Pediatr Transplantation 2008: 12: 57–66 Copyright Ó 2007 Blackwell Munksgaard

Pediatric Transplantation
DOI: 10.1111/j.1399-3046.2007.00785.x

Pediatric Transplant Rating

Instrument – A scale for the pretransplant
psychiatric evaluation of pediatric organ
transplant recipients
Fung E, Shaw RJ. Pediatric Transplant Rating Instrument – A scale for Ernest Fung1 and Richard J. Shaw2
the pretransplant psychiatric evaluation of pediatric organ transplant 1
California School of Professional Psychology/Alliant
recipients. International University, San Francisco, CA, USA,
2
Pediatr Transplantation 2008: 12: 57–66. Ó 2008 Blackwell Munksgaard Division of Child Psychiatry, Stanford University
School of Medicine, Palo Alto, CA, USA
Abstract: Although the majority of pediatric solid organ transplant
centers in the United States employ psychosocial criteria to assess the
suitability of potential transplant candidates, there are no standardized
pretransplant psychosocial assessment measures. Assessment scales that
have been developed were designed for adult transplant recipients and
are not suitable for use in the pediatric population. The P-TRI was Key words: transplant – pediatric – candidate
developed to address this gap in the pediatric pretransplant psychoso- selection – rating scale
cial evaluation. It is intended to identify areas of psychosocial vulner-
Richard J. Shaw, Division of Child Psychiatry,
ability that may be associated with poor treatment adherence and to
Stanford University School of Medicine, 401 Quarry
facilitate the development of informed and focused psychosocial inter- Road, Palo Alto, CA 94305-5719, USA
ventions for pediatric patients before and after transplant surgery. Items Tel.: 650-723-5457
on the rating instrument were generated based on a review of the major E-mail: rjshaw@stanford.edu
correlates of treatment adherence in the pediatric population. Data are
currently being collected for further reliability and validity analyses. Accepted for publication 29 June 2007

Psychosocial assessment plays an important role
in evaluating potential solid organ transplant
candidates based on research that has shown a
clear relationship between psychosocial factors
and post-transplant outcomes, in particular those
related to treatment adherence (1, 2). Although
most transplant centers in the United States
employ psychosocial criteria during candidate
selection, there are no standardized or well-
validated psychosocial assessment criteria. In the
field of adult organ transplantation, there are
two assessment instruments generally used for
adult transplant patients, the PACT (3) and the
TERS (4). There are, however, no standardized
psychosocial instruments available for the pedi-
atric organ transplant population.
To address this current gap, we have devel-
oped the P-TRI, an assessment tool that specif-
Abbreviations: PACT, Psychosocial Assessment of Candi-
dates for Transplantation; P-TRI, Pediatric Transplant
Rating Instrument; TERS, Transplant Evaluation Rating
Scale.
ically evaluates psychosocial risk factors that
may be relevant for potential child and adoles-
cent organ transplant recipients. The instrument
is modeled on the PACT and TERS but
specifically adapted for the pediatric population.
Items in the P-TRI were developed based on a
literature review of the relevant pediatric risk
factors, specifically those known to be associ-
ated with treatment adherence. The P-TRI is
intended initially to help identify and describe in
a standardized manner the potential psychoso-
cial risk factors prior to transplant surgery that
may affect post-transplant outcome. It is also
hoped that systematic identification of these risk
factors will suggest potentially useful psychoso-
cial interventions that may enhance treatment
outcomes.
Existing pretransplant evaluation rating scales
The Psychosocial Assessment of Candidates for
Transplantation
The PACT is a 10-item rating scale developed by
Olbrisch et al. (3) for use in adult transplant

