Clown Group Research Articles

Medical clowns improve sleep and shorten hospitalization duration in hospitalized children

Intervention by medical clowns was proven to have a positive effect in reducing stress and anxiety, increasing cooperation and improving the child's experience prior to a medical procedure and during the various stages of hospitalization. Sleep has long been known to be essential for recovery from injury and sickness, improving immune functions, and there is an emerging understanding of the restorative role quality sleep has on health and diseases. Hospitalized children are more exposed to sleep disorders and sleep deprivation due to the hospitalized environment, anxiety, and illness. Different behavioral interventions to promote sleep were previously studied in hospitalized children, some showing potential benefits. In this study, we sought to examine the ability of medical clowns to positively impact the child's sleep during hospitalization. The study is an observational matching (case–control) interventional study which took place at the department of pediatrics in Carmel Medical Center. Forty-two hospitalized children ages 2–17 were included in two equal groups of intervention or control. Children in the control group were recruited based on a method of matching the chief complaint plus the medical diagnosis and age of the children in the intervention group in a 1:1 matching. The children's sleep parameters were objectively evaluated for two consecutive nights using an Actigraph device and subjectively by parent's questionnaire. Additional factors such as hospital length of stay and demographics were also monitored. The study group had an encounter with a medical clown (15–30 min) before bedtime on either the first or the second night, and the control group was not exposed to a medical clown at all. We then compared the data from both groups using unpaired t-tests. Hospitalized children exposed to a medical clown prior to bedtime (n = 21) and children not exposed to a medical clown (n = 21) were comparable in age and clinical characteristics. The study group had a significantly delayed wake-up time compared to the control group (06:59 ± 46 min vs. 07:26 ± 42 min, p < 0.05) (mean difference of 27 min). Night's duration (from bedtime to wake-up) was significantly longer in the study versus the control group (570 ± 76 vs. 500 ± 66.1 min, p < 0.05), a total mean increase of 70 min, and sleep efficiency were significantly increased (92.3 ± 4.6% vs. 87.9 ± 8.7%, p < 0.05). Within the clown group, when comparing nights with and without exposure to a medical clown, total sleep time was prolonged by a mean of 54 min on the night of the intervention (518 ± 74 min vs. 464 ± 59 min, p < 0.01), and the total wake time during the night were reduced (52 ± 27 min vs. 77 ± 61 min, P < 0.05), mean difference of 25 min), mainly by reduction of wake period after sleep onset (WASO) (42 ± 25 min vs. 66 ± 58 min, p < 0.05), mean difference of 24 min). Regarding general medical outcomes, hospital stay was significantly shorter in the clown group vs. control (104 ± 42 h vs. 128 ± 42 h, p < 0.05), a mean reduction of 23 h—nearly an entire day. An encounter with a medical clown before bedtime in hospitalized children positively affects sleep parameters, which may be of great importance for healing in general. The clown intervention was also shown to shorten the hospital stay. Larger scale studies are warranted to establish these findings.

