You are on page 1of 15

475900

2013
HPQ19510.1177/1359105313475900Journal of Health PsychologyAgostini et al.

Article

Journal of Health Psychology

Parental anxiety and stress before 2014, Vol. 19(5) 587­–601
© The Author(s) 2013
Reprints and permissions:
pediatric anesthesia: A pilot study sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1359105313475900
on the effectiveness of preoperative hpq.sagepub.com

clown intervention

Francesca Agostini, Fiorella Monti, Erica Neri,
Sara Dellabartola, Leonardo de Pascalis and
Laura Bozicevic

Abstract
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.

Keywords
child age, clown intervention, maternal anxiety, maternal stress, pediatric anesthesia

Introduction
A considerable amount of evidence exists on the associated with crying, fear of separation, fussi-
significant distress and anxiety that children ness, and anger or freezing. Besides, pediatric
experience during the preoperative period, even anesthesia can be linked to postoperative mala-
in case of minor day surgery (Fortier et al., 2010; daptive behaviors and to possible negative con-
Kain et al., 1996, 2006; Kotiniemi et al., 1997; sequences on the child’s long-term development
Wright et al., 2007).
The induction of anesthesia can, in fact, be a
frightening, incomprehensible event for chil- University of Bologna, Italy
dren, as it represents an unknown situation;
Corresponding author:
before surgery, up to 75 percent of children Francesca Agostini, Department of Psychology, University
undergoing anesthesia experienced severe anxi- of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy.
ety or distress (Kain et al., 1996) that is often Email: f.agostini@unibo.it

sev. 2001). et al. one related to intervention trails on the child Martin and Dobbin. 2009.. for example. besides. Vagnoli et al. et al. 2007. it has not been possible to have a clear overview 2004. Meisel et al.. 2005. Wennstrom et al. Vagnoli et al.. methods versus pharmacological ones. 2007. 2004a). particular attention has effects. but less effective than hypnosis and operative anxiety. Vagnoli on the effectiveness of nonpharmacological et al. 2005. hypnosis (Calipel et al. Hansen et al.588 Journal of Health Psychology 19(5) (Caldas et al. 2008). anesthesia with very promising results is the port postoperative awakening. 2004a).. and clown doctors With respect to the reduction of child anxiety. showing proved more effective than music therapy in that the possibility to play. Golan et al. thus strengthening the immune system be divided into two main categories: the first (Bennett and Lengacher. 2009... 2001). 2005).. therapy (Kain et al. The results 2010) have identified clown intervention as an from these studies are very heterogeneous effective source of psychoemotional support for and inconclusive.. documenting the benefits of humor and laugh- sibility of affecting the children’s postoperative ter in clinical populations is still at a prelimi- functioning (McGraw and Kendrick. sia induction (Kain et al. 2003. one that assessed the effectiveness of the techniques has recently been experimented in pediatric used to reduce preoperative anxiety and to sup. 2005. 2006. quality of life and well-being and in mediating ies on the effectiveness of video games (Patel the perception of a condition of illness in the et al... children were more likely to child anxiety that are addressed to parents pri- be cooperative during induction in a low sensory marily focus on their presence during anesthe- stimulation group (Kain et al.. 2006). 2008. with a specific training. Moreover.. clown doctors can have several beneficial when not in the presence of severe stress and effects on the child. has proved effective (Calipel forming artists. Up to now. are professional per- ceutical technique. music (Martin. 2009. Golan et al.. on parents. presence of clown doctors in hospitals. 1988). among these techniques. in most cases. Palermo et al. dress as doctors. Nonpharmacological methods to reduce 2006). Regarding this.. 2011. improve circulation. 2006). midazolam has children undergoing minor surgery. For these reasons. however. many studies (Fernandes and Arriaga. preoperative preparation promising nonpharmacological interventions of pediatric patients and their environment is an such as hypnotherapy and hand-held video important issue in pediatric anesthesia (Astuto games need to be investigated further. an important factor in determining the As to the former... The physiological and the second one related to intervention trails correlates associated with humor represent. of the pos. 2010. Clown midazolam. Patel et al. Fry. 2001). working at many different levels: they been paid to nonpharmacological methods can relax muscles. Messeri et al. 2003) suggest The implementation of techniques such as avoiding the use of pharmaceutical sedation. even in a hospital counteracting preoperative anxiety (Kain et al.. and lower the production of quite different (Wright et al.. 2004b. 2004. (Fernandes and Arriaga. therefore.. Kain et al. doctors. the literature includes stud. 2007). improve used to reduce the child’s anxiety and distress the production of natural painkillers (beta- in this specific moment. and a large number of studies have However.. as parental presence . 2000). 1992. Even though the research agitation. 2010. video games (Calipel et al.. 2005.. 1998) and nary stage and it is difficult to determine how because of a longer stay in hospital (Viitanen they may relate to any specific disease process. is effective in reducing the levels of pre- 2004a). because of its side effects. low physiological mechanisms of the human body sensory stimulation (Kain et al.. humor and laughter have yielded beneficial As a consequence. These techniques are endorphins). 2005. 1999). but can cortisol. 2010).. eral authors (Watson and Visram... Kain et al. ward. who et al. the most commonly used pharma.

