As I responded to your other post, much of this does vary from state to state, from county to county within the same state, and to an extent on the situation and type of placement. We have largely taken treatment/medically fragile/ and emergency (often medically fragile as well) placements. Through this program, in our state, and especially in our county, it is not uncommon for judges to give foster parents guardianship in these situations. Because we have guardianship, my husband or I can sign as readily for DFD6's medical care as we can for our two younger biological daughters DD5 and DD2. I do need to keep the caseworker apprised of what we are doing and I suspect there is some oversight (although we've never really had anyone question our choices) that is not there with our younger daughters. In our state, if we did not have guardianship, it is my impression that the caseworker would actually need to be authorizing most medical care. As far as Medicaid, our state insurance regulations recently changed allowing us to not consider Medicaid primary for our foster daughters. In the past although they were also covered on the insurance that DH covers the entire family with and the insurance that my employer provides our family their Medicaid was still considered primary and that was just cumbersome. Now we can still use their Medicaid if we choose to but don't need to jump through hoops where we end up ultimately paying out of pocket because Medicaid won't pay (or the only pediatric nephrologist in the area won't take Medicaid) and DH's insurance doesn't feel they should pay because Medicaid is primary and won't pay.

We have never foster parented in KY so our experiences may not be completely relevant [because state laws and regulations do guide much policy], but generally in our area counseling/evaluation are part of the foster care package. I will also say that in general foster parents are encouraged not to speak unkindly about the children's biological parents to them. There are many reasons for this and I think it is important to understand that even horribly abused children may still have some connection and bond to their abusive biological parents. When we have adopted through the foster care system we have always viewed our family as their second chance family, because, truly in an ideal world the parents who created them would also be the parents who were capable of raising them in a safe, loving, and nurturing home. Unfortunately that doesn't always happen and I think that is where adoption can be a great thing but I think that as adoptive parents we have to understand that as much as these children really are a blessing to us, and as much as we really are doing our best for them, that their adoption may evoke feelings of loss (of their original biological family). I think we need to be understanding and compassionate about that and only by doing that will we really become their parents.

You and your husband can hang out with me and my husband. We're equally cool [or boring I suppose depending on perspective]. We're also big believers that adolescent brains [and adolescence really can extend up to age 25] are particularly vulnerable to the effects of drugs and alcohol and we share that with our kids as our basis for zero tolerance [at least while they are living in our home, deriving financial support from us, and or driving automobiles we own or purchased for them].

Two of my husband's relatives [one uncle and said uncle's wife] are veterinarians. Additionally, his son married a veterinarian's daughter and DFD10 and DFD6's biological father was a veterinarian. Our eldest daughter considered pursuing veterinary medicine when she was 12/13 but ultimately got more interested in biochemistry and molecular biology and the human applications of both disciplines which will probably translate into her pursuing a MD or MD/PhD after college [right now she is finishing up her sophomore year]. Now DFD10 thinks she wants to either be a veterinarian or a pediatric pulmonologist so we've continued to have an interest in the field. Random thoughts based on what we understand from our family connections and some conversations we had relating to our kids possibly have similar aspirations: -Kids considering pursuing this field definitely need to have some exposure to it [applications usually ask about animal experience hours for example and may want recommendation letters from current DVMs familiar with the applicant] ideally by some internships and or paid work in the field. Our eldest daughter could have worked for her uncle (or her brother's FIL) during later high school summers and then continued with that during college summers and breaks but by the time she was old enough to do that she was more interested in molecular biology bench research and she did that. This will be an option for DFD10 when she is older if the interest is still there and I think it will give her a good look at what the career really entails as well as meeting the animal experience requirement. Actually in her case, I think her dad's former partner would love nothing better than to mentor her in this way and I think for many reasons that may be good for both of them even if she doesn't ultimately pursue a DVM. -Vet school admissions are definitely competitive. This is one area where I do think that selecting undergrad which has an on campus Vet school can be really helpful in terms of establishing connections, having opportunities for respected undergraduate research that will aid in admissions etc. From a financial standpoint, it may also make sense to do what one needs to do to establish residency in the state where one wishes to go to school because that can make significant difference in tuition. Tuition also varies quite widely from state school to state school and, in some cases, it may make sense for a child to plan to establish state residency in a different state for this reason. -As far as Vet's making 70k their first year out, I think that salary does fit in some scenarios [there is a bit of geographic variation and differences based on practice focus etc]. Interestingly, it is much more than I made my first year out of medical school and still about 15-20K more than my husband's son is making now in his first year out with his MD. Now my current salary, even working only part time in emergency medicine/toxicology, is much more than that and I fully believe that DSS will see his salary climb significantly when he finishes his surgery residency but I just wanted to point that out for some context. -As far as specialization for increasing salary I think that really depends. We have a family member who is a DVM surgeon and is making a lot more in private practice doing a mix than he/she would working in academia (which is where the most of the subspecialty jobs still are in the DVM world). There were other family factors that influenced their decision beyond the money but I know that at least for them the money is much better being paid as a generalist in the private sector than a sub specialist in the university setting.

I didn't vote because no option completely fits our situation. We eat breakfast (which is usually prepared by DH or myself but often with some involvement and assistance from the kids) together as a family eat morning. We meal plan and try to do something that has a good mix of fat and protein and is not carb heavy. Since we eat breakfast around six thirty the kids usually do get a balanced snack between 9 and 9:30. On days they attend classes on campus they head to school right after that snack and brushing teeth.

I would pursue a full evaluation with both his MD/DO PCP (FM, IM or Peds) to exclude organic causes and then psychiatry for medication evaluation. I personally would be quite wary to push anyone to take supplements recommended by a naturopath. I realize that some people feel more comfortable using supplements over medications that have actually been through the FDA approval process but I really think this is a false security for most. Good luck!

If you want to share more via PM that would be fine. My husband and I have been/are currently therapeutic foster parents and have adopted through the foster care system. [Additionally, if you're a member of our foster parenting group which is private you could share there without the concerns of your post being google searchable later and would get a broader range of opinions.] As far as TF-CBT it is based on the PPRACTICE approach and can be very parent collaborative. Our daughter was 11/12 when she did TF-CBT so we did a lot of modeling skills and reinforcing and encouraging skills use at home. I think that the younger the child is the more critical this collaborative aspect will be. Having said that, TF-CBT has been adapted enough to be used with very young children; I believe that the studies included children down to age three. PPRACTICE Psychoeducation (What is PTSD, trauma responses, etc) Parenting Skills (Adapting parenting to the traumatized child) Relaxation Affective Modulation Cognitive Coping Trauma Narrative (with cognitive processing of the narrative) In-vivo Exposure (gradual) Conjoint Sessions (parent and child sessions which may involve some additional cognitive processing) Enhancing Safety/ Encouraging Future Development

How old is the child in question? How long have they been with your family and what is their current status (i.e. foster, long term guardianship, adopted)? Are there other comorbid attachment concerns and behaviors?

TF-CBT would be my recommendation. I will also acknowledge that EMDR does have an evidence base (at least theoretically although sometimes it is hard to really buy into that since the mechanism is still not well defined) so that could be another option. We didn't pursue that for our daughter both because I was a bit skeptical and because I was she would find it a bit traumatic and disruptive itself. As far as medications there isn't a lot of great evidence for their use in kids with PTSD. It seems like alpha and other adrenergic blockers hold the greatest potential but they haven't been studied quite enough and they were never really an option for our daughter because of her underlying renal disease.

Prayers for you and little Caden.

A lot of the inherent risk would depend on what actual doses of the three drugs she was on and how much she actually took. Did she just get a double dose or did she take a handful. Dosing may not be certain if the child self administered and is not reliable (as seems to be the case from the information shared) or mom may have been able to back calculate what she actually took based on the quantities left in the bottles and perhaps that did exceed a double dose. Additionally since both TCAs and Risperidone have the potential to prolong the QT interval poison control may have recommended that the child go to the ED and at least get an EKG done. I really think that unless you happen to be a fully licensed physician who is also board certified in child & adolescent psychiatry AND who has evaluated this child you really have nothing to back up your criticism. If you do meet the above criteria then I would hope you would be a bit more professional in regards to safe guarding protected health information of your patients. The reality is that this cocktail of medications may be very appropriate prescribing within the standard of care. The issue didn't arise because the child took the medications as prescribed and had a problem. The problem seems to arise because the child took extra doses of the medication not as prescribed. I really don't understand why you are sending your wrath to the prescribing physician and feeling sorry for a school counselor who (if accounting of events is accurate) at best exercised very poor judgment which could have resulted in significant harm or even death of a child, and depending on state laws may have actually committed a few felonies in the process. Lashing out at the child's mom does seem to be a bit of victim blaming. Perhaps she does need a better filter, or perhaps she was just overwhelmed and terrified in the moment and turned to social media. I will admit that is not how I process but there are many worse things I think this mom could have done. Just to clarify: -Risperidone is actually FDA approved for use in kids down to age 6 for certain diagnoses. I would not say it was rare in the population of kids with those diagnoses who come through the ED where I work. -Sertraline does tend to be activating enough that it is usually dosed in the morning. Most clinicians use once daily Risperidone and have no reason not to dose it in the morning (and may be even more likely to do this if they are giving other AM medications in an effort to improve adherence). I suspect you are thinking of extended release Trazodone in the context of off label use for sleep with QHS administration. This is possible, of course there is also immediate release Trazodone which is usally given in split doses through out the day. If being used for pediatric depression it would be likely given this way. As a caveat I will say that, in peds I see psychatry sometimes much more likely to stick with the TCAs because there is so much less testing of/ experience with the SSRIs (excepting Fluoextine) and SNRIs in children. In adults TCAs have largely been surpassed by the SSRIs and SNRIs and we are more likely to see TCAs being used off label for insomnia or chronic pain. I'm not saying that what the counselor is reported to have done is in any way appropriate and if she really did everything that has been attributed then she should definitely be losing her job AND any license she may have. So perhaps you are right that this just didn't happen but sadly I have seen professionals at all levels exercise poor judgement and or practice outside of their accepted scope so it is not unfathomable to me that this could have happened.

The posters who have suggested that Eclampsia can present after pregnancy are correct and that could explain the swelling (although usually blood pressure will not be normal with this). Another consideration (and what it sounds like your doctor is more concerned about) is postpartum cardiomyopathy. This is where the heart doesn't function (or squeeze) the way it should and as a result fluid does build up and this can lead to pulmonary edema (where fluid accumulates in the lungs which interferes with gas exchange so patients can present with breathing difficulties and hypoxia). Diagnosis of Postpartum Cardiomyopathy is supported by an elevated BNP and evidence of decreased systolic function on the echocardiogram. Stronger diuretics (ie Furosemide as opposed to HCTZ) can be used to manage fluid and medications to help the heart squeeze better (ie. ACE inhibitors, certain B-blockers, aldosterone agonists etc) can be used to treat. In more severe cases IV medications like Dobutamine or other pressors can be used for unstable patients. The prognosis with PostPartum Cardiomyopathy is variable. Some women do get back to having completely normal heart function (although the problem can recur with subsequent pregnancies and the outcome may be much worse a second time around so this is generally to be avoided) so even if your doctor's concerns are completely correct it is still very possible for you to have a good outcome. If you have edema as a result of renal failure, congestive heart failure, and or liver failure that lead to volume overload states drinking lots will not help with the edema. It will increase the volume overload and thus increase the likelihood of developing pulmonary edema.

It depends on what you are looking for. I think it is a relatively large but very decent state public university. They would have her potential major. Out of state tuition is nearly 40K/year so that may be a deterrent depending on your college budget. I will concede I have more exposure to the sciences than the humanities at UVM. My stepson was accepted there for medical school and strongly considered it, ultimately he ended up with a substantial, and really too good to turn down, merit scholarship at another school closer to home and went there.

This is interesting to me because although our eldest daughter is currently a scholarshipped D1 athlete playing one of her childhood sports she took a medically required break from athletics during the late middle school years. That break put her in a position to go places with her music that I don't think would have been possible if she had continued at the highest level with her sport continuously. When she was able to go back to her sport she had to be a little creative to continue with both but they were both important to her so she did. [Having a gifted IEP that allowed a hybrid approach with our local high school and our home school certainly made this easier but we fell into this approach because she was looking at outside of the box solutions and we and her school administrators were trying not impede forward progress.] Ironically, I believe that for her science/medicine are her passions above either sport or music and she selected her college based on their molecular biology and biochemistry departments. Although she still plays music (and managed to place into a jazz composition course usually reserved for majors to fulfill a general education requirement) she has decided at this point that there just aren't enough hours in the day to be involved in any kind of ensemble and I think this is wise. At another point in her life I could see this changing.

You might be describing our DD2. Of course she is still two so it is a little early to tell and she was entranced with the piano before she could speak in full sentences to really beg for anything. My husband is musically gifted and those genes clearly passed to our eldest daughter so this could certainly be her gift and passion or the interest may fade. I guess we just kind of follow her lead and make her clean her room and at eat her vegetables as we go.

If the first X-ray was done right after the injury this can be the case (and even up to the first 48 hours after injury). Generally, if the patient remains symptomatic without improvement we repeat plain films at 5-7 days post injury. If repeat films are still negative then we look for other explanations. Plain films are good at identifying fractures, dislocations, gross joint effusions, and some soft tissue swelling. They do not image ligaments, menisci, or fine details of joint spaces well so MRI or CT may be useful in this case. Another thought would be to look at referred pain patterns, and to consider that some of this may be self stimulating behavior. If it is self stimulating behavior she can still injure herself in the process so that doesn't mean you shouldn't make sure she hasn't done that or that you shouldn't try to keep her from doing further damage by using a splint or brace to protect the injured hand. That of may just cause her to injure something else but I think that is just an example of the sad situation your daughter and family are in. In some cases medication adjustment may also help with this so that may be something to discuss with her pediatrician and/or child psychiatrist. :grouphug:

Prayers for your son and his team.

I think what is "standard" for a Sweet Sixteen varies based on family culture and to an extent location/community. In our family culture, Sweet Sixteen parties are formal affairs so there is a multiple course catered meal with the dessert course usually based around the cake but also augmented by a dessert bar (fondue is big right now). I would say that this approach to Sweet Sixteen is also fairly common in our community just based on the parties we and/or our daughters have been invited to over the past five years. Personally I have not heard of a Sweet Sixteen party that consisted of only Cupcakes and Candy to keep with the "sweet" theme based on having friends with teen daughters or having two teen daughters of my own who have attended these things over the years. As far as having a cake and icecream only birthday party I'm sure they happen (and to some extent I think when you do just cake and ice-cream at least you get some protein/fat from the ice cream to stave off a bit of the reactive hypoglycemia from all that sugar) but at least here they are more common for the under five crowd where parties may only last an hour because that is age appropriate. Having said that, obviously it is your daughters party and you are free to do whatever you want. I can say that both of my own girls would be unlikely to eat the candy and ultimately would have likely been much happier if real food or at least something with some protein was provided. However, they would also recognize that it wasn't their party so it wasn't their choice and I don't see either of them being impolite about it.

I'm glad you finally got an answer, Martha. :grouphug: Hugs to you and your family.

DFS/DGS29 was also already in school when I met him. From things he and my husband have said I am guessing he was not reading in kindergarten and not really excelling with reading in first grade. I know he expressed his concerns regarding his own little boy based on his experiences but he is reading well and seems to be doing well. Having two proactive loving parents and a mom who is an elementary educator probably have helped on this front. DSS28 was already in school when I met his dad (and him). However, he remembers being all excited that he could pick out words and sometimes even read entire portions of the law contracts his mom was reviewing at home. Sadly, she died when he was four so I presume he was reading quite fluently by kindergarten. DD19 grew up with books and being read to (and running around outside, kicking soccer balls, and riding horses). Although her dad and spent a lot of time reading to her and answered and encouraged her many questions we didn't do formal instruction or try to teach her to read. Something clicked when she was around three and she made the connection that letters came together to form words and wanted to understand more. We just kind of went with it all and she was reading fluently by the time she started kindergarten when she was four. DFD6 was just beginning to read a little when she started kindergarten in Fall 2013. She had turned five the prior May and at that time had not been reading at all (and I really had no idea whether she even really knew numbers, letters, or anything) but she was profoundly depressed and I think she had a lot of skills regression and no interest in anything for that reason. School readiness was so far off our radar at that point but once the antidepressants kicked in or a miracle occurred and she became a child again it was clear that she was a bright kid (not a total surprise given that her older full sister tested PG). We did do more specific prep for school stuff with her that summer because she wanted to go to kindergarten. I admit I had my reservations, there was a part of me that just wanted to keep her home, love her, and enjoy that she was no longer miserable. But I also thought that it would be good for her to have a peer group beyond her siblings (and both her caseworker and the child psychiatrist thought school could be good especially if she could get into the part time hybrid track--which she did). She gained a lot of ground over that fall between kindergarten and what we did at home. She was reading fluently by Christmas 2013 and there has been no stopping her since. DD5 also grew up with books and being read to---by many people who loved her. This didn't cut into play time. She also had plenty of time to run around outside, nurture the family horse gene, and swim many miles (no not at a time but over the course of her childhood so far that has definitely happened this is the child who thinks she was born with fins). She also was making the first steps to reading around three so DH and I helped and encouraged and she was reading well when she started kindergarten last fall at age four. We did do a little more formal phonics with her because we were working with DFD6 (when she was DFD5 and DD5 was DD3/DD4) and we often let both girls participate in whatever we were doing. DD2 learned her letters playing scales (she has been entranced with the piano since she could sit and DH taught her scales to divert her preferred activity of banging on keys). She has yet to meet a book she doesn't want someone to read. She also wants to do everything her big sisters do and loves trips to the farm to see her favorite cows. She can read some simple phonetic words (animal sounds are easy to sound out) and has good letter recognition. I suspect she will be reading soon but we're in no rush for that. DD15 and DFD10 came into our lives when they had already completed fourth and second grades so I'm not sure where they were before kindergarten. DFD10 has a lot of memories of books she loved when she was little that her biological parents read so I suspect she grew up in a literature rich home before her parents' death. I know that DD15 attended full day academic pre-school at ages three and four and I get the impression that she was taught to read there.

:grouphug: Ok, I guess don't take this as medical advice because I don't believe in practicing online but some things to think about and discuss with the doctors who are treating you in realtime: -Are they basing the eight week estimate on the level of the quantitative B-HCG? There can be some variation with that from woman to woman so it really should be used only as a rough guideline. I realize that some women have irregular cycles and other women just don't track their cycle but in women who do have a good understanding of their cycles I find it most prudent as a physician to approach the situation as if they know what they are talking about until I have objective evidence that they are somehow mistaken. -If the B-HCG is sufficiently high (usually >2000 definitely >2500) and they can't visualize anything (like a gestational sac) in the uterus with a transvaginal approach then that should be considered an ectopic pregnancy until proven otherwise. -Ectopic pregnancies need to be identified and addressed in prompt fashion as there is the potential for rupture and hemorrhage which can be life threatening. -If they can see a gestational sac in the uterus but no heart beat then this may represent a pregnancy that is unlikely to continue but (and especially if your dates suggest you are really only four or five weeks) it can also represent an early perfectly healthy pregnancy. In this case, since it is clearly in the uterus there is not the ectopic concern, so it is reasonable to continue to monitor (climbing/doubling B-HCGs are reassuring and repeat ultrasound in 7-10 days should show growth of the embryo and ideally a beating heart) and hope and pray for the best possible outcome. I hope this was helpful and I hope you get some good answers soon. Hang in there!