57
Fung and Shaw
organ transplant recipients. The PACT has high
inter-rater reliability (96%), and all items corre-
late with clinical ratings. It has been demon-
strated that the PACT ratings were not related to
social desirability, suggesting that even if patients
presented themselves in a socially acceptable and
desirable fashion, clinical observations were not
likely to be influenced (5). Another study has
shown that the PACT has concurrent validity
with standard measures such as the Minnesota
Multiphasic Personality Inventory and Beck
Depression Inventory (6).
The Transplant Evaluation Rating Scale
The TERS is a 10-item rating scale also deve-
loped for adult organ transplant recipients (4). It
has been demonstrated to have a good inter-rater
reliability (3, 7) and internal consistency (7).
Furthermore, highly significant correlations have
been found between the pretransplant TERS
scores and the level of treatment adherence,
substance abuse, and health behaviors, as well as
a significant correlation between the TERS and
quality of life, all measured one to three years
post-transplant (3). It has been utilized in other
clinical studies (8, 9).
Both the PACT and the TERS have reason-
able internal consistency and comparable inter-
rater reliability (10). However, the PACT is
more flexible in both the range of each rating
scale and the manner in which the summary
score is determined (11), while TERS showed
better inter-rater reliability than the PACT
across more domains and better relationship
with outcome variables (12). While both mea-
sures serve as helpful tools for the adult trans-
plant patient population, pediatric transplant
candidates were not considered in the design of
these instruments.
Pediatric Transplant Rating Instrument
The P-TRI is a 17-item rating scale designed to
identify potential psychosocial risk factors associ-
ated with post-transplant treatment adherence in
the pediatric transplant population (see Appen-
dix). Design of the P-TRI incorporates both a
developmental perspective as well as psychoso-
cial and familial factors that have been shown in
the literature to correlate with treatment adher-
ence in medically ill children and adolescents (13,
14). The emphasis on treatment adherence used
to develop the P-TRI is based on the finding that
non-adherence with treatment is the leading
cause of graft loss after the first three months
post-transplant in all age groups and may lead to
increased rates of mortality, utilization of health
58
services, and higher healthcare costs (15–17).
Non-adherence to the medical regimen has also
been identified as one of the most commonly
identified sequelae of psychosocial impairment in
a transplant recipient (18). One important differ-
ence between adult and pediatric organ trans-
plant recipients is that the pediatric transplant
team generally holds the patientÕs primary care-
taker responsible for managing the patientÕs
medical treatment. Therefore, apart from evalu-
ating psychosocial factors that are conducive to
positive disease management behavior, the P-
TRI includes an evaluation of the primary
caregiversÕ ability to manage and supervise their
childÕs post-transplant treatment regimen.
To generate items on the rating scale, we
compiled correlates of treatment adherence in the
pediatric population based on a comprehensive
review of the literature of treatment adherence
and chronic disease management in this popula-
tion. medline and psychinfo were used to search
for studies that explore the relationships between
psychosocial factors, treatment adherence, and
post-transplant outcomes. The cut-off date for
the literature search was June 2006.
The P-TRI emphasizes the need for a collab-
orative and multidisciplinary approach in assess-
ing young patients and their families. Through
our experience in the psychosocial assessment of
organ transplant candidates, we have grouped
and categorized these correlates into the follow-
ing subscales to increase its utility for use in the
medical setting:
Illness factors
Illness factors related to treatment adherence
include the patient’s and familyÕs knowledge of
the transplant procedure, attitude towards trans-
plant, and level of motivation for transplant.
Knowledge about medical treatment, belief in its
importance, and therapeutic motivation have all
been correlated with higher rates of adherence
(19, 20). In addition, adolescents are more likely
to comply with therapeutic regimens that they
believe are likely to be effective (20). To provide
ratings in these areas, the clinician should inquire
as to whether the patient and family have been
given a full explanation about the transplant
process, and whether they appear to understand
the major medical and surgical issues related to
the surgery. If there is a gap between knowledge
of the transplant procedure and the post-trans-
plant medical management, the clinician may
recommend an additional meeting with the
transplant team to remediate these deficits. The
clinician should also assess the general attitude

