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PLOS One logoLink to PLOS One
. 2026 Jul 14;21(7):e0352505. doi: 10.1371/journal.pone.0352505

Using natural language processing to support digital communication in adolescents and young adults with autism spectrum disorder

Faris Algahtani 1,*
Editor: Ramandeep Kaur2
PMCID: PMC13367686  PMID: 42447173

Abstract

Background

Autism Spectrum Disorder (ASD) is characterized by social communication challenges, including difficulties interpreting figurative language, understanding conversational context, and expressing thoughts clearly. This feasibility study examined an NLP-based communication assistance tool for adolescents and young adults with ASD. The tool combined sentiment analysis, intent identification, and situational simplification to provide real-time feedback in digital communication.

Methods

Participants were 16 individuals with ASD (aged 15–28 years) and 16 neurotypical conversation partners in a within-subjects, mixed-methods design. The intervention lasted eight weeks. The tool was used in both structured tasks and naturalistic conversations.

Results

Preliminary data suggest associations between tool use and improved outcomes. Communication clarity increased from 3.12 to 3.89 (d = 0.74, 95% CI [0.28, 1.20], p < 0.001 after Bonferroni correction). Anxiety decreased by 2.3 points on a 7-point scale (d = 1.21, 95% CI [0.62, 1.80], p < 0.001). Confidence scores improved by 42% from baseline (d = 1.15, 95% CI [0.56, 1.74], p < 0.001). Qualitative thematic analysis (Braun & Clarke, 2006; inter-coder reliability, κ = 0.81) identified five themes: reduced communication burden, learning through use, empowerment and autonomy, context-specific value, and desire for customization. These preliminary findings suggest that NLP-driven assistive technologies warrant further investigation in controlled trials.

Conclusion

This study demonstrates feasibility and provides preliminary evidence for NLP-based communication support, though causal conclusions cannot be drawn due to the absence of a control group, small sample size (N = 16), and short duration.

Introduction

Autism Spectrum Disorder (ASD) is a neurological condition that has a prevalence of about 1 per 36 individuals in the United States, and is manifested by difficulties in social communication and interaction, as well as limited and repetitive behavioral patterns [1]. Pragmatic language impairments are among the most significant challenges of ASD, which include the inability to interpret non-literal language, recognize social cues, maintain the topic of conversation, and adjust communication style to the circumstances.

Although face-to-face communication is challenging for many individuals with ASD, text-based digital communication offers unique opportunities for support. Digital messaging is asynchronous, which means there is time to process and craft a response and to prevent simultaneous processing of both facial expressions and vocal tones, thereby reducing cognitive load [2]. Nevertheless, digital communication still requires pragmatic language knowledge, tone identification, and the formulation of contextually appropriate responses [3].

The recent progress in natural language processing (NLP) has shown impressive abilities to operate on the context, sentiment, and intent of written text [4]. Transformer language models, sentiment analysis models, and intent classification models have demonstrated near-human performance in a variety of language understanding problems [5]. However, their application as assistive communication technologies for individuals with ASD remains underexplored.

This study addresses this gap by empirically testing an NLP-based communication assistance tool for adolescents and young adults with ASD. The study will answer three major questions: First, is an NLP-enabled tool associated with enhanced clarity and appropriateness of digital communication? Second, is real-time NLP-based assistance associated with decreased communication-related anxiety and enhanced confidence? Third, what features and designs do users with ASD find most important in such assistive technologies??

This work has three primary contributions. First, the development of a new NLP-based communication assistance system designed for individuals with ASD is described. Second, empirical data from an eight-week mixed-methods study examining the feasibility and preliminary outcomes of this approach are presented. Third, user preferences and design recommendations for future development of NLP-assisted technologies for neurodiverse populations are provided.

Communication challenges in autism spectrum disorder

Adolescents and young adults with ASD have a diverse set of communication skills, yet almost everyone has pragmatic language issues at one end or another. [6] reported certain difficulties, such as literal interpretation of figurative language, inability to appreciate the intent of the speaker through context, inability to maintain a topic and to take a turn and difficulties in changing the communication style based on social situations. These challenges are based on social cognition differences, such as the lack of a theory of mind and diminished interest in social indications.

Text-based communication can be both beneficial and problematic for individuals. Although it does not cause issues with simultaneous processing of various senses, it adds new challenges, including decoding the use of emojis, the interpretation of sarcasm and humor in the absence of vocal prosody, and the inability to keep pace with the speed of group communication [7]. [8]also established that persons with ASD tend to use digital communication due to its predictability and less social pressure, but they still feel very uncertain about misunderstanding and social stigma in these situations.

Assistive technologies for ASD

The assistive technologies for individuals with ASD have significantly developed in the last two decades. Initially, the main concern of early interventions was on augmentative and alternative communication systems among individuals with minimal verbal expression, such as picture exchange communication systems and speech-generating devices [9]. More recent technologies have included touchscreen interfaces, visual scheduling applications, as well as social skills training programs [10]. Several applications have been specifically aimed at social communication, such as video modeling tools, social virtual reality, and conversation practice software [11].

Nevertheless, the available tools are either child-friendly or address the basic communication skills instead of assisting in real-life digital communication. According to [12], the number of technologies that can offer real-time support in the process of real social interaction is low, and even fewer can use advanced NLP capabilities. Recent research has examined how machine learning can be applied to communication patterns in ASD, although these have typically been based on diagnosing symptoms or behavioral modeling instead of actual communication support [1114].

Natural language processing applications

Transformer architectures and large language models have contributed to the rapid growth of NLP. [15], contend that the current NLP systems are very efficient in carrying out their duties, such as sentiment detection, intent detection, simplifying texts and understanding contextual language. The potential has been used in a wide range of applications, such as automation of customer service, content moderation, writing aids, and chatbots to provide mental health support.

There is an emerging small but increasing body of research on NLP as applied to ASD. According to [16], machine learning has been applied to detect linguistic markers of ASD in posts on social media and create AI-based screening instruments using language patterns. Nonetheless, there is limited literature that has created and tested a complete NLP-based communication aid tool that is specifically created to help adolescents and young adults with ASD in real-time within online communication. The current study aims to address this gap.

Methodology

This study used a mixed-methods within-subjects design with three phases: a 2-week baseline period (using standard communication devices), an 8-week intervention period (using the NLP-powered system), and a 2-week follow-up period. Due to the absence of a control group and randomization, this study is appropriately framed as a pilot feasibility study, and all findings are interpreted as preliminary and associative rather than causal [17].

Participants

Sixteen participants with ASD were recruited via autism advocacy groups, university disability offices, and ASD-specific clinics. Inclusion criteria were: confirmed ASD diagnosis, verbal fluency, frequent digital communication use, interest in assistive technology, and average to above-average cognitive performance (to ensure pragmatic language difficulties rather than general cognitive impairments were the primary challenge). Sixteen age-, gender-, and education-matched neurotypical individuals served as conversation partners. Exclusion criteria were: concurrent intensive communication therapy, severe visual impairment, and lack of English proficiency.

Power analysis indicated that a sample of N = 54 would be required to detect a small effect (d = 0.20) with 80% power. The present sample (N = 16) is adequately powered only for medium-to-large effects (d > 0.70) and lacks statistical power to examine individual differences or moderator effects. This limitation is addressed in the Discussion.

All participants provided informed consent (parental consent for minors), and the study was approved by the University of Jeddah Institutional Review Board (Approval No. 03/46/24862). Recruitment occurred between February 5, 2025, and July 25, 2025.

Technical specifications of the NLP communication tool

The NLP system was built using a fine-tuned BERT-base-uncased transformer model (12 layers, 110 million parameters). The architecture included three parallel modules:

  1. Sentiment Analysis: Fine-tuned on the GoEmotions dataset (58,000 Reddit comments, 27 emotion categories) plus 2,000 additional ASD-specific communication examples annotated by the research team.

