Skip to main content

Advertisement

Log in

Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials

  • Original Article
  • Published:
European Journal of Pediatrics Aims and scope Submit manuscript

An Erratum to this article was published on 10 March 2017

Abstract

Children and/or their parents are in fear and anxiety when admitted to hospitals or undergo invasive surgeries or investigations. Clown therapy has been shown as an effective measure in reducing this hospital fear and anxiety. Hence, we carried out a systematic compilation of the existing evidence on the clinical utility of hospital clowns in pediatric population. Electronic databases were searched with an appropriate search strategy, and only randomized controlled trials comparing the effect of clown therapy with standard care in children were included. The key outcome measures were as follows: extent of anxiety and pain felt by children and extent of state and trait parental anxiety. Random effect model was applied when moderate to severe heterogeneity was observed. Forest plot, I2 statistics and risk of bias were evaluated using RevMan 5.3 software. A total of 19 studies were found eligible to be included in the systematic review and 16 for meta-analysis. The pooled SMD [95 % CI] for child anxiety score was −0.83 [−1.16, −0.51] favoring clown therapy. Similarly, a statistically significant reduction {SMD [95 % CI] −0.46 [−0.7, −0.21]} in the state anxiety was observed amongst parents.

Conclusion: We found that hospital clowns play a significant role in reducing stress and anxiety levels in children admitted to hospitals as well as their parents.

What is known:

• Trials with clown doctors in pediatric population have shown conflicting results in allaying anxiety amongst children undergoing either hospitalization or invasive procedures

What is new:

• This is the first systematic review and meta-analysis on hospital clowns

• We found out that hospital clowns reduce anxiety amongst children before undergoing either hospitalization or invasive procedures

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

Abbreviations

CI:

Confidence interval

NRS:

Numerical rating scale

RR:

Relative risk

SMD:

Standardized mean difference

VAS:

Visual analogue scale

References

  1. Agostini F, Monti F, Neri E, Dellabartola S, de Pascalis L, Bozicevic L (2014) Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol 19:587–601

    Article  PubMed  Google Scholar 

  2. Alcantara PL, Wogel AZ, Rossi MIW, Neves IR, Sabates AL, Puggina AC (2016) Interaction effect of clowns in vital signs and non-verbal communication of hospitalized children. Paulista Journal of Pediatrics. doi:10.1016/j.rpped.2016.02.001

    Google Scholar 

  3. Alverson BK, Wilson KM, Shah SS (2013) A randomized trial of facilitated family-centered rounds. Hosp Pediatr 3:156–161

    Article  PubMed  Google Scholar 

  4. Barkmann C, Siem A-K, Wessolowski N, Schulte-Markwort M (2013) Clowning as a supportive measure in pediatrics—a survey of clowns, parents, and nursing staff. BMC Pediatr 13:166

    Article  PubMed  PubMed Central  Google Scholar 

  5. Bekinschtein TA, Davis MH, Rodd JM, Owen AM (2011) Why clowns taste funny: the relationship between humor and semantic ambiguity. J Neurosci 31:9665–9671

    Article  CAS  PubMed  Google Scholar 

  6. Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, et al. (2014) Laughter and humor therapy in dialysis. Semin Dial 27:488–493

    Article  PubMed  Google Scholar 

  7. Bertini M, Isola E, Paolone G, Curcio G (2011) Clowns benefit children hospitalized for respiratory pathologies. Evid Based Complement Alternat Med 2011:879125. doi:10.1093/ecam/neq064

    Article  PubMed  PubMed Central  Google Scholar 

  8. Bossert E (1994) Stress appraisals of hospitalized school-age children. Children’s Health Care 23:33–49

    Article  CAS  PubMed  Google Scholar 

  9. Cantó MA, Quiles JM, Vallejo OG, Pruneda RR, Morote JS, Piñera MJ, et al. (2008) Evaluation of the effect of hospital clown’s performance about anxiety in children subjected to surgical intervention. Cir Pediatr 21:195–198

    PubMed  Google Scholar 

  10. Cohen J (1998) Statistical power analysis for the behavioral sciences, 2nd edn. Lawrence Erlbaum Associates, Hillsdale, NJ

    Google Scholar 

  11. Colville G, Kerry S, Pierce C (2008a) Children’s factual and delusional memories of intensive care. Am J Respir Crit Care Med 177:976–982

    Article  PubMed  Google Scholar 

  12. Cumino DO, Cagno G, Gonçalves VFZ, Wajman DS, Mathias LAST (2013) Impact of pre-anaesthetic information on anxiety of parents and children. Rev Bras Anestesiol 63:473–482

