Current status of psychological research in organ transplantation.

Journal of Clinical Psychology in Medical Settings, VoL 1, No. 1, 1994

Current Status of Psychological Research in Organ Transplantation James R. Rodrigue, t,2 Anthony F. Greene, I and Stephen R. Boggs 1

Research addressing the psychological concomitants of organ transplantation is reviewed. Specifically, cognitive, behavioral, and psychosocial correlates of kidney, heart, liver, and bone marrow transplantation in both children and adults are discussed. Despite several conceptual and methodological shortcomings of the psychologically-based research in this area, results seem to indicate that organ transplantation is associated with many psychological issues at pretransplantation, posttransplantation, and follow-up periods. Implications of these general findings for the advancing roles of the health psychologist in organ transplantation are discussed. KEY WORDS: organ transplantation; end-stage disease; children; adults.

INTRODUCTION Organ transplantation is now unquestionably a viable treatment alternative for many medical disorders. Timely advances in medical technology and the development of the immunosuppressive drug cyclosporine in 1975 have revolutionized organ transplantation. Kidney, heart, liver, and bone marrow transplantations are being performed throughout the world at a rapid pace. In addition, significant progress has been made in transplantation procedures involving the pancreas, lung, heart-lung, cornea, skin, and islet cells (Cerilli, 1988). Surgical techniques and expertise are continually improving and transplantation success rates are correspondingly higher. The fact that the 1University of Florida, Gainesville, Florida. 2Correspondence should be directed to James R. Rodrigue, Ph.D., Center for Pediatric Psychology Research, Department of Clinical and Health Psychology, Box J-165, Health Science Center, University of Florida, Gainesville, Florida 32610-0165. 41 1068-9583/'94/0300-0tM1507.00/0© 1994Plenum PublishingCorporation

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general public no longer marvels at the success of this life-preserving strategy exemplifies its arrival as an acceptable modality of treatment. Ironically, this same public malaise has been implicated as a contributing factor in the shortage of organ donors (Shanteau & Harris, 1990). Indeed, the number of transplantations is limited mainly by the worldwide organ shortage (Kilner, 1990; Perkins, 1987). The significance of organ transplantation is underscored by both the number of transplantations and survival rates. For instance, it is estimated that approximately 2500 liver transplants were performed in the United States during 1991, with 14% in children (Whitington, Emond, Black, Whitington, Boone, Smith, Thistlethwaite, & Broelsch, 1991). This represents a significant increase over the number of transplantations performed in previous years. This rapid growth in liver transplantation is exemplified by the fact that organ transplantation, generally, blossomed only two decades ago (Cerilli, 1988). Prior to transplantation technology, children and adults with end stage disease had relatively short life expectancies or decreased quality of life. Indeed, with the exception of renal disease for which dialysis was available, there was nearly 100% mortality associated with end-stage heart disease, liver failure, and many cancerous disorders. Today, however, transplantation has made it possible for many of these individuals to live disease free for longer periods of time and to experience an improved quality of life. As transplantation has evolved from a controversial, experimental research procedure to a more viable therapeutic alternative, so too has the role of the psychologist. Numerous clinical case studies have documented the psychological plight of the transplant candidate and subsequent adaptation to longer-term survival. Health psychologists, in particular, are increasingly being called upon to provide consultative, evaluative, and treatment services to transplant patients and many have assumed an integral role on transplant teams. The increasingly visible role of psychologists in this area has led to a relatively small, but growing, body of research that examines the psychological factors associated with transplantation. The purpose of this review is to discuss recent research examining the psychological concomitants of selected types of organ transplantation as well as issues and questions for future research. The two main topics covered in the review include: (a) empirical evidence of psychological correlates of kidney, heart, liver, and bone marrow transplantation, and (b) conceptual and methodological considerations for future research. Unlike previous reviews in this area (e.g., Beidel, 1987), this paper will discuss research pertaining to both children and adults and focus predominantly upon those studies in which observational or self-report measures of known or reported psychometric properties were used.

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EVIDENCE OF PSYCHOLOGICAL CORRELATES OF TRANSPLANTATION

Kidney Transplantation Children

There have been more kidney transplants worldwide than any other type of transplantation in children (First & Schroeder, 1991). Kidney transplantation is an especially good treatment alternative for children with chronic renal failure or end-stage renal disease (ESRD) because it can partially, or in some cases dramatically, reverse growth retardation (Tejani & Ingulli, 1991; Van Dop, Jabs, Donohoue, Bock, Fivush, & Harmon, 1992). Although physiological improvement after transplantation exceeds that observed for children on hemodialysis, complete growth recovery is not always achieved and depends upon factors such as age at transplantation, use of corticosteroids, and graft function (Ohmori, Aikawa, Yoshimura, Yasumura, & Oka, 1989). For instance, accelerated catch-up growth is most likely to occur for children who receive transplantation under age 7 and for whom steroid immunosuppression can be kept to a minimum (Ingelfinger et aL, 1981). Little growth can be recovered after 12 years of age (Kamil, Yadin, Ettenger, Boechat, Pyke-Grimm, Nelson, Lippe, & Fine, 1991). Three-year survival rates for cadaver and living-related donor transplants for children under 16 years of age are 90% and 95%, respectively, for patient survival, and 65% and 87%, respectively, for graft survival (Broyer, 1989). In addition to evidence of the beneficial effects of kidney transplantation on physical growth and development, data are beginning to emerge regarding the influence of transplantation on the neurocognitive, emot i o n a l , and b e h a v i o r a l f u n c t i o n i n g of c h i l d r e n with E S R D . Neuropsychological studies, for instance, have genera-lly found mild to moderate cognitive deficits in children with ESRD prior to transplantation and some improvement in functioning posttransplantation (Hobbs & Sexson, 1993). Earlier research by Rasbury, Fennell, and Morris (1983) demonstrated that children with ESRD exhibited impairments in cognition and learning and that subsequent transplantation resulted in improved academic achievement and problem-solving abilities at 1 month follow-up. However, at 1 year follow-up, no further significant improvements were noted (Fennell, Rasbury, Fennell, & Morris, 1984). In a comparison of the neurocognitive effects of different therapeutic interventions on children with renal disease, Fennell, Fennell, Mings, and Morris (1986) found that patients showed deficits in visuomotor skills related to attentional and

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visuoanalytic function, with the transplant recipients being least affected. Additionally, these researchers reported that patients with successful kidney transplants and those undergoing continuous ambulatory peritoneal dialysis performed better on vigilance and memory tasks than those patients receiving hemodialysis. The emotional and behavioral adjustment of children receiving kidney transplants has been examined in a number of studies and case reports. For instance, in comparing 44 children with renal disease (22 receiving dialysis, 22 with chronic renal failure but not receiving dialysis) to a group of healthy peers, Garralda, Jameson, Reynolds, and Postlethwaite (1988) found a trend for increased psychiatric problems among the children with renal failure, particularly those with more severe disease. Additionally, research has found that parents of children with ESRD also are at higher risk for problems related to anxiety, depression, and psychosomatic complaints (Fielding, Moore, Dewey, Ashley, McKendrick, & Pinkerton, 1985). Studies of children treated with kidney transplantation suggest that although such problems continue to exist for children and adolescents posttransplantation, difficulties may be less severe and that the level of adjustment may be related to the status of the graft and the visibility of the illness. Poznanski, Miller, Salguero, and Kelsh (1978) studied two groups of adolescents who survived 2 years or longer after transplantation. One group showed little evidence of graft rejection and good kidney function and one group showed evidence of intermittent or chronic rejection episodes. They discovered that those adolescents in the latter group reported greater difficulties with school and employment, social relationships, self-perception, and depressive feelings. Beck, Nethercut, Crittenden, and Hesins (1986) found that older adolescents and young adults who had received kidney transplants reported more difficulties in adjustment when visible signs of the illness were present (cushingoid appearance, obesity, transplant scars, orthopedic aids, or atypical height or proportions). The relationship between psychosocial variables and adherence to immunosuppressive therapy following transplantation has received scant empirical attention. This is somewhat surprising considering noncompliance may precipitate allograft dysfunction and a return to dialysis. Recently, Foulkes, Boggs, Fennell, and Skibinski (1993) examined the relationship between social support, family functioning, and adherence to three posttransplant medications (azathioprine, prednisone, and cyclosporine) among 32 children who had received a renal transplant. Transplantation had occurred an average of 31 months prior to the study. Interestingly, results indicated that nonadherence to one or more of the medications was


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significantly associated with more emotional and informative support from fathers (as perceived by the child), greater number of stresses experienced by the family, and younger child age. While the first finding may initially seem counterintuitive, the authors suggest that fathers' increased activity in their child's support may have occurred as a result of child nonadherence. Despite a few methodological weaknesses (e.g., small sample size, assessment of compliance at only one point in time), this study provides an empirical segway into the evaluation of individual, family, and social factors that may identify children at risk of medication nonadherence following renal transplantation. Adu/ts Kidneys received from histocompatible living related donors appear to produce the best results for adults younger than 50 years of age. Oneyear rejection rates are 25% and 39% for living related and cadaveric renal transplants, respectively. Levy (1986) reported that about 30% of all renal transplants performed in the United States involve related donors. Unfortunately, the majority of individuals newly diagnosed with renal disease are over 50 years old and do not have a histocompatible donor. The research literature examining psychological aspects of kidney transplantation in adults is much more extensive than the literature relating to pediatric kidney transplantation. Topics investigated include prevalence of psychopathology, psychological consequences of transplantation, sexual functioning posttransplantation, comparisons of quality of life with different treatment modalities, psychological factors affecting outcome, psychological response to treatment failure, and psychological adjustment of living related donors (for reviews see Abram & Buchanan, 1977; Chambers, 1982; Gulledge, Buszta, & Montague, 1983; Levenson & Glocheski, 1991; Levy, 1986; Stewart, 1983). Studies of the psychological well-being of transplant recipients have suggested that psychological morbidity is a serious problem among adults with renal disease regardless of treatment modality and that between 22-43% of these patients may be classified as significantly psychologically distressed (Farmer, Snowden, & Parsons, 1979; Kalman, Wilson, & Kalman, 1983; Livesley, 1979; Petrie, 1989). Interestingly, studies comparing the frequency of psychological distress between groups of dialysis and transplant patients have provided mixed results. Kalman et al. (1983) found no differences in psychiatric impairment between dialysis and transplant groups while Petrie (1989) reported significantly poorer levels of adjustment in patients receiving dialysis. In a well-designed study of 859