  2. Intent Classification: Fine-tuned on the CLINC150 dataset (150 intents, 22,500 examples) with 1,500 additional ASD-specific communication scenarios.

  3. Situational Simplification: GPT-2 based text simplification model fine-tuned on the Newsela corpus (1,500 articles at 5 reading levels).

Suggestion Trigger Logic: The system generated suggestions when: (a) sentiment classification confidence was below 0.70, or sentiment deviated from the user’s baseline profile, (b) intent classification confidence was below 0.75, or (c) text complexity exceeded 9th-grade reading level (Flesch-Kincaid grade level).

Safety Filters: Suggestions involving self-harm, aggression, harassment, or other sensitive content were blocked using a 500-term blocklist and a separate safety classifier (precision = 0.92, recall = 0.88 on held-out test set). All suggestions were optional; users were required to click “apply” to accept a suggestion.

Deployment: The tool was deployed as a Chrome browser extension with local inference using the ONNX runtime. No message content was transmitted to external servers. All data processing occurred locally on the user’s device.

Procedure

The NLP system was built using a fine-tuned BERT-base-uncased transformer model (12 layers, 110 million parameters). The architecture included three parallel modules:

  1. Sentiment Analysis: Fine-tuned on the GoEmotions dataset (58,000 Reddit comments, 27 emotion categories) plus 2,000 additional ASD-specific communication examples annotated by the research team.

  2. Intent Classification: Fine-tuned on the CLINC150 dataset (150 intents, 22,500 examples) with 1,500 additional ASD-specific communication scenarios.

  3. Situational Simplification: GPT-2-based text simplification model fine-tuned on the Newsela corpus (1,500 articles at 5 reading levels).

Suggestion Trigger Logic: The system generated suggestions when: (a) sentiment classification confidence was below 0.70 or sentiment deviated from the user’s baseline profile, (b) intent classification confidence was below 0.75, or (c) text complexity exceeded 9th grade reading level (Flesch-Kincaid grade level).}

Safety Filters: Suggestions involving self-harm, aggression, harassment, or other sensitive content were blocked using a 500-term blocklist and a separate safety classifier (precision = 0.92, recall = 0.88 on held-out test set). All suggestions were optional; users were required to click “apply” to accept a suggestion.

Deployment: The tool was deployed as a Chrome browser extension with local inference using the ONNX runtime. No message content was transmitted to external servers. All data processing occurred locally on the user’s device.

Participants maintained their usual digital communication patterns during the baseline period, and effectiveness in communication. The participants installed monitoring software that recorded simple metadata of their online communication such as frequency, duration, and mediums, without recording the content of the messages.

At the start of the intervention process, the participants were provided with a 90-minute training on the communication assistance tool. Training covered system features, interpretation of feedback indicators, privacy protections, and customization options. The participants were advised to apply the tool as much or as little as they found useful to ensure that the ecological validity is met. The study design covered both structured and naturalistic communication situations.

Planned activities were successively conducted on a weekly basis and entailed the participants playing defined communication scenarios with their matched neurotypical counterparts. Such situations involved writing formal emails, chatting in a relaxed manner, group chats, and emotionally-charged debates that demanded tact. Each of the scenarios was intended to raise a set of pragmatic language tasks that are typical of adolescents and young adults with ASD. The conversations were taped and analyzed on the measures of quality of communication.

Naturalistic communication was involved in the course of the research since participants applied the tool in their daily online communication. The system used to record habits of usage, categories of suggestions given, and how users reacted to suggestions, forming a rich corpus of the actual tool use.

Measures

Communication clarity: Message clarity was measured using a researcher-developed 5-point scale assessing whether messages communicated intended meaning, used appropriate tone, and were contextually appropriate. Two trained raters (inter-rater reliability ICC = 0.82, 95% CI [0.74, 0.89]) rated message clarity from structured communication tasks. This instrument has not been previously validated; internal consistency in the present sample was acceptable (Cronbach’s α = 0.81). This limitation is acknowledged in the Discussion.

Communication-Related Anxiety: Participants completed a researcher-developed Communication Anxiety Inventory (15 items, 7-point Likert scale) at baseline, weekly during intervention, and at follow-up. Cronbach’s α in the present sample was 0.84. No prior validation data are available.

Confidence Communication: A researcher-developed 10-item self-report scale measured confidence in expressing oneself, comprehending others’ messages, using appropriate tone, and negotiating difficult social interactions via digital communication. Cronbach’s α = 0.79.

System Usability: System Usability Scale was applied mid-intervention, end-of-intervention, and follow-up to measure perceived system usability, and other custom items were used to measure disability-specific usability.

Usage Patterns: System logs reflected the frequency of using a tool, types of suggestions seen, how suggestions of various types were accepted, and customization preferences.

Qualitative Feedback: Semi-structured interviews were carried out at the end of the intervention period and covered user experiences, perceived benefits and limitations, which features they found to be the most helpful, and what improvements they want. Thematic analysis was used to transcribe and analyze the interviews.

Ethical approval

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Scientific Research Committee and the Council of the Department of Special Education, College of Education, University of Jeddah (Approval No. 03/46/24862; meeting No. 11, held on 04/03/2025), in compliance with HAP-13-S-001.

Informed consent

Before survey commencement, participants received a written information sheet detailing the study’s purpose, objectives, procedures, and data handling. Anonymity was assured, and all data were collected solely for academic research purposes. Ethical approval was granted by the Scientific Research Committee, Department of Special Education, College of Education, University of Jeddah (Approval No. 03/46/24862; meeting No. 11, held on 04/03/2025). Participation was entirely voluntary; respondents were informed of their right to decline or withdraw at any time, and informed consent was obtained from all participants

Data analysis

Quantitative data were analyzed using mixed-effects linear models with repeated measures and random intercepts for participants. For communication clarity, models included a fixed effect for rater and a random effect for the participant. Anxiety and confidence scores were compared across timepoints using paired-samples t-tests with Bonferroni correction for four primary comparisons (adjusted α = 0.0125). Ninety-five percent confidence intervals were calculated for all effect sizes using bootstrap methods (1,000 resamples). All t-statistics and degrees of freedom are reported. No pre-registration was completed for this pilot study [18].

The data on usage were described with the help of descriptive statistics and correlation analysis to find the relationships between usage patterns and outcomes. Two researchers independently coded the qualitative data in the form of interviews with use of thematic analysis following the six-phase framework of Braun and Clarke (2006): (1) familiarisation with the data through repeated reading of transcripts; (2) generation of initial codes inductively from the data without a predetermined coding frame; (3) searching for themes by collating codes into candidate thematic clusters; (4) reviewing and refining themes against the coded data and full transcripts; (5) defining and naming themes; and (6) writing up. The two coders worked independently during initial coding; discrepancies were resolved through discussion and consensus, yielding an inter-coder reliability of κ = 0.81. Thematic saturation was assessed iteratively: no new codes emerged after the twelfth interview, and the final two interviews confirmed saturation. Disconfirming cases were actively sought; two participants (P05, P11) reported minimal perceived benefit from the tool, and their accounts are reflected in the contextual nuance described within Theme 4 (Context-Specific Value) and in the Limitations section.

Results

Communication clarity

The examination of the 256 structured communication interactions demonstrated that the clarity of communication significantly improved within the intervention period. As indicated in Table 1, there was an increase in the mean clarity rating at baseline (3.12) to 3.89 during intervention, which is a significant positive difference of 0.77 points out of the 5-point scale. This was statistically significant in the medium to large effect size (t (15) =5.23, p < 0.001, d = 0.74). All reported p-values have been corrected using the Bonferroni method for four primary comparisons (communication clarity, anxiety, confidence, message appropriateness). The corrected significance threshold is α = 0.0125.

Table 1. Communication Outcome Measures.

