Off-Time Puberty in Autism Spectrum Disorder and ADHD: A Scoping Review of Pubertal Timing, Social Cognition, and...

Off-time pubertal development defined as pubertal onset or progression deviating meaningfully from age- and sex-matched normative expectations confers heightened risk for internalizing and externalizing psychopathology during adolescence. Children and adolescents with neurodevelopmental disorders (NDDs), including autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD), carry pre-existing impairments in theory of mind (ToM) the capacity to represent and respond to the mental states of others that substantially compromise their capacity to navigate the increasingly complex social demands that puberty introduces. Evidence indicates that ASD is associated with elevated rates of precocious puberty and altered pubertal tempo, and that ADHD in females is linked to earlier pubertal onset with consequent internalizing symptom exacerbation; yet the mechanisms connecting pubertal timing, ToM impairment, and psychopathological risk in these populations have not been systematically reviewed. This scoping review, guided by the PRISMA extension for Scoping Reviews (PRISMA-ScR), synthesises evidence from 19 studies (2016-2026) examining pubertal timing in ASD and ADHD, the neurobiological mechanisms linking puberty to social cognition, and the clinical and psychopathological consequences of their convergence. We identify three mechanisms through which off-time puberty and pre-existing ToM impairment interact: (1) demand-capacity mismatch amplification, (2) masking and camouflaging under elevated social load, and (3) physical-cognitive developmental asynchrony. No primary studies have directly examined the moderating role of ToM on the puberty-psychopathology relationship in NDD populations, representing a critical research gap. We propose a dual-vulnerability framework and outline research priorities for future longitudinal and intervention studies in this underserved population.