European Journal of Pediatrics

, Volume 178, Issue 8, pp 1283–1289 | Cite as

Benefits of medical clowning in the treatment of young children with autism spectrum disorder

  • Shahar SheferEmail author
  • Odelia Leon Attia
  • Ruth Rosenan
  • Ori A. Wald
  • Hamutal Ende
  • Lidia V. Gabis
Original Article


We investigated the contribution of group therapy delivered by a medical clown to young children diagnosed with autism spectrum disorder (ASD). So far, scientific publications regarding medical clowning focus on general health advantages. The current study is the first controlled research examining the use of medical clowning in the therapy for children with ASD. Twenty-four children aged 2–6 years old with ASD enrolled in our special education intensive program were examined before and after group sessions with clown intervention (CI) and other intervention (OI). We tested stereotypic behaviors, verbal expression, play reciprocity, and social smiles. Data was collected during 12 weeks of intervention, and the trajectory of change was evaluated in addition to the pre-/post-intervention.

Conclusion: improvement over time in all measures: Significant increase in word production, play reciprocity, and amount of social smiles during CI as compared with OI. We also found a reduction in frequency of stereotypic behaviors during and following CI as compared with before CI. These preliminary results indicate that medical clowning may be beneficial for young children with ASD, since it promotes communication and social reciprocity in a fun and lively interventional setting.

What is Known:

Many therapies are used and proven as efficacious interventions for children with ASD.

So far, medical clowning was not tested as an intervention or therapy for ASD.

What is New:

Medical clowning sessions with children with ASD elicited enhanced communication during the interventions as compared with other interventions.

Medical clowning sessions contributed to a decrease in frequency of stereotypic movements over time, in children with ASD.


Autism spectrum disorder Treatment Medical clowning Complementary and alternative therapies for ASD 



Autism Diagnostic Observation Schedule-2nd Edition


Autism spectrum disorder


Clown intervention


Medical clowning


Other intervention


Authors’ contributions

Shahar Shefer: Conception and design of the research, initial draft of the article.

Ruth Rosenan: Data analysis, editing of final draft and final approval of the version to be published.

Odelia Leon Attia: Data analysis and interpretation of results, approval of final draft.

Hamutal Ende: Medical clown, performed the interventions in the study and contributed to data collection, approval of final draft.

Ori A. Wald: Data collection and data processing, approval of final draft.

Lidia V. Gabis: Conception and design of study, interpretation of results and drafting the initial article.


This study was partially funded by Magi Foundation and Foundation Adelis.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict 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. Helsinki committee at the Sheba Medical Center, Ramat-Gan, Israel, approval no. SMC-0551-13, approved the current study.

Informed consent

Informed consent was obtained from all parents of the children whom participated in the study.


