Effectiveness of the Mindful Motherhood Support Program on Quality of Life Among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was will be performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. 

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.  

Revised: "A quasi-experimental study with 56 mothers assigned to experimental or control groups was conducted. Quality of Life (QoL) was measured using the WHOQOL-BREF at baseline, post-intervention, and at a six-month follow-up. The 12-week, group-based program led to significant improvements in all QoL domains for the experimental group compared to the controls, with the highest effect sizes in psychological (|δ|= 0.70) and overall QoL (|δ| = 0.68),  (Page 1  line 15-18 in the revises manuscript). Addition: The sentence, "The study found significant improvements in all QoL domains for the experimental group compared to the control group...", was followed with: "These gains were largely sustained at the six-month follow-up assessment   (page1   line 21-22)

Comments 2: [Please include a short note about cultural or contextual modifications would strengthen the methodology section]

Response 2: We agree with this suggestion. Accordingly, the '2.5 Developing the Intervention' section now includes a new paragraph that outlines the cultural and contextual adaptations.

Added paragraph: "Crucially, the program was culturally and contextually adapted for Palestinian mothers. This included integrating discussions on navigating social stigma and leveraging extended family networks, framing coping strategies within cultural and religious values, and focusing on practical problem-solving tailored to a context with limited access to professional resources and financial hardship. In addition, Recruitment for the intervention was conducted during a period of political instability in Palestine. Consequently, we enrolled only mothers who could safely and reliably access the program site to ensure consistent participation (line 167-174  page 4 &5)

Comments 3: Throughout the text, standardize capitalization and phrasing (e.g., “children with ASD” instead of “(ASD) children”; “Quality of Life (QoL)” consistently after first mention).

Response 3: We thank the reviewer for this careful observation. We have thoroughly revised the entire manuscript to ensure consistent terminology and capitalization. This included a systematic search-and-replace to standardize all instances to "children with ASD" and to use the abbreviated form "QoL" consistently after the first full mention of "Quality of Life." We have also checked for consistency in other related terms throughout the text.

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

Comments 4: [While the sample is described, please provide a short rationale or reference supporting that n = 56 was adequate to detect meaningful effects for nonparametric comparisons]

Response 4: Thank you for your valuable insights. In response to the reviewer's comment, we have added a sample size justification to the Methods section, which was based on a power analysis for a large expected effect size (d=0.80). This analysis indicated a requirement of 52 subjects for a parametric test, which we inflated to a target of approximately 60 to account for the use of non-parametric statistics. We recruited 60 participants, but 2 participants from each group withdrew from the study, resulting in a final analyzable sample of 56. This final sample was deemed sufficient as it closely approximated the initial target.

A new paragraph was added in the revised manuscript ( page 3 line 108-117)

Comments 5: [Consider reporting exact p-values (e.g., p = .004) and confidence intervals for effect sizes when possible.]

Response 5: Agree. We thank the reviewer for this valuable suggestion to improve our statistical reporting. In response, we have thoroughly revised the manuscript to report exact p-values throughout the results text, Tables 3 and 4, replacing all previous inequalities. Furthermore, we have calculated and included 95% confidence intervals for all Cliff's Delta effect sizes in Table 3 using a bootstrapping method.

"P-values and confidence intervals are reported in Table 3. In line with convention, p-values of .000 are reported as p < .001."

Comments 6: [Include a short paragraph in the Discussion or Conclusion acknowledging limitations such as nonrandomized design, reliance on self-reported measures, and potential selection bias.

Response 6: Agree. We appreciate the reviewer's insightful suggestion. Accordingly, we have added a "Limitations" subsection to the Discussion, where we explicitly acknowledge the non-randomized design, reliance on self-reported data, and potential for selection bias

A new "Limitations" paragraph has been added to the "4. Discussion" section, before the "5. Conclusions". (page 12  line 370-376 )

New paragraph: Several limitations of this study should be acknowledged. The use of a quasi-experimental design with non-random assignment, while pragmatic, introduces the potential for selection bias. Furthermore, the reliance on self-reported measures for the primary outcome may be subject to social desirability bias. The use of purposive sampling also limits the generalizability of the findings to all Palestinian mothers of children with ASD. Future research would benefit from a randomized controlled trial design incorporating more objective biomarkers of stress and well-being.

