Amy presents with the classical features of Asperger’s syndrome.

Diagnosis of this condition needs to be made by the appropriate healthcare professional, usually a clinical psychologist or a psychiatrist. It should be explained to Amy’s mother (in private) what your suspicions are, and the need to consult a mental healthcare expert. The impact of Asperger’s on both the child and her family cannot be underestimated. Repercussions from their behaviour may affect physical, mental and emotional wellbeing of the child and his/her carers.

The full criteria are available from reference 1 at the end of this chapter.

One feature of this disorder is a preoccupation with a limited number of activities. The nature of the favoured activity — if involving sedentary behaviours — may decrease the amount of exercise the child does. Similarly, difficulties in social interaction with peers may limit the time spent in normal physical activities of childhood playing and games.

The stereotyped and repetitive mannerisms that are typical of the syndrome may potentially interfere with normal motor function. Spending many hours hunched up over the computer or a book may cause muscle tension and/or possible pain.

Puberty is a time of great change for every child, and the reaction each individual has to it is equally diverse. It is possible that Michelle’s behaviour is quite normal. However, it is also a possibility that she has a problem, which needs to be identified and managed. To clarify the situation, it may be helpful to suggest that she consult a professional who is trained in such matters. Her medical practitioner would be the first port of call and, if necessary, a consultation with a paediatrician, clinical psychologist or paediatric psychiatrist may be required.

There is insufficient information given in this case to make a judgment. Many criteria use the terms ‘persistent’ and ‘repeatedly’, in addition to qualitative terms such as ‘intense’, ‘significant’ and ‘strong’ in reference to particular characteristics of the condition. A much more detailed history would be required to make such a diagnosis.

In addition, it is not the role of a physical therapist to make such a decision. What is important, however, is to have sufficient knowledge about the existence of a large range of conditions, and to know when referral may be helpful or even vital for the wellbeing of the patient.

Given that the findings are largely negative, a serious pathology is less likely (but cannot be totally excluded) to be the cause of Marcus’s problems. The suboccipital tenderness is suggestive of tension headaches, however the patient’s general lack of cooperation, flat affect and recent family history are also suggestive of depression. School phobia and learning difficulties also cannot be ruled out at this stage. Referral for psychological assessment is probably necessary.

Major depressive episode with concomitant tension-type headaches. Having met the DSM-IV-TR^[3] criteria for major depressive episode and considering his current family dynamic it would appear that Marcus’s headaches may originate from his hypertonic suboccipital muscles secondary to his depression. Children with depression often present with somatic symptoms such as headache and abdominal pain. There is a correlation between childhood depression and parental divorce and a family history of affective disorders.^[4]