Messeri et al. 2000). their child and made the child more stressed. To this end. caregivers for the child development. literature (Yip et al.. pharmacological treatment and video games midazolam was significantly more effective on intervention) have showed an agreement in con- child anxiety than parental presence (Arai et al. who might feel helpless anxiety (trait anxiety) conveyed their anxiety to and concerned (Chundamala et al. On the whole. few studies have considered a younger ones generally show greater suffering... while some studies suggest that as a moderator of the relation between child and parental presence during anesthesia induction parental anxiety. experiences (such as separations and hospitali- One plausible explanation of this is the pos. Small. or cartoons. O’Conner-Von. 2010). 2010). in a developmental per- video games plus parental presence had better spective. 2000. in line with the framework of Developmental only a few studies have analyzed the effects of psychology: the intense stressful situation repre. variety of preoperative preparation programs also linked to the separation from the family addressed to parents. 2010) evaluating the effects of (Amanor-Boadu.Agostini et al. 2006). the younger the children are. increased how. and For example. the higher videos. 1990. This can explain tour.e.... to deal with a wide range of emo- dren’s anxiety or cooperation on entering the tions. this reasons. 2006. 2006). comparisons who interact in a supportive way help the child between parental presence and parental absence to negotiate and pass through main develop- have showed no relevant differences in chil.. Fortier et al. and this is negative outcomes. especially in the context of relevant emotional Palermo et al. iety and also improves his or her cooperation 2009. Yip et al. (2004) clearly evidenced (Thompson et al. Kain et al. social.. 2000.. this issue arises the critical role played effects on child anxiety than parental presence by the interactions between the child and his or midazolam alone (Kain et al. the child’s age should be included However. 1996. 2010). parental presence compared to other conditions Wright et al. hospital staff involved in child surgery. in the context of child’s anesthesia induc- evidence in the literature shows that pediatric tion.. up to . Caregivers Patel et al.. cluding that generally parental presence during 2007. nonpharmacological methods on parental anxi- sented by the surgery elicits different responses ety. 2007a. 2003. up to now. and this represents a considerable lack in the in children.. 1996). tions aimed at reducing parental anxiety could This relationship can be particularly strong be considered a useful strategy to prevent child when the child’s age is considered.. zations).. In the light of these results and in considera- and show—especially in the preoperative phase— tion that parental presence is a constant element anxious behavior that may directly influence or factor in the daily routine of health care and their child’s preoperative anxiety (Bevan et al. Cameron et al. emotional. can inhibit child’s self-confidence and sibility that anxious parents. Kain et al. midazolam plus parental presence or hand-held More generally. adaptation (PDM Task Force. 589 could effectively minimize child distress and the level of anxiety parents can experience. however. 2007a). interven- 1990. the parents with both high levels of anesthesia can represent a stressful event situational anxiety (state anxiety) and baseline for parents alike.. Kain et al. For anxiety. But induction area or during induction itself (Bevan interactions with anxious and worried parents.. 2009. mental stages. or peer modeling preparation by means of why. Two recent reviews (Chundamala et al. Notwithstanding. and to adapt to stressful situations. and personality maturity. others have underlined that (i. 1996. et al. depending on their level of cognitive. 2002. when present.. 2002). 1996). Vagnoli et al. it anesthesia induction does not seem to signifi- has been verified how the combined effect of cantly reduce neither child nor parental anxiety.. 1998. For may contribute to transmit anxiety to the child instance. 1998. such as an operating area (Patel et al. 2010. does decrease the level of child distress and anx. puppets. furthermore..

Besides. (2012) used a standardized preoperative clown intervention could be effective in decreas- preparation program that gave information to ing the level of perceived stress. anesthesia on parents’ level of stress (Vessey the general aim of the current study was to explore et al. proved effective in reducing tial effects of clown intervention on parental preoperative anxiety and improving postopera. Kain et al. which depicted According to Lazarus and Folkman’s (1984) the sequence of events. (Kain et al. 2007). 2012) used in few studies is clown intervention. McGraw. no differ. clown intervention. Therefore. in order to better explore the poten- aration program. objective comparing a condition with anxiety–reduction characteristics of the stimulus. a minor attention has been paid doctors on child anxiety and the need to further to the investigation of the effects of pediatric investigate on their effects on parental anxiety. parental coping skills et al. method to reduce parental anxiety that has been Litman and Lunsford. stress and coping framework. to explore any et al.590 Journal of Health Psychology 19(5) now. can play a relevant role for the perception of (2010) evidenced how a high level of anxiety stress in the situation of pediatric anesthesia.. the adaptation to a stressor is no differences emerged neither in state nor in strongly associated with how the individual trait anxiety after clown intervention (Vagnoli copes. Hatava et al. 2007b). recent literature on health psychology (Donovan- Another potential nonpharmacological Kicken and Caughlin... lize resources or coping options. and to 1998. This program effectively reduced an event as stressful based on how much it parental anxiety in the preoperative period. results have not been exhaustive (Cassady of child’s developmental level. A recent preparation program. coping is a relevant part of the significantly decreased the level of anxiety. The starting assumption was thesia. parents by means of a photo file. and strategies to tolerate or reduce external and cant decrease of parental state anxiety after internal demands and conflicts among them. experienced by parents was strongly associated with possible consequences on child adaptation with a child’s younger age. other than anxiety. For these reasons. Specifically. emotional state. The child’s age was All consecutive pediatric patients scheduled included in order to take into account the relevance to undergo general anesthesia for minor day . and a tour of the preop. 1999. (2004) focused their intervention on parents of factors: subjective perception. Considering this. Method going minor surgery.. anxiety.. Ngai et al. decreasing the latter might possibly lead to low preoperative anxiety and more collaborative behavior from children under. in order to whether clown intervention can be effective in improve the understanding on parental emo- decreasing the levels of parental anxiety in the tional reactions during child’s induction of anes- preoperative phase. Despite that. tion of own resources and coping skills. 2009. even threatens them and how able they are to mobi- though it did not reduce child anxiety. 1994). we included a measurement of tive outcomes (McEwen et al.... while in two Italian studies therefore. Wang of stress is the result of the action of three kinds et al. 2010). Vagnoli et al. 2000. Considering the promising effects of clown in the literature. 2003. people evaluate erative room. tion. hypothesizing that et al. and the evalua- acupuncture to a condition with sham acupunc. our hypothesis Participants was that clown intervention could be effective in reducing parental anxiety. The perception ences emerged as to postoperative effects. 2005. Kraaji et al. 1994). Fincher stress. possible relation with parental anxiety. ture: parents in the first group and their children Especially. the describe any specific effect of the clown interven- family-centered preoperative ADVANCE prep.. and refers to cognitive and behavioral efforts Fernandes and Arriaga (2010) found a signifi. 2011. we included in our study the evaluations that child anxiety is strictly dependent on parental of both parental anxiety and stress. 2009. therefore.

