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CPJ521210.1177/0009922813502257Clinical PediatricsWolyniez et al

Clinical Pediatrics

The Effect of a Medical Clown on Pain 52(12) 1168­–1172
© The Author(s) 2013
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DOI: 10.1177/0009922813502257

Pediatric Emergency Department: A

Randomized Prospective Pilot Study

Ido Wolyniez, MD1, Ayelet Rimon, MD1, Dennis Scolnik, MBChB2,
Alejandro Gruber3, Oren Tavor, MD1, Eli Haviv1, and
Miguel Glatstein, MD1

Background. We report the effect of the presence of a medical clown during insertion of an intravenous catheter
during their emergency department visit. Methods. Prospectively randomized to either the presence or absence of
a male medical clown during the procedure. Pain was assessed using the Faces Pain Scale–Revised in children 4 to
7 years old, and visual analog scales in children 8 years and older. Parental situational anxiety was recorded using
the State-Trait Anxiety Inventory after the procedure. Results. 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 years.
Parental situational anxiety was significantly reduced in parents of children older than 8 years (P = .02). Conclusion.
Therapeutic clowns are useful for diminishing pain and anxiety during painful procedures being performed on
children in the emergency department.

pediatrics, therapeutic clown, pain, emergency department, procedure

Background have been shown to have a positive effect on patients.9
In the past decade, there has been a rapid growth in the
The relief of pain and suffering is one of the most com- presence of therapeutic clowns in hospitals, particularly
mon reasons for seeking care in an emergency depart- in pediatric settings,10 although with varying degrees of
ment (ED).1 Painful procedures are also commonly training and accountability. The therapeutic clown pro-
indicated in children attending the ED, and the experi- gram at our institution has 6 clowns, but this service has
ence can be very traumatic for children and their fami- not been extended to full-time coverage in the ED. We
lies, with real long-term negative emotional and are unaware of any studies conducted related to the
psychological sequelae.2 The anxiety, fear, and behav- effect of the use of therapeutic clowns during ED proce-
ioral distress caused by medical procedures, particu- dures in children. We hypothesized that the participation
larly those involving needles, exacerbate children’s
pain and may interfere with the procedure.3 Cognitive
psychological techniques, including distraction, can 1
Dana-Dwek Children Hospital, University of Tel Aviv, Tel Aviv,
increase pain tolerance4 and physicians are morally Israel
obligated to be aware of, and use, this modality.5 The Hospital for Sick Children, University of Toronto, Toronto,
Ontario, Canada
Examples reported in studies for distraction techniques 3
Therapeutic Clown Program Association, Dream Doctors Program,
for venous blood sampling are nursing students who Tel Aviv, Israel
read stories to children6 and use of a handheld kaleido-
Corresponding Author:
scope by children.7
Miguel Glatstein, Division of Pediatric Emergency Medicine, Dana-
In recent years, there have been claims that humor Dwek Children Hospital, Sourasky Medical Center, 6 Weizman
and laughter possess unique characteristics that help Street, Tel Aviv 64239, Israel.
coping with pain and stress.8 Medical clowns and humor Email:

