises a child’s pincer grasp—a fine motor skill that involves picking up a raisin with two fingers. While fine motor skills are important, child life should remain focused on psychosocial care that emphasizes strengths and risks associated with a child’s social and emotional well-being. Let’s leave pincer grasp assessments to the occupational therapists!

A New Theoretical Vision for Child Life

Professionals have the responsibility to challenge dominant discourses and to be open to alternative ways of knowing. This notion is consistent with the Code of Ethics (Association of Child Life Professionals, 2019), revised by the Association of Child Life Professionals’ Child Life Certification Commission to guide and enforce the ethical standards for Certified Child Life Specialists. These regulations are communicated through 13 fundamental principles that are directly related to professional development and the implementation of best practices within the field. 

Specifically, Principles 5 and 6 state that Certified Child Life Specialists have a duty to maintain competencies in order to provide high-quality programs; this can be accomplished by “continually seek[ing] knowledge and skills that will update and enhance their understanding of all relevant issues affecting the children and families they serve” (Association of Child Life Professionals, 2019, p. 1).

Sociology of Childhood

Developmental theories are woven into the fabric of our society; these paradigms have shaped the ways in which children are understood (James & Prout, 1997). Because developmental frameworks are not always helpful in our work with children and families, professionals have looked elsewhere for theoretical relevance (Penn, 2014). For the past several years, the sociology of childhood and research involving child participants have shifted the focus from developmental stages to a strengthsbased model that views children as autonomous rights-holders (Alderson, 2007; Brady et al., 2015; James & James, 2012; Woodhead, 2005).

This alternative narrative emerged in the 1990s in response to dominant child development discourses (James & Prout, 1997). It posits that childhood is a social construction that is influenced by historical, political, and cultural contexts (Coyne, Hallström, & Söderbäck, 2016). Therefore, children are expected to develop differently based on a multitude of factors. Sociology of childhood “allows us to see the individual child as a social actor in the collectivity of children and allows us to recognise both the uniqueness of his/her childhood as well as its commonality as a life course phase” (James & James, 2004, p. 27).

We should make deliberate attempts to scrutinize our assumptions about how children develop and decide which aspects of developmental theories are worth keeping. We should also be prepared to embrace a strengths-based model that more adequately depicts the resilience and agency we see in children every day.

Social Determinants of Health

Because the sociology of childhood accounts for differences in how children develop, the social determinants of health are viewed as a way of understanding disparities in health outcomes (Johnson, Dickinson, Mandic, & Willis, 2011). Social determinants can include risk factors such as poverty, disability, racial minority, homelessness, and immigrant status (American Academy of Pediatrics [AAP], 2010; Carter, 2018; Ferraro, Schafer, & Wilkinson, 2016; Johnson et al., 2011; Newland, 2015). The greater the number of risk factors, the more devastating the effects on health (Ferraro et al., 2016). In practice, acknowledging that poverty has an insidious effect on children’s health demands a clinical approach that advocates equitable care for marginalized children and families. This approach differs drastically from a focus on whether a child’s behavior is “developmentally appropriate” or whether a child has a “developmental delay”—two terms that I propose should be eliminated from the child life vocabulary. Acknowledging diversity and the social determinants of health are key to ethical pediatric care (AAP, 2010; AAP, 2018; CLCC, 2019; Wheelwright, 2018), and current foundational theories in child life do not explicitly address these issues in practice.

Children’s Rights

Children as rights-bearers is another central premise of the sociology of childhood (Brady et al., 2015; Mayall, 2000). In child life, we have always believed that young people are experts in their own lives and are capable of communicating their perspectives with others. Indeed, child life specialists are often involved in promoting the inclusion of children in decision-making processes (Koller, 2017). These principles are consistent with Article 12 within the United Nations Convention on the Rights of the Child (UNCRC; United Nations General Assembly, 1989) and with Article 24, which advocates for the availability of quality healthcare. These tenets are represented in the “Position Statement on Child Life Services in Health Care Settings” (Child Life Council, 2011). The right to play and leisure—described in Article 31 of the UNCRC—constitutes the essence of child life practice. In summary, childhood is constructed as a unique period of life comprised of valuable “beings” with rights, rather than “becomings” who require control and protection (James & James, 2004; Mayall, 2000).

Inviting Discourse on a Way Forward

The sociology of childhood acknowledges that young people are constantly constrained by societal structures, and yet, if given the opportunity, can navigate these systems to enact change (Coyne & Gallagher, 2011; King & Cross, 1989; Koller & Farley, 2019; Koller & McLaren, 2012). In addition, the sociology of childhood offers contemporary views of what it means to be a child in today’s world and affords greater applicability in complex care environments than standardized theories of development. The sociology of childhood, therefore, offers a strengths-based model and should be considered a central feature of foundational theories in child life.

As a community of child life professionals, we need to engage in meaningful discourse around how we understand childhood and what it means to our work. Do our current theories capture the essence of what we do today? How do we combat against social determinants such as racial discrimination that often impede ethical care in pediatrics? Are children autonomous rights-holders or vulnerable patients in need of developmental assessments?

Critical discourse on theoretical foundations can create new purpose and stimulate growth in the child life profession. We should make deliberate attempts to scrutinize our assumptions about how children develop and decide which aspects of developmental theories are worth keeping. We should also be prepared to embrace a strengthsbased model that more adequately depicts the resilience and agency w see in children every day (Coyne et al., 2016; Jordan & Tseris, 2018; Mayall, 2000). This is not the time for complacency or a resistance to change. Let’s come together, celebrate our professional achievements, and build a progressive theoretical foundation for the future.


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