From ADHD symptoms to parental stress: The roles of functional impairment, family functioning, and parental ADHD

Nitchawan Jongrakthanakij; Thanavadee Prachason; Nida Limsuwan; Komsan Kiatrungrit; Masatha Thongpan; Passaporn Lorterapong; Pattarabhorn Wisajun; Sudawan Jullagate

doi:10.1371/journal.pone.0341817

Peer Review History

Original SubmissionNovember 17, 2025
7 Dec 2025 Decision Letter - Gerard Hutchinson, Editor Dear Dr. Prachason, plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. We look forward to receiving your revised manuscript. Kind regards, Gerard Hutchinson, MD Academic Editor PLOS One Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. 3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. 4. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. Please update your Data Availability statement in the submission form accordingly. 5. In the online submission form, you indicated that due to the inclusion of personal and sensitive information, the data from this study cannot be made publicly available. This restriction complies with the protocol approved by the Institutional Review Board (IRB) of Ramathibodi Hospital, Mahidol University. Data may be made available upon reasonable request and with approval from the IRB. Requests for data access should be directed to nitchawan.jon@mahidol.ac.th . All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 5. We notice that your supplementary [figures/tables] are included in the manuscript file. Please remove them and upload them with the file type 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list. 6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 7. 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. 8. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [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? Reviewer #1: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: I Don't Know Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: No Reviewer #2: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: This is a very important area and I commend the authors for embarking on a study such as this. The integrative framework is a major strength of the study. However, there are a couple of important considerations I note below that may impact on the conclusions and implications stated by the authors. 1. The authors have not included a neurotypical control group- the reasons for this have not been elucidated. 2. The authors have also not considered the impact of comorbidities on family functioning and thereby on parental stress. The only consideration has been the child's ADHD symptoms - it would be important to consider the impact of comorbidities on family functioning and parental stress- if this is not able to be considered, at the very least, the reasons must be clarified and included in the limitations. Reviewer #2: Thank you for giving me the opportunity to review the manuscript. I read it with great interest. The study investigated the role of child factors (ADHD severity and impairment) and family factors (parental ADHD severity and family functioning) in parental stress. Structural equation modelling revealed that child impairment, parental ADHD and family functioning are key factors in parental stress and should be addressed in multimodal ADHD treatment, rather than focusing solely on treating the child's ADHD symptoms. The abstract provides an informative overview of the study. The introduction is clearly focused and includes rigorous argumentation to deduce the study's research question and the methods applied. The sample (recruitment and characteristics), instruments and statistics are all clearly described. The results are presented precisely and discussed adequately, including the study's limitations and clinical consequences. I only have a few minor suggestions for changes that could be made. The suggested changes are mandatory. It would also be possible to accept it as it is. Abstract: Methods: Please consider adding basic sample characteristics such as age and gender. p.1, l.16f: Please consider adding the notion that 'functional impairment' refers to the child (“Caregivers completed standardized measures of parental stress, child ADHD symptoms, child functional impairment, family functioning, and parental ADHD symptoms”). Results: Why are the statistical data for significant effects only presented for child- and family-related models, and not for the integrated model? Please consider presenting the data in the same way for all models, or for none of them. Material and methods: Why is inclusion criterion (3) restricted to the availability of data on parental stress? What about the other variables included in the equation modelling? It would be helpful to add information on the diagnostic strategy applied in routine clinical care at the psychiatric outpatient department at Ramathibodi Hospital for assessing ADHD according to the DSM-5 and comorbid conditions. Please provide information on the strategies employed to develop the Thai versions of the PSS-10 and ASRS-V1.1. Literature on the Thai versions of the other instruments is cited. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0341817.r001