  1. 1.
    Association AP (2013) Diagnostic and statistical manual of mental disorders: Dsm-5. Amer Psychiatric Pub IncorporatedGoogle Scholar
  2. 2.
    Bass MM, Duchowny CA, Llabre MM (2009) The effect of therapeutic horseback riding on social functioning in children with autism. J Autism Dev Disord 39:1261–1267. CrossRefPubMedGoogle Scholar
  3. 3.
    Ben-Pazi H, Cohen A, Kroyzer N, Lotem-Ophir R, Shvili Y, Winter G, Deutsch L, Pollak Y (2017)Clown-care reduces pain in children with cerebral palsy undergoing recurrent botulinum toxin injections-a quasi-randomized controlled crossover study. PLoS One 12.
  4. 4.
    Blumberg SJ, Bramlett MD, Kogan MD, Schieve LA, Jones JR, Lu MC (2013) Changes in prevalence of parent-reported autism spectrum disorder in school-aged U.S. children: 2007 to 2011–2012. Natl Health Stat Report 65:1–12Google Scholar
  5. 5.
    Bodfish JW, Symons FJ, Parker DE, Lewis MH (2000) Varieties of repetitive behavior in autism: comparisons to mental retardation. J Autism Dev Disord 30:237–243. CrossRefPubMedGoogle Scholar
  6. 6.
    Brondino N, Fusar-Poli L, Rocchetti M, Provenzani U, Barale F, Politi P, Brondino N, Fusar-Poli L, Rocchetti M, Provenzani U, Barale F, Politi P (2015) Complementary and alternative therapies for autism spectrum disorder. Evid Based Complement Alternat Med 2015:258589. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Curtis P, James A, Birch J (2007) Space to care: children’s perceptions of spatial aspects of hospitals. Swindon: ESRC End of Award Report. 1–25Google Scholar
  8. 8.
    Dalton KM, Nacewicz BM, Johnstone T, Schaefer HS, Gernsbacher MA, Goldsmith HH, Alexander AL, Davidson RJ (2005) Gaze fixation and the neural circuitry of face processing in autism. Nat Neurosci 8:519–526. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Dawson G (2008) Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder. Dev Psychopathol 20:775–803. CrossRefPubMedGoogle Scholar
  10. 10.
    Emery MJ (2004) Art therapy as an intervention for autism. Art Ther 21:143–147. CrossRefGoogle Scholar
  11. 11.
    Farmer C, Thurm A, Grant P (2013) Pharmacotherapy for the core symptoms in autistic disorder: current status of the research. Drugs 73:303–314. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Feniger-schaal R, Citron A, Mittlelberg E, Ben EY (2018) Intervention of medical ( therapeutic ) clowns in a kindergarten for children with intellectual disability: a case study intervention of medical ( therapeutic ) clowns in a kindergarten for children with intellectual disability: a case study. Int J Disabil Dev Educ:1–13.
  13. 13.
    Golan G, Tighe P, Dobija N, Perel A, Keidan I (2009) Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial. Pediatr Anesth 19:262–266. CrossRefGoogle Scholar
  14. 14.
    Grelotti DJ, Klin AJ, Gauthier I, Skudlarski P, Cohen DJ, Gore JC, Volkmar FR, Schultz RT (2005) fMRI activation of the fusiform gyrus and amygdala to cartoon characters but not to faces in a boy with autism. Neuropsychologia 43:373–385. CrossRefPubMedGoogle Scholar
  15. 15.
    Hansen LK, Kibaek M, Martinussen T, Kragh L, Hejl M (2011) Effect of a clown’s presence at botulinum toxin injections in children: a randomized, prospective study. J Pain Res 4:297–300.;10.2147/JPR.S23199 CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Henderson SW, Rosario K (2008) But seriously: clowning in children’s mental health. J Am Acad Child Adolesc Psychiatry 47:983–986. CrossRefPubMedGoogle Scholar
  17. 17.
    Holden M (2011) Don’t send in the clowns – reuters oddly enough. Reuters Retrieved December 8, 2011Google Scholar
  18. 18.
    Ilan U, Davidov A, Mendlovic J, Weiser G (2018) Disaster zones—should we be clowning around? Eur J Pediatr 177:247–249. CrossRefPubMedGoogle Scholar
  19. 19.
    Kingsnorth S, Blain S, McKeever P (2011) Physiological and emotional responses of disabled children to therapeutic clowns: a pilot study. Evid Based Complement Alternat Med 2011:1–10. CrossRefGoogle Scholar
  20. 20.
    Linge L (2012) Magical attachment: children in magical relations with hospital clowns. Int J Qual Stud Health Well-being 7.
  21. 21.
