Linking System of Care Services to Flourishing in School-Aged Children with Autism

Abstract

Flourishing in children is an indicator of positive development in the areas of emotional, social, and cognitive development. Using a recent dataset from the US National Survey of Children’s Health, this study investigates the association between access to a quality healthcare system and flourishing indicators in school-aged children with autism. The outcome variable describes the proportion of children aged 6–17 with autism meeting the flourishing criteria, which include measures related to learning, resilience, and self-regulation. The main independent variable includes six core indicators for school-aged children and adolescents, which assess whether the family feels like a partner in their child’s care, the child has a medical home, receives regular medical and dental preventive care, has adequate insurance, has no unmet needs or barriers to accessing services, and has prepared for transition to adult healthcare. Multivariable logistic regression models were used to examine the relationships between various independent variables and the outcome of interest. The results show that children with autism who receive comprehensive and coordinated care are more likely to flourish compared to those without such care for five of these six indicators, while controlling for sex, race, parental education, household income, self-reported autism severity, general health status, and the number of adverse childhood experiences. Children with autism are more likely to flourish when their families and healthcare providers work together effectively. Addressing gaps in the quality care system is essential for developing holistic approaches that empower children with autism to thrive and reach their full potential. Supportive health policies and effective coordination between families and healthcare providers are crucial for fostering the flourishing of children with autism, ensuring comprehensive, individualized, and continuous care.

1. Introduction

Flourishing in children refers to a state of optimal psychological, social, and emotional well-being. It encompasses positive mental health, resilience, and growth in learning and social skills [1,2,3]. Key attributes include finding meaning, engagement, positive relationships, and experiencing positive emotions, aligning with US national guidelines for healthy child development [4,5]. For children with developmental disabilities such as autism spectrum disorder, flourishing is characterized by the ability to form meaningful relationships, manage emotions and behaviors effectively, and engage in learning and curiosity [6]. For children with autism spectrum disorder, flourishing also involves successfully navigating social interactions, maintaining calmness, and showing a genuine interest in their activities and surroundings [7]. Flourishing is more than just the absence of illness or difficulties and it can exist even in the presence of challenging circumstances [8]. Flourishing in children with developmental disabilities/autism spectrum disorder occurs when they are provided with the right support and opportunities to thrive despite their challenges.

Flourishing in children with autism involves a range of positive developments in emotional and relationship development, and social engagement [9]. Despite facing unique challenges associated with their disabilities, flourishing in individuals with autism can be facilitated through a holistic, coordinated approach to health and well-being. As with neurotypical children, for children and adolescents with autism, flourishing involves a multifaceted approach to achieving optimal well-being and growth, tailored to their unique needs. Children with autism face unique challenges that can affect their long-term quality of life compared to neurotypical children [10,11], including scoring lower in social competence and behavioral control factors compared to those without autism [7]. Given these challenges, attention to the promotion of flourishing is particularly key for the continued growth and development of children with autism spectrum disorder. Importantly, research shows that flourishing helps adolescents with autism spectrum disorder develop independence, which is essential for their transition into adulthood [12].

The National Survey of Children’s Health (NSCH) conceptualizes flourishing through three core behavioral indicators: interest in learning, task persistence, and emotional regulation [8,13]. Our study aligns with these dimensions. Children with special healthcare needs, including autism, flourish at about half the rate of those without such needs [14]. While the developmental trajectory of children with autism may differ from neurotypical children, flourishing for children with autism relies more heavily on a supportive healthcare environment. Children with autism often require specialized medical services, therapies, and interventions to address their unique needs and challenges. However, disparities in access to care, such as inadequate insurance, a lack of pediatric specialists, and uncoordinated care, can prevent timely and appropriate therapeutic and medical services [15,16,17,18]. Without access to quality healthcare services, children with autism may experience delays in diagnosis, treatment, and early intervention, leading to more severe health issues and poorer long-term outcomes [19].

