Linking System of Care Services to Flourishing in School-Aged Children with Autism
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThank you for inviting me to revise the current manuscript.
I appreciate the authors' clear writing style and the linearity of the research process. Likewise, the DB the authors display is interesting since it concerns a survey of caregivers.
Nonetheless, the manuscript's strengths merit consideration for publication; I have to ask the authors to improve some essential points.
Title
The title does not reflect the meaning of the survey.
Consider alternatives (interaction between Care Services and Children ?)
Abstract
I found it clear.
Introduction
Please check if the editor has changed to APA style.
57-59
The authors should specify the clinical sample (ASD?)
61-63 (cit. 13)
Which dimensions were investigated in the studies?
The primary concern regarding the introduction is that the authors do not sufficiently address the dimensions studied in the literature included in the Flourishing definition. I still noted such limitations in the method.
81-83 (cit. 23)
It is not clear; please.
2.1 Data source
Is the DB you refer to an open-access database?
Nevertheless, I think you should include a website as a reference.
Check line 119 (subtitle)
120-124
It's redundant.
I have doubts regarding the content validity of the dependent variable.
The authors do not furnish the literature and methods for selecting such questions.
In what manner is such a question theoretically based?
Since the authors split the response to perform Regression, they should align the introduction and method on this point.
I think you should include the survey in the appendix.
2.3 St. An
I think it's a methodology for bias reduction (proportion between subgroups, item reliability, and convergent validity).
Adverse childhood experiences
The authors should specify what this item asks throughout the manuscript.
Figure 1
Consider adding the second axis, which includes outcome variables.
Discussion
266
Add citation
267
add website
279
add citation
280-291
Improving and extending such a section would be a good idea since it appears challenging. Consider adding studies about telehealth (in the ASD population) that offer services similar to those you are investigating.
Your discussion does not include the future development of projects addressing care services and children's outcomes, including technology.
After methodological revision and some sections to improve, your survey (DB) is informative and would be considered for publication.
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsThe paper is well written and offers a novel contribution to autism research. The secondary data analysis capitalized on a large and rich data set. There are two areas that require clarification and revision:
- There is no clear definition of the term ‘flourishing’ provided in the introduction. It would be helpful to more clearly define what is meant by this term early in the paper.
- Figure 1 is misleading given the value of the y-axis. The Y axis should extend to 100% to better reflect the percentages displayed in the bar graph. As it appears, the values seem much greater than they actually are. The percentage of children who are flourishing overall is quite low, but appears higher given the Y axis range.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsTitle: Receiving System of Care Services and Flourishing in School-aged Children with Autism
General Evaluation: This manuscript addresses a highly relevant and timely topic that is the role of a well-coordinated system of care in promoting flourishing among school-aged children with autism. The paper uses a large, nationally representative dataset (NSCH 2021–2022), employs strong methodology (weighted logistic regression), and presents findings with implications for health policy and practice. The structure follows well. Authors clearly outline their purpose, findings, and significance. However, several minor revisions are necessary before the manuscript can be considered for publication.
Introduction: Introduction presents a strong rationale for studying flourishing in children with autism, drawing upon key constructs like positive mental health, resilience, and social-emotional development. The authors framed flourishing as more than the absence of difficulties. They also highlight systemic inequities in access to high-quality care and the importance of holistic approaches. However, the introduction is somewhat repetitive in its discussion of flourishing and could be simplified to improve flow. For example, several definitions and implications of flourishing are presented across multiple paragraphs, which could be condensed into a more concise overview.
Materials and Methods: Methods section is detailed. Authors described how the dependent and independent variables were constructed, and the decision to use CAMHI’s established indicators is well-supported. However, further clarification is needed on how the composite “system of care” variable was defined; particularly whether each component was weighted equally or required full satisfaction across all domains. The decision to dichotomize the flourishing variable by requiring all three behaviors may be overly conservative; some justification for this decision, or discussion of its implications, would strengthen the analysis. Additionally, while the authors describe statistical controls and the software used, the rationale for excluding interaction terms should be explained in detail; especially given potential differences in outcomes by age, race, or autism severity.
Results: The results section presents data clearly. Tables and figures are appropriate and help convey the statistical findings. The results demonstrate that multiple aspects of a coordinated care system, particularly parental partnership, adequate insurance, and transition services are significantly associated with higher odds of flourishing. These are important findings that support the central thesis of the paper. However, the narrative summary of results could be improved by foregrounding the most critical takeaways such as the low overall rate of flourishing (15.5%), before moving into detailed subgroup breakdowns. The unexpected finding that children without preventive care visits had higher flourishing scores is particularly notable and should be better contextualized or flagged for further exploration. In general, the statistical interpretation is sound, though the implications of odds ratios (e.g., OR = 1.5) should be more clearly explained in practical terms.
Discussion: The Discussion interprets the findings tand highlights relevant implications, especially regarding family-provider partnerships and transition planning. Authors are correct to emphasize the importance of individualized and continuous care in promoting positive developmental outcomes. They also connect their results to concrete policy recommendations, such as the need for accessible transition services and better integration of health and education systems. However, the discussion occasionally strays from the core topic. References to machine learning techniques for autism diagnosis, while interesting, are tangential to the paper’s focus on systems of care and could be removed or reduced. The discussion would benefit from greater focus on the key findings and clearer delineation between background information and interpretation of results. Additionally, some points are repeated across multiple paragraphs, such as the impact of transition services and family involvement and could be tightened to improve readability. The limitations are well-stated. The authors acknowledge the cross-sectional design and the use of parent-reported data, both of which constrain causal interpretation. The discussion of potential bias introduced by parental education and perception could be expanded further. Conclusion reiterates main findings and calls for investment in systems of care and transition services.
Overall Recommendation: Minor Revisions
This is a strong and policy-relevant manuscript that makes an important contribution to our understanding of how systems of care can support flourishing in children with autism. It is suitable for publication pending moderate revisions. The authors are encouraged to revise the introduction, provide more clarity in the methods, highlight key findings more prominently in the results, and focus the discussion more directly on the paper’s central themes.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
