Commentary: Competencies and Standardization in Chiropractic Pediatric Education: An Opinion on Taking the Next Step

By Anna E.Papadopoulou, MChiro,D.C.,DACNB.,MSc (MSK health in Pediatrics), FRCC

Competencies and standardization for any profession are a sign of a well-established, healthy organization. Educational as well as professional competencies and standardizations are currently in place to ensure the safety and effectiveness of the chiropractic profession. Different versions of codes of ethics are globally available to guide clinicians and safeguard the public according to each country and region1,2,3

The chiropractic profession has evolved and expanded to create several special interest groups over the years. These include sports, orthopedics, pediatrics, radiology, neurology and animal chiropractic. Unlike the global standardization of the chiropractic profession as a whole, there is a lack of guidelines in terms of special interest groups in general, as well as more specifically in the pediatric chiropractic arena.

It is understood that undergraduate chiropractic education is predominantly concerned with the development of education to further safe and effective practice for chiropractors to serve their community and adhere to evidence-based, collaborative healthcare standards.4 Although an introduction to special and specific population groups (athletes, geriatrics and pediatrics) are made in the undergraduate curriculum, this is to provide the students exposure to the practice of chiropractic and how it can be applied at different ages in a community’s life span. Further training in the specific interest groups is offered at a post graduate level. In 2016, Hewitt, Core Competencies of the Certified Pediatric Doctor of Chiropractic: Results of a Delphi Consensus Process it was stated that, “All doctors of chiropractic are adequately trained in basic pediatric skills and are licensed to examine, treat, and manage pediatric patients.”5

The goal of this commentary is to examine, in 2022, the education offered to the chiropractic profession, around the world. What does the current curriculum in undergraduate education provide students in chiropractic pediatrics education? Are there any discrepancies between institutions in the curriculum or delivery of undergraduate chiropractic pediatric courses? Are all graduates competent in treating pediatric cases? To further education, what are the additional postgraduate opportunities that are available to globally achieve the above standard in chiropractic pediatric education?

In the 2016 paper, Hewitt et al. stated that there are core competencies that must be met following the completion of a postgraduate education. “Many of these skills naturally overlap with those of the general doctor of chiropractic. Normalizing these competencies does not imply that only certified pediatric doctors of chiropractic may treat children; rather, the certified pediatric doctor of chiropractic has obtained a deeper knowledge and skillset compared to the general doctor of chiropractic.”5 Therefore, the skillsets for chiropractors in the area of pediatrics have been found adequate.

Table one shows all current undergraduate chiropractic programs which provide specific pediatric education. The information was gathered from their published information at the time this paper was written and could be incomplete. What the table does show is that there are discrepancies in pediatric chiropractic education in undergraduate chiropractic university programs. Undergraduate pediatric chiropractic education is currently taught in 14/19 schools in North America (73%), 4/8 in Latin America (50%), 5/12 in Europe (42%), and no information is available on the 7 schools in Asia and two in Africa.

Table 01

The comparison of contact hours and credit hours for pediatrics in the undergraduate programs, not only between schools on different continents but also neighboring countries, may be difficult and this must be taken into consideration by those who regulate chiropractic education, international chiropractic examining bodies and political bodies within the chiropractic profession. This is the time to regroup, reflect and create undergraduate competencies that all approved/accredited chiropractic institutions could adopt to ensure consistency in chiropractic pediatric education. If a baseline of fungible curriculum content were adopted by every undergraduate chiropractic program, it would serve to ensure that all students were credentialed to provide safe care for the pediatric patient.

Are all graduates competent in treating pediatric cases?
This is a good time to evaluate current undergraduate pediatric chiropractic education in terms of theory and contact hours (“hands on time”) and chiropractic techniques considered appropriate or modifiable for the pediatric population. In addition, it is appropriate to compare and contrast areas that need to be standardized to establish competencies that apply across the board. Moreover, it is paramount that students understand current research and are able to utilize such to support their work within special interest groups and to educate the public.

