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. |
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Abbreviations
- CAPS:
-
Children anxiety and pain scales
- ED:
-
Emergency department
- NRS:
-
Numerical rate scale
References
Alexander J, Manno M (2003) Underuse of anelgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med 41:617–622
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 13:166
Bennet MP, Lengacher CA (2006) Humor and laughter may influence health. I. History and background. Evid Based Altern Complement Med 3:61–63
Bertini M, Isola E, Paolone G, Curcio G (2011) Clowns benefit children hospitalized for respiratory pathologies. Evid Based Complement Alternat Med 2011:879125
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 26:367–374
Fernandes S, Arriaga P (2010) The effects of clown intervention on worries and emotional responses in children undergoing surgery. J Health Psychol 13:405–415
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):286–96
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):303–309
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 5:17–25
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
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 21:198–209
Martin RA (2002) Is laughter the best medicine? Humor, laughter, and physical health. Curr Dir Psychol Sci 13(6):216–220
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 14:8–14
Murphy G (2009) Distraction techniques for venepuncture: a review. Paediatr Nurs 21(3):18–20
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 13:74–78
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 117:1162–1168
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:S143
Vagnoli L, Caprilli S, Robiglio A, Messeri A (2005) Clown doctors as a treatment for preoperative anxiety in children: a randomized, prospective study. Pediatrics 116:563–567
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 13:937–943
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):223–7
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):771–3
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 52:1168–1172
Wong D, Baker C (1988) Pain in children: comparison of assessment scales. Pediatr Nurs 14:9–1
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.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
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.
Additional information
Communicated by Jaan Toelen
Revisions received: 26 November 2015; 9 December 2015
Rights and permissions
About this article
Cite this article
Felluga, M., Rabach, I., Minute, M. et al. A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children’s anxiety and pain levels in emergency department. Eur J Pediatr 175, 645–650 (2016). https://doi.org/10.1007/s00431-015-2688-0
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00431-015-2688-0