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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?

Reviewer #1: Yes

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

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The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #1: Parent Perspectives on Services Available to Autistic Children in Canada: A Mixed Methods Survey Study

Thank you for the opportunity to review this important study about parents’ perspectives on services for autistic children in Canada. The authors found varying degrees of support for ABA, OT, and SLP services. Qualitative data suggests that parents have concerns about behavioral approaches and support neurodiversity-affirming practices. This is a very timely paper that will be of interest to many in the field. The study has many strengths, including an advisory group, clear explanation of study methods, and clear reporting of results. Limitations are also clearly identified. Additionally, the paper is well written and easy to follow. Nevertheless, I have several comments related to the method/analysis and have also suggested a variety of literature that could be included to strengthen the rationale for the study and to which the current study’s results could be compared.

Introduction:

-Introduction is very well written and easy to follow. I suggest below a few areas where more detail could be added to make the study rationale stronger.

-The framing of the first part of the introduction could be updated to highlight that the recent research on autistic adults’ perspectives on services is in direct response to autistic people’s voices being ignored for decades. At least in ABA research, when acceptability/satisfaction is assessed, it is usually from the parent’s (or a clinician’s) point of view; rarely is the perspective of the autistic person considered. While it is of course still important to get parents’ perspectives – especially the kind of in-depth perspectives obtained in this study! – there could be more explanation as to why researchers have been focusing more on autistic voices.

-Another larger interview study with autistic adolescents also found several critiques of “social intervention” practices: Bottema-Beutel K, Mullins TS, Harvey MN, Gustafson JR, Carter EW. Avoiding the “brick wall of awkward”: Perspectives of youth with autism spectrum disorder on social-focused intervention practices. Autism. 2016;20(2):196-206. doi:10.1177/1362361315574888

-Another recent survey study looked at autistic and non-autistic individuals’ perspectives on intervention goals. While they did not specifically report on parents, this study may be of interest: Hersh L, Dwyer P, Kapp SK, et al. Community Member Views on Autism Intervention: Effects of Closeness to Autistic People with Intellectual Disabilities And Nonspeaking Autistic People. Autism in Adulthood. 2024;6(3):253-271. doi:10.1089/aut.2023.0202

-Waddington et al. also recently published a qualitative investigation of support goals, which includes input from parents (Waddington H, Jordan P, Scott E, et al. Community perspectives on support goals for young autistic children: A qualitative investigation. Neurodiversity. 2023;1:27546330231218587. doi:10.1177/27546330231218587)

-In ABA, researchers/clinicians are supposed to be assessing “social validity,” which includes appropriateness/acceptability of goals, procedures, and outcomes. While this is certainly done way less than it should be, there are many instances of ABA studies where parents have been asked about their satisfaction with the service provided. However, these assessments are often done in very crude ways, usually without validated instruments. Thus, studies often end up reporting something like, “Parents rated it 6.9/8, so it’s great,” when really we don’t have any way of knowing what “6.9” means, nor do we have nuanced detail about what was good versus bad. You allude to this on page 5, but highlighting this in more detail would strengthen the rationale for your study, because your study actually goes into much more nuance.

-Even if social validity assessment in ABA has been a bit of a mess, many researchers likely see social validity as a theoretical framework that incorporates the significance of goals, appropriateness of procedures, and importance of the effects (Wolf, 1978; for an updated framework, see: Snodgrass MR, Chung MY, Kretzer JM, Biggs EE. Rigorous Assessment of Social Validity: A Scoping Review of a 40-Year Conversation. Remedial and Special Education. 2022;43(2):114-130. doi:10.1177/07419325211017295). Therefore, the authors should reconsider saying that no existing research has explored parental perspectives through the lens of a theoretical framework.

-The introduction would also benefit from more explanation of what ABA, OT, and SLP services look like.

Methods:

-The PAG is a huge strength of this study! Also great explanation as to how an advisory board differs from true CBPR.

-On page 8, consider saying no “published” or “validated” survey relating to acceptability of autism services exists, as multiple other studies have used questionnaires to ask about this (eg the one used by Waddington, the “Autism Intervention Attitudes Scale” used by Hersh et al. and Baiden et al.).

-Were there any inclusion/exclusion criteria related to age of child?

-Were any measures taken to ensure data integrity (i.e., to ensure participants were “real” and not fraudulent?).

Results:

-Were parents asked about whether children were currently receiving the service and, if not, how long ago their children were enrolled? (Sorry, I couldn’t find the demographics survey in the supplemental materials.) This could impact acceptability ratings.

-Table 1 makes it seem like OT was universally associated with neurodiversity-affirming practices, SLP was associated with potential harms, etc. While I can tell from the narrative that this is not the case, this is somewhat confusing.

