Review Reports - Characterization of Children with Intellectual Disabilities and Relevance of Mushroom <i>Hericium</i> Biomass Supplement to Neurocognitive Behavior

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Introduction should be rewritten in a more summarized way. I suggest to introduce a table to schematize previous studies about the use of this mushroom in ASD therapy.

Figure 4: there are no controls subjects without treatment for comparison. How can you exclude that the amelioration is not due to the progression of the development in any case in one year life of the subject? Then, ASD and Asperger patients can be very different from a clinical point of view in terms of speech, cognitive and social impairment. How can you pull together all the data? Can you discriminate the effect of treatment between ASD and Asperger patients? Is it possible to stratify the data on a gender basis?

Since the age of children is between 3 and 6 years, a time window with enormous changes in brain development, I suggest to divide data to understand effects of this long-term treatment in the 3-4 year and in the 5-6 year time window.

Minor points

Fig. 3 is unuseful for a scientific paper.

You should put how it is calculated the dose for children according to the study done on mice instead of “1,050 mg 243 in a 70 kg adult, within the daily dose range of 1-3 g”.

Author Response

Please find attached all the replies to the 5 Reviewers.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Journal

Manuscript ID

nutrients-4041561

Type

Article

Title

The Impact of Mushroom Hericium erinaceus Biomass Supplementation in Children with Autism Spectrum Disorder (ASD)

Authors

Plamen Dimitrov * , Alexandra Petrova , Victoria Bell , Tito Horácio Fernandes *

Section

Phytochemicals and Human Health

Special Issue

Bioactive Natural and Synthetic Products in Human Health and Diseases: Basic, Preclinical and Clinical Studies—2nd Edition

OVERVIEW OF THE MANUSCRIPT

Based on the widely recognized interplay between nutrition, physical activity, and mental health, it enhances brain resilience to stress and overall human health. In this sense, brain mapping enables researchers to identify deviations or abnormalities and to track changes in neurological patterns when a targeted drug or specific nutrition is used. The authors aimed to investigate and characterize an extremely vulnerable group of children with functioning ASD, disclosing their overall pattern of cognitive abilities and areas of difficulty. Furthermore, they intended to investigate the relevance of a mushroom (Hericium erinaceus) biomass dietary supplement for improving neurocognitive behaviour. The study used qEEG to track changes in neurological brain patterns in 147 autistic children, and the mushroom biomass was used for 6 and 12 months. The results of this study showed that the Hericium erinaceus biomass may have a complex effect on the deficits of ASD.

Some inconsistencies in Grammar and punctuation should be reviewed along with the text.
Other comments are divided by section as shown below.

TITLE

The title is “The Impact of Mushroom Hericium erinaceus Biomass Supplementation in Children with Autism Spectrum Disorder (ASD)”.

However in theAbstract (lines 21-26) we can read that: “The objective of the present study was twofold: first, to characterize extremely vulnerable group of children with 22 functioning Autism Spectrum Disorder (ASD), disclosing their overall pattern of cognitive abilities and areas of difficulty, and second, to investigate the relevance of the effects of a mushroom (Hericium erinaceus) biomass dietary supplement on eventual improvement on neurocognitive behaviour.” When I read this sentence, it seems to me that the first objective is not the use of the mushroom but “characterize extremely vulnerable group of children with functioning Autism Spectrum Disorder”. For this reason, the title needs to be rebuilt.

ABSTRACT

Some abbreviations in the Abstract should be defined, even though they are defined later in the text.
As noted above, it is necessary to revise the title or the aims of the study.
Furthermore, the abstract overstates the findings, conveying a conclusive tone while failing to adequately reflect the lack of randomization, lack of blinding, and high risk of bias.

KEYWORDS

Keywords are:

“Hericium biomass; bioactive compounds; encephalogram; autism; 36 neurocognitive disabilities

I suggest "

“Hericium erinaceus biomass; bioactive compounds; encephalogram; Autism Spectrum Disorder; neurocognitive disabilities.”