Revision 1
9 Jan 2026 Author Response Reviewer #1: This is a very important area and I commend the authors for embarking on a study such as this. The integrative framework is a major strength of the study. However, there are a couple of important considerations I note below that may impact on the conclusions and implications stated by the authors. We sincerely thank you for your thoughtful and constructive feedback on our manuscript. We greatly appreciate your recognition of the importance of this area of research and your positive remarks regarding the integrative framework of our study. Your comments are invaluable in helping us improve both the clarity and interpretation of our findings. We have carefully considered your points and addressed them as follows: 1. The authors have not included a neurotypical control group- the reasons for this have not been elucidated. R1.1: We thank the reviewer for raising this important point. This study utilized data derived from a clinical registry without including neurotypical families as a comparator because our primary aim was to examine the interrelationship between child-related and family-related factors associated with parental stress within families affected by ADHD, rather than to compare them with neurotypical families. However, we agree that the absence of a neurotypical control group limits direct comparison with normative levels of family functioning and parental stress. Therefore, we have now revised the Introduction to clarify the focus of our study on families affected by ADHD and have explicitly acknowledged the limitation of not having neurotypical comparators in the Discussion, as shown below. Introduction “…The present study aimed to address this gap by applying structural equation modeling (SEM) to examine the contributions of both child- and family-related factors to parental stress within families affected by ADHD. … Such insights would be a stepping stone to developing targeted, evidence-based interventions to mitigate parental stress and optimize treatment outcomes, not only for children with ADHD, but also for the entire family unit.” Strengths and Limitations “…Second, as this study aimed to explore the interrelationships between factors associated with parental stress within families affected by ADHD, we did not include neurotypical children as a control group, which limits the comparison of our findings with normative levels of family functioning and parental stress.” 2. The authors have also not considered the impact of comorbidities on family functioning and thereby on parental stress. The only consideration has been the child's ADHD symptoms - it would be important to consider the impact of comorbidities on family functioning and parental stress- if this is not able to be considered, at the very least, the reasons must be clarified and included in the limitations. R1.2: Thank you for this thoughtful comment. We agree that comorbid conditions may affect family functioning and parental stress. However, the registry data used in this study were derived from a single assessment of routine psychiatric service, normally lasting 60-90 minutes; therefore, comorbidities that were not evident at the initial encounter may be overlooked or inadequately evaluated due to the time limit. As the prevalence of comorbid conditions commonly co-occurring with ADHD was low in our dataset, except for specific learning disorder, we conducted additional SEM sensitivity analyses adjusting for specific learning disorder, which also confirmed the main analysis. The results of these analyses were added to the revised manuscript as shown below, with detailed information in the supplement. Result Pathway from child ADHD symptoms to parental stress “… Sensitivity analyses additionally controlling for family income or comorbid specific learning disorder confirmed the significant indirect effect of child ADHD symptoms on parental stress via functional impairment (S1 and S2 Fig)…” Pathway from parental ADHD symptoms to parental stress “.. Sensitivity analyses, additionally adjusting for family income and comorbid specific learning disorder, confirmed that both the direct and indirect effects remained significant (S4 and S5 Fig)…” Integrated pathway from ADHD symptoms to parental stress “...In sensitivity analyses, all models confirmed a significant indirect effect of parental ADHD symptoms on parental stress via family functioning, but not child functional impairment (S7-S9 Fig). However, the significant direct effect of parental ADHD was only confirmed in the model additionally adjusted for specific learning disorder (S8 Fig). The insignificant direct and indirect effects of child ADHD symptoms on parental stress through functional impairment remained consistent across all sensitivity analyses (S7-S9 Fig), but the indirect effect of child ADHD symptoms on parental stress through family functioning became significant in the model additionally adjusted for specific learning disorder (S8 Fig)…” Furthermore, we have also added this point in the Limitation section as follows: “Third, the registry data used in this study were derived from a single assessment