-Anemia -Renal Dysfunction -Various Vitamin/Mineral Deficiencies -Sleep Disorders (with resulting fatigue) -Brain Disorders/Malignancy **This is a real reach--the MRI of the Brain was ordered mainly because the pediatrician is very thorough.

Good point. I wasn't really thinking of that (and now looking at her kids ages I'm guessing she has at least four already in carseats/boosters so there is that as well).

Thanks for this thread. Our foster daughter will be five later this month. She has been miserable since she came to us in February. Our pediatrician did a very targeted but thorough workup (including CMP, CBC, T4, TSH, Vitamin D, Zinc, Copper, and B-12, Folate and MRI of the Brain) and then agreed that it was likely a mix of malnutrition (which we're fixing), grief, and depression. We saw two different child psychiatrists and eventually ended starting her on Prozac about three weeks ago. She is maybe improving a little with this but not significantly. I'm hoping it is just that the medicine hasn't had enough time to get into the system (and I know it does take awhile with the SSRIs usually at least a month or longer). She is the right age to be starting kindergarten in the fall and her CP/FS caseworker (who in general really listens to us and trusts our judgment) feels that is what should happen. At this point I don't see how she can function in school. I'm also not sure if she is prepared well enough to succeed from a cognitive/academic standpoint there. I suspect that her delays are due to the depression but I really have no idea. She would probably benefit from a full educational evaluation but I don't think it would really be accurate at this point. We live within walking distance of a really good neighborhood elementary school. Her older sister is attending there part time in a special gifted program and they have a really neat kindergarten program that we had been anticipating sending our younger daughters (who are currently three and seven months so neither will be going next fall) to for kindergarten and then assessing where to go from there. I would like to just give her another year at home to assimilate into the family, and heal and then let her go to kindergarten the summer after she turns six. This would be legal (although atypical) by our state education laws but my impression is that the CP/FS caseworker will not want to go along with this. For this reason I'm considering homeschooling kindergarten. I'm also trying to assess whether maybe just being required to be up and out of the house and functioning might be necessary nudge for her. I'm a bit afraid it would just make the whole process more traumatic.

My husband will be so proud of this thread. We've been in we really need to find something bigger mode since our newest foster daughter joined us but I hate vans and life hasn't exactly been full of lots of free time to search. We've been making it work as DH's Escalade can seat eight and our seventeen year old has her own license and her own car so if I'm taking all the kids somewhere without DH we can split up between the two vehicles but it is less than ideal and I guess we really do need to address it. Our daughter is off to college in the fall so we'll have one less child (but also one less driver) and I can imagine that her brother (and his wife and son) might like to join the family caravan to go watch one of her soccer games or something this fall so it might be nice to be able to seat ten plus comfortably for extended travel. So, moms (or dads) of many, what do you drive?

I know when my husband got his Escalade last year there was an option to have a second and third row of bench seats. We went with that even though at the time (believe it or not we only had three children at home then and only one carseat) we didn't need it. Now, (I gave birth to our youngest at the end of last year, and we have two more foster daughters both still in boosters) being able to seat eight comes in very handy. It makes taking only one car doable even if a little tight. So maybe you can find a similar option in your minivan. In the Escalade the seats both fold down and slide forward so the kids can get in and out but we do have to think a little when loading and unloading. We're tentatively looking for something bigger but I really hate vans so at the moment we're making this work.

Impressive!

We do have a playroom with an indoor playset and swings. Most toys are kept in the playroom and that is the usual go to spot to play for the younger kids when friends come over and it isn't nice enough to play outside. The swings are a bit unique so that tends to draw kids in there. We also have a large outdoor playset, several large yards, and an inground pool so usually if the weather permits everyone wants to go outside and play or swim. One of our family rooms is modern (and I suppose a bit less personalized with family photos and treasures) so that (or our music room) tends to be where the pre-teen/teen crowd prefer to hang out. I do allow friends (and even boyfriends in our oldest daughter's case if there is a good reason) in bedrooms but they need to leave the door open. Most of the time they do not spend a lot of time with friends in their bedrooms because other places are actually preferred to hang out. They do tend to hang out in their bedrooms for sleepovers when they are winding down before bed.

