Autism-adapted cognitive behavioral therapy for social anxiety in an adolescent with late-identified autism spectrum disorder: a case report

Abstract Background Autism spectrum disorder (ASD) without intellectual disability may be identified late in adolescence when the presenting complaint is dominated by internalizing distress and functional decline rather than explicit neurodevelopmental concerns. Social anxiety is among the most frequently reported comorbidities in adolescents with ASD. We report the case of an adolescent with late identified ASD and prominent social anxiety who received an autism adapted cognitive behavioral therapy (CBT) program. Case presentation Maxence is a 13-year-old boy referred for progressive social withdrawal, severe freezing in evaluative school situations, and escalating screen-related behaviours with family conflict. A multi-informant multidisciplinary assessment supported autism spectrum disorder level 1 without intellectual disability, with prominent social anxiety and clinically significant alexithymic features. Treatment was complicated by low initial motivation, over-analysis, poor emotional differentiation, avoidance of homework tasks, and screen use as a rapid tension regulator. Treatment followed a phase-based autism-adapted cognitive behavioral programme combining a highly predictable therapeutic frame, early somatic cue detection, minimal emotional labeling, brief protective scripts, planned graded exposures with reduction of safety behaviors, structured family guidance, and school coordination. The intervention was adapted by lowering performance demands, using body-first emotional work, replacing silence with brief rescue sentences, making exposure predictable and repeatable, and modifying the tension-to-screen-for-relief contingency rather than focusing on screen time alone. Symptoms and functioning improved from baseline to post-treatment and at 3-month follow-up, with reduced anxiety and freezing, better engagement in school and daily activities, and improved regulation of screen use. Conclusions This case study supports an integrated mechanistic formulation and a structured autism adapted CBT approach to reduce the cost of exposure and restore functional engagement in late-identified autistic adolescents with prominent social anxiety.