according to a sched. Block ferent phases of pain. simplified 6-face adaption of Bieri’s validated faces pain ule prepared in advance. a visual ana- ing the days when the clown was present at the ED. anchored by the terms “no hurting” to a “whole lot” or “severe pain” was used. previous immunizations or .12 which uses a picture scale with faces in dif- gender distribution in each of the 2 study arms. higher scores indicating greater anx- other pharmacologic or nonpharmacologic method of iety. To minimize information. and positively correlating with the anxiety-related pain relief was used. The group randomized to the medical children in the ED to one simple pain score may be inac- clown spent 15 minutes with the medical clown before curate and may not truly represent children’s perception. Measurements Randomization The primary outcome measurement was the child’s rat- ing of pain after intravenous cannulation. child such as magic tricks. Children aged 3 to 16 years whose treatments such as games. cope with the pain/distress of the procedure by having them imagines a pleasant object. to shift attention away from the plan included blood tests or intravenous cannulation in procedure. no between 20 and 80. Prior to this study. the effect of other behavioral factors. to in the question.15 The cognitive interventions by the medical clown Information obtained from medical records included employed for this project were as follows11: the child’s age and gender. Imagery: A technique to encourage the child to parent’s anxiety. Children were enrolled in the study only if they were accompanied by at least one of their parents. It does not contain smiling faces or tears. in the pediatric ED would reduce the child’s pain and the 2. Children undergoing employed various methods for entertaining the urgent intravenous cannulation and those with develop. which was not known to study scale. logue scale 100 mm in length. rated on nous cannulation was performed. on the age- Study participants were randomly assigned to a control appropriate scale at the end of the procedure. Recruiting eligible patients was done only dur. randomized •• Behavioral distraction: Behavioral techniques design. in both groups of The State-Trait Anxiety Inventory is a validated patients we did not prepare the parents or give them any instrument used to measure anxiety in adults. Our comparison group consisted of chil. gags. change in measured patient pain severity is 13 mm. A single medical clown was involved in and we were aware that we may miss other valuable the study to reduce variation in technique. demonstrated that the minimum clinical significant dren undergoing the procedure with the regular distrac. To measure situational anxiety. puppets. Cognitive distraction: A cognitive technique to intravenous cannulation or the taking of a blood sample shift attention away from the procedure.14 tion and comfort techniques that ED nurses and/or Attempting to reduce the entire painful experience of parents provided. the clown had not been part of routine Former work done to validate the visual analogue scale care in the ED. the time of patient enrollment by accessing consecutive Patients indicate the level of their pain by identifying the sealed envelopes maintained in a dedicated location in face picture of the pain they experienced. The behavioral interventions used were9: Methods Subjects •• Virtual reality: The use of technology and equip- ment to occupy the child’s attention. It consists instructions regarding how to aid their child as intrave.Wolyniez et al 1169 of medical clowns during a painful procedure involving 1. during a 1-year •• Humor before and during the procedure: this period ending September 2012. For children aged older than 7 years.13 The children were asked to mark the point on the line that Intervention they felt represented their pain during the procedure. and mental disabilities were excluded from the study. the ED were enrolled consecutively. or intervention group by a patient allocation scheme Children aged 3 to 7 years used the Faces Pain Scale– implementing a stratified block design to assure equal Revised. of reported anxiety symptoms. The Faces Pain Scale–Revised is a size varied randomly from 4 to 8. This pilot study employed a prospective. nor did the ED nurses a 4-point Likert-type scale. of 20 questions. thus personnel. telling jokes during the entire procedure.13. the result being a number emphasize the clown’s effect during the procedure. We used the subscale to use any guided imagery or distraction techniques. the ED. the procedure. Patient group assignment was determined at avoiding the confounding of affect and pain intensity.

  Pain and Parental Anxiety in the Study Groups. mean ± SD 4. When evaluating the duration control group (Table 1).5 ± 3.3 ± 2. n (%) 10 (83) 16 (100) .52 Visual analogue scale     Number of patients 9 10     Value score.52   Procedure success. mean ± SD 4.  Demographic and Clinical Features of the Study Groups. n (%) 9 (100) 10 (100) —   State-Trait Anxiety Inventory score. n (%) 6 (29) 9 (35) Table 2. .2 4 ± 2. All children had had a previous of the procedure.162   State-Trait Anxiety Inventory score.3 in the control group to 1.7 .9 ± 2. the 2 groups when comparing the duration of the ducted using Microsoft Excel 2010.5 3. n (%) 19 (90) 26 (100) . but only a trend toward a decrease the study intervention (medical clown present in the overall. with a decrease from an average pain score of Fisher’s exact test. The parental situational anxiety score in the inter- eight patients were 3 to 7 years old and 19 were 8 to 16 vention group with the medical clown present during years old.18   Procedure duration in minutes. we did not add in the time spent by painful experience in the form of immunization. In younger children.5 ± 3 . n (%) 21 (100) 26 (100) Previous painful procedure.2 ± 1.6 . mean ± SD 37 ± 13 31 ± 12 .79   Procedure success. There were no statistically significant Details of the procedure.02).77   Procedure success. ence of patients assigned to either the intervention or the dure. For con. and the clown with the patient before the procedure since it approximately one third of the patients in each group did not consume any time or effort from medical had previously undergone intravenous cannulation. continuous variables with normal distribution. mean ± SD 3.5 ± 3. mean ± SD 36 ± 9 27 ± 6 .3 . and any use of medications.6 ± 2 . representing to receive standard care (control group) and 26 patients decreased situational anxiety.4 4. mean ± SD 4.68   Procedure duration in minutes. 3.4 5. T-test was used for procedure. There was no statistically significant difference between Data were recorded and statistical analysis was con. were documented. Pain scores in the older age-group were unchanged by the presence of the medical clown (see Results Table 2). A total of 47 children were enrolled in the study. including overall success. Variable Control Group (n = 21) Clown Group (n = 26) Age in years. personnel.3 ± 4 1.02 Total     Number of patients 21 26     Procedure duration in minutes mean ± SD 4. Variable Control Group Clown Group P Faces Pain Scale–Revised (3-7 years)     Number of patients 12 16     Value score.166   State-Trait Anxiety Inventory score.14 other painful procedures. in parents of children 8 to were assigned to receive standard care combined with 16 years old (P = . Twenty.5 ± 3. mean ± SD 8±4 7±4 Male. mean ± SD 38 ± 16 34 ± 15 . procedure room).18).6 in the intervention group (P = . n (%) 14 (67) 19 (73) Previous immunization.1170 Clinical Pediatrics 52(12) Table 1. Twenty-one patients were randomly assigned the procedure showed a lower score. there was a tendency for the tinuous variables with nonnormal distribution the pain score to be lower when the medical clown was Wilcoxon test was used and for categorical data the present. and the time taken for the proce. differences in demographics or previous clinical experi- number of attempts.