INTRODUCTION

This section is too long. I suggest reducing the size of the topic regarding the mushroom.
Is qEEC “Quantitative Electroencephalography”? Please define all the abbreviations the first time they are cited in the text. For the authors, the meaning of qEEG is obvious. However, for the reader, it can not be.
It seems to me that many molecular mechanisms discussed in this section are not directly related to studies in humans.
Since this section is long (even if the authors reduce the mushroom part), I suggest including more references published in 2024-2025.
In lines 233-234 we can read that “As already outlined, Hericium erinaceus biomass has demonstrated molecular therapeutic action.” Please include reference (s) here.
Do the same for the sentence “The use of qEEG comparative analysis addresses the circuit mechanisms that outline the patterns of neurophysiological effects of Hericium erinaceus biomass via pattern comparison with pharmaceutical drugs” (lines 233-235).
Regarding the objectives of this study, they are usually placed at the end of the Introduction section (which does not happen here). In lines 99-101we can read tha “This can be evaluated using innovative qEEG [19] and the present clinical study aimed at improving the current understanding of the role of mushroom biomass derived 1nutrients and secondary metabolites, on promoting brain health and neuronal adaptation”. Please see the objectives found in the Abstract (lines 21-25): “The objective of the present study was twofold: first, to characterize extremely vulnerable group of children with functioning Autism Spectrum Disorder (ASD), disclosing their overall pattern of cognitive abilities and areas of difficulty, and second, to investigate the relevance of the effects of a mushroom (Hericium erinaceus) biomass dietary supplement on eventual improvement on neurocognitive behaviour.”
Please make the objectives just the same in both sections. It seems to me that they are quite different.

METHODS

In this section,
ETHICS:

In lines 301-306 we can read that "The Medical Center Plamak/Пламък in Varna, Bulgaria, where the study was conducted, does not have an Ethics Committee established in accordance with international standards. Nevertheless, the highest ethical standards were maintained to protect the rights and welfare of participants, in collaboration with three major University Hospitals in Bulgaria, namely St. I am not familiar with the specific rules of Bulgaria; however, I believe approval by an ethics committee is essential." Please tell me about the rules of your country.

Furthermore, although the patient group is a very specific group, there are some weaknesses in this section:

The study is not randomized,
There is no placebo group,
The control group is not equivalent (composed of neurotypical children, not untreated children with ASD),
There is no blinding of the evaluators,

There is no information on relevant neuropsychiatric comorbidities beyond those explicitly excluded,

There is no detail on the concomitant use of behavioral therapies, which can be strong confounders,
The experience of the evaluators and whether the processing was blinded to the group were not described,
To the best of my knowledge, the DAYC-2 is internationally validated for assessing child development. However, I wonder: are there limitations to its use in autistic children?

RESULTS

Except for Figure 3, all the other are fine. Please improve the quality of Figure 3.
Comparison with the control group (neurotypical children) is inadequate for evaluating intervention.
Changes in the EEG may reflect natural development, parallel interventions, or spontaneous maturation. What do the authors think about this?

DISCUSSION

I feel the need to see more comparable clinical studies on H. erinaceus in children with ASD for more critical contextualization.
There is no discussion of the parental placebo effect (which can influence behavioral assessments and reports).
In my opinion, the “tone” is very positive and not very critical, citing complex physiological mechanisms that were not investigated in the study.

LIMITATIONS AND FUTURE PERSPECTIVES

I suggest the inclusion of a section named “Limitations and Future Perspectives” where the authors could discuss all the limitations of this study.
Furthermore, it would be nice to see what is next. I think that the authors could include points such as:
Perform randomized, double-blind, placebo-controlled clinical trials to confirm the efficacy of Hericium erinaceus in ASD, overcoming biases present in the current study,
Studies should investigate biological mechanisms through inflammatory biomarkers, microbiota, and pediatric pharmacokinetics,
Studies should also assess response moderators, such as age, severity, and concomitant therapies, which can help clarify heterogeneities,
Multimodal approaches integrating EEG, sensitive behavioral scales, and neuroimaging can elucidate real neurofunctional effects. Long-term analysis is needed to determine the sustainability of potential benefits,
Integrating clinical, functional, and quality-of-life outcomes is crucial. These advancements will allow for stronger and more translational evidence on the use of the supplement in ASD.

