What is hypersensitivity or hyposensitivity? Do children with ASD suffer from hypersensitivity or hyposensitivity? How can it be detected? How can we help them? The following article attempts to answer these questions.
Many parents and professionals who work with children and adolescents with Autism Spectrum Disorders (ASD) have observed the experience of irregular responses to painful stimuli experienced by many children with ASD. This is generally expressed as decreased sensitivity (hyposensitivity) to pain, although hypersensitivity is also possible. The DSM-5 includes a criterion within Group B, referring to restrictive and repetitive patterns of behavior, that indicates:
Hyper- or hyporeactivity to sensory stimuli or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse responses to specific sounds or textures, excessive sniffing or palpation of objects, visual fascination with lights or movement).
This article refers only to physical pain and hyposensitivity to pain, given the risks for non-verbal children with ASD who cannot express their painful experience.
WHAT IS PAIN?
Pain is the integration of a series of physical perceptions that warn a person of the risk of "physical harm" or that such "harm" has already occurred. Not everyone perceives pain in the same way because, in addition to the physical experience, this perception is accompanied by a series of emotional elements that can alter the response. In other words, pain is an unpleasant sensory and emotional experience associated with a present or potential injury (Kandel E et al., 2000). Here we can see the first point, because the definition refers to the "integration of a series of perceptions," and we know that sensory integration and perception present irregularities, problems, or differences within the population with ASD.
This pain can be acute or chronic. Acute pain is a reflection of an injury that activates immediate protective mechanisms; it has that purpose: to protect us. However, chronic pain has no meaning; it is simply the persistent experience over time of the result of an injury or of physiological mechanisms that have been altered as a result of that injury.
HOW DO WE PERCEIVE PAIN?
Pain is a complex perception. To simplify this complex mechanism, we will use a schematic diagram, without going into the complex neural mechanisms that provide the basis for the sensation and perception of pain.
- Nociceptors receive information and trigger an immediate protective response that is reflexive.
- The pain is then localized, and there is a general alert response in the individual, who is now fully aware of the stimulus felt and perceived. Pain is both a sensory and emotional experience.
- Behavioral changes then occur.
- Analgesia is sought and achieved, to varying degrees, through various mechanisms.
WHAT CHANGES ARE OBSERVED IN CHILDREN WITH ASD IN RELATION TO PAIN?
The point of concern is the hyposensitivity to pain and the resulting risk of serious injuries without warning signs that allow us to detect them. But another important point is that hyposensitivity doesn't mean it doesn't hurt; it literally means it hurts less. The following graph seeks to consolidate information regarding changes related to pain perception in children with ASD:
To complete this point I would like to note some general ideas for reflection:
- Children inevitably experience pain as part of their daily lives and often rely on their caregivers to provide relief. It is therefore important for caregivers to be able to recognize expressions of pain and provide relief. For children with communication difficulties, this can be particularly challenging. Language limitations in this population may contribute to limitations in communicating their pain to others (Messmer RL, 2008).
- Facial activity, or changes in facial expression, are presented as the most important indicator for judging pain. Many of the mechanisms for coping with pain are related to changes in behavior, among which changes in facial expression are common and very important.
- We find little written about pain in children with ASD in the entire literature on pain. Their communication difficulties can lead to two problems: their pain going unrecognized and their pain going untreated (Alley CS, 2013).
PRECAUTIONS WE SHOULD TAKE
Hyposensitivity to pain doesn't mean that it isn't felt or that it isn't harmful, as we mentioned in the previous section. We all need to be alert:
- In children with ASD, the sensation of pain may be different, but its interpretation may be different. This implies the need to find mechanisms to avoid, minimize, and alleviate pain.
- Although they respond little to pain, the possibility of physical damage exists and must be prevented.
- They can learn inappropriate mechanisms seeking to provoke pain as a form of internal regulation in the face of excessive or very demanding stimuli.
How much pain can they experience? Measuring the degree of pain perception is complex, especially in nonverbal children with ASD. A primary response we should be alert to is crying; however, this doesn't always occur. Various scales have been developed and validated in a variety of groups (nonverbal children, children with physical or intellectual disabilities, etc.) that can be used at any given time.
Finally, it is recommended to pay attention to facial expressions because they may be our only indication of the perception of a painful stimulus.
LITERATURE:
- Allely CS. Pain sensitivity and observer perception of pain in individuals with Autistic Spectrum Disorder. The scientific World Journal 2013.
- Kandel ER, Schwarts JH, Jessel T. Principles of Neuroscience, 4th Edition. McGraw Hill Interamericana, Spain, Inc., 2001.
- Messmer RL, Nader R, Craig KD. Brief report: judging pain intensity in children with autism undergoing venipuncture. Journal of Autism and Developmental Disorders 2008; 38: 1391-1394.
- Prkarchin KM. Assessin pain by facial expression: facial expression as nexus. Pain Red Management 2009; 14(1): 53-58.
Text edited by Mariona Alsedà Florensa from the website Autism Daily and Carlos Orellana