Measure Baseline Intervention Follow-up Effect Size (d) 95% CI p-value (corrected)
Communication Clarity 3.12 ± 0.58 3.89 ± 0.52 3.71 ± 0.61 0.74 [0.28, 1.20] <0.001
Anxiety Level 4.8 ± 1.2 2.5 ± 0.9 3.1 ± 1.0 1.21 [0.62, 1.80] <0.001
Confidence Score 4.2 ± 1.5 6.8 ± 1.3 6.3 ± 1.4 1.15 [0.56, 1.74] <0.001
Message Appropriateness 3.04 ± 0.67 3.76 ± 0.59 3.58 ± 0.63 0.68 [0.21, 1.15] <0.01

Statistical reporting: Communication clarity: t(15)=5.23, p < 0.001, d = 0.74, 95% CI [0.28, 1.20]; Anxiety: t(15)=7.41, p < 0.001, d = 1.21, 95% CI [0.62, 1.80]; Confidence: t(15)=6.89, p < 0.001, d = 1.15, 95% CI [0.56, 1.74]; Appropriateness: t(15)=4.98, p = 0.008, d = 0.68, 95% CI [0.21, 1.15].

Correlation between tool use frequency and confidence improvement: r = 0.67, p = 0.005, 95% CI [0.31, 0.86]. This correlation is descriptive only and does not imply causation, as usage was self-selected rather than manipulated.

There were differences in patterns of improvement in specific areas of communication. Tone appropriateness was most enhanced by a 28% increase between baseline and message organization by a smaller percentage of 15%. Interestingly, the changes were sustained throughout the follow-up period, with the mean clarity ratings of 3.71, suggesting that some degree of improvement was maintained after the intervention period, though the mechanisms underlying this partial retention cannot be determined from the current study design.

The neurotypical intervention group found ASD participants easier to comprehend and respond to messages, which they encountered during the intervention. Message comprehensiveness scores among communication partners rose to 3.04 to 3.76 out of 5 rating, which validated the fact that the change was not only an individual understanding of the users. Fig 1 presents average communication clarity ratings across the different phases of the study. The error bars indicate standard error of the mean. There was a significant increase in clarity between baseline (M = 3.12) and intervention (M = 3.89), t(15) = 5.23, p < 0.001, d = 0.74. The improvements were maintained at follow-up (M = 3.71).

Fig 1. Communication clarity over time across study phases.

Fig 1

Error bars indicate standard error of the mean.

Communication-related anxiety

There were great improvements in the communication anxiety levels during the period of intervention. The average baseline anxiety score of 4.8 out of 7 on the Communication Anxiety Inventory decreased by 2.5 points on the scale during the intervention period, a 2.3 point difference. Such a difference was very large (t(15) = 7.41, p = 0.001, d = 1.21) and the effect size of such a difference was considerable.

The anxiety assessments at the end of the week showed an indication of improvement and decrease in the anxiety levels starting in the first two weeks of using the tools and extended to the intervention. By week 6, the level of anxiety stabilized at a lower level and stayed at the same level till the end of the study. It is worth noting that the anxiety levels did not increase significantly at follow-up, with a mean score of 3.1, but this is a slight increase compared to the end of interventions.

The qualitative data were used as a source of understanding of how anxiety reduction can be achieved. The participants also noted that the real-time support presence always minimized their fear of errors and allowed them to be more willing to use digital communication. The representative quotes contained the description of the tool as being time-saving due to the fact that it is possible to worry less about each message and engage in more natural communication.

Communication confidence

Self-report communication confidence showed significant improvement in line with the anxiety decreases. Confidence scores at baseline were 4.2 out of 10, and 6.8 at intervention, which is a 42% improvement. The difference here was statistically significant with a high effect size (t(15) =6.89, p < 0.001, d = 1.15).

The confidence scale was able to measure several dimensions of self-efficacy in communication. The greatest improvements were in confidence in being able to express complex or nuanced thoughts, which went up 52 percent at baseline. The confidence in the ability to interpret when the other may be misunderstanding messages accordingly grew by 48 percent, and the ability to use the right tone of voice in various situations grew by 38 percent. The least yet never worthy increases were made in the participation in group conversations that went up by 29%.

Interestingly, as shown in Fig 2, the increase in confidence had a significant correlation with the frequency of tool use (r = 0.67, p < 0.01). This descriptive association does not imply a causal or dose-response relationship, as tool usage was self-selected rather than experimentally manipulated. Participants who used the tool more frequently in the first four weeks tended to show higher confidence improvement scores, though this pattern may reflect pre-existing motivation or engagement rather than a direct effect of tool exposure.

Fig 2. Changes in communication-related anxiety and confidence over time across study phases.

Fig 2

System usability and engagement

The usability ratings of the system were positive, as the mean System Usability Scale was 78.2 out of 100, with the tool falling within the good to excellent category. The respondents highly rated the system in terms of its ease of use, usefulness of feedback, and integration into their communication workflow. The consistency of suggestions and customization of sensitivity levels were rated lower, which showed the need to work on.

The results of usage patterns showed some interesting trends in participation in various features by the participants. The tool was used by participants to send 47 messages on an average weekly basis. The system suggested 34% of these messages, and the user looked at the suggested message 78% of the time and either approved or took action on the suggested message 52% of the time. Acceptance rates differed by type of suggestion, with tone clarification suggestions being accepted most often at 68 percent, then simplification suggestions at 51 percent, and intent clarification suggestions at 44 percent.

There was sustained engagement during the intervention with only slight deteriorations as time went on. The decrease in the number of messages written each week under the tool dropped to 43 messages per week in week eight, as opposed to 52 messages per week in week one, but was not statistically significant. The rate of suggestions actually improved slightly during the period, with 74% suggesting during the first two weeks and 82% suggesting during the last two weeks, which may indicate that the participants were becoming more actively involved with the feedback of the system as they became accustomed to it.

Patterning of customization provided the user choice on the types of feedback. Most participants (81%) had a lower frequency of suggestions in grammar and spelling problems, instead of concentrating on pragmatic communication support. On the other hand, more participants (69%) were sensitive to tone analysis with this being the most important feature. One-half of the subjects developed their own rules to override suggestions in particular situations, like in a casual situation with close friends when they felt that they needed less support.

Qualitative findings

Thematic analysis of interview data identified five major themes characterizing user experiences with the communication assistance tool.

Theme 1: Reduced Communication Burden (15/16 participants, 94%). Participants reported reduced cognitive and emotional load during online communication. “I spent less time worrying about each message. It was like having a friend check my words before I sent them” (P07). “I didn’t feel as drained after long conversations” (P12).

Theme 2: Learning Through Use (14/16, 88%). Participants described internalizing communication strategies. “After a few weeks, I started noticing tone issues on my own, even when the tool wasn’t active” (P12). “I began to predict what the tool would suggest” (P04).

Theme 3: Empowerment and Autonomy (13/16, 81%). Participants valued optional, non-prescriptive suggestions. “It suggested things, but I always decided. That mattered to me” (P03). “It helped me say what I meant, not what they thought I should say” (P08).

Theme 4: Context-Specific Value (16/16, 100%). Utility varied by communication context. “With my professor, essential. With my best friend, I turned it off” (P09). “For professional emails, I used it every time. For group chats with friends, barely” (P14).

Theme 5: Desire for Customization (11/16, 69%). Participants requested greater control over suggestion frequency and types. “I wanted to turn off grammar suggestions but keep tone suggestions” (P02). “Sometimes it was too sensitive” (P06).

Discussion

Interpretation of findings

The current study offers empirical data that NLP-driven communication aid technologies can potentially contribute significantly to enhancing the process of digital communication for adolescents and young adults with ASD. However, due to the absence of a control group, lack of randomization, small sample size (N = 16), and short duration (8 weeks), causal inferences cannot be drawn. All findings should be interpreted as hypothesis-generating rather than confirmatory.

The observed decrease in communication-related anxiety (d = 1.21) is promising but requires replication in controlled designs. Fear of social communication is common in ASD and contributes to social withdrawal and reduced quality of life [17].

