In this article, Dr Kathryn Newns, Director and Clinical Psychologist at Applied Psychology Solutions, explores how pain is experienced, interpreted and communicated by autistic individuals and why standard medico-legal approaches risk underestimating its impact. Drawing on emerging research, the article highlights key considerations for experts assessing pain in personal injury and clinical negligence claims involving neurodivergent claimants.
Introduction
Pain assessment is central to personal injury and clinical negligence claims, yet remains particularly complex when the claimant is neurodivergent.
Autistic people, and others with sensory or interoceptive differences, often experience, interpret and communicate pain in atypical ways. Unless these factors are accounted for, medico-legal evaluations risk underestimating the presence or impact of pain. Sensory sensitivity and changes in how pain is interpreted, including difficulties with interoception, are common across many types of neurodiversity. However, for the purposes of this article, the focus will be on autism.
Autism is a neurodevelopmental difference characterised by distinct social communication styles, unique patterns of sensory processing (including heightened or reduced sensitivity), focused interests, and a preference for predictability and routine. Engaging in repetitive behaviours and routines can be important coping strategies, both to self-regulate and restore a sense of predictability. These characteristics can interact with the environment in ways that may increase vulnerability to stress or trauma, especially in settings not adapted to their needs.
Autism and pain
It is increasingly recognised that chronic pain is common in autistic populations (Hutton & Aslam, 2025). Historically, autism has been associated with an “apparent indifference to pain” or pain hyposensitivity (Bogdanova et al., 2022). However, current research demonstrates a more complex and heterogenous picture, with a likely “paradox of pain” (ibid.), whereby autistic people may appear hypo-reactive behaviourally but display atypical or heightened physiological responses.
Impaired interoception is a significant challenge for this client group (Kalingel-Levi et al., 2022) and may lead autistic patients to struggle to identify and report internal sensations. They may be unable to distinguish whether their discomfort is pain or another sensation, such as hunger, tiredness or sensory overload. Even when a sensation is identified as pain, there are challenges in identifying its precise location, intensity and quality (e.g. stabbing, burning, aching).
Furthermore, autistic people frequently struggle with pain awareness, reporting uncertainty in recognising the existence, nature and severity of pain. It is likely that this issue is less one of universal somatic hyposensitivityand more one of impaired interoception, subjective cognitive appraisal and communication (ibid.). Research by Yasuda et al. (2016) found that autistic individuals were hyposensitive to subjective pain intensity and to the affective or emotional dimensions of pain. This dissociation indicates that the cognitive pathways for pain processing and emotional evaluation are altered in autistic individuals. For clinicians, this means a low self-reported pain score cannot be interpreted as proof of minimal nociceptive input.
The role of co-occurring mental health conditions
The relationship between pain and mental health is bidirectional and complex. Greater autism severity has been found to predict a stronger behavioural pain response (Garcia-Villamisar et al., 2019). Critically, this relationship appears partially mediated by co-occurring anxiety and depression. This underscores that anxiety and depression are not merely secondary reactions to pain, but are integral factors that can amplify the pain experience, including for autistic individuals.
Barriers and misinterpretations
Barriers to healthcare access compound these difficulties. Autistic people frequently report that their descriptions of pain are not believed or are dismissed as psychosomatic or anxiety-related. Such diagnostic overshadowing can delay treatment and lead to significant adverse outcomes.
Qualitative reports from autistic people consistently identify negative experiences, including lack of autism awareness among healthcare staff (Vogan et al., 2017; Mayor, 2021), feeling disrespected, not being taken seriously, and receiving inadequate treatment (Kalingel-Levi et al., 2022). For some, the experience of medical settings is aversive to the point that the need to escape the sensory and social overload of the environment is more urgent than the need to seek treatment for the pain. These repeated negative experiences can foster a deep-seated mistrust of healthcare providers, leading to a preference to cope with pain without seeking professional help.
Difficulties with social communication, a core characteristic of autism, are significantly exacerbated by the cognitive and emotional load of being in pain. When an autistic person is assessed, they may struggle to “translate” the abstract, internal experience of pain into words. This difficulty extends to conventional assessment tools, as they may not know how to accurately map their sensation onto a numerical rating scale or a series of facial expressions. The effort required to process the pain experience and communicate it simultaneously can be overwhelming, leading to truncated or seemingly non-cooperative responses. Finally, an autistic person might wait for a clinician to explicitly offer help or ask about pain, which may be misinterpreted as an absence of significant pain.
Furthermore, autistic individuals frequently possess considerable experience in suppressing or disregarding aversive sensory stimuli and social discomfort. Throughout their lives, many develop compensatory strategies – “masking” – to conceal their difficulties. The onset of a novel pain experience may, for some, constitute an additional sensation to be tolerated or ignored. Conversely, it may represent a threshold event: the point at which cumulative sensory and emotional demands exceed coping capacity, resulting in pronounced distress in response to an ostensibly minor physical injury.