본산대 탈놀이패로서의 ‘반인(泮人)’설 재론에 대한 반론

Seonggyun-gwan's (성균관, the national school in Goryeo and Joseon Dynasties) slaves, known as Ban-in (반인, 泮人), was regarded as the Bonsandae (본산대) mask play troupe and was also regarded as the butcher. This theory associates Ban-in with Su-cheok (수척, 水尺), a butcher originating from northern nomadic cultures, traditionally grouped under the umbrella of Gwangdae (광대) in the northern regions. The 'Ban-in' theory was already wrong from the beginning due to the fact that the Ban-in was not a Sandae-hui (산대희) player. Despite its questionable foundation, Jeon Gyeong-uk has steadfastly supported this “Ban-in” theory since 1997, bolstering it with publications like 'Su-cheok and Ban-in as Performers seen through new Materials' (2014) and recent works such as 'History of Korean Traditional Play” (2020), “Dictionary of Korean Traditional Play” (2014), and “Books of Korean Traditional Play” (8 volumes) (2020), with the aim of popularizing it, even among researchers in the field.&#x0D; In response, this paper seeks to broaden and reinforce the arguments put forth by Son Tae-do and Sa Jin-sil, who have opposed the “Ban-in” theory The theory suggests that Jeon Gyeong-uk's Seonggyun-gwan's slaves, Ban-in, is regarded as northern region Gwangdae group.&#x0D; He says that Chuyeop-ryong (추엽륭. 秋葉隆) was convinced that Ban-in served as the Bonsandae mask play troupe. He also contests the claim that Ban-in participated in the unique Sanbung-japhui performance during the 12th year of King Yeongjo's reign and that Ban-in was indeed the butcher. These contentions collectively refute the 'Ban-in' theory's validity.&#x0D; Furthermore, the additional materials Jeon Gyeong-uk introduced to support the “Ban-in” theory lack substantial evidence for its reinforcement. Previously, interpretations of texts such as 'Munjong-sillok' and 'Gyerimyusa' indicated that 'Su-cheok' referred to characters participating in Sohakjihui, while 'Gojak' denoted the offspring of clowns, rather than reinforcing the “Ban-in” theory. Hence, the notion that “Su-cheok,” the butcher, is synonymous with a clown or part of the northern Gwangdae group is no longer tenable.&#x0D; Conversely, the paper explores the presence of the Hwarangi group, Mubu, and the musicians, and clowns in the southern region, postulating that they may have made their way to Hwarang of Silla from distant places. In contrast, musicians and clowns belonging to the northern Jaein-chon came from Gisaeng's sons and became musicians and subsequently musicians and clowns during the middle of the Goryeo Dynasty, as evidenced by the historical record that “Gisaeng's sons become Akgong” in 'Gyerimyusa' (1103).&#x0D; Traditional society in Korea operated on a caste system, with specific roles assigned to individuals based on their caste. Understanding the history of traditional performing arts in Korea requires a comprehensive examination of the establishment of the Gwangdae group, the official entertainment group of traditional society. While the Hwarangi group, consisting of clowns in the southern region, was well-known in the past, research on the northern region's Jaein-chon, a group of clowns, only gained momentum following the investigations of Kim Yeong-taek (1920-2000) conducted by Son Tae-do and Lee Ja-gyun in 1998, based on the life of Kim Yeong-taek (1920-2000), a native of Jaein-chon. It was not until 2001 that the Jaein-chon men were formally recognized as a northern clown group.&#x0D; The 'Ban-in' theory has cast a shadow over the proper understanding of the northern Jaein-chon clown group. Thus, it remains imperative to debunk Jeon Gyeong-uk's erroneous theory of 'Ban-in' and to facilitate more accurate investigations and research into the Jaein-chon men, who were indeed a northern clown group.

Fear of being laughed at in Italian healthcare workers: Testing associationswith humor styles and coping humor.

Humor is a strategy that healthcare workers can use to help patients cope with stress and manage complex situations. However, people differ in how they deal with laughter. Our aim was to investigate gelotophobia (fear of being laughed at) among healthcare professionals and its relationships with humor styles and inclinations to use humor for coping. A sample of 550 Italian healthcare-workers was assigned to three groups: Professional Hospital Clown Group (PHCG, people who trained as professional clown in health-care setting), Humor Training Group (HTG, people who attended health-care relevant training courses related to humor), or Control Group (CG, people who attended healthcare or professional training courses not related to humor), and provided self-reports in the GELOPH < 15 > , the Coping Humor Scale, and the Humor Style Questionnaire. Participants from humor-related interventions, in particular PHCG, were lower in gelotophobia and used humor as a coping strategy. Gelotophobia correlated negatively with coping humor, and affiliative and self-enhancing humor styles. We discuss the findings with regard to the use of humor and laughter in healthcare settings.

Medical Clowning: A Cost-Effective Way to Reduce Stress Among Children Undergoing Invasive Procedures.