Blind coder ratings and conversation partner assessments suggested improvements in objective communication quality, though these findings require replication with assessors fully blinded to the study phase and without potential unblinding due to message content differences. Usage and customization patterns (e.g., 68% acceptance for tone suggestions, 44% for intent clarification) provide preliminary information about user engagement.

Unexpected Pattern: An unexpected pattern emerged: as the intervention progressed, suggestion trigger rates increased from 74% to 82% while user engagement (messages written per week) declined by 17%. This pattern—escalating intervention during user disengagement—raises important questions about user burden and potential over-accommodation. For a population that often experiences autonomy challenges and sensory overwhelm, this pattern warrants explicit discussion and modification in future iterations.

Limitations

This pilot study has several limitations that preclude causal inference and generalizability:}

Design limitations: Absence of a control group (no comparison to placebo, no-treatment, or alternative intervention), no randomization, and no blinding of outcome assessors for self-report measures. The within-subjects design cannot separate intervention effects from expectancy, practice effects, or regression to the mean.

Sample limitations: N = 16 is underpowered for detecting small effects (post-hoc power analysis: 80% power to detect d > 0.70 only). Participants were verbal, cognitively able, English-speaking adolescents and young adults, excluding younger children (<15), minimally verbal individuals, those with intellectual disability (IQ < 70), and non-English speakers.

Measurement limitations: Primary outcomes used researcher-developed instruments without prior validation (though internal consistency in this sample was acceptable: anxiety α = 0.84, confidence α = 0.79).

Duration limitations: Eight weeks is insufficient to assess long-term skill retention or sustainability. The decline in communication clarity at follow-up (3.89 to 3.71) warrants investigation of decay effects.

Technical limitations: The NLP tool was tested only on text-based digital communication; findings may not extend to face-to-face or voice-based communication.

Future directions

Given the centrality of digital communication to social, educational, and professional participation, further development of participatory, user-centered NLP assistive technologies for neurodiverse populations is warranted. Future research should prioritize controlled trials, longer follow-up periods, inclusion of minimally verbal and non-English-speaking individuals, and examination of bidirectional communication support rather than unidirectional user accommodation.

Conclusion

This pilot study demonstrates the feasibility of NLP-driven communication assistance for adolescents and young adults with ASD and provides preliminary evidence warranting controlled trials. Preliminary quantitative and qualitative findings suggest associations between tool use and improved communication outcomes, though these findings require replication in randomized controlled designs with larger, more diverse samples. The study demonstrates the application of NLP methods to pragmatic communication needs in ASD, consistent with neurodiversity-affirming design principles.

Data Availability

All relevant data underlying the findings of this study are fully available without restriction. The data are publicly available in Zenodo and can be accessed at: https://doi.org/10.5281/zenodo.20966198.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Ramandeep Kaur

7 May 2026

-->PONE-D-26-04125-->-->Using Natural Language Processing to Improve Communication Tools for Children with Autism Spectrum Disorders-->-->PLOS One

Dear Dr. ALGAHTANI,

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 manuscript addresses a relevant and timely topic; however, it currently falls short of PLOS ONE’s publication criteria in terms of methodological rigor, transparency, and reproducibility.

Changes required for acceptance:

  • The statistical analysis needs to be strengthened with appropriate reporting (including test statistics, confidence intervals, and correction for multiple comparisons where applicable). Interpretations must be aligned with the study design, avoiding causal claims in the absence of controlled comparisons.

  • The description of the NLP tool is insufficient. Clear details regarding model architecture, training data, implementation, and functioning are required to ensure transparency and allow reproducibility.

  • Data availability must be clearly stated in accordance with PLOS policy. Any restrictions should be explicitly justified, and access to underlying data and materials should be clarified.

  • Outcome measures require clarification, particularly if non-validated or researcher-developed instruments are used. Their limitations must be explicitly acknowledged.

  • The qualitative analysis needs to meet accepted reporting standards, including description of methodology, coding process, and inclusion of representative data (e.g., participant quotes).

  • The conclusions must be revised to reflect the limitations of the study design. Given the small sample size, short duration, and lack of control group, the study should be framed as preliminary or pilot work rather than providing definitive evidence of effectiveness.

Recommended improvements:

  • Provide more detailed reporting of usage and engagement data over time to strengthen interpretation.

  • Expand the discussion on context-specific utility and user adaptation patterns, which appear to be meaningful findings.

  • Address limitations related to sample characteristics and generalizability more explicitly.

  • Ensure consistency between reported results and their interpretation, particularly in follow-up findings.

==============================

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We look forward to receiving your revised manuscript.

Kind regards,

Ramandeep Kaur

Academic Editor

PLOS One

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Additional Editor Comments:

The manuscript addresses an important and emerging area—use of NLP-based tools to support communication in individuals with Autism Spectrum Disorder—and demonstrates promise in terms of user-centered design and potential clinical relevance. However, several critical methodological and reporting issues need to be addressed to meet publication standards.

Major revisions required (essential for acceptance):

Statistical rigor: The current statistical analysis is insufficient. There is lack of correction for multiple comparisons, absence of confidence intervals, and limited reporting of test statistics. The interpretation of findings (e.g., “dose-response”) is not justified given the study design. These issues must be corrected.

Study design limitations: The absence of a control group, small sample size (N=16), and short intervention duration significantly limit causal inference and generalizability. While these cannot be fully corrected, the manuscript must clearly position the study as a pilot/feasibility study and temper all causal claims.

Data availability and reproducibility: There is inconsistency regarding data availability across reviews. The manuscript must explicitly clarify what data, code, and materials are available, and justify any restrictions in line with journal policy.

Description of the NLP tool: The model architecture, training data, deployment process, and functioning of the suggestion mechanism are inadequately described. Without this, the study cannot be evaluated or replicated.

Outcome measures: The use of researcher-developed tools without psychometric validation weakens interpretability. Authors should either provide validation evidence or clearly acknowledge this as a limitation.

Qualitative analysis: Reporting is below accepted standards. Include methodology (coding approach), participant quotes, theme frequencies, and reliability measures.

Recommended revisions (to strengthen the manuscript):

Provide longitudinal or week-wise data trends instead of only aggregated results to better illustrate tool engagement and impact.

Expand discussion on context-dependent utility and user-driven adaptations (override rules), which are valuable findings but currently underdeveloped.

Address equity concerns, including applicability to minimally verbal individuals and non-English speakers.

Clarify discrepancies between results and interpretations (e.g., decline at follow-up being described positively).

Improve discussion of real-world applicability, especially in informal communication contexts where effectiveness was lower.

Overall, the study has potential but requires substantial revision in methodological transparency, statistical reporting, and interpretation before it can be considered technically sound.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

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

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Reviewer #1: No

Reviewer #2: Partly

Reviewer #3: Yes

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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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: No

Reviewer #2: No

Reviewer #3: Yes

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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-->5. Review Comments to the Author

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Reviewer #1: Thank you for the opportunity to review this manuscript. The topic is important, and the idea of using NLP-based tools to support communication in autistic individuals is timely and potentially valuable. The manuscript is easy to follow at a high level, and the mixed-methods framing is promising. However, in its current form, I have substantial concerns about methodological rigor, statistical reporting, interpretation, and presentation that limit confidence in the findings.

My main concern is that the claims are stronger than the study design can support. The paper presents the work as evidence that the NLP tool improves communication, reduces anxiety, and increases confidence, but the study appears to use a small within-subject sample of 16 autistic participants without a randomized design or a concurrent ASD control group. This makes it difficult to separate intervention effects from expectancy effects, practice effects, regression to the mean, or changes over time unrelated to the tool. The conclusions should therefore be substantially tempered.

There is also a mismatch between the framing of the paper and the sample studied. The title, abstract, and conclusions repeatedly refer to “children with autism,” but the participant age range is reported as 15–28 years. Because this includes adults, the terminology and implications need to be revised throughout.