their is experiencing a very stressful reaction to a level of education. which evaluates the response to stress Ethic Committee.g. we were interested in evaluating the stressful iety and distress. where the indi- following sociodemographic information: the vidual does not feel exposed to particularly child’s age and gender. . and the total Measures score ranges between 0 and 45. Cronbach’s socioeconomic status. The scale and the children were contacted by an expert showed high internal consistency in the psychologist when they arrived at the hospital. admitted to the hospital. both state and trait anxiety scores Italian nationality (to avoid any misinterpretation were used as we were interested in both evalu- of the instruments used). and their situation. 1989). and their a stressful event or situation. 591 surgery (e. and absence of The second instrument used was the Rapid chronic illness. the child’s illness or stressful events. The the operating room. spe- was obtained from all the mothers included in cifically. quick (15 items).73). it was considered suitable to assess the research. evidencing a high level of anxiety. For the study. and Lack of social support. measuring state (STAI Y-1) and trait (STAI Y-2) anxieties. absence of prematu. did not change over time. clinical range for high-risk mothers is set at In relation to the research design. each Procedures consisting of 20 items. and the total score can range ard procedures. before the child is taken to of 80. The inclusion criteria were as follows: present study. indicating that the and the child arrive at the Pediatric DH and sit subject feels no anxiety at all. The first one was ious response.93 (trait anxiety). In the present respective mothers were recruited for the study. and a maximum in a waiting room. normative sample (0. Somatization. VRS was created for the self- years of age (M = 5. the study.95). American Society of Anesthesiology anxiety and controlling whether trait anxiety physical statuses I and II. standard deviation evaluation and perception of one’s reactions to (SD) = 2. the mothers completed two reaction to child surgery and any possible anx- specific self-report measures. Fathers were not included in this study possible parental stressful reactions to their because the frequency of their presence at Day child’s surgery. so we specifically focused on the State and Trait Anxiety Inventory (STAI. For the assessment of maternal levels of anx. between 3 and 12 Biondi. the VRS total score and on the Anxiety and Spielberger. their marital status. The model proposed by Lazarus and Folkman study protocol was approved by the Hospital (1984). 1983. and 45 indicating that he or she diagnosis (if present). Italian version by Pedrabissi Somatization subscales. This self-report measure is very Hospital (DH) was irregular (on the total sam. the parents 41 or higher in the Italian version. In the present sample. Aggressiveness. and Santinello. and written informed consent in different psychopathologic dimensions.81. this self-report measure is divided into two scales.18. VRS includes five subscales: Anxiety. Depression. removal of ade. with 0 indicat- All mothers completed a questionnaire on the ing a situation of well-being.Agostini et al. alpha for VRS was 0. intestinal biopsy. Tarsitani and A total of 50 children. in the present noids. Cronbach’s alphas for STAI were 0. and it is based on the stress ple recruited only 13 fathers were present).92 (Italy) were considered for eligibility in the (state anxiety) and 0. the mother’s age. Stress Assessment Scale (VRS. In the present study. or tonsils) at Bufalini Hospital in Cesena sample. according to which the family between a minimum of 20. 1999). Each item is scored on a 4-point scale (ranging from 0 to 3).91–0. Each item is scored on a All subjects underwent the same hospital stand- 4-point scale. residence in the town or ating any possible change in the level of state close to it. rity and developmental delay.

38). Besides. For the control group.592 Journal of Health Psychology 19(5) the mothers who consented to participate in the the adults stayed during the induction of anes- study were asked to sign an informed consent thesia. staying with statistical power of 80 percent in the study. It was also explained that this room/after separation) variables on the scores of was a preliminary project for the realization of STAI Y-1. Significant results control group depended on the hospital timeta. 6–12 years. and mothers were then administered two self-report the child was accompanied to the operating instruments (baseline) and were informed that room by a nurse and his or her mother. the assignment to index or variable in mixed ANOVAs. mixed ANOVAs The study was presented to all mothers asking were carried out to explore a possible effect of whether they were interested to participate in a the interaction between the “Group” (Clown or study investigating their emotional reactions to Control) and the “Time” (for the mother: waiting child’s surgery. the differences between the index and waiting room without clowns for the same the control groups. all 0. variables. in detect significant differences between groups. p = 1. Maternal later they would be asked to complete the tests anxiety and distress were assessed again imme- again. were in fact comparable with reference to the Afterward. the children’s age (t(49) = and the clowns to the operating room. were analyzed through Pearson’s chi- In both groups. such as magic Results tricks. diately after the separation of the mother from The families recruited for the study were the child. his or her mother. p = 0. in the waiting room. the clowns entered the waiting room adequate size of the sample. Second. the children’s age range (Fisher’s . each child in the clown group distribution of the children’s gender (Fisher’s was accompanied by a nurse. soap bubbles.00). the being that the clowns were never present. and independ- the sequences of questionnaires were identical.89. were considered when p values were lower bled admission service. STAI Y-2. music. in this condition. we divided and interventions aimed at reducing family’s the subjects into two age groups (3–5 years and negative emotions around child’s surgery. In order to obtain a and started playing with the child. Each Characteristics of the sample method was used according to the child’s age. (version 20. respectively) As clown doctors were present at the hospi. regarding sociodemographic period of time as the experimental group. randomly assigned to (1) an experimental group subject to clown intervention (n = 25). (2) a control needed to enroll a minimum of 2 × 23 subjects to group with a routine procedure (n = 25). in which Data analyses children interacted with clowns in the waiting room. the only difference personal information. the than 0.0). we him or her for about 30 minutes. and puppets.05. As a consequence. exact test. they in the “playing” atmosphere. Fisher’s exact test. which children and their mothers stayed in the First. and VRS. the procedure and form along with one on the management of the timing were the same. by means of different activities and toys. once the tests were Power analysis was run in order to evaluate the completed. and included “Child age” as an independent tal in specific days. n = 30 and n = 20. as to the future studies on the evaluation of techniques children’s age range (3–12 years). Statistical analyses were carried out control and intervention participants never using the SPSS statistical software for Windows interacted with each other. The clown intervention was aimed at dis- tracting and entertaining children. the instructions given and squared test. here. ent samples t test. The clowns’ humor and actions were directed at The sociodemographic characteristics were sim- involving not only the child but also the mother ilar between the two groups (see Table 1).