of routine psychiatric service, normally lasting 60-90 minutes, with assurance of comprehensive clinical evaluation for ADHD diagnosis. Therefore, comorbidities that were not evident at the initial encounter may be overlooked or inadequately evaluated due to the time limit. Indeed, the prevalence of comorbid conditions commonly co-occurring with ADHD was low in our dataset, except for specific learning disorder. For this reason, we only additionally adjusted for specific learning disorder in our sensitivity analyses to confirm the robustness of the findings, rather than including it as a separate predictor in the models.” Reviewer #2: Thank you for giving me the opportunity to review the manuscript. I read it with great interest. The study investigated the role of child factors (ADHD severity and impairment) and family factors (parental ADHD severity and family functioning) in parental stress. Structural equation modelling revealed that child impairment, parental ADHD and family functioning are key factors in parental stress and should be addressed in multimodal ADHD treatment, rather than focusing solely on treating the child's ADHD symptoms. The abstract provides an informative overview of the study. The introduction is clearly focused and includes rigorous argumentation to deduce the study's research question and the methods applied. The sample (recruitment and characteristics), instruments and statistics are all clearly described. The results are presented precisely and discussed adequately, including the study's limitations and clinical consequences. I only have a few minor suggestions for changes that could be made. The suggested changes are mandatory. It would also be possible to accept it as it is. We sincerely thank you for the time and effort dedicated to reviewing our manuscript and for providing such thoughtful and constructive feedback. We greatly appreciate your positive remarks regarding the focus, rigor, and clarity of our study, as well as the informative presentation of the abstract, methods, and results. Your insights have been extremely helpful in improving the clarity and completeness of our manuscript. We have carefully considered all your suggestions and addressed them as follows: 1. Abstract: Methods: Please consider adding basic sample characteristics such as age and gender. R2.1: We thank the reviewer for this constructive comment. In response, the Abstract has been revised to include basic sample characteristics, including mean age and gender distribution, as shown: “Methods: A cross-sectional study included 127 children and adolescents with ADHD (70.9% males; mean age 9.6 ± 3.3 years) and their caregivers, recruited from the ADHD Registry at Ramathibodi Hospital, Bangkok (2019–2023).” 2. p.1, l.16f: Please consider adding the notion that 'functional impairment' refers to the child (“Caregivers completed standardized measures of parental stress, child ADHD symptoms, child functional impairment, family functioning, and parental ADHD symptoms”). R2.2: The wording in the Abstract has also been clarified to explicitly indicate that functional impairment refers to child functional impairment, as shown: “Caregivers completed standardized measures of parental stress, child ADHD symptoms, child functional impairment, family functioning, and parental ADHD symptoms.” 3. Results: Why are the statistical data for significant effects only presented for child- and family-related models, and not for the integrated model? Please consider presenting the data in the same way for all models, or for none of them. R2.3: The Results section has been revised to ensure consistent reporting across all models, as follows: “Results: Examining child- and family-related factors separately, child ADHD symptoms indirectly influenced parental stress via functional impairment, whereas parental ADHD symptoms significantly influenced parental stress both directly and indirectly via family functioning. In the integrated model examining both child- and family-related factors concurrently, the direct and indirect pathways from parental ADHD symptoms to parental stress via family functioning remained significant, but not the pathway from child ADHD symptoms to parental stress via functional impairment.” 4. Material and methods: Why is inclusion criterion (3) restricted to the availability of data on parental stress? What about the other variables included in the equation modelling? R2.4: Thank you for your thoughtful suggestion. This study utilized secondary data from the ADHD registry, a longitudinal cohort of children suspected of having ADHD, with the aim of investigating pathways to parental stress; therefore, the availability of this outcome variable was required for study inclusion. The sample with over 20% missing items of any questionnaire used in the models was excluded from the related analysis. To clarify these points, we have revised the Study design and participants section to make a clear distinction between the enrollment process of the ADHD registry and the inclusion and exclusion criteria for the current analyses. The justification for the inclusion criterion and the number of missing