A survey of psychosocial adaptation in long-term survivors of pediatric liver transplants

Family Function in Pediatric Liver Transplant Recipients Residing In a Developing Country

BACKGROUND

Pediatric liver transplantation (LT) can affect recipients' family function; however, inconsistent results between studies exist, and data from developing nations are sparse. We aimed to evaluate family function and identify factors associated with suboptimal function in pediatric LT recipients.

METHODS

A cross-sectional study was performed at a teaching hospital in Bangkok, Thailand between May 2018 and December 2018. We included the families of children aged 2 to 18 years who underwent LT for at least 1 year. Chulalongkorn Family Inventory (CFI) was used to evaluate the family function in these children comparing with families of healthy children. Family function was interpreted from the total CFI score and characterized as dysfunctional, normal-functioned, and well-functioned.

RESULTS

We enrolled families of 82 LT recipients and 72 healthy children. LT recipients had median age of 7.4 (interquartile range: 4.5-10.3) years. Eighteen children (22%) had a single parent, and at least one unemployed parent was reported in 25%. Most (96%) had well-functioned families, and none had a dysfunctional family. Furthermore, the total score was not significantly different between families of LT and healthy children (P = .95). LT families had a higher score in problem-solving (P < .01) and lower score in the affective involvement and general functioning dimension (P < .01 and .02, respectively). Among the LT children, postoperative bile leakage was associated with lower overall family function score.

CONCLUSIONS

Even though most recipients had good family function, physicians should pay close attention to specific aspects of family function, especially in children with certain postoperative complications.

Adherence to medical regimen after pediatric liver transplantation: a systematic review and meta-analysis

PURPOSE

Adherence to the medical regimen after pediatric liver transplantation is crucial for good clinical outcomes. However, the existing literature provides inconsistent evidence regarding the prevalence of and risk factors for nonadherence to the medical regimen after pediatric liver transplantation. This study aimed to investigate such nonadherence after pediatric liver transplantation and risk factors associated with this nonadherence using findings of reported studies.

METHODS

The electronic databases of Excerpta Medica, Ovid Technologies, PubMed and WanFang Data were searched using the keywords "adherence", "liver transplant" and "paediatric". Additionally, relevant references cited in related studies were used to obtain original articles. Using 22 original articles, data regarding nonadherence to the medical regimen after pediatric liver transplantation were quantitatively combined, and risk factors associated with nonadherence were qualitatively identified. Average rates of nonadherence in four areas of medical regimens were calculated. The heterogeneity of the included original articles was also analyzed. When I ²>50 and P<0.05, a random effects model was used; otherwise, a fixed effects model was used. Moreover, Egger's and Begg's tests were used to evaluate publication bias, if any, and original articles with P>0.05 were considered to have no publication bias.

RESULTS

The clinical attendance nonadherence rate was 45% (95% confidence interval [CI]: 39-51), global nonadherence rate was 17% (95% CI: 13-21) and immunosuppression non-adherence rates were 39% (95% CI: 26-52) and 34% (95% CI: 30-39) for cyclosporine and tacrolimus, respectively. Risk factors included older age of the pediatric patient, low family cohesion, poor social functioning, poor mental health and single-parent family.

CONCLUSIONS

The nonadherence rate in pediatric liver transplantation is high. Therefore, intervention on the basis of risk factors, such as mental health and family function, may be necessary. Moreover, a standard technique for assessing nonadherence to the medical regimen after pediatric liver transplantation, comprising as many dimensions as possible, is required in order to be more objective and comprehensive when assessing nonadherence.

