Clowns in hospitals may help improve psychological well-being and physical symptoms in children and adolescents who are undergoing treatment for acute or chronic conditions, according to researchers. Their analysis suggests that children and adolescents who were in the presence of hospital clowns, either with or without a parent present, reported significantly less anxiety during diverse medical procedures, as well as improved psychological well-being, compared with standard care.
The team, which includes experts from Federal University of Espírito Santo, Brazil; University of Saskatchewan, Canada; University of Alberta, Canada; and Federal University of Santa Maria, Brazil, says the results indicate that the involvement of a clown during medical procedures reduces fear, pain, and symptoms of invasiveness.
“Overall, our findings suggest that hospital clowns might have a positive effect in improving psychological well-being and emotional responses in children and adolescents in hospital with acute as well as chronic disorders. Our findings also support the continued investigation of complementary treatments for better psychological adjustment during the hospital admission process in pediatrics,” write authors in the study published in The BMJ.
What are hospital clowns?
According to experts, in a hospital setting, hospital clowns are usually part of a therapeutic clowning program, which are also known as “hospital clowning or clown care program.”
“The first modern register of hospital clowning was reported in September 1908 in the Parisian newspaper Le Petit Journal, which depicted on its front page an illustration of clowns and children in a London hospital ward. The American physician Patch Adams started clowning for patients in the mid-1970s and has been considered a pioneer in therapeutic clowning. In the mid-1980s, two models of hospital clowning originated independently in North America: clown doctors, which originated in New York City; and therapeutic clowns, which operate within the child life programs and originated in Manitoba, ON, Canada,” says the report.
Hospital clowning continues to grow around the world, but each country operates differently in terms of professional standards and training. Many hospital clowning programs currently operate in the US, the UK, Australia, New Zealand, Canada, Israel, South Africa, Hong Kong, Brazil, Belarus, and several countries in Europe.
“In general, clown doctors provide a complementary form of healthcare by using techniques such as music, juggling, improvisation, magic, storytelling, and puppetry, to entertain children and adolescents in hospital; they also visit adults in some hospitals. The clown doctors help create a positive emotional state and environment that promotes interaction between parents and child and foster a hopeful attitude,” explains the team. They add, “With a high level of adaptability, sensitiveness, and attentiveness, clown doctors adapt their toolbox to each patient, situation, and medical procedure being performed.”
What did investigators find?
Researchers examined evidence on the effectiveness of hospital clowns for a range of symptoms in children and adolescents admitted to hospital with acute (short-term) and chronic (long-term) conditions. They went through research databases looking for suitable clinical trials, published up to February 2020 and found 24 relevant trials (13 randomized controlled trials and 11 non-randomized controlled trials) involving 1,612 children.
The trials were designed differently and were of varying quality, but the authors were able to allow for that in their analysis. Anxiety was the most frequently analyzed symptom, followed by pain, psychological and emotional responses, and perceived well-being, stress, cancer-related fatigue and crying.
Several studies, for example, described that children and adolescents who interacted with hospital clowns (with or without a parent present) showed a reduced increase in anxiety scores in the preoperative room before painful procedures and during the induction of anesthesia compared with those in control groups with standard care. One study showed that children who interacted with hospital clowns reported significantly fewer worries and an increased positive affect in the preoperative room compared with the control group. The presence of a medical clown during a painful procedure in the pediatric emergency department tended to improve pain scores in children younger than 7.
Three trials that evaluated chronic conditions, such as cancer, showed significant reductions in stress, fatigue, pain, and distress in children who interacted with hospital clowns, compared with standard care. Only one trial found no difference in the level of distress among children who interacted with hospital clowns compared with a control group.
“Results indicated that interaction with hospital clowns during medical procedures, during induction of anesthesia, in the preoperative room, and as part of routine care for chronic conditions might be a beneficial strategy to manage symptom clusters (for example, anxiety, stress, pain, and fatigue). Furthermore, hospital clowns might help improve the psychological adjustment of children and adolescents in hospital compared with those who received only standard care,” conclude authors.