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renal patients, Evans, Manninen, Garrison, Hart, Blagg, Gutman, Hull, and Lowrie (1985) using objective and subjective measures of quality of life that included indices of functional impairment, work status, life satisfaction, and psychological adjustment found transplant recipients far better adjusted on most measures than those patients receiving dialysis. The most frequently studied single psychological reaction to ESRD and transplantation in adults has been depression (Levenson & Glocheski, 1991). Generally, studies have reported a higher rate of depressive symptoms in individuals prior to transplantation and a subsequent decrease in symptoms posttransplantation, although individuals with poorly functioning grafts or significant life stressors report continued difficulties (Keegan, Shipley, Dineen, & Steiger, 1983; Schlebusch, Pillay, & Louw, 1989). Sexual dysfunction in adults with renal disease is another area of concern to health psychologists working with transplant candidates or recipients. Procci, Hoffman, and Chatterjee (1978) reported a significant decline in frequency of sexual intercourse in both male and female dialysis patients with the decline for male patients most dramatic. An increase in frequency of intercourse after transplantation was noted only for the male patients in their sample. Abram, Hester, Sheridan, and Epstein (1975) studied the sexual behavior of 32 married, male dialysis, and transplant patients and found that 45% had reduced sexual potency after onset of kidney disease with another 35% experiencing sexual problems after beginning dialysis. Of the patients receiving kidney transplants, 45% reported a subsequent increase in sexual activity. The physiological mechanisms resulting in the fluctuations in sexual activity observed in renal patients are complex (Foulks & Cushner, 1986; Nghiem, Corry, Picon-Mendez, & Lee, 1983), but there can be little doubt that psychological factors contribute to the observed sexual dysfunction and that psychological treatment of sexual problems in these patients may be necessary (Glass, Fielding, Evans, & Ashcroft, 1987; Procci et al., 1978). Finally, several studies have addressed the quality of life of the transplant recipient after treatment failure and return to dialysis. Although researchers have reported that patients returning to dialysis after transplant failure experience a decrease in quality of life greater than that of individuals on dialysis who have never been transplanted (Johnson, McCauley, & Copley, 1982), other researchers have failed to find this contrast effect (Binik & Devins, 1986; Rodin, Voshart, Cattran, Halloran, Cardella, & Fenton, 1985; Streltzer, Moe, Yanagida, & Siemsen, 1983). It is apparent, however, that some individuals experiencing the loss of a transplanted kidney and return to dialysis may be at risk for new adjustment difficulties and may be in need of psychological intervention.

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In summary, research evidence clearly suggests that ESRD places children at risk for psychosocial adjustment problems and these problems may continue posttransplantation, although severe psychological reactions posttransplantation are rare. Furthermore, cognitive impairments attributable to such physiological complications of ESRD as uremic toxicity can be expected in children with renal disease; however, there are empirical data to suggest that these deficits may improve posttransplantation to varying degrees. For adults, psychological distress, especially depression and sexual dysfunction, is commonly reported during the pretransplant period. Although earlier research failed to find differences in psychological functioning between transplant recipients and those receiving dialysis, more recent research has clearly documented improvement in functional status and several areas of psychological adjustment following transplantation, perhaps paralleling recent advances in transplantation technology and improved survival rates. Heart TranspLantation Children

Heart transplantation has become an increasingly accepted form of treatment for children with terminal heart disease and now accounts for 9% of all heart transplantations conducted (Martin, Bricker, Fishman, Frazier, Price, Radovancevic, Louis, Cabalka, Gelb, & Towbin, 1992). One-year and 5-year survival rates of 80-90% and 50--60%, respectively, have been reported in children (Addonizio & Rose, 1987; Bailey, Wood, Razzouk, van Arsdell, & Gundry, 1989; Bouckek, Kanakriyeh, Mathis, Triman, & Bailey, 1990; Heck, Shumway, & Fayue, 1989). However, about 20-30% of children awaiting heart transplantation die before a suitable donor can be found (Addonizio & Rose, 1987), and many child recipients develop renal insufficiency, hypertension, and neurological complications (Martin et al., 1992). Despite increasing use of orthotopic heart transplantation in infants and young children (e.g., Bailey et al., 1989), there are few published empirical studies examining the effects of this procedure on children's cognitive, behavioral, or psychological development. Pennington, Sarafian, and Swartz (1985) determined that most children and adolescents receiving a heart transplant attend school, participate in sports, and/or work several months after transplantation. Lawrence and Fricker (1987) reported adequate or improved quality of life (i.e., emotional adjustment, school

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achievement, peer relationships, self-care) among seven child heart transplant recipients. In a published summary of the proceedings of a conference on pediatric heart transplantation, several papers addressed the neurodevelopment of pediatric heart transplant recipients (Baum, Cutler, Fricker, & Trimm, 1991). The general conclusions offered by the presenters included the following: (a) following transplantation, most infants grow normally, (b) the use of corticosteroids contributes to delayed linear growth and bone maturation, but catch-up growth resumes once these drugs are discontinued, (c) the majority of young recipients are neurologically normal as measured by cranial ultrasonography and serial neurological examinations at 6, 12, 24, and 48 months postsurgery, and (d) most infant recipients are found to have normative mental and motor development as measured by the Bayley Scales of Infant Development. In the most comprehensive, conceptually-driven study reported to date, Uzark, Sauer, Lawrence, Miller, Addonizio, and Crowley (1992) examined the psychosocial functioning of 49 child heart transplant recipients and their families from five transplantation centers. Children were an average of 10 years old, and time since transplantation ranged from 4 months to 5 years. When compared to instrument normative samples, child heart transplant recipients did not differ significantly from their peers in selfconcept and anxiety; however, their parents reported significantly more depressive symptoms and less social competence relative to normative groups. Behavior problems, including depression, were significantly associated with increased family stress and fewer family resources for managing stress. These findings highlight the significance of systematically assessing children's psychological functioning posttransplantation as well as the importance of examining family factors that may be related to psychological adjustment. Certainly, as the use of heart transplantation as a treatment alternative for children increases, we are likely to see a concomitant rise in the number of published reports addressing the psychological or developmental functioning of these children. Adults

The primary indication for transplantation among adults is end-stage cardiac disease (generally meaning a prognosis of less than 1 year). This encompasses a broad band of pathophysiological processes for which medical therapy is only palliative, The majority of adults referred for transplantation are diagnosed with ischemic or dilated cardiomyopathy (damage to the heart muscle due to idiopathic, viral or postpartum causes) or coronary


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artery disease (occluded coronary arteries), with increased risk of mortality in patients transplanted for congenital or valvular disease (Kaye, 1987; Futterman, 1988). Several studies report short-term survival rates of 85% or better (Aravot, Banner, Khaghani, Fitzgerald, Radley-Smith, Mitchell, & Yacoub, 1989; Baumgartner, Augustine, Borkon, Gardner, & Reitz, 1987; Neiminen, 1990), with others reporting survival rates closer to 7080% at 1 year (Klein, Anderson, Ferguson, Rogers, & Cintron, 1989) and 45-50% at 5 years or more (Suszycki, 1988). Several studies have examined the cognitive functioning of adult candidates and recipients of heart transplantation. Our review of the available data regarding cognitive status suggests that the typical candidate for heart transplantation presents in the average range of intellectual ability, with no significant deficits in memory or mental control (Hecker, Norvell, & Hills, 1989). However, deficits in neuropsychological functioning, including stroke, seizure activity, and delirium, may result from prior cardiac arrest or surgery, congenital heart disease, aortic balloon pump use, medications (e.g., cyclosporine toxicity, steroid psychosis), and/or graft rejection (Willner & Rodewald, 1991). In cases where there has been a decline in functioning, organic brain syndrome at pretransplant has been associated with satisfactory quality of life at posttransplant (Brennan, Davis, Buchholz, Kuhn, & Gray, 1987). Indeed, several studies have recently documented that improvement in cardiac functioning following transplantation may reverse subtle or even moderate cognitive deficits (see review by Levenson & Olbrisch, 1993). Recent studies have begun to emerge in the literature which provide a better longitudinal perspective on more global indices of psychological adjustment to heart transplantation. For example, Shapiro and Kornfeld (1989) examined 73 cardiac transplant recipients at varying periods posttransplant, and found that affective disturbances had been experienced by 51%, chiefly as a steroid-related syndrome. A broader perspective was taken by the United Kingdom Department of Health and Social Security, who used the Nottingham Health Profile to measure quality of life in transplant recipients (O'Brien, Buxton, & Ferguson, 1987). They confirmed that patients who were "sickest" had the lowest survival rates, but all patients improved significantly at 3 months posttransplantation compared to pretransplant quality of life. Using the same measure of quality of life, Caine, Sharpies, English & Wallwork (1990) found that, in 122 patients who were followed for up to 6 years posttransplantation, the improvements in mobility, energy, sleep, social activity and emotional behavior were maintained throughout the follow-up period. The only symptom which showed deterioration was pain, which was higher at 5 years posttransplant.

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These data suggest that posttransplantation adjustment is likely to be marked by affective and psychosocial disturbances, and that appropriate attention during the evaluation phase may reduce the risks for adverse consequences. It has been noted that there is a lack of consensus as to the most appropriate clinical assessment approach for the heart transplant candidate (Kay & Bienenfeld, 1991). However, there does seem to be consensus that clinical psychological assessment may complement medical selection criteria in predicting survival and complications posttransplantation. More information is available regarding psychiatric and affective features of selection for adult heart transplantation candidates, but this research too is replete with small sample sizes and unreplicated findings. Too often, data regarding adults with psychiatric diagnoses are of the case study format, which is informative but limited in its generalizability (Frierson & Lippman, 1987; Herrick, Mealey, Tischner, & Holland, 1987; Lane, Roche, Leung, Greco, & Lange, 1988). Several authors have reported that anxiety and depression are c o m m o n in adult heart transplant candidates (Brennan et al., 1987; Kuhn, Davis, & Lippmann, 1988a; Kuhn et al., 1988b; Mai, McKenzie, & Kostuk, 1986). While anxiety may decrease in the months following transplantation (Levenson & Olbrisch, 1993), fear of graft failure, infections, and death may persist for some patients (Shapiro & Kornfeld, 1989). Curiously, one study reported a higher frequency of panic disorder in patients with idiopathic cardiomyopathy compared to those with congestive heart failure or rheumatic heart disease (Kahn, Drusin, & Klein, 1987). In addition to anxiety, depression is reportedly common among heart transplant candidates (Levenson & Olbrisch, 1993); however, distinguishing symptoms of cardiac cachexia (e.g., sleep and appetite loss, fatigue, poor concentration, loss of energy) from depression is essential but often very difficult.