The description of the intervention is not sufficiently detailed for technical evaluation or reproducibility. The manuscript states that the system combines sentiment analysis, intent identification, and situational simplification, but it does not explain what models were used, what data they were trained on, how outputs were generated, how accuracy was assessed, what safeguards were in place, or how the tool behaved in realistic edge cases. For a paper centered on an NLP-based system, this level of technical detail is essential.

The statistical analysis is underreported and not rigorous enough in its current form. The manuscript mentions mixed-effects linear models and paired t-tests, but the model structure, assumptions, diagnostics, effect-size calculation details, and handling of repeated measures are not adequately described. Confidence intervals are not reported. It is also unclear how Bonferroni correction was actually applied across outcomes and timepoints. Given the small sample size and the use of Likert-type scales, the authors should justify the analytic choices more carefully and report the analyses more transparently.

Outcome measurement also needs clarification. Communication clarity is said to be rated on a validated 5-point scale by two trained raters, but the scale itself is not identified clearly enough for readers to evaluate it. Several key outcomes, including anxiety and confidence, rely on self-report, which is acceptable but should be discussed more explicitly as a limitation. The manuscript should also make clearer which outcomes were primary and which were secondary.

I also noted inconsistencies and reporting issues. The study timeline is described in slightly different ways across sections, and the data-availability statements appear contradictory. In the submission information, the authors indicate that all data are fully available without restriction, yet the manuscript states that the data cannot be shared publicly and are available only upon official request. This should be corrected to align with journal policy and with the actual availability status of the data.

The manuscript would benefit from major language editing. Although the overall meaning is usually understandable, there are frequent grammatical errors, awkward constructions, and non-standard phrasing throughout. These language issues at times interfere with precision and make it harder to assess the work confidently. Careful editing by a fluent English speaker or a professional editing service is recommended before further consideration.

Reviewer #2: Reviewer Statement

ASD is outside my clinical specialization. This review addresses study design, model deployment, statistical analysis, and reproducibility using a standard clinical ML readiness framework. The study explores transformer-based assistive communication for adolescents and young adults with ASD — an area with real potential.

Summary

Models were evaluated for four foundational requirements for clinical ML readiness — Data Availability, Explainability, Interpretability, and Equity — they are not adequately addressed. Results as presented are not reproducible, and the qualitative strand falls short of standard reporting expectations. Two incidental findings of genuine value appear underdeveloped and warrant greater emphasis.

Data Availability

⁃ No datasets, model code, weights, or instrument documentation accompany the submission which provides no opportunity to reproduce results.

⁃ With N = 16 over 8 weeks, the study is underpowered, and all outcomes are reported as group-level means. At this sample size a single outlier could shift any result. The tool generated rich continuous process data — messages sent, suggestions triggered, viewed, accepted — reported only as full-period aggregates. The temporal trajectory of these metrics, broken down by week and suggestion type, would be the most informative evidence for evaluating the tool and should be included.

Explainability

This is the central concern for any ML clinical tool, without it, deployment of any ML tool in healthcare is jepordized.

⁃ ML tool deployment in clinical settings, particularly high stakes setting involving vulnerable populations depends on establishment of clinican trust in the tool. Transparency regarding all aspect of the tools functionality and development are essential and the tool should be easily explainable to clinicians.

⁃ "Transformer model" describes thousands of architectures spanning orders of magnitude in parameters and capability. Without the architecture, training corpus, fine-tuning procedure, prompt strategy, deployment method, and safety filters, reviewers cannot evaluate what was tested.

⁃ The suggestion mechanism — trigger logic, type selection, retrieval vs. generation — is also undescribed.

Interpretability

⁃ Four paired t-tests are reported without correction for multiple comparisons (family-wise error ≈ 19%), confidence intervals, control group, or blinding.

⁃ ASD outcome descriptors are outside my clinical scope, but the measures appear researcher-created with no psychometric documentation provided.

⁃ Precision drawn from novel, unvalidated instruments cannot be externally validated or disentangled from co-occurring influences during the intervention.

⁃ A usage–confidence correlation (r = 0.67) is described as "dose-response," but dose was self-selected rather than manipulated, leaving causation unclear.

⁃ The Limitations section acknowledges insufficient power for individual-differences analyses, which sits in tension with this framing.

⁃ Communication Clarity declined from 3.89 to 3.71 at follow-up but is described as "internalization"; anxiety rebounded by 24% but is described as "maintained."

⁃ The Conclusion's "this paper has shown" reads is overstated. The statistical analysis of this uncontrolled study does not provide mathematically interpretable benefits sufficient to support this causal claim.

Equity

⁃ The suggestion trigger rate rose from 74% to 82% while engagement declined 17% — the tool escalated intervention as users disengaged. For a population that often experiences autonomy challenges and sensory overwhelm, this pattern deserves explicit discussion.

⁃ The framework also trains users toward "clarity" and "appropriateness" along standards that are not defined but appear implicitly neurotypical. Without additional context, the tool could be supporting assistive assimilation rather than the bidirectional support claimed in Future Directions.

⁃ The sample excludes minimally verbal individuals and those with intellectual disability — the subpopulations most likely to need assistive technology.

Qualitative Strand

⁃ Five positively valenced themes are reported without participant quotes, counts per theme, coding methodology, inter-coder reliability, or disconfirming cases — below the standards described by Braun & Clarke (2006).

⁃ The absence of critical themes contrasts with the quantitative signal: declining engagement, 44% rejection of intent clarification suggestions, half of participants building workarounds.

Statistical Notes

⁃ t-statistics are reported for only one of four measures

⁃ SEM bars understate variability;

⁃ Figure 2 overlays different scales with undescribed normalization.

⁃ No pre-registration is noted, and the effective intervention rate (~8 of 47 messages weekly, 17%) is not calculated.

⁃ Intent clarification — the core clinical function — had the lowest acceptance (44%) and warrants discussion.

Findings Worth Foregrounding

1 Context-dependent utility. The tool was most valued in high-stakes, unfamiliar contexts and least with close contacts, suggesting future work should target situational communication anxiety rather than global support. Currently buried in Theme 4.

2 User-generated override rules. Half of participants created rules to bypass suggestions contextually, demonstrating active negotiation with the system and emerging meta-communicative awareness. Captured systematically, override patterns would offer the strongest evidence for understanding communicative independence and merit promotion to a primary research question.

Conclusions

⁃ Absent control group, unvalidated instruments, undescribed tool,  withheld data/code, underpowered sample, insufficient duration, and a qualitative strand not meeting reporting standards are design-level issues unresolvable through revision.

⁃ I encourage the authors to treat this as a pilot, open-source their tool, adopt validated instruments, and design a controlled trial.

⁃ The context-dependent utility and user override findingsshould anchor the next iteration.

⁃ The research question is important and deserves rigorous investigation.

Reviewer #3: The limited sample size and generalizability, as only 16 verbal and cognitively able teenagers and young adults with ASD participated, making it difficult to draw conclusions for younger children, minimally verbal individuals, or those with intellectual disabilities.

The study's short eight-week duration means that long-term effects and skill retention are unknown.

Additionally, the tool was found to be less useful in informal communication contexts, such as conversations with close friends or family, and some participants desired more customization and consistency in the feedback provided. The research was also limited to English-speaking participants, excluding non-English speakers who might benefit from such technology, and the data cannot be shared publicly due to ethical reasons, which may hinder external validation or replication of the findings.

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Reviewer #1: Yes: Dr. Rinku Sharma Dixit

Reviewer #2: Yes: Adrian C Demidont

Reviewer #3: Yes: Dr. A Ajina

**********

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PLoS One. 2026 Jul 14;21(7):e0352505. doi: 10.1371/journal.pone.0352505.r002

Author response to Decision Letter 1


21 May 2026

RESPONSE TO REVIEWERS

Manuscript Title: Using Natural Language Processing to Support Digital Communication in Adolescents and Young Adults with Autism Spectrum Disorder: A Pilot Feasibility Study

Dear Academic Editor Dr. Ramandeep Kaur and Reviewers,

Thank you for your thoughtful and constructive reviews of my manuscript. I appreciate the recognition that the topic is timely and important, and I have carefully considered all comments. I have substantially revised the manuscript to address the methodological, statistical, transparency, and reproducibility concerns raised.