Despite significant advancements in understanding the challenges faced by children with autism, there remains a notable research gap concerning the factors that facilitate or hinder their flourishing. Previous studies have explored parental perceptions and flourishing in children with autism [7], the influence of functional challenges on flourishing among youth with autism [20], and the effects of educational factors on autistic flourishing [21]. A systematic review study on service access for children with autism suggests that additional approaches should prioritize care systems [22]. Pellicano and Heyworth highlight the importance of engaging autistic individuals and their families in defining research questions and approaches, which they argue is critical to accurately capturing the conditions that support autistic flourishing [23]. However, there is a lack of research on which healthcare system factors enable these children to meet flourishing criteria. Understanding the elements that promote growth and well-being in children with autism is important for developing effective interventions and support systems that foster their holistic development. Using the dataset from the US 2021–2022 NSCH, the purpose of this study is to investigate the association between access to quality health systems and flourishing indicators in children with autism. We hypothesized that children with autism who receive high-quality, coordinated healthcare are more likely to meet the flourishing criteria from the Data Resource Center for Child and Adolescent Health (CAMHI), compared to those who do not receive such care. In this study, we examine flourishing as a measurable outcome based on three behavioral indicators from the NSCH. For analysis, these indicators were combined into a binary variable to identify children who consistently demonstrate flourishing characteristics.

2. Materials and Methods

2.1. Data Source and Data Collection Process

We used the publicly available 2021–2022 NSCH dataset, sponsored by the Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA-MCHB) in collaboration with the US Census Bureau (https://mchb.hrsa.gov/data-research/national-survey-childrens-health, accessed on 25 October 2024). The NSCH is a national survey of US households with children under 18 years old. The NSCH includes a variety of healthcare access and services utilization outcomes. It also provides nationally representative estimates of key indicators of child health and well-being, offering valuable insights that help guide policymakers, advocates, and researchers in their efforts to improve child health policies and programs [24]. In addition, the constructed National Outcome Measures (NOMs) from the CAMHI have been made available since 2016. The NSCH is conducted using a combination of telephone interviews and online questionnaires. Data collection is designed to reach a broad and diverse population, ensuring the inclusion of families from various geographic and socio-economic backgrounds [24]. Households are selected through a multi-stage sampling process. Initially, a national frame was created using information from the US Census Bureau’s demographic surveys. This frame is then used to select primary sampling units (PSUs). Within selected PSUs, households are randomly chosen to participate in the survey. The US Census Bureau and HRSA-MCHB collaborate to ensure that the survey meets high standards for reliability and validity. A total of 104,995 surveys were completed for the combined 2021 and 2022 dataset. This analysis includes 2440 children aged 6–17 with a current diagnosis of autism. The determination of autism is based on parental responses to whether their child currently has autism or autism spectrum disorder. The autism status is determined by the question “Has a doctor or other healthcare provider ever told you that this child has autism or autism spectrum disorder?” This analysis did not require IRB approval as the data were publicly available [25].

2.2. Study Measures

2.2.1. Dependent Variables

The flourishing variable includes three questions related to learning, resilience, and self-regulation for school-aged children. The survey questions asked, “How often does this child: show interest and curiosity in learning new things, work to finish tasks they start, and stay calm and in control when faced with a challenge?” A response of “Always” or “Usually” indicates that the child meets the criteria for flourishing. This variable is a composite indicator created and validated by CAMHI based on the NSCH items, and it was constructed following established psychometric procedures by CAMHI [26]. Therefore, we relied on this existing, standardized variable for our analyses and did not conduct additional reliability testing. Our dependent variable is dichotomous based on CAMHI’s standard [26], with CSHCN with autism who met all flourishing items coded as 1 and CSHCN with autism who did not meet all flourishing items coded as 0. The decision to dichotomize the flourishing variable by requiring all three items to be met reflects the CAMHI scoring standard and has been used in previous research to indicate consistent and well-rounded flourishing behavior [8,27]. We acknowledge that this is a conservative approach and may exclude children who demonstrate some, but not all, flourishing behaviors. However, it provides a clear and standardized threshold for comparison and aligns with the outcome measure reported in national datasets. Sensitivity analyses using partial thresholds may be explored in future studies.