BackgroundDistraction techniques like medical clowning and the use of soap bubbles can aid in reducing children’s stress levels while undergoing invasive medical procedures. Such complementary therapies are not a common practice in Pakistan, and data exploring the potential benefits of complementary therapies are sparse. This study aimed to determine whether distractions like medical clowns and soap bubbles could reduce anxiety and pain perceived by children undergoing invasive medical procedures in a hospital in Pakistan.Material and methodsWe conducted a randomized controlled trial of 76 pediatric patients (aged six to 12 years) whose treatment required a peripheral intravenous (IV) catheter insertion at the pediatric ward of the Fauji Foundation Hospital in Rawalpindi, Pakistan, from March 2016 to June 2016. Peripheral IV catheter insertion was required for all patients as part of their treatments (no participants received IV catheter placement solely for this study). Our sample size was selected via random sampling, and we excluded patients whose parents or legal guardians did not consent for their inclusion. Study participants were randomly assigned to either a clown group (n=38) or a control group (n=38). The patients in the clown group underwent IV catheter placement while interacting with the medical student clown and soap bubbles in the presence of a parent. Patients in the control group underwent IV catheter placement with support provided only by the parent. We assessed the patient’s distress and anxiety before, during, and after the procedure. We used the Observation Scale of Behavioral Distress (OSBD), before and after the procedure with the short version of self-reported Spielberger’s State-Trait Anxiety Inventory-Children (STAI-C), the visual analog anxiety scale (VAS), and pain experienced with the Wong-Baker Faces pain scale (FPS) only after the procedure. Additionally, we collected demographic information. The hospital's ethical review committee approved our study design.ResultsOf the 76 study participants, 53.9% were male and 46.1% were female. Most patients lived in a rural setting (67%). Mean values of the FPS, OSBD, and STAI-C for the clown group (3.21, 6.23, and 8.52, respectively) were all lower than those for the control group (8.00, 18.02, and 15.29, respectively; p<.001); however, the difference was not statistically significant for children older than 10 years. After IV catheter placement, the mean VAS score for the clown group was also significantly lower than that for the control group (2.84 vs. 8.92, respectively; p<.001).ConclusionThe use of distractions via medical clowns and soap bubbles was an effective nonpharmacological method of reducing anxiety and perceived pain in children undergoing invasive medical procedures. Therefore, proceduralists could use such techniques as powerful, noninvasive, and cost-effective complementary and alternative medicine tools in pediatric treatment settings in Pakistan. Further studies on the potential benefits of the aforementioned techniques are warranted.

A LUTA POR SORORIDADE

O artigo faz reflexões acerca de estímulos patriarcais à competição entre mulheres e o esforço feminista para combater essa competitividade com seu oposto – a mútua e profunda união feminina, o que chamamos de sororidade. Além disso, são analisados aspectos da chamada “masculinidade tóxica” e de premissas que visam a subalternização da mulher. Uma ação no âmbito das Artes da Cena, promovida pelo grupo de palhaçaria feminina do Distrito Federal Cabaré das Rachas, teve uma clara prerrogativa de engrandecer a união entre mulheres artistas da cena e de contestar a cultura machista satirizando-a e ironizando padrões que precisam ser destruídos. Pensar a arte como instrumento de militância e meio para abordar pautas relevantes como a opressão de gênero é o que impulsiona o texto.&#x0D; Palavras-chave: Feminismo, sororidade, militância.

