Comparative effectiveness of structured clinician-guided and self-guided parent training for preschool attention-deficit/hyperactivity disorder (ADHD) risk: a randomized controlled trial

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a major global neurodevelopmental condition, affecting millions of children and exerting substantial burdens on families, educational systems, and public health infrastructure worldwide (1,2). Epidemiological data estimate prevalence rates of 2–4.3% among preschool-aged children (3–5 years), rising to 5–10% in school-aged populations, positioning ADHD as the most common neurodevelopmental disorder of childhood (3-5). Core symptoms—persistent inattention, hyperactivity, and impulsivity—interfere with academic performance, peer interactions, and adaptive functioning across key developmental domains (6,7). Preschool years constitute a sensitive period during which ADHD symptoms typically manifest, often as heightened motor activity, impulsivity, communication difficulties, and regulatory challenges (8). However, diagnostic accuracy at this stage remains difficult. Developmentally normative traits—such as variable temperament, immature inhibitory control, and fluctuating attention spans—often obscure pathological presentations (9,10). Consequently, clinical assessment in preschoolers demands a comprehensive, multi-informant approach that includes culturally validated screening instruments and structured behavioral observations (11,12).

Among early intervention strategies, parent management training (PMT) is internationally recognized as the first-line treatment for preschool ADHD, supported by a robust evidence base demonstrating significant reductions in ADHD symptoms and improvements in child functioning (13,14). PMT interventions focus on modifying maladaptive parent-child interactions, enhancing parental efficacy, and reducing coercive or inconsistent disciplinary practices (15,16). Meta-analyses consistently report large effect sizes across diverse delivery settings, with benefits often sustained over time (17,18). Despite these compelling findings, substantial gaps remain regarding PMT’s effectiveness in Asian populations. Specifically, within low- and middle-income countries (LMICs) such as Thailand, where healthcare infrastructure and cultural practices differ from Western contexts, limited data exist on the real-world effectiveness and cultural acceptability of PMT (19,20). Currently, Thailand lacks standardized PMT programs. Intervention typically occurs through individualized counseling or generic educational materials disseminated during clinical consultations (21). This represents a significant implementation gap, as increasing awareness of ADHD has prompted greater service-seeking behavior among Thai families.

Moreover, the potential value of group-based delivery models has not been thoroughly examined in collectivist societies, despite their theoretical advantages. These include peer support, normalization of shared experiences, and improved cost-efficiency—benefits particularly relevant for resource-constrained settings (22,23). In cultural contexts like Thailand, where community-centered problem-solving is normative, group interventions may align better with social expectations and family dynamics (24,25). However, previous studies using standardized measures have found that many Thai caregivers of children with ADHD score poorly on domains of positive parenting (26), highlighting the urgent need for structured, culturally congruent parenting interventions. The absence of locally adapted, empirically tested PMT programs remains a barrier to effective ADHD management in Thailand (27,28).

To address these gaps, the current study investigates the efficacy of a culturally adapted, group-based PMT program for Thai families of preschoolers at risk for ADHD. This randomized controlled trial (RCT) represents the first empirical evaluation of group PMT in Thai settings and aims to inform scalable, evidence-based practices suitable for LMICs with similar socio-cultural characteristics. ADHD risk was determined using the Thai ADHD Screening Scales (THASS) preschooler form (12), a caregiver-reported screening instrument developed and validated for Thai preschool populations. The scale evaluates inattentive and hyperactive-impulsive behaviors and produces standardized T-scores based on age-appropriate Thai normative data. A T-score ≥51 indicates elevated ADHD risk relative to population norms. Detailed scale structure and psychometric validation are described in the original validation study. We present this article in accordance with the CONSORT reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-898/rc).

Methods

Study design

This single-blind, parallel-group RCT assessed the effectiveness of a culturally adapted parent training intervention vs. standard care in Thai preschool-aged children at risk for ADHD. The study was conducted at the Division of Developmental and Behavioral Pediatrics, Queen Sirikit National Institute of Child Health (QSNICH), Bangkok, Thailand. The study was conducted between September and December 2024. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Queen Sirikit National Institute of Child Health (IRB No. 00007346). Informed consent was obtained from all caregivers prior to participation. The study was prospectively registered with the Thai Clinical Trials Registry (TCTR20260202021), approved on 02 February 2026, in accordance with international clinical trial reporting standards.

Participants and eligibility criteria

Eligible participants were primary caregivers aged 20–60 years without significant disability, caring for children