To the best of our knowledge, this is the first report of COVID-19 phobia in a child with undiagnosed ASD and provides two important insights. Firstly, children with undiagnosed ASD may develop COVID-19 phobia following the recent pandemic. Secondly, in diagnosed cases, intervention for ASD, such as sharing information with parents and teachers to explain what autism is and how it is likely to affect the child’s development and function, and to make an individual education plan may be more appropriate than starting treatment for anxiety disorders as the first-line option.
Children with undiagnosed ASD suffer from social difficulties related to the traits  and we suggest that their overlooked distress can be a predisposing factor for the development of anxiety disorders. Children with ASD often show anxiety, which Boulter et al. (2014) pointed out to be associated with intolerance to uncertainty . Children with ASD interpret all ambiguous information as threatening, contributing to significant somatic stress responses in the face of novel or uncertain situations . It is highly possible that children with ASD are more vulnerable to verbal threat information from the media because they interpret it literally, possibly worsening their anxiety. In undiagnosed cases, children do not have any support for their ASD traits and anxiety can exacerbate . The effect of the COVID-19 pandemic on mental health concerns, including anxiety symptoms, has been reported , which can continue to increase in such an unprecedented condition. Even during the outbreak of the SARS  and the H1N1 influenza , pandemic-related anxiety was reported to be associated with high publicity in the mass media.
Many children with ASD remain undiagnosed as early symptoms of ASD can easily be overlooked. Among ASD patients, there are significant differences in phenotypic expressions, associated with high rates of comorbidity with other psychiatric disorders . Psychiatric comorbidities can also obscure an underlying ASD and delay its diagnosis, although in some cases, ASD can be diagnosed before the third birthday. We, therefore, expect that more undiagnosed ASD patients developing anxiety disorders caused by the pandemic may seek treatment.
Our findings suggest that intervention for ASD may be more appropriate than starting treatment for anxiety disorders as the first-line option in children with ASD who developed COVID-19 phobia caused by the pandemic. We simply helped the parents and teachers understand the ASD characteristics such as literal interpretation and hypersensitivity. We gave visual support and allowed him to play by himself, not in a group, for his personal space. After our treatment, his anxiety was relieved and dysphagia improved. Spain et al. (2015) reported that for individuals with an ASD and an anxiety disorder but no intellectual disability, cognitive behavioral therapy modified by the direct instruction of social skills, increased family involvement, visual supports, individualized reinforcers, embedded perseverative interests in sessions, and reduced emphasis on abstract concepts and visualization have been supported by research . In cases of ASD with Anorexia nervosa (AN), which is a relatively common comorbidity, the presence of underlying ASD traits, such as rigidity and low introspection, effectively maintains AN. Thus, the patients require adapted or targeted treatment programs . A previous study reported that cognitive remediation therapy to address problems with cognitive style and meta-cognition by stimulating the neural connections involved in cognitive processing through cognitive tasks, reflection, and behavioral experiments, was efficient for the treatment of patients with ASD and AN . Their findings support our contention that intervention for ASD may be more appropriate than starting treatment for anxiety disorders as the first-line option in children with ASD who developed COVID-19 phobia caused by the pandemic. Our strength is that we diagnosed ASD based on the DSM-5 criteria through the standardized semi-structured interview. The therapeutic potential in the treatment of these cases, however, need to be further examined in future studies.