Psychosocial functioning in pediatric heart transplant recipients and their families

Across pediatric organ transplant populations, patient and family psychosocial functioning is associated with important health-related outcomes. Research has suggested that pediatric heart transplant recipients and their families are at increased risk for adverse psychosocial outcomes; however, recent investigation of psychosocial functioning in this population is lacking. This study aimed to provide a contemporary characterization of psychosocial functioning in pediatric heart transplant recipients and their families. Associations between psychosocial function, demographic variables, and transplant-related variables were investigated. Fifty-six parents/guardians of pediatric heart transplant recipients completed a comprehensive psychosocial screening measure during transplant follow-up clinic visits. Descriptive statistics, correlational analyses, and independent samples t tests were performed. Forty percent of pediatric heart transplant recipients and their families endorsed clinically meaningful levels of total psychosocial risk. One-third of patients presented with clinically significant psychological problems per parent report. Psychosocial risk was unassociated with demographic or transplant-related factors. Despite notable improvements in the survival of pediatric heart transplant recipients over the past decade, patients and families present with sustained psychosocial risks well beyond the immediate post-transplant period, necessitating mental health intervention to mitigate adverse impact on health-related outcomes.

A systematic review of parent and family functioning in pediatric solid organ transplant populations

The process of pediatric solid organ transplantation (SOT) places new and increased stressors on patients and family members. Measures of family functioning may predict psychological and health outcomes for pediatric patients and their families, and provide opportunity for targeted intervention. This systematic review investigated parent and family functioning and factors associated with poorer functioning in the pediatric SOT population. Thirty-seven studies were identified and reviewed. Studies featured a range of organ populations (eg, heart, liver, kidney, lung, intestine) at various stages in the transplant process. Findings highlighted that parents of pediatric SOT populations commonly report increased stress and mental health symptoms, including posttraumatic stress disorder. Pediatric SOT is also associated with increased family stress and burden throughout the transplant process. Measures of parent and family functioning were associated with several important health-related factors, such as medication adherence, readiness for discharge, and number of hospitalizations. Overall, findings suggest that family stress and burden persists post-transplant, and parent and family functioning is associated with health-related factors in SOT, highlighting family-level functioning as an important target for future intervention.

Systematic Review of Screening Instruments for Psychosocial Problems in Children and Adolescents With Long-Term Physical Conditions

Children and adolescents with long-term physical conditions (LTPCs) are at greater risk of developing psychosocial problems. Screening for such problems may be undertaken using validated psychometric instruments to facilitate early intervention. A systematic review was undertaken to identify clinically utilized and psychometrically validated instruments for identifying depression, anxiety, behavior problems, substance use problems, family problems, and multiple problems in children and adolescents with LTPCs. Comprehensive searches of articles published in English between 1994 and 2014 were completed via Medline, Embase, PsycINFO, CINAHL, and Cochrane CENTRAL databases, and by examining reference lists of identified articles and previous related reviews. Forty-four potential screening instruments were identified, described, and evaluated against predetermined clinical and psychometric criteria. Despite limitations in the evidence regarding their clinical and psychometric validity in this population, a handful of instruments, available at varying cost, in multiple languages and formats, were identified to support targeted, but not universal, screening for psychosocial problems in children and adolescents with LTPCs.

Parents' quality of life and family functioning in pediatric organ transplantation

Solid organ transplantation is an important treatment option for pediatric patients in end-stage organ failure. The impact of pediatric organ transplantation on parents' quality of life and family functioning has been found to be substantial, but findings on this topic have not previously been consolidated. Thirty-one studies were selected for analysis after a database search on this topic. We present future research questions and suggestions to improve clinical practice based on the integration of this knowledge.

Post-transplant adjustment--the later years

As survival rates for pediatric solid organ transplantation have continued to improve, researchers and healthcare providers have increasingly focused on understanding and enhancing the HRQOL and psychosocial functioning of their patients. This manuscript reviews the psychosocial functioning of pediatric transplant recipients during the "later years," defined as more than three yr post-transplant, and focuses on the day-to-day impact of living with a transplant after the immediate period of adjustment and early years after surgery. Key topics reviewed include HRQOL, cognitive functioning, impact on the family, regimen adherence, and transition of responsibility for self-management tasks. Overall, pediatric transplant recipients evidence impairment in HRQOL, neuropsychological outcomes, and family functioning as compared to non-transplant recipients. However, the degree of impairment is influenced by a variety of factors including, disease severity, age, solid organ type, and study methodologies. Studies are limited by small samples, cross-sectional design, and the lack of universal assessment battery to allow for comparisons across solid organ populations. Areas for future research are discussed.