    Article  Google Scholar 

  13. Dionigi A, Sangiorgi D, Flangini R (2014) Clown intervention to reduce preoperative anxiety in children and parents: a randomized controlled trial. J Health Psychol 19:369–380

    Article  PubMed  Google Scholar 

  14. Dvory A, Goshen Y, Ruimi S, Bikov S, Halevy R, Koren A (2016) Dream doctor intervention instead of sedation: performing radionuclide scanning without sedation in young children: a study in 142 patients. J Altern Complement Med 22:408–412

    Article  PubMed  Google Scholar 

  15. Felluga M, Rabach I, Minute M, Montico M, Giorgi R, Lonciari I, et al. (2016) 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

    Article  CAS  PubMed  Google Scholar 

  16. Fernandes SC, Arriaga P (2010) The effects of clown intervention on worries and emotional responses in children undergoing surgery. J Health Psychol 15:405–415

    Article  PubMed  Google Scholar 

  17. Festini F, Liguori S, Stacchini M, Ciofi D, Giusti F, Olivini N, Bisogni S (2014) O-143 effectiveness of a new method to reduce preoperative anxiety in children: randomised controlled trial. Arch Dis Child 99:A79

    Google Scholar 

  18. Fu KTL (1998) The healing hand in literature: Shakespeare and surgery. Hong Kong Med J 4:77–88

    PubMed  Google Scholar 

  19. Golan G, Tighe P, Dobija N, Perel A, Keidan I (2009) Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial. Paediatr Anaesth 19:262–266

    Article  CAS  PubMed  Google Scholar 

  20. Goldberg A, Stauber T, Peleg O, Hanuka P, Eshayek L, Confino-Cohen R (2014) Medical clowns ease anxiety and pain perceived by children undergoing allergy prick skin tests. Allergy 69:1372–1379

    Article  CAS  PubMed  Google Scholar 

  21. 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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Heilbrunn BR, Wittern RE, Lee JB, Pham PK, Hamilton AH, Nager AL (2014) Reducing anxiety in the pediatric emergency department: a comparative trial. J Emerg Med 47:623–631

    Article  PubMed  PubMed Central  Google Scholar 

  23. Higgins JPT, Green S (2016) Cochrane Handbook for Systematic Reviews of Interventions. 5.1.0 edition. Available from www.cochrane-handbook.org. Accessed 02 Feb 2016

  24. 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. doi:10.1093/ecam/neq008

    PubMed Central  Google Scholar 

  25. Kocherov S, Hen Y, Jaworowski S, Ostrovsky I, Eidelman AI, Gozal Y, Chertin B (2016) Medical clowns reduce pre-operative anxiety, post-operative pain and medical costs in children undergoing outpatient penile surgery: a randomised controlled trial. J Paediatr Child Health. doi:10.1111/jpc.13242

    PubMed  Google Scholar 

  26. Koller D, Gryski C (2007) The life threatened child and the life enhancing clown: towards a model of therapeutic clowning. Evid Based Complement Alternat Med 5:17–25

    Article  PubMed Central  Google Scholar 

  27. Koller D, Gryski C (2008) The life threatened child and the life enhancing clown: towards a model of therapeutic clowning. eCAM 5:17–25

    PubMed  Google Scholar 

  28. Kontos P, Miller K-L, Colobong R, Lazgare LIP, Binns M, Low L-F, et al. (2016) Elder-clowning in long term dementia care: results of a pilot study. J Am Ger Soc 64:347–3532016

    Article  Google Scholar 

  29. Meiri N, Ankri A, Hamad-Saied M, Konopnicki M, Pillar G (2016) The effect of medical clowning on reducing pain, crying, and anxiety in children aged 2-10 years old undergoing venous blood drawing-a randomized controlled study. Eur J Pediatr 175:373–379

    Article  CAS  PubMed  Google Scholar 

  30. Meisel V, Chellew K, Ponsell E, Ferreira A, Bordas L, Garcia-Banda G (2009) The effect of “hospital clowns” in psychological distress and maladaptive behaviours of children undergoing minor surgery. Psicothema 21:604–609

    PubMed  Google Scholar 

  31. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) The PRISMA group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62:1006–1012

    Article  PubMed  Google Scholar 

  32. Muscara F, McCarthy MC, Woolf C, Hearps SJ, Burke K, Anderson VA (2015) Early psychological reactions in parents of children with a life threatening illness within a pediatric hospital setting. Eur Psychiatry 30:555–561

    Article  CAS  PubMed  Google Scholar 

  33. Needle JS, O’Riordan M, Smith PG (2009) Parental anxiety and medical comprehension within 24 hrs of a child’s admission to the pediatric intensive care unit. Pediatr Crit Care Med 10:668–674