Effects of Therapeutic Clowning on Pain and Anxiety During Intrathecal Chemotherapy in Turkey

PurposeThe aim of the present study was to explore the effect of therapeutic clowning on pain and anxiety during intrathecal chemotherapy. Design & methodsThe study was conducted using a quasi-experimental method with a pretest-posttest control group design. The study sample was composed of children between 7 and 12 years old (N = 78) who had been diagnosed with acute myeloid leukaemia and acute lymphoblastic leukaemia and were undergoing intrathecal chemotherapy in a hospital in Turkey. The study was conducted with children who received services at this hospital. The results were obtained from 74 children (i.e. 36 in the control group, 38 in the clown group). The data were collected with a questionnaire developed by the researchers, the Visual Analogue Scale (VAS) and the Faces Pain Rating Scale (FACES). VAS and FACES were used to measure pain and anxiety levels. Therapeutic clowning was applied to children in the intervention group. Analyses included percentage distributions, mean, chi-square, t-test, variance, and correlation analysis. ResultsResults showed that children in the clown group had significantly lower pain and anxiety than children in the control group (p < .001). ConclusionsAccording to the results, therapeutic clowning was effective in relieving the pain and anxiety of children between the ages of 7 and 12 years who undergone intrathecal chemotherapy. Practice implicationsDue to its positive effects, therapeutic clowning could be explore for use in other areas of paediatric nursing for the children between the ages of 7 and 12 years as a complementary treatment.

Clown Group - Engineers without Borders (Knowledge Connections): Building a Humanistic Training in Engineering Courses

The Clown Group – Engineers without Borders (Knowledge Connections) is a group of clowns formed by Engineers and Engineering students. The theoretical basis of the Clown Group goes back to the origins of Jerzy Grotowski's “poor theater” (1933–1999). Concerning the use of music, theater and dance to present and promote the pleasure of art, the Group values the interaction with the public and does not worry about the structural elements commonly characterized by the theater as stage and lighting. In this way, the Clown Group promotes a Humanistic Formation of its members by providing a development in the capacity of communication, contact with the external community and also the satisfaction, by allowing the art to be spread in a simple and effective way. The objective of this work is to analyze the importance of Humanistic Training in the professional and personal development of Engineers and Engineering students, treating as a special case the Humanistic Training linked to the actions of the Clown Group – Engineers without Borders (Knowledge Connections). As a hypothesis, it is expected that the experience of members and ex–members of the Clown Group can be proven through their training and presentations over the years. In order to evaluate the personal and professional development of members and ex–members of the Clown Group during the training process, a qualitative research was carried out, via an applied questionnaire, in addition to a documentary research by observation, in which data were collected through analysis and observation of photos and documents of the Clown Group. In addition, Artificial Neural Networks were used to correlate the members and ex–members based on the two applied researches. The members and ex–members of the Clown Group have experienced a major break in introspection, significantly improving their way of communicating with society. The members and ex–members presented an improvement in the way they relate to each other in a team, a fundamental aspect of an Engineer's professional life. The Clown Group presents itself as a very important action for Humanistic Training and the professional and personal development of Engineers and Engineering students. The diffusion of art in the academic and external community promoted by the Clown Group also allows the deconstruction of the stereotype that the areas of Engineering and the Arts cannot coexist.

Do clowns attenuate pain and anxiety undergoing botulinum toxin injections in children?

Botulinum toxin injection (BTI) is the primary treatment for spasticity in children. Anxiety and pain are important concerns to address to attenuate the discomfort of BTI. The aim of this study was to compare the effectiveness of medical clowns and usual distractions, both added to nitrous oxide (N2O) and analgesic cream, on pain and anxiety during BTI sessions in children. The primary outcome was pain evaluated by the Face, Legs, Activity, Cry, Consolability (FLACC) scale. Secondary criteria were pain rated on a Visual Analog Scale (VAS) by the child and parent, anxiety rated on a VAS before and during BTIs by the child and parent(s), rating of the success of the sessions on a 4-point Likert scale by the physician and parent(s), and rating of the benefits of the distraction by the parent(s). Non-parametric tests were used for between-group comparisons. Baseline group characteristics of the clown and control groups did not differ. During 88 BTI sessions (40 with clown distraction and 48 with control distraction) in 59 children (35 boys; 52 with cerebral palsy, 12 with moderate to severe cognitive disorders), median maximal FLACC score was 2.5 (interquartile range [IQR]: 1-4) in the clown group and 3 (IQR: 1-4.3) in the control group. VAS self-reported pain score was 2.5 (IQR: 0-5) and 3 (IQR: 1-6.3) in the clown and control groups (P=0.56), and VAS proxy-reported pain score was 2.5 (IQR: 0.3-3.4) and 3 (IQR: 1-4.5) (P=0.25). After BTI sessions, the 2 groups did not differ in VAS self- and proxy-reported anxiety (P=0.83 and P=0.81). Physician and parent ratings of the success of sessions were similar between the groups (P=0.89 and P=0.11). Parent ratings of the perceived benefits of distraction were higher in the clown than control group (P=0.004). Although clown distraction was particularly appreciated by parents, it did not significantly reduce pain or anxiety in children as compared with usual distraction. ClinicalTrials.gov ID: NCT03149263.