Meta-analysis of medical regimen adherence outcomes in pediatric solid organ transplantation

BACKGROUND

Adherence to the medical regimen after pediatric organ transplantation is important for maximizing good clinical outcomes. However, the literature provides inconsistent evidence regarding prevalence and risk factors for nonadherence posttransplant.

METHODS

A total of 61 studies (30 kidney, 18 liver, 8 heart, 2 lung/heart-lung, and 3 with mixed recipient samples) were included in a meta-analysis. Average rates of nonadherence to six areas of the regimen, and correlations of potential risk factors with nonadherence, were calculated.

RESULTS

Across all types of transplantation, nonadherence to clinic appointments and tests was most prevalent, at 12.9 cases per 100 patients per year (PPY). The immunosuppression nonadherence rate was six cases per 100 PPY. Nonadherence to substance use restrictions, diet, exercise, and other healthcare requirements ranged from 0.6 to 8 cases per 100 PPY. Only the rate of nonadherence to clinic appointments and tests varied by transplant type: heart recipients had the lowest rate (4.6 cases per 100 PPY vs. 12.7-18.8 cases per 100 PPY in other recipients). Older age of the child, family functioning (greater parental distress and lower family cohesion), and the child's psychological status (poorer behavioral functioning and greater distress) were among the psychosocial characteristics significantly correlated with poorer adherence. These correlations were small to modest in size (r=0.12-0.18).

CONCLUSIONS

These nonadherence rates provide benchmarks for clinicians to use to estimate patient risk. The identified psychosocial correlates of nonadherence are potential targets for intervention. Future studies should focus on improving the prediction of nonadherence risk and on testing interventions to reduce risk.

Study of the factors affecting health-related quality of life in adolescents after liver transplantation

The aim of the study was to identify factors affecting health-related quality of life (HRQL) in adolescents after liver transplantation. HRQL was measured using the CHQ-CF87 in 55 adolescents, aged 12-18 years. Factors associated with HRQL included allograft morbidity, psychological and family-related variables measured through standardized questionnaires. The domains of the CHQ-CF87 were reduced using factor analysis to give physical, psychological and social domains. Impacting factors were identified through stepwise, multiple regression analysis. Adolescents had significantly lower HRQL in every domain except for role/social-behavior and family cohesion compared to the general population. Adolescents experienced median 18 (range 4-31) symptoms related to immunosuppression, 40(75%) had one or more chronic illnesses related to immunosuppression and 12(22%) had a history of emotional difficulties. Self-esteem and emotional health were similar to the general population but behavior and aspects of family function were lower. Following regression analysis, the factors associated with HRQL were: age at transplant, secondary chronic illness, symptom distress, headaches, history of emotional difficulties, self-esteem and family conflict. These explained 57% of the variance in physical function, 61% of psychological function and 39% of social function. HRQL is significantly reduced in adolescents after transplantation, which could be related to immunosuppression and psychosocial factors.

The influence of clinical variables on the psychological adaptation of adolescents after solid organ transplantation

