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Send in the clowns


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Clowns – you either love them or you hate them.  There is no middle ground.  But what do children think about them? Hospitals can be strange, scary places, even in daylight. So some have introduced ‘clown’ doctors to help allay fears. But do they?

(Editor note: If you have *coulrophobia then don’t read this post)

Today I’m going to look a paper I wish I had written.

Sridharan K, Sivaramakrishnan G. Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials. European Journal of Pediatrics. 2016 Sep 8:1-8.

This meta-analysis looked at the role of clowns to alleviate the fear and anxiety of cannulation or minor surgery under anaesthesia.  The authors identified an amazing 19 studies looking at this very issue.  They wanted to know their effect on:

  • Extent of anxiety felt by children
  • Extent of pain felt during procedure by children
  • Extent of anxiety felt by parents during the procedures

“Want your boat, Georgie?’ Pennywise asked. ‘I only repeat myself because you really do not seem that eager.’ He held it up, smiling. He was wearing a baggy silk suit with great big orange buttons. A bright tie, electric-blue, flopped down his front, and on his hands were big white gloves, like the kind Mickey Mouse and Donald Duck always wore… 

Stephen King, It (1986)

Up to 75% of children undergoing general anaesthesia experience severe anxiety or dread. This might be linked to fear of the unknown, separation anxiety and a host of other factors. This pre-operative experience is also linked with post-operative maladaptive behaviours and so many techniques, both pharmacological and non-pharmacological, have been tried to reduce anxiety. Many studies have shown that clowns provide a degree of emotional support for such children. Interestingly when one looks at the effect of parental presence on induction and number of studies have showed no difference between presence or absence.

Looking at the Forest plot for ‘Clowns’ versus standard of care it appears that Pennywise would have a great impact on reducing the anxiety of children undergoing painful procedures as well as alleviating some of the parent’s fears. Perhaps the lack of benefit of parental presence might be due to their own anxieties and so that if they are calmed by humor and laughter then this will be compounded in the child?

These findings are all well and good for those that work in the operating department but it is nice to see that they also appear to alleviate stress in the emergency department (ED) though they had little impact on pain scores.

Therapeutic clowning has been shown to

  • facilitate verbal and non-verbal communication
  • improve mood and increase expression of positive emotions
  • support empowerment of the patient

They have also been shown to have a physiological as psychological effect on their audience.  Children in one study of respiratory patients showed a reduction in respiratory rate and diastolic blood pressure in the clown group compared to the control group.

In a study so bizarre it seems like something out of an episode of League of Gentleman, one Israeli group tried using clowns to reduce the anxiety and post-traumatic distress of anogenital examinations in alleged abuse sufferers. They did.

And George saw the clown’s face change.
What he saw then was terrible enough to make his worst imaginings of the thing in the cellar look like sweet dreams; what he saw destroyed his sanity in one clawing stroke                                                                                   

Stephen King, It (1986)

Try as I might I have yet to find a study that suggests clowns are actually harmful. Though when a hospital in Sheffield were looking to decorate their children’s ward the fact that the vast majority of their patients felt uncomfortable around clowns put an end to the circus theme.

But I am a child of the ’80’s. I remember furtively turning over the yellowed pages of a second or third hand copy of Stephen King’s masterpiece by torchlight so my parents wouldn’t know.  When I was supposed to be studying for my A-levels I would be down the video shop working my way through the B- and C-grade horror movies.  So instead of an actual scientific reference I’m going to give you some cultural ones to take a look at. Do that, then come back and tell me what you really think of clowns?


  • Hamlet  – Shakespeare – Long dead court jester, Yorick, makes king question his own mortality
  • It (1986) – Stephen King – Kindly clown helps rid the town of Derry from bullies


  • The Greatest Show on Earth (1952) – Jimmy Stewart, kind doctor who is unaware of the double effect of morphine, turns to clowning in order to escape AHPRA
  • Rentaghost (1976-1984) – Timothy Claypole – a man who could brick any iPhone
  • Poltergeist (1982) – Lovable clown puppet reminds children to switch off the television and go out and do something less boring instead.
  • It (1990) – Miniseries based on the book of the same name with Tim Curry as Pennywise
  • Saw (2004) – Kind puppet helps detective solve puzles
  • The Dark Knight (2008) – Heath Ledger makes pencils disappear, right before your very eyes.

Actually I did find one study that compared rabbits to clowns for facilitated family centred rounds.  The bunnies had the best level of parental satisfaction and the clown arm was stopped early due to adverse events… need I say more?

* Yes, ‘coulrophobia’ – or fear of clowns is a real thing, as is ‘globophobia’ – the fear of balloons, and ‘arachybutyrophobia’ – the fear of peanut butter sticking to the roof of your mouth

Also take a look at Andrew Weatherall’s Songs or Stories for more on distraction by clowns.


Sridharan K, Sivaramakrishnan G. Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials. European Journal of Pediatrics. 2016 Sep 8:1-8.

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

Kingsnorth S, Blain S, McKeever P. Physiological and emotional responses of disabled children to therapeutic clowns: a pilot study. Evidence-Based Complementary and Alternative Medicine. 2011 Mar 13;2011.

Bertini M, Isola E, Paolone G, Curcio G. Clowns benefit children hospitalized for respiratory pathologies. Evidence-Based Complementary and Alternative Medicine. 2011 Mar 15;2011.

Felluga M, Rabach I, Minute M, Montico M, Giorgi R, Lonciari I, Taddio A, Barbi E. A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children’s anxiety and pain levels in emergency department. European journal of pediatrics. 2016 May 1;175(5):645-50.

Heilbrunn BR, Wittern RE, Lee JB, Pham PK, Hamilton AH, Nager AL. Reducing Anxiety in the Pediatric Emergency Department: A Comparative Trial. The Journal of emergency medicine. 2014 Dec 31;47(6):623-31.

Meiri N, Ankri A, Hamad-Saied M, Konopnicki M, Pillar G. 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. European journal of pediatrics. 2016 Mar 1;175(3):373-9.

Tener D, Lang-Franco N, Ofir S, Lev-Wiesel R. The use of medical clowns as a psychological distress buffer during anogenital examination of sexually abused children. Journal of Loss and Trauma. 2012 Jan 1;17(1):12-22.

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