and motivation of the patient and family towards
the proposed transplant surgery.
History of treatment adherence
The past history of treatment adherence with
respect to medications, medical appointments,
and dietary and exercise prescriptions has been
shown to be predictive of future patterns of
treatment adherence (21). Factors that may raise
concern about potential future difficulties with
treatment adherence include a past history of
forgetfulness, resistance to taking medications
due to concerns about side effects, or a pattern of
acting out behavior that is expressed by the child
refusing to take their medications (17, 20, 22–26).
Ratings of past adherence history are generally
based on information obtained from the patientÕs
medical record but should also include reports
from the members of the transplant and medical
team and primary caretakers. The clinician
should also assess the patientÕs and familyÕs level
of acknowledgment and responsibility for any
past history of poor adherence to treatment.
Past psychiatric history
The presence of pretransplant psychiatric symp-
toms and disorders is often cited as a major
contraindication to organ transplantation in
adult patients due to its relationship with treat-
ment adherence (10). For example, anxiety,
anger, hostility, denial, and depression have all
been associated with poor treatment adherence
(15, 27). Studies of pediatric transplant recipients
have also similar relationships with symptoms of
anxiety and depression (17, 28). Pretransplant
psychiatric assessment should include a careful
review of current and past psychiatric disorders
and their potential relevance during the trans-
plant process. Parental psychiatric history is also
a pertinent factor since parental psychopathol-
ogy has the capacity to adversely affect the
parentsÕ ability to support and supervise their
childÕs treatment. Areas of assessment related to
parental psychopathology should include paren-
tal coping, family support, family communica-
tion, and parental supervision which are factors
that have been shown to be correlated with
treatment adherence (29). Cognitive issues
should also be considered since cognitive deficits
related to end-stage organ failure may impair the
patientsÕ ability to comply with complex post-
transplant treatment regimens (10). Patients with
cognitive impairments are at particularly high
risk for non-adherence with treatment unless
appropriate interventions are offered before and
after transplant surgery (30).
Pediatric Transplant Rating Instrument
Ratings of past psychiatric history on the
P-TRI are generally based on clinical interview
and review of medical records. If there is current
psychiatric illness in the family, the clinician
should assess the severity of the illness, and
establish whether the affected patient or family
member is currently participating in appropriate
psychiatric treatment, or if not, whether they are
willing to pursue treatment that may be recom-
mended prior to surgery.
Substance abuse history
Alcohol and substance abuse is often cited as
either an absolute or a relative contraindication
to organ transplantation in the adult transplant
population (31, 32), since there is evidence that
substance abuse history may be associated with
higher rates of non-adherence (33). Within the
pediatric population, issues of substance abuse
are also pertinent, particularly in the adolescent
population. Furthermore, if there is a parental
history of substance use, in particular if there are
current active symptoms of abuse, there may be
serious concerns about the ability of the family to
adequately supervise the post-transplant treat-
ment regimen. If there is current evidence of
alcohol or substance abuse in the patient or
family members, the clinician should assess the
severity of the abuse, and establish whether the
affected patient or family member is currently
participating in appropriate substance abuse
treatment, or if not, whether they are willing to
pursue recommended treatment.
Family environment
Much of the responsibility of treatment adher-
ence lies with the patientÕs parents or primary
caregiver. Adequate parental resources have been
suggested to buffer the effects of stress on
psychosocial functioning and perceived social
support seems to have a predictive effect on
adaptation to chronic illness in adolescents (34,
35). The presence of a supportive family envi-
ronment has been shown to be associated with
increase treatment adherence while, by contrast,
family instability has been associated with non-
adherence (36, 37). This section of the P-TRI
primarily focuses on the transplant recipientÕs
family environment and its relevance to support-
ing post-transplant treatment. Ratings are made
based on the availability and willingness of
family members to provide appropriate supervi-
sion of the childÕs medical and medication
