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Publishers Preface Introduction. Agenda for Action. Threefold System. Bonding and Attachment. Concrete Language. Analogical Language. Subtle System. Abstract to Concrete. The goal of qualitative analysis is to identify relevant themes and categories, which are later given interpretive meaning. The present efforts have also been influenced by Gadamer's hermeneutic approach to language, as a guide to understanding and interpreting the individual's outer and inner lifeworld. In the present study, psychological theories have served as a guide in interpreting the latent aspects of children's narratives.

First, the hospital directors gave their permission for the researcher to visit the respective hospitals in southern and central Sweden , as well as to interview the children and parents on the wards. The children were or had been admitted to an oncology, general medicine or orthopedics ward. One selection criterion was that the children interviewed were to have encountered hospital clowns at a hospital during the past few years. Another criterion was that the children were to represent an age range between 2 and 18 years of age so that the study would include different age levels.

The final selection criterion was that the families were willing to participate, considering the child's diagnosis, health and wishes. The contact nurses at the respective hospitals then helped in identifying the names of families that might consider participating in the study. The goal was to be able to interview 10 families with ailing children, and possibly the children's siblings. Of the 10 families contacted, nine agreed to participate and one did not wish to because the child was too ill; in total nine children participated.

Six girls and three boys took part, including two siblings a four-year-old girl and a year-old boy.

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The parents were represented by eight women and one man. Most of the children made regular visits to the hospital to undergo additional treatments and evaluations of their health. At the first meeting with the parents, which was arranged by the contact nurses at the respective hospitals, the parents received an information sheet describing the study. The children received their own information sheet containing age-appropriate terms.

The older children had access to a semi-structured interview guide containing the themes that would be discussed: encounters with hospital clowns, their meaning and associated difficulties and possibilities. The semi-structured interview format included opportunities to ask follow-up questions. The younger children required an open interview format that would enable them to narrate freely about all their experiences with the hospital clowns. The present author was the interviewer in all of the interviews. The interviews were carried out at the children's hospitals, except in two cases, where they were conducted in a home environment.

The interviews began by reiterating for the parents and children the study aim, ethical guidelines and what participation would involve. Thereafter, the parents gave their written consent for their own and their child's participation. The parents were present in the hospital room, listened in the background and on occasion commented on what the child had said.

When the two youngest children two and three years were asleep following a cancer treatment, the parents shared their reflections on their child's encounters with the hospital clowns.

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The year-old's parent did leave the hospital room, but could be reached by telephone if necessary. The interviews lasted between 45 and 60 minutes each. They were audio-recorded and later transcribed verbatim. The regional ethics board at Lund University, Sweden, approved the study reg. These guidelines were shared with the families from the outset. The parents also gave their permission for the interviews, as the children were under 18 years of age. Analysis of the results was based on reading through all of the interview data a number of times to achieve an initial understanding of the data as a whole.

In two cases, narratives from the youngest children's parents were included. The analysis resulted in a number of themes , which came to reflect the children's narratives and promote increased understanding: 1 of the children's experiences of the hospital clowns in relation to age; 2 of the children's experiences of the magical aspects of these encounters; and 3 of the children's experiences of well-being together with the hospital clowns.

Another aspect of the analysis was the fact that some of the children in the study the older ones contributed to the results by not only reflecting on their own encounters with the hospital clowns, but also on the encounters of other children in the hospital. This collaboration in the interview situation was initiated by the child and accepted and appreciated by the researcher.

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The psychological interpretation Ainsworth, ; Bowlby, ; Martin, ; Wandersee, of the results entailed a deeper understanding of the magical world, which the children expressed in different ways. The idea underlying the theoretical interpretation was to illustrate two patterns , first a magical safe area, then a kind of magical attachment.

The magical safe area is seen as a world of possibilities with the hospital clowns, where aspects of both fantasy and reality were present. Given an understanding of this magical safe area and its importance to the children's mental well-being, the last part of the theoretical analysis came to emphasize magical attachment in relation to the hospital clowns, which is presented in the discussion section with a focus on the children's developmental level. Viewed from a child perspective, the children's various experiences of the hospital clowns emerged, often through narratives about magic, music and play.

The youngest children were said to have been afraid of the hospital clowns at the beginning of their hospital stay, but gradually got used to them, because the clowns maintained a physical distance and gave the children the time they needed to habituate:. We met the hospital clowns in the beginning, when Little Brother was ill… there weren't any problems with the clowns… the last time there was a male clown who was very tall… that scared Little Brother a bit… maybe he was used to them being women and this didn't fit in… but the clowns were so good at noticing when the children weren't interested… they kept their distance… because Little Brother was a little shy, but at least he didn't cry.

