Clown Therapy in Pediatric Neurodiversity: A Scoping Review

TITLE Clown Therapy in Pediatric Neurodiversity: A Scoping Review INTRODUCTION Neurodevelopmental disorders are a heterogeneous group of conditions with early onset during central nervous system development, characterized by persistent impairments in domains such as cognition, language, attention, social communication, learning, and motor skills. Among the main conditions identified in the DSM-5 diagnostic criteria are autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), intellectual disability, communication disorders, specific learning disorders, and motor disorders (American Psychiatric Association, 2013). Prevalence estimates vary: ADHD 5–11%, ASD 0.7–3%, learning disabilities 3–10%, and communication disorders 1–3% in the global pediatric population (Thomas et al., 2022). These conditions are typically chronic, often persisting into adolescence and adulthood, with frequent comorbidity between the different disorders, and significantly impact emotional adjustment, behavior, social relationships, and school inclusion. Difficulties in emotional regulation, communication, and social interaction are common features of many neurodevelopmental disorders, particularly ASD and ADHD. Children and adolescents with these conditions frequently exhibit emotional dysregulation, internalizing and externalizing behaviors, and a reduced ability to manage stress and complex relationships (Mazefsky et al., 2013; Samson et al., 2023). In healthcare settings, these difficulties translate into anxiety, oppositionality, or withdrawal, making medical and rehabilitation procedures particularly stressful. Pharmacological treatments, although effective in reducing core symptoms such as hyperactivity and impulsivity, show limited efficacy on emotional regulation, social skills, and psychological adjustment, often associated with adverse effects (Cortese et al., 2022). Integrated and personalized interventions, combining psychosocial, educational, and relational strategies, are therefore essential to address the complex needs of this population. Psychosocial and complementary interventions, such as music therapy, art therapy, and play therapy, are part of an integrated care framework aimed at promoting emotional and relational well-being beyond the management of clinical symptoms alone (Krüger & Murphy, 2025; Dionigi & Gremigni, 2017). Clown therapy, one of these approaches, supports emotional expression, social interaction, and stress management, contributing to child-friendly and family-centered care experiences (UNICEF, 2019). International guidelines for Mental Health and Psychosocial Support (MHPSS) highlight the importance of strategies that involve family members, caregivers, and the community to support child resilience and active participation (IASC/UNICEF, 2019). Similarly, the Council of Europe's Guidelines on Child-Friendly Health Care emphasize the need for an approach that values protection, participation, and respect for children's rights (Council of Europe, 2011). The nurse's role is central in promoting comfort, reducing anxiety and distress, and facilitating the child-family-team relationship through empathic communication and a holistic approach (Bice & Wyatt, 2017). Nurses can act as facilitators or co-designers of psychosocial interventions such as clown therapy, observing and evaluating behavioral and emotional outcomes in daily care. This approach reflects the principles of caring, humanizing care, and family-centered care, integrating creative and relational interventions into the therapeutic process. Clown therapy, also known as clown care or healthcare clowning, uses adapted clowning techniques to create playful and positive relationships with patients, aiming to improve mood and psychological well-being. Hypothesized mechanisms include therapeutic humor, distraction, building an empathic relationship, emotional restructuring, and child empowerment (Xin et al., 2024). Pediatric studies show significant reductions in preoperative and procedural anxiety, a tendency toward pain reduction, and a decrease in biological stress, also measured by cortisol levels (Fusetti et al., 2022; Sliman et al., 2023; Sánchez et al., 2024). Despite this, the evidence regarding the use of clown therapy in children with neurodevelopmental disorders is fragmented, heterogeneous and often qualitative or observational in nature, with highly variable outcomes, settings and diagnoses. Existing reviews mainly focus on acute hospitalization, pain, preoperative anxiety or pediatric oncology, without dedicated syntheses for neurodivergent populations (Sliman et al., 2023; Wang et al., 2024; Xin et al., 2024). To date, there is no scoping review available that systematically synthesizes the evidence on the use of clown therapy in the pediatric population with neurodevelopmental disorders. The pre-registration of the protocol on the Open Science Framework (OSF) aims