This study assessed the influence of clinical and socio-demographic variables on the psychological adaptation of transplanted adolescents. Twenty-six transplanted adolescents and 25 healthy adolescents, aged 13-17, and their parents participated in the study. The following domains were measured: social competence, emotional/behavioral problems, self-concept, self-esteem and subjective well-being. The findings revealed that transplanted boys presented significantly less social competence (U = 26,000, p < .05) and more externalizing problems (U = 25,000, p < .05), social problems (U = 25,000, p < .05) and attention problems (U = 17,500, p < .01) than healthy boys. In contrast, transplanted girls displayed significantly more internalizing problems (U = 47,000, p < .05) and lower physical self-concept (U = 49,500, p < .05) than healthy girls. Hierarchical regression analysis showed clinical variables, especially waiting-list time, significantly predicted attention problems (beta = .364, p < .05) and negative affect (beta = .632, p < .05) in transplanted adolescents. Also, male (beta = -0.554, p < .01) and younger (beta = -0.444, p < .01) transplanted adolescents were at risk for attention problems. Our data suggest the importance of the waiting-list time for transplanted adolescents. Efforts to reduce the pretransplant phase would help adolescents achieve better psychological adaptation at long-term posttransplant.

Psychosocial functioning of pediatric renal and liver transplant recipients

The current study examined child- and parent-reported child psychosocial functioning in a large sample of children who received solid organ transplantation. Participants included 64 children who received kidney or liver transplantation and 64 parents who completed a standardized measure of children's psychosocial functioning (BASC; Reynolds & Kamphaus, 1992). Although post-transplant children reported significantly fewer psychosocial difficulties than the normative average, parents reported that children had some psychosocial difficulties, particularly internalizing problems. There were no differences in psychosocial functioning between deceased donor organ and living donor organ recipients. Given the discrepancy between parent and child report, the results suggest that children may underreport psychosocial difficulties following transplantation or parents may over-report children's difficulties. Clinicians and researchers are encouraged to obtain assessment information from multiple reporters when assessing psychosocial functioning in this population.

Liver transplantation in children: part 2--long-term issues

This two-part review provides a comprehensive summary of clinical and research literature on paediatric liver transplantation. Part 2 focuses on the long-term physical consequences and psychological impact of transplantation and critically examines neurobehavioural, sexual development, psychosocial function and overall impact on children's quality of life. This review highlights the implications for clinical practice in specialist and local services and suggests areas where research is required to improve the lives of children after liver transplantation.

A critical review of the health-related quality of life of children and adolescents after liver transplantation

We critically examined research on health-related quality of life (HRQL) in children and adolescents after liver transplantation. The specific aims were to identify research studies on HRQL after liver transplantation, to critique the methodological quality of the studies, to estimate overall HRQL after transplant, and to make recommendations for future research. Databases searched included Medline, Cumulative Index to Nursing and the Allied Health Literature, PsycINFO, EMBASE, Allied and Complementary Medicine, Institute for Scientific Information Web of Science, and Applied Social Sciences Index and Abstracts. Searches also were made on related Web sites and proceedings of transplantation and associated conferences. Eligible studies involved children between birth and 18 years of age who received isolated orthotopic, auxiliary, or living related liver transplantation. HRQL was assessed through 2 or more of the domains of physical health, psychological functioning, social functioning, family functioning, or general well-being. Eligible studies were abstracted, assessed for methodological quality, and synthesized using the sign test to provide an indication of the effect of liver transplantation on each HRQL domain. The synthesis of findings suggested an improvement in HRQL in comparison with pretransplant status; there was a trend toward a worse HRQL in comparison with the healthy population and better than those with other chronic illnesses. In conclusion, liver transplantation in childhood has a negative impact on some aspects of HRQL. However, this finding is tentative because of the small number of studies and variable study quality found.

Pediatric transplantation of the kidney, liver and heart: summary report

The following is a summary report of an extensive review of the literature from 1966 to 2001 on growth and development in children receiving kidney, liver and heart transplants. The literature was assessed for relevancy to current clinical practice and for reliability and generalizability of the inferences based on the study design, controls, sample size, age distribution, confounding factors, use of standardized instruments, and consistency with other findings. While studies on growth are included in the review, the main emphasis is on research in cognitive and psychosocial development since these areas have been far less thoroughly studied and contain various methodological deficiencies. On the basis of the literature review both general methodological recommendations and specific recommendations for future research studies are made. Access to the full is provided on the World Wide Web at http://light.emmes.com/pedstransplantation/.

