PONE-D-22-12337 Complex early childhood experiences: characteristics of Northern Territory children across health, education and child protection data PLOS ONE

Dear Dr. Roper,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The comments provided by the individual reviewers - sent with this writing - note the potential (impact) of the manuscript, but at the same time several aspects are identified which require additional attention. Based on my own additional reading, I concur in these evaluations. In line with the reviewer comments, the current manuscript shows a strong and in-depth methodological approach, however grounding in a theoretical framework is underrepresented in the introduction. A more balanced approach is advised. Please try to address the reviewer concerns through your best efforts. Although all comments require attention, of special concern are 1) the abstract, 1) overall grammar and punctuation, 2) the clarity in the abstract, 3) the discrepancies in sample size(s), 4) the issue raised by reviewer 2 on the input of Native Aboriginals in the interpretation and message brought through this manuscript and 5) the framing of the current work in a theoretical framework or model. In addition, I have some concerns related to the K-means approach, listed below under Editor Comments. Please submit your revised manuscript by Aug 15 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Academic Editor

PLOS ONE

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Additional Editor Comments

E1) the authors write that K-means is a simple technique (and I agree), but use a very complex statistic (silhouette) for evaluation. Although useful, it is difficult to grasp for non-involved readers. The manuscript does not describe why statistics well-known to more readers (such as the CH-index or DB-index) were not used (in addition to the silhouette) and how they (do not) relate.  E2) the authors rely on K-means before and after dimensionality reduction, but do not reflect on the fact that K-means is also not very strong at dealing with different cluster densities and cluster shapes, and do not allow for cluster boundary overlap. Could the authors reflect on the implications of this choice over e.g. density mixtures, especially in higher dimensionality in the current application? E3) the authors describe that they applied 10 (random?) starts to circumvent the local minimum issue. However, with higher K, the number of local minima strongly increases, and thus a higher number of random starts than 10 is needed. A plethora of examples shows that local minima are still encountered with 100+ random starts for K=6. If the authors did not use random starts, the exact initialization procedure should be explained.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review the manuscript describing important research that links databases across service sectors (education, health, and child welfare) in the Northern Territories in Australia. My overall concerns with the manuscript are that it needs to be revised for clarity and that potential biases in child abuse and neglect reporting are not emphasized enough. Please see below for more detailed comments and suggestions:

OVERALL

1) The manuscript should needs some revision related to grammar and punctuation. For example, several places have unnecessary commas and 'data' should be plural not singular, i.e. data are rather than data is...

ABSTRACT:

2) The first sentence of the abstract is so non-specific that it isn't particularly helpful. Please provide more specificity or delete that sentence. In general, the first paragraph could be shortened to provide additional information as I have requested below in the limited space.

3) The research question or objective should be more clearly stated in the abstract.

4) The abstract should clearly identify the study type (ie retrospective cohort) and how the research cohort was identified.

5) The abstract should clearly identify the specific data sources that were used beyond the broad description that is currenlty provided.

INTRODUCTION:

6) Given the complexity of the research project, the manuscript and project would be improved if they were clearly guided by a theoretical or conceptual model. For example, this project and resulting manuscript could be framed using the social-ecological model. The introduction would be clarified if it were more structured using the social-ecological model or another model that the authors think is most appropriate. Then, the structure that was set up in the introduction could be carried on in the results and the discussion.

METHODS:

7) The section describing how data were linked at the individual level then de-identified (I think) was unclear and should be revised for clarity.

8) The method for identifying the study cohort should be clarified. Consider using a flow diagram that shows the different data sources and how those were integrated to create the cohort that was ultimately used for the analysis.

METHODS/RESULTS:

9) Related to my comments (#7 and #8 above) The cohort of 8,267 children seems low given that 15,284 were born during the selection period--the paper should clearly indicate that 8,267 represents 54% of those born during the selection period. If 65% of all Australian children and 83% of Aboriginal children attended government schools, shouldn't the study cohort be closer to at least 65%? What happened to the 'missing' 10 to 20%?

DISCUSSION:

10) As noted above, a theoretical or conceptual model should be used to structure the discussion.

11) While CPS reporting bias is included in the limitations, I think the potential for this bias should be reported and discussed earlier and in more detail. Systemic oppression is a cause of poverty and diminished access to resource as well as a cause of toxic stress all of which can lead to an actual increased incidence of child abuse and neglect. However, the authors should note more strongly that systemic racism may also influence reporting and substantiation decision-making.

12) I agree with the authors that cross-sector interventions should be considered; however, can they provide more examples or what these types of interventions might look like?

Reviewer #2: PlosONE-D-22-12337

Cluster analysis of dataset including 8k NT children now 13 to 16y. The premise is a very important one that a subset of children have a multitude of challenges (whereas most studies adjust for the association of one factor against another rather than accept both as cumulative risks). This is interesting work but I have a few comments and suggestions for the authors.