treatment. The P-TRI also rates the presence of
family conflict between family members, com-
munication style and ability to supervise their
59
Fung and Shaw
childÕs treatment. If there are currently significant
conflicts or communication difficulties between
family members, the clinician should explore
with the family their willingness to engage in
family therapy particularly if such issues are
believed to have a potential adverse effect on the
childÕs pattern of treatment adherence.
Psychosocial and financial support
Multiple previous studies have documented the
importance of psychosocial and financial support
for positive post-transplant outcomes. For exam-
ple, it has been suggested that close peer
relationships may help foster good treatment
adherence in adolescent transplant patients (20).
The presence of social support has also been
shown to improve treatment adherence in cardiac
transplant recipients while the provision of emo-
tional and practical support by family and
friends has repeatedly been found to promote
treatment adherence (1, 15). Optimally, the
family should also have adequate financial
resources to support the transplant procedure.
This section of the P-TRI assesses the quality of
financial, logistical and social support available
to the family. Deficits in any of these areas may
lead to recommendations for additional
resources to support the family during the
transplant process. The P-TRI also rates the
quality of peer relationships and the level of
participation in age appropriate social activities,
which are generally believed to be good indica-
tors of peer relationships and support (38).
Relationship with the medical team
The quality of the relationship between adoles-
cent patients with a chronic medical condition
and the health care provider has been shown to
have an effect on treatment adherence while
instability in this relationship may predict poor
post-operative treatment adherence (15, 39). The
P-TRI rates the quality of the patient’s and
familyÕs relationship with the medical team. The
presence of conflict or tension between the family
and the transplant team, in particular feelings of
anger or distrust, may lead to recommendations
to resolve these issues by facilitating a dialogue.
Rating directions
Transplant candidates are assessed on a Likert
Scale. A score of 1 indicates a greater level of
concern while a score of 4 indicates no concern
related to that item. Each item is accompanied
with a series of anchors to assist the clinician
during the rating process. Scores on the P-TRI
60
may be plotted graphically to give a visual
representation of specific areas of concern that
may lead to recommendations for intervention.
It should be noted that some of the items on
the P-TRI are age specific, for example, item #2
(‘‘Patient Motivation for Transplant’’) is consid-
ered more suitable for assessing older pediatric
patients. This issue highlights the need to assign
different weightings to items for assessing candi-
dates in different age groups [with parental issues
being more salient for younger children (40)]. At
this current juncture, the evaluator can utilize
his/her clinical expertise to decide if it is appro-
priate to rate a particular item (e.g., deciding to
forgo item #2 when assessing a three-year-old
transplant candidate). If the evaluator decides
not to rate a particular item, the reasons should
be specified, as information on missing and
irrelevant items will be utilized in further devel-
opment of the instrument.
As P-TRI is primarily an information-gather-
ing tool at this stage, the total score of all the
items is not utilized as a global or final rating.
Hence, age-specific items that are not rated
should not significantly affect the current
intended use of the P-TRI.
Future statistical analyses
To perform reliability and validity investigations,
data collected by the P-TRI will be analyzed with
the following list of variables that includes both
health status indicators in addition to measures
of adherence, with an understanding that both
are related but not identical, a common concep-
tual confound reported by Johnson (41).
1. Serum immunosuppressant levels as objective
measures of treatment adherence.
2. Serum creatinine concentrations to be used as
a potential clinical marker of graft dysfunc-
tion.
3. Occurrence of episodes of both acute and
chronic rejection.
4. Graft loss.
5. Number of inpatient hospital days/year due to
graft complications.
6. Patient/parent report on treatment adherence.
In addition, candidatesÕ gender, age, race/ethnic-
ity, living or cadaveric donor, type of transplant,
first or repeat transplant, and date of transplant
are recorded as part of the assessment process.
This database will facilitate statistical analyses to
assess the reliability and validity of the scale.
Principal components analysis will enable item
reduction and provide us with information on the