-It should be made clearer that parents were asked about services even if their child had never received such services. It would also be helpful, if possible, to look into whether responses differed significantly between those whose children had versus had not participated in the service (especially for ABA since it was about 50/50). A critique of research with autistic adults is that some never had ABA, so those folks’ perspectives are not relevant. (To be clear, I do not agree with this, but it is a critique I’ve seen.) Some might have this critique of parents in this study who are commenting on ABA but whose children have never engaged in it. If not possible to look into this more, this could just be discussed more the discussion.

Discussion:

-The authors may also want to consider citing a recent qualitative study of autistic adults’ perspectives on “intervention” goals, as many of these studies are showing that parents’ and autistic adults’ perspectives converge: Schuck RK, Geng A, Doss Y, et al. A qualitative investigation into autistic adults’ perspectives on intervention goals for autistic children. Neurodiversity. 2024;2:27546330241266718. doi:10.1177/27546330241266718

-The authors make a great point about behavioral approaches being present across services!

-See another recent study about parents’ views of neurodiversity: Dwyer P, Gurba AN, Kapp SK, et al. Community views of neurodiversity, models of disability and autism intervention: Mixed methods reveal shared goals and key tensions. Autism. Published online September 18, 2024:13623613241273029. doi:10.1177/13623613241273029

Reviewer #2: In this very interesting article, the authors designed a survey to assess how parents of autistic individuals perceive three types of intervention (Occupational Therapy (OT), Speech Language Pathology (SLP) and Applied Behaviour Analysis (ABA)), using an acceptability framework and a mix of quantitative and qualitative methods. They found that the overall acceptability of OT and SLP (overall score of 40-42 out of 64) was higher than ABA (overall score of 28). They also elaborate on the verbal responses of participants to identify key components affecting how they perceive the acceptability of these methods. I found the article well written. I really appreciate the high level of transparency that the authors put into their work, and also the level of care displayed for all the groups involved in the study (autistic children and adults, parents, clinicians, students). I do have several major and minor points that need to be addressed. In particular, I think that additional analyses could be performed on the quantitative data.

Major concerns

1. Why focus on these three interventions and not others? Have they been chosen because they are one on one interventions and not group ones? Some very important types of interventions seem to have been left out of this work (e.g. parent training, early sociodevelopmental interventions such as the Denver Model, etc.). Please provide a rationale for focusing on these three interventions only. Please also provide summary descriptions of these three types of intervention.

2. One possible bias affecting the results is that parents whose child did not benefit from the intervention could also provide answers regarding that type of intervention. Are the ABA related results credible, since only half of the parents had the occasion to engage with this form of intervention? Are the quantitative results different between the participants familiar with ABA (i.e. with their child having benefited from ABA) and the others?

3. I would recommend providing a scatterplot of participants by age, just to get a full picture of the age demography of the sample. Also, it could have been interesting to make the parents assess the approximate date of intervention for their child(ren), to get a grasp of a possible effect of date/time on their responses (maybe more recent interventions are more acceptable ? Regardless of intervention type?). Please provide some additional data if you have some, or maybe just comment on this point in the limitation section? Maybe you could get this info if you cross sociodemographical data from the parents (their age at moment of survey for example) with the « age beginning therapy » variable available in Table 1. Of course this suggestion might be too complex for the qualitative data, but maybe it could be worthy to try it on quantitative data?

4. Some of the durations of therapy seem to be really extreme (up to 16 years for SLP and OT). Are these profiles associated with peculiar answers or attitudes toward the interventions? The median value is also very interesting, since all intervention types have a median duration of 2 to 3 years, which is more than what is usually recommended or allowed by public fundings (but I come from a French background).

5. Page 27, last paragraph of the conclusion. « In conclusion, across this sample parents of autistic children, Ethicality was a key construct shaping acceptability ». It is an interesting view but nothing in the design or the results allow for prioritizing this dimension over Effectiveness and Self-Efficacy. One methodology that could have solved this is to make participants rank the 7 TFA dimensions from most to least important to them, but I don’t think the authors used this kind of methodology?

Minor concerns

1. Figure 1 : please input a maximum Y value of 64 for the graph, to help readers integrate the maximum and minimum values of the scale. Please also add a short description of the meaning of the box plot, or clearly state that it is a boxplot in order for readers to find info by themselves to interpret the graph (2 medium quartiles within the box, etc.). Also, what is the meaning of the X? The X of the SLP is not aligned with the median so I don’t understand what the X means.

