Advertisement

European Journal of Pediatrics

, Volume 175, Issue 5, pp 645–650 | Cite as

A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children’s anxiety and pain levels in emergency department

  • Margherita Felluga
  • Ingrid Rabach
  • Marta Minute
  • Marcella Montico
  • Rita Giorgi
  • Isabella Lonciari
  • Andrea Taddio
  • Egidio Barbi
Original Article

Abstract

The aim of the study is to investigate if the presence of medical clowns during painful procedures in the emergency department (ED) affects children’s anxiety and pain. Forty children (4–11 years) admitted to the ED with the need of painful procedures were prospectively enrolled. They were randomly assigned to the clown group, where children interacted with clowns or to the control group in which they were entertained by parents and ED nurses. The children’s anxiety was assessed by the Children’s Anxiety and Pain Scales; pain was evaluated with the Numerical Rating Scale and Wong-Backer Scale, according to the children’s age. Staff and clown’s opinions were evaluated by means of dedicated questionnaires. Children’s anxiety levels in the clown group were significantly lower than those compared with the control group, while children’s pain levels did not change between the two groups.

Conclusion: The presence of clowns in the ED before and during painful procedures was effective in reducing children’s anxiety.

What is Known:

Anxiety and fear caused by medical procedures exacerbate children’s pain and may interfere with the procedure.

To reduce anxiety, fear, and pain and to facilitate patient’s evaluation, different non-pharmacological approaches have been proposed and positive effects of laughter and humor have been reported.

What is New:

The presence of clowns in the waiting room and in the ED during medical evaluation and painful procedures helps to reduce children’s anxiety.

Keywords

Clown therapy Procedural pain Anxiety Emergency department 

Abbreviations

CAPS

Children anxiety and pain scales

ED

Emergency department

NRS

Numerical rate scale

Notes

Acknowledgments

We would like to thank the clowns of the Gruppo Azione Umanitaria (GAU) association who volunteered in this study: Lara Siega (dott.ssa Pepyta), Gabriella Goglia (dott.ssa Luna), Barbara Slobez (dott.ssa Cirypà), Dragica Hrovatin (dott.ssa Biskottina), Luciana Domini (dott.ssa Fiordaliso), Marina Poretti (dott.ssa Ssaibon), and Massimo Gasperini who helped us with the English version.

Author’s contribution

MF, IR, MM, IL, RG, and EB were involved in the design of the study; MF, IR, MM, and RG collected and analyzed the reported data; and MM, IR, and EB drafted the initial manuscript and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Compliance with ethical standards