P-TRIÕs scale dimensionality. Through examin-
ing the associations between ratings on the
P-TRI and post-transplant outcomes, it will be
possible to calculate the P-TRIÕs construct and
predictive validity. In addition to assigning
weightings to items based on their suitability to
different age groups, validity analysis can also
help assign weightings to items that are shown to
be more predictive of post-transplant outcomes.
Finally, the reliability of the instrument will be
assessed by computing CronbachÕs alpha (42) on
data collected from different raters and trans-
plant sites.
Discussion
The P-TRI is the first clinical rating scale
developed for the psychiatric assessment of
potential pediatric solid organ transplant recip-
ients. The scale was developed based primarily
on a comprehensive review of the literature
related to risk factors of treatment adherence in
this population. In contrast to two existing
measures developed for adult transplant recipi-
ents, the P-TRI incorporates a developmental
perspective that is relevant to children with
chronic physical illness in addition to considering
important family issues that may affect the
transplant outcome. It is designed to identify
areas of psychosocial vulnerability that may be
associated with poor treatment adherence in the
pediatric transplant population. At this point, in
the absence of reliability and validity data, it is
not intended for the P-TRI to score or rank
patients, or to be used to determine eligibility for
listing for transplant. Specifically, the P-TRI
does not have cut off scores that determine likely
clinical outcome. Rather, the P-TRI should be
used to identify areas of concern that may be
amenable to intervention both pre and post-
transplant surgery. By identifying areas of psy-
chosocial vulnerability that could lead to poor
treatment adherence and post-transplant out-
come, the P-TRI can play a role in providing the
transplant team with comprehensive information
on potentially problematic psychosocial issues,
facilitating the development of informed and
focused psychosocial interventions for patients
and their families before and after the transplant
surgery. To improve the psychometric properties
of the P-TRI, outcome data are currently being
collected for further reliability and validity anal-
yses.
The development of rating scales for solid
organ transplant recipients raises a number of
important clinical and ethical issues. In trans-
plant centers that employ psychosocial criteria in
Pediatric Transplant Rating Instrument
screening potential transplant recipients, there is
a relative lack of empirical data related to the
ability to predict post-transplant treatment out-
come. Although there have been multiple studies
that have examined the association between
specific risk factors and treatment outcome, there
are very few studies that have demonstrated a
clear causal relationship between psychosocial
factors and graft survival. This is true within
both the adult and pediatric transplant literature.
As we move on to the next phase of our study,
when outcome data on the P-TRI become
available, the relationships between the psycho-
social risk factors listed on the P-TRI and graft
survival can be studied in a quantitative manner.
We believe empirical study of this nature has the
potential to contribute significantly to the re-
search on clinical outcomes in the solid organ
transplant population.
However, until empirically derived predictive
data become available, we understand that it
may be difficult for a transplant team to support
a decision to withhold listing for transplant based
on the identification of factors that the team
believes to be potentially associated with poor
medical outcomes. Similar issues arise in assign-
ing a priority level for transplant when compar-
ing potential candidates with significant yet
different psychosocial risk factors. Should, for
example, a child from a family with significant
family conflict or dysfunction be rated as more or
less suitable for transplant when compared with a
child with a past history of substance abuse. Due
to the lack of empirical data on which to assign
levels of medical risk related to specific psycho-
social risk factors, weightings have not yet been
assigned to individual subscales or items on the
P-TRI. Once the necessary outcome data are
available, we plan to assign weightings to items
based on their predictive ability for positive post-
transplant outcome, and establish a global rating
that would summarize the overall psychosocial
risk.
Another important clinical and ethical issue
relates to the willingness of pediatric transplant
centers to consider psychosocial risk factors
when making eligibility decisions. Although it is
common practice for adult organ transplant
centers to use psychological criteria as a screening
measure in the selection of candidates – in
particular, criteria associated with alcohol and
substance abuse – pediatric transplant centers
have historically been less willing to employ such
criteria. Although the presence of significant
psychological dysfunction in the childÕs family
is known to be associated with higher rates of
non-adherence with treatment, there is a general
61
Fung and Shaw
reluctance to penalize the child by withholding a
life saving medical procedure for a child based on
family psychopathology that may be beyond the
control of the child (43). However, the common
dilemma that arises is that the transplant team
does ultimately hold the family responsible for
the childÕs adherence to the post-transplant
treatment regimen, suggesting that some consid-
eration of family risk factors does need to occur
prior to listing for transplant. In some cases, the
transplant team may in fact advocate out of
home foster care placement in an effort to
enhance outcome in children with a problematic
family environment with the hope that the child
will at some time develop adequate skills to
independently manage their own treatment. This
illustrates the need to obtain the necessary
psychosocial information on the family, which
the P-TRI can provide, for the transplant team
design informed and focused psychosocial inter-
ventions to support both the patients and their
families before and after the transplant surgery
to ensure optimal post-transplant outcomes.
The large discrepancy between the supply and
demand of available organs for transplantation
will continue to create interest in ways to screen
