Challenging Case January 2025: An Autistic Youth With ARFID During the COVID Pandemic.

Case: Andrew is a 12-year-old boy living in Southeast Asia with autism spectrum disorder (minimally verbal), who first presented with new symptoms of low mood and anhedonia during the COVID pandemic. This was associated with loss of appetite, which culminated in him eventually refusing to eat any food or swallow any liquids (including saliva). He would hold his saliva in his mouth in the daytime and refused to swallow. He would spit out the saliva when instructed to do so. Because of his worries about swallowing his saliva involuntarily during sleep, he also experienced insomnia. If he managed to fall asleep, he would involuntarily swallow his saliva.Three months from his initial symptoms, he was relocated by his family, to another southeast Asian country for specialty care. At this time, he also refused to speak. He went from intermittently accepting some foods, to being completely averse to any food or fluid intake. He was diagnosed with avoidant restrictive food intake disorder. Because of his acute refusal to eat or drink, a nasogastric tube was inserted and subsequently a gastrostomy tube for enteral nutrition. With this intervention, he was able to maintain good weight and nutrition.Simultaneously, he began treatment in a multidisciplinary feeding and nutrition program. Genetic testing done for concerns of neurological regression yielded a variant of unknown significance. He also began an anti-depressant and sleep medication.During this period, he returned to his country of origin and was no longer able to receive direct in-person specialty feeding support, but did have a dedicated caregiver. He was seen once every few months either in-person or by telehealth by the multidisciplinary feeding and nutrition clinic in the second country. His caregiver was taught to implement behavior strategies with a goal of him resuming oral food intake eventually.What factors should be considered when evaluating a child with co-existing neurodevelopmental and psychiatric conditions, who completely stops eating or drinking in the midst of a global pandemic? What feeding approach would be helpful in managing a complex case like this? What feeding interventions can be actualized at home to reintroduce solids? How did the pandemic impact access to services?