Abstract:

• Suggest including more detail on datasets and summary of how clustering was done- I understand this is complex but a summary of L443 paragraph would help the reader follow what was done and thereby interpret the findings. There are many ways to determine clustering and what you accept as a clear pattern of similarity

• Child Protection Services should be expanded as different anagrams in different jurisdictions

• Suggest explaining/defining what you mean by ‘moderate’ and ‘mostly’ Aboriginal

• It would be good for the reader to have a summary of the dataset (e.g., description of the variables in line 245)

Background:

• L40 suggest rewording society ‘should’ support optimal development- not sure we do!

• L58 suggest replace ‘developed countries’ with ‘high income countries’

• L70-79, 11: data should be plural throughout

Methods

• What is the potential effect of excluding 7k children with no records on attendance?

• L255: 5 years

• Not sure I am convinced about using the 4 variable set described. Hospitalisations and attendance rates are outcomes whereas number of neglect and abuse notifications are risk factors from my perspective. Also, I completely understand why you might not disaggregate by ethnic variables in other settings, but in the Northern Territory, there is a substantial difference between the lived experience of a remote Aboriginal child and an urban non-Aboriginal child. Can you explain the justification for not running two analyses here (one analysis for clustering in Aboriginal kids and a completely separate cluster analysis for non-Aboriginal) pls? Although you have explained the justification for doing this work to inform decision makers about coordinated services, this would be very different for Aboriginal (cultural safety, and Aboriginal led design) vs. non-Aboriginal. I think the reason for not doing this needs much more detailed explanation at least as you have found 3 clusters that are almost all Aboriginal (non-attender, neglect and ill) and 2 clusters with lower rates of Aboriginal kids.

Results

• L415-421: all descriptions of ‘higher’ should have p values or confidence intervals

• Table 1 footnote: does 744 missing (Aboriginal children) mean there were 980 missing values of which 744 were Aboriginal and 236 not? It just seems unusual to word this way and does that mean there were no missing data for other variables except the 2 with asterisks? That seems unusual so it might be more informative to have n/Ns too?

• Suggest 5 years rather than 5

• L464 has the ill group with the ‘lowest school attendance’ whereas L471 is lower

• I am afraid I cannot really read the Figure at the end, and it is confusing as it appears to suggest that 100% of the ‘thriving’ category have attendance <80%, whereas only 15% of the ‘abuse’ cluster has attendance <80%

• In several places, including text and appendices, proportions are presented with whole percentages in one place and then 2 decimal places in another. Suggest could be all rounded to whole numbers for this sort of study.

Discussion

• L628: Not sure I agree with the comment that you are unlikely to have differential misclassification of maltreatment. Indeed, it is almost certainly the case that Aboriginal communities are much less likely to report any form of abuse given the long history of the Stolen Generations in Australia with community fear of removal if there is anything adverse found in relation to a child (also a reason for less attendance at healthcare)

Finally, these issues are quite complex and potentially sensitive. In Aboriginal research there is a move to ensure an Aboriginal perspective. I do not know the authors, but I think it would be critical to have Aboriginal authors (more than one) or Aboriginal reviewers of this work to assist with ensuring that it is not sending the wrong message that the problems only exist among Aboriginal children. The dataset was mostly Aboriginal kids (4,624 vs 3,643), whereas in the Territory you state only 43% of children are Aboriginal, so any cluster in your dataset is automatically more likely to have a higher proportion of Aboriginal children than otherwise and further reason to disaggregate the clustering by Aboriginality so that the findings can be targeted appropriately if the clusters are different in the 2 populations.

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Reviewer #1: Yes: Mandy A Allison

Reviewer #2: No

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Complex early childhood experiences: characteristics of Northern Territory children across health, education and child protection data

PONE-D-22-12337R1

Dear Dr. Roper,

Firstly I would like to apologize for the longer-than-usual procession time of your revised manuscript. The original Reviewer 1 was not available after to evaluate the revised manuscript after all, and has proven difficult to find new reviewers in this stage of the process. Therefore, I have myself again evaluated your responses in light of the original R1.R1 comments, and I come to the same conclusion as that of Reviewer 2 who has also evaluated your revised manscript. We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. 

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Ralph C. A. Rippe, Ph.D.

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Thank you for the responses. Although I accept your response in relation to Aboriginal authorship as it is the common standard in Australia, even as a non-Aboriginal researcher, I still feel that we need to move away from the ongoing paradigm of non-Aboriginal researchers conducting studies and just having an Indigenous reference group give the "OK". Aboriginal engagement should be from design to publication and be part of the authorship team if they are helping to design the study and report the findings. Just a comment for future reference from a non-Aboriginal researcher.

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Reviewer #2: No

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