2.2.2. Independent Variables

Our primary independent variable of interest was a composite NOMs variable assessing the system of care for CSHCN, which was constructed by CAMHI. This variable was dichotomous: CSHCN with autism who receive care in a well-functioning system and CSHCN with autism who do not receive care in a well-functioning system. Further, this composite variable included six age-relevant core measures among school-aged children: the family feels like a partner in their child’s care, the child has a medical home, the child receives medical and dental preventive care, the child has adequate insurance, and the child has no unmet need or barriers to access services. For children aged 12–17 years, an additional variable assessing preparation for the transition to adult healthcare was included, alongside the five previously described measures. This composite measure included three criteria: (1) time alone with a healthcare provider, (2) doctors actively working with the child to plan their future healthcare needs, and (3) discussion of the transition to adult care providers. According to CAMHI’s standard, the child was considered to have received an adequate transition to adult healthcare if at least one criterion was positively met. Children were categorized as receiving care in a well-functioning system if they had a valid positive response to at least one of the age-appropriate components and no negative responses among the remainder (with remaining items either missing or legitimately skipped). Respondents with all components missing were coded as missing. This approach aligns with the standardized method used in national reporting by CAMHI [28].

Covariates were chosen based on prior research indicating their association with flourishing children [29,30,31]. These covariates included sex (male/female), age (6 to 11 or 12 to 17 years), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, others), parental education (high school or less, some college, college degree or above), household income (0–99% federal poverty level [FPL], 100–199% FPL, 200–399% FPL, ≥400% FPL), self-reported autism severity, children’s general health, and the number of adverse childhood experiences (ACEs). The number of ACEs was based on the NOMs defined by CAMHI, using parent-reported responses from the NSCH. The ACEs item includes experiences such as parental divorce or separation; household economic hardship; exposure to violence; living with someone with mental illness or substance abuse issues; and household incarceration. Responses were categorized into two groups according to the NOMs framework: children who experienced 0–1 ACEs and those who experienced 2 or more ACEs [28].

2.3. Statistical Analysis

Data analysis was performed using Statistical Analysis System (SAS) 9.3, developed by SAS Institute Inc. (Cary, NC, USA) in 2011. Bivariate associations between flourishing and system of care were analyzed and compared using chi-squared tests to detect significant differences. Adjusted logistic regression models were then used to examine the associations between SOC variables and flourishing status while controlling for demographic characteristics, autism severity, child general health, and ACEs. Tests for multicollinearity showed that variance inflation factors (VIFs) were below 10, suggesting that multicollinearity was not a significant issue in our analysis. We did not include interaction terms in our logistic regression models as our primary aim was to evaluate the main effects of each independent variable without exploring these potential moderating effects. Odds ratios and 95% confidence were calculated to quantify the strength and precision of these associations. All p-values were two-sided, with p < 0.05 considered statistically significant. All the analyses were weighted using survey weights provided by CAMHI based on the US Census Bureau.

3. Results

The 2021–2022 NSCH had 104,995 completed surveys. Of 64,185 school-aged children with a valid response to the autism spectrum disorder question, 2440 children currently have autism. Therefore, the sample for this study was restricted to school-aged children (6–17 years) with autism (n = 2440, weighted n = 1,661,777). The sample was further narrowed down to children with complete data on the flourishing question (N = 2253).

Table 1. Sample characteristics and flourishing criteria for school-aged children with autism.