0   Mean age (in years).0   Low 20. (p = 0.50.95 ± 3. stressful situation respectively). when we considered VRS–Anxiety scores.004) in the number of both the assessments are shown in Table 2.84 ± 1. As regards trait anxiety 0. p = 0. p = 0.2   University degree 14.61).7 SD: standard deviation.45 ± 5. η2p=0.27). p = 0. SD = 0.0 Mother   Mean age (in years).62) and clown groups (p = 0. p = 0. there was not any fact. only in the measured at baseline and after separation from Clown group.Agostini et al.14). No relevant effects linked to the Group and Child Maternal responses to the age variables were detected (p = 0. p = to the variable Time (F(1.84).17).86) variables.99   Education (%)    Middle school certificate 28. The means and standard deviations for (McNemar test. nor significant differences related to Time × Group (p = 0. (STAI Y-1) significantly changed over time.3 10.0 40.19. Group ers were married. Maternal state and trait anxiety When considering the categorical scores of The mothers’ state and trait anxiety were STAI related to state anxiety.91.35).0 60.0 48. no (χ2[2]=0. and Child age (p = 0. 48) = 32.22. no significant tendencies toward recov- decrease from the first assessment to the second ery or worsening emerged in the control (p = assessment (waiting room: M = 44.1 63. their education (χ2[2]=0. there was a significant decrease the child.6 26.0 13. which revealed a significant scores. there was a significant main effect related significant change (5 vs 1.34  4. all moth.3   Medium 60.0 60. the mothers’ age (t(49) = interactions and the three-way interaction (p = −0. see Table 3). mean ± SD 36. and Group × Child age (p = 0. separation: M = 36.3    High school diploma 57.62) significant results for “Time × Group” interaction .95   Age range (%)   3–5 years 60.54.90. and none of the possible interactions among all factors resulted significant (all p values > 0.33. 0. and their socioeconomic status As to trait anxiety scores (STAI Y-2).0   6–12 years 40.23) were noted. mothers showing high anxiety compared to the The results showed that state anxiety scores number of women becoming anxious (9 vs 0).50. In both groups. see Table 3). exact test.90. In while in the control group.74).91). p = 1. Time × Child age First. main effects emerged for Time (p = 0.0 26. (p = 0.05). p = 0. male (%) 52. mean ± SD  5.34.71 35.00). McNemar test.42 ).0001. SD = 8.53 ± 3. Clown group (N = 25) Control group (N = 25) Child   Gender.  Sociodemographic characteristics of the sample.5   Socioeconomic status (%)   High 20. 11. 593 Table 1.34 and 0.

43 14 ± 6.90 0. *p < 0.26 0.92 3.77 ± 1.37 38.83** 5.96* 4.84 ± 8.91** 0.08 ± 1.12*   After separation 8.6 ± 5.26 0.26 15.0001.25 2.15   After separation 34.89 2.42 11. Journal of Health Psychology 19(5) .24   VRS: Rapid Stress Assessment Scale.82 0.87 2.63 3.7 ± 6.54   VRS–Total score   Waiting room 11.03 ± 6.01 3.05.13 7.18 2.50*   After separation 2.2 ± 1.2 0.87 2.35 2.72 ± 5.04 ± 11.6 ± 1.93 ± 1.5 ± 7.14 0.4 ± 1.24 36.64 ± 1.35 ± 1. **p < 0.67 37 ± 9.46 4.89 ± 5.89 37.33 ± 8.9 ± 5.67 13.6 ± 2.58   VRS–Anxiety   Waiting room 2.04 ± 8.8 ± 5.91 2.77 12.96 38.4 ± 10.37 12.68 38.63 ± 9.18 2.42 0.02 3. Measures Group Child age F   Clown Control 3–5 years 6–12 years Group Child age Time Group × Group × (N = 25) (N = 25) (N = 30) (N = 20) Child age Time STAI Y-1   Waiting room 43.2 ± 1.39 0.68 ± 7.44 ± 7.55 36.27   After separation 35.66 3.14 2.19*   After separation 1.51* 4.36 36.93 0. 594 Table 2.24 32. STAI: State and Trait Anxiety Inventory.8 ± 9.  Means and standard deviations of mother’s and child’s self-report measures.56 ± 1.38 38.77 ± 2.17 ± 6 9.38 34.82   STAI Y-2   Waiting room 35.9 ± 8.38 32.95   VRS–Somatization   Waiting room 2.81 0.76 ± 11.9 ± 1.85 2.65 2.45 46.32 ± 2.75 ± 7.03 2.36 ± 8.5 ± 1.65 0.8 ± 1.70 0.