    Article  PubMed  Google Scholar 

  34. Oren-Ziv A, Hanuka P, Rotchild M, Gluzman A, Uziel Y (2012) Medical clowns—dream doctors as important team members in the treatment of young children with juvenile idiopathic arthritis. Harefuah 151:332–334

    PubMed  Google Scholar 

  35. Quintero A, Henao ME, Villamil MM, Leon J (2015) Changes in depression and loneliness after laughter therapy in older adults hospitalized. Biomedical Journal 35:1

    Google Scholar 

  36. Raviv A (2013) Humor in the “twilight zone”: my work as a medical clown with patients with dementia. J Holist Nurs 32:226–231

    Article  PubMed  Google Scholar 

  37. Rees G, Gledhill J, Garralda ME, Nadel S (2004) Psychiatric outcome following paediatric intensive care unit (PICU) admission: a cohort study. Intensive Care Med 30:1607–1614

    Article  PubMed  Google Scholar 

  38. Rennick JE, Rashotte J (2009) Psychological outcomes in children following pediatric intensive care unit hospitalization: a systematic review of the research. J Child Health Care 13:128–149

    Article  PubMed  Google Scholar 

  39. Rennick JE, Morin I, Kim D, Johnston CC, Dougherty G, Platt R (2004) Identifying children at high risk for psychological sequelae after pediatric intensive care unit hospitalization. Pediatr Crit Care Med 5:358–363

    Article  PubMed  Google Scholar 

  40. Tener D, Lang-Franco N, Ofir S (2012) The use of medical clowns as a psychological distress buffer during anogenital examination of sexually abused children. Journal of Loss and Trauma 17:12–22

    Article  Google Scholar 

  41. 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:e563–e567

    Article  PubMed  Google Scholar 

  42. Vagnoli L, Caprilli S, Messeri A (2010) Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option? Paediatr Anaesth 20:937–943

    Article  PubMed  Google Scholar 

  43. Viggiano MP, Giganti F, Rossi A, Di Feo D, Vagnoli L, Calcagno G, et al. (2015) Impact of psychological interventions on reducing anxiety, fear and the need for sedation in children undergoing magnetic resonance imaging. Pediatr Rep 7:5682

    Article  PubMed  PubMed Central  Google Scholar 

  44. Weintraub Y, Rabinowicz N, Hanuka P, Rothschild M, Kotzki S, Uziel Y, et al. (2014) Medical clowns facilitate nitrous oxide sedation during intra-articular corticosteroid injection for juvenile idiopathic arthritis. Isr Med Assoc J 16:771–773

    PubMed  Google Scholar 

  45. Wigert H, Dellenmark MB, Bry K (2013) Strengths and weaknesses of parent-staff communication in the NICU: a survey assessment. BMC Pediatr 13:71

    Article  PubMed  PubMed Central  Google Scholar 

  46. Wild B, Wetzel P, Gottwald U, Buchkremer G, Wormstall H (2007) A pilot project with crowns in psychiatric clinics. Nervenarzt 78:571–574

    Article  CAS  PubMed  Google Scholar 

  47. Wilson ME, Megel ME, Enenbach L, Carlson KL (2010) The voices of children: stories about hospitalization. J Pediatr Health Care 24:95–102

    Article  PubMed  Google Scholar 

  48. Wolyniez I, Rimon A, Scolnik D, Gruber A, Tavor O, Haviv E, et al. (2013) The effect of a medical clown on pain during intravenous access in the pediatric emergency department: a randomized prospective pilot study. Clin Pediatr (Phila) 52:1168–1172

    Article  Google Scholar 

Download references

Acknowledgments

We thank Prospero for registering this review protocol and Cochrane for utilizing RevMan 5.3 software in generating the pooled results and forest plot.

Authors’ contribution

KS—conceived the idea, analyzed the data, wrote the first draft of the manuscript, and approved the final draft. KS and GS—literature search, identified the studies, extracted the data, revised the draft of the manuscript, and approved the final draft of the manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Kannan Sridharan.

Ethics declarations

Funding

No fund was obtained for conducting this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Additional information

Communicated by Jaan Toelen

Revisions received: 29 June 2016; 2 August 2016

An erratum to this article is available at http://dx.doi.org/10.1007/s00431-017-2889-9.

Electronic supplementary material

Table S1

(DOCX 20 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sridharan, K., Sivaramakrishnan, G. Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials. Eur J Pediatr 175, 1353–1360 (2016). https://doi.org/10.1007/s00431-016-2764-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00431-016-2764-0

Keywords

Navigation