Current status of liver transplantation in children

There are two critical issues on opposite ends of the timeline for patients who are eligible for liver transplantation. On the one hand, the crisis in the cadaveric organ supply makes surviving to transplant ever more risky. On the other hand, patients who receive successful transplants face the consequences of long-term immunosuppression and its potentially life-threatening complications. The donor shortage is forcing difficult decisions that affect all patients who await liver transplantation. It is important to scrutinize carefully the results of all policies that govern allocation and the ethics of the solutions we advocate to ensure that no patient subgroup is being at a disadvantage. Current immunosuppression practices are being challenged by an increasing understanding of the immunologic events triggered by the allograft and the goal to free patients from consequences of a lifetime of immunosuppression. Clinicians can expect, and perhaps require, that new immunosuppressive protocols will address how the planned intervention might be expected to advance the understanding of tolerance mechanisms. As knowledge increases, clinicians can anticipate innovative new immunosuppressive proposals. Calcineurin and steroid-free induction, the use of donor-derived bone marrow infusion, recipient pretreatment, costimulatory blockade, and new antibody induction approaches are all being proposed--often in combination--for clinical trials. Researchers face additional challenges in defining endpoints if the goal is not just the short-term reduction in rejection but the minimization, and eventual discontinuation, of immunosuppressive drugs while maintaining excellent long-term graft function. How much "failure" will be accepted and how will it be defined? How will clinicians interpret liver biopsies if they begin to accept that some lymphocytic infiltrates may be beneficial mediators of the ongoing immune activation necessary for the maintenance of tolerance? How will they adjust immunosuppression practices to the dynamic processes in the immune response that maintain tolerance? Remarkable short-term successes in providing transplants for thousands of children with liver failure have brought these challenges into sharp focus. Clinicians must seek to move the life-giving science of transplantation toward a new goal: providing long lifetimes of excellent graft function with minimal toxicity from immunosuppressive drugs and the hope of freedom from immunosuppression altogether. Pediatric liver recipients, whose grafts have inherent tolerogenic potential and for whom we can anticipate decades of life after transplant, may prove to be an ideal study population to further these goals.

Symptoms of posttraumatic stress disorder in parents of transplant recipients: incidence, severity, and related factors

OBJECTIVE

To examine the incidence, severity, and factors related to posttraumatic stress disorder (PTSD) symptoms in parents of pediatric solid organ transplant recipients.

METHOD

A total of 170 caregivers of pediatric transplant recipients completed self-report measures of psychological functioning between 10 and 38 months after their child's most recent transplant. Demographic data, child health variables, and ratings of medical attitudes and social functioning were also collected to help explain individual differences in psychological functioning.

RESULTS

Although caregivers of pediatric transplant recipients did not report elevated levels of depression or anxiety, they did report elevated levels of PTSD symptoms. Multiple regression analyses revealed that PTSD symptoms were most strongly associated with parent reports of child health, family impact of the transplant, and attitudes toward medical caregivers.

CONCLUSIONS

PTSD seems to be relatively common in parents of pediatric transplant recipients and may be largely the result of how parents perceive and interpret the transplant experience.

In their own words: the lived experience of pediatric liver transplantation

Liver transplantation is the treatment of choice for children with end-stage liver disease. Few studies have examined the experience of transplantation from the child's perspective. Using a phenomenological approach establishes a safe environment for children to reflect on their lives as transplant recipients. The aim of this study was to uncover the experiences of pediatric liver transplant recipients from the period prior to transplantation, through surgery, and beyond. In-depth conversations with 9 pediatric recipients were carried out. Phenomenological methodology guided the data collection and analysis. The children faced many challenges, including surviving a life-threatening illness while accomplishing normal developmental tasks. The predominant theme was striving for normalcy in their lives.