Child, two years, Parent. The clowns tried connecting with our daughter… but she was quite ill, so she was afraid of them at first, which is pretty common… but they built up her trust… then two days later she had made a drawing for the clowns and put it in their mailbox. Child, three years, Parent. The seven-year-old boy had met the clowns since he was one, on several occasions during his stays at the children's hospital for heart surgery.

He also described wanting to meet everyone in the clown team to see what they could come up with. The year-old felt the clowns were better suited to younger children, but they were still fun for children his age. He felt they were good for his little brother, who had cancer. I was never afraid of them… I want to see them all the time… all of them.

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Child, seven years. They're probably best for kids around five or six years old… My little brother made music with them and thought they were really funny. Child, 10 years, Sibling. They treat you like a baby… the older you get, the more mature you become… and then it's not fun to see somebody dressed up… I try to keep my distance… Child, 14 years.

The year-old girl had experienced many clown encounters, as she had been admitted to the hospital several times between 11 and 18 years for her chronic intestinal disorder. She talked about many encounters over the years with other children on the wards. Instead, she took advantage of all breaks in the daily routine that could lighten up the mood and give some relief from all her difficulties and burdens.

The year-old girl also felt the hospital clowns adapted well to the children's age and mood. She said:. I shared a room with a girl before who was my age and she thought it was so embarrassing… she'd only seen them in the hall… at a certain age kids think lots of things are embarrassing… maybe they haven't found themselves really… I've never been in that age of thinking like that… considering that life at the hospital gives you lots of experiences….

Child, 18 years. The children 10 years of age and younger described the magic encounter as follows:. I think they began with us playing doctor… like they were going to prick somebody's finger… take a blood sample… and then they checked us with a stethoscope… it worked great. Child, 3 years, Parent. Magic… with balls… I held them in my hand… and then I said abracadabra… all gone… once the clown was going to pick up a feather duster… then it flew up… up, up, up… they have things in their pockets they can do magic with… they have soap bubbles too… I popped them.

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Child, 4 years. She made an egg appear out of nowhere… that turned into a hen… I asked her why she couldn't make a dog appear for me instead… then she said she could only do magic twice, and she'd already done it… she made an egg appear first, then a hen… I know that Fiffikus can walk through walls… I've never seen that they can do magic and walk through walls, but they can do other things I don't know about. Child, 7 years. You can place the card in the pile like this… that's for sure… Then we watch this while the clown watches… so that card is in front… I remembered the card here… the clowns couldn't learn it… they're usually pretty stupid.

Of the two year-old girls, one never talked about wanting to be in a magical state, quite the opposite; she stressed the importance of being treated like an adult and adapting to reality. If they did come then they could forget the clown role for a while and be a regular person, a little more private. Child, 14 years.

The other one joined in on the magic games and had fun with the younger children on their terms, playing the role of assistant clown. The year-old girl, however, clearly described the magical aspect in terms of fantasy in reality, trance and magic; she felt the clowns constructed a world together with the children —a world that was not the real one, but one in which the children were seen and acknowledged in an atmosphere of joy, in her case through music and words. In the world of fantasy, this teenage girl did not see herself as ailing, but as a person who simply wanted to see herself in a more healthy way:.

It's a kind of reality you build with them… a fantasy in reality… it's very magical… it's a mixture between music and words… you construct a world together with the clowns that becomes your own… it feels so great that they're spending time on me… just for me… it feels like I mean something to them… I think it's important that they build this world together with us, the patients… a world that maybe isn't the real world… but for us, at the time, it is… they don't see the illness… they only see us… and the message of joy and music… like magic… you're almost in a trance, you could say… a little outside reality, but still in our reality… right, in the fantasy… because at the moment, you don't see yourself as a sick person… you just see that you should have fun.

The year-old girl reflected on the younger children's interest in magic and described how one four-year-old boy identified with a clown who performed magic:. There was one little boy years old who has been in the hospital as much as I have… he loves the clowns too and as learned how to do magic from them… he has a favorite clown and behaves just like him. What emerged clearly from the interview data was the fact that for children the clown encounter was a matter of being able to relax in the hospital situation and feel a sense of joy together with the clowns.

