A visualisation of the Cliniclowns clic: A pilot study about the assessment of psychological effects of the performance of hospital clowns on sick children

Hospital clowns aim to divert sick children from their illness and the hospital
environment. In The Netherlands, many hospital clowns sharing these aims work
at the Cliniclowns Association (Stichting Cliniclowns). These hospital clowns
perform in a children*s hospital setting, usually at the child*s hospital bed.
A lot of anecdotal material has been gathered about the positive effect of
hospital clowns on children*s well-being. However, empirical evidence about
these effects is rare. One line of research has shown that hospital clowns may
reduce anxiety in children ahead of an operation. Another line of evidence
comes from descriptions of opinions about hospital clowning from the
perspective of children, hospital clowns, parents and hospital staff. These
studies have shown that although a number of parents and hospital staff dislike
clowns, the general opinion of hospital clowning is positive. However,
emotional and behavioural data on responses of the children are unavailable so
far. Basic requirements for hospital clown pairs have been investigated in
Sweden. These are empathic readiness and a balance between verbal and
non-verbal behaviors in clowns6. To be able to draw conclusions about possible
effects, it is important to develop measures that could gives us a valid
impression of these effects. It will be interesting to see how the children*s
responses can be effectively measured, how hospital clowns operate and how
basic elements in their performances may possibly affect the psychological
states of children referred to a children*s hospital.

The primary objective of this pilot study is to find out how the effects of
hospital clowning on children*s emotions and behaviours may be measured in a
valid way. A secondary objective of this study is to get a first impression of
behavioural interventions hospital clowns use and how the child responds
behaviourally and emotionally to these interventions.

Because there are so few studies focusing on the actual child-clown
interaction, we decided to use a qualitative design focused on
behavioral observations of hospital clowns and children. The state of the art
in this research domain does not allow for randomized
controlled trials yet. This study will contain 5-10 minute performances by the
hospital clowns, videotaping and questioning the
child, their parent(s), the hospital clowns and pedagocial assistants. This
procedure, triangulation, will increase the validity of the study.
The setting of the study will be the children*s hospital.
The procedure is aimed at capturing a number of psychological variables around
thirty performances of clown pairs for sick
children in a children*s hospital. The first step in the procedure is to inform
the children and their parent about the aims and
procedures of the study. It will be explained to them that questionnaires will
be administered and that video recordings of the child
will be made. After informed consent the parent will be asked to read and sign
the informed consent form. After consent,
demographic data (age, gender, type of illness) will be collected. The parent
will be asked to be supportive of the child during the
performance.
In this study questionnaires and video recordings will be used. The
questionnaires are aimed at measuring the child*s mood,
illness experience and impact of the performance. Children, their parent,
hospital clowns and pedagogical assistants are involved
in questionnaire administration. This is done to ensure triangulation, a
procedure aimed at optimizing validation in qualitative
studies. Six time points are used in the study. At breakfast (t0), lunch (t4)
and dinner time (t5) thm child*s mood will be assessed
by the pedagogical assistant. Self-reported mood and illness experience will be
measured right before (t1) and right after (t2) the
performance. These measurements will be repeated one week after the performance
(t6). Impact of the performance is measured
by asking the children right after the performance (t2) how they experienced
it. Also, they will be asked what the clowns did and
which parts of the performance the child appreciated best or worse. This
measurement will be repeated one week later. To measure the child*s distraction
a colored card will be clipped onto one of the cameras that is in sight of the
child. One week after the performance the child will be asked whether it
noticed the card and whether it memorized the color of the card. To
crossvalidate the child*s questionnaire responses, the parent present at the
performance is asked to assess the child*s mood and illness experience at t2
and t3 and also to describe the impact of the performance on the child at t3.
The clown pair will be asked what impact they thought the performance had, what
responses they saw in the child and how these responses affected them. Also,
they will be asked about the techniques they used and their appreciation of the
performance.
To describe the interaction between clown pairs and children fully,
performances will be videotaped with three cameras. One camera is directed at
the child to record his or her responses; a second camera is directed at the
clowns to record their performance and a third camera is used to record the
overall scene, including the child and the clown pair. The cameras will be
synchronized. Afterwards, a split-image recording will be created allowing
simultaneous viewing of the recordings made by three cameras. To further
analyze the impact of the performance on the child, the videos will then be
analyzed with regard to the emotional responses (facial expression, movement)
of the child, the eye contact they made with the clowns and the physical
distance between clown and child. Eye contact is a good indicator of emotional
involvement. Speaking during eye contact is an indicator of active emotional
involvement, whereas listening during eye contact and avoiding eye contact show
average and low involvement, respectively. Eye contact can be measured
systematically using specific observation software (Observer by Noldus).
Variation in physical distance between clowns and child could indicate how
clowns adapt their behaviors in response to the child.

Since performances of hospital clowns are aimed at pleasure and diversion, it
is expected that the study will have no specific
burdens or risks for the child involved. Children may be nervous because of the
realization that they are videotaped, but test
trials have shown that when well prepared, the child gets used to the cameras
and feels at ease with them.