CONCLUSION

In my opinion, in this section, the authors note that the study presents an interesting hypothesis and potentially useful exploratory data, but does not provide sufficient evidence to conclude that Hericium erinaceus improves brain development or electrical activity in children with ASD. At most, the findings can be considered hypothesis-generating and require randomized, controlled, and blinded clinical trials for validation.

REFERENCES

This section is adequate; however, I suggest including more references published in 2024 and 2025.

FINAL COMMENTS

Dear authors, I wish you good luck with the publication process.

Author Response

Please see attached

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript titled "The Impact of Mushroom Hericium erinaceus Biomass Supplementation in Children with Autism Spectrum Disorder (ASD) " describes an exploratory research work testing the oral intake of lions mane's supplement by children diagonised with high functionin ASD for 6 months, being tested by qEE comparative analysis at baseline, 6 months and 12 months with normalized average brain functioning of the control sample. This interesting study is well designed and it is well explored, bringing novelty to the field. However, the qEE parameters could be more detailed in their description for a better understanding of the naive reader why this method was chosen over others to assess the differential physiological functioning under the intake of Hericium erinaceus supplement.

Line. 49-50: "Autism is a neurodevelopmental condition that affects how a person communicates, interacts socially, and processes sensory information. " In the current state of art, autism diagnosis has been considered in a context of a spectrum of signs and symptoms, as well stated in the title of this work. The diagnosis includes the categorization in levels to provide a guide within the communication among professionals as well there are used Autism Spectrum Rating Scales among other tools to help to diagnosis the level of functioning of the individual within the society. In lines 90-94, some reference to this is given to the readers, but it would be interesting to include a generalized description of the definition of the ASD mentioning the degrees of diagnosis, underlining the criteria that distinguishes a high functional individual within the context of ASD diagnosis.

Lines 52-53: "Around 30 to 40% of people with autism also have an intellectual disability. " Please, provide reference for this information.

Line 109: " Some 102 compounds were preliminarily identified ". It would be possible to kindly clarify?

Lines 123-124: "particular species of mushroom used, the production process implemented, and handling procedures practiced, and hence, the results can vary. " Soil's properties, type of climate and surrounding flora can also interfere with the biochemical composition of the fully developed mushroom. It also, varies if it is grown in the wild of within controlled conditions.

Lines 234-235: "The use of qEEG comparative analysis addresses the circuit mechanisms that outline the patterns of neurophysiological effects"Regarding qEEG principles, it would interesting to give more information regarding the composition and interrelation between different waves in the spectrum with brain activity's status as well as which biochemical parameters could modify the wave spectrum and their impact in the individual's behaviour/physiological functioning.

Figure 4: the starting values are the baseline ( time 0) and the end are the values after 12months? If so, it would be interesting to add the assessment for mid-time (6 months), i.e. if available.

Lines 609-612: "This triad of high anxiety, poor sensory integration and weakness in the functions of empathy and understanding of the surrounding environment are in practice the main three components with which the autism spectrum is described. In practice, Hericium erinaceus affected favorably these components ". This triad is associated also to poor rest and sleep which may further hinder the CNS functioning and condition social interaction in a physiologically energy impaired system. Any suggestions for complemmenting the future studies considering sleep and rest patterns?

Lines 694-695: "These are critical methodological and clinical issues that must be considered in both data interpretation and the design of future studies. " Please, indicate the most imporant limitations found in this study and propose future guidelines to overcome those same limitations.

Figures are of good resolution and easy interpretation as well as the results presented in tables. References are updated and appropriately used in the justification of the results.

Author Response

Please see attach

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript addresses an interesting and valuable topic, and the structure of the study is promising.

However the introduction is currently too broad in scope , it would be beneficial to narrow the literature review and removing more distant, less directly relevant sections (e.g detailed discussions of AD and PD..etc..) would make the introduction more focused and easier to follow.

The methodological description is detailed, yet one of the study’s most important limitations - the lack of a randomized, placebo-controlled group , is not highlighted sufficiently. In a pediatric population, natural developmental maturation can cause rapid EEG changes, so it would be important to address this openly in the manuscript and clarify how it may affect the interpretation of the results.

Because the current data are correlational, a more cautious wording would be advisable (“the results suggest…” or “these findings raise the possibility that…” ... This would strengthen scientific precision.

