SPECIAL ARTICLE Clown Doctors as a Treatment for Preoperative Anxiety in Children: A Randomized, Prospective Study

Background. The induction of anesthesia is one of the most stressful moments for a child who must undergo surgery: it is estimated that 60% of children suffer anxiety in the preoperative period. Preoperative anxiety is characterized by subjective feelings of tension, apprehension, nervousness, and worry. These reactions reflect the child’s fear of separation from parents and home environment, as well as of loss of control, unfamiliar routines, surgical instruments, and hospital procedures. High levels of anxiety have been identified as predictors of postoperative troubles that can persist for 6 months after the procedure. Both behavioral and pharmacologic interventions are available to treat preoperative anxiety in children. Objective. The aim of this study was to investigate the effects of the presence of clowns on a child’s preoperative anxiety during the induction of anesthesia and on the parent who accompanies him/her until he/she is asleep. Methods. The sample was composed of 40 subjects (5–12 years of age) who had to undergo minor day surgery and were assigned randomly to the clown group (N 20), in which the children were accompanied in the preoperative room by the clowns and a parent, or the control group (N 20), in which the children were accompanied by only 1 of his/her parents. The anxiety of the children in the preoperative period was measured through the Modified Yale Preoperative Anxiety Scale instrument (observational behavioral checklist to measure the state anxiety of young children), and the anxiety of the parents was measured with the State-Trait Anxiety Inventory (Y-1/Y-2) instrument (self-report anxiety behavioral instrument that measures trait/baseline and state/situational anxiety in adults). In addition, a questionnaire for health professionals was developed to obtain their opinion about the presence of clowns during the induction of anesthesia, and a self-evaluation form was developed to be filled out by the clowns themselves about their interactions with the child. Results. The clown group was significantly less anxious during the induction of anesthesia compared with the control group. In the control group there was an increased level of anxiety in the induction room in comparison to in the waiting room; in the clown group anxiety was not significantly different in the 2 locations. The questionnaire for health professionals indicated that the clowns were a benefit to the child, but the majority of the staff was opposed to continuing the program because of perceived interference with the procedures of the operating room. The correlation between the scores of the form to self-evaluate the effectiveness of the clowns and of the Modified Yale Preoperative Anxiety Scale is significant for both the waiting room and induction room. Conclusions. This study shows that the presence of clowns during the induction of anesthesia, together with the child’s parents, was an effective intervention for managing children’s and parents’ anxiety during the preoperative period. We would encourage the promotion of this form of distraction therapy in the treatment of children requiring surgery, but the resistance of medical personnel make it very difficult to insert this program in the activity of the operating room. Pediatrics 2005; 116:e563–e567. URL: www.pediatrics.org/cgi/doi/10.1542/ peds.2005-0466; analgesia, anesthesiology, anxiety, parenting stress, psychological impact. ABBREVIATIONS. OR, operating room; m-YPAS, Modified Yale Preoperative Anxiety Scale; STAI, State-Trait Anxiety Inventory. Multiple studies, beginning in the 1970s, have shown that humor has many positive effects on physical and mental health and well-being. Previous investigations have reported that humor has beneficial effects on the immune system,1,2 stress related to potentially fatal illnesses,3 pain tolerance,4 and mental functions (vigilance, memory, and anxiety).5 Induction of anesthesia can be a frightening event for children, and it is estimated that 60% of children suffer anxiety in the presurgical period.6 Therefore, we designed this randomized study to investigate if the presence of clowns is able to reduce preoperative anxiety in children who must undergo minor surgery.