01. VRS–Total scores showed different sig- cantly increased over time. η2p=0.85 ± 0. emerged (F(1.62 “No change” refers to subjects showing stability (low or high anxiety) at both assessments.52). 6–12 years. nor with relation to group: 3–5 years. × Group” interaction (F(1.50 ± Time (p = 0. No change Change p   Low anxiety High anxiety Recovery Worsening   State anxiety   Clown group (N = 25) 10  6 9 0 0. M = 3.06).2 3. cantly decreased from the first assessment to where younger children’s mothers in the the second assessment (see Figure 1). this can be in the direction of a recovery or worsening.Agostini et al.09) variables.44. and Child age (p = 0. VRS: Rapid Stress Assessment Scale. Group (p = 0. Considering only 4 4 3.4 2. p = 0.06).54.44.004   Control group (N = 25)  9 10 5 1 0.50).6 2. possible interactions among factors (all p val- tion (F(1. p = 0. VRS–Somatization scores showed signifi. VRS–Anxiety and Somatization mean scores related to Time and Group variables.51. revealing the moth. Control group showed an evident tendency to nificant main effects emerged with relation to somatize (Control group: 3–5 years. 48) = 7.22 Trait anxiety   Clown group (N = 25) 19  4 0 2 0. p = 0.19.20 ± 0.03).  Stability and change over time in state and trait anxiety. No sig.8 2 1 1 Clown group Clown group Control group Control group 0 0 Waing room Aer separaon Waing room Aer separaon Figure 1.50.7 2. M = 2. “Change” refers to subjects showing a change in their level of anxiety at the second assessment.1 3. and Child 0. No significant results emerged p values > 0.42) variables and other cant results related to “Time × Group” interac.5 2 1. any other interaction among all factors (all M = 2. 48) = 4.09)—as ues > 0. 48) = 4.11 ± 0.05).04. nificant results in relation to main effects and ers’ tendency to somatize more than the Clown interactions among factors.14): group (see Figure 1)—and related to “Child age only for the Clown group. . Group (p = 0. Clown age (p = 0. only in the Control group. 595 Table 3.05).1 VRS-Somazaon mean score 3 3 VRS-Anxiety mean score 2. η2p=0. mean scores signifi.62). the scores signifi. in relation to Time (p = 0.50   Control group (N = 25) 15  6 1 3 0. M = 2. 6–12 years.

Wright et al.2 Waing room 16 14. η2p=0. Golan et al.. SD = 6.68). after separation: M = 10. can be easily transmitted to the child (Bevan et al.15). 2005.1 8. Palermo tive period. SD = 5. which still needs to be further nificant decrease in their levels of stress. 2009. Vagnoli effect emerged for Time variable (F(1. pared to younger children’s mothers. 1996. VRS–Total scores related to Time and Child age variables. Parental presence during the preoperative phase of child surgery has been extensively Discussion investigated as a potential helpful strategy to This study aimed at analyzing the possible ben. whereas in Parental anxiety is a relevant matter to be the Control group younger children’s and older taken into consideration by anesthetists and children’s mothers showed similar values and a hospital staff especially when parents are tendency to stability over time (see Figure 2). parental .596 Journal of Health Psychology 19(5) 18 16. η2p=0. the results with higher observed power. but its effects on par- 15.87 10 9. 1996.007. globally decreased at the second assessment Given the relevance of the assumptions compared to the first one (waiting room: M = emphasizing how parental stress and anxiety 12. (2010) has anxiety and negative emotional states and in stated that to promote low anxiety in the improving postoperative adaptation (Fernandes child during anesthesia induction. 2010. Clown intervention has been shown et al.. 2007. Kain et al.. Kain et al. 2010. 1998. p = 0. 2007a.89. 2002.9 Aer separaon 13.. present during the child’s preoperative phase.83. 48) = indirectly.. Bevan et al. reduce child’s preoperative anxiety (Amanor- eficial effects of clown intervention on maternal Boadu. 2000. com. 2010).. 1996) × Child age interaction was found (F(1. to be effective in reducing child’s preoperative the Cochrane review by Yip et al. atric anesthesia. a main and Arriaga.11.87 14 VRS-Total mean scores 12 10.0001. 48) = et al.94. however.26). Cameron et al. 1990... VRS: Rapid Stress Assessment Scale.7 10. 2010). p = 0. investigated.67..47 8 6 4 2 0 3-5 y 6-12 y 3-5 y 6-12 y Clown group Control group Figure 2. as in the Clown our study as a relevant topic in the area of pedi- group older children’s mothers showed a sig. Fortier et al. a significant Time × Group 1990.7 9. Besides. anxiety and distress during the child’s preopera.. as VRS scores ents’ emotional states still are not clear. we have considered the objectives of 7.

2011. and skin tem- where overall the levels of anxiety visibly perature). respiratory was confirmed by the VRS–Anxiety subscale. maternal state and trait anxiety were represents—to our knowledge—the first one explored in this study. Vagnoli et al. while the con.. Notwithstanding. confirming that. only in the Clown group. while parental physiological responses trol mothers maintained similar levels of anxiety have been directly measured in the studies by over time. This result parental anxiety. in which parental show relevant variations in their somatizing presence plus clown intervention reduced child of stress. no differences were dren has always given secondary relevance to found. showing a positive effect on some of decreased at the second assessment only for the them (Bertini et al. measures other than STAI. while while they would not confirm the studies by the mothers after the clown intervention did not Vagnoli et al. as expected. The lack of vidual patient basis. found. this study primarily aimed remember that the choice of STAI as unique at investigating whether clown intervention. State anxiety scores investigating other psychological constructs showed a decrease over time independently other than anxiety during the preoperative from the Clown condition. The ferences between groups as result of the inter- previous literature investigating the potential vention variable. showed high STAI scores. in fact. as a stable the impact of the same technique on parents element of personality. Specifically. evidence found in the abovementioned Italian tial negative effects on the child due to high studies may be due to the influence of different parental anxiety. it indicated phase on which clown intervention could exer- anxiety to be higher upon arrival at DH and cise its influence. positive effects of clown intervention on chil. it The Somatization subscale was considered is worth highlighting that when considering quite relevant for the aims of our study. better describe mothers’ negative emotional reac. On the whole. mothers in the Clown condition. . anxiety but not parental anxiety. could was not sensitive enough to detect relevant dif- have a beneficial effect also on parents. and no use of other self-report this. 2005. 2011). electrodermal activity. Kain et al. was also similar in the studies by Vagnoli et al. 2010). In regard to maternal levels of stress.Agostini et al.e. The results showed that an evident reduction in parental anxiety after a only the women in the control condition tended Clown session (Fernandes and Arriaga. these results on mater. 2005). trait anxiety did not and has been strictly confined to the evaluation of change in the situation investigated. then to settle in all mothers. especially when they are anxious. the STAI 2009. a underlines the impact of a stressful situation on significant trend toward improvement was the mothers’ possible physiological responses. 597 presence should be considered on an indi. to increase their somatization over time. it is tions to child’s induction of anesthesia. Kingsnorth et al. as it categorical scores. probably.. in daily elements. heart rate. important to underline that the present study First. in order to (2005. 2003). frequency. 2010.. parents are almost always present. 2010).. indicating a significant reduction in A few studies have focused on the effects of anxiety. perceived stress was also investigated. mostly all the mothers (Fernandes and Arriaga. Golan et al. no categorization of and it is utterly difficult to restrain them from STAI scores. even if not in relation nal anxiety would confirm the studies that found to clown intervention. it is to For this reason. (2005. clown intervention on the physiological responses This result for STAI Y-1 categorical scores of children in hospital (i. 2010). 2007. (1996. 2010). (Vagnoli et al. As to trait anxiety. instrument to measure parents’ anxiety could already known in the literature and identified have led to a ceiling effect: considering that in as an effective method to reduce child anxiety the baseline assessment. as there may be poten. among which a small sample size routine. For these reasons.. Nevertheless. in this study.