Liver Transplantation Children

Liver t r a n s p l a n t a t i o n has d e m o n s t r a t e d success with children (A-Kader, Ryckman, & Balistreri, 199I; Esquivel et al., 1987; Gordon & Starzl, 1988). By far, the most common diagnosis in children treated with transplantation has been biliary atresia, or obstruction of the ducts that drain bile from the liver into the intestinal tract (Whitington et al., 1991). I n b o r n m e t a b o l i c anomalies, including alpha-1 antitrypsin ( A A T ) deficiency, Wilson's disease, and tyrosinemia, rank a distant second


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(Malatack, Gartner, Zitelli, & Urbach, 1988; Starzl, Demetris, & Van Thiel, 1989). Gordon and Starzl (1988) reported 1-year and 5-year survival rates for children to be 70% and 68%, respectively. Mortality is highest during the first 6 months following transplantation. Several investigators have documented significant delays in the cognitive, motor, and physical development of children with end-stage liver disease (Burgess, Martin, & Lilly, 1982; Stewart, Uauy, Waller, Kennard, & Andrews, 1987; Stewart, Uauy, Kennard, Waller, Benser, & Andrews, 1988). For instance, Stewart et al. (1987) assessed the mental and motor development of 27 infants and 14 children with end-stage biliary atresia. Significant delays in both mental and motor development were found in about 50% of the sample. Delays during infancy were most highly correlated with growth stagnation, whereas delays during childhood were positively related to disease severity. Moreover, the delays in functioning appear to be more pronounced among those children whose disease onset occurred during their first year of life (Stewart et aL, 1988). Perhaps because of nutrient deficiencies commonly associated with cholestatic and noncholestatic liver disease (e.g., Andrews, Pau, & Chase, 1981), presence of liver disease during a time when the brain is especially vulnerable to malnutrition places children with early disease onset at particularly high risk for cognitive and physical developmental abnormalities (Dobbing, 1975; Stewart et al., 1988). In light of the documented developmental deficiencies in children with end-stage liver disease, it seems important to examine whether transplantation provides an opportunity for recovery of developmental functions and improved life quality. Indeed, previous researchers have documented accelerated growth in children following liver transplantation (Urbach et al., 1987; Spolidoro, Berquist, Pehlivanoglu, Busuttil, Saluski, Vargas, & Ament, 1987; Gartner, Zitelli, Malatack, Shaw, Iwatsuki, & Starzl, 1984). Furthermore, children have demonstrated similar gains in social competence (Stewart, Uauy, Waller, Kennard, Benser, &.Andrews, 1989), fewer hospitalizations, improved behavioral adjustment, and increased life quality (Colonna, Brems, Hiatt, Millis, Ament, Baldrich-Quinones, Berquist, Besbris, Brill, Goldstein, Nuesse, Ramming, Saleh, Vargas, & Busuttil, 1988; Zitelli, Gartner, Malatack, Urbach, Miller, Williams, Kirkpatrick, Breinig, & Ho, 1987; Zitelli, Miller, Gartner, Malatack, Urbach, Belle, Williams, Kirkpatrick, & Starzl, 1988). However, Stewart et aL (1989) found no significant gains on intellectual or developmental measures 1 year following transplantation, especially for children with early disease onset. Moreover, a more recent study by Stewart and her colleagues (1991) found deficits in verbal and nonverbal intelligence as well as in visual--spatial and abstract reasoning skills when compared to a matched group of young children with

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cystic fibrosis. Similar delays in cognitive functioning following transplantation have been reported by Zitelli and his colleagues (1987, 1988). Thus, although improvements in growth, social competence, and behavior may be apparent, liver transplantation may not necessarily lead to recovery of disease-related impairments in cognitive and motor functions. Furthermore, these deficits tend to be longstanding and most apparent among children with liver disease onset during infancy. Adults

Among adult liver transplant recipients, chronic active hepatitis, cryptogenic cirrhosis, alcoholic cirrhosis, and primary biliary cirrhosis are the most common diagnoses (Starzl eta[, 1989). One-year and 5-year survival are 69% and 55%, respectively (Gordon & Starzl, 1988). Similarly, Eid, Steffen, Sterioff, Porayko, Gross, Wiesner, and Krom (1989) reported 1- and 2-year survival rates to be 83% and 78%, respectively. Although survival rates tend to be higher for young adults, recent data suggest that 5-year survival rates for older adults (>50 years of age) are rapidly improving (Starzl et aL, 1987). Adults with primary biliary cirrhosis have the best survival rate (approximately 70%), whereas adults with inborn errors of metabolism and advanced hepatic encephalopathy have the poorest prognosis (Cerilli, 1988; Gordon & Starzl, 1988). Although there is no convincing evidence, there are data indicating that perioperative and long-term survival rates are better when transplantation is performed before serious complications have emerged. Markus (1989) found that patients with more severe liver disease have a two-thirds higher mortality rate than those with less severe disease immediately preceding transplantation. Posttransplant complications are life threatening and may include infection, rejection, vascular thrombosis, biliary leakage, and renal dysfunction, among others. Considering encephalopathy is a common symptom associated with advanced liver disease (Malatack et aL, 1988), it is not surprising that neuropsychological studies have consistently revealed deficits among adults during the pretransplantation period. Rikkers, Jenko, Rudman, and Freides (1978) found subtle neuropsychological problems in as many as 60-80% of cirrhotic patients. Wolcott, Norquist, and Busuttil (1989) and Tarter, Erb, Biller, Switala, and Van Thiel (1988) similarly reported neuropsychological deficits implicating cerebral dysfunction. However, these same researchers (Tarter et aL, 1984, 1988; Wolcott eta[, 1989) found that neuropsychological functioning does improve after transplantation, although it does not return to premorbid levels. In fact, visuopractic deficits, which are thought to be the most common neuropsychological features of hepatic encephalopathy (Tarter eta[, 1987), persist for as long as 3 years after transplantation (Tarter et aL, 1984, 1988).


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Clearly, the daily lifestyle and quality of living also can be adversely affected by the progressive and chronic course of hepatic failure. Numerous studies and case reports have documented the poor emotional adjustment of adults with fiver disease immediately prior to transplantation (e.g., House, Dubovsky, & Penn, 1983; Trzepacz, Brenner, & Van Thiel, 1989; Trzepacz, Maue, Coffman, & Van Thiel, 1986). However, to what extent does fiver transplantation promote positive changes in psychological functioning? Several authors have reported significant improvements in quality of life among a majority of adults as a result of transplantation (Colonna et aL, 1988; Foley, Davis, & Conway, 1989). Using a comprehensive prospective design where patients were studied before and 2 years after transplantation, Tarter and his colleagues (1988) found that liver transplantation results in significant improvement in health status, emotional adjustment, and social functioning relative to the recipient's pretransplant status. More physical than psychological improvements were noted, and overall scores on a standardized instrument of sickness impact remained significantly lower than that of control subjects. Nevertheless, the authors concluded that the absolute magnitude of the reported disturbances in fife quality was minimal and that the statistical difference between recipients and control subjects was not clinically important. Overall, behavioral and emotional adaptation of adults appears to be enhanced by liver transplantation, although the long-term impact of postoperative complications, rehospitalization, and medication side-effects on psychological adaptation have not been adequately delineated.

Bone Marrow Transplantation

Although still considered experimental for certain types of disorders (e.g., sarcoma, melanoma, breast cancer, aplastic anemia), bone marrow transplantation (BMT) is recognized as a viable treatment alternative for several oncologic and hematologic conditions, including acute myelogenous leukemia (AML), chronic myelogenous leukemia (CML), acute lymphocytic leukemia (ALL), and the lymphomas (National Institutes of Health m NIH, 1989). Once considered only for individuals with refractory end-stage hematologic disorders, BMT is now performed successfully earlier in the course of illness. Over 260 BMT centers worldwide have performed more than 15,000 transplants, and the number of BMTs done annually is increasing at a rapid rate (Bortin & Rimm, 1989). Furthermore, the number of BMTs performed each year is likely to increase substantially as more individuals volunteer to be bone marrow donors. Presently, the United States National Bone Marrow Donor Registry has over 20,000 volunteer donors and this figure is expected to increase over the next few years (Sullivan, 1989).

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There are three types of BMTs. Autologous transplants occur when the source of the infused bone marrow is the patient. Here, bone marrow was previously aspirated from the patient while in remission and then cryopreserved. In a syngeneic transplant, an identical twin, who presents perfect histocompatibility with the patient, is the source of the new marrow. An allogeneic transplant occurs when the patient receives marrow from a healthy donor who has matched the patient on several human leukocyte antigens ( H L A ) . The ailogeneic marrow source may be a relative of the patient (e.g., sibling) or an unrelated donor who has previously registered with the Bone Marrow Transplant Registry. BMT is unlike solid organ transplantation in that it is the pretransplant conditioning regimen that serves as the treatment and it typically requires a minimum of 4--6 weeks of hospitalization. U p o n admission to the B M T unit, a central venous catheter is inserted while the patient is under general anesthesia. The placement of this catheter permits subsequent transfusion of medications, blood products, total parenteral nutrition (TPN), and other parenteral fluids. The BMT "operation" involves two primary phases: the conditioning regimen and the infusion of new bone marrow. During the conditioning regimen, which may last several days, lethal doses of cytotoxic drugs are administered to ablate residual disease and to suppress immune function. Total body irradiation (TBI) also may be used to destroy the patient's malignant or deficient bone marrow. Without the subs e q u e n t infusion of new b o n e marrow, the conditioning regimen would certainly be fatal. Following the conditioning regimen, new bone marrow is infused via the central venous catheter during the course of 30-45 minutes. Brown and Kelly (1976) and H a b e r m a n (1988) provided comprehensive reviews of the psychological plight of the BMT candidate and recipient. According to these reviewers, the decision to undertake BMT begins the dynamic process of adapting to the BMT experience. For adult BMT candidates, the decision to pursue BMT often must be made when their disease is in remission and when they are feeling physically well. It is difficult for some who are in remission to pursue the possibility of an earlier BMT-related death, despite its potential curative effect. Preparing for relocation, organizing personal affairs, making childcare arrangements, waiting for a donor (i.e., unrelated allogeneic BMT), drafting living wills, and preparing for the possibility of death characterize the pre-BMT period. Indeed, these stressors have led some to characterize this transplantation stage as one of anxious anticipation (Haberman, 1988).


