Selective mutism and autism spectrum disorder in girls: a critical narrative review

Abstract

Selective mutism (SM) is traditionally classified as an anxiety disorder characterized by a persistent failure to speak in specific social contexts despite preserved language abilities in familiar environments. However, accumulating evidence suggests that SM represents a heterogeneous clinical phenotype in which neurodevelopmental factors may play a significant role. Concurrently, Autism Spectrum Disorder (ASD), particularly in girls, often presents with subtle or atypical manifestations, including social camouflaging and increased internalizing symptoms, contributing to underdiagnosis and delayed recognition. This study aimed to conduct a critical narrative review of contemporary literature (2018–present) examining the interface between SM and ASD in girls, with emphasis on neurobiological mechanisms, dimensional psychopathology, and diagnostic and therapeutic implications. A structured literature search was performed using PubMed, Scopus, and PsycINFO databases, including studies published between January 2018 and the present. Articles were selected based on predefined inclusion and exclusion criteria, focusing on empirical and theoretical contributions addressing SM, ASD, female phenotype, and related neurobiological and clinical frameworks. The findings reveal converging evidence of shared neurobiological substrates, including amygdala hyperreactivity and altered connectivity within social brain networks, alongside a higher prevalence of autistic traits among children with SM. Additionally, social camouflaging emerges as a central mechanism contributing to the underrecognition of ASD in girls presenting with SM. The persistent artificial dissociation between anxiety and neurodevelopmental frameworks may obscure underlying mechanisms and compromise diagnostic accuracy. An integrative, sex-sensitive, and transdiagnostic approach is essential for improving assessment and guiding more effective interventions.