to ensure methodological transparency and reduce the risk of reporting bias. The general objective of this scoping review is to systematically synthesize the evidence on the use of clown therapy in children with neurodevelopmental disorders. Specific objectives include: (1) describing the types and characteristics of interventions; (2) map outcomes and results; (3) explore theoretical models and implementation modalities; (4) identify barriers and facilitators; (5) highlight recommendations for future research and clinical implications. METHODS Study Design The review will follow the Arksey & O'Malley framework, as revised by Levac et al., and the Joanna Briggs Institute recommendations for scoping reviews (2024 edition), with PRISMA-ScR-compliant reporting. Research Questions To map the evidence, in line with the Joanna Briggs Institute recommendations for scoping reviews (JBI Manual for Evidence Synthesis – Scoping Reviews 2024 edition), the PCC (Population – Concept – Context) framework will be used (Table 1). Table 1 - Framework PCC. Letter Meaning Question Answer P-Population Who What is the population of interest? Children and adolescents with neurodivergent conditions or neurodevelopmental disorders (autism spectrum disorder, intellectual disability, cerebral palsy, etc.) C-Concept What What is the main phenomenon or intervention or concept to be mapped? Clown therapy, medical clowning (relational, playful, therapeutic interventions) C-Context Where, or in what context In which settings, circumstances, or systems? Any care or educational setting (hospital, outpatient, school, child neuropsychiatry service) This review will aim to answer the following primary question: what is the evidence on the effect of clown therapy on children with neurodevelopmental disorders? Specific sub-questions will include: 1) What are the types and characteristics of clown therapy interventions used? 2) What outcomes and results are assessed and reported? 3) What are the underlying theoretical models and implementation methods? 4) What barriers and facilitators can be identified? 5) What recommendations for future research and clinical implications emerge? Inclusion and Exclusion Criteria The following inclusion criteria will be applied: 1) Target population: children and adolescents (0-18 years) diagnosed with neurodevelopmental disorders, including autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), Down syndrome, intellectual disability, communication disorders, motor disorders, global developmental delay, or other cognitive or sensorineural disorders; 2) Intervention implemented: any form of clown therapy by professionals, volunteers, clown doctors, or hospital clowns, including therapeutic entertainment programs or more or less structured clown-based interventions; 3) Type of study: quantitative, qualitative, mixed-method studies, pilot studies, case reports, or case studies; 4) Outcome: effects on anxiety, mood, stress, behavior, social interaction, perceived pain (or other indicators of psychophysical well-being), experiences of caregivers, family members, or healthcare staff; 5) Language of publication: any; 6) Publication date: no time limit, to include all available scientific literature. Exclusion criteria will be as follows: 1) studies on adults or populations without neurodevelopmental disorders; 2) interventions not attributable to clown therapy; 3) studies in which it is not possible to distinguish the effects on subjects with neurodevelopmental disorders; 4) opinions, editorials, or articles without original data. Search strategy The literature search will be conducted by querying the following electronic databases: PubMed/MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus. Google Scholar will also be consulted. Key terms related to clown therapy and neurodevelopmental disorders, combined with the Boolean operators "AND" and "OR," will be used to retrieve records of interest (Table 2). Table 2 - Search strategy Source Search string PubMed/ MEDLINE (clown*[tiab] AND (autis*[tiab] OR ASD[tiab] OR ADHD[tiab] OR "neurodevelopmental"[tiab] OR "intellectual disabilit*"[tiab] OR DCD[tiab] OR "communication disorder*"[tiab])) AND (child*[tiab] OR pediatric*[tiab] OR adolescen*[tiab]) EMBASE (clown*:ti,ab AND (autis*:ti,ab OR ASD:ti,ab OR ADHD:ti,ab OR neurodevelopmental:ti,ab OR "intellectual disabilit*":ti,ab OR DCD:ti,ab OR "communication disorder*":ti,ab)) AND (child*:ti,ab OR pediatric*:ti,ab OR adolescen*:ti,ab) CINAHL (clown* TI,AB) AND (autis* OR ASD OR ADHD OR neurodevelopmental OR "intellectual disabilit*" OR DCD OR "communication disorder*") TI,AB AND (child* OR pediatric* OR adolescen*) TI,AB PsycINFO (clown*.ti,ab. AND (autis*.ti,ab. OR ASD.ti,ab. OR ADHD.ti,ab. OR neurodevelopmental.ti,ab. OR "intellectual disabilit*".ti,ab. OR DCD.ti,ab. OR "communication disorder*".ti,ab.)) AND (child*.ti,ab. OR pediatric*.ti,ab. OR adolescen*.ti,ab.) Web of Science (clown OR clowns) (Title) AND (