Variable	Meeting Flourishing Criteria N = 329 Weighted N = 225,667	Not Meeting Flourishing Criteria N = 1924 Weighted N = 1,233,122	All N = 2253 Weighted N = 1,458,789
Flourishing variable	15.5%	84.5%	100%
Age
6–11	52.1%	49.6%	50.0%
12–17	47.9%	50.4%	50.0%
Sex
Male	67.1%	77.8%	76.1%
Female	32.9%	22.2%	23.9%
Race
White	50.0%	52.2%	51.8%
Black	10.2%	15.7%	14.8%
Hispanic	32.4%	23.0%	24.4%
Other	7.4%	9.2%	8.9%
Household poverty level
0–99% FPL	17.4%	20.0%	19.6%
100–199% FPL	22.9%	28.4%	27.6%
200–399% FPL	30.8%	27.6%	28.1%
400%+ FPL	28.8%	24.0%	24.8%
Parent education level
Below high school	33.4%	30.6%	31.0%
High school	26.5%	26.1%	26.2%
Above high school	40.1%	43.3%	42.8%
ASD severity
Mild	68.1%	39.7%	44.1%
Moderate/severe	31.9%	60.3%	55.9%
General health
Excellent or very good	83.2%	61.2%	64.6%
Good	15.2%	29.9%	27.6%
Fair or poor	1.6%	8.9%	7.8%
Adverse childhood experiences
0–1	77.0%	52.8%	56.5%
2 or more	23.0%	47.2%	43.5%

Percentages are commonly rounded when presented in tables. As a result, the sum of the individual numbers does not always add up to 100%. NSCH was weighted to represent the population of children residing in US households. ASD: autism spectrum disorder.

describes the characteristics of our analytic sample. Our sample was mostly male (76.1%), nearly half were 12–17 years old, 51.8% were White, 64.6% self-reported very good to excellent health conditions, 44.1% had mild autism spectrum disorder symptoms, 19.6% lived in households with incomes below the federal poverty line, and 31% of the parents/guardians had less than high school education. Approximately 43.5% of children experienced two or more adverse childhood experiences. Among these children with autism, fewer than one-fifth (15.5%) indicated meeting the flourishing criteria. Overall, fewer than one in five children with autism met the criteria for flourishing, highlighting a concerningly low rate of positive developmental indicators in this population. This overall finding underscores the need for targeted support. Subgroup analyses further revealed disparities in flourishing based on demographic and system of care-related variables.

A higher proportion of children with autism who received care through an integrated care system met the flourishing criteria, compared to those who did not (23.9% vs. 14.5%, p = 0.0402). For families of children with autism, 9.2% of children whose parents felt like partners in their care were reported to be flourishing, compared to only 3.6% of children whose parents did not feel like partners in their care (p < 0.001). Approximately 17.7% of children with autism who had a medical home met the flourishing criteria versus only 14.2% of those without a medical home, although this difference was not statistically significant. A significantly higher number of children with adequate insurance were flourishing versus those without adequate insurance (18.5% vs. 9.9%, p = 0.0021). Chi-squared analysis also shows that about 17.6% of children from families with no frustration were flourishing, while only 7.1% of those from families experiencing unmet needs and frustration indicated the same (p = 0.0022). However, approximately 30.1% of children without preventive care visits met the flourishing criteria, compared to only about 14.4% of children who had one or more preventive care visits. More than one-fifth of adolescent children with autism (22.3%) who received services to prepare for transition were reported to be flourishing, compared to 13.4% of adolescent children who did not receive such services. Figure 1 shows the proportion of children meeting the flourishing criteria by each of the six system of care measures.

Table 2. Multivariable logistic regression results.

Variable	Odds Ratio (95% CI)	p
System of care
Receive care in a well-functioning system (vs. without such care)	1.517 (1.495–1.540)	<0.001
Age
12–17 (vs. 6–11)	1.209 (1.197–1.222)	<0.001
Sex
Female (vs. male)	1.581 (1.564–1.598)	<0.001
Race
Black (vs. White)	0.940 (0.925–0.956)	<0.001
Hispanic (vs. White)	1.579 (1.561–1.598)	<0.001
Other (vs. White)	1.002 (0.984–1.021)	0.7934
Household poverty Level
0–99% FPL (vs. 400+)	0.717 (0.704–0.729)	<0.001
100–199% FPL (vs. 400+)	0.733 (0.722–0.744)	<0.001
200–399% FPL (vs. 400+)	0.894 (0.881–0.906)	<0.001
Parent Education Level
High school (vs. below)	0.808 (0.797–0.819)	<0.001
Above high school (vs. below)	0.484 (0.477–0.491)	<0.001
ASD Severity
Moderate/severe (vs. mild)	0.381 (0.377–0.385)	<0.001
General Health Status
Excellent or very good (vs. fair or poor)	6.334 (6.120–6.556)	<0.001
Good (vs. fair or poor)	2.507 (2.418–2.598)	<0.001
Adverse Childhood Experiences (ACEs)
2 or more (vs. 0–1)	0.417 (0.413–0.422)	<0.001

