Friday, February 19, 2010

Therapeutic clowns stir unresponsive children

In the first study to measure the long-term physiological effect of therapeutic clowns on hospitalized children, Canadian researchers show that even a child in a vegetative state and those with profound disabilities respond to the red-nosed performers with changes in skin temperature, sweat level and heart and breathing rate.

“Every child showed a physiological response to the clowns that they didn’t show when watching television, and this included children who can’t express themselves verbally or through movement and who appear to be non-responsive,” says lead author Shauna Kingsnorth, a postdoctoral fellow at Bloorview Kids Rehab. Research shows that changes in body signals are reliable indicators of emotional states.

The study was published February 4 online in Evidence-based Alternative and Complementary Medicine.

The scientists measured physiological arousal, emotion and behaviour in eight inpatients at Bloorview over four days. Their conditions included severe cerebral palsy, traumatic brain injury and brainstem stroke. Velcro bands worn around the children’s fingers measured skin temperature, sweat level and heart rate, and a belt around the chest tracked breathing.

On two of the four days, the scientists measured the children’s reaction to watching 10 minutes of a television show. “Television was a good comparison because the TV is noisy and colourful, like the clowns,” says Stefanie Blain, a PhD biomedical engineering student at Bloorview and co-author of the study. On alternate days, researchers tracked the children’s response to 10-minute visits with Ricky and Dr. Flap (above) – two clowns who engage them with physical and emotional comedy and music, letting the kids direct the action as a means of empowering them.

Five of the eight youth – aged four to 21 – could speak, express emotion through facial expressions and point; two were non-verbal but could show facial emotion; and one child was non-verbal and unable to gesture or use facial expression.

“The physiological data was our main assessment tool and allowed us to include children with profound disabilities who are generally left out of research,” Kingsnorth says. “But we augmented this information with observed information – documenting the frequency of typical expressions of emotion such as smiling, laughing, crying and grimacing – and asking children who could speak to identify their mood by talking about, or pointing to, a card with a face that best depicted how they were feeling.” At the end of the four-day study, children who were verbal participated in a brief interview.

“Most exciting was that every child showed a unique physiological change with the clowns,” Kingsnorth says. “With one child who wasn’t verbal or physically expressive, the research assistant was sure he had been asleep the entire time. But then Stefanie downloaded the physiological data and came running over just about to cry, and you could see how much the child was responding.”

Children’s skin, heart and breathing signals were pulled more frequently out of resting states or the pattern of the four signals changed when the children visited with the clowns. “They’re subtle cues that can’t be picked up by the eye and demonstrate that clowning has a direct effect,” Kingsnorth says.

But what happy or sad looks like physiologically in one child may be different in another, and more research is needed to decode the signals in children who can’t corroborate how they’re feeling through behaviour or speech.

The study began because the therapeutic clowns at Bloorview wanted a way to evaluate their work with children who couldn’t give feedback in conventional ways.

Study results from participants who could report or show their feelings included significant increases in smiling and laughing and decreases in grimacing when interacting with the clowns, as opposed to watching television. Children who could speak showed a positive change in mood following their time with the clowns and no change in mood following television viewing.

The findings suggest therapeutic clowning has a direct, positive impact on hospitalized children – including those with profound disabilities – “and provide hard evidence to support its funding,” Blain says.

The researchers say physiological tracking is a tool that can be used to evaluate a variety of arts interventions for children with disabilities who can’t express themselves in traditional ways. “In future, if we can identify positive and negative physiological responses, we can use that information to create stimulating environments for children who can’t overtly tell us what they like,” Blain says.


Well...all those physiological responses...I had to laugh. Can I tell you, every time the clowns came in when we were in hospital in London, we had to make sure they stayed away from Sophie. They petrified her. Hopefully those locked-in kids aren't feeling the same way!

Hi Claire -- thanks for your comment. I certainly understand your concern. Many of the children on our CCC unit have been here for a long time and the nurses know them very well (as opposed to in an acute-care setting where stays are much shorter). I asked one of our therapeutic clowns to respond. Here is his reply:

We do our best and almost 100% of the time we take our lead from the nurses and or parents. They know the children best, in terms of these very specific body signals, which the lay person may not pick up on and they spend more time with them than anyone, so they are our best resource. If, in their opinion, the child is seeming agitated by our presence, in whatever small way, then we back off immediately.

In instances when neither the nurse or parent knows what the child is feeling or thinking, we keep our play interactions very simple and limit them to music, rhythm, and or gentle touch. We behave in a manner close to any empathetic caregiver, embodying a caring, loving and open presence, sharing this moment in time with them; nothing more. Sometimes just being present with another person is all that is required. Even that can have a profound impact on a child's life.