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From the time of admission to the hospital and for several weeks thereafter, the patient remains isolated in a germ-free, intensive care environment. The specific nature of this protective environment varies across institutions, but generally includes a laminar air flow room that contains a bed, reclining chair, portable commode, exercise equipment (e.g., stationary bicycle), television, and videocassette recorder. Observing sterile precautions is essential because even the slightest infection while the patient is immunosuppressed could prove fatal. Staff and visitors wear gowns, shoe covers, and masks, and are strongly encouraged not to visit the patient when they are feeling ill. Fears of isolation, entrapment, and contamination predominate throughout this immediate hospitalization period as do frequent mood fluctuations, pain crises, disrupted sleep patterns, and anorexia. Despite its increasing use and success, BMT is not without significant, potentially life-threatening, side effects. The pretransplant conditioning regimen of chemotherapy and TBI can produce numerous acute and long-term complications. Acute side effects are most apparent immediately following transplantation and can remain severe until early engraftment. These include gastrointestinal toxicity (e.g., nausea, vomiting, mucositis, diarrhea) and various hematologic, renal, pulmonary, cardiac, and neurologic complications. Perhaps the most serious complication is graft-vs.-host disease (GVHD) which can give rise to many other complications. Unlike in other organ transplants, in which the host may reject the implanted organ, cells of the implanted bone marrow may attack the host cells and give rise to GVHD. GVHD is most apt to occur when the marrow source is a close but not perfect match, as with unrelated allogeneic transplants. Initiating immunosuppressive treatment with cyclosporine, and the use of methotrexate in some instances (Beatty, Hansen, Anasetti, Sanders, Buckner, Storb, & Thomas, 1989), immediately after the transplant may decrease the occurrence and/or severity of GVHD. The use of large doses of corticosteroids to prevent rejection may further complicate the psychological picture as their effects can range from mild nervousness, euphoria, and insomnia to severe depression and possible psychosis. To prevent some of these side-effects, other techniques are presently being developed to help identify and remove donor marrow cells that are more inclined to attack the host. Late-onset (>100 days after BMT) complications may include opportunistic infections, leukoencephalopathy, infertility, cataracts, growth and development abnormalities, neurological abnormalities, graft failure, chronic GVHD, recurrent or secondary malignancy, pulmonary disorders, and death (Rubin & Kang, 1987; Sullivan, 1989).

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Relapse and long-term survival rates vary greatly and depend largely upon age, disease type, disease state at time of transplantation, and type of transplant. Generally, the risks associated with BMT increase with age. In reviewing survival rates for allogeneic transplants performed across several transplant centers, Sullivan, Witherspoon, Storb, Buckner, Sanders, and Thomas (1989) reported 10-year survival rates exceeding 80% for individuals with severe aplastic anemia; 14-40% survival rates for individuals with advanced-stage leukemia, with greater probability of relapse among those transplanted during refractory relapse or blast crisis; and 45-60% long-term disease-free survival for those receiving BMT in the early stages of leukemia. Fifty to 60% long-term disease-free survival rates have been reported for adults with chronic myelogenous leukemia receiving BMT during the chronic phase of their disease (Sullivan, 1989), and survival rates as high as 80% can be achieved if BMT occurs within 6-12 months after diagnosis (Thomas et al., 1986). Projected 5-year survival rates of 50-60% have been reported for adults receiving autologous and allogeneic BMT while in first remission (Burnett, 1989; Goldman et al., 1988; Gratwohl et al., 1988). Children

Most of the psychological literature on BMT in children has been primarily descriptive (e.g., Bradlyn & Boggs, 1989; Freund & Siegel, 1986; Gardner, August, & Githens, 1977; Patenaude, Szymanski, & Rappeport, 1979; Pfefferbaum, Lindamood, & Wiley, 1977). These clinical reports have focused predominantly on the behavioral and emotional reactions to extended hospitalization, although more recent attempts have been made to describe children's stress responses during the immediate postdischarge period. Although these earlier publications lacked empirical focus, identification of these clinical responses was a necessary step in promoting the benefits of psychological intervention for children and their families during the BMT experience. In one of the earliest studies involving child BMT recipients, Gardner et al. (1977) identified five problem areas through the use of objective and projective psychological instruments. These psychological difficulties ineluded: (a) anxiety and depression secondary to invasive medical procedures and fear of dying; (b) overly dependent behavior and associated feelings of helplessness; (c) anger toward parents and staff; (d) diminished tolerance for medical procedures; and (e) episodic refusal to cooperate with treatment demands. In a retrospective review of the medical records of 54 child BMT recipients, Phipps and DeCuir-Whalley (1990) also found that


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52% of child recipients, especially preschool and elementary-aged children, manifest significant adherence problems with the oral antibiotic regimen while in their protective environment. Kellerman and his colleagues (Kellerman, Rigler, & Siegel, 1979; Kellerman, Rigler, Siegel, McCue, Pospisil, & Uno, 1976), however, provide evidence that suggests such negative stress responses to protective isolation are transitory and do not lead to long-term emotional or behavioral disturbances. In contrast to the findings reported by Kellerman et aL (1976, 1979), one group of investigators recently reported significant psychological disturbance among children several months after BMT. Stuber, Nader, Yasuda, Pynoos, and Cohen (1991) used a structured interview format and behavioral observations to examine the incidence of posttraumatic stress disorder (PTSD) in six preschool children seen immediately before BMT and at 3-, 6-, and 12-month intervals. They found that while only one child met the diagnostic criteria for PTSD at pretransplant, three of the six children met criteria at the 12-month follow-up assessment. The authors suggest that a PTSD model may be very useful in understanding denial, avoidance, and reexperiencing the events that are commonly observed in young children following BMT. Adults

Despite clinical lore suggesting that the pretransplant period may be rife with emotional disturbance (Brown & Kelly, 1976), there are contradictory findings in the empirical literature. In a retrospective study, Hengeveld, Houtman, and Zwaan (1988) interviewed 17 BMT recipients 1-5 years after transplantation. Although emotional experiences were quite idiosyncratic, BMT recipients generally found the pretransplant and conditioning phases to be most stressful. Likewise, Jenkins, Linington, and Whittaker (1991), using standardized questionnaires and clinical interviews to examine the current psychological adjustment of BMT recipients and to explore their emotional status during the various BMT phases, found that depressive symptomatology was most prevalent during the pre-admission evaluation period. Indeed, this was a time when respondents reported being most psychologically vulnerable. In contrast to these findings, Rodrigue, Boggs, Weiner, and Behen (1993) reported normative levels of emotional functioning for adult BMT candidates. Using standardized instruments to assess the personality, affect, and coping of 38 adult BMT candidates an average of 3 weeks prior to hospital admission, Rodrigue et al. (1993) found that BMT candidates did not report experiencing significantly high levels of anxiety, anger, or depression. Furthermore, there were no apparent disturbances in personality functioning or coping styles.

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In addition to the foregoing, several o t h e r investigators have examined the psychological functioning of BMT recipients several months to years posttransplantation. Hengeveld et al. (1988) reported that the immediate discharge period was often characterized by strong feelings of anxiety, insecurity, and emotional vulnerability. Andrykowski, Henslee, and Farrall (1989b) examined the long-term functioning and adaptation of 23 BMT survivors more than 2 years posttransplant. Bone marrow transplant recipients, particularly those over 30 years of age, reported more mood disturbance when compared to adults recently diagnosed with lung cancer, survivors of testicular cancer, and healthy bone marrow donors. Interestingly, however, BMT survivors did not differ significantly from patients currently receiving cytotoxic chemotherapy on any measures of psychological adaptation. This latter finding is consistent with the Jenkins et aL (1991) study, in which BMT recipients did not differ significantly from adults with other types of medical problems on measures of depression, anxiety, and general psychosocial functioning. Wolcott, Wellisch, Fawzy, and Landsverk (1986) also assessed the functional health status and psychosocial adaptation of 26 adult BMT recipients who were an average of 40 months posttransplant. Approximately 75% reported being in good health with few or no residual psychosocial problems, and the recipients did not differ from their donors on these same measures. These researchers found that psychosocial status was not significantly influenced by time since transplantation. Similarly, Andrykowski, Henslee, and Barnett (1989a) found minimal changes in psychological functioning among BMT recipients assessed at 2, 3, and 4 years post-BMT. Previous research has consistently demonstrated the potential for both acute and chronic neurotoxicity secondary to conventional chemotherapy and radiation therapy (Goldberg, Bloomer, & Dawson, 1982; Weiss, Walker, & Wernik, 1974). Neuropsychological impairment is particularly apparent for individuals treated with cranial radiation in combination with intrathecal chemotherapy. For instance, numerous studies of children receiving such central nervous system (CNS) treatment have consistently found evidence of short- and long-term problems of attention, memory, visuospatial abilities, motor output, and learning of new concepts (e.g., Brouwers, Riccardi, Fedio, & Poplack, 1985; Fletcher & Copeland, 1988; Taylor, Albo, Phebus, Sachs, & Bierl, 1987; Waber, Gioia, Paccia, Sherman, Dinklage, Sollee, Urion, Tarbell, & Sallan, 1990; Williams & Davis, 1986). Similarly, adults treated with chemotherapy and radiation have experienced memory loss and other neuropsychological deficits (e.g., Johnson et al., 1985).


