A combined intervention of art therapy and clown visits to reduce preoperative anxiety in children

J Clin Nurs. 2017 Mar;26(5-6):632-640. doi: 10.1111/jocn.13578. Epub 2016 Nov 14.


Aims and objectives: To test whether a combined intervention of art therapy and clown visits could enhance the efficacy of oral medication in reducing children's anxiety at parental separation prior to induction of anaesthesia.

Background: Approximately 50% of children undergoing surgery report high anxiety at anaesthesia induction. Complementary therapies have been used to decrease children's anxiety, but no study has evaluated the efficacy of a combination of such therapies.

Design: This is an observational study, which involved allocating different interventions to two groups and measuring their anxiety at two time points.

Methods: This study assigned 78 children (aged 3-11 years) undergoing general anaesthesia for surgery to two conditions. The control group underwent general anaesthesia following standard practice, and the intervention group received an intervention of integrated art therapy and clown visits upon their arrival at the hospital and throughout their time in the preoperating room. Each child in both groups received 0·5 mg/kg oral midazolam 30 minutes before surgery and had a parent present throughout their time in the preoperating room. Each child's anxiety was evaluated twice using the Modified Yale Preoperative Anxiety Scale: at baseline and at separation from parents. Repeated measures anova was used to test for differences between the time points and the two groups.

Results: Children in the intervention group showed a significant (p < 0·001) reduction in Modified Yale Preoperative Anxiety Scale scores at parental separation compared to those in the control group. Additionally, the majority of parents and nurses evaluated the intervention to be effective for reducing children's anxiety.

Conclusions: This study found that an intervention based on art therapy and clown visits enhanced the effect of midazolam in reducing children's anxiety at preoperative separation from parents.

Relevance to clinical practice: Paediatric staffs may consider using such a combination of strategies in preparing children for anaesthesia induction.

Keywords: anxiety; art therapy; clowns; paediatric surgery; parental presence; premedication.

Publication types

  • Comparative Study

MeSH terms

  • Anesthesia, General / psychology*
  • Anxiety Disorders / therapy*
  • Art Therapy*
  • Child
  • Child, Preschool
  • Female
  • Humans
  • Laughter Therapy*
  • Male
  • Midazolam / administration & dosage*
  • Pediatric Nursing / methods*
  • Preoperative Period


  • Midazolam