What Happened to Paul? Manifestation of Abnormal Pain Response for Individuals With Autism Spectrum Disorder

Abstract

During the progression of a pilot nutrition intervention designed to teach cooking skills to young adults with autism spectrum disorder (ASD), one participant-Paul-fell in the parking lot. Prior to the accident, Paul had been making significant gains in the program and had communicated in a number of ways his enthusiasm. After his accident, which resulted in broken and dislocated bones in his ankle, his demeanor was dramatically altered, program gains were lost, and staff noted the appearance of many new challenging behaviors. This article analyzes Paul's behavior in reference to the pain response in autism. For some time, it was believed that many individuals with ASD did not experience pain based on anecdotal reports of how individuals responded to injury with seeming indifference. This view has given way of late to a more nuanced understanding of how atypical sensory processing and stimulus over-selectivity spill over into pain pathways and pain amplification mechanisms. The consequence is not a reduction in pain sensation, but a different expression of pain, determined by that individual's particular communicative, cognitive, or physiological challenges. From this perspective, many of the disruptive and harmful behaviors that emerged after Paul's accident can be seen as a delayed response to the incident. This article concludes by arguing that professionals across all domains of health care need to begin to see behavior as communicative for those with ASD. This is particularly true of changes in behavior, which can be significant indicators of health care problems rather than something to be dismissed as another manifestation of the condition.

<p>Bridging the Gap Between Physical Health and Autism Spectrum Disorder</p>

“…Covering all of the primary sensesauditory, visual, tactile, olfactory and gustatory inputthere is a wealth of scientific literature noting differences in the sensation and/or processing of sensory data in ASD. 190 Sensory dysfunctions and abnormal processing of pain also seemingly underlie some of the more challenging behaviours associated with ASD 191,192 and are a facet of the current diagnostic criteria for ASD. Various studies have highlighted a strong connection between sensory dysfunction and the presentation of other core ASD features.…”

Challenging behaviours at early adulthood in autism spectrum disorders: topography, risk factors and evolution

“…The finding of sleep and gastrointestinal disorders being related to stereotypy is of particular interest. As suggested by Goldschmidt (2016), such challenging behaviours can be significant indicators of health care problems rather than a direct manifestation of the ASD condition. Finally, sleep disorders were related to irritability and hyperactivity which can easily be explained by the impact of these disorders on the ASD subject's state of arousal impacting daily activities.…”

“…Challenging behaviours can also increase when the environment is not congruent to the person's specific needs, for example, lack of daytime engagement (Bowring et al . ) and sensory overstimulation or understimulation (Goldschmidt ). For those reasons, challenging behaviours might increase at adulthood because of the lack of appropriate services and effective interventions (Barnard et al .…”

“…Chiang et al (2008) showed that a high proportion of children with ASD with severe speech impairments used challenging behaviour as a form of expressive communication. Challenging behaviours can also increase when the environment is not congruent to the person's specific needs, for example, lack of daytime engagement (Bowring et al 2017) and sensory overstimulation or understimulation (Goldschmidt 2016). For those reasons, challenging behaviours might increase at adulthood because of the lack of appropriate services and effective interventions (Barnard et al 2001;Gerhardt and Lainer 2011;van Heijst and Geurts 2014).…”

Self-Injury in Autism Spectrum Disorder and Intellectual Disability: Exploring the Role of Reactivity to Pain and Sensory Input

“…Goldschmidt [ 70 ] described the case of “Paul”, a 20-year-old nonverbal adult with ASD who developed SIB after falling and suffering an injury to his leg and ankle. Paul was reportedly oblivious to his injury initially (failing to show a response to acute pain) until it resulted in changes in his routine.…”