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Considering neurotoxicity may be related to both chemotherapy dosage (Meadows & Evans, 1976) and cranial radiation (Rowland et aL, 1984), several researchers have begun to examine the neuropsychological effects of the BMT regimen (i.e., high dose chemotherapy and total body irradiation). Among adults, there is some evidence that BMT recipients are at risk for cognitive impairment. Andrykowski and Henslee (1989) interviewed 21 adult BMT recipients and found that 62% reported experiencing memory difficulties and 29% reported problems with attention and concentration. Parth, Dunlap, Kennedy, Lane, and Ordy (1989) studied a small group of child and adult BMT recipients before and after (50 and 100 days post-BMT) transplantation. Using a computerized neuropsychological assessment methodology, these researchers found significant slowing of cognitive functions from baseline to post-BMT in both children and adults. More recently, Andrykowski and his colleagues (1990) found that disturbances in reaction time, attention and concentration, reasoning, and problem-solving may persist several months or even years after transplantation. Moreover, particularly noteworthy was the finding that increased cognitive dysfunction was associated with higher doses of total body irradiation.

CONCEPTUAL AND METHODOLOGICAL CONSIDERATIONS FOR FUTURE RESEARCH Overall, our review leads to several general conclusions. First, psychological research in organ transplantation is in its infancy. Previous conclusions regarding the psychological aspects of transplantation that were based primarily on clinical observation are only now beginning to be empirically evaluated. Second, while sophisticated research designs are beginning to e m e r g e , many reported studies have methodological shortcomings which necessarily limit the generalizability of the findings. Third, while certain psychological reactions may be common to all child or adult transplant recipients, it appears that some psychological symptoms are specific to the type of transplantation. Fourth, factors predictive of short- and long-term successful adaptation to transplantation have not been well elucidated to date. Finally, the available evidence suggests that, with a few exceptions, there is mild to m o d e r a t e i m p r o v e m e n t in psychological functioning among both children and adults as a result of transplantation. Our knowledge about the psychological aspects of organ transplantation is necessarily limited by our methodological sophistication. As noted, research in this area is in its infancy and some methodological problems

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are apparent. Reliable and valid methods of assessment are essential elements in advancing knowledge in a particular field. Studies employing more psychometrically sound instrumentation and greater consistency across studies in the methods used to assess psychological adaptation or variables presumed to be related to adaptation are needed. For instance, survival, noncompliance, rejection episodes, psychiatric interviews, symptom self-reports, quality of life measures, and various other psychometric indices of psychological and cognitive functioning have been used to determine psychological adaptation among children, adolescents, and adults. Such global indices are susceptible to bias and potentially unreliable. Virtually all of the available psychological literature in transplantation has been correlational in nature. This is understandable given the recent interest in the psychological aspects of transplantation. However, when transplant candidates or recipients are studied at a single point in time, relationships among variables can be examined but it is not possible to determine cause and effect. The very nature of transplantation lends itself well to systematic longitudinal study and a few investigators have initiated programmatic research (e.g., Andrykowski et al., 1989a, b, 1990; Stewart et al., 1987, 1988, 1989, 1991). Although correlational designs permit the identification of relationships in need of further study, prospective designs are necessary to more accurately measure the dynamic nature of psychological adaptation throughout the transplantation process. Surprisingly few researchers have studied the psychological adaptation of families or spouses of transplant recipients (Buse & Pieper, 1990; Stewart, Kennard, DeBolt, Petrik, Waller, & Andrews, 1993; Uzark et al., 1992). Similarly, considering the extant literature regarding the stress buffering effects of social support and family relations in adjustment to medical illness, the role of family or social support in mediating the association between transplantation and adaptation warrants further investigation. The lack of such research is surprising considering the great burden that is placed on families (e.g., financial, relocation, separation from other family members) and the requirement by some transplant programs that a family member be present throughout the entire transplantation process (i.e., evaluation, hospitalization, follow-up care). Having one's parent or spouse present throughout extended hospitalization may be beneficial to those with good relations yet potentially detrimental to those whose relationship is marred with strife. Although not the focus of this review, family members who have served as donors have been particularly neglected by researchers. The study of donors seems especially warranted during the engraftment period when survival depends on the success or failure of the transplanted organ.


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In addition to increased study of the family, consideration of other environmental variables and their relationship to psychological adaptation is essential. For instance, numerous systems beyond the family which potentially impact on the patient include various social networks (peers, extended family) and the health care system (patient's relationship and satisfaction with medical team). Multisystemic research that examines these environmental factors is now needed. Our review also highlights several other issues worthy of consideration. First, in medicine today, it is no longer acceptable to simply document a treatment's effectiveness solely in terms of its biological merits. One must also demonstrate that the procedure or treatment makes a significant contribution to the way in which an individual lives (Weinman, 1990). The preponderance of studies purporting to evaluate "quality of life" in transplant recipients perhaps best reflects this growing tendency to document the qualitative aspects of medical treatment. However, our review indicates a lack of consistency across child and adult studies in the conceptualization, definition, and measurement of quality of life. In addition to increasing clarification of this important construct and its measurement, there is a need to identify the components that are associated with quality of life, especially since findings from these studies are often used by health economists to determine the relative merits of transplantation and the allocation of its scarce medical resources (Kilner, 1990; Wright, 1990). As poignantly noted by Weinman (1990), there is a sense of exigency for health psychologists to reach consensus regarding the nature and measurement of core concepts (e.g., quality of life). Second, whenever psychologists begin to apply research methodologies to new domains within medicine, there is a tendency to focus exclusively on assessing the psychological adjustment of patients. This tendency has been witnessed within many medical disorders (e.g., diabetes, cancer, heart disease) and perhaps reflects the perceived need to demonstrate or justify the role of psychology in medicine. While there is a need to continue evaluating the psychological adaptation of transplant recipients and to refine our evaluative techniques in this area, it also is necessary for researchers to thrust forward with investigations bearing equal clinical importance and utility. For instance, despite the numerous compliance demands associated with transplantation (e.g., life-long immunosuppression medications for heart, liver, and kidney recipients; multiple administrations of oral antibiotics and daily use of antibacterial mouth cleansers for BMT recipients) and the vast literature on compliance in other areas of health psychology, there are few studies addressing this important dimension of health care as it relates to transplantation.

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Third, while psychologists, social workers, and other allied health professionals continue to offer and provide clinical services to transplant recipients and their families, there are no published studies documenting the efficacy of these assessment procedures or interventions. For instance, while psychosocial screening of transplant candidates is routinely conducted at transplant centers and often play into the decision-making process, there is little empirical data regarding how well psychosocial variables predict clinical outcome. Recent development of the Psychosocial Assessment of Candidates for Transplantation (PACT; Olbrisch, Levenson, & Hamer, 1989) and the Transplant Evaluation Rating Scale (TERS; Twillman, Manetto, Wellisch, & Wolcott, 1993) is promising and these instruments should prove useful in evaluating the relationship between pretransplant psychosocial variables and medical outcome. Moreover, additional research is needed to determine how health professionals can distinguish psychological symptoms which are a consequence of the distress associated with transplantation from premorbid psychological status, medication side-effects, and neurotoxicity associated with the underlying disease process. Regarding clinical interventions, what are the benefits of individual therapy, family therapy, relaxation and imagery training, and support groups in altering survival and complication rates? What changes can be observed in patients and families following the implementation of these techniques, and how favorably do these services compare with each other? Fourth, a foremost research need is to introduce appropriate comparison groups when assessing the adaptation of transplant recipients. It is difficult to assess the effects of transplantation on adjustment unless we simultaneously measure the adjustment of individuals with similar disease parameters (i.e., disease type, length, severity) who are undergoing other forms of medical intervention. For instance, studies comparing the adaptation of adults with chronic myelogenous leukemia who select transplantation and those who opt for traditional chemotherapy regimens would be appropriate. Fifth, for children undergoing transplantation, more consideration must be given to how developmental variables interact with or contribute to successful adaptation. For instance, the relationships among age, gender, and degree of cognitive impairment have yet to be fully and systematically examined. Finally, the small number of children and adults receiving organ transplants at most centers makes it very difficult for the individual researcher to accrue ample sample sizes for sophisticated data analyses. Illnesses for which individuals require transplants are often rare and expensive, which may partly account for the lack of funding in this area relative to others. The prospective, longitudinal studies advocated above may take several


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years to complete and may deter researchers from pursuing this line of investigation. It is our impression that the advancement of knowledge regarding the psychological concomitants of transplantation will occur more rapidly once more collaborative, multisite research efforts are initiated.

ACKNOWLEDGMENTS This work was supported, in part, by funding to the first author from the American Cancer Society (No. 89-092A) and the University of Florida Division of Sponsored Research. The authors thank three anonymous reviewers for their helpful comments.