Psychosocial aspects of the organ transplant experience: what has been established and what we need for the future

This article briefly describes the current status and limitations of the organ transplant process that has now become a routine medical procedure. The article discusses how transplantation is not a cure for end-stage organ disease but an alternative form of treatment with both potential medical and psychosocial problems. Both transplant candidates and recipients encounter psychosocial problems. The article examines how these psychosocial problems affect transplant patients prior to transplant, immediately following surgery, and posttransplant. The psychosocial problems include psychiatric diagnoses, individual and family adjustment and relationship problems, sexual dysfunction, return-to-work (RTW) difficulties, and compliance problems and variables related to noncompliance. The article also reviews the special problems of pediatric and adolescent transplant recipients. The need for empirically supported interventions is noted in each of the problem areas. The author outlines problems with previous research studies that hamper solid interpretations of the data, and discusses literature suggesting that the psychosocial problems of transplant candidates and recipients are likely to be underreported. The article concludes with recommendations about the need to switch research efforts toward intervention studies in the problem areas already solidly identified by the literature.

Liver transplantation. The pediatric challenge

Successful liver transplantation in a child is often a hard-won victory, requiring all the combined expertise of a dedicated pediatric transplant team. This article outlines the considerable challenges still facing pediatric liver transplant physicians and surgeons. In looking to the future, where should priorities lie to enhance the success already achieved? First, solutions to the donor shortage must be sought aggressively by increasing the use of from split-liver transplants, judicious application of living-donor programs, and increasing the donation rate, perhaps by innovative means. The major immunologic barriers, to successful xenotransplantation make it unlikely that this option will be tenable in the near future. Second, current immunosuppression is nonspecific, toxic, and unable to be individually adjusted to the patient's immune response. The goal of achieving donor-specific tolerance will require new consideration of induction protocols. Developing a clinically applicable method to measure the recipient's immunoreactivity is of paramount importance, for future studies of new immunosuppressive strategies and to address the immediate concern of long-term over-immunosuppression. The inclusion of pediatric patients in new protocols will require the ongoing insistence of pediatric transplant investigators. Third, the current immunosuppressive drugs have a long-term morbidity and mortality of their own. These long-term effects are particularly important in children who may well have decades of exposure to these therapies. There is now some understanding of their long-term renal toxicity and the risk of malignancy. New drugs may obviate renal toxicity, whereas the risk of malignancy is inherent in any nonspecific immunosuppressive regimen. Although progress is being made in preventing and recognizing PTLD, this entity remains an important ongoing concern. The global effect of long-term immunosuppression on the child's growth, development, and intellectual potential is unknown. Of particular concern is the potential for neurotoxicity from the calcineurin inhibitors. Fourth, recurrent disease and new diseases, perhaps potentiated by immunosuppressive drugs, must be considered. Already the recurrence of autoimmune disease and cryptogenic cirrhosis have been documented in pediatric patients. Now, a new lesion, a nonspecific hepatitis, sometimes with positive autoimmune markers, that may progress to cirrhosis has been recognized. It is not known whether this entity is an unusual form of rejection, an unrecognized viral infection, or a response to immunosuppressive drugs themselves. Finally, pediatric transplant recipients, like any other children, must be protected and nourished physically and mentally if they are to fulfill their potential. After liver transplantation the child's growth, intellectual functioning, and psychologic adaptation may all require special attention from parents, teachers, and physicians alike. There is limited understanding of how the enormous physical intervention of a liver transplantation affects a child's cognitive and psychologic function as the child progresses through life. The persons caring for these children have the difficult responsibility of providing services to evaluate these essential measures of children's health over the long term and to intervene if necessary. Part of the transplant physician's our duty to protect and advocate for children is to fight for equal access to health care. In most of the developing world, economic pressures make it impossible to consider liver transplantation a health care priority. In the United States and in other countries with the medical infrastructure to support liver transplantation, however, health care professionals must strive to be sure that the policies governing candidacy for transplantation and allocation of organs are applied justly and uniformly to all children whose lives are threatened by liver disease. In the current regulatory climate that increasingly takes medical decisions out of the hands of physicians, pediatricians must be even more prepared to protect the unique and often complicated needs of children both before and after transplantation. Only in this way can the challenges of the present and the future be met.