ASD: autism spectrum disorder.

presents adjusted results from multivariable logistic regression analysis for the association between system of care and flourishing among school-aged children with autism. After adjusting for covariates such as family and child characteristics, children with autism who received care in a well-functioning system were 1.5 times more likely to be flourishing than those who did not [OR 1.517, 95% CI (1.495, 1.540, p < 0.001)], indicating a meaningful association between coordinated care and positive developmental outcomes. Female children with autism were more likely to be flourishing than their male counterparts [OR 1.581, 95% CI (1.564, 1.598, p < 0.001)], suggesting potential sex-related differences in social-emotional development and/or access to supportive environments. Hispanic children with autism were more likely to be flourishing than White children with autism [OR 1.579, 95% CI (1.561, 1.598, p < 0.001)], while Black children with autism were less likely to be flourishing than White children with autism [OR 0.940, 95% CI (0.925, 0.956, p < 0.001)]. This finding may reflect disparities in access to resources, differences in cultural perceptions of behavior, or systemic barriers within health and education systems that affect Black autistic children and their families. The odds ratios of flourishing for children living in households with incomes between 0% and 400% of the FPL, compared to those in households with incomes at or above 400% of the FPL, ranged from 0.72 to 0.89. However, children of parents without a high school diploma were more likely to be reported as flourishing compared to children of parents with a high school degree or higher (Table 2). Children with excellent or very good health had much higher odds of flourishing compared to those with fair or poor health [OR = 6.334, 95% CI (6.120, 6.556), p < 0.001)]. In addition, children with two or more ACEs were less likely to flourish compared to those with fewer than two ACEs [OR 0.417, 95% CI (0.413, 0.422), p < 0.001], indicating that exposure to multiple adversities may substantially hinder positive developmental outcomes in children with autism.

Table 3. Adjusted odds ratios of six types of system of care.

System of Care	Odds Ratio (95% CI) *	p
Families are partners in decision making
Yes (vs. no)	2.280 (2.216–2.346)	<0.001
Current insurance is adequate
Yes (vs. no)	1.768 (1.747–1.789)	<0.001
Care meets medical home criteria
Yes (vs. no)	1.221 (1.209–1.233)	<0.001
Having preventive care visits
Yes (vs. no)	0.853 (0.511–1.425)	0.5434
Unmet needs and frustration
No (vs. experienced some)	1.726 (1.698–1.753)	<0.001
Received services to prepare for transition **
Yes (vs. no)	2.075 (2.039–2.113)	<0.001

* Adjusting for sex, age, race, parental education, household income, self-reported autism severity, children’s general health, and the number of adverse childhood experiences (ACEs); ** only for 12–17 years old.

shows the adjusted logistic regression results for each system of care indicator. After adjusting for covariates, children with autism from families who felt like a partner in their child’s care were 2.3 times more likely to meet the flourishing criteria compared to those from families who did not [OR 2.280, 95% CI (2.216, 2.346), p < 0.001]. Families without unmet needs or frustration were more likely to report their children as flourishing compared to those with unmet needs and frustration [OR 1.726, 95% CI (1.698, 1.753), p < 0.001]. The odds ratio for meeting the flourishing criteria was 1.2 for children with a medical home compared to those without a medical home [OR 1.221, 95% CI (1.209, 1.233), p < 0.001)]. Children with adequate insurance were nearly twice as likely to be flourishing compared to those without adequate insurance [OR 1.768, 95% CI (1.747, 1.789, p < 0.001)]. There was no significant association between preventive visits and flourishing indicator after adjusting for covariates. Additionally, adolescent children receiving the necessary services to prepare for the transition to adult healthcare were twice as likely to be flourishing compared to those not receiving such services [OR 2.075, 95% CI (2.039, 2.113, p < 0.001)].

