Muchos de los padres y profesionales que trabajamos con niños y adolescentes con Trastornos del Espectro del Autismo (TEA) hemos vivido la experiencia de las respuestas irregulares de una buena parte de los niños con TEA a estímulos dolorosos, generalmente expresada como menor sensibilidad (hiposensibilidad) al dolor, aunque también cabe la hipersensibilidad.
El DSM-5 incluye dentro del grupo B referente a los patrones restrictivos y repetitivos de comportamiento un criterio que indica:
- Hiper o hiporreactividad a los estímulos sensoriales o interés inhabitual por aspectos sensoriales del entorno (p.ej., indiferente aparente al dolor/temperatura, respuestas adversas a sonidos o texturas específicos, olfateo o palpación excesiva de objetos, fascinación visual por las luces o el movimiento.
En este artículo nos referiremos únicamente a la hiposensibilidad al dolor dado los riesgos que comporta para el niño con TEA, nos referimos únicamente al dolor físico.
¿CÓMO PERCIBIMOS EL DOLOR?
El dolor es una percepción compleja, de hecho, ha dado origen a una especialidad dentro de la neurología o la anestesiología: la algología o medicina del dolor.
Para simplificar este complejo mecanismo recurriremos a un esquema, pero no entraremos en los complejos mecanismos neurales que ofrecen el sustrato para la sensación-percepción del dolor, para eso les refiero a un excelente artículo publicado en Wikipedia bajo el título “Dolor” y que, como todo en esa enciclopedia, es de acceso gratuito.
|Nocioceptores||Protección inmediata||Alerta y localización||Cambios conductuales||Analgesia|
|Son los receptores localizados en la piel, articulaciones y tejidos profundos (con amplia distribución en el organismo) y cuyo objeto es la detección de estímulos nocivos.|
Son receptores sensitivos encargados de percibir el dolor y transmitirlo para activar los mecanismos de protección.
Se dividen en tres grupos:
Su nombre proviene del latín “nocere” que significa “dañar”.
|Respuestas reflejas inmediatas que provocan la retirada de la parte del cuerpo expuesta al estímulo doloroso.||Se activan estructuras encefálicas que provocan aumento de la vigilancia. Se acompaña de respuestas hormonales o bioquímicas, cardiovasculares y respiratorias dentro del mecanismo general de “huída”.||Constituyen el conjunto de respuestas emocionales-comportamentales que acompañan a las experiencias dolorosas.||El cuerpo humano dispone de una serie de mecanismos que se activan inmediatamente, y pueden sostenerse a lo largo del tiempo, que buscan producir analgesia, es decir alivio del dolor aunque no de manera completa. Incluyen mecanismos físicos y bioquímicos.|
¿QUÉ ALTERACIONES SE OBSERVAN EN LOS NIÑOS CON TEA EN RELACIÓN AL DOLOR?
El punto que me preocupa es la hiposensibilidad al dolor y el consecuente riesgo de sufrir lesiones importantes sin que estas se acompañen de cambios físicos que nos permitan detectarlas.
Pero también otro punto es importante: hiposensibilidad no implica que no duela, literalmente significa que duele menos pero personalmente considero que no es el caso en los niños con TEA, deberíamos decir “duele diferente” y que nosotros aún no hemos logrado entenderlo, como nos ha ocurrido con tantos aspectos relacionados con esta población.
El gráfico siguiente busca consolidar información referente a los cambios relacionados con la percepción del dolor en niños con TEA:
Hiposensibilidad no implica que no duela, literalmente significa que duele menos pero personalmente considero que no es el caso en los niños con TEA, deberíamos decir “duele diferente” y que nosotros aún no hemos logrado entenderlo, como nos ha ocurrido con tantos aspectos relacionados con esta población.
Para completar este punto quiero anotar algunas ideas generales para la reflexión:
- Los niños inevitablemente experimentan dolor como parte de sus vidas diarias y con mucha frecuencia dependen de sus cuidadores para lograr alivio de ese dolor. Es importante, entonces, que los cuidadores sean capaces de reconocer las expresiones de dolor y proveer de las medidas inmediatas para aliviarlo. En el caso de los niños en general y de manera especial en los niños con TEA esto puede ser muy dificultoso. Las limitaciones del lenguaje en esta población puede contribuir a las limitaciones en la comunicación de “su dolor” a otros (Messmer RL, 2008).
- La actividad facial o las variaciones en la expresión facial se presentan como el indicador más importante para juzgar el dolor en niños con TEA. Muchos de los mecanismos para lidiar con el dolor se relacionan con cambios en el comportamiento, dentro de estos los cambios en la expresión facial resultan ser frecuentes y muy importantes, de hecho en infantes los cambios faciales pueden ser el único comportamiento expresa (Prkarchibn KM, 2009).
- Los defensores de la teoría del “exceso de opioides” en los niños con Trastornos del Espectro del Autismo en parte apoyan sus argumentos en esta hiposensibilidad al dolor. En todo caso, es importante saber, que estudios adecuadamente realizados no han logrado demostrar exceso de opioides endógenos o exógenos en muestras de orina de niños con TEA.
- Poco encontramos escrito sobre dolor en niños con TEA en toda la bibliografía referente al dolor. Sus dificultades en la comunicación pueden conducir a dos problemas: que su dolor no sea reconocido y que su dolor quede sin tratamiento (Alley CS, 2013).
PRECAUCIONES QUE DEBEMOS TOMAR
Hiposensibilidad al dolor, es decir menor sensibilidad a los estímulos dolorosos, no implica que el dolor no se sienta o que no sea dañino, como ya hemos referido en el aparato anterior (es la idea principal de este artículo). Todos tenemos que estar alerta:
- Ocurre en los niños con TEA la sensación de dolor pero su interpretación puede ser diferente. Esto implica la necesidad de buscar mecanismos para evitar, minimizar y aliviar el dolor aunque se observen pocas respuestas a estímulos dolorosos.
- Aunque respondan poco al dolor la posibilidad de daño físico existe y tenemos que prevenirlo. Los golpes, aunque expresen poco o nada el dolor, necesitan ser adecuadamente revisados y asegurarnos que no han ocurrido daños mayores y no aparentes a simple vista.
- Pueden aprender mecanismos no apropiados buscando provocar dolor como forma de regulación interna ante estímulos excesivos o muy demandantes
¿Qué tanto puede dolerles? Medir el grado de percepción del dolor es complejo, especialmente en niños con TEA que no son verbales.
Una respuesta primaria a la que debemos estar atentos es el llanto, sin embargo no siempre ocurre. Se han desarrollado diversas escalas cuya validación se ha logrado en diversidad de grupos (niños no verbales, con discapacidades físicas o intelectuales, etc.) a las que en determinado momento se puede recurrir.
Finalmente recomiendo estar atento a las expresiones faciales porque pueden ser nuestro único indicativo de la percepción de un estímulo doloroso.
- 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. Principios de Neurociencia, IV edición. Editorial McGraw Hill Interamericana de España, S.A., 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.
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