Long-term psychosocial adjustment following pediatric liver transplantation

This study assessed long-term psychosocial adjustment to pediatric liver transplantation in 146 patients aged 4-25 yr, who had received a transplant 2-12 yr previously. Evaluations of psychosocial adjustment and related variables were based on the Harter Self-Perception Profiles for children, Child Behavior Checklist (CBCL), and children's academic level. Up to the age of 8 yr, transplant children as a group did not perceive themselves as less competent than healthy peers. Gender effects were characterized by older girls perceiving significantly less scholastic cognitive competence than their healthy peers. Adolescent and young adult boys had significantly lower global self-worth and lower perceived athletic competence than their healthy peers. In comparison to normative data of healthy children, CBCL parent-reported scores revealed significant deficits in competences for all age groups. Only for the older boys, however, did these deficits reported by the parents reach a pathological level. The majority of transplant children also had significantly higher problem scores, but they remained within the normal range, except for the older boys whose internalizing problems reached a borderline level. Our results suggest that liver transplantation does not substantially affect schooling. Regardless of statistically significant differences in psychosocial adjustment, the majority of the transplant children functioned at a normal level. For adolescent and young adult boys, however, the presence of problems and the lack of competences observed by parents and by the youngsters themselves reached borderline to pathological levels. Our findings stress the importance of psychological post-transplant follow-up with increased attention of caregivers to child and parental concerns about their long-term psychosocial adjustment process.

Care of the pediatric solid organ transplant recipient. The primary care perspective

Although transplantation is an effective therapy for many end-stage organ diseases, this treatment cannot be totally successful without continued careful medical management, monitoring, and psychosocial support. Transplantation is a lifelong commitment. Primary care physicians can lay the foundation for ongoing care by providing medical intervention when appropriate and maintaining close communication with the transplant center, but perhaps more importantly by developing a relationship with these children and their families that impacts adherence to care will promote an optimal quality of life.

Parental psychosocial outcomes in pediatric liver and/or intestinal transplantation: pretransplantation and the early postoperative period

Although liver transplantation has become an effective treatment for end-stage liver disease and liver/intestine transplantation is becoming an increasingly viable procedure for end-stage short-gut syndrome in children, little is known about the impact of these procedures on the child's family. Examination of the impact of these transplantations on the family is needed to identify psychosocial factors that may adversely affect the child's physical and emotional health and to plan for preventive interventions. The psychosocial impact of pediatric liver and/or intestine transplantation on parents was assessed in a cross-sectional sample of 41 mothers and 20 fathers evaluated pretransplantation and 2 months posttransplantation. Parental mental health, parenting stress, and quality of life were assessed, as well as demographic, child, and family characteristics as they related to parental outcomes. Parent adjustment did not differ with regard to time of assessment. A majority of parents (n = 31) reported elevated psychological symptoms on the Brief Symptom Inventory (BSI), with fathers showing greater distress than mothers (P < .05). Parents' total scores on the Parenting Stress Index and the Parent and Child Domain subscales were in the normal range. Quality of life was assessed by the Physical Health, General Health Perception, and Vitality subscales of the SF-36. Parents reported better physical functioning (P = .02) but lower vitality ratings than a normative population (P < .01). Family conflict was associated with higher psychological distress on the BSI (P = .02), whereas demographic factors, including the child's age, sex, and number of people in the household, proved most useful in predicting parenting stress and quality of life. These findings of significant psychological distress in parents of children undergoing liver and/or small-intestine transplantation have implications for the child's adaptation and underscore the need for psychosocial assessment of both parents in the perioperative period. Early identification of families at psychosocial risk and the development of interventions that may prevent or reduce psychological distress are indicated to ensure the best possible outcomes for these children and their families.