4. Discussion

Using the current US national survey for children’s health, findings from this analysis suggest gaps in meeting NOM flourishing criteria for school-aged children with autism with differences depending upon receiving system of care or not. Compared to their counterparts without needed care, children with autism receiving system of care were significantly more likely to flourish. Several indicators of the system of care had a strong impact on these children’s flourishing outcomes. Notably, children with autism who had effective coordination between their families and healthcare providers were much more likely to flourish compared to those without such coordination. This collaboration ensures that care plans are comprehensive, personalized, and continuously adapted to meet each child’s specific needs. Families can provide invaluable insights to guide healthcare decisions as they are intimately aware of their child’s unique strengths and challenges. Another notable finding was that adolescents who received needed services to prepare for transition to adult healthcare were twice as likely to flourish than adolescents who did not receive these services. This finding suggests that not all adolescents with autism have equal access to transition services, leading to disparities in flourishing outcomes.

The availability of specialized programs is crucial because these programs reduce gaps in care by offering personalized services and consistent support. Autism Speaks offers a series of comprehensive toolkits designed to support families, educators, and healthcare professionals in managing autism spectrum disorder [32]. These toolkits provide practical, evidence-based resources tailored to various aspects of ASD, including educational strategies, and navigating healthcare systems [33]. These resources are continually updated to reflect the latest research and best practices in autism care [34]. In the United Kingdom, the National Health Service (NHS) implements structured care pathways for the diagnosis and management of autism spectrum disorder [35]. The NHS care pathways are designed to provide a coordinated approach to autism care, integrating services from multidisciplinary teams (e.g., pediatricians, psychologists, speech therapists). This approach ensures that children with autism receive timely and comprehensive assessments, individualized treatment plans, and ongoing support tailored to their specific needs.

New technology such as machine learning and vision techniques can assist clinicians to provide a reliable and timely diagnosis of autism spectrum disorder [36,37,38,39]. Ko et al.’s study indicated that machine learning and vision technologies can be scaled to screen large populations, making it easier to identify autism spectrum disorder in diverse settings [39]. By accurately assessing the severity of autism spectrum disorder symptoms, these technologies can help tailor interventions to individual needs, thereby improving the effectiveness of treatment plans. Telehealth interventions have proven to be highly effective for individuals with autism spectrum disorder, offering services comparable to traditional face-to-face methods [40,41,42,43]. These programs can provide diagnostic assessments, early interventions, and ongoing support, making them accessible to families in rural or underserved areas. Studies have shown that telehealth can deliver high-quality care, ensuring diagnostic consistency and patient satisfaction [40,41]. By leveraging technology, telehealth can bridge gaps in service delivery, reduce wait times, and offer personalized care plans, ultimately improving outcomes for children with autism spectrum disorder [42,43]. Furthermore, initiatives aimed at improving systems of care, such as infrastructure-building and enabling services, can enhance coordination across different clinics and organizations, ensuring that families have access to comprehensive and timely support. The future development of projects addressing care services and children’s outcomes, including technology-driven approaches, holds promise for enhancing the overall quality of care and support for individuals with autism spectrum disorder.

Socio-demographic characteristics and children’s health status were associated with flourishing outcomes among children with autism. These characteristics include sex, race/ethnicity, and family income level. Compared to children from the highest income level families, children from lower income level families were less likely to meet the flourishing criteria. Specifically, children from the lowest income level families were over a quarter less likely to flourish than their counterparts from the highest income level families. The negative association between family income levels and flourishing outcomes among children with autism highlights significant socioeconomic disparities impacting these children’s well-being. Families with lower income levels often face barriers such as limited access to high-quality healthcare, educational resources, and specialized services that are critical for the development and flourishing of children with autism [44]. Financial constraints can also increase family stress, affecting the child’s overall growth and development environment [45]. Effective public policies and programs aimed at reducing these disparities play a vital role in providing support to low-income families [46]. Female children across our sample were more likely to flourish than male children. Boys are more frequently diagnosed with autism spectrum disorder, and they often have more difficulties with social interactions and managing their behavior [47]. These challenges can impact their overall well-being and ability to flourish compared to female children with autism, who might exhibit less severe or different symptoms.