I think there is a lot more to this than your husband's work schedule. -If you can't manage soccer right now and also manage to meet her little siblings needs then I think it is fine to say we just can't do this right now. Why don't we re-evaluate next season, year, etc. -If she doesn't want to play soccer then I would not force her. However, I don't think playing soccer at five is necessarily too early depending on the child. We are allowing our three year old to play on a very informal 5 & under team this summer (mainly because our oldest will be volunteer coaching with this team and I want to give her the opportunity to play with her adored big sister who will be going off to college and the wonderful world of D1 soccer in the fall) but we are allowing not requiring and I think that is key. -In an ideal world parents would make it to every sporting event, art show, class play, and recital. In reality sometimes life gets in the way of that. One of our daughters just finished up her L10 gymnastics season at JO Nationals this morning. My husband and my mom and stepfather were there cheering her on. I stayed home because physician staffing has gotten tight in the ED recently and I really needed to work Wednesday and yesterday and because my husband and accepted that bringing our four year old foster daughter to this meet would be a traumatic and miserable experience for her and we couldn't do that so someone had to stay home with her. My husband missed several of our oldest daughter's soccer tournaments during the period he was living out of state so her sister could attend a partial day program for PTSD and there have been other missed moments. Our kids know we love them, we support them and we do the best we can. -If your core reason for saying no is that you feel it will be devastating for your daughter to play if dad isn't at every game I might encourage you to rethink that. I played soccer formally on a team from age six on through college. My dad made it to the games he could but he worked very hard and was in a profession where he sometimes had to go in to work on the weekends if there was a problem. He missed some soccer games as a result but I never doubted his love or support. Sometimes it was more fun to tell him about a game when he didn't know the ending.

Anemia with evidence of adequate iron stores and elevated MCV is seen with Pernicious Anemia (autoimmune destruction of gastric parietal cells leads to loss of intrinsic factor and sets up a B-12 deficiency state), B-12 Deficiency, and Folate Deficiency.

We tend to follow the Ellyn Satter philosophy as well. We also seem to have naturally lean and strong athletic kids so I perhaps I don't really understand because we've never been in a position where this would be a consideration. However, unless your son is at a weight that is higher than what could possibly be a healthy adult weight, I would not encourage him to loose weight. I would focus on ensuring he has an active lifestyle, minimizing screen time, encouraging good nutrition, and allow him to grow into his weight.

If you want to continue to have access to protected health information then she needs to sign a release that allows you this access. At least here many physicians include this release as part of their privacy practices packet. Medical Powers of Attorney vary from state to state (and in some states they are called something else---NY has Health Care Proxies which are essentially state specific MPOAs) but generally the health care agent is only allowed access to protected health information when the patient has been determined unable to make their own medical decisions. The patient must have decision making capacity at the time that the MPOA/HCP is executed. If the patient is unable to make their own medical decisions and hasn't designated a health care agent then state laws will determine how the surrogate decision maker is determined (usually next of kin but how this is defined varies from state to state). Medical guardianship and or durable power of attorney are other options and may actually be most appropriate if your feeling is that your daughter doesn't have decision making capacity now and will not for an extended period of time. State laws again vary on the requirements and process for this.

If she is at or above grade level in everything but reading I would probably have her progress on to second grade. I would also explore whether further educational and or vision testing would be worthwhile.

