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


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.

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Children anxiety and pain scales


Emergency department


Numerical rate scale


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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.

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Corresponding author

Correspondence to Marta Minute.

Ethics declarations


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

Revisions received: 26 November 2015; 9 December 2015

Communicated by Jaan Toelen

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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

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  • Clown therapy
  • Procedural pain
  • Anxiety
  • Emergency department