Comments 7: Some citations (e.g., #27 and #7) appear duplicated or inconsistently formatted. Ensure uniform use of journal abbreviations and proper punctuation in accordance with the journal’s reference style

Response 7:  We acknowledge the reviewer's precision in identifying these inconsistencies. The necessary corrections have been made to the reference list, including the removal of duplicates and the enforcement of uniform formatting throughout.

Comments 8: There are occasional grammatical inconsistencies (e.g., “mothers of children with (ASD)” or “a comprehensive and holistic that addresses…”). A careful language edit will improve flow and readability.

Response 8: The entire manuscript has undergone a comprehensive language edit.

Phrases like "a comprehensive and holistic that addresses" have been corrected to "a comprehensive and holistic program that addresses". "Mothers of children with (ASD)" has been corrected to "Mothers of children with ASD". Sentence structure, article usage, and prepositional phrases have been reviewed and corrected for improved fluency and academic tone.  I sent the manuscript to the English editing through MDPI’s services

*Important note: In preparation for submission, the final manuscript underwent professional English language editing to ensure grammar accuracy and clarity. This editing was performed using the official language services provided by MDPI

Comments 9: The conclusion could briefly expand on how local health and education authorities might implement or scale the program in community or telehealth contexts.

Response 9: Agree. The conclusion has been expanded with specific, actionable recommendations for implementation.

Added Text: "To scale this intervention, local health and education authorities could integrate the 'Mindful Motherhood' curriculum into existing community health centers or parent support networks. Training master trainers from among experienced social workers and special education teachers could facilitate wider dissemination. Furthermore, adapting the program for a hybrid or fully telehealth format could overcome geographical barriers and increase accessibility for mothers in remote villages, ensuring a more family-centered approach to ASD care across Palestine." ( page 12 line 388-394)

Comments 10: [Double-check table formatting (e.g., consistent decimal places, alignment of N and % columns) and ensure Appendix A is clearly titled and referenced in the main text].

Response10: All tables (1, 2, 3, 4) have been checked for consistent decimal places, column alignment, and formatting. For example, in Table 1, the "%" column is now consistently aligned. (Line 213,230-231,245,272)

Appendix A: The appendix is now clearly titled "Appendix A: Session Agenda for the 'Mindful Motherhood' Support program". The main text in "2.6 Intervention description" explicitly references it: "Table A in the appendix describes all sessions and agenda. (line 195)

Important note: In preparation for submission, the final manuscript underwent professional editing to ensure accuracy and clarity. This editing will be performed using the official language services provided by MDPI

4. Response to Comments on the Quality of English Language

Response 1:    In preparation for submission, the final manuscript underwent professional English language editing to ensure accuracy and clarity. This editing was performed using the official language services provided by MDPI

Cover letter

We would like to thank you for reviewing our article and providing valuable feedback. We sincerely appreciate the time and effort you dedicated to evaluating our manuscript, and we are grateful for your insightful comments and constructive suggestions, which have contributed significantly to improving the quality of our paper.

In the following section, we provide a detailed, point-by-point response to each of the reviewers’ comments and describe the corresponding revisions made to the manuscript.

Point-by-point response to Comments and Suggestions for Authors

 Reviewer # 1

Thank you for the opportunity to review the manuscript titled “Effectiveness of the Mindful Motherhood Support Program on Quality of Life among Palestinian Mothers of Children with Autism Spectrum Disorder: A Quasi-Experimental Study.” This paper makes an important contribution to the literature on caregiver well-being and intervention research in underrepresented contexts. The topic is timely, the methodology is well organized, and the results are clearly reported. The intervention is both theoretically grounded and culturally relevant, offering valuable insights for professionals and policymakers aiming to strengthen family-centered ASD services in low-resource settings.

Comments 1: [The abstract is informative but could benefit from concise phrasing. Consider shortening the description of statistical methods and explicitly noting that the improvements were maintained at six months to highlight longitudinal impact.]

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, the abstract has been revised for conciseness. The description of statistical methods was shortened, and the maintenance of improvements at the six-month follow-up was explicitly stated.