    Lord C, Rutter M, DiLavore PC, Risi S, Gotham K, Bishop S (2012) Autism Diagnostic Observation Schedule--Second Edition (ADOS-2). West Psychol Serv, Los AngelesGoogle Scholar
  22. 22.
    Lovaas OI, Koegel R, Simmons JQ, Long JS (1973) Some generalization and follow-up measures on autistic children in behavior therapy. J Appl Behav Anal 6:131–165CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Luby J, Mrakotsky C, Stalets MM, Belden A, Heffelfinger A, Williams M, Spitznagel E (2006) Risperidone in preschool children with autistic spectrum disorders: an investigation of safety and efficacy. J Child Adolesc Psychopharmacol 16:575–587. CrossRefPubMedGoogle Scholar
  24. 24.
    Meiri N, Ankri A, Ziadan F, Nahmias I, Konopnicki M, Schnapp Z, Sagi OI, Saied MH, Pillar G (2017) Assistance of medical clowns improves the physical examinations of children aged 2–6 years. Isr Med Assoc J 19:761–766Google Scholar
  25. 25.
    Perrin JM, Coury DL, Hyman SL, Cole L, Reynolds a M, Clemons T (2012) Complementary and alternative medicine use in a large pediatric autism sample. Pediatrics 130:S77–S82. CrossRefPubMedGoogle Scholar
  26. 26.
    Pierce K, Müller RA, Ambrose J, Allen G, Courchesne E (2001) Face processing occurs outside the fusiform “face area” in autism: evidence from functional MRI. Brain J Neurol 124:2059–2073. CrossRefGoogle Scholar
  27. 27.
    Raz R, Lerner-Geva L, Leon O, Chodick G, Gabis LV (2013) A survey of out-of-pocket expenditures for children with autism spectrum disorder in Israel. J Autism Dev Disord 43:2295–2302. CrossRefPubMedGoogle Scholar
  28. 28.
    Reschke-Hernández AE (2011) History of music therapy treatment interventions for children with autism. J Music Ther 48:169–207. CrossRefPubMedGoogle Scholar
  29. 29.
    Ruch W, Platt T, Hofmann J (2014) The character strengths of class clowns. Front Psychol 5.
  30. 30.
    Scherf KS, Luna B, Minshew N, Behrmann M (2010) Location, location, location: alterations in the functional topography of face- but not object- or place-related cortex in adolescents with autism. Front Hum Neurosci 4:26. CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Solomon O (2010) What a dog can do: children with autism and therapy dogs in social interaction. Ethos 38:143–166CrossRefGoogle Scholar
  32. 32.
    Sridharan K (2016) Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials. Eur J Pediatr 175:1353–1360. CrossRefPubMedGoogle Scholar
  33. 33.
    Tanaka JW, Sung A (2016) The eye avoidance hypothesis of autism face processing. J Autism Dev Disord 46:1538–1552. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    van Venrooij LT, Barnhoorn PC (2017) Hospital clowning: a paediatrician’s view. Eur J Pediatr 176:191–197. CrossRefPubMedGoogle Scholar
  35. 35.
    Wallace GL, Case LK, Harms MB, Silvers JA, Kenworthy L, Martin A (2011) Diminished sensitivity to sad facial expressions in high functioning autism spectrum disorders is associated with symptomatology and adaptive functioning. J Autism Dev Disord 41:1475–1486. CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Warren B, Warren B, Warren B (2008) Healing laughter: the role and benefits of clown-doctors working in hospitals and healthcare. In: Using the creative arts in therapy and healthcare: a practical introduction, 3rd edn, pp 213–228Google Scholar
  37. 37.
    Whyte EM, Behrmann M, Minshew NJ, Garcia NV, Scherf KS (2016) Animal, but not human, faces engage the distributed face network in adolescents with autism. Dev Sci 19:306–317. CrossRefPubMedGoogle Scholar
  38. 38.
    Wieder S, Greenspan SI (2003) Climbing the symbolic ladder in the DIR model through floor time/interactive play. Autism 7:425–435. CrossRefPubMedGoogle Scholar
  39. 39.
    Zablotsky B, Black LI, Maenner MJ, Schieve LA, Blumberg SJ (2015) Estimated prevalence of autism and other developmental disabilities following questionnaire changes in the 2014 National Health Interview Survey. Natl Health Stat Report:1–20Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Weinberg Child Development CenterThe Chaim Sheba Medical CenterTel HaShomer Ramat GanIsrael
  2. 2.Center of Academic StudiesOr YehudaIsrael
  3. 3.Sackler School of MedicineTel Aviv UniversityTel Aviv-YafoIsrael

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