and prioritize potential transplant recipients.
Pediatric transplant teams who carry the respon-
sibility of listing candidates for surgery are in the
position of having divided loyalties including
those towards patients, family members, the
transplant team that will be responsible for
post-surgical care, as well as to the general pool
of transplant candidates (44). Although it is the
transplant teamÕs responsibility to advocate for
their own patients, allocation of an organ
ultimately affects the likelihood of others on the
waiting list receiving that organ. Although there
are no hard and fast rules to guide the clinician
regarding these decisions, it is important that all
professionals who are involved in pretransplant
candidate assessment should abide by the pro-
fessional ethics codes such as those published by
the American Psychological Association and
American Medical Association.
Development of rating scales such as the P-
TRI does have the potential to assist the trans-
plant team with some of these dilemmas. The
existence of a reliable and well validated measure
to assess candidates for surgery would enhance
the evaluation process, particularly if data can
demonstrate a relationship with specific item
ratings and post-transplant outcome. In an effort
to further this research, data collection for both
reliability and validity studies is in progress in the
hope that the P-TRI may demonstrate clinical
utility as a predictive measure.
62
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Appendix
Pediatric Transplant Rating Instrument
1. P-TRI instructions
Description
The P-TRI is a 17-item semi-structured interview that is designed to assess relevant areas of risk for candidates for pediatric
solid organ transplantation. The scale is divided into seven primary categories that have been derived from review of the
scientific literature of risk factors related to outcomes for transplant recipients, with a particular focus on outcomes related to
treatment adherence.
The goal of the P-TRI is to help identify potential areas of risk prior to transplant surgery that may be related to potential
difficulties after surgery. Although there are no current data to support a predictive relationship between ratings on the P-TRI
and medical or psychosocial outcome, low scores on any of the items may suggest potential areas that warrant clinical
attention. Reliability and validity studies of the P-TRI are currently being conducted to help strengthen the clinical utility of
the P-TRI.
Assessment process
The interview questions for the P-TRI contain a list of relevant areas of inquiry that should be conducted during the rating
process. Information for each of these questions may be obtained by direct interview of the transplant candidate and his/her
family. Information may also be obtained from past medical records, or from assessments provided by members of the
transplant team, or other health care providers. All available sources of information should be reviewed to help provide the
most accurate assessment.
Scoring
After the clinical assessment, the rater should assign a numerical value between 1 and 4 for each item of the P-TRI, with low
values generally indicating areas of concern or risk. Low scores may prompt discussion of specific psychosocial risk factors
and suggest potential treatment interventions to reduce the severity of risk. In rare cases where the question is not applicable,
for example, items that are not applicable for very young children (Question2), the item should not be rated.
2. P-TRI interview questions
I. Illness factors
1. Have the patient and family had a full explanation about the transplant process?
2. Do the patient and family appear to understand the major medical and surgical issues related to transplant?
3. What is the general attitude of the patient and family towards the proposal for transplant?
4. What is the general motivation of the patient and family towards the proposal for transplant?
II. Treatment adherence
1. Is there a past history of poor adherence with medications, appointments, diet, lab tests, and other aspects of the
prescribed treatment?
2. Do the patient and family acknowledge and take responsibility for any past history of poor adherence to the treatment?
3. Is there a history of forgetting medications, poor supervision by the parents, refusing to take medications due to concerns
about medication side effects, or a tendency for the child to act out by not adhering to the medical treatment?
III. Psychiatric history
1. Do the patient or family members have a past or current history of psychiatric illness?
2. If there is current psychiatric illness, is the affected patient or family member currently participating in appropriate
psychiatric treatment?
3. If there is current psychiatric illness, how severe are the symptoms of this illness?
IV. Substance abuse history
1. Do the patient or family members have a past or current history of alcohol or substance abuse or dependence?
2. If there is current alcohol or substance abuse or dependence, is the affected patient or family member currently
participating in appropriate substance abuse treatment?
3. If there is current alcohol or substance abuse, how severe are the symptoms of abuse?
V. Family environment
1. Are there family members available to provide appropriate supervision of the patientÕs medical and medication treatment?
2. Are there family members willing to provide appropriate supervision that may be recommended by the transplant team?
3. Is there significant interpersonal conflict between family members?
4. Is the family able to communicate appropriately around parenting and supervision issues related to the patientÕs treatment?
5. Is the family willing to enter family therapy to address relevant family issues if recommended by the transplant team?
VI. Psychosocial support
1. Does the family have adequate financial resources to support the transplant process?
2. Are there extended family members or friends available to help provide logistical and emotional support to the family?
3. Does the patient have a satisfactory peer or social support network?
4. Does the patient participate in age appropriate social activities?
VII. Relationship with medical team
1. Is there a history of conflict or tension between the family and the transplant team?
2. Are there current feelings of anger or lack of trust between the family and the transplant team?

