Indicated Interventions 457follow-up assessment. The “ndings suggest that further re-
search to test social skills training in an empirically rigorous
manner is required.
Transplantation
In the past 15 years, transplantation has become the treatment
of choice for children with end stage disease due largely to
the availability of effective immunosuppressive agents. Solid
organ transplants (such as kidney, cardiovascular, and liver)
and stem cell transplants are the most common pediatric
transplants in children and adolescents. Multiple organ trans-
plants remain experimental in children and adolescents.
Three-year survival rates vary by type of transplant and age
of the child (younger children have poorer survival rates), but
the rates vary between 70% and 90% (Stuber & Canning,
1998).
Children treated with transplantation show psychological
dif“culties similar to those reported for other children with
chronic illnesses. For instance, DeBolt, Stewart, Kennard,
Petrik, and Andrews (1995) used standardized measures of
child and family functioning to compare 41 children and ado-
lescents at least four years post-liver transplant with pub-
lished norms for chronically ill and medically well children.
Although the functioning of the transplant patients was simi-
lar to that of children with chronic illness, children with trans-
plants showed lower social competence and more functional
dif“culties than the medically well children. The impact of
the transplant on family functioning was less signi“cant than
with other children with chronic illness. Age at hospitaliza-
tion, years posttransplant, and other demographic factors
were not associated with child and family functioning. Simi-
lar “ndings were reported in a study of children and their
families awaiting heart or heart-lung transplantation at two
points six months apart, with the exception that family and
marital stress were signi“cant (Serrano-Ikkos, Lask, &
Whitehead, 1997). In a review of the literature on cognitive
and psychological functioning of children who have under-
gone heart transplant, Todaro and colleagues (2000) found
that children with complicated transplants (such as those who
experience infection or rejection) are at risk for problematic
cognitive functioning, and children in the “rst year posttrans-
plant may be at risk for psychological dif“culties. However,
children•s distress reduces over time and children without
complications do not show problematic cognitive outcomes.
Subclinical levels of distress have been reported for parents
of children undergoing transplantation especially prior to ad-
mission, compared to during and after the transplant (Heiney,
Neuberg, Myers, & Bergman, 1994; Streisand, Rodrique,
Houck, Graham-Pole, & Berlant, 2000).
The psychological transplantation literature is sparse, re-
”ecting insuf“cient standardization of assessment strategies
and few empirical studies of interventions. From the extant
literature, assessment and intervention in organ and bone mar-
row transplants are approached on multiple levels (patient,
family, and health care context) and over three phases of
transplant: pretransplant, during the transplant, and posttrans-
plant (Stuber & Canning, 1998). Unlike adult transplant, as-
sessment pretransplant usually does not serve as a gatekeeper
to transplant in pediatrics but as a method for anticipating
problems with adjustment to the transplant and adherence
with burdensome hospitalization and medical interven-
tions during and after. Speci“cally, pretransplant assessment
focuses on child and parent psychological adjustment, the
child•s cognitive functioning as it impacts ability to under-
stand and to adhere to treatment, the availability of social
support during the hospitalization, understanding of the trans-
plant and commitment to the procedure by both the child and
at least one parent, and current and past treatment adherence
issues (Shaw & Taussig, 1999).
Interventions pretransplant are aimed at preparing the
child and family for the stress of transplant hospitalization by
addressing misunderstandings about the procedure, by treat-
ing problems in adjustment, and by teaching the child and the
family adaptive coping strategies and cognitive-behavioral
approaches to pain management. In addition, pretransplant
interventions aim to improve outcome by building strong al-
liances between families and the medical team and bolstering
family and community supports. Streisand et al. (2000)
reported a pilot intervention aimed at improving the coping
responses of parents of children undergoing bone marrow
transplantation. A stress-inoculation approach, with cognitive
and behavioral components, was implemented in a random-
ized, controlled, one-session design. The authors reported
that parents who participated in the intervention showed
more adaptive coping efforts, suggesting that the intervention
was successful in teaching parents stress-reduction tech-
niques. However, the change in coping did not result in less
distress for intervention parents when compared to parents
receiving standard transplant care.
During the transplant, which involves an extensive period
of hospitalization, psychological and physical aspects of the
transplant are the foci of assessment and intervention. Most
commonly, pain management, reduction of the fear, anger,
and anxiety associated with pain and prolonged hospitaliza-
tion, addressing withdrawal often exhibited by children, and
addressing strains in the relationship of staff to families are
helpful in this phase (Slater, 1994; Stuber & Canning, 1998).
Transplantation is associated with long-term medical com-
plications including rejection of the organ or bone marrow,