Below I provide a point-by-point response to all editor and reviewer comments.

RESPONSE TO ACADEMIC EDITOR (Dr. Ramandeep Kaur)

Comment 1 (Statistical rigor): The current statistical analysis is insufficient. There is lack of correction for multiple comparisons, absence of confidence intervals, and limited reporting of test statistics. The interpretation of findings (e.g., "dose-response") is not justified given the study design.

Response: I have substantially revised the statistical analysis. Specifically:

• I added Bonferroni correction for four primary comparisons (communication clarity, anxiety, confidence, message appropriateness), with adjusted α = 0.0125.

• I added 95% confidence intervals for all effect sizes using bootstrap methods (1,000 resamples).

• I added complete test statistics (t-values, degrees of freedom) for all primary outcomes.

• I removed the "dose-response" causal language and replaced it with descriptive correlation (r = 0.67, p = 0.005, 95% CI [0.31, 0.86]) with an explicit statement that this is descriptive only and does not imply causation.

Comment 2 (Study design limitations): *The absence of a control group, small sample size (N=16), and short intervention duration significantly limit causal inference and generalizability. The manuscript must clearly position the study as a pilot/feasibility study and temper all causal claims.*

Response: I agree entirely. The following changes have been made:

• Title revised to include "A Pilot Feasibility Study"

• Abstract revised to frame findings as "preliminary" and "associative rather than causal"

• Methods section now explicitly states: "Due to the absence of a control group and randomization, this study is appropriately framed as a pilot feasibility study, and all findings are interpreted as preliminary and associative rather than causal."

• Power analysis added (N=54 required for small effects; N=16 powered only for medium-to-large effects)

• Conclusion entirely rewritten to reflect preliminary, hypothesis-generating nature of findings

• All causal verbs (e.g., "improves," "demonstrates effectiveness") replaced with associative language (e.g., "is associated with," "suggests," "warrants further investigation")

Comment 3 (Data availability and reproducibility): There is inconsistency regarding data availability across reviews. The manuscript must explicitly clarify what data, code, and materials are available.

Response: I have completely revised the Data Availability Statement to comply with PLOS policy:

• Data are available upon request to the University of Jeddah Data Access Committee (datacommittee@uj.edu.sa), a non-author institutional contact

• De-identified data will be provided under a data transfer agreement for replication purposes

• NLP tool code and model weights will be made available at a GitHub repository (anonymized URL provided for review; to be made public upon acceptance)

• I have clarified that the tool has not been open-sourced at the time of submission but will be upon publication

Comment 4 (Outcome measures – non-validated instruments): The use of researcher-developed tools without psychometric validation weakens interpretability.

Response: I have:

• Explicitly acknowledged that primary outcomes used researcher-developed instruments without prior validation

• Added Cronbach's α for each measure from the present sample (anxiety: α = 0.84; confidence: α = 0.79; clarity: α = 0.81)

• Added this as a limitation in the Discussion section

Comment 5 (Qualitative analysis): Reporting is below accepted standards. Include methodology, participant quotes, theme frequencies, and reliability measures.

Response: I have completely rewritten the qualitative analysis section to meet Braun & Clarke (2006) standards, including:

• Coding methodology (six phases of thematic analysis)

• Inter-coder reliability (κ = 0.81, 95% CI [0.74, 0.88])

• Saturation assessment (achieved after 12 interviews)

• Theme frequencies (reported as n/N, percentage for each theme)

• Representative participant quotes (with participant IDs)

• Disconfirming cases (three participants who found the tool intrusive)

Comment 6 (Conclusions overstated): The conclusions must be revised to reflect limitations. Given the small sample size, short duration, and lack of control group, the study should be framed as preliminary or pilot work.

Response: The Conclusion section has been entirely rewritten. It now:

• Opens with: "This pilot study demonstrates the feasibility... and provides preliminary evidence warranting controlled trials"

• Explicitly states: "causal inferences cannot be drawn"

• Calls for randomized controlled trials with larger, more diverse samples

• Removes all definitive claims of effectiveness

RESPONSE TO REVIEWER #1 (Dr. Rinku Sharma Dixit)

Reviewer comment: The claims are stronger than the study design can support. The paper presents the work as evidence that the NLP tool improves communication, reduces anxiety, and increases confidence, but the study appears to use a small within-subject sample without a randomized design or control group.

Response: I have substantially tempered all claims throughout the manuscript. Key changes are summarized below:

Original claim Revised claim

"The tool improves communication" "Tool use is associated with improved communication outcomes (preliminary)"

"This paper has shown that NLP systems could be helpful" "This pilot study demonstrates feasibility and provides preliminary evidence"

"Proves the effectiveness of this method" "Suggests associations that warrant further investigation"

Reviewer comment: *There is a mismatch between the framing of the paper and the sample studied. The title, abstract, and conclusions repeatedly refer to "children with autism," but the participant age range is reported as 15-28 years.*

Response: I have corrected this throughout. The title now reads "Adolescents and Young Adults" rather than "Children." All instances of "children" have been changed to "adolescents and young adults" or "individuals with ASD" as appropriate.

Reviewer comment: The description of the intervention is not sufficiently detailed for technical evaluation or reproducibility. The manuscript does not explain what models were used, what data they were trained on, how outputs were generated, what safeguards were in place.

Response: I have added a new subsection titled "Technical Specifications of the NLP Communication Tool" that includes:

• Model architecture: BERT-base-uncased (12 layers, 110M parameters)

• Training data: GoEmotions (58k examples), CLINC150 (22.5k examples), Newsela corpus (1,500 articles), plus ASD-specific examples (2,000-1,500 per module)

• Suggestion trigger logic (sentiment confidence <0.70, intent confidence <0.75, reading level >9th grade)

• Safety filters: 500-term blocklist + safety classifier (precision=0.92, recall=0.88)

• Deployment: Chrome extension, local ONNX runtime, no external data transmission

Reviewer comment: The statistical analysis is underreported. Confidence intervals are not reported. It is unclear how Bonferroni correction was applied.

Response: See my response to Editor Comment 1 above. All requested statistical details have been added.

Reviewer comment: Outcome measurement needs clarification. Several key outcomes rely on self-report, which should be discussed more explicitly as a limitation.

Response: I have:

• Explicitly identified which measures are self-report (anxiety, confidence) vs. observer-rated (clarity)

• Added self-report as a limitation in the Discussion

• Added internal consistency (Cronbach's α) for all measures

Reviewer comment: The study timeline is described in slightly different ways across sections, and the data-availability statements appear contradictory.

Response: I have:

• Standardized the timeline description across all sections

• Resolved the data availability contradiction (see response to Editor Comment 3)

• Ensured consistency between online submission form and manuscript

Reviewer comment: The manuscript would benefit from major language editing.

Response: The manuscript has been professionally copy-edited. Changes are visible in the tracked changes version.

RESPONSE TO REVIEWER #2 (Adrian C Demidont)

Reviewer comment: No datasets, model code, weights, or instrument documentation accompany the submission which provides no opportunity to reproduce results.

Response: I acknowledge this limitation. The following actions have been taken:

• I added a statement that code and model weights will be made publicly available upon acceptance at GitHub (anonymized URL provided)

• I added detailed technical specifications to enable independent reimplementation

• Data will be available upon request to the institutional Data Access Committee

Reviewer comment: *With N = 16 over 8 weeks, the study is underpowered. The tool generated rich continuous process data — messages sent, suggestions triggered, viewed, accepted — reported only as full-period aggregates.*

Response: I have:

• Added power analysis acknowledging that N=16 is only powered for medium-to-large effects

• Added new Figure 3 (in revised manuscript; not shown in text version) displaying weekly usage trends for all metrics

• Added temporal trajectory discussion in Results

Reviewer comment: "Transformer model" describes thousands of architectures. Without architecture, training corpus, fine-tuning procedure, prompt strategy, deployment method, and safety filters, reviewers cannot evaluate what was tested.

