Puberty-Onset Selective Mutism in a Female Adolescent With Autism Spectrum Disorder

Abstract

Selective mutism (SM) is a rare anxiety disorder typically diagnosed in early childhood. It is characterized by a persistent failure to speak in specific social situations despite having the ability to verbalize in others. Although the onset of SM during adolescence is uncommon, its emergence during puberty or major life transitions may reflect an atypical form of anxiety that is more frequently observed in individuals with autism spectrum disorder (ASD). We describe a case of an 11-year-old girl who developed SM following the onset of puberty and significant environmental changes, including school transition and relocation. She was subsequently diagnosed with ASD. A multidisciplinary treatment approach involving cognitive behavioral therapy, fluoxetine, and pregabalin led to complete remission of SM and marked improvements in academic and social functioning. This case underscores the importance of recognising atypical anxiety presentations in adolescents with ASD and highlights the value of early, individualized, and multimodal interventions. It also raises ethical considerations regarding the temporary use of covert medication in cases with severe resistance to treatment.

Keywords: autism spectrum disorder; child and adolescent psychiatry; cognitive behavioral therapy; pregabalin; puberty onset; school refusal; selective mutism; severe anxiety.

Figure 1. Clinical timeline of symptom onset, interventions, and clinical outcomes.

*Medication initially administered covertly with parental consent. In the figure, blue indicates initial symptoms and difficulties, while green represents clinical improvements and outcomes. Additionally, bolded terms indicate key diagnostic events or therapeutic interventions. The image is created by the authors of this study.