Do the authors plan to conduct a randomized, placebo-controlled trial in the future to better disentangle developmental maturation effects from the potential impact of Hericium?
Was any parallel evaluation performed using behavioral or clinical assessment tools (e.g. ADOS-2, Vineland) to support the clinical relevance of the EEG findings?

Was any correction applied for multiple comparisons, and if so, which method?

Overall the manuscript is built on solid foundations and with the suggested revisions it could become even more compelling.

Author Response

Please see attach

Author Response File: Author Response.pdf

Reviewer 5 Report

Comments and Suggestions for Authors

This study aimed to characterize an extremely vulnerable group of children with functioning Autism Spectrum Disorder (ASD), disclosing their overall pattern of cognitive abilities and areas of difficulty, and to investigate the relevance of the effects of a mushroom (Hericium erinaceus) biomass dietary supplement on eventual improvement in neurocognitive behaviour. The study used quantitative-EEG (qEEG), which compares the raw data to a normative database, to track the changes in neurological brain patterns in 147 children with high-functioning autistic attributes when mushroom Hericium erinaceus biomass supplementation was consumed over 6 and 12 months. The study showed that Hericium erinaceus biomass in children with ASD (F84.0) or Asperger syndrome (F84.5) significantly improved the maturation of the CNS, after 6 - 12 months’ oral use, decreased the dominant slow-wave activity, and converted slow-wave activity to optimal beta1 frequency. Therefore, it was concluded that the Hericium erinaceus biomass may have a complex effect on the deficits of the autism spectrum when applied to high-functioning ASD children.

When authors mention MBID for the first time in the abstract of their manuscript, it is necessary to write the full name for this abbreviation. Also, within the Introduction section of the manuscript, authors should write the full name before introducing the abbreviations “MBID” and “ROS”.

The Introduction section of the manuscript, although very informative and detailed, is too long and needs to be shorter, more compact, and more fluid, i.e., clear and sufficiently informative, enabling readers to quickly understand the background for this study. Also, the authors must include one paragraph at the end of the Introduction section in which they will clearly state the aim of the present study.

The statistical methods used in data analysis should be described within the Materials and Methods section of the manuscript. Within this section, the approval code of the Ethics committee should be written. The explanation for the DAYC-2 – Developmental Assessment of Young Children should be placed within the Materials and Methods section. Within the Materials and Methods section of the manuscript, the authors should clearly state the design of their study and explain why this research was not registered as a clinical trial.

The Result section should contain only pure results without any comments. All comments should be placed within the Discussion section of the manuscript.

In the Discussion section of the manuscript, the authors should not repeat the text from the Introduction section of the manuscript, but focus on their results achieved in this clinical study and explain these in the context of available knowledge regarding the investigated issues. Within the Discussion section of the manuscript, the authors should clearly state the main strengths and limitations of their study, as well as possible directions for continuing their research. Some of the latter are present in the Conclusion section of the manuscript and should be moved to the Discussion section.

The Conclusion section of the manuscript should be significantly shortened and focused exclusively on the conclusions that can be made based on the results of this research. All other text should be omitted or potentially included in the Discussion section of the manuscript, but without the repetition of the text that is already written in the Introduction or Discussion sections of the manuscript.

This topic is very important, original, and highly relevant to the field. The study addresses a specific gap in the field dealing with the potential possibility of using mushroom (Hericium erinaceus) biomass dietary supplement for the eventual improvement of neurocognitive behavior in children with functioning Autism Spectrum Disorder. Because of the latter, it can be said that this study is relevant to the field and would probably be of interest to the readers of the Nutrients journal.

This is the first study in which mushroom (Hericium erinaceus) biomass dietary supplementation was applied as an adjunct therapeutic approach in children with functioning Autism Spectrum Disorder and healthy controls. Because of the latter, the study brings valuable new insights into the possible effect of the investigated supplementation on the maturation of the CNS.

The references are appropriate, and the reference list is sufficiently extensive.

Comments on the Quality of English Language

The English language should be improved regarding the quality of explanation and appropriate expressions.

Author Response

Please see attach

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors reply to my questions. Even if the study shows some weakness due to the plan approved by the Ethical committee, it is done according their request and consequently it should be published.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,
Thank you very much for performing so many modifications.
With best regards,