then how?” (p. also with rela. 2009) showed a similar kind of research. 2005. younger children’s mothers. frequency) in mothers and of a long-term assess- lining the importance to evaluate the level of ment of postoperative anxiety and stress. younger children (1–4 years) results on the efficacy of the clown intervention. so as outcome: the clown intervention was effective to possibly confirm the obtained results. under..” Since family dynamics are even if high. Generally. (2009). represented by a significant decrease in children’s mothers in the control group main. Messeri et al. Kain the characteristics of their coping strategies. where a significant reduction in the erative period with a more favorable emotional global level of stress was found.598 Journal of Health Psychology 19(5) In relation to the global measure of perceived in future research. This element reflects a limitation already would highlight an important characteristic of found in other studies on the same topic (Bertini clown intervention. tained similar degrees of stress. so they would get “Should we be treating parents as well. 2006). (2009). mothers can experience the preop- years). This outcome size. the level of stress.g. while the oldest state.. the et al. the inclusion of objective physio- These data are relevant when considered in a logical measures (e. Only evidencing some difficulties in conducting this one study (Meisel et al. no evident The main methodological limitation of the effects were found among the younger chil. through the clowns’ evident for the oldest children’s mothers (6–12 intervention. The repetition of this study on result and. the youngest ones (3–8 years). stratification of age Taking into consideration the common condi- should never be ignored and investigated deeply tion of parental presence during child anesthesia . Fernandes and Arriaga. including separation anxiety. might be imagined one. 2010. parental anxiety.. dealing with negative emo. 2010). as a relevant moderator for stress. more significantly. Furthermore. ciently defined up to now: its effectiveness on Golan et al. the question remains. The overall results of the present study have therefore. For this developed their mental processes to such an reason. consid- on the eldest children (9–13 years) but not on ering also wider demographic characteristics. 2001. however. with relation to being present ation. Moreover. even if we only assessed mothers. and their level of Chundamala et al. if the more benefit from the intervention offered by answer is yes. deciding factor. 2004) evidenced presence of an adult is very important in order to how in similar situations mothers reported promote support and reassurance (PDM Task higher anxiety levels and appeared more reac- Force. differentiating perceived reality from during child’s anesthesia induction. have poorer cognitive and emotional abilities. stated: “What Considering this. heart rate and respiratory developmental psychology framework. is still lower when compared to important. Children of 5 years and older have tive to stressors compared to fathers.. 69). and developing symbolic solutions. parents would be sensitive to child’s age. as in child maturity: in front of unknown and highly Meisel et al. present study is represented by its small sample dren’s mothers in both conditions. we can hypothesize that in is best and safest for the child is the major oldest children’s mothers. is lower tages and disadvantages of parental presence (PDM Task Force. 2011. affected by a gender difference. anxiety and perceived stress. showing high levels of anxiety. it would be desirable to confirm whether extent as to be able to better understand the situ. our the positive effect of the clown intervention was results seem to show how. et al. arguing on the advan- anxiety. related to child wider samples would in fact be desirable. tion to separation from the parents. 2006). they cope better through behavioral useful implications for clinical practice. 2003. which has not been suffi.. might give more exhaustive stressful situations.. For this reason. Vagnoli et al. a relevant three-way interaction emerged: the effects of clown intervention. tions. because of previous results (Caumo et al. 2009. future studies should include the fathers as well. during child anesthesia induction.. and cognitive strategies. the clown.