2. “Data analysis and integration” section (page 10). Just to be completely sure I understood correctly: the authors say that they included data from one parent as soon as they had completed the whole set of questions for one therapy type. They wrote in parentheses that it amounts to 15 questions per intervention type. But in the Appendix A I see 16 questions (15 specific questions and 1 summary question). This 16 is more consistent with the maximum overall score of acceptability (64 = 16 items * 4, if we admit that Strongly Disagree = 0 and Strongly Agree = 4 (except for reverse scoring items). Am I right? If so, maybe change the number in parenthesis line 193 by 16 instead of 15 ?

3. Table 1, page 15. Again, I love that the authors are so transparent about everything, but here the note « No quotations were from parent respondents who identified as autistic. » felt weird to me as the reader could understand that such answers have been voluntarily removed from Table 1. Since the main text of this section is so nuanced about when a quotation is from an autistic parent or not, maybe this note could be removed from this table?

4. Typos :

a. Line 136 : alterative should be alternative

b. Line 198 : calcualted should be calculated

c. Line 199 : socre should be score

d. Line 210 : quantiative shoud be quantitative

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PONE-D-25-32240R1

Parent Perspectives on Services Available to Autistic Children in Canada: A Mixed Methods Survey Study

PLOS One

Dear Dr. Caven,

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.

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Academic Editor

PLOS One

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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.

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Reviewer #1: Thank you for the opportunity to review the revised version of "Parent Perspectives on Services Available to Autistic Children in Canada: A Mixed Methods Survey Study." The authors were very responsive to the reviewers' comments, and their revisions greatly strengthen the paper. I just have two comments that I feel need to be addressed before endorsing publication:

1. The construct of social validity still warrants more attention. The authors could explain why the TFA is a preferable framework (e.g., it is more specific/nuanced), though “social validity lacks rigor, so TFA is better” is not a reasonable argument, as many of the pitfalls discussed in the cited Snodgrass paper could be applied to the use of TFA too (e.g., people creating their own instruments, people defining the constructs as they see fit). To me, these frameworks seem pretty similar, so it would be helpful to know what TFA can give us that social validity can't (or hasn't).

2. Thank you to the authors for explaining that they did not explicitly screen for – but also found no evidence of – fraudulent participants. This should be mentioned in the paper itself, as readers will undoubtedly be concerned about fraud, especially since there was a monetary incentive, which always attracts bots/fraudulent folks. Even if there was no systematic screening, it would be helpful to mention that you did not note any incoherent responses.

Reviewer #2: I thank the authors for their hard work addressing my concerns quite successfully. I just have a few minor concerns left (I used the track changes version for my second round of review, when referencing pages and lines):

1. Page 7, line 135: “Occupations” instead of “occupation”.

2. Page 15, line 266-271: Among those who identified accessing a therapy, the median acceptability scores were 42 (IQR = 10.25, n = 64) for SLP, 40.5 (IQR = 11.75, n = 74) for OT, and 30 (IQR = 18, n = 35) for ABA. There were no significant differences based on those who had and had not accessed OT and SLP; however, this difference was significant for ABA (t = 3.36, p< 0.01).

Thank you for adding this very interesting result. I think it could even be better if such data were included in a graph (maybe boxplots for each therapy type and each group? People who accessed the therapy Vs people who didn’t?). But it’s up to the authors and editorial decision. I don’t want to seem to be pushing for endless rounds of reviews.

I just have a minor concern here that needs addressing: the sentence “There were no significant differences based on those who had and had not accessed OT and SLP” is a little bit confusing and could be interpreted as a test of difference between OT and SLP. Maybe rephrase as following: “There were no significant group differences between participants who had access to therapy and those who did not for OT and SLP”.

3. Page 25, line 472-473: “suggesting that parents who did not have personal experience with ABA might have been informed by external sources.”

I don’t think this interpretation really adds to the understanding here. I think this result might reflect lingering prejudice against ABA, maybe an heritage of how early punishment procedures used in the 60-70’s by Lovaas or other influential ABA practitioners infused in North American culture (Donvan & Zucker, 2016).

Donvan, J., & Zucker, C. (2016). In a different key : The story of autism (p. xiv, 672). Crown Publishers/Random House.

4. Page 29, line 562-563: Maybe “we identified that Ethicality appears to play…” instead of “we identified Ethicality appeared to play”.

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Reviewer #2: Yes: Matias Baltazar

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Parent Perspectives on Services Available to Autistic Children in Canada: A Mixed Methods Survey Study

PONE-D-25-32240R2

Dear Dr. Caven,

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.

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PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #1: No

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Thank you again for the opportunity to review this paper. The authors have been very responsive to the reviewers' comments. The paper is ready for publication in my opinion.

Reviewer #2: (No Response)

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what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: Yes: Matias Baltazar

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