Sensory integration and coping strategies
For many autistic people, sensory regulation is a core part of daily functioning. Some individuals adopt a “sensory diet”- regular, structured activities that help manage arousal, reduce anxiety and maintain focus. These might include rhythmic or repetitive activities such as trampolining, running, or swimming. Pain can significantly disrupt this regulatory system.
When such activities are restricted, the result is not only a loss of physical exercise but also a loss of an essential regulatory mechanism. This can increase anxiety, heighten sensory overload and contribute to greater psychological distress.
For medico-legal experts, it is important to consider whether pain is not only causing physical impairment, but also restricting access to a person’s established sensory coping strategies. This interaction can magnify the overall functional impact of an injury. Case managers may need to support the identification of alternative regulation strategies, while mental health experts should consider the impact on anxiety, mood and coping capacity.
Assessment in a litigation context
It is vital that those working with autistic individuals going through litigation consider autism as one factor shaping the individual’s pain experience, alongside injury, co-morbid health conditions and psychosocial stressors.It is likely that assessment and intervention will require a fully interdisciplinary approach, including psychologists, occupational therapists and physiotherapists, to build a rounded picture of the claimant’s pain, functioning and prognosis.
For those assessing autistic individuals, specific adaptations should be considered to ensure equitable and accurate assessment of pain:
- Environmental modifications: Sensory elements of the setting can significantly influence how pain is experienced and reported. A quieter, less stimulating environment, with a clear visual agenda outlining the process, supports predictability and reduces distress. Be explicit about any physical contact required and allow regular breaks to prevent sensory overload. Autistic people may need longer appointments or a slower pace to allow for processing time.
- Additional informant: It may be necessary to involve a trusted family member or caregiver as a communication partner and interpreter of behavioural changes, rather than relying solely on self-report (Kalingel-Levi et al., 2022).
- Language adjustments: Use clear, concrete language supported by visual aids such as diagrams or charts. Abstract numerical scales may be difficult for an autistic person, and an alternative approach might be to ask: “Show me on this body diagram where you feel something. How does this feeling stop you from doing things you normally do?”
- Validate the experience: Explicitly acknowledge the patient’s pain and their potential uncertainty about it. Simple statements such as, “I understand it can be difficult to describe these feelings, but I’m here to help you figure it out,” can counteract past experiences of being dismissed (ibid.).
- Interpreting behavioural and physical signs: When faced with pain, typical reactions may be absent in autistic patients (e.g. lack of protective body positioning or withdrawal reactions; Vaughan et al., 2020; Bogdanova et al., 2022). An increase in restrictive or repetitive behaviours, self-injurious behaviour, agitation or social withdrawal may be a primary indicator of pain and should not be dismissed as a purely mental health symptom (Kalingel-Levi et al., 2022).
Implications for interventions
These principles also extend to treatment and rehabilitation:
- Psychological therapies: Cognitive Behavioural Therapy and Acceptance and Commitment Therapy can be effective, but they rely on concepts such as psychological flexibility, which can be challenging for some autistic individuals. To be successful, these interventions require modification.
- Physiotherapy and rehabilitation: Interventions may take longer to deliver effectively. Sensory sensitivities, communication needs and the claimant’s own coping strategies must be taken into account. Ideally, such interventions should be provided by professionals with experience in neurodiversity.
In both psychological and physical interventions, it is likely that treatment would benefit from the active involvement of parents or caregivers to provide support, ensure consistency of practice at home, and assist with communication.
Conclusion
For autistic individuals, pain assessment and intervention will likely require specific considerations and reasonable adaptations to ensure assessment and treatment are accurate, evidence-based and helpful. Pain is shaped by interoceptive differences, sensory processing, communication style and prior healthcare experiences. In civil litigation, where accuracy and equity are paramount, experts must move beyond assumptions of “pain hyposensitivity” and adopt evidence-based, context-sensitive approaches.
References
Bogdanova, O. V., Bogdanov, V. B., Pizano, A., Bouvard, M., Cazalets, J.-R., Mellen, N., & Amestoy, A. (2022). The current view on the paradox of pain in autism spectrum disorders. Frontiers in Psychiatry, 13, 910824. https://doi.org/10.3389/fpsyt.2022.910824
Garcia-Villamisar, D., Moore, D., & Garcia-Martínez, M. (2019). Internalizing symptoms mediate the relation between acute pain and autism in adults. Journal of Autism and Developmental Disorders, 49(3), 1197–1209. https://doi.org/10.1007/s10803-018-3796-3
Hutton, T., Aslam, N. (2025) Autism and chronic pain: the holistic way forward, Rheumatology, Volume 64, Issue Supplement_3, April 2025, keaf142.307, https://doi.org/10.1093/rheumatology/keaf142.307
Kalingel-Levi, M., Schreuer, N., Granovsky, Y., Bar-Shalita, T., Weissman-Fogel, I., Hoffman, T., & Gal, E. (2022). “When I’m in pain, everything is overwhelming”: Implications of pain in adults with autism on their daily living and participation. Frontiers in Psychology, 13, 911756. https://doi.org/10.3389/fpsyg.2022.911756
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