This was described as being given a moment of distance from the problems by being able to laugh and dance. One example, provided by the two-year-old's mother, depicted a relaxed encounter before the doctor was to arrive and perform a six-month evaluation following the child's cancer treatment:.

We were going to talk to the doctor… the clowns came in and they'd hidden a guitar behind their backs, and they said to Little Brother-Where's the guitar? Child, 2 years, Parent. The hospital clowns stand for harmony and fun… I think that with time… the more times you meet them, you come to trust them… our daughter is so happy when she sees them… she can even ask in advance, if they'll be there on the day she goes to the hospital.

The year-old boy had often accompanied his little brother to the hospital and experienced how the clowns were able to brighten the mood and get the children to laugh. He related this to the notion that the children needed music and play to create a distance to their illness. He could also see an indirect benefit for himself, as he also got to laugh.

But the year-old girl had another opinion:. They make the kids happy, and then they laugh and that's good for me… they play a lot of music and things… I never get sad, because I don't think it his brother's cancer will return and that's because you think about something else. I don't think anything about the clowns is fun… nothing is fun at the hospital… rather be with friends. The year-old girl had experienced long hospital stays and stressed several things that had been important to her, such as moments of joy laughing with the clowns, but also inspiration to move on in her life through various forms of artistic expression, i.

She described the acknowledgement she felt when the clowns wrote a special birthday song for her, and how her self-confidence increased as she received help with finding her own resources and new, creative solutions:. I was sad and felt very bad… then the clowns wrote me a song and it made me so happy, and touched… they sang the song for me… I stood there and cried… they've given me so much joy, but they also inspired me to move on… because when you're ill maybe you don't have the energy to do what you want… so they help you get started.

One common aspect that children in the entire age range stressed was how they alternated between sorrow and joy: sorrow in terms of being sad, crying and feeling bad because of the illness; joy in terms of having fun, being happy and laughing:. There're funny, happy and strong… otherwise you're sad all the time. So the children maybe get to laugh a little too… instead of crying. It's a lot of fun… it means a lot… I have a hard time laughing when I've been sick so long… hard to crack a smile… but when one of the clowns shows up… then something happens… if I'm in pain then I don't feel it as much… I get my endorphins going… then I lie around thinking about what they did and said… and you have that with you for the next time.

You get some peace and quiet… if you're only sad then it's hard to move on in your illness… they get you on your way, motivate you and joke around… they can transform your problems into the funniest thing in the world. She also wanted to call attention to the embarrassing aspect of the situation, the fact that several people laughed, but also that she overcame this, because her willingness to help was greater than her feeling of wanting to give up.

I helped out as a clown the first time… it was sort of embarrassing… everybody stood there laughing… but it went well… you can be an assistant clown. In the children's narratives, there is a common thread in the form of memories of having been acknowledged in their illness state by the hospital clowns.

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Yet this acknowledgement did not stop at the children's clinical picture, instead it started from the inner strength and mental resources, which strengthened their self-confidence and gave hope of improvement. The year-old illustrated this in the following way:. It seems like your self-confidence increases quite a bit… because they want to encourage that as much as possible… you often lose your self-confidence when you feel bad and can't do the same things as other people… the clowns want you to keep going in your own little way….

A comprehensive understanding of the complexity of child patients' experiences of clown encounters reveals how the deeper meaning of the sequences age, magic and well-being can be interpreted as bridging the gap between the healthy and non-healthy parts of the child's life in the hospital. The pleasurable unexpected possibilities in the magical safe area helped the children distance themselves from their problems, by alternating between different emotional states and through anonymous identification with the clown character.


This distance from their problems gave free rein to hope, acknowledgement and self-confidence. But the age of the children played an important role in how the magic aspects of the encounters were experienced. The next step in the discussion section will be to position this phenomenon of magic in a psychological context and, in light of theory, to link it to certain psychological aspects in children — such as developmental level and mental well-being — in order to gain a deeper understanding of the magic relations to hospital clowns.

To shed additional light on the relation between the child and the hospital clowns, the discussion section will deal with magical aspects by focusing on developmental level. To achieve a deeper understanding of the children's narratives about what happens during encounters with hospital clowns, the pattern magical safe area can be used. Publication Date: August 4, List Price: For the 20 million parents of to year-olds, The Roller-Coaster Years is a lively guide to mastering the ups and downs of early adolescence. Every parent knows about the terrible twos and the brooding teens, but few have anticipated the wild ride of these magical yet maddening years that can provide all the thrills and chills of a carnival ride.

Charlene C.

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Giannetti is a journalist and the author of three previous books.