Taking a broad view of the current landscape of undergraduate chiropractic pediatric education, it is appropriate to review the discrepancies in the way undergraduate chiropractic pediatric courses are taught:
• There are a number of differences in the credit hours, course material, hands on experience and amount of educational material provided between educational institutions based in different countries and continents.
• Observing that this is a challenge faced by other professions, like allopathic medicine, allows an opportunity for interprofessional learning. Self-perception surveys on whether the courses fulfill certain criteria /are efficiently preparing students to meet basic competencies is one way utilized by medical educational research to evaluate such points.6 Additionally, performing cross sectional studies and comparing material against competencies in chiropractic pediatric education may support and enhance undergraduate chiropractic pediatric courses.
• Are all graduates competent in treating pediatric cases, considering that children are not ‘small adults’ and if not, what are the additional postgraduate opportunities available?7,8

More information is needed to draw robust conclusions on these questions. Considering the discrepancies in hours of course delivery and with little information on the quantity and quality of education of new graduates, it is difficult to ascertain whether all graduates have been provided with adequate undergraduate training in pediatrics. Thus, the development of competencies in the basic knowledge and skills to treat children as chiropractors is paramount with the caveat that a graduate can pursue further education in pediatric chiropractic. This can be informed, for example, by the ‘Tuning Education Project’.9

According to the Core Competencies of the Certified Pediatric Chiropractor - Hewitt, et al. 2016 state that, “These postgraduate programs entail between 280 and 400 hours of training taken over 2 to 3 years. As the purpose of these postgraduate training programs is to expand on and deepen the knowledge base obtained during the undergraduate chiropractic curriculum, the resulting competencies (applied to them) will be a combination of both the basic chiropractic training and the additional acquired skills.”5

Current Chiropractic Profession organization structure
Chiropractic is organized in three tiers, local (National Associations), regional (European Chiropractors Union, Latin American Chiropractic Federation (FLAQ), East Mediterranean Middle East Chiropractic Federation (EMMECF), African Federation etc.) and global level of governance World Federation of Chiropractic (WFC). In this manner, chiropractors are represented in the organizations that create practice policies in over 90 countries.

An excellent example of this structure of command and regulation is observed amongst one of the special interest groups, sports chiropractic International Federation of Sports Chiropractic: (FICS). This special interest group enrolls members who comply with the existing undergraduate chiropractic education requirements and further build upon their knowledge and skills following graduation. Although pediatrics is one of the popular special interest groups within the profession, the FICS structure is not mirrored. A lack of three-tiered (national, regional and global) regulation and representation is observed. Some isolated attempts are seen in different counties such as the Royal College of Chiropractors - Pregnancy and Paediatric Faculty in the UK, Australian College of Chiropractic Paediatrics (ACCP), American Chiropractic Association (ACA) Pediatrics Council and International Chiropractic Association Pediatrics Council.9 Despite attempts from local associations to create unity and discipline members with guidelines at a local or regional level, there is yet to be a more universal level of organization and competencies to follow.

Creating the three tiers of regulation allows for national cultural consideration, ethical consideration and community customs of each country to be taken into play. Similarly, regional representation can have an overview and collate data from each country and relay information to and from the global representation. It is appreciated that different geographical regions have unique requirements in terms of education. However, the core competencies for chiropractic care of the pediatric patient could be universally accepted and implemented aiding in reduction of educational discrepancies. This ensures a baseline minimum standard of pediatric chiropractic education that provides a guideline for the safety of both the patient and the practitioner.

As seen in the latest professional scoping review by Beliveau 2017, only five articles were cited that included the pediatric patient population.10 An organized attempt to provide fungible education would help structure and provide more impactful and meaningful and plentiful pediatric research as well.

2022 is an exciting time for the pediatric chiropractic community as a number of initiatives around the world are being or have been put in place to address these concerns. In Europe, especially in the UK, the Royal College of Chiropractic (RCC) and the European Chiropractors’ Union (ECU), special interest group (SIG) paediatrics, are drafting history and examination forms that would help standardize the baseline for chiropractic practitioners.11 Similarly in Australia, there is a world-wide consensus process being developed to provide standards of practice for chiropractors who see pediatric patients, as a follow-on to the Safer Care Victoria report.12 When these endeavors are added to the widely accepted best practice consensus processes previously published,5,13,14 including the current examination of chiropractic pediatric education, the profession’s undergraduate and postgraduate curriculum is designed to keep the pediatric patient safe. Adverse events in this age group under chiropractic care have been found to be exceedingly rare.12,15-18 It is of utmost importance that a focus on education ultimately provides a focus on safety. Keeping the patients of this profession safe, as it has proven to be in the last 100 years, is of primary importance.

