An Examination of Factors Associated with Child Life Internship Acquisition
The clinical internship is a key milestone in child life training, a pivotal juncture in the child life certification process (Boles et al., 2024). While each child life clinical internship site has the autonomy to specify its preferred qualifications for potential interns, child life training supervisors and coordinators generally prefer that aspiring professionals accumulate a diverse range of volunteer and/or paid experience hours working with children and families both in and outside of healthcare settings (Sisk et al., 2023). Some institutions and programs require a child life practicum prior to a child life internship placement, although child life practicum has never been a requirement for certification as a child life specialist (Association of Child Life Professionals (ACLP), 2024b, 2024a; Child Life Certification Commission (CLCC), 2024). Even the ACLP has acknowledged the competitive nature of the child life internship application process, noting that students commonly do not obtain an internship on their first attempt, given the wide variations in requirements between individual internship sites (ACLP, 2024b; Boles et al., 2024).
Existing literature purports a present “bottleneck” of aspiring child life professionals, perhaps exacerbated by the COVID-19 pandemic, in which high levels of competition for unpaid internships were co-occurring alongside an unprecedented staffing crisis in the larger field (Johnson & Read, 2024). During the COVID-19 pandemic, many practicums and internships were paused or delayed for several cycles out of an abundance of caution and heightened hospital safety measures (Howard, 2020; Sisk & Wittenberg, 2021). Rates of turnover also increased among healthcare professionals working during the global pandemic (Lluch et al., 2022), resulting in fewer child life professionals who had accumulated the 4,000 hours of experience necessary to supervise interns (Holley et al., 2024). This combination of factors has resulted in a large number of prospective interns applying for a low number of open spots.
With the ratio of applicants to available positions seemingly unbalanced (Boles et al., 2024), aspiring professionals have reported a variety of ways in which the internship application process has adversely impacted their wellbeing. More specifically, a recent study revealed this highly competitive environment has fostered early burnout (Boles et al., 2024). Although the average child life student applying for internship in their study was highly qualified, having earned a 3.8 GPA, accumulated over 150 hours of experience with children, and sent out more than 10 applications, they remained only moderately confident in their chances of receiving a child life internship placement. It is possible experiencing burnout symptoms this early in the child life career trajectory could have damaging effects on not only entry into the profession, but also longevity in the field.
Due to the growing number of qualified applicants and limited ability to offer internship positions, child life clinical internship sites and supervisors may struggle to determine which individuals to select each cycle. Recent scholarship has explored how child life academicians prioritize assisting students applying to internship (Wittenberg Camp et al., 2023), as well as the skills internship supervisors value most highly (Sisk et al., 2023). Especially when faced with dozens or hundreds of qualified applicants competing for acceptance each application cycle, supervisors must determine site-specific methods or criteria for narrowing the pool. This process is known in educational psychology, developmental science, and graduate medical education as the “hidden curriculum” (a set of unwritten rules that can greatly impact student success) and reflects a demographic of individuals who are most highly valued at the institutional level (Kärner & Schneider, 2024; Killick, 2016; Schultz et al., 2024). The hidden curriculum tends to most disproportionately affect individuals whose incomes are below the federal poverty threshold, are members of marginalized groups, first-generation college students, or those who are disabled (Koutsouris et al., 2021; Lee, 2011; Smith, 2014) and has previously been noted to exist in the child life profession and pediatric healthcare as a whole (Boles et al., 2024; Ferrer, 2021).
The lack of diversity in the child life profession, however, predates the onset of the COVID-19 pandemic (Ferrer, 2021; Lookabaugh & Ballard, 2018). The current internship application process continues to further this lack of diversity, as financial hardships are seen to disproportionately affect Black and Hispanic communities, therefore making it more difficult to acquire and manage unpaid pre-internship experience hours (Gourley et al., 2023; Sisk & Wittenberg, 2021). While the internship application process is almost universally stressful, students of color note additional socioemotional challenges compared to their White peers (Gourley et al., 2023). Students with disabilities also face their own set of obstacles, including discrimination and assumptions about their abilities (if they risk disclosing their condition), especially when the condition is immediately visible (Knight, 2016). The lack of clear communication from many internship sites is an especially difficult barrier for neurodivergent students (Gill, 2023).
The ACLP has responded to concerns about the current internship application process primarily in two ways. In January 2023, the Internship Readiness Common Application was launched with the hopes of increasing equity and decreasing bias in the application process. Further, the ACLP has strongly encouraged internship sites to extend offers to multiple applicants (even past the initial offer date) to ensure these internship spots do not go unfilled (ACLP, 2024b). Although some recent research has addressed this issue from the perspectives of student applicants (Boles et al., 2024), less is known on a more systematic level. Therefore, the purpose of this study was to describe the current state of the internship application process in the child life profession by describing the demographic, educational, and training experiences of child life internship applicants while identifying predictive factors associated with successfully obtaining a child life internship. The research questions guiding the study included:
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What demographic, education, training, and application preparation experience characteristics describe child life internship applicants?
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What sociodemographic and training factors are and are not associated with successfully securing a child life internship?
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What self-reported challenges exist for those who are or are not able to secure a child life internship?
Anticipating broad differences between candidates for child life internships, we hypothesized that specific sociodemographic and training factors of individual candidates would emerge as predictors of successful internship acquisition. Likewise, other candidate factors will be identified that are not significant predictors of internship acceptance.
Method
As the first study to systematically describe child life clinical internship application processes and outcomes, a survey-based design was used. This not only allowed for collection of multiple types of data simultaneously but also made study participation accessible to students pursuing child life internships across the United States. Data for this study were collected with exempt-level IRB approval from Vanderbilt University under protocol #230051. Approval for data analysis was also granted by the Missouri State University IRB.
Participants
Participants in this study were those who self-identified as 1) pursuing certification as a child life specialist, 2) had completed at least one cycle of clinical internship applications, and 3) were proficient in the English language. Eligible participants were recruited using an informational flyer posted on several social media platforms commonly used by aspiring child life specialists, as well as the research team’s personal and professional social media profiles. The recruitment flyer gave brief information about the study, contact information for the research team, and a link and QR code to the online consent form and study surveys. As the ACLP recommends three child life internship offer dates each year (typically in March, May, and October; ACLP, 2024a) the recruitment flyer was posted weekly for a period of four weeks after each offer date.
A total of 147 discrete participants completed the study surveys between March 2023 and May 2024. The majority of participants described themselves as female (98.0%, n = 143), not Hispanic or Latino (92%, n = 132; 8.3% Hispanic or Latino, n = 12), and White (87.0%, n = 126; 6.2% Black/African American, n = 9; 2.1% Asian, n = 3; and 4.8% specified as Other, n = 7), together a demographic pattern reflecting what is currently known to be true of the child life profession (Ferrer, 2021). Thirty-six of the participants (24.5%) were first-generation students (meaning neither parent had completed a four-year college degree). Participant ages ranged from 20 to 50 years, with a median age of 24.0 (M = 25.4, SD = 4.27). The majority (46.6%, n = 81) had completed at least some graduate-level education (additional participant demographics are given in Table 1 of the Results section).
Procedures
Interested individuals entered the study survey using the hyperlink or QR code provided on the recruitment flyer. These links took them to the REDCap platform (Harris et al., 2009, 2019) where they first reviewed and signed a study information sheet. Next, they completed a “Student Characteristics” survey that gathered details about their sociodemographic factors, educational history, and relevant volunteer, work, or practicum experiences. Finally, they completed an “Internship Outcomes” survey about their experiences applying for and navigating the most recent child life clinical internship cycle. All of the instruments were designed by the study team based on more than fifteen years of experience with research design and instrument development, as well as the team’s knowledge of child life internship application procedures. A full list of survey questions can be seen in Appendix A. Completing these three instruments took approximately 10 to 20 minutes, after which the participant’s involvement in the study ended.
Analyses
Quantitative survey data were analyzed by the third and fourth authors using R statistical software. Due to the nature of the dataset, a logistic regression model was chosen to examine predictors of internship acceptance. The full model included demographic, education, training experience, and application support variables. For ordinal variables, orthogonal polynomials were used to estimate effects. Model diagnostics, including AUC (area under the curve), were used to evaluate fit and predictive performance. Bivariate analyses were conducted using chi-square tests and Fisher exact tests for categorical variables, and t-tests for continuous variables, to explore potential associations with internship acceptance. Spearman correlations were used to assess the relationships between ordered variables and placement outcomes.
Open-ended responses to the survey question, “what factors or reasons affected your ability to relocate for an internship,” were treated as qualitative data. These were analyzed by the first, second, and fifth authors using an inductive, analytic process informed by Moustakas’ (1994) psychological phenomenology. First, all responses were combined in a central document; these responses were then coded line-by-line to identify emergent concepts and ideas. As this question comprised only a small portion of the overall survey and did not in itself constitute a distinct research question, formal themes were not developed; rather, emerging categories were noted and expanded in narrative form for presentation in the results section.
Results
Before creating and fitting the logistic regression model, it was important to explore the training experience and application support characteristics of the participant sample.
Child Life Practicum Completion. Of the 147 participants in this study, 140 (95.2%) reported that they had completed at least one child life practicum before applying for the child life clinical internship cycle; some participants reported completing more than one (n = 22, 15.0%). The majority of these (75.5%, n = 111) had completed a “traditional” (healthcare-based) child life practicum, whereas 15 (10.2%) completed a community-based practicum, 18 (12.2%) completed a virtual practicum, nine (6.1%) completed an international practicum, and five (3.4%) completed a hybrid practicum with both virtual and in-person components.
Internship Application Experiences. Of the 147 participants, 73 (49.7%) indicated they had only applied to child life internships during the most recently completed application cycle. Thirty-one (21.1%) reported applying to two different cycles, 16 (10.9%) had applied to three cycles, another 17 (11.6%) had applied to four to six cycles, and eight (5.4%) had applied to seven or more clinical internship cycles.
Participants applied to varying numbers of internship sites per cycle. Of the 147 participants, 35 (23.8%) applied to fewer than 10 internship sites, 42 (28.6%) applied to between 10 and 19 sites, 36 (24.5%) applied to between 20 and 29 sites, 14 (9.5%) applied to between 30 and 39 sites, and 19 (12.9%) applied to 40 or more sites.
Internship Placement Success Rate. Of the 147 participants, 80 (54.4%) reported they had successfully obtained an internship, and 65 (44.2%) did not. There were also two participants (1.4%) who chose not to indicate whether they obtained an internship.
Factors Associated with Successful Placement. Bivariate analyses were used to examine relationships between individual predictor variables and internship placement outcomes. Full results can be seen in Table 1. Factors associated with successfully securing a child life internship included younger age (p = .007), at least some graduate level education (p = .014), higher GPA (p = .004), and having completed a traditional healthcare-based practicum (p = .025). Individuals were also more likely to be placed in an internship if they submitted more applications (p = .005) and were able to apply as an affiliated intern (p = .018). Individuals who had a CCLS academic advisor or instructor to help edit or prepare their application were significantly more likely to secure an internship (p = .011); however, paying or hiring a CCLS to help edit or prepare the application was not a significant predictor of obtaining a child life internship (p = .15).
Relocation Ability. Of the 147 participants, the majority (n = 85, 57.8%) stated they could relocate to an internship “in any location.” On the other hand, 26 (17.7%) could only relocate “a moderate distance” for internship, seven (4.8%) could relocate “only a small distance,” and 10 (6.8%) indicated they could only accept an internship “within commuting distance.” There were also 18 (12.2%) who reported being able to relocate, but “only to specific locations” irrelevant of proximity (due to factors like being able to live with family and friends or more affordable local costs of living).
When given a free-text box to describe their perception of the factors impacting their application process and potential outcomes, aspiring professionals primarily spoke to financial strains as a significant limiting factor. As one participant shared:
The financial burden from the way this system is set up is honestly ridiculous. We are not only asked to work for free for 600 hours but have no opportunity to work outside of this due to uncertain work schedules and assignments – there is no way to make income. On top of that, we are asked to move and find our own housing… We are paying to move, have no income, and work for free…It is a system set up for us to fail from the beginning.
In addition to the financial hardships of needing to relocate for an unpaid internship, several participants spoke to extra stress incurred by leaving their social support networks, moving away from trusted mentors and healthcare service providers, and “being alone in an unfamiliar place during a really stressful time.” Some participants clearly articulated considerations such as, “my husband and family having a place to live if we needed to relocate,” “being able to buy new scrubs or a uniform for my internship,” “I’m not sure my car can make it that far,” “paying two rents at once,” “my whole state only has 2 internship spots,” “the safety of the internship location,” and “an additional semester of paying out-of-state tuition to my university.” Other listed concerns about relocation for internship included availability of family and friends to share housing costs with, transportation (e.g., access and safety), availability of short-term housing, and proximity to religious centers, quality healthcare services, and notable personal needs.
Experiences of Successfully Placed Students. Individuals who successfully obtained a child life clinical internship placement (n = 80) were asked additional questions about their placement. Of those respondents, most (n = 49, 61.3%) received an internship placement out of state. When asked about scholarships or stipends to support their living expenses and relocation, 68 participants (85.0% of those who obtained an internship) said they did not receive any financial support. Among those who did receive funding (n = 11), seven received a scholarship or stipend from their internship site, three received a scholarship or stipend from their academic institution, and one received a scholarship or stipend through ACLP or a regional organization.
Finally, participants were asked about housing. The majority of respondents (n = 64, 80.0%) were bearing the full cost of housing expenses, as no other support was available. Eleven participants (13.8%) did not receive help from their internship site for housing but were able to stay with friends or family. Two participants (2.5%) had reduced-rate housing through their internship site, and another two (2.5%) had housing fully provided by their site.
Discussion
The purpose of this study was to describe the current state of the internship application process in the child life profession, while seeking to identify sociodemographic, educational, and training factors associated with successful internship acquisition. Overall, the findings of this study demonstrated that only about half of applicants in this study were successful in obtaining a child life internship, a notable proportion of whom had applied to at least one prior cycle without receiving an offer. Though their educational institutions, geographic locations, and amounts of relevant experiences varied, obtaining a child life internship was predicted by several variables: a graduate level education, high grade point average, completion of a healthcare-based child life practicum, maintaining academic affiliation during the application process, receiving application support from a full-time CCLS faculty advisor, applying to a larger number of internship sites, and being younger in age. Furthermore, participants reported a variety of factors that affected their internship application process, such as limited ability to relocate for placement, financial constraints, work/home responsibilities, and concerns about access to social support and needed healthcare and personal services in a new geographic location.
The implications of these results are notable, shedding light on relationships and patterns in the child life internship process that have previously only been points of conjecture. As the child life profession, still quite young compared to other healthcare disciplines, continues to grow and evolve, understanding its own internal needs and preferences will be critical insight. Although somewhat expected, these findings first demonstrate that an accumulation of specific and varied educational, clinical, and volunteer experiences are associated with successful acquisition of a child life internship (Boles et al., 2024). Namely, applicants with at least some graduate education (either graduate degree in progress or already completed) are more likely to receive an internship placement than those with only undergraduate education. Further, they have a higher likelihood of receiving an internship placement if they are able to maintain a high grade point average and have access to a full-time CCLS faculty advisor who can provide support during the internship application process.
Currently, only a bachelor’s degree (in any field of study) with coursework in the ten required areas identified by CLCC is required for child life certification (CLCC, 2024), which contradicts the pattern observed in this study. Additionally, most child life internship programs do not state an education level requirement for prospective applicants, nor do internship coordinators identify this as a selection factor (Sisk et al., 2023). At the same time, the child life profession is one of the only remaining healthcare disciplines that does not require a discipline-specific degree at any level, which could contribute to the pattern observed here (Child Life Academic Society, 2025). Thus, there appears to be a significant disconnect between certification requirements, posted application criteria, and which candidates are successful in obtaining a child life internship.