Effects of a clown's presence on pain and anxiety during botulinum toxin injections in children with motor disabilities

Botulinum toxin injections (BTI) in children often involve several sites of injections and repetitions of the procedure. Reducing pain and anxiety during this procedure is a high priority but remains a challenge. The aims of this study were to evaluate the effectiveness of medical clown presence on pain and anxiety during BTI with premedication (Nitrous Oxyde, EMLA) compared to usual distraction procedures. Children with motor disabilities, mostly cerebral palsy (1–18 years old) were recruited from the pediatric rehabilitation department of the Brest University Hospital. Children were randomized into the usual distraction group (music, movies…) or the clown distraction group. Pain was evaluated using the Face Legs Activity Cry Consolability (FLACC) scale by an independent observer and using the visual analogic scale (VAS) by the child and his parents. Anxiety before and during the BTI was evaluated using a VAS by the child and his parents. Proceeding of BTI was evaluated by the physician and child's parent, and benefit of distraction was evaluated by child's parent using a 4 point Likert scale. Eighty-seven children were included [55 males, mean age = 8.2 years (SD 3.6)]; 40 children in the clown group and 47 in the usual distraction. The two groups were comparable on the main sample characteristics and in term of procedures. There were no significant differences between groups on the FLACC and VAS anxiety and pain. Both distractions were considered beneficial by the parents but the result was significantly higher in the clown group ( P = 0.002). No differences were found between groups for the different subgroups. The clown presence during BTI does not seem to reduce significantly pain or anxiety in children/parents compared to usual distraction. However the presence of the clowns likely improves the level of distraction as evaluated by the parents which is a key result for such a repetitive procedure.

Effects of a clown's presence on pain and anxiety during botulinum toxin injections in children with motor disabilities

Botulinum toxin injections (BTI) in children often involve several sites of injections and repetitions of the procedure. Reducing pain and anxiety during this procedure is a high priority but remains a challenge. The aims of this study were to evaluate the effectiveness of medical clown presence on pain and anxiety during BTI with premedication (Nitrous Oxyde, EMLA) compared to usual distraction procedures. Children with motor disabilities, mostly cerebral palsy (1–18 years old) were recruited from the pediatric rehabilitation department of the Brest University Hospital. Children were randomized into the usual distraction group (music, movies…) or the clown distraction group. Pain was evaluated using the face legs activity cry consolability (FLACC) scale by an independent observer and using the visual analogic scale (VAS) by the child and his parents. Anxiety before and during the BTI was evaluated using a VAS by the child and his parents. Proceeding of BTI was evaluated by the physician and child's parent, and benefit of distraction was evaluated by child's parent using a 4 point Likert scale. Eighty-eight children were included (55 males, mean age = 8.2 years [SD 3.6]); 40 children in the clown group and 47 in the usual distraction. The two groups were comparable on the main sample characteristics and in term of procedures. There were no significant differences between groups on the FLACC and VAS anxiety and pain. Both distractions were considered beneficial by the parents but the result was significantly higher in the clown group ( P = 0.002). No differences were found between groups for the different subgroups. The clown presence during BTI does not seem to reduce significantly pain or anxiety in children/parents compared to usual distraction. However the presence of the clowns likely improves the level of distraction as evaluated by the parents, which is a key result for such a repetitive procedure.