Funding

This study was not funded by any grant.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Alexander J, Manno M (2003) Underuse of anelgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med 41:617–622CrossRefPubMedGoogle Scholar
  2. 2.
    Barkmann C, Siem AK, Wessolowski N, Schulte-Markwort M (2013) Clowning as a supportive measure in paediatrics—a survey of clowns, parents and nursing staff. BMC Pediatr 13:166CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Bennet MP, Lengacher CA (2006) Humor and laughter may influence health. I. History and background. Evid Based Altern Complement Med 3:61–63CrossRefGoogle Scholar
  4. 4.
    Bertini M, Isola E, Paolone G, Curcio G (2011) Clowns benefit children hospitalized for respiratory pathologies. Evid Based Complement Alternat Med 2011:879125CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Cohen LL, Blount R, Cohen RJ, Ball CM, McClellan CB, Bernard RS (2001) Children’s expectations and memories of acute distress: short-and long-term efficacy of pain management intervention. J Pediatr Psychol 26:367–374CrossRefPubMedGoogle Scholar
  6. 6.
    Fernandes S, Arriaga P (2010) The effects of clown intervention on worries and emotional responses in children undergoing surgery. J Health Psychol 13:405–415CrossRefGoogle Scholar
  7. 7.
    Ford K, Courtney-Pratt H, Tesch L, Johnson C (2014) More than just clowns—clown doctor rounds and their impact for children, families and staff. J Child Health Care 18(3):286–96CrossRefPubMedGoogle Scholar
  8. 8.
    Fuss S, Pagé MG, Katz J (2011) Persistent pain in a community-based sample of children and adolescents: sex differences in psychological constructs. Pain Res Manag 16(5):303–309CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Koller D, Gryski C (2008) The life threatened child and the life enhancing clown: towards a model of therapeutic clowning. Evid Based Complement and Altern Med 5:17–25CrossRefGoogle Scholar
  10. 10.
    Krauss BS, Calligaris L, Green SM, Barbi E (2015) Current concepts in management of pain in children in the emergency department. Lancet. doi: 10.1016/S0140-6736(14)61686-X PubMedCentralGoogle Scholar
  11. 11.
    Kuttner L, LePage T (1989) Face scales for the assessment of pediatric pain: a critical review. Cana J Behav Sci/Revue Can Des Sci Du Comportement 21:198–209CrossRefGoogle Scholar
  12. 12.
    Martin RA (2002) Is laughter the best medicine? Humor, laughter, and physical health. Curr Dir Psychol Sci 13(6):216–220CrossRefGoogle Scholar
  13. 13.
    Meisel V, Chellew K, Ponsell E, Ferreira A, Bordas L, García-Banda G (2010) The effect of “hospital clowns” on psychological distress and maladaptive behaviours in children undergoing minor surgery. Psychol Spain 14:8–14Google Scholar
  14. 14.
    Murphy G (2009) Distraction techniques for venepuncture: a review. Paediatr Nurs 21(3):18–20CrossRefPubMedGoogle Scholar
  15. 15.
    Pinquart M, Skolaude D, Zaplinski K, Maier RF (2011) Do clown visits improve psychological and sense of physical well-being of hospitalized pediatric patients? A randomized-controlled trial. Klin Padiatr 13:74–78CrossRefGoogle Scholar
  16. 16.
    Sinha M, Christopher NC, Fenn R, Reeves L (2006) Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics 117:1162–1168CrossRefPubMedGoogle Scholar
  17. 17.
    Uziel Y, Weintraub Y, Rabinowicz N, Hanuka P, Rothschild M, Kotzki S (2014) A107: dream doctors-medical clowns increase the effect of nitrous oxide sedation in intra-articular corticosteroid injection for juvenile idiopathic arthritis. Arthritis Rheumatol 66:S143CrossRefGoogle Scholar
  18. 18.
    Vagnoli L, Caprilli S, Robiglio A, Messeri A (2005) Clown doctors as a treatment for preoperative anxiety in children: a randomized, prospective study. Pediatrics 116:563–567CrossRefGoogle Scholar
  19. 19.
    Vagnoli L, Caprilli S, Messeri A (2010) Parental presence, clowns or sedative premidication to treat preoperative anxiety in children: what could be the most promising option. Pediatr Anesth 13:937–943CrossRefGoogle Scholar
  20. 20.
    von Baeyer CL, Spagrud LJ, McCormick JC, Choo E, Neville K, Connelly MA (2009) Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children’s self-reports of pain intensity. Pain 143(3):223–7CrossRefGoogle Scholar
  21. 21.
    Weintraub Y, Rabinowicz N, Hanuka P, Rothschild M, Kotzki S, Uziel Y (2014) Medical clowns facilitate nitrous oxide sedation during intra-articular corticosteroid injection for juvenile idiopathic arthritis. Isr Med Assoc J 16(12):771–3PubMedGoogle Scholar
  22. 22.
    Wolyniez I, Rimon A, Scolnik D, Gruber A, Tavor O, Haviv E, Glatstein M (2013) The effect of a medical clown on pain during intravenous access in the pediatric emergency department: a randomized prospective pilot study. Clin Pediatr 52:1168–1172CrossRefGoogle Scholar
  23. 23.
    Wong D, Baker C (1988) Pain in children: comparison of assessment scales. Pediatr Nurs 14:9–1PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Margherita Felluga
    • 1
  • Ingrid Rabach
    • 2
    • 3
  • Marta Minute
    • 2
    • 3
  • Marcella Montico
    • 4
  • Rita Giorgi
    • 2
  • Isabella Lonciari
    • 1
  • Andrea Taddio
    • 2
    • 3
  • Egidio Barbi
    • 2
  1. 1.Division of Child Neuropsychiatry UnitInstitute for Maternal and Child Health – IRCCS “Burlo Garofolo”TriesteItaly
  2. 2.Departement of PediatricsInstitute for Maternal and Child Health - IRCCS “Burlo Garofolo”TriesteItaly
  3. 3.Departement of PediatricsUniversity of TriesteTriesteItaly
  4. 4.Clinical Epidemiology and Public Health Research UnitInstitute for Maternal and Child Health – IRCCS “Burlo Garofolo”TriesteItaly

Personalised recommendations