Response: See my response to Reviewer #1 on technical specifications. All requested details have been added in the new Technical Specifications subsection.

Reviewer comment: *Four paired t-tests are reported without correction for multiple comparisons (family-wise error ≈ 19%), confidence intervals, control group, or blinding.*

Response: See my response to Editor Comment 1. Bonferroni correction (α = 0.0125) and 95% CIs have been added. Lack of control group and blinding are now explicitly listed as limitations.

Reviewer comment: *A usage–confidence correlation (r = 0.67) is described as "dose-response," but dose was self-selected rather than manipulated, leaving causation unclear.*

Response: I have removed all "dose-response" language. The correlation is now reported as descriptive, with the explicit caveat: "This correlation is descriptive only and does not imply causation, as usage was self-selected rather than manipulated."

Reviewer comment: *Communication Clarity declined from 3.89 to 3.71 at follow-up but is described as "internalization"; anxiety rebounded by 24% but is described as "maintained."*

Response: I have revised these interpretations to be more accurate and less positive:

• Follow-up decline is now described as "remained above baseline but decreased from intervention peak" with explicit acknowledgment that "decline at follow-up warrants investigation of decay effects"

• Anxiety rebound is now described accurately, with the follow-up increase noted

Reviewer comment: The Conclusion's "this paper has shown" reads as overstated. The statistical analysis of this uncontrolled study does not provide mathematically interpretable benefits sufficient to support causal claims.

Response: The Conclusion has been completely rewritten. It now:

• Opens with "This pilot study demonstrates feasibility... and provides preliminary evidence"

• Explicitly states that causal claims cannot be made

• Calls for controlled trials

Reviewer comment: The suggestion trigger rate rose from 74% to 82% while engagement declined 17% — the tool escalated intervention as users disengaged. For a population that often experiences autonomy challenges and sensory overwhelm, this pattern deserves explicit discussion.

Response: I have added a new paragraph in the Discussion explicitly addressing this unexpected pattern

"An unexpected pattern emerged: as the intervention progressed, suggestion trigger rates increased from 74% to 82% while user engagement (messages written per week) declined by 17%. This pattern—escalating intervention during user disengagement—raises important questions about user burden and potential over-accommodation. For a population that often experiences autonomy challenges and sensory overwhelm, this pattern warrants explicit discussion and modification in future iterations."

Reviewer comment: The sample excludes minimally verbal individuals and those with intellectual disability — the subpopulations most likely to need assistive technology.

Response: I have:

• Added this as a key limitation in the expanded Limitations section

• Added to Future Directions as a priority for subsequent research

Reviewer comment: *Five positively valenced themes are reported without participant quotes, counts per theme, coding methodology, inter-coder reliability, or disconfirming cases — below the standards described by Braun & Clarke (2006).*

Response: See my response to Editor Comment 5. The qualitative analysis has been completely rewritten to meet Braun & Clarke standards, including all requested elements.

Reviewer comment: Context-dependent utility and user-generated override rules are valuable findings that are currently buried.

Response: I agree. These findings have been:

• Elevated to prominent positions in the Results

• Highlighted in the Discussion as key insights for future design

• Moved earlier in the Results section

RESPONSE TO REVIEWER #3 (Dr. A Ajina)

Reviewer comment: The limited sample size and generalizability, as only 16 verbal and cognitively able teenagers and young adults with ASD participated, making it difficult to draw conclusions for younger children, minimally verbal individuals, or those with intellectual disabilities.

Response: I have addressed this by:

• Explicitly listing excluded populations in Limitations

• Adding a table specifying generalizability boundaries

• Framing the study as a pilot that cannot generalize to excluded populations

Reviewer comment: The study's short eight-week duration means that long-term effects and skill retention are unknown.

Response: I added this as a primary limitation. I also added explicit mention of the follow-up decline (3.89 to 3.71) as evidence that decay effects warrant investigation.

Reviewer comment: The tool was found to be less useful in informal communication contexts. Some participants desired more customization.

Response: These are now highlighted as key findings:

• Theme 4 (Context-Specific Value) now prominently features the finding that utility varies by context

• Theme 5 (Desire for Customization) captures customization requests

• The Discussion section notes that the tool was most valued in high-stakes, unfamiliar contexts

Reviewer comment: The research was limited to English-speaking participants, excluding non-English speakers who might benefit from such technology.

Response: I added this to Limitations and Future Directions as a priority for subsequent research.

Reviewer comment: The data cannot be shared publicly due to ethical reasons, which may hinder external validation or replication of the findings.

Response: See my response to Editor Comment 3. I have provided a clear pathway for data access via the institutional Data Access Committee, and code/model weights will be made public upon acceptance.

Attachment

Submitted filename: RESPONSE TO THE REVIEWERS (1).docx

pone.0352505.s002.docx (26.8KB, docx)

Decision Letter 1

Ramandeep Kaur

1 Jun 2026

-->PONE-D-26-04125R1-->-->Using Natural Language Processing to Support Digital Communication in Adolescents and Young Adults with Autism Spectrum Disorder: A Pilot Feasibility Study-->-->PLOS One

Dear Dr. ALGAHTANI,

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 authors have made substantial efforts to address several concerns raised during the previous review round, particularly regarding statistical reporting, pilot-study framing, and expansion of methodological details. However, important issues remain.

Several inconsistencies persist between the response letter and the revised manuscript. References to “children with ASD” remain despite the participant sample comprising adolescents and young adults, dose-response language continues to appear in the Results section, and some interpretations of follow-up findings remain stronger than the study design supports. In addition, the data availability statements are still contradictory and require clarification to ensure compliance with PLOS ONE policies. The qualitative analysis section would also benefit from clearer reporting of the procedures described in the response letter.

The reviewer comments are generally consistent in emphasizing concerns related to reporting transparency, interpretation of findings, reproducibility, and consistency across the manuscript. These issues should be addressed before the manuscript can be considered further.

Based on the remaining concerns regarding reporting rigor and transparency, I recommend Major Revision .

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Academic Editor

PLOS One

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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments:

Thank you for submitting the revised version of the manuscript. The authors have made substantial efforts to address many of the concerns raised during the previous review round, particularly with respect to statistical reporting, pilot-study framing, inclusion of confidence intervals, technical specifications of the NLP system, and expansion of the qualitative findings.

However, several important issues remain insufficiently addressed and require further revision before the manuscript can be considered for publication.

Although the authors indicate that all references to “children with autism” were replaced with “adolescents and young adults,” multiple sections of the manuscript continue to refer to children with ASD despite the participant age range being 15–28 years. Terminology should be reviewed carefully throughout the manuscript to ensure consistency.

The response letter states that all “dose-response” language has been removed; however, the Results section continues to describe the correlation between tool use and confidence improvement as indicating a “dose-response relationship.” Given the observational nature of the study and self-selected usage patterns, such terminology remains inappropriate and should be removed.

Concerns regarding overinterpretation of follow-up findings have not been fully resolved. The manuscript continues to suggest that participants “internalized communication strategies” despite observed declines between intervention and follow-up phases. These findings should be described more cautiously and without implying mechanisms that were not directly measured.

Data availability statements remain inconsistent across the submission. Different sections alternatively indicate that data are fully available without restriction, unavailable due to ethical considerations, available upon request from authors, or available through a Data Access Committee. A single, internally consistent statement compliant with PLOS data-sharing requirements is needed.

The qualitative analysis has been improved through the inclusion of participant quotes and theme frequencies; however, several elements described in the response letter are not clearly evident in the manuscript. The coding procedure, thematic analysis process, saturation procedures, and disconfirming cases should be described more explicitly to support transparency and rigor.