Our results indicate that necessary transition services significantly impacted flourishing outcomes among adolescents with autism. This finding underscores the critical role of using appropriate transition services. Evidence shows that proactive assistance from healthcare providers significantly enhances the ability of youth with autism to manage their health independently and transition successfully to adult care [48]. However, one significant challenge is ensuring continuity of care. Policy changes should be implemented to address health insurance challenges faced by adolescents during transitions [49]. Adolescents with autism may have complex medical histories and ongoing needs that require a seamless transition to avoid disruptions in treatment. Effective programs that advance care transitions within the medical home are crucial for ensuring a successful shift to adult care [50].

Effective coordination between families and healthcare providers is another key factor for promoting flourishing among school-aged children with autism. Families are often the primary advocates and caregivers for children with autism, and their involvement in care planning and decision-making is critical. Physicians who actively engage with families, respect their insights, and work collaboratively to develop individualized care plans can significantly enhance the well-being of these children [51]. This partnership ensures that care is tailored to each child’s unique needs and maintains continuity in managing their health conditions. Additionally, coordinated care models that integrate medical, educational, and community services offer significant benefits. These models foster communication among families, healthcare providers, educators, and community health partners, ensuring a comprehensive approach to the child’s development and well-being [52]. Such integrated care systems can address the multifaceted needs of children with autism, promoting better health outcomes and greater overall flourishing.

This analysis has several limitations. First, the cross-sectional design restricts the ability to draw causal inferences. Longitudinal data are needed to determine how the system of care affects flourishing in children with autism over time. Second, all the information was provided by the children’s caregivers, which could introduce bias. The subjectivity inherent in self-reported data also introduces variability, as different respondents may have different interpretations of the questions, leading to inconsistent reporting. These biases can result in over- or underestimations of specific health conditions, behaviors, or outcomes. For instance, parents’ educational levels might influence how they perceive and report their children’s flourishing. Parents with lower educational attainment might have different perspectives or criteria for defining and assessing their child’s flourishing compared to those with higher educational backgrounds, potentially influencing the reported outcomes. Moreover, parents with higher educational backgrounds may be more familiar with the language and constructs used in standardized assessments, which could influence the accuracy or alignment of their responses with the intended measures. Future research should explore these factors comprehensively to better understand the dynamics at play in reporting children’s flourishing outcomes across different parental educational levels. Additionally, there is the possibility of inaccuracies if parents mis-reported autism spectrum disorder diagnoses. Due to the relatively small sample size of children with autism, interaction effects (e.g., by age, race, or autism severity) were not examined, as they were outside the scope of our primary research aim and would require additional statistical power. Future studies with larger samples should consider these subgroup analyses. Finally, the flourishing indicator in this analysis was a composite measure made by CAMHI for CSHCN. Different aspects of development and emotional well-being may vary in their impact on a child’s overall flourishing among children with autism. Further studies should develop measures that encompass all relevant aspects supporting flourishing, considering the cultural values of children with autism and their families. While the NSCH provides valuable insights into the health and well-being of children in the US, it is important to interpret the results with an understanding of the potential biases and limitations. Recognizing these factors allows researchers and policymakers to more accurately assess the data and make informed decisions based on the findings.

5. Conclusions

Access to a well-coordinated healthcare network is paramount for promoting flourishing in children with autism. Such access ensures timely and comprehensive care tailored to their specific needs, facilitating early intervention and ongoing support. Supportive public policies and effective coordination between families and healthcare providers are essential for fostering the flourishing of school-aged children with autism, ensuring comprehensive, individualized, and continuous care. By integrating early intervention, specialized therapies, and coordinated care models, these approaches collectively contribute to better outcomes and the flourishing of children with autism. Our findings also highlight the need for healthcare systems to prioritize and invest in transition programs that address the unique needs of adolescent children with autism, ultimately supporting their long-term well-being and development.