Development and validation of the Pain Awareness Scale (PAS) for autistic adults: A mixed-methods study

This study aimed to develop and validate the Pain Awareness Scale (PAS), a novel self-report questionnaire designed to assess pain awareness in autistic adults. Using a mixed-methods approach, the PAS was developed through literature review, expert consultation, and cognitive interviews with nine autistic adults (5 females, mean age= 29.1, SD= 7.9). The questionnaire was then administered to 59 autistic (24 females, mean age=26.8, SD=7.4) and 73 neurotypical adults (19 females, mean age=27.8, SD=6.7). Principal Axis Factoring revealed four distinct subscales: Pain Recognition, Pain Characterization, Nonverbal Pain Communication, and Verbal Pain Communication. The PAS demonstrated good internal consistency across all subscales (Cronbach's α=0.71–0.92) and strong construct validity, with autistic adults scoring significantly higher than neurotypical adults’ total score and on three out of four subscales (p < 0.001). Convergent validity was supported by significant correlations between the PAS and the Toronto Alexithymia Scale-20 (TAS-20) total scores (ρ= 0.69, p< 0.01). The PAS offers a reliable and valid tool for assessing pain awareness difficulties in autistic adults. Perspective: This article introduces the Pain Awareness Scale (PAS), a psychometrically validated measure of pain awareness in autistic adults. The PAS may enhance clinical assessment and deepen understanding of pain processing differences in autism, offering insight into underlying mechanisms relevant for both clinical and basic science research.