Another area of tension illuminated by this study is the finding that those who have completed a “traditional” healthcare-based child life practicum are more likely to obtain an internship than those completing practicums or pre-internship experiences in non-healthcare settings or those who have not completed a practicum at all. The CLCC does not require a child life practicum for certification (CLCC, 2024) and the ACLP (2024b, 2024a) has clarified that a child life practicum has never been a required component of preparation for the profession. When COVID-19 placed significant restrictions on student access to healthcare-based learning environments, a slew of innovative approaches to practicum were developed to provide hybrid, online, and even international experiences to prepare aspiring professionals for child life internships (Hammond, 2022; Johnson & Read, 2024; Sisk & Wittenberg, 2021). Many child life internship sites report that completion of a child life practicum is not required for internship consideration; however, this again appears to contradict the observed selection trends, perhaps contributing to a hidden curriculum along with education level. This reflects previous research indicating the existence of the hidden curriculum within higher education (Kärner & Schneider, 2024; Killick, 2016; Schultz et al., 2024) as well as pediatric healthcare professions, including child life (Boles et al., 2024; Ferrer, 2021).
There appeared to be several factors related to application preparation and the application process that predicted a candidate’s chances of obtaining a child life internship. First, receiving support from a full-time CCLS faculty advisor was associated with internship placement success, whereas paying an independent child life specialist “mentor” did not predict success. This finding may suggest the critical role that full-time CCLS faculty members may play in helping students navigate both explicit and implicit expectations during the application process; it is likely that these individuals’ duality of experiences in both the clinical and academic realms may uniquely poise them to view and interpret the selection process from multiple vantage points. When this is paired with the result that university affiliation is also predictive of internship acquisition, it can be hypothesized that child life academic programs who offer affiliation, employ full-time CCLS faculty members, and offer graduate level education may equip students well for the challenges of the internship application process.
Two particularly interesting findings are those about the predictive strength of applicant age and the number of internship sites to which they apply. As younger age shows to be a significant predictor of successful internship acquisition, this suggests that there may be unique barriers or biases hindering those who are older, such as career changers and non-traditional college students, from achieving their goals in this process. The number of applications submitted is also notable, as many clinical sites report receiving hundreds of applications for what may only be one or two positions that they are able to offer each cycle. Though some may be critical of aspiring professionals’ strategy of applying to multiple sites each round, the results of this study show that the more sites an applicant does apply for, the more likely they are to receive an internship offer. This observed pattern may contribute to lessen the efficiency of the internship application process for all involved, especially with the finding that nearly half of students apply to more than one cycle before they receive an internship, but applying to greater numbers of sites does appear to predict applicant success.
Implications
Overall, the results of this study highlight a shift in the preferred preparation of aspiring child life professionals that does not align with current certification requirements or posted criteria for internship applicants. At the same time, this may reflect significant progress in solidifying and evolving the professional identity of the CCLS as an academically specialized, rigorously trained clinical professional serving children and families. It appears that the academic component of a student’s pathway may be more influential than previously thought, with education level, grade point average, and access to a full-time CCLS faculty advisor all emerging as significant predictors of internship acquisition; perhaps enhanced collaboration between academic and clinical sites may help to alleviate some of the pressure points in the system felt by professionals in these respective vantage points.
Limitations
Limitations of this study somewhat mirror those found in other child life research, as the majority of participants were female, non-Hispanic or Latino, and White which may not represent student characteristics in all groups. This study also spanned internship application cycles both before and after the introduction of the ACLP Internship Readiness Common Application. With this new application introduced, many sites changed procedures for reviewing and evaluating candidates for internship, and therefore some results may have been impacted by this development. Future studies should aim to replicate this work with a more diverse participant sample, a more homogenous span of time, and could incorporate additional data sources like evaluation tools used by internship supervisors to gather more insights.
Conclusion
The results of this study address a longstanding gap in the child life professional literature base, as little has been done to systematically examine relationships between student/applicant factors and outcomes in the child life clinical internship application process. Participant responses in this study demonstrate that a clear pattern in academic training and clinical preparation is emerging: young, graduate level aspiring child life specialists with a high grade point average, access to a full-time CCLS faculty advisor, experience completing a healthcare-based child life practicum, who maintain academic affiliation and apply to larger numbers of clinical sites are more likely to receive a child life internship. Since these patterns hold across sociodemographic factors, it is important to continue exploring how these results may contradict career entry requirements, illuminate hidden expectations, and call for collaboration across stakeholder groups to make these success factors more consistent, known, and accessible. In doing so, it may be possible to optimize the child life clinical internship pathway, and in turn, bring needed aid to child life staffing and enhance the sustainability of the profession.