Lucas-Polomeni MM. Wright JG and Kemp SM (2009) Arai YC. therefore. emotional responses to induction of anaesthesia in children. et al. in order to limit the neg. Paolone G. Haig MJ. psychologists. Minerva Anestesio. et al. 275–281. In this way. Laughter and place of care for the body. clown intervention can be promoted Bennett MP and Lengacher C (2006) Humor and as a method that would aim both at minimizing laughter may influence health: II. Wysocki TT. Pais-Ribeiro JL and Carneiro SR (2004) General anesthesia. the hospital. building a work alliance with the medical and Bennett MP and Lengacher C (2008) Humor and paramedical staff. Risk factors for preoperative anxiety in adults. Paediatric Anaesthesia 14: 910–915. we would like to thank all the families involved emotional and sociobehavioral development: A in the study and Dr Mauro Pocecco. Head of the review. tal presence at induction of anaesthesia on the Caumo W. et al. Kandatsu N.Agostini et al. (2001) behaviour of unsedated Nigerian children pre. Paediatric Anaesthesia 15(4): Francesca Gobbi and Francesca Lupi. Caldas JC. (2006) Preoper. (1999) Cesena. Rosano G. Wodey E. West African Anaesthesiologica Scandinavica 45(3): 298–307. et al.1093/ecam/neq064 hospital environments. Acta senting for day-case anaesthesia. for their precious role in starting the project and col. Canadian Journal of Anaesthesia salivary amylase activity before the anesthe. Cameron JA. Use of a preanesthetic video for facilitation of parental education and anxiolysis before pediat- References ric ambulatory surgery. 51–56. are encouraging for the use and ogies. surgery and hospitalization in Acknowledgements children and their effects upon cognitive. Miller KM. (1990) Preop- ative impact of anesthesia on pediatric patients’ erative parental anxiety predicts behavioural and well-being and to promote a precocious nor. gave his support for the realization of the study. Bond MJ and Pointer SC (1996) Reduc- lecting the data. sia. (2007) Induction An evidence-based review of parental pres- and emergence behavior of children undergo. cal distress: The mediating role of coping. Journal of Medicine 21(1): 28–30. Evidence-Based Complementary and Alter- promotion of clown intervention in clinical– native Medicine 1–9. et al. (2011) Clowns The data. a laughter may influence health: III. Pediatric Unit of Bufalini Hospital in Cesena. favoring well. Fernandes SC and Arriaga P (2010) The effects of logica 72(6): 461–465. Schneider CN. ing the anxiety of children undergoing surgery: Parental presence during anaesthetic induction. Canadian Journal of Anaesthesia 37: malization of negative emotional states in chil- 177–182. Chundamala J. cancer patients’ topic avoidance and psychologi- Astuto M. during hospitalization and treatment and at Evidence-Based Complementary and Alternative Medicine 3(2): 187–190. Anesthesia and Analge- Amanor-Boadu SD (2002) The effect of paren. tary and Alternative Medicine 5(1): 37–40. et al. Acta Anaesthesiologica Scandinavica 52: Donovan-Kicken E and Caughlin JP (2011) Breast 285–288. Jour- ative parental information and parents’ presence nal of Health Psychology 16(4): 596–606. Head of the Pediatric Unit of Bufalini Hospital in Cassady JF. when confirmed on benefit children hospitalized for respiratory pathol- wider samples. Rizzo G. Evidence-Based Complemen- the emotional aspects of illness. 56(1): 57–70. academic. We (2005) Premedication in children: Hypnosis ver- also give special thanks to the medical staff and to sus midazolam. clown intervention on worries and emotional . doi:10. sia 88(2): 246–250. First. Complementary the patient’s and his or her family’s stress therapies and humor in a clinical population. 599 induction. Bertini M. at induction of anaesthesia. might also contain health outcomes. Ito H. who Calipel S. being as a whole. Isola E. Funding Journal of Paediatrics and Child Health 32(1): This study was supported by Mauro Pocecco. dren and their mothers. ence during anesthesia induction and parent/ ing general anesthesia correlates with maternal child anxiety. et al. Bevan JC. Johnston C. Schmidt AP.

more effective? Anesthesiology 89(5): 1147–1156. Martin SR. sedative premedication: Which intervention is Fortier MA. premedication and postoperative behaviour in Kain ZN. Caldwell-Andrews AA. Shaw J and Ramet AS (2012) The effec. Blain S and McKeever P (2011) Physio- Effect of a clown’s presence at botulinum toxin logical and emotional responses of disabled children injections in children: A randomized. postoperative pain. (2006) Preoperative anxiety. use and impact of coping strategies assessed Kain ZN. Lazarus RS and Folkman S (1984) Stress. laughter. dren. et al. Litman JA and Lunsford GD (2009) Frequency of iors. prospec. Anesthesiology 107: 545–552. Journal of A randomized controlled trial. JAMA 267(13): 1857–1858. et al. Caldwell-Andrews AA. Kibaek M. Journal of Anaesthesia 41(11): 1094–1103.1093/ecam/neq008 Preoperative psychological preparation for chil. (1998) Paren- single-blind randomised controlled trial. Maranets I. (2007b) ating-room—Psychological issues. Journal of anesthesia: Physiological effects on parents. (2009) Clowns Kain ZN. Paediatric Anaesthesia 8: 117–121. Kain ZN. Journal of Pain Research 4: 297–300. Caldwell-Andrews AA. Martin RA (2001) Humor. Mayes LC. (2010) Perioperative anxiety in children. health: Methodological issues and research find- going surgery. O’Connor TZ. Mayes LC. Del Rosario AM. Wang SM. MacLaren J. Mayes LC. (2011) Kingsnorth S. Martinussen T. Olsson GR and Lagerkranser M (2000) 1–10. Anesthesia and Analgesia 99(6): 1648–1654. Mayes LC. sory stimuli and anxiety in children undergoing dren: A randomized controlled trial. Based Complementary and Alternative Medicine Hatava P. New York: Springer Publishing (2004b) Preoperative anxiety and emergence Company. cognitive abilities. (1996) of Health Psychology 15(3): 405–415. Anesthesiology Anaesthesia 17(6): 534–539. and other Fry WF (1992) The physiologic effects of humor. et al. Hansen LK. et al. Kotiniemi LH. Pediatrics 118: 651–658. Psychological Bulletin 127(4): 504–519. delirium and postoperative maladaptive behav. Dobija N. Anesthesia and Health Psychology 14: 18–26. Journal Kain ZN. Weisman SJ. et al. Archives of Pediatrics & Adolescent tiveness of a standardised preoperative prepa. and physical and behavioral recovery in young children under. 106(1): 65–74.600 Journal of Health Psychology 19(5) response in children undergoing surgery. The effect of videotaped preoperative informa- (2007a) Family-centered preparation for surgery tion on parental anxiety during anesthesia induc- improves perioperative outcomes in children: tion for elective pediatric procedures. . ings. McGraw T (1994) Preparing children for the oper- Kain ZN. Anesthesiology 96(1): 58–64. Mayes LC. Appraisal Kain ZN. and Coping. et al. Preoperative anxiety in children: Predictors and Fincher W. Quantock C. Paediatric A randomized controlled trial. Journal of Clinical Anesthesia 12: 549–554. predictors for children’s reactions to surgery. Anaesthesia 52: 970–976. mirth. Mayes LC. Ryhanen PT and Moilanen IK (1997) dren undergoing ENT operations: A comparison Behavioural changes in children following day- of two methods. Mayes LC. (2000) atric Anaesthesia 20: 318–322. controlled trial. doi:10. Journal tal presence during induction of anesthesia versus of Clinical Nursing 21(7–8): 946–955. Garnefski N and Schroevers MJ (2009) et al. (2007) Kain ZN. Caldwell-Andrews AA. Moorthy C. by the COPE Inventory and their relationships (2003) Parental presence during induction of to post-event health and well-being. Paedi. Wang SM. Anesthe- Anaesthesia 19(3): 262–266. et al. et al. children. Kraaij V. goal adjustment. ness of midazolam administered preoperatively to McGraw T and Kendrick A (1998) Oral midazolam children. Paediatric Anaesthesia 10(5): case surgery: A 4-week follow-up of 551 chil- 477–486. Caldwell-Andrews AA. et al. to therapeutic clowns: A pilot study. Analgesia 98(5): 1260–1266. Health Psychology 14(7): 982–991. Kain ZN. outcomes. Evidence- tive study. et al. Canadian Effects of age and emotionality on the effective. and laughter. Social adaptability. and positive and nega- treatment for preoperative anxiety in children: tive affect in definitive infertility. et al. Medicine 150: 1238–1245. et al. McEwen A. et al. Tighe P. McClain BC. (2001) Sen- for the prevention of preoperative anxiety in chil. ration in reducing child and parent anxiety: A Kain ZN. Krivutza DM. Paediatric surgery: A randomized. (2004a) Interactive music therapy as a Coping. sia and Analgesia 92(4): 897–903. Golan G.