REFERENCES Abram, H. S., & Buchanan, D. C. (1977). The gift of life: A review of the psychological aspects of kidney transplantation, h~ternational Journal of Psychiatry in Medicine, 7, 153-164. Abram, H. S., Hester, L. R., Sheridan, W. F., & Epstein, G. M. (1975). Sexual functioning in patients with chronic renal failure. Journal of Nervous and Mental Disease, 160, 220-226. Addonizio, L. J., & Rose, E. A. (1987). Cardiac transplantation in children and adolescents. Journal of Pediatrics, 111, 1034-1038. A-Kader, H. H., Ryckman, F. C., & Balistreri, W. F. (1991). Liver transplantation in the pediatric population: Indications and monitoring. Clinical Transplantation, 5, 161-167. Andrews, W. S., Pau, C. M. L., & Chase, H. O. (1981). Fat soluble vitamin deficiency in biliary atresia. Journal of Pediatric Surgery, 16, 284-288. Andrykowski, M. A., & Henslee, P. J. (1989). Quality of life in adult survivors of allogeneic bone marrow transplantation. European Journal of Cancer and Clinical Oncology, 25, 1004 (abstract). Andrykowski, M. A., Henslee, P. J., & Barnett, R. L. (1989a). Longitudinal assessment of psychosocial functioning of adult survivors of aUogeneic bone marrow transplantation. Bone Marrow Transplantation, 4, 505-509. Andrykowski, M. A., Henslee, P. J., & Farrall, M. G. (1989b). Physical and psychosocial functioning of adult survivors of allogeneic bone marrow transplantation. Bone Marrow Transplantation, 4, 75-81. Andrykowski, M. A., Altmaier, E. M., Barnett, R. L., Burish, T. G., Gingrich, R., & Henslee-Downey, P. J. (1990). Cognitive dysfunction in adult survivors of allogeneic marrow transplantation: Relationship to dose of total body irradiation. Bone Marrow Transplantation, 6, 269-276. Aravot, D. J., Banner, N. R., Khaghani, A., Fitzgerald, M., Radley-Smith, R., Mitchell, A. G., & Yacoub, M. H. (1989). Cardiac transplantation in the seventh decade of life. American Journal of Cardiology, 63, 90-93. Bailey, L. L., Wood, M., Razzouk, A., van Arsdell, G., & Gundry, S. (1989). Heart transplantation during the first 12 years of life. Archives of Surgery, 124, 1221-1226. Baum, M. F., Cutler, D. C., Fricker, F. J., & Trimm, R. F. (1991). Physiologic and psychological growth and development in pediatric heart transplant recipients. Journal of Heart and Lung Transplantation, 10, 848-855. Baumgartner, W. A., Augustine, S., Borkon, A., Gardner, T. J., & Reitz, B. A. (1987). Present expectations in cardiac transplantation. Annals of Thoracic Surgery, 43, 585-590.

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Beatty, P. G., Hansen, J. A., Anasetti, C., Sanders, J., Buckner, C. D., Storb, R., & Thomas, E. D. (1989). Marrow transplantation from unrelated HLA-matched volunteer donors. Transplantation Proceedings, 21, 2993-2994. Beck, A. L., Nethercut, G. E., Crittenden, M. R., & Hesins, J. (1986). Visibility of handicap, self-concept, and social maturity among young adult survivors of end-stage renal disease. Developmental and Behavioral Pediatrics, 7, 93-96. Beidel, D. C. (1987). Psychological factors in organ transplantation. Clinical Psychology Review, 7, 677-694. Binik, Y. M , & Devins, G. M. (1986). Transplant failure does not compromise quality of life in end-stage renal disease. International Journal of Psychiatry in Medicine, 16, 1986-I987. Bortin, M. M., & Rimm, A. A. (1989). Increasing utilization of bone marrow transplantation. Transplantation, 48, 453-458. Bouckek, M. M., Kanakriyeh, M. S., Mathis, C. M., Triman, R. F., & Bailey, L. L. (1990). Cardiac transplantation in infancy: Donors and recipients. Journal of Pediatrics, 116, 171-176. Bradlyn, A. S., & Boggs, S. R. (1989). Bone marrow transplantation in children: A case study. In M. C. Roberts & C. E. Walker (Eds.), Casebook of child and pediatric psychology (pp. 346-359). New York: Guilford. Brennan, A. F., Davis, M. H., Buchholz, D. J., Kuhn, W. F., & Gray, L. A. (1987). Predictors of quality of life following cardiac transplantation. Psychosomatics, 28, 566-571. Brouwers. P., Riccardi, R., Fedio, P., & Poplack, D. G. (1985). Long-term neuropsychologic sequelae of childhood leukemia: Correlation with CT brain scan abnormalities. Journal of Pediatrics, 106, 723-728. Brown, H. N., & Kelly, M. J. (1976). Stages of bone marrow transplantation: A psychiatric perspective. Psychosomatic Medicine, 38, 439-446. Broyer, M. (1989). Kidney transplantation in children: Data from the EDTA Registry. Transplantation Proceedings, 21, 1985-1988. Burgess, D. B., Martin, H. P., & Lilly, J. R. (1982). The developmental status of children undergoing the Kasai procedure for biliary atresia. Pediatrics, 70, 624-629. Burnett, A. K. (1989). International experience of autologous bone marrow transplantation in acute myeloid leukaemia. In R. P. Gale & R. E. Champlin (Eds.), Bone marrow transplantation: Current controversies. New York: Alan R. Liss. Buse, S. M., & Pieper, B. (1990). Impact of cardiac transplantation on the spouse's life. Heart and Lung, 19, 641-648. Caine, N., Sharpies, L. D., English, T. A. H., & Wallwork, J. (1990). Prospective study comparing quality of life before and after heart transplantation. Transplantation Proceedings, 22, 1437-1439. Cerilli, G. J. (1988). Highlights of recent progress in transplantation. In G. J. Cerilli (Ed.), Organ transplantation and replacement (pp. 16-33). Philadelphia, PA: J. B. Lippincott Company. Chambers, M. (1982). Psychological aspects of renal transplantation, hzternationat Journal of Psychiatry b~ Medicine, 12, 229-236. Colonna, J. O., Brems, J. J., Hiatt, J. R., Millis, J. M., Ament, M. E., Baldrich-Quinones, W. J., Berquist, W. E., Besbris, D., Brill, J. E., Goldstein, L. I., Nuesse, B. J., Ramming, K. P., Saleh, S., Vargas, J. H., & Busuttil, R. W. (1988). The quality of survival after liver transplantation. Transplantation Proceedings, 20, 594-597. Dobbing, J, (1975). Human brain development and its vulnerability. In J. C. Sinclair, J. B. Warshaw, & R. S. Bloom (Eds.), Biologic and clinical aspects of brain development (pp. 3-12). Evansville, IL: Mead Johnson & Co. Eid, A., Steffen, R., Sterioff, S., Porayko, M. K., Gross. J. B., Wiesner, R. H., & Krom, R. A. F. (1989). Long-term outcome after liver transplantation. Transplantation Proceedings, 21, 2409-2410. Esquivel, C. O., Koneru, B., Karrer, F., Todo, S., Iwatsuki, S., Gordon, R. D., Makowka, L., Marsh, W. J., & Starzl, T. E. (1987). Liver transplantation before I year of age. Journal of Pediatrics, 110, 545-548.


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Evans, R. W., Manninen, D. L., Garrison, L. P., Hart, L. G., Blagg, C. R., Gutman, R. A., Hull, A. R., & Lowrie, E. G. (1985). The quality of life of patients with end-stage renal disease. New England Journal of Medicine, 312, 553-559. Farmer, C. J., Snowden, S. A., & Parsons, V. (1979). The prevalence of psychiatric illness among patients on home haemodialysis. Psychological Medicine, 2, 509-514. Fennell, E. B., Fennell, R. S., Mings, E., & Morris, M. K. (1986). The effects of various modes of therapy for end stage renal disease on cognitive performance in a pediatric population: A preliminary report. International Journal of Pediatric Nephrology, 7, 107-112. Fennell, R. S., Rasbury, W. C., Fennell, E. B., & Morris, M. K. (1984). The effects of kidney transplantation on cognitive performance in a pediatric population. Pediatrics, 74, 273-278. Fielding, D., Moore, B., Dewey, M., Ashley, P., McKendrick, T., & Pinkerton, P. (1985). Children with end-stage renal failure: Psychological effects on patients, siblings and parents. Journal of Psychosomatic Research, 29, 457-465. First, M. R., & Schroeder, T. J. (1991). Solid-organ transplantation in the pediatric population. Clinical Transplantation, 5, 132-136. Fletcher, J. M., & Copeland, D. R. (1988). Neurobehavioral effects of central nervous system prophylactic treatment of cancer in children. Journal of Clinical and Experimental Neuropsychology, 10, 495-537. Foley, T. C., Davis, C. P., & Conway, P. A. (1989). Liver transplant recipients: Self-report of symptom frequency, symptom distress, quality of life. Transplantation Proceedings, 21, 2417-2418. Foulkes, L., Boggs, S. R., Fennell, R. S., & Skibinski, K. (1993). Social support, family variables, and compliance in renal transplant children. Pediatric Nephrology, 7, 185-188. Foulks, C. J., & Cushner, H. M. (1986). Sexual dysfunction in the male dialysis patient: Pathogenesis, evaluation, and therapy. American Journal of Kidney Diseases, 8, 211222. Freund, B. L., & Siegel, K. (1986). Problems in transition following bone marrow transplantation: psychosociaI aspects. American Journal of Orthopsychiatry, 56, 244252. Frierson, R. L., & Lippman, S. B. (1987). Heart transplant candidates rejected on psychiatric indications. Psychosomatics, 28, 347-355 Futterman, L. G, (1988). Cardiac transplantation: A comprehensive nursing perspective, Part 1. Heart and Lung, 17, 499-509. Gardner, G. G., August, C. S., & Githens, J. (1977). Psychological issues in bone marrow transplantation, Pediatrics, 60 (Suppl.), 625-631. Gartner, J. C., Zitelli, B, J., Malatack, J. J., Shaw, B. W., Iwatsuki, S., & Starzl, T. E. (1984). Orthotopic liver transplantation in children: Two-year experience with 47 patients. Pediatrics, 74, 140-145. Gerralda, M, E., Jameson, R. A., Reynolds, J. M., & Postlethwaite, R. J. (1988). Psychiatric adjustment in children with chronic renal failure. Journal of Child Psychology and Psychiatry, 29, 79-90. Glass, C. A., Fielding, D. M., Evans, C., & Ashcroft, J. B. (1987). Factors related to sexual functioning in male patients undergoing hemodialysis and with kidney transplants. Archives of Sexual Behavior, 16, 189-207. Goldberg, I. D., Bloomer, W. D., & Dawson, D. M. (1982). Nervous system toxic effects of cancer therapy. Journal of the American Medical Association, 247, 1437-1441. Goldman, J. M., et aL (1988). Bone marrow transplantation for chronic myelogenous leukaemia in chronic phase. Annals of Internal Medichze, 108, 806-814. Gordon, R. D., & Starzl, T. E. (1988). Changing perspectives on liver transplantation in 1988. Clinical Transplants, 5-27. Gratwohl, A., et al. (1988). Allogeneic bone marrow transplantation for leukaemia in Europe. Lancet, 1, 1379-1382. Gulledge, A. D., Buszta, C., & Montague, D. K. (1983). Psychosocial aspects of renal transplantation. Urologic Clinics of North America, 10, 32%335.