Humor and Laughing: The Benefit of Hospital Clowns in Pediatrics for Hospitalized Children and their Families: A Review

Introduction: Laughter and humor have been reported as an effective way to achieve physiological and psychological health-related benefits to reduce pain and increase stress tolerance during medical evaluation and painful procedures. Objective: This literature review examines the effect of clown intervention in reducing anxiety, pain for pediatric patients before preoperative or during invasive medical procedures and evaluate methodological points used to assess the impact of clown intervention. Methods: The search via PubMed was conducted on publications from 2005 to 2016. All studies published in English, in French and in Spanish were included, focusing on clown therapy intervention visits for children less than 18 years present on the pediatrics services. We analyzed for each publication: population targeted, medical service categories, medical procedure, measurement tools for anxiety, pain and other clinical outcomes, data focused on methodological points including design and analysis of clinical trial, population size, sample size calculation and statistical analysis. Results: We selected 54 studies based on title relevance. After reading their abstracts we selected 28 publications, most were randomized prospective and controlled studies (n=18, 64%). The total studies sample was distributed considering the following children age groups: from 2 to 12-year-old (n=12, 43%), from 5 to 18 year-old (n=9, 32%) and from 0 to 18 year-old (n=7, 25%). The main result showed that the impact of clown intervention had a positive effect in clown group compared with control group. 10 studies showed the positive impact on reducing children’s anxiety and 7 studies on reducing parent’s anxiety before surgery. 5 studies described reduced pain perception during medical invasive procedure and/or postoperative period. This review provided some empirical evidences of the effect of clown interventions on anxiety and/or pain reduction in pediatric hospitals, and demonstrated that more evidence-based studies are needed in the future.

Effects of a clown's presence on pain and anxiety during botulinum toxin injections in children

Botulinum toxin injections (BTI) in children often involve several sites of injections and repetitions of the procedure. Reducing pain and anxiety during this invasive procedure is a high priority but remains a challenge. The intervention of medical clowns for improving distraction during painful procedures is increasing and the question of their benefit during BTI raises. The aims of this study were to evaluate the effectiveness of medical clown presence on pain and anxiety during BTI compared to usual distraction procedures. Pain and anxiety of children between 1 and 18 years undergoing first or repetitive BIT at Brest University Hospital were evaluated. The presence of the clowns was randomized based on their availability. The usual distraction included individualized distraction, such as music, movies, discussion… Pain was evaluated using the Face Legs Activity Cry Consolability (FLACC) scale by an independent observer and using the Visual Analogic Scale (VAS) by the child and his parents. Anxiety before and during the BTI was evaluated using a VAS by the child and his parents. Proceeding of BTI was evaluated by the physician and child's parent, benefit of distraction was evaluated by child's parent, using a 4 point Likert scale. Eighty-eight children (56 males, mean age = 7.92 years, 453 injections), 42 children in the clown group and 46 in the usual distraction group were evaluated. The two groups were comparable on the main sample characteristics and in terms of procedures (Nitrous oxide, EMLA patch…). There were no significant between group differences on the FLACC and VAS anxiety. However, clown distraction was significantly better than usual distraction according to the parents. Subgroups analyses suggested that some children, like children with cognitive impairment may have a better benefit of the presence of clowns in terms of pain. The clown presence during BTI did not reduce significantly pain or anxiety in children compared to usual distraction. However, the presence of the clowns likely improves the level of distraction as evaluated by the parents, which is a key result for such a repetitive procedure. Some specific groups of children may have a better benefit of clown presence, which suggests other analyses to be performed and confirmed by future studies.

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. The presence of clowns in the ED before and during painful procedures was effective in reducing children's anxiety. • 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.