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 Pediatric Transplant Rating Instrument

3. P-TRI Rating Form

Name: Date of Evaluation:

Rater:

I. ILLNESS FACTORS

1. Knowledge about Transplant:

1 2 3 4
Patient and family have Patient and family have received Patient and family have received Patient and family have received
received inadequate education adequate education about adequate education about adequate education about
about transplant. transplant. transplant. transplant.

Patient and family demonstrate Patient and family demonstrate Patient and family demonstrate Patient and family demonstrate
minimal understanding of poor understanding of transplant adequate understanding of comprehensive understanding of
transplant issues. issues. transplant issues. transplant issues.

2. Patient Motivation for Transplant:

1 2 3 4
Patient has negative motivation Patient has ambivalent Patient is generally motivated Patient is motivated for
for transplant. motivation for transplant. for transplant. transplant.

3. Parent/Family Motivation for Transplant:

1 2 3 4
Parent/Family has poor Parent/Family has ambivalent Parent/Family has generally Patient/Family has very positive
motivation for transplant. motivation for transplant. positive motivation for motivation for transplant.
transplant.

II. TREATMENT ADHERENCE

4. Adherence with Medications:

1 2 3 4
Past and current history of Past and current history of Past but not current history of No history of any difficulties
consistently poor medication consistently poor medication poor medication adherence. with medication adherence.
adherence. adherence.
Acknowledgment of adherence
No acknowledgment of Acknowledgment of adherence difficulties
adherence difficulties. difficulties.

5. Adherence with Medical Appointments (including lab tests):

1 2 3 4
Past and current history of Past and current history of Past but not current history of No history of any difficulties
consistently poor adherence to consistently poor adherence to poor adherence to medical with adherence with medical
medical appointments. medical appointments. appointments. appointments.

No acknowledgment of Acknowledgment of adherence Acknowledgment of adherence

adherence difficulties. difficulties. difficulties.

6. Presence of Risk Factors for Poor Adherence:

[Concern about side effects; forgetfulness; history of acting out]
1 2 3 4
Presence of MULTIPLE risk Past history of at least TWO risk Past history of ONE risk factor No history of any risk factors for
factors for poor adherence. factors for poor adherence. for poor adherence. poor adherence.

III. PSYCHIATRIC HISTORY

7. Patient Psychiatric History:

1 2 3 4
History of psychiatric illness. History of psychiatric illness. History of psychiatric illness. No current or past history of
psychiatric illness.
Current symptoms of illness. Current symptoms of illness. No current symptoms of illness.

No current psychiatric Patient in psychiatric treatment. Patient willing to enter treatment

treatment. if recommended.

8. Parental Psychiatric History:

1 2 3 4
History of psychiatric illness. History of psychiatric illness. History of psychiatric illness. No current or past history of
psychiatric illness.
Current symptoms of illness. Current symptoms of illness. No current symptoms of illness.

No current psychiatric Parent in psychiatric treatment. Parent willing to enter treatment

treatment. if recommended.

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Fung and Shaw

IV. SUBSTANCE ABUSE HISTORY

9. Patient Substance Abuse History:

1 2 3 4
History of substance abuse. History of substance abuse. History of substance abuse. No current or past history of
substance abuse.
Current symptoms of substance Current symptoms of substance No current symptoms of
abuse. abuse. substance abuse.

No current substance abuse Patient in treatment for Patient willing to enter treatment
treatment. substance abuse. if recommended.

10. Parental Substance Abuse History:

1 2 3 4
History of substance abuse. History of substance abuse. History of substance abuse. No current or past history of
substance abuse.
Current symptoms of substance Current symptoms of substance No current symptoms of
abuse. abuse. substance abuse.

No current substance abuse Parent in treatment for substance Parent willing to enter treatment
treatment. abuse. if recommended.

V. FAMILY ENVIRONMENT

11. Parental Supervision:

1 2 3 4
No availability of family No availability of family Limited availability of family Availability and willingness of
members to supervise members to supervise treatment. members to supervise treatment. family members to supervise
treatment. treatment.
Willingness of family members Willingness of family members
No willingness of family to supervise treatment. to supervise treatment.
members to supervise
treatment.

12. Presence of Family Conflict:

1 2 3 4
Presence of significant conflict Presence of significant conflict Presence of minor conflict No evidence of presence of
between family members. between family members. between family members. conflict between family
members.
No willingness of family to Willingness of family to engage Willingness of family to engage
engage in family treatment. in family treatment. in family treatment if
recommended.

13. Communication Style:

1 2 3 4
Poor ability of family members Poor ability of family members Presence of minor difficulties No evidence of difficulties
to communicate around to communicate around regarding family ability to regarding family ability to
treatment issues. treatment issues. communicate around treatment communicate around treatment
issues. issues.
No willingness of family to Willingness of family to engage
engage in family treatment. in family treatment. Willingness of family to engage
in family treatment if
recommended.

VI. FINANCIAL, LOGISTICAL AND PSYCHOSOCIAL SUPPORT

14. Financial and Health Insurance Resources:

1 2 3 4
Inadequate financial and health Very limited financial and health Limited financial and health Adequate financial and health
insurance resources to support insurance resources to support insurance resources to support insurance resources to support
mental health and logistical mental health and logistical mental health and logistical mental health and logistical
needs. needs. needs. needs.

15. Presence of Support from Extended Family Members:

1 2 3 4
No support from extended Very limited support from Limited support from extended Adequate support from extended
family members. extended family members. family members. family members.

16. Presence of Support from Friends and Peer Relationships:

1 2 3 4
No support from friends and Very limited support from Limited support from friends Adequate support from friends
peer relationships. friends and peer relationships. and peer relationships. and peer relationships.

VII. RELATIONSHIP WITH MEDICAL TEAM

17. Relationship with Medical Team:

1 2 3 4
Past history of significant Past history of significant Past history of mild conflict with Adequate and trusting
conflict with medical team. conflict with medical team. medical team. relationship with medical team.

Current lack of trust and/or Current trusting relationship Current trusting relationship
anger with medical team. with medical team. with medical team.

© Ernest Fung, California School of Professional Psychology/Alliant International University; Richard Shaw,
Stanford University. Reprinted with permission.

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