Behavior Modification 31(1): Tarsitani L and Biondi M (1999) Sviluppo e validazi. Pediatrics 116(4): 563–567. Silver Spring. et al. gery—An integrative research review. Pae- PDM Task Force (2006) Psychodynamic Diagnostic diatric Anaesthesia 13(3): 188–204. Paediatric Wang SM. thesia induction in children: A psychological Vagnoli L. Caprilli S and Busoni P (2004) Anaes. Nursing 28(4): 393–398. (2004) Anaesthesia 10(5): 487–491. Cyna AM. Forma Y: Manuale. Italiana dello STAI. of the efficacy of parental presence for pediat- comes in children following intensive care hos. Wright KD. tal presence. Psicothema 21(4): 604–609. nal coping during early motherhood among Vessey JA. after ambulatory sevoflurane anesthesia in chil- tal presence during anaesthesia induction for dren. Clown doctors as a treatment for preoperative Paediatric Anaesthesia 14(7): 551–556. ric anesthesia. Maranets I. are parents helpful? A randomized clinical trial Small L (2002) Early predictors of poor coping out. Vagnoli L. erative anxiety and postoperative behavior. Weinberg ME. Anesthesia and Analgesia 89: 75–79. Hallberg LRM and Bergh I (2008) analytic Organizations. Gunawardene WMS. . Cochrane Database of Systematic Reviews sia 51: 1008–1012. Robiglio A. 601 Martin RA and Dobbin JP (1988) Sense of humor. Caprilli S. Bastiani C. (1996) Pre-operative parental anxiety. et al. Anaesthesia 20(10): 937–943. (2009) The Vagnoli L. AORN Viitanen H. et al. anxiety in children: A randomized. Stewart SH and Finlay GA (2010) When Organizzazioni Speciali. et al. study. Caprilli S and Messeri A (2010) Paren- effect of “hospital clowns” on distress and mal. traction with a hand-held video game reduces Anesthesiology 100(6): 1399–1404. Davidson M. Firenze: Wright KD. Journal of Advanced l’Ansia di “Stato” e di “tratto”: Nuova Versione Nursing 62(1): 96–106. Algia Hospital 2: 114–119. prospective Ngai FW. Schieble T. Chan SWC and Holroyd E (2012) Mater. could be the most promising option? Paediatric Messeri A. Use of perioperative dialogues with children Pedrabissi L and Santinello M (1989) Inventario per undergoing day surgery. Anaesthe. et al. Pediatric 57(8): 751–758. (2007) Spielberger CD (1983) Manual for the Stait-Trait Anxi.Agostini et al. Middleton P. Self-Evaluation Ques. et al. Watson AT and Visram A (2003) Children’s preop- thesia 16(10): 1019–1026. Chellew K. (3): 1–61. Paediatric Anaes. has. medication with midazolam delays recovery Palermo TM. erative anxiety in pediatrics: Is clown’s interven- moderating effect of humor. parental presence during induction of anesthesia. Prevention and intervention strategies to ety Inventory (STAI: Form Y). Medicina Psicosomatica 44: 163–177. Journal of Anaesthesia 41(4): 276–280. Ponsell E. Canadian O’Conner-Von S (2000) Preparing children for sur. 52–79. Journal of Health Parental upset associated with participation in Psychology 17(2): 189–196. (1999) Pre- Journal 71(2): 334–343. Viitanen M. Tripi PA and Burgess E (2000) Paren. et al. to treat preoperative anxiety in children: What ing minor surgery. Irwin MG. (2006) Dis. MD: Alliance of Psycho. CA: Consulting Psychologists. pediatric preoperative anxiety. Bogetz MS. Parental auricular acupuncture as an adjunct for Patel A. International Journal tion effective to alleviate children discomfort? of Psychiatry in Medicine 18(2): 93–105. Turchi F. (2007) Preop- sles. (1994) first-time Chinese mothers. induction of anaesthesia in children. Manual. alleviate preoperative anxiety in children: A tionnaire. et al. Stewart SH. (2010) Non- Stress). ing the induction of anaesthesia in children. pharmacological interventions for assist- Thompson N. Canadian Journal of Anaesthesia pitalization and stressful encounters. one della scala VRS (Valutazione Rapida dello Yip P. Caserza CL. clowns or sedative premedication adaptive behaviours of children who are undergo. Finley GA. Meisel V. and immunoglobulin A: Evidence for a stress. Wennstrom B. (2005) evaluation of the efficiency of parents’ presence. critical review. Palo Alto. et al. outpatient surgery of the infant. Annila P. et al.