"Dear Mr M----------,
I
wanted to give you the following updates regarding ----.
Current
Diagnoses:
The
most recent evaluation we had done for him (And what his current
psychiatric nurse practitioner is going by) state that his primary
diagnosis is Autism
Spectrum Disorder and
Bipolar Disorder
is secondary.
Current
Medications and Medication Related Concerns:
--'s
current
medications
include Lithium ER, Abilify, Clonidine, Tenex, Cogentin, Qvar and
Metformin. The psychiatric nurse practitioner just increased his
Abilify last week due to showing some signs of mania and anxiety.
With his Lithium, he does best when his levels are at the higher end
of the therapeutic range. Because of that, if he doesn't drink
enough (But sweats a lot when it's hot), he is at high risk of
Lithium
toxicity. We try
to encourage
him to drink,
but don't really push the issue too much because that backfires.
Over the Summer, he drank plenty and it was not an issue. I send him
in with a water bottle and flavor packets to add to the water. If
he
seems to not be drinking much, please let me know.
In the past when that happens we've seen success with just changing
the flavors of the packets we send him with. On days when it's very
hot I send him with Powerade or Gatorade as the salt in them helps
prevent Lithium toxicity and dehydration. His Abilify and Lithium
both make him at higher risk of getting heat
exhaustion and heat stroke.
I apply sunscreen
before school in the mornings when it's hot but would appreciate it
if either you or the nurse could assist him with reapplying it before
afternoon recess on hot days as well. (I
have a bottle of sunscreen in his backpack to leave at school.)
He has his Tenex
around 11:30-12:00
each day. He has a PRN
prescription for Clonidine
for when he’s very agitated (In my opinion, the only time I would
want to give it to him is if he seems like he's going to be
physically aggressive towards people and uncontrollable as a last
resort). It is on
the medication order form “Call Mom first”
before having the nurse give it to him because we only want to use it
rarely, when other calming techniques have not worked and not too
close to his dose of Tenex. I did leave some with the nurse and
filled out the proper paperwork just in case he might need it at
school.
Concerns
and Challenges:
When -- is hungry
he gets very irritable,
especially if made to wait. He has a hard
time waiting in general,
but is even more impatient when it comes to food. At home over the
Summer he often ate breakfast at 5 am or 6 am at the latest. He has
a morning snack at different times when he's hungry usually around 8
or 9 am. By 10:15-10:30 he is usually ready for lunch. If I tried
making him wait until 11-11:30 he often got angry. He's been sleeping
well at home for the most part, but is a very early riser always
waking between 4-5 am and sometimes earlier.
His
brain
often gets stuck on one thing and it's hard to change it.
For example, when he orders things off Ebay which he does often, he
wants to check the tracking information literally about 30+ times per
day. He still
does best when things remain consistent. He still likes
to test people.
He
did wander a few times last year at school,
which is my biggest
concern during unstructured times.
It would be in his best interest if he is supervised well until he
can show he is trusted (Even on walks to the nurse's office). He's
been threatening
us
a lot with what he will or won't do
(For example “If you don't let me ____ then I'll _____”) His
threats are usually about throwing or breaking things but sometimes
aggression. -- using words is an improvement and beneficial
because it helps us often divert these threats from becoming actions.
He
still struggles
with transitions.
Besides the change of him coming into your class, he’s had other
changes in his life.
His best friend next door (Who was his 1st
out of school friend) moved at the end of July. He was mad at her
for moving. He still has a hard time knowing how to express sadness,
so often times it comes out in anger instead. He still struggles with
identifying the correct words for how he is feeling, although we've
seen some improvement at that area (Usually to tell us he's
mad/angry). When he’s upset
he needs his space and doesn’t like to talk
(At least not
immediately). The counselor B who he was seeing at YOU Inc for the
past six months got a new job a couple weeks ago. He
has his first appointment with the new counselor (Named
Melissa)
who is taking over his case this Thursday.
The previous counselor L, who he seen there from ages 4-10 years
old, finally retired at the end of last year. He
still has sensory issues and cannot tolerate loud, crowded activities
(Such as assemblies, crowded cafeterias etc).
Demanding him to be in such a place after he's used his words
stating he doesn't want to be there almost always causes aggression
or other behaviors.
Home-School
Communication:
I am
hopeful that we can use a home-school communication book and/or email
to communicate frequently. It's
important
for me to be updated on how his days (Behavior, attention span, etc)
go for medication purposes.
I
appreciate being updated
on any changes you see with him.
For example, some things such as odd movements especially facial
ones including lip puckering/tongue slithering (Which are both
symptoms of Tardive
Dyskinesia from
Abilify), abnormal limb movements (Such as jerking arms and legs
which could be a Dystonic
reaction
that he's presented with in the past on a different med, but is
possible on one of his current ones),
internal restlessness (Akathisia
which he also presented with in the past from Abilify),
other
movements + behaviors that are out of his norm
could be medication side effects and need to be brought to his
doctors attention right away. The
lip puckering is the most recent side effect we've noticed, even last
week so please keep an eye out for that.
It's best to know about behaviors or side effects early on (Even when
things you mention might not seem important), so I can share concerns
with his psychiatric nurse practitioner. By doing so, we have been
successful stabilizing him again with just making small changes with
his medications.
Upcoming
Appointments:
---
is being followed by several doctors (Endocrinologist and
Gastroenterologist) down at (The big hospital). We have found
that afternoon appointments, before his dinner time (Which is a very
strict 4 pm in his brain with no leeway unless it's a few minutes
early) help him be more cooperative for his counseling, psychiatry
and other appointments. Unfortunately these times do interfere with
school just a bit. His
upcoming appointments in the next month are:
August
29th
(Counseling) Pick up at 2:10
September
4th:
(Psychiatry) Pick up at 1:30
September
12th
(Counseling) Pick up at 2:25
(Will
pick up every other Thursday for counseling at this time until
further notice.)
September
18th:
(Endocrinologist) Pick up at around 1:30
September
19th:
(Physical) will be late (Estimate around 10 am)
September
26th
(Counseling) Pick up at 2:25
I
will write reminders about his upcoming appointments in his
communication book.
Recent
Interests and Positive Traits:
--- loves police, trains, ambulances, fire trucks, bugs, caterpillars,
spiders, Beanie Babies, Webkinz and trains. He likes to wear his
play police badges and carry around his handcuffs as he pretends to
arrest people. He loved it when Officer S--- stopped in front of
our house frequently to talk to him over the Summer. His favorite
school activity last year was “Word-of-the-day” which he liked to
take home and do with either his sister Monica or I. One thing he
does that shows his caring heart is that he sometimes gives us
rewards for when we do a good job and lets us pick from a prize box
he makes us.
He
often thinks about his sisters giving them money or buying candy for
them at the store with his yard sale money. He notices any little
changes in the environment, has a good sense of direction and an
amazing memory. He loves getting $2 bills, dollar coins, fifty cent
pieces and other uncommon denominations of money from the bank. He
has very good negotiating skills (Which he's been putting to use a
lot lately). His imagination has blossomed over this Summer (For
example has an imaginary police boss named Andy who he has to call to
check in with). His favorite thing to do on his Ipad is Dragon City.
How
His Summer Went:
--- spent most of his Summer outside (Riding his bike, playing with the
little girl next door who recently moved, looking for spiders, etc).
He found a new hobby of setting up a table out front with some of his
old Beanie Babies, books and other toys having himself a little “Yard
sale”. He made a good amount of money doing so which kept his
interest. He's
still very reward driven.
At
home we have a system we call “Marvelous Marbles”. This has been
working okay because we can change up the rewards based on his
interests. Currently the three goals have been using his coping
skills (Deep breaths, taking space, etc), using nice hands + words
and picking up after himself. He can get 3 marbles per hour. When
he gets to 100 marbles he earns something from “The Marvelous Bag”
which is filled with cheap toys, flashlights, bug catchers, games and
other small stuff I find at Dollar Tree. Over the Summer, he did have
some ups and downs with his moods, some aggression and irritability,
but nothing major. They mostly happened around the full moon each
month and also in the past few weeks when I think it was related to
feelings regarding coming back to school.
I look
forward to all the progress that --- is going to continue to make
with you this year and working as a team with you to make his
educational experience fit his needs the best it can.
Thanks,
-----------
Attachments:
Summer Heat and Sun Risks, Information on Tardive Dyskinesia,
Akathisia and Dystonia.(The last three are excerpts from NIH.gov.)"
**************************************************************
So there is the four page letter I wrote to Mr. M. I plan on writing the counselor just a quick update about his Summer. Since she worked with him last year, she knows some things about him and got the extended version upon beginning to work with him. I also am sending in the Summer Heat and Sun Risks pamphlet, the info about TD, Akathisia, Dystonia, and Lithium toxicity to the nurse (Who is going to be a new person this year too as the previous one retired).