In conclusion, ensuring a uniform minimum undergraduate education in pediatric chiropractic will raise the standard of education, skill set and experience of chiropractors and allow an easier transition to this domain’s postgraduate studies. This could potentially allow doctors of chiropractic to hold the credential of ‘expert in the pediatric MSK (PMSK) field’ through development and maintenance of rigorous standardized competencies.

It is this author’s sincere desire to see all organizations involved in pediatric chiropractic education come together to strengthen the education provided, create consistency in education and enhance the professional level of care offered and provide enhanced and continued safety for the patient. Creating three-tiered chiropractic pediatric special interest groups would enhance and develop the consistent collection of data and support of current research as well as inform future research needed to be done in areas such as safety, effectiveness and clinical management of pediatric chiropractic care.


1. Canadian Chiropractic Association, The Code of Ethics, 2022 Accessed: 3 March 2022.

2. General Chiropractic Council, The Code: Standards of conduct, performance and ethics for chiropractors, 2019., Accessed 3 March 2022.

3. Australian Chiropractors Association: The ACA Code of Ethics, 2022 Accessed 3 March 2022.

4. The International Chiropractic Education Collaboration Clinical and Professional Chiropractic Education: a Position Statement. World Federation of Chiropractic Educational Statement formulated in November 2014 at the Miami Education Conference. Accessed 12 March 2022.

5. Hewitt E, Hestbaek L, Pohlman KA. Core Competencies of the Certified Pediatric Doctor of Chiropractic: Results of a Delphi Consensus Process. J Evid Based Complementary Altern Med. 2016 Apr;21(2):110-4. doi: 10.1177/2156587215622769. Epub 2016 Jan 5. PMID: 26739669.

6. Nieto-Gutierrez W, Hanae Zafra-Tanaka J, Pacheco-Barrios K, Taype-Rondan A. Self-perception of competences in clinical practice among recently graduated physicians from Lima, Peru.2020;6: 11.Published 2020

7. Larcher V. (2015) Children Are Not Small Adults: Significance of Biological and Cognitive Development in Medical Practice. In: Schramme T., Edwards S. (eds) Handbook of the Philosophy of Medicine. Springer, Dordrecht.

8. Vallone SA, Miller J, Larsdotter A, Barham-Floreani J. Chiropractic approach to the management of children. Chiropr Osteopat. 2010;18:16. Published 2010 Jun 2. doi: 10.1186/1746-1340-18-16.

9. Bologna Process. Tuning educational structures in Europe: Work programme of the Bologna Follow-up group 2001-2003, modified: 18/05/2016; Accessed 11 March 2022.

10. Beliveau PJH, Wong JJ, Sutton DA, et al. The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided. Chiropr Man Therap. 2017;25:35. Published 2017 Nov 22. doi:10.1186/s12998-017-0165-8.

11. Weber S and Miller AS, Chiropractic history and examination forms for the infant, pre-school, and school-aged child. Journal of Clinical Chiropractic Pediatric. 2021;20:1

12. Genevieve Keating. Parent reports of chiropractic care for children: A preliminary report from 22,043 parents in Australia. Journal of Clinical Chiropractic Pediatric. 2021;20:1.

13. Hawk C, Schneider M, Ferrance RJ, Hewitt E, Van Loon M, and Tanis L. Best practices recommendations for infants, children and adolescents: Results of a consensus process. JMPT 2009;32.8:639-647.

14. Hawk C, Schneider MJ, Vallone and Hewitt EG, Best practices for chiropractic care of children: A consensus update. JMPT 2016; 39 (3):158-168.

15. Zorzela L, Boon H, Mior S, Yager J, Gross A, Vohra S. Serious adverse events associated with pediatric complementary and alternative medicine. Eur J Integr Med. 2014;6:467–72.

16. Todd AJ, Carroll MT, Robinson A, & Mitchell EKL. Adverse events due to chiropractic and other manual therapies for infants and children: A review of the literature. J Manipulative Physiol Ther, 2015,38(9), 699-712.

17. Vohra S, Johnston BC, Cramer K and Humphreys K. Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics [online]. 2007.