the use of topical anesthetics was not controlled on hospitalized children.147:30-32. it the pain that is experienced during invasive procedures. and/or publication of this role in the 10-point change. we found no impact on this study because only 1 case involved pretreatment with a The effect of the presence of a medical clown. ducibility of the instruments used in our study and on nificant 9-point decrease did occur among the parents of larger numbers of children. combined with a change in 2 faces indicates a more significant reduc. and they clown on children treated with botulinum toxin in an may have missed other valuable information. The parents of the intervention group dem. Although our pilot study showed a trend toward to reduce pain and anxiety. Our data show that the presence Ido Wolyniez and Ayelet Rimon contributed equally to this work as first authors. therefore larger studies are cal staff of every ED. data are limited to cannulation attempts and may not be niques. especially when the children clowns during painful procedures being performed on were older. Research on the repro- the known to be significant 7. we were unable to blind the subjects and parents to the References intervention because of the nature of the intervention. First. preventing their being able to ben.6 in the intervention group) does been well implemented on pediatric wards19 and we seem clinically important. children in the ED was able to demonstrate pain reduc- onstrated an average drop of 6 points in the validated tion in younger children and reduced stress and anxiety State-Trait Anxiety Inventory score. In addition. 1. Bornstein Y. has been shown that a change in 1 face in the Faces Pain Medical clowns are personnel who have undergone spe- Score represents a small change in pain intensity. Hansen Finally. because every effort should be made to reduce clinically significant improvement in pain in children. This pilot study involving the use of medical child’s painful procedure. Harefuah. Nevertheless. eutectic mixture of local anesthetics. would further elucidate the the older children (8-16 years old). We suggest that in the future stud- indicated. Parental response role of the medical clown in the pediatric ED. our ing humor in addition to traditional distraction tech. however.18 A larger sample may have allowed these results to behavior. efit from the “calming” effect of the clown’s presence. Distraction by humor has clown. article. some of which have been amelioration of pain through the use of a therapeutic successfully implemented. This may Declaration of Conflicting Interests be because the clown’s effect is nullified by the fact that blood drawing in younger children is often more diffi. . while cial training in acting and clowning. only rarely been studied and in small numbers. most of the differences did not reach statistical also proven to be more economical than the use of cer- significance. There are several limitations to our study. tistical significance in pain measurements. A sig.Wolyniez et al 1171 Discussion for in the design. Medical clowns at hospitals and their effect Third. and an understanding of patient tion. (anxiety or reassuring calm) may affect a child’s percep- tion of pain. ies should look at comparison of the clown approach to We also found that the parents were less anxious proven pain-reducing alternatives (mainly pharmaco- when the therapeutic clown was present during their logical).3 in the control an adult. The author(s) declared no potential conflicts of interest with cult and may involve the parent wanting to take an active respect to the research. so we were able to demonstrate a trend and no sta. Implementing interventions aimed at reduc. 2008. and as such are a very useful addition to medi- reach statistical significance. predicted setting. of a medical clown had a calming effect on parents. the difference in pain scores tain analgesics and it is easier to make a child laugh than in the younger group of children (3. Second. When trying to quantify the believe should be part of the routine care of children in amount of change in pain severity that is equivalent to a the ED. Tener et al17 looked at the study employing a different measure may show other effect medical clowns had on anxiety expressed by chil. employ. size. during urgent medical procedures in children has generalizable to any painful procedure in the ED. and/or publication of this article. significant advantages to the use of a therapeutic clown. medical knowledge. the pain scores we used may not measure aspects et al16 studied the effect of the presence of a hospital of pain perception that are relevant to patients. authorship. this Funding study being a pilot study was limited by a small sample The author(s) received no financial support for the research. Authors’ Note ing stress is thus important for caregivers and also children in this setting. dren undergoing evaluations after allegations of sexual Many techniques have been introduced into the ED abuse. authorship. which is less than in the families of older children.7 The use of medical clowns has been already group compared with 1. A similar outpatient. especially when the child was 8 years or older.

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