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Haberman, M. R. (1988). Psychosocial aspects of bone marrow transplantation. Seminars in Oncology Nursing, 4, 55-59. Heck, C. F., Shumway, S. J., & Fayue, M. P. (1989). The Registry of the Internal Society for Heart Transplantation: Sixth Official Report 2989. Journal of Heart Transplantation, 8, 271-276. Hecker, J. E., Norvell, N., & Hills, H. (1989). Psychologic assessment of candidates for heart transplantation: Toward a normative data base. Journal of Heart Transplantation, 8, 17t-176. Hengeveld, M. W., Houtman, R. B., & Zwaan, F. E. (1988). Psychological aspects of bone marrow transplantation: A retrospective study of 17 long-term survivors. Bone Marrow Transplantation, 3, 69-75. Herrick, C. M., Mealey, P. C., Tischner, L. L., & Holland, C. S. (1987). Combined heart failure transplant program: Advantages in assessing medical compliance. Journal of Heart Transplantation, 6, 141-146. Hobbs, S., & Sexson, S. (1993). Cognitive development and learning in the pediatric organ transplant recipient. Journal of Learnhzg Disabilit&s, 26, 104-113. House, R., Dubovsky, S. L., & Penn, I. (1983). Psychiatric aspects of hepatic transplantation. Transplantation, 36, 146-150. Ingelfinger, J., et aL (1981). Growth acceleration following renal transplantation in children less than 7 years of age. Pediatrics, 68, 255-259. Jenkins, P. L., Linington, A., & Whittaker, J. A. (1991). A retrospective study of psychosocial morbidity in bone marrow transplant recipients. Psychosomatics, 32, 65-71. Johnson, B. E., et aL (1985). Neurologic, neuropsychologic, and computed cranial tomography scan abnormalities in 2- to 10-year survivors of small-cell lung cancer. Journal of Clinical Oncology, 4, 1659-1667. Johnson, J. P., McCauley, C. R., & Copley, J. B. (1982). The quality of life of hemodialysis and transplant patients. Kidney International, 22, 286-291. Kahn, J. P., Drusin, R. E., & Klein, D. F. (1987). Idiopathic cardiomyopathy and panic disorder: Clinical association in cardiac transplant candidates. American Journal of Psychiatry, 144, 1327-1330. Kalman, T. P., Wilson, P. G., & Kalman, C. M. (1983). Psychiatric morbidity in long-term renal transplant recipients and patients undergoing hemodialysis. Journal of the American Medical Association, 250, 55-58. Kamil, E. S., Yadin, O., Ettenger, R. B., Boechat, M. I., Pyke-Grimm, K., Nelson, P. A., Lippe, B. M., & Fine, R. N. (1991). Growth after renal transplantation: A potential role for growth hormone therapy. Clinical Transplantation, 5, 208-213. Kay, J., & Bienenfeld, D. (1991). The clinical assessment of the cardiac transplant candidate. Psychosomatics, 32, 78-87. Kaye, M. (1987). The Registry of the International Society for Heart Transplantation: Fourth Official Report - - 1987. Journal of Heart Transplantation, 6, 63-67. Keegan, D. L., Shipley, C., Dineen, T., & Steiger, M. (1983). Adjustment to renal transplantation. Psychosomatics, 24, 825-831. Kellerman, J., Rigler, D., Siegel, S. E., McCue, K., Pospisil, J., & Uno, R. (1976). Psychological evaluation and management of pediatric oncology patients in protected environments. Medical and Pediatric Oncology, 2, 353-360. Kellerman, J., Rigler, D., & Siegel, S. E. (1979). Psychological response of children to isolation in a protected environment. Journal of Behavioral Medicine, 2, 263-274. Kilner, J. F. (1990). Who lives? Who dies? Ethical criteria in patient selection. New Haven, CT: Yale University Press. Klein, K. L., Anderson, S., Ferguson, J., Rogers, K., & Cintron, G. (1989). Cardiac transplantation: University of South Florida-Tampa General Hospital Experience. Journal of the Florida Medical Association, 76, 311-315. Kuhn, W. F., Davis, M. H., & Lippmann, S. B. (1988a). Emotional adjustment to cardiac transplantation. General Hospital Psychiatry, 10, 108-113. Kuhn, W. F., Myers, B., Brennan, A. F., Davis, M. H., Lippmann, S. B., Gray, L. A., & Pool, G. E. (1988b). Psychopathology in heart transplant candidates. Journal of Heart Transplantation, 7, 223-236.


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Lane, R. J. M., Roche, S. W., Leung, A. A. W., Greco, A., & Lange, L. S. (1988). Cyclosporin neurotoxicity in cardiac transplant recipients. Journal of Neurology, Neurosurgery, and Psychiatry, 51, 1434-1437. Lawrence, K. S., & Fricker, F. J. (1987). Pediatric heart transplantation: Quality of life. Journal of Heart Transplantation, 6, 329-333. Levenson, J. L., & Glocheski, S. (1991). Psychological factors affecting end-stage renal disease: A review. Psychosomatics, 382-389. Levenson, J. L., & Olbrisch, M. E. (1993). Psychiatric aspects of heart transplantation. Psychosomatics, 34, 114-123. Levy, N. B. (1986). Renal transplantation and the new medical era. Advances in Psychosomatic Medicble, 15, 167-179. Livesley, W. J. (1979). Psychiatric disturbance and chronic hemodialysis. British Medical Journal 22, 306. Mai, F. M., McKenzie, F. N., & Kostuk, W. J. (1986). Psychiatric aspects of heart transplantation: Preoperative evaluation and postoperative sequelae. British Medical Journal, 292, 311-313. Malatack, J. J., Gartner, J. C., Zitelli, B. J., & Urbach, A. H. (1988). The who, when, and how of liver transplants. Contemporary Pediatrics, 5, 152-166. Markus, B. H. (1989). Efficacy of liver transplantation in patients with primary cirrhosis. New England Journal of Medichle, 320, 1709-1713. Martin, A. B., Bricker, J. T., Fishman, M., Frazicr, O. H., Price, J. K., Radovancevic, B., Louis, P. T., Cabalka, A. K., Gelb, B. D., & Towbin, J. A. (1992). Neurologic complications of heart transplantation in children. Journal of Heart and Lung Transplantation, 11, 933-942. Meadows, A. T., & Evans, A. E. (1976). Effects of chemotherapy in the central nervous system: A study of parenteral methotrexate in long-term survivors of leukemia and lymphoma in childhood. Cancer, 37, 1079-1085. National Institutes of Health (1989). Bone marrow transplantation (NIH Publication No. 90-1178). Washington, D. C.: U.S. Government Printing Office. Nghiem, D. D., Corry, R. J., Picon-Mendez, G., & Lee, H. M. (1983). Factors influencing male sexual impotence after renal transplantation. Urology, 49-52. Nieminen, M. S. (1990). Evaluation and selection of the heart transplantation patient. Transplantation Proceedblgs, 22, 186-187. O'Brien, B. J., Buxton, M. J., & Ferguson, B. A. (1987). Measuring the effectiveness of heart transplant programmes: Quality of life data and their relationship to survival analysis. Journal of Chronic Diseases, 40, 137S-153S. Ohmori, Y., Aikawa, I., Yoshimura, N., Yasumura, T., & Oka, T. (1989). Long-term prognosis of kidney transplantation in children. Transplantation Proceedings, 21, 1992-1994. Olbrisch, M. E., Levenson, J. L., & Hamer, R. (1989). The PACT: A rating scale for the study of clinical decision-making in psychosocial screening or organ transplant candidates. Clinical Transplantation, 3, 164-169. Parth, P., Dunlap, W. P., Kennedy, R. S., Lane, N. E., & Ordy, J. M. (1989). Motor and cognitive testing of bone marrow transplant patients after chemoradiotherapy. Perceptual and Motor Skills, 68, 1227-1241. Patenaude, A. F., Szymanski, L., & Rappeport, J. (1979). Psychological costs of bone marrow transplantation in children. American Journal of Orthopsychiatry, 49, 409-422. Pennington, G., Sarafian, J., & Swartz, M. (1985). Heart transplantation in children. Heart Transplantation, 4, 441-445. Perkins, K. A. (1987). The shortage of cadaver donor organs for transplantation: Can psychology help? American Psychologist, 42, 921-930. Petrie, K. (1989). Psychological well-being and psychiatric disturbance in dialysis and renal transplant patients. British Journal of Medical Psychology, 62, 91-96. Pfefferbaum, B., Lindamood, M. M., & Wiley, F. M. (1977). Pediatric bone marrow transplantation: Psychosocial aspects. American Journal of Psychiatry, 134, 1299-1301. Phipps, S., & DeCuir-Whalley, S. (1990). Adherence issues in pediatric bone marrow transplantation. Journal of Pediatric Psychology, 15, 459-476.