Parental anxiety and stress before pediatric anesthesia: A pilot study on the effectiveness of preoperative clown intervention

As induction of pediatric anesthesia can elicit anxiety in children and parents alike, this study was aimed at evaluating the effectiveness of clown intervention in decreasing maternal anxiety and stress in the preoperative phase. Before anesthesia induction, 25 children were randomly assigned to clown intervention and 25 to a control group with a routine procedure. In the waiting room and after separation from the child, maternal anxiety and stress were measured. The results showed that after separation, only in the clown group, maternal state anxiety significantly decreased and the tendency to somatization did not increase. Moreover, after clown intervention, older children's mothers significantly reduced the level of perceived stress. As clown intervention can positively influence maternal anxiety and stress in the preoperative period, its promotion in clinical-hospital environments is recommended.

Clown intervention to reduce preoperative anxiety in children and parents: A randomized controlled trial

This study investigated whether a clown doctor intervention could reduce preoperative anxiety in children hospitalized for minor surgery and in their parents. A randomized controlled trial was conducted with 77 children and 119 parents: the clown group consisted of 52 children accompanied in the preoperating room by their parents (n = 89) and two clowns while the comparison group consisted of children accompanied by the parents only. The clown intervention significantly reduced the children's preoperative anxiety: children benefited from the clown's presence and showed better adjustment than children in the comparison group. Mothers in Comparison Group showed higher anxiety.

Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option?

A significant number of children undergo surgery experience high levels of anxiety in the presurgical period. The aim of this study is to investigate which intervention is more effective in reducing preoperative anxiety. The sample was composed of 75 subjects (aged 5-12 years) who had to undergo minor day surgery. Children were randomly assigned to: the Clowns group (N = 25) accompanied to the preoperative room by the clowns and by a parent; Premedication group (N = 25) premedicated with oral midazolam and accompanied to the preoperative room by one parent; or the Control group (N = 25) only accompanied by one parent. Anxiety in the preoperative period was measured by using the Modified Yale Preoperative Anxiety Scale (m-YPAS). Parental anxiety was measured by using the State-Trait Anxiety Inventory (STAI Y-1/Y-2). The Clown group was significantly less anxious during the induction of anesthesia compared with Premedication group and Control group. There were not any significant differences between Control group and Premedication group. There was an increased level of anxiety in the induction room in comparison with the waiting room: this difference was statistically significant for Control group and Premedication group, whereas it was not significant in Clown group. PPIA+clown intervention is more effective in reducing anxiety in children during the preoperative period than PPIA alone or PPIA+oral midazolam.

Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial

To determine if specially trained professional clowns allayed preoperative anxiety and resulted in a smooth anesthetic induction compared to the use of midazolam or no intervention. This was a randomized, controlled, and blinded study conducted with children 3-8 years of age undergoing general anesthesia and elective outpatient surgery. Patients were assigned to one of three groups: Group 1 did not receive midazolam or clown presence; group 2 received 0.5 mg x kg(-1) oral midazolam 30 min before surgery up to a maximum of 15 mg; and group 3 had two specially trained clowns present upon arrival to the preoperative holding area and throughout operating room (OR) entrance and mask application for inhalation induction of anesthesia. The children were videotaped for later grading. The clown group had a statistically significant lower modified-Yale Preoperative Anxiety Scale score in the preoperative holding area compared to the control and midazolam group. The clowns' effect on anxiety reduction continued when the children entered the OR but was equal at this point to the midazolam group. Upon application of the anesthesia mask no significant differences were detected between the groups. This study found that the use of preoperative medically trained clowns for children undergoing surgery can significantly alleviate preoperative anxiety. However, clowns do not have any effect once the anesthesia mask is introduced.

