FROM : Family-Based Support as a Social Determinant of Health-Protective Factor for Parents of Children with Autism Spectrum Disorder

Reviewer Response Report 1 & 2

 

 FAMILY-BASED SUPPORT AS A SOCIAL DETERMINANT OF HEALTH-PROTECTIVE FACTOR FOR PARENTS OF CHILDREN WITH AUTISM SPECTRUM DISORDER

All newer responses are highlighted in yellow in the manuscript.

I recommend the article for publications with the following changes/suggestions:

1. In your introduction address, in more detail, all of the social determinant of health factors (contexts), and why you decided to focus more so on the social and community context and its bearing on depression. Your focus is on 3 domains, it may not hurt to briefly mention the others. Also, severity of ASD symptoms is linked to the Healthcare/Access/Quality domain--- this is acceptable, but a bit of a stretch- severity of ASD may be impacted by SDOH, but I am not certain if it is directly a SDOH. Provide research to support this or consider rewording the connection.

 

Response: Thank you for your comment. We have added a sentence acknowledging the five domains of Social Determinants of Health (SDOH) and have clarified and expanded upon the rationale for including child symptom severity as an SDOH factor. This update is reflected in the Introduction section and is highlighted in yellow for your reference.

2. Provide more research on the impact of depression on caregiving/parenting and the receptiveness/utilization of family-based supports.

 

Response: We appreciate the reviewer’s suggestion to include more research on the impact of depression on caregiving/parenting and the receptiveness and utilization of family-based supports. In the manuscript, we have expanded the literature review to include additional studies that explore how depressive symptoms in parents of children with ASD can influence their role as caregivers and engagement with family-based supports.

3. Expand more on the “gap’ mentioned on pages 1 and 5, “While social support, particularly family-based support, has been shown to alleviate stress and depression….its role in mitigating depression in parents of child with ASD remains underexplored…”---Offer more research support. Addressing item #2 and #3 will strengthen the literature review section. Also, some of the content under Implications (Practicing Counselors) might be appropriate for the literature review section.

 

Response: We appreciate the reviewer’s suggestion to include more research addressing the gap in the literature. We have updated this section with more recent research to better address the identified gap.

4. Don’t forget to address in the Discussion what you mentioned on page 2, the end of para 2 ,“The current study expands the application of the SDOH framework through a family systems level perspective on adjustment when a child has ASD”---Also, expand on how the study has “the potential to inform policies aimed at improving financial stability”—page 2, last sentence of para 3. If these items cannot be addressed, consider deleting mention of them. It will enrich your discussion.

 

Response: Thank you for your feedback. The discussion and implications section has been expanded to emphasize the importance of family-based support for parents of children with ASD. We have added a sentence at the end of paragraph 3 to further elaborate on this point. In the policy and social justice advocacy implications section, we previously included examples of policies that advocates can use to champion financial support initiatives based on the study’s findings. To strengthen the alignment between our findings and financial support policies, we have now updated this section with an additional sentence. Please refer to the highlighted section under policy implications for the updated response.

5. Clarify that the data cleaning mentioned under Sampling and Data Collection refers to the data cleaning mentioned under Data Analysis- first para. Clarify under Data Analysis the # of participants retained for analysis. Is the total 195 or 196? or 199? -mentioned in your Abstract?

 

Response: Thank you very much for this feedback. 199 participants were retained for analysis. This has been updated throughout the manuscript.

6. Under Limitations and Future Research- it is worth mentioning that most participants were also educated (possessing a bachelor/master’ degree). How does educational level factor into your results/implications?

 

Response: Thank you for your comment. We appreciate your suggestion regarding the inclusion of educational level as a factor in the limitations section. While we did acknowledge the sample’s predominantly educated background (with most participants possessing at least a bachelor’s or master’s degree), we did not explicitly examine educational level as a variable in this study. Therefore, it was not tested or analyzed in relation to the outcomes. However, we recognize that educational attainment could potentially influence how parents of children with ASD engage with family-based support, and our future research section includes exploring this area.

7. The following are not on the reference list:

 

Delobel-Ayoub et al.; Schopler & Mesibov et al.; Yu et al.; Pottie et al.; Jonathan et al., Kateryna et al., McStay, et al.; Adak & Halder, and the American Psychiatric Association.

Response: Thank you for pointing these out. We have updated the references in the manuscript accordingly. Kateryna et al., 2020 has been replaced with Drogomyretska et al., 2020, using the correct first author’s last name. Additionally, Pottie et al. have been replaced with more recent literature reviews, as suggested by another reviewer.

 

 

 

 

 Peer Review Report: Manuscript on Family-Based Support as a Social Determinant of Health in Parents of Children with ASD

All newer responses are highlighted in yellow in the manuscript.

General Assessment This manuscript addresses an important and timely topic, the influence of family-based support on the mental health of parents raising children with autism spectrum disorder (ASD). The integration of the Social Determinants of Health (SDOH) framework with mental health outcomes in caregivers provides a meaningful lens for exploring both resilience and vulnerability in this population. The study is clearly grounded in the literature, employs rigorous statistical analysis, and translates findings into relevant implications for training, clinical application, and policy development. That said, there are a few areas where the manuscript could be strengthened.