18. Miller J. Safety of Chiropractic Manual Therapy for Children: How Are We Doing? J Clinical Chiropractic Pediatrics 2009 (Dec); 10 (2): 655–660.

19. Life Chiropractic College West Published 2021. Accessed February 24, 2022.

20. Cleveland University-Kansas City Published 2008-2021. Accessed February 24, 2022.

21. D’Youville University. Chiropractic D.C. & lt; D’Youville University. txt. Published 2021. Accessed February 24, 2022.

22. Keiser University published 2022. Accessed February 24, 2022.

23. Life Chiropractic College Published 2015. Accessed February 24, 2022.

24. Logan University Published 2021. Accessed February 24, 2022.

25. National University of Health Science Published 2022. Accessed February 24, 2022.

26. Northeastern Health Sciences University Published 2022. Accessed February 24, 2022.

27. Northwestern Health Sciences University Published 2022. Accessed February 24, 2022.

28. Palmer College of Chiropractic Published 2022. Accessed February 24, 2022.

29. Parker University Published 2022. Accessed February 24, 2022.

30. Sherman College of Chiropractic Published 2022. Accessed February 24, 2022.

31. Southern California University of Health Sciences Published 2022. Accessed February 24, 2022.

32. Texas Chiropractic College Published 2022. Accessed February 24, 2022.

33. University of Bridgeport Published 2022. Accessed February 24, 2022.

34. University of Western States Published 2022. Accessed February 24, 2022.

35. Canadian Memorial Chiropractic College Published 2022. Accessed February 24, 2022.

36. University of Quebec at Trois-Rivières Published 2022. Accessed February 24, 2022.

37. Universidad Estatal del Valle de Ecatepec Published 31/08/2020, Accessed February 24, 2022.

38. Toluca Valley State University Published 2017, Accessed February 24, 2022.

39. Universidad Veracruzana Published 2022. Accessed February 24, 2022.

40. Universidad Central de Chile Friday, September 4, 2020.

41. Universidad Central del Caribe - Doctor of Chiropractic Program Published 2020. Accessed February 24, 2022.

42. Centro Universitario Uceff Published 2020. Accessed February 24, 2022.

43. Universidade Anhembi Morumbi Published 2020. Accessed February 24, 2022.

44. Universidade Feevale Accessed February 24, 2022.

45. Southern Denmark University Published 2022. Accessed February 24, 2022.

46. Institut Franco-Européen de Chiropratique Published 2022. Accessed February 24, 2022.

47. Institut Franco-Européen de Chiropratique-Toulouse Published 2022. Accessed February 24, 2022.

48. The Barcelona College of Chiropractic Published 2022. Accessed February 24, 2022.

49. Madrid College of Chiropractic-RCU (formerly RCU College of Chiropractic) Accessed February 24, 2022.

50. The Scandinavian Chiropractic Academy Accessed February 24, 2022.

51. University of Zurich Published 2021. Accessed February 24, 2022.

52. AECC University College Published 2021. Accessed February 24, 2022.

53. London South Bank University Accessed February 24, 2022.

54. McTimoney College Published 2022. Accessed February 24, 2022.

55. Teesside University Published 202022. Accessed February 24, 2022.

56. University of South Wales - Welsh Institute of Chiropractic University of South Wales - Welsh Institute of Chiropractic Published 2022. Accessed February 24, 2022.

57. Durban University of Technology Published 2022. Accessed February 24, 2022.

58. University of Johannesburg Published 2021. Accessed February 24, 2022.

59. New Zealand College of Chiropractic Published 2022. Accessed February 24, 2022.

60. Central Queensland University*1wva4da*_ga*MzE0MjQ2OTkwLjE2NDgwNTcxNTc.*_ga_HZ0LQNHND8*MTY0ODA1NzE1Ni4xLjAuMTY0ODA1NzE1Ni42MA..&_ga=2.178358176.520536797.1648057157-314246990.1648057157 Accessed February 24, 2022.

61. Macquarie University Accessed February 24, 2022.

62. Murdoch University Accessed February 24, 2022.

63. RMIT University Published 2022. Accessed February 24, 2022.

64. Tokyo College of Chiropractic Accessed February 24, 2022.

65. International Medical University Accessed February 24, 2022.