68


Poznanski, E. O., Miller, E., Salguero, C., & Kelsh, R. C. (1978). Quality of life for long-term survivors of end-stage renal disease. Journal of the American Medical Association, 239, 2343-2347. Procci, W. R., Hoffman, K. I., & Chatterjee, S. N. (1978). Sexual functioning of renal transplant recipients. Journal of Nervous and Mental Disease, 166, 402-407. Rasbury, W. C., Fennell, R. S., & Morris, M. K. (1983). Cognitive functioning of children with end-stage renal disease before and after successful transplantation. Journal of Pediatrics, 102, 589-592. Rikkers, L., Jenko, P., Rudman, D., & Freides, D. (1978). Subclinical hepatic encephalopathy: Detection, prevalence, and relationship to nitrogen metabolism. Gastroenterology, 75, 462-469. Rodin, G., Voshart, K., Cattran, D., Halloran, P., Cardella, C., & Fenton, S. (1985). Cadaveric renal transplant failure: The short-term sequelae. International Journal of Psychiatry in Medicine, 15, 1985-1986. Rodrigue, J. R., Boggs, S. R., Wether, R. S., & Behen, J. (1993). Mood, coping style, and personality functioning among adult bone marrow transplant candidates. Psychosomatics, 34, 159-165. Rowland, J. H., et al. (1984). Effects of different forms of central nervous system prophylaxis on neuropsychologic function in childhood leukemia. Journal of Clinical Oncology, 2, 1327-1335. Rubin, A. M., & Kang, H. (I987). Cerebral blindness and encephalopathy with cyclosporin A toxicity. Neurology, 37, 1072-1076. Schlcbusch, L., Pillay, B. J., & Louw, J. (1989). Depression and self-report disclosure after live related donor and cadaver renal transplants. South African Medical Journal, 75, 490-493. Shanteau, J., & Harris, R. J. (1990). Organ donation and transplantation: Psychological and behavioral factors. Washington, D.C.: American Psychological Association. Shapiro, P. A., & Kornfcld, D. S. (1989). Psychiatric outcome of heart transplantation. General Hospital Psychiatry, 11, 352-357. Spolidoro, J. V. N., Berquist, W. E., Pehlivanoglu, E., Busuttil, R., Saluski, I., Vargas, J., & A m e n t , M. E. (1987). Growth acceleration in children after orthotopic liver transplantation. Journal of Pediatrics, 112, 41-44. Starzl, T. E., et aL (1987). Liver transplantation in older patients. New England Journal of Medicine, 316, 484-485. Starzl, T. E., Demetris, A. J., & Van Thiel, D. (1989). Liver transplantation (first of two parts). New England Journal of Medicb~e, 321, 1014-1021. Stewart, R. S. (1983). Psychiatric issues in renal dialysis and transplantation. Hospital and Community Psychiatry, 34, 623-628. Stewart, S. M., Uauy, R., Waller, D. A., Kennard, 13. D., & Andrews, W. S. (1987). Mental and motor development correlates in patients with end-stage biliary atrcsia awaiting liver transplantation. Pediatrics, 79, 882-888. Stewart, S. M., Uauy, R., Kennard, B. D., Waller, D. A., Benser, M., & Andrews, W. S. (1988). Mental development and growth in children with chronic liver disease of early and late onset. Pediatrics, 82, 167-172. Stewart, S. M., Uauy, R., Waller, D. A., Kennard, B. D., Benser, M., & Andrews, W. S. (1989). Mental and motor development, social competence, and growth one year after successful pediatric liver transplantation. Journal of Pediatrics, 114, 574-581. Stewart, S. M., Silver, C. H., Nici, J., Waller, D., Campbell, R., Uauy, R., & Andrews, W. S. (1991). Neuropsychological function in young children who have undergone liver transplantation. Journal of Pediatric Psychology, 16, 569-584. Stewart, S. M., Kcnnard, B. D., DeBolt, A., Petrik, K., Waller, D. A., & Andrews, W. S. (1993). Adaptation of siblings of children awaiting liver transplantation. Children's Health Care, 22, 205-215. Streltzer, J., Moe, M., Yanagida, E., & Siemsen, A. (1983). Coping with transplant failure: Grief vs. denial. International Journal of Psychiatry in Medicb~e, 13, 97-106.


69

Stuber, M. L., Nader, K., Yasuda, P., Pynoos, R. S., & Cohen, S. (1991). Stress responses after pediatric bone marrow transplantation: Preliminary results of a prospective longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 952-957. Sullivan, K. M. (1989). Congress review: Progress and prospects in bone marrow transplantation. Transplantation Proceedings, 21, 2919-2922. Sullivan, K. M., Witherspoon, R. P., Storb, R., Buckner, C. D., Sanders, J., & Thomas, E. D. (1989). Long-term results of allogeneic bone marrow transplantation. Transplantation Proceedings, 21, 2926-2928. Suszycki, L. H. (1988). Psychosocial aspects of heart transplantation. Social Work, May-June, 205 -209. Tarter, R. E,, et aL (1984). Liver transplantation: Long-term neuropsycbiatric status. Journal of Laboratory and Clinical Med&ine, 103, 776-782. Tarter, R. E., et aL (1987). Neurobehavioral characteristics of cholestatic and hepatocellular disease: Differentiation according to disease specific characteristics and severity of the identified cerebral dysfunction. International Journal of Neuroscience, 32, 901-910. Tarter, R. E., Erb, S., Biller, P. A., Switala, J., & Van Thiel, D. H. (1988). The quality of life following liver transplantation: A preliminary report. Gastroenterology Clinics of North America, 17, 20%217. Taylor, G. H., Albo, V. C., Phebus, C. K., Sachs, B. R., & Bierl, P. G. (1987). Post-irradiation treatment outcomes for children with acute lymphocytic leukemia: Clarification of risks. Journal of Pediatric Psychology, 12, 395-411. Tejani, A., & Ingulli, E. (1991). Growth in children post-transplantation and methods to optimize post-transplant growth. Clhzical Transplantation, 5, 214-218. Thomas, E. D., Cliff, R. A., Fefer, A., Appelbaum, F. R., Beatty, P., Bensinger, W. I., Buckner, C. D., Cheever, M. A., Deeg, H. J., Doney, K., Flournoy, N., Greenberg, P., Hansen, J. A., Martin, P., McGuffin, R., Ramberg, R., Sanders, J. E., Singer, J , Stewart, P., Storb, R., Sullivan, K., Weiden, P. L., & Witherspoon, R. (1986). Marrow transplantation for the treatment of chronic myelogenous leukemia. Annals of hzternat Medicine, 104, 155. Trzepacz, P. T., Maue, F. R., Coffman, G., & Van Thiel, D. H. (1986). Neuropsychiatric assessment of liver transplantation candidates: Delirium and other psychiatric disorders. International Journal of Psychiatry hi Medichze, 16, 101-111. Trzepacz, P. T., Brenner, R., & Van Thiel, D. H. (1989). A psychiatric study of 247 liver transplantation candidates. Psychosonzatics, 30, 147-153. Twillman, R. K., Manetto, C., Wellisch, D. K., & Wolcott, D. L. (1993). The Transplant Evaluation Rating Scale: A revision of the Psychosocial Levels System for evaluating organ transplant candidates. Psychosomatics, 34, 144-153. Urbach, A. H., et aL (1987). Linear growth following liver transplantation, American Journal of Diseases of Children, 141, 547-549. Uzark, K. C., Sauer, S. N., Lawrence, K. S., Miller, J., Addonizio, L., & Crowley, D. C. (1992). The psychosocial impact of pediatric heart transplantation. Journal of Heart and Lung Transplantation, 11, 1160-1167. Van Dop, C., Jabs, K. L., Donohoue, P. A., Bock, G. H., Fivush, B. A., & Harmon, W. E. (1992). Accelerated growth rates in children treated with growth hormone after renal transplantation. Journal of Pediatrics, 120, 244-250. Waber, D. P., Gioia, G., Paccia, J., Sherman, B., Dinklage, D , Sollee, N., Urion, D. K., Tarbell, N. J., & Sallan, S. E. (1990). Sex differences in cognitive processing in children treated with CNS prophylaxis for acute tymphoblastic leukemia. Journal of Pediatric Psychology, 15, 105-122. Weinman, J. (1990). Health psychology: Progress, perspective and prospects. In P. Bennett, J. Weinman, & P. Spurgeon (Eds.), Current developments hz health psychology (pp. 9-34). New York: Harwood Academic Publishers. Weiss, H. D., Walker, M. D., & Wernik, P. H. (1974). Neurotoxicity of commonly used antineoplastic agents. New England Journal of Medichre, 291, 127-133.

70


Whitington, P. F., Emond, J. C., Black, D. D., Whitington, S. H., Boone, P., Smith, C., Thistlethwaite, J. R., & Broelsch, C. E. (1991). Indications for liver transplantation in pediatric patients. Clinical Transplantation, 5, 155-160. Williams, J. H., & Davis, K. S. (1986). Central nervous system prophylactic treatment for childhood leukemia neuropsychological outcome studies. Cancer Treatment Reviews, 13, 113-127. Willner, A., & Rodewald, G. (Eds.). (1991). The impact of cardiac surgery on the quality of life: Neurological and psychological aspects. New York: Plenum. Wolcott, D., Norquist, G., & Busuttil, R. (1989). Cognitive function and quality of life in adult liver transplant recipients. Transplantation Proceedings, 21, 3563. Wolcott, D. L., Wellisch, D. K., Fawzy, F. I., & Landsverk, J. (1986). Adaptation of adult bone marrow transplant recipient long-term survivors. Transplantation, 41, 478-484. Wright, S. J. (1990). Health status measurement: Review and prospects. In P. Bennett, J. Weinman, & P. Spurgeon (Eds.), Current developments in health psychology (pp. 93-104). New York: Harwood Academic Publishers. Zitelli, B. J., Gartner, J. C., Malatack, J. J., Urbach, A. H., Miller, J. W., Williams, L., Kirkpatrick, B., Breinig, M. K., & Ho, M. (1987). Pediatric liver transplantation: Patient evaluation and selection, infectious complications, and life-style after transplantation. Transplantation Proceedings, 19, 3309-3316. Zitelli, B. J., Miller, J. W., Gartner, J. C., Malatack, J. J., Urbach, A. H., Belle, S. H., Williams, L., Kirkpatrick, B., & Starzl, T. E. (I988). Changes in life-style after liver transplantation. Pediatrics, 82, 173-180.

Current status of organ transplantation.

Current Status of Research on Osteoporosis after Solid Organ Transplantation: Pathogenesis and Management.

Organ Transplantation in HIV Patients: Current Status and New Directions.

Current problems in organ transplantation.

Introduction to the special issue on "psychological research and practice in organ transplantation".

Current Antioxidant Treatments in Organ Transplantation.

Current status of liver transplantation.

Current status of renal transplantation.

Clinical research in pediatric organ transplantation.

Psychological guidelines in the management of paediatric organ transplantation.

Current status of pediatric transplantation in Japan.

Current status of heart transplantation in Taiwan.

Laryngeal transplantation: current status 1974.

Robotic renal transplantation: Current status.

Current status of biomarker research in neurology.

Current research on organ donor management.

[Heart transplantation in France: Current status].

Current status of encapsulated islet transplantation.

Psychological therapies for auditory hallucinations (voices): current status and key directions for future research.

Current status of intestinal and multivisceral transplantation.

Transplantation of the parathyroid glands: current status.

Current status of allogeneic bone marrow transplantation.

Classic and current opinion in embryonic organ transplantation.

Transplantation genetics: current status and prospects.