Strengths

• Relevance: The authors make a compelling case for why family-based support should be viewed as a social determinant of health and how this aligns with broader public health frameworks. The study also extends existing literature by positioning family support within a systems-level lens.
• Methodological Soundness: The analytic approach, particularly the use of SEM and moderation analysis, is well executed and appropriate for the research questions posed. The handling of missing data, transformations, and model fit are described clearly and show methodological rigor.
• Practical Implications: The implications drawn from the findings are thoughtful and extend beyond surface-level recommendations. The manuscript provides concrete examples, such as use of specific screeners and proposed legislative advocacy, that enhance its relevance for practitioners and policymakers alike.
• Writing and Structure: The manuscript is clearly written and well-organized, making complex methods accessible to a broad audience without oversimplifying the analysis.

 

Areas for Improvement

1. Reference Currency Some of the foundational studies cited in the literature review are more than a decade old. While these works remain relevant, the field has seen considerable development, particularly since the pandemic, in how family systems adapt to stress and isolation.

 

Suggestion: Update or supplement several citations with more recent sources, especially in areas discussing parental mental health, support mechanisms, or SDOH models within disability contexts. This would also help balance the reliance on earlier ASD literature.

Response: Thank you for your feedback. The researchers focus on the literature pre-pandemic, as the data collected for this study were pre-pandemic and did not account for the impact of COVID-19 on some of the participants' experiences. We have updated several citations in the literature review on the role of social support in parental mental health, social determinants of health, and parental depression. For example, we replaced (Bishop et al, 2007 with Lindsay & Barry, 2018). The added in-text citations and references are highlighted in yellow.

2. Measurement of Child Symptom Severity (CSS) The moderation findings related to CSS were inconclusive, and the authors rightly note limitations with the scale used. However, the issue deserves greater attention in the discussion, especially given that CSS was central to one of the hypotheses.

Suggestion: Expand discussion of the limitations inherent in the CSS scale, namely, its focus on frequency rather than impact or severity, and suggest validated alternatives for future work (e.g., Vineland-3, ADOS severity scores, or SRS-2).

Response: Thank you for the feedback and suggested child behavioral assessment alternatives. I have suggested additional validated alternatives prominent in ASD research in the limitations and future directions sections: “Future studies can use more comprehensive scales prominent in ASD research, such as the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2000) and Autism Diagnostic Observation Schedule (ADOS) severity scores (Shumway et al., 2012).”

I have also provided a justification for using the CSS scale specifically as a moderator in the methodology section to further provide an explanation for its use. Under research design: “The CSS measured the frequency of behaviors as reported in the DSM-5 (APA, 2013). There are several measures of symptom severity of ASD that studies have used to examine severity and to challenge behavior in other parent studies on ASD (e.g., Giovangoli et al., 2015; Wayment et al., 2019). However, few studies have specifically included the potential influence of differences in the frequency of ASD symptoms (Kochazuck, 2020).”

3. Moderation vs. Post-Hoc Interpretation There is a risk of over-interpreting the post-hoc slope analyses, particularly since the main moderation effects were non-significant. While the additional probing is helpful, the discussion should more clearly distinguish between exploratory follow-up and hypothesis-driven results.

 

Suggestion: Frame the slope analyses as exploratory insights that warrant further study, rather than evidence of robust conditional effects. Acknowledge the potential for Type I error due to multiple comparisons.

Response: Thank you for your insights on the data analysis. We have reworded our results of the slope analyses to explicitly discuss them from an exploratory perspective. Additionally, the discussion and implications sections focused solely on applying and discussing the results from the SEM and Moderation analyses. To address this comment, this is updated in the methods section under data analysis: “It is important to note the potential of a Type 1 error as a result of multiple comparisons during this analysis, which warrants caution in the interpretation of the moderation effects.” In the limitation and future research section, we included “To further probe the relationships, future researchers should employ longitudinal designs to observe how family-based support interacts with income and CSS. They can also track the effects of family-based support and other SDOH over time.”

4. Sample Demographics and Generalizability The sample is overwhelmingly White, middle- to upper-income, and female, limiting the ability to generalize to more diverse populations of caregivers.

Suggestion: While this is already acknowledged, consider briefly addressing how racial/ethnic and socioeconomic variation might influence access to family-based support and the nature of depressive symptoms.

Response: Thank you for the comment regarding the lack of diversity in the sample. To address this feedback, this is updated in the limitation and future research section: “Racial and ethnic minorities, as well as lower-income families, often face additional barriers to accessing resources, which can impact their ability to benefit from family-based supports.”

Additional Notes

• The discussion of implications is strong overall. The section on professional training could benefit from concrete examples of how to integrate SDOH and disability content into course curricula or supervision models.

 

Conclusion

This is a thoughtful, well-executed study with meaningful implications for supporting caregivers of children with ASD. The authors’ use of the SDOH framework is both timely and appropriate, and the findings are positioned in ways that will be useful to multiple stakeholders. With relatively minor revisions, particularly around construct specificity, measurement nuance, and

 

reference updating, the manuscript will be well-positioned for publication and contribution to the field.

Response: We sincerely thank the reviewer for the thoughtful and encouraging feedback. We are pleased that the study’s use of the Social Determinants of Health (SDOH) framework was considered timely and appropriate, and that the findings are seen as meaningful for supporting caregivers of children with Autism Spectrum Disorder (ASD). We also appreciate the acknowledgment of the study’s potential value to multiple stakeholders in the field.