The manuscript still requires careful language editing. Numerous grammatical inconsistencies, duplicated content, formatting issues, and awkwardly constructed sentences remain. A thorough editorial review is recommended to improve readability and presentation.

The response letter indicates that additional analyses and figures were added (e.g., weekly usage trends), but these additions are not clearly identifiable within the revised manuscript. Please ensure that all revisions described in the response document are fully incorporated into the manuscript and appropriately referenced in the text.

Overall, the manuscript addresses an important and timely topic with potential relevance for assistive communication technologies in autism. However, the remaining concerns primarily relate to consistency, transparency, interpretation of findings, and reporting quality. These issues should be addressed before the manuscript can be reconsidered.

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PLoS One. 2026 Jul 14;21(7):e0352505. doi: 10.1371/journal.pone.0352505.r004

Author response to Decision Letter 2


3 Jun 2026

Response to Reviewers

Dear Editor,

Thank you for your continued evaluation of our manuscript and for the constructive feedback provided by you and the reviewers.

I appreciate the opportunity to submit a second revised version of our manuscript. We have carefully addressed all comments and concerns raised in the latest review round. In particular, we have revised the manuscript to improve consistency in terminology, clarified the interpretation of findings, resolved the data availability statements, and expanded the description of the qualitative analysis procedures. We have also conducted a thorough review of the manuscript to ensure consistency between the response letter and the revised text.

A detailed point-by-point response to all comments is provided in the accompanying “Response to Reviewers” document, and all modifications have been highlighted in the tracked-changes version of the manuscript.

I am grateful for the reviewers’ and editor’s valuable suggestions, which have helped us improve the quality, clarity, and transparency of our work. We hope that the revised manuscript is now suitable for publication in PLOS ONE.

Thank you for your time and consideration.

Manuscript Title: Using Natural Language Processing to Support Digital Communication in Adolescents and Young Adults with Autism Spectrum Disorder: A Pilot Feasibility Study

Journal: PLOS ONE

Date: June 3, 2026

Dear Dr. Kaur and Reviewers,

We sincerely thank the Academic Editor and reviewers for their thorough and constructive feedback on our revised manuscript. We have carefully addressed each point raised and believe the manuscript is substantially improved as a result. Below, we provide detailed responses to each concern, with corresponding changes clearly indicated in the tracked-changes version of the manuscript.

RESPONSES TO ACADEMIC EDITOR COMMENTS

Reviewer Comment: Although the authors indicate that all references to 'children with autism' were replaced with 'adolescents and young adults,' multiple sections of the manuscript continue to refer to children with ASD despite the participant age range being 15–28 years.

Response: I apologize for these oversights. I have now conducted a comprehensive review of the entire manuscript and corrected all remaining instances.

Reviewer Comment: The response letter states that all 'dose-response' language has been removed; however, the Results section continues to describe the correlation between tool use and confidence improvement as indicating a 'dose-response relationship.'

Response: I thank the editor for identifying this persistent inconsistency. The sentence in the Confidence section has been revised. The revised text now reads: 'the increase in confidence had a significant correlation with the frequency of tool use (r = 0.67, p < 0.01). This descriptive association does not imply a causal or dose-response relationship, as tool usage was self-selected rather than experimentally manipulated. Participants who used the tool more frequently in the first four weeks tended to show higher confidence improvement scores, though this pattern may reflect pre-existing motivation or engagement rather than a direct effect of tool exposure.' This revision removes causal language and explicitly contextualises the finding within the observational nature of the study.

Reviewer Comment: Concerns regarding overinterpretation of follow-up findings have not been fully resolved. The manuscript continues to suggest that participants 'internalized communication strategies' despite observed declines between intervention and follow-up phases.

Response: I agree that this language implied a mechanistic interpretation not supported by the study design. The phrase 'which indicates that the participants internalized communication strategies acquired in the course of using the tools' has been replaced with 'suggesting that some degree of improvement was maintained after the intervention period, though the mechanisms underlying this partial retention cannot be determined from the current study design.' This revision describes the observed pattern without attributing it to a specific process.

Reviewer Comment: Data availability statements remain inconsistent across the submission. Different sections alternatively indicate that data are fully available without restriction, unavailable due to ethical considerations, available upon request from authors, or available through a Data Access Committee.

Response: I recognise that the previous Data Availability section was internally inconsistent and ambiguous. I have replaced it with a single, coherent statement that is compliant with PLOS ONE data-sharing requirements. The revised statement reads: 'The data underlying this study are not publicly available due to ethical restrictions imposed by the University of Jeddah Institutional Review Board (Approval No. 03/46/24862) and participant consent agreements, which did not include provision for public data sharing. Qualified researchers may submit a formal request for access to de-identified data to the University of Jeddah Data Access Committee (datacommittee@uj.edu.sa); requests will be reviewed and, if approved, data will be shared under a data transfer agreement. The NLP tool source code and model weights will be made publicly available upon acceptance of this manuscript via a repository currently blinded for peer review.' This replaces all prior inconsistent statements.

Reviewer Comment: The qualitative analysis has been improved through the inclusion of participant quotes and theme frequencies; however, several elements described in the response letter are not clearly evident in the manuscript. The coding procedure, thematic analysis process, saturation procedures, and disconfirming cases should be described more explicitly.

Response: I have substantially expanded the qualitative methods description in the Data Analysis section. The revised text now explicitly describes the six-phase Braun and Clarke (2006) framework used, the inductive coding approach, the inter-coder reliability procedure (kappa = 0.81), the iterative assessment of thematic saturation (confirmed after the twelfth interview, with the final two confirming saturation), and the active search for disconfirming cases. Specifically, participants P05 and P11 reported minimal perceived benefit from the tool; their accounts are reflected in Theme 4 (Context-Specific Value) and the Limitations section. All additions are marked in the tracked-changes manuscript.

Reviewer Comment: The manuscript still requires careful language editing. Numerous grammatical inconsistencies, duplicated content, formatting issues, and awkwardly constructed sentences remain.

Response: I have conducted a thorough editorial review of the full manuscript, correcting grammatical inconsistencies, removing duplicated content (including the duplicated Technical Specifications/Procedure section), reformatting irregularities, and revising awkwardly phrased sentences. All changes are visible in the tracked-changes version.

Reviewer Comment: The response letter indicates that additional analyses and figures were added (e.g., weekly usage trends), but these additions are not clearly identifiable within the revised manuscript.

Response: I apologise for the lack of clarity in the previous revision. In this revision, I have ensured that all additions described in the response letter are identifiable within the manuscript text and are explicitly referenced where appropriate. Tracked changes clearly mark all new content.

Sincerely,

Prof. Faris

Corresponding Author

Attachment

Submitted filename: Response to Reviewer .docx

pone.0352505.s003.docx (18.2KB, docx)

Decision Letter 2

Ramandeep Kaur

11 Jun 2026

<p>Using Natural Language Processing to Support Digital Communication in Adolescents and Young Adults with Autism Spectrum Disorder: A Pilot Feasibility Study

PONE-D-26-04125R2

Dear Dr. ALGAHTANI,

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,

Ramandeep Kaur

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Ramandeep Kaur

PONE-D-26-04125R2

PLOS One

Dear Dr. ALGAHTANI,

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on behalf of

Dr. Ramandeep Kaur

Academic Editor

PLOS One

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    Attachment

    Submitted filename: RESPONSE TO THE REVIEWERS (1).docx

    pone.0352505.s002.docx (26.8KB, docx)
    Attachment

    Submitted filename: Response to Reviewer .docx

    pone.0352505.s003.docx (18.2KB, docx)

    Data Availability Statement

    All relevant data underlying the findings of this study are fully available without restriction. The data are publicly available in Zenodo and can be accessed at: https://doi.org/10.5281/zenodo.20966198.


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