In general we focus on meeting the needs of all of our children. We also try to accommodate their reasonable wants but in the context of looking at the big picture (safety, age appropriateness, other wants/activities) and what is feasible in the context of the family. We don't try to give them all the same thing because that would be silly. Our thirteen year old (who happens to be a L10 gymnast) would be very unimpressed with an expensive horse but our now seventeen year old got one the Christmas she was fourteen. She had been riding for almost twelve years (she started young because we have horses and DH, big brother, and I all ride) at that time and was competing in equestrian eventing. She was ready to have a horse that could help her go to the next level. She continues to enjoy and appreciate that gift. She also makes it a point to attend her sister's gymnastics meets whenever possible. Her sister has little interest in horses but has sat through quite a few soccer tournaments and made a huge banner when her sister achieved her national qualifying score and had it out on the front lawn when we came home. I love that the girls have individual interests but support each other. Our eight year old just started formal riding lessons (our oldest taught her a lot last summer and fall and she definitely has the love horses bug) we'll support her wherever this goes. Our three year old has dabbled a little in both soccer and gymnastics (as much as a three year old can dabble) following her big sisters' lead but I'm beginning to wonder if swimming is going to be her real passion. She loves the water and has several very proficient strokes already. She may throw in the towel tomorrow or there may be years of Chlorine ahead of us. We'll follow her lead on that. I will admit that our four year has been so miserable that I would probably gladly sign her up for the first safe and age appropriate activity she asked for. She probably also has more than her weight in stuffed animals because all that she seems to want to do is curl up somewhere and sleep. We probably do indulge her a little more than some of her siblings but her situation is different right now and we're just trying to do what she needs.

Just remember that Head CTs can (and sadly do) miss posterior fossa tumors. In children (as opposed to adults) more than half of brain tumors are located in the posterior fossa so MRI is the recommended test.

We have breakfast together as a family every morning and sit down at the table around 6:30 every morning. For the most part our kids are up before this and are down in the kitchen helping with breakfast preparations prior to this. Our four year old would sleep way past this (and for days at time it sometimes seems) if we let her so I do wake her and help her get ready for the day before we sit down.

Am I correct in understanding that she has tumors in all locations?

Our daughter did algebra I (with some sidestepping through logic as an introduction to proofs) and then geometry with a little algebra II in the same year. In her case she finished the algebra I way before the year was over and wanted to go on so we (truly more she I admit) started working through the next material. She took the algebra II and trigonometry course the following year (when she was considered a freshman) on campus but mostly just attended one problem solving session a week and took the tests. This approach did prepare her well for the independent study option of AP Calculus which she took the year her school considered her sophomore year. So I guess I would advocate for more of an appropriately paced sequence that might allow her to get both courses in the same year if she was able. I do think in our daughter's case she really had been exposed to so much (because her school really did go wide and deep with their accelerated kids rather than pushing them forward in a linear direction just to check off the box) that some of the concepts were already there and that was why she was able to move along a good clip.

Ok I'm back... I'll be honest and state that we kind of fell into homeschooling because of our daughter's health (coupled with her determination to keep up with school). Before this we did a lot of "after schooling" (but never really called it that) and we both believed that her education was much more than what happened at school. We were also fortunate to have access to an outstanding private school which I think did give her a more comprehensive experience than we could have given her (especially while I was a medical student/resident physician and her dad was a busy prosecutor) so I suppose that we were biased towards more organized and formal school. We moved back to where her dad's family was (and where her dad owned a home) when she was sick so she was enrolled in a local school within a school charter for gifted kids at the same high school her big brothers graduated from. When she was twelve her health wasn't such that she could just do regular full school days but she wanted to go to school (partly because her friends were there, partly because she is a good student, and probably partly because going back to school was symbolic of hope and she was clinging desperately to that). Although she was enrolled as an eighth grader we did most of her eighth grade year at home. She took the tests for algebra I on campus (because her math teacher was pretty adamant about that and it was workable), and she attended her spanish III class on campus because class speaking/participation was a big piece of the learning environment (and grading scheme) but we did everything else at home. We had arranged with the school that she would take major exams or do major projects and we would use their books and syllabus but take responsibility for teaching. They went with this. This was a difficult time for our family because of our concerns for her and what her life might hold and all that she was dealing with in the moment. Our family has been very blessed because she battled back and is doing very well now. She is back to playing ODP soccer, looking forward to playing college soccer, riding horses and playing sax and trumpet in our state youth ensemble. Her health is still our priority and she has some chronic medical conditions that do require her to be very responsible with making health maintenance a priority and adequate sleep (which had always been a priority) is absolutely non-negotiable. Our experiences with home education also changed our perspectives some. Working with her at home gave us a different perspective on our own child and deepened our relationship in many ways. She was amazed at how much more efficient we could be at home but admitted that her friends were at school and she liked getting out of the house. Even when she was getting better we saw that adequate sleep was a non negotiable so continuing with an adapted educational plan let her get back into soccer and still have family and sleep time because she wasn't spending 30+ hours a week in class. This led us to a develop a formal individualized educational plan which was a hybrid model of on campus courses and home based instruction. Starting in ninth grade we worked out a model where she would attend partial days on Tuesday, Wednesday, and Thursday. She took algebra II & trigonometry (we/she had done Geometry at the end of the year and over the summer after she finished Alegbra I early working ahead of the class and wanted more) AP Biology, and Spanish IV on campus on those days. She was attending a charter school within a school gifted program which used a university block model for course scheduling so she could attend all of the meetings of those courses and still have four day weekends. Of course she did some school work on those "four day weekends" but it also allowed her the flexibility when she needed to travel for a soccer tournament or when they had an extra rehearsal for the state orchestra she plays in. She is a senior this year and is taking most of her courses at a local four year university. She is taking AP Psychology on campus (her brother suggested this to her), has been involved in student government, and was even homecoming queen this fall. Her principal thinks she is a great kid who has accomplished so much and jokes that he just tries not to impede forward progress. In many ways we have the best of both worlds as she has had a high school experience but school has not interfered with her real education. We know some of that has happened on the soccer field, working dressage patterns, on tour with her orchestra, and just working through the challenges of daily life. We will miss her when she goes off to college this fall but we feel she has been well prepared to take the next step and live her life. We love her dearly and are so proud of the young lady she is becoming. Our thirteen year old has followed her own path as well. She is a competitive gymnast who is happiest in stalder to handstand and swinging bars. She is a very bright girl who had some very difficult years before she came into our family. We initially embarked on the same hybrid home/on campus model with her in sixth grade (the first full school year she lived with our family) but adapted a lot over that year and ended up converting to only homebound instruction that spring. She spent about three months in an out of state day treatment program for PTSD in the fall of seventh grade and we opted to just let her finish that year at home. This year she started eighth grade and the three day hybrid option is working well for her. She isn't as science interested as our oldest (although she is taking algebra I and non calculus based physics as her on campus cores as an eighth grader so she has the ability to do more math and science if needed) and thinks she may want to be an attorney like her dad. Next year she will be taking the high school level (not AP) biology course and geometry as on campus cores and we're still working out the at home stuff. We do need to get that done because it needs to be approved before the end of the school year (which is mid-June in our state). Our eight year old joined our family full time this past November. She attended her locally zoned public school until Christmas break. We received permission from CP/FS to homeschool prior to that and used that as the logical break. She qualified for a spanish immersion (language, social studies, and culture) gifted and talented program at our local charter school and attends that on Tuesday and Thursdays from 9-11. We do everything else at home and there are at least four or five other kids in her class in similar situation. The other half of the class has this experience as a "pull out" from their regular school day and attend a brick and mortar public school full time. I'm afraid I've given you way too much information. (The reality that I've been interrupted a few times while typing this out should tell me something.) Please let me know if you have questions.

We have done this although the arrangement is a bit more individualized to the individual student. We're about to sit down to dinner (I have a good husband who makes dinner on the days I work---ok and some days I don't work too) but I'll try to pop back in later tonight or something to add more.

Suicidal thoughts need to be taken seriously (and sadly often are not). I can't fault how the school handled things yesterday and I would encourage you to not dismiss this as something she just said because she was upset. I presume they gave you some referrals from the psych ED, please follow through with those. ***I think I missed your earlier post or posts about the bullying incidents so I'm not excusing the school if they didn't handle that well. However, I think the most important thing now is to focus on helping your your daughter heal and I'm concerned that pursuing legal action against the school on this front may interfere with that. I do understand that we have to stand up and correct injustices so that those who come after us will have something better. I would strongly support you to pursuing this matter after your daughter is in a better place for that reason. Best wishes to your daughter and your family!***

Congratulations to Rebecca on a successful season and best wishes on L5 (and of course the kip). I'm sorry that things aren't going so well at the gym. Our (now thirteen) daughter was ten when she switched gyms (mainly because she came to live with us and the gym she is at now is very close to where we live but my MIL was familiar with her old gym and had vetoed it for my husband's little sister so we sensed it wasn't the best place for her) after taking a more than six month break from the sport completely. At the time she started at the gym my husband's little sister was finishing up her final L10 season and my MIL was very involved in the parents' organization so we had a connection there which did help. My SIL has continued with D1 gymnastics in college, still trains at her old gym during summer/ school breaks, and drives her niece to practice on those days which probably does up her "cool stock" considerably. In spite of these advantages this is really the first year that our daughter has a training teammate she is really friends with. In the past all of the girls were good teammates (they cheered for her, encouraged her, and included her in things at practice) but they weren't involved with her outside of the gym. I didn't think this was so bad because she was ten when she scored out of L8 and then competed an abridged L9 season right after she turned eleven. The rest of her L9 team were 14-18 so the age gap was significant. I would say it was a bit more significant because emotionally she was probably a little younger than her chronological age as well. Honestly, I would have let her go to teen night at a local club with them even if they had invited her. Things have gotten better as the age gap has closed and she has healed from her earlier trauma (with her biological parents not due to gymnastics). Are the girls on Rebecca's L4 team her age? Our gym doesn't compete L4 (although I guess we will this fall when L5 is renamed L4) but we usually have some seven year old L5s and the gap between seven and ten can be large for some girls. If this is the issue then moving up with some girls closer in age may work some of this out. I will also concede that there are some crazy gym moms out there and maybe you have some at your gym. We're blessed that we really don't. We had one mom who came across that way (but as I got to know her I realized that she was so over invested in her daughter's gymnastics because that was an escape from everything else in life that was pretty awful for their family at the time). Her daughter is no longer rushing through the levels and had a successful L8 season. With the changes to L8 and her struggles with bars she may repeat L8 in 2013-2014 but her mom's reaction to that is totally different to her reaction three years ago when the coaches wanted her to compete L7 instead of scoring out and her mom pulled her from the gym with a lot of drama. Her second tour through our gym has been much different and she acknowledges that gymnastics is her daughter's sport. So even purported crazy gym moms can have epiphanies. We all have our moments…. Best wishes to Rebecca in her gymnastics journey. If she doesn't already have her kip then we're sending strength, coordination, and timing to help with that.

Tam, Thank you for your empathy. I think if the PRS elements are better described by an organic medical problem then it isn't PRS. In our foster daughter's case I really think so much of this is grief (and some reactive depression). She came to us from the only parents she had ever really known. She is only four and I understand that this is difficult for her to process but we are concerned because she is miserable and that is just so hard to see.

With the disclaimer that I am not actually seeing the child and thus I am NOT offering medical advice, if this child presented to our ED with this story I would order a Head CT. It is pretty much accepted practice in our ED and considered the standard of care in the field of emergency medicine in general. In children under 2 years roughly 10% of kids with intracranial pathology (noted on CT) will appear normal and have normal neurologic exams. The younger the kids the more difficult it is to get a good neurologic exam and there is a lot of developmental variability which can confound the clinical picture as well. Thus there is good rationale for this approach. Additionally children in this age group (and even more so in children <1 year) skull fractures after even relatively minor head trauma can be common. Studies of pediatric head trauma have identified scalp hematomas (which sounds like what the OP is describing) as a positive predictor in this context. Am I certain that this child has a skull fracture or some other intracranial pathology based on what has been posted? No, but I am not certain that everything is fine either. If I apply an evidence based approached (which I really try to do in general) then I'm going to order the Head CT and go from there (unless of course my exam identifies other problems that need to be addressed first of course). Our youngest daughter is almost six months. If she was in this situation I would certainly expect our pediatrician/ ED physician etc to order the Head CT.

Clinical judgment is based on an attempt to put together the big picture from all pieces. I can't really commit one way or the other without seeing the child and having all of the information to put together. I guess I can perhaps see a few situations where if there was good follow up and the CT of the brain was completely normal and the skull fracture was linear and not depressed that I might be comfortable with that. I can also envision some scenarios where I probably wouldn't be. It really depends and there are probably some nuances that can't be conveyed well through online environments. Good Luck!

Well, after reading half of this thread, I am so thankful for the wonderful neighbors we have.