Elizabeth McRae, Ph.D., is a psychologist embedded within the Children’s of Alabama Neurosurgery team.
The young child was beyond terrified of the hospital. Born with hydrocephalus, he’d had numerous surgeries, and his anxiety was so high that just getting him to the car for doctors’ appointments was a struggle. It could take an hour to get from the parking garage to the hospital entrance given his tantrums and refusal to walk. The behavior continued at home every time someone opened the front door. “The parents really couldn’t live their life because it was so intense,” said Elizabeth McRae, Ph.D., a pediatric clinical child psychologist at Children’s of Alabama.
Here was a clear case of post-traumatic stress disorder (PTSD) related to the boy’s illness. Resolving it is exactly what McRae, who joined the neurosurgery team in January 2024, was hired to do.
For years, neurosurgeons and families caring for children with hydrocephalus understood the physical stakes: shunts that could fail without warning, repeated surgeries, emergency trips to the hospital. What was less visible—and often unaddressed—was the psychological toll of living in constant vigilance both for the patient and the family.
Earlier work at Children’s helped bring that reality into focus, documenting high rates of medical post-traumatic stress among families coping with hydrocephalus. But identifying the problem was only the beginning.
“Based on the results of that previous survey, we brought Dr. McRae on board and embedded her in our neurosurgery practice to provide psychological support for PTSD from screening and diagnosis through interventions to getting people plugged in to community resources,” pediatric neurosurgeon Brandon Rocque, M.D., said.
What’s emerged is an integrated, trauma-informed model of care that treats psychological health as part of standard neurosurgical practice.
From Measuring Stress to Building Resilience
Families of children with hydrocephalus face a unique kind of uncertainty, McRae said. Even when a child is medically stable, the possibility of sudden deterioration and a need for a new shunt never disappears. That’s why resilience, which she defines as strengthening the ability of families and patients to view difficulties as challenges rather than barriers, is so important.
Whether she’s meeting a family for the first time at diagnosis or after a child’s 10th surgery, she starts from the same place: helping them identify strengths they already have that can enable them to cope.
McRae also emphasizes connection. “One of the key predictors of potential traumatic stress is feeling like we’ve lost power and feeling isolated,” she said. “So if, right off the bat, we can empower them and encourage a connection, to me, those are two of the best things we can do up front.”
“There’s also a big piece of how do we prevent the trauma?” she continued. One approach, she said, is “taking a trauma-informed approach to our service so we mitigate the risk on the front end.” That includes explaining what’s going to happen to children; giving them options and a sense of control whenever possible; creating a sense of structure and predictability in the hospital setting as much as possible; and relying on other services such as Child Life to help children cope and adjust through play.
McRae works closely with the surgeons, nurses and residents in both clinic and hospital settings, participating in the morning clinical discussions. Nurses refer families they see struggling, and surgeons seek her input about how to provide trauma-informed care in communication and interactions with patients.
The clinical model emphasizes brief, targeted interventions—an intentional choice in a population already burdened by multiple appointments. “I’m doing them a disservice if I can’t do something fairly efficiently,” McRae said.
These strategies were helpful with the aforementioned young child. McRae worked with him and his mother using developmentally appropriate coping strategies such as play-based breathing exercises, predictable reassurance and gradual exposure. She had him pretend to be a snake and breathe in slowly and deeply like a snake to quell his anxiety. A scavenger hunt throughout the hospital helped provide distraction so he could become comfortable in the medical setting. And Rocque met with him dressed in his blue scrubs for a meet-and-greet, no medicine involved, since the child was usually so frightened by anyone in blue scrubs. McRae also involved the boy’s mother in the interventions, providing a greater sense of control over the situation.
The result? The walk from the car to the hospital takes just a few minutes. The tantrums in the clinic are over. His parents have space to breathe. All this was achieved over the course of just six, one-hour sessions.
Research is also a big part of the program, McRae said. To that end, she and the team are collecting data on how the model functions, including who benefits most, how referrals happen, what interventions are feasible, and whether the approach is sustainable.
“This is the first time anybody has tried to integrate psychology into pediatric neurosurgery like this,” Rocque said. “So there are so many questions that we need to answer.”
That includes developing screening tools to identify which families need support most urgently and tracking service metrics to ensure the model can be replicated.
“We really want to show that this works,” Rocque said.
Early signs suggest it is. The model has already been adopted in other specialty clinics, including tuberous sclerosis.
“Ideally,” Rocque said, “I would love for this to become the standard of care in pediatric neurosurgery.”
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