Clown Doctors as a Treatment for Preoperative Anxiety in Children: A Randomized, Prospective Study

The induction of anesthesia is one of the most stressful moments for a child who must undergo surgery: it is estimated that 60% of children suffer anxiety in the preoperative period. Preoperative anxiety is characterized by subjective feelings of tension, apprehension, nervousness, and worry. These reactions reflect the child's fear of separation from parents and home environment, as well as of loss of control, unfamiliar routines, surgical instruments, and hospital procedures. High levels of anxiety have been identified as predictors of postoperative troubles that can persist for 6 months after the procedure. Both behavioral and pharmacologic interventions are available to treat preoperative anxiety in children. The aim of this study was to investigate the effects of the presence of clowns on a child's preoperative anxiety during the induction of anesthesia and on the parent who accompanies him/her until he/she is asleep. The sample was composed of 40 subjects (5-12 years of age) who had to undergo minor day surgery and were assigned randomly to the clown group (N = 20), in which the children were accompanied in the preoperative room by the clowns and a parent, or the control group (N = 20), in which the children were accompanied by only 1 of his/her parents. The anxiety of the children in the preoperative period was measured through the Modified Yale Preoperative Anxiety Scale instrument (observational behavioral checklist to measure the state anxiety of young children), and the anxiety of the parents was measured with the State-Trait Anxiety Inventory (Y-1/Y-2) instrument (self-report anxiety behavioral instrument that measures trait/baseline and state/situational anxiety in adults). In addition, a questionnaire for health professionals was developed to obtain their opinion about the presence of clowns during the induction of anesthesia, and a self-evaluation form was developed to be filled out by the clowns themselves about their interactions with the child. The clown group was significantly less anxious during the induction of anesthesia compared with the control group. In the control group there was an increased level of anxiety in the induction room in comparison to in the waiting room; in the clown group anxiety was not significantly different in the 2 locations. The questionnaire for health professionals indicated that the clowns were a benefit to the child, but the majority of the staff was opposed to continuing the program because of perceived interference with the procedures of the operating room. The correlation between the scores of the form to self-evaluate the effectiveness of the clowns and of the Modified Yale Preoperative Anxiety Scale is significant for both the waiting room and induction room. This study shows that the presence of clowns during the induction of anesthesia, together with the child's parents, was an effective intervention for managing children's and parents' anxiety during the preoperative period. We would encourage the promotion of this form of distraction therapy in the treatment of children requiring surgery, but the resistance of medical personnel make it very difficult to insert this program in the activity of the operating room.

PERIOPERATIVE CLOWN THERAPY FOR PEDIATRIC PATIENTS

S306 INTRODUCTION: Anesthesiologists have long known that surgery can be emotionally stressful for both pediatric patients and their parents. [1] Previous attempts to alleviate this anxiety have included parental presence during induction, preoperative preparation and distractions. [2,3,4] Presently, specifically trained professional clowns entertain pediatric patients in in-patient and out-patient settings in many pediatric hospitals. The purpose of this study was to determine if perioperative clown exposure would reduce distress in children undergoing surgery. METHODS: After IRB approval, 292 children presenting for surgery were enrolled in the study. Children who were less than six-months old or could not see the clowns were excluded from the study. A day of surgery was randomly assigned to "The Big Apple Circus" clown exposed group or to the no clown exposed group. In this way, the children in the control group (no clown) could not accidentally be exposed to clowning. The parents and patients were told that they were in a study to measure distress but were unaware that we were studying the effect of clowns. The clowns did not accompany the children during induction and the anesthesiologists were not informed which patients were in the study arm. Children were asked pre-clowning to rate their distress using a "faces scale" (1-5). At the end of the first hour of recovery the children were again asked to rate their distress. Immediately after induction the anesthesiologist was asked to rate the patients' cooperation, ease of induction and distress. RESULTS: There were no differences between the two groups regarding induction techniques, anesthesiologist or demographics. All patients reported that their distress level increased postoperatively. The patients in the no clown group reported the highest level of distress (mean faces score 2.7), the patients who were exposed to clowns only preoperatively, reported less distress (mean faces score 2.5) and those who were treated with clowns pre and post operatively had the least distress (mean faces score 2.3). The difference between the no clown group and the pre + postop clown group was significant (p<0.05). The anesthesiologists reported that the clowned group was more cooperative, less distressed and had easier inductions (p<0.05). DISCUSSION: This study shows that perioperative clown therapy can demonstrably decrease patient's distress.