School's Reintroduction to Honeybunches Letter

School begins next week.  I have been working on a "Reintroduction to (Honeybunches)" for a couple weeks now.  I finally have it pretty much done.  Although he had this teacher in the past, it's been a few years.  Here is what I wrote:

"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 1^st 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 29^th (Counseling) Pick up at 2:10

September 4^th: (Psychiatry) Pick up at 1:30

September 12^th (Counseling) Pick up at 2:25

(Will pick up every other Thursday for counseling at this time until further notice.)

September 18^th: (Endocrinologist) Pick up at around 1:30

September 19^th: (Physical) will be late (Estimate around 10 am)

September 26^th (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.)"

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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).