Who cooks in our family? In short, pretty much everyone. [before anyone gets concerned DD2 really more "cooks" or "bakes" by dumping pre measured/prepared (by mommy, daddy or responsible older teenage sister) dry ingredients into whatever creation is in process. My now DD19 had similar opportunities when she was that age and it is because she enjoyed them that we have allowed her younger sisters to continue the family tradition.] More practically, DH and I* alternate breakfast and dinner preparation depending on our work schedules. These are the two meals we sit down with the whole family. Lunch is shared by those who are home at lunch time and prep is supervised by whichever parent is home. We menu plan together for two weeks at a time and develop a plan at that time. *Our teen daughters will often take a night or two of dinner when they are home and our younger children will cook with us for (or their siblings) for fun and family bonding.

:grouphug: My husband's godson who we raised as a teen struggled with this a lot during adolescence. I didn't know him when he was your son's age but, from things my husband has said, I suspect he struggled then although to what sounds like a lesser degree than your son does and definitely to a much lesser degree than during adolescence. I do think that some of his struggles when he was younger didn't stand out as much because his peers were also younger and the reality is that even neurotypical four and five year olds can be a bit unpredictable and emotionally labile at times. I also think that his biological father really knew him and all of his cues and quirks which helped smooth things out a lot. I think we saw a lot more struggling in adolescence because in addition to all of the circulating hormones there were also grief issues (he came to live with us after his father's death after a brief stint living with his biological mother who was in no position to parent) and to an extent his whole life at that point was a series of abrupt and unpleasant transitions. In full disclosure, our godson was also diagnosed with ADHD and treating that did help a lot with transition issues and life in general. There was also a lot of question about some kind of conduct disorder or intermittent explosive disorder but neither of those diagnoses really fit from my husband's perspective even during the worst moments. Ultimately, once he had some measure of stability in our family and the ADHD was managed successfully none of the professionals really felt those diagnoses were right either. Years have passed, he is now a detective with our state police force and married with a little boy of his own. His son is a few years older than your little boy and he has benefited from medication for ADHD (and from having two parents who love him and get him and devote a significant chunk of their lives to helping him succeed). Because his father managed to transition to non stimulant medications for his ADHD in later adolescence our grandgodson's pediatrician opted to start there initially and see if by treating early and titrating they could be successful without stimulant therapy. That approach is working well so far but I know his parents are willing to consider stimulants if it comes to that point. Admittedly, I don't know your son and only have a partial picture of everything from what you have shared here but I do see some flags for impulsivity that many not all be explained by developmental stage. I know for our godson getting the impulsivity issues addressed were key for allowing for overall emotional regulation. Just something to consider....

Is the work he is not doing intended to reinforce concepts you have already taught? Generally what I have found works best with most of our kids is to go over the concepts and then assign problems, reading, and or projects to reinforce/solidify those concepts. This often also can double as an assessment tool. If they aren't able to work through problems then we may need to go back to the concepts again in a different way to ensure that they are really understanding. I realize that this is congruent with the approach in good school systems and therefore there are some posters that the idea will be distasteful just because of this common ground. I don't know you well enough to know if you fall in that camp, however, if you don't, I think I would take some steps to make the day more interactive and have you be more involved in teaching. If you can't, or don't want to, take that kind of an approach then you may want to consider other educational opportunities where you child could have a taste of that approach and see if it worked better for him. As an aside, I grasp that whatever approach you are using likely worked very well for your daughter. While that is great for her, it doesn't necessarily mean that the solution is to just keep up with the same approach for your son. All kids are different. Our eldest daughter did reach a point where she pretty much self taught most of her high school math from an assigned curriculum. DH and I were available to answer questions, provide assistance, and throw out some problems she hadn't seen to make sure she really understood what she was doing not just learning how to solve the specific problems from her text through repetition. We were a bit wary but she really was quite fine on her own. More than that, she enjoyed figuring it out herself. In contrast, DD15 benefited from much more structure and instruction in algebra I&II, geometry, and now trigonometry and advanced algebra. With that she has been successful and has a great foundation in math. Both daughters are bright and competent but different learning approaches work better for them.

Who owns the property where the RV is currently parked?