variables was now provided, as shown below. “This cross-sectional study utilized baseline data from the ADHD Registry of the Department of Psychiatry at Ramathibodi Hospital, Bangkok, Thailand, a longitudinal cohort that consecutively enrolled children and adolescents suspected of having ADHD who first visited the psychiatric outpatient unit from October 2019 to October 2023. Children and adolescents who were unable to communicate in Thai were excluded. After informed written assent and consent were obtained from the participants and their parents, respectively, child and adolescent psychiatrists or psychiatry residents performed comprehensive clinical interviews with both the children and their caregivers to determine the diagnoses for the presenting problems as part of routine clinical care. A checklist of the DSM-5 criteria for ADHD [36] was recorded. The diagnosis of ADHD was defined as the presence of ≥6 symptoms in either the inattention or hyperactivity/impulsivity domains, beginning before age 12, present in at least two settings, and causing functional impairment. Children were excluded if symptoms occurred only during a psychotic disorder or were better explained by another psychiatric condition or substance use. Comorbidity identified at the initial visit was also recorded. Caregivers provided demographic and personal information (age, sex, living arrangements, marital status, education level, and family monthly income) and completed standardized questionnaires assessing parental stress, child ADHD symptoms, child functional impairment, family functioning, and parental ADHD symptoms. Multiple follow-up assessments were conducted over a one-year period after the initial visit. The Ethics Committee of Ramathibodi Hospital, Mahidol University, approved the data collection protocol of the registry (MURA2019/815). For the present study, we retrieved anonymized baseline data from the ADHD registry comprising 164 children and adolescents who met the DSM-5 diagnostic criteria of ADHD. Only participants with available data on parental stress were included in this study because it was the primary outcome variable in the structural equation modeling. The sample with over 20% missing items of any questionnaire used in the models was excluded from the related analysis. The final sample for the main analyses comprises 127 participants. The characteristics of the excluded sample were not significantly different from the included sample (S1 Table). The Ethics Committee of Ramathibodi Hospital, Mahidol University, waived the requirement for informed consent to use the de-identified data for this study (MURA2025/340).” 5. It would be helpful to add information on the diagnostic strategy applied in routine clinical care at the psychiatric outpatient department at Ramathibodi Hospital for assessing ADHD according to the DSM-5 and comorbid conditions. R2.5: Thank you for this helpful comment. We added clarification on the diagnostic strategy used in routine clinical care in the Method section as shown below. Study design and participants “…child and adolescent psychiatrists or psychiatry residents performed comprehensive clinical interviews with both the children and their caregivers to determine the diagnoses for the presenting problems as part of routine clinical care. A checklist of the DSM-5 criteria for ADHD [36] was recorded. The diagnosis of ADHD was defined as the presence of ≥6 symptoms in either the inattention or hyperactivity/impulsivity domains, beginning before age 12, present in at least two settings, and causing functional impairment. Children were excluded if symptoms occurred only during a psychotic disorder or were better explained by another psychiatric condition or substance use. Comorbidity identified at the initial visit was also recorded.” 6. Please provide information on the strategies employed to develop the Thai versions of the PSS-10 and ASRS-V1.1. Literature on the Thai versions of the other instruments is cited. R2.6: We thank the reviewer for this helpful suggestion. We have now clearly referenced the original studies that developed and validated the Thai versions of the PSS-10 and ASRS-v1.1 with appropriate citations in the Measures section as follows: “The Thai version PSS-10 has demonstrated good reliability and validity in Thai populations [38]…” “The Thai version ASRS-v1.1 has been shown to be psychometrically reliable and valid for screening adult ADHD in Thai populations [51].” Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0341817.r002
13 Jan 2026 Decision Letter - Gerard Hutchinson, Editor From ADHD symptoms to parental stress: The roles of functional impairment, family functioning, and parental ADHD PONE-D-25-61073R1 Dear Dr. Prachason 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Gerard Hutchinson, MD Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0341817.r003
Formally Accepted
Acceptance Letter - Gerard Hutchinson, Editor PONE-D-25-61073R1 PLOS One Dear Dr. Prachason, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Gerard Hutchinson Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0341817.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .