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ELECTRONIC ARTICLE: Laura Vagnoli, Simona Caprilli, Arianna Robiglio, and Andrea Messeri Clown Doctors as a Treatment for Preoperative Anxiety in Children: A Randomized, Prospective Study Pediatrics 2005; 116: e563-e567 [Abstract] [Full text] [PDF]

eLetters published:

Soccorso Clown: Some Reflections on Problems Revealed During the Study of our Treatment

Yury Olshansky, Vladimir Olshansky, Artistic Director, Caterina Biccochi Admiinistrative Director   (3 November 2005)

Clowning, a serious business

Caroline Simonds, Pr. Alain Fischer ( Hopital Necker-Enfants Malades), Dr. Jacques Grill ( Institut Gustave Roussy), Pr. Gerard Michel ( Hopital Le Timone-Enfants), Dr. Thierry Leblanc ( Hopital St.Louis) and Caroline Simonds ( founder-director, Le Rire Medecin)   (17 May 2006)

Soccorso Clown: Some Reflections on Problems Revealed During the Study of our Treatment 3 November 2005
Yury Olshansky, General Director, Supervisor hospital-clown Soccorso Clown s.c. Sociale ONLUS, Vladimir Olshansky, Artistic Director, Caterina Biccochi Admiinistrative Director Send letter to journal: Re: Soccorso Clown: Some Reflections on Problems Revealed During the Study of our Treatment info{at}soccorsoclown.it Yury Olshansky, et al.	Dear Sir or Madam: On behalf of Soccorso Clown, we would like to offer our appreciation for your article, “Clown Doctors as a Treatment for Pre-operative Anxiety in Children: A Randomized, Prospective Study” (Pediatrics Volume 116, # 4 October 2005, pp. e563-e567). The research has brought to light the many positive results of our work, and the article opens up new horizons for further exploration in the field. We would, however, like to clarify some important points raised during the process of the study. The first concerns some problems regarding interference with pre-operative procedures which were reported by some of the medical staff during the application of our treatment. After our own analysis and discussion with Dr. Laura Vagnoli, the author of the study, we believe we have discovered the source of this discomfort. In the Pediatric Hospital of Meyer, which was the site of the present research study, our Treatment for Preoperative Anxiety in Children has not yet become routine. It is still at the introductory stage and is performed only by special request of the medical staff. Furthermore, the methodology used by Dr. Vagnoli’s group was designed to intensify our presence during the pre- operative period. Under these circumstances, it is not at all surprising that this sometimes created stress and possibly inner resentment among those on the medical staff who were not yet used to this sudden increase in our presence. Although during the short period of the study our hospital clowns met with no refusals to collaborate on the part of the medical staff, the presence in a relatively small space -- not only of our usual couple of hospital clowns, but also the parent(s) and the researcher with her particular aims and questionnaires -- also inevitably could only contribute to an uncomfortable atmosphere and create the impression of an “invasion”-- something that we seek to avoid at all times, as it contradicts one of our basic principles of operation. Such cases had never before been reported. For instance, in the Hospital (ASL4 ) of Prato and Poloclinico Scotti of Siena, the work of our hospital clowns has always proceeded in total collaboration and harmony with the medical staff. At this hospital site our services primarily focus on the department of surgery headed by Prof. Mario Messina and include both the pre- and post-anesthetic period. Soccorso Clown never interferes with the methods of scientific research done on our work, and tries to accommodate researchers, but in the particular case of Dr. Vagnoli’s group, we did overlook the eventual problem. The problem could easily have been resolved had we been sufficiently forewarned of the study, in which case we would have worked with the study group to structure the study a little differently, working closely with the research group over a longer period. Presently, we continue to attend Meyer hospital five days a week and we meet with constant success there in all departments. In the surgery ward our treatment is applied only at the special request of medical staff. To date, this has proved to be the correct and harmonious approach, satisfying the needs of the department. The second point raised in the study, and which will be less evident to those who are not specialists in our field, concerns the general lack of knowledge about our new profession--that of the hospital clown or clown-doctor. This lack of basic awareness takes place against the background of an ever- growing demand for such services by hospitals in Italy. To fully understand the success of our treatment and the benefits that it provides to young patients, it is important to have a clear idea about the training and the methods of Soccorso Clown. It is particularly important to realize that our professional team is not composed simply of “clowns,” as has been written in this article and elsewhere. The members of our team are experienced, professional performing artists with specialties ranging from music to magic who have been carefully selected and then trained to apply their skills to a hospital’s highly special needs. A synthesis of classical circus and theatre forms the basis of this new profession of the hospital clown, and provides the necessary prerequisite for a new type of training. Created by Soccorso Clown, the First European Training Project for professional hospital clowns was recognized and financed by the European Social Fund and supported by the Region of Tuscany, Italian State Theatrical Organization (ETI) Ministry of Labor and the Meyer Pediatric Hospital of Florence. The birth of this new profession founded a new type of performing art aimed at becoming a part of hospital life. This professional approach and demand for proper qualifications distinguishes Soccorso Clown from other services such as visiting clowns, animators, and volunteers. Therefore, the positive results achieved during the thesis research by Dr. Vagnoli’s group, e.g. a fifty percent decrease in anxiety in children due to our treatment, should not, as it may seem to non- specialists in this new field, be generalized as something that can necessarily be attributed to any and every clown intervention. These research results can properly be applied only to Soccorso Clown’s specific training and standard of work, and possibly can be extended to other organizations originating from or basing their methods either on our model or on the model of the originator of this profession, the Clown Care Unit of the Big Apple Circus of New York which has been successfully operating in the United States for the last twenty years. Facilitating the work of medical staff is one of our primary goals. After we have understood the needs of the medical staff and they have gained an appreciation of our treatment methods, we work together to benefit the patients. Other types of intervention by other “clown organizations” should be treated via separate research, on a case-by-case basis, so as to determine their own specific merits and impact on the medical field. In conclusion, we will use this incident to remind us to continue to identify all possible pitfalls when working with research groups, and to improve our service wherever necessary. Sincerely, Yury Olshansky , General Director Conflict of Interest: None declared
Clowning, a serious business 17 May 2006
Caroline Simonds, founder-director Le Rire Medecin, Pr. Alain Fischer ( Hopital Necker-Enfants Malades), Dr. Jacques Grill ( Institut Gustave Roussy), Pr. Gerard Michel ( Hopital Le Timone-Enfants), Dr. Thierry Leblanc ( Hopital St.Louis) and Caroline Simonds ( founder-director, Le Rire Medecin) Send letter to journal: Re: Clowning, a serious business riremed{at}club-internet.fr Caroline Simonds, et al.	As one of the pioneering companies of professional clowns working on pediatric wards in France ("le Rire Medecin", founded in 1991)1, it was with great interest that we read "Clown Doctors as a Treatment for Preoperative Anxiety In Children: A Randomized, Prospective Study" (Vagnoli et al, Pediatrics 2005, vol 116 - N° 4; pp 563-567) reporting beneficial lowering of preoperative anxiety both in children and their parents. We welcome the study as a serious attempt to evaluate the therapeutic value of clowns in hospitals objectively, but in the light of our experience also feel it may be useful to underline a number of significant criteria that were not taken into account in the study and which might have had an impact on the results recorded by the authors. Establishment of staff cooperation and understanding is vitally important in the success of working with clowns in a hospital environment and great care should be excercised in achieving this before any evaluation begins. The recorded comments by medical staff of hindrance in their professional activities, despite the averred beneficial effects of the presence of clowns, should have been investigated further, either by extending the questionnaire given to survey opinions of medical personnel (Table 1 in the article) to ascertain the actual causes of dissatisfaction with greater accuracy or at least by broadening the discussion of reasons behind the opinions given. Our principal concern however involves more fundamental issues raised by this study. Fifteen years experience has taught us that a number of factors should not be underestimated in the success of "clown doctors" in pediatrics. Briefly, these factors include professionalism of the actor-clowns, their continuous vocational training and long-term presence as part of the medical team as well as frequency of interventions. None of these points are clarified in the article. The study fails to indicate whether the clowns were professionals, amateurs or voluntary workers. Equally, no information is given about their experience of working in a hospital environment.2 Considering the study was carried out on children hospitalized for minor day surgery, it seems unlikely they had time to become accustomed to interaction with clowns. But above all, since the nursing team were the least satisfied group, it is unfortunate no information is supplied about how the doctors and nurses were briefed beforehand, or whether the invasion of clowns was organised for the purposes of the study over the six-month study period without any preliminary preparation of staff. Evidence for the latter assumption comes from the type of comments recorded by unhappy medical staff (Table 8 in the article), who complained about slower induction times, interference in staff- child communication and overcrowded conditions, all of which indicate a lack of staff preparedness and motivation. Familiarity is a decisive parameter in relations between clowns and medical staff. This can only happen by taking the time needed to overcome initial embarrassments – such as coping with additional noise on the ward or allaying fears in very young children. More importantly, long-term relationships build up confidence on all sides when the positive effects of comfort and sometimes euphoria can be witnessed on a regular basis. Living through difficult experiences together also helps build up an undeniable mutual respect between clowns and medical teams. Other aspects of the study that might be improved include the possible bias introduced by asking the clowns themselves to evaluate their effect on the children. Despite the correlation of these results with those of the independant observers, the only purpose of this self-evaluation questionnaire seems to have been to test the reliability of the clowns in indirectly assessing anxiety in the children they accompanied. The study is also a little vague on the conditions in which clown groups and non-clown groups were allocated and scheduled. We presume that each group was unaware of the other but if this was not the case, vexation or jealousy among children in the non- clown group could possibly influence their preoperative anxiety state. Conducting a study on the effect of clowns on children (and their parents) experiencing stress and anxiety prior to operation seems an intersting choice, since clowns are often effective in situations where improvisation and sensitivity are called for. Future studies we hope will also include evaluations of the effect of clowns visiting children with chronic pathologies where a bond of familiarity has been allowed to develop. Perhaps such studies could also adopt a more qualitative approach, or sociological angle, analysing for example a given situation before and after introduction of a long-term program involving clowns. Finally, the above criticisms are in no way intended to disparage the study in question which we consider of great interest and most pertinent to the question of clowns working in hospitals. In particular, the use of an adapted Yale anxiety scale is to be applauded and we can only hope that as for all aspects of medical care, the efficacy of clowns on children's wards should continue to be evaluated as objectively as possible, even if they cannot be fully considered as primary health care (in the same sense as anxiolytic drugs). The process of integrating clowns into hospital health care is complex and requires time but we must continue seeking and developing all pathways that improve the quality of life of children in hospital. 1 c.f. Clowning on Children's Wards, D. Oppenheim, O. Hartmann, C.Simmonds, The Lancet, Vol.350, 20/27 December, 1997, pp.1838-40 2 However, the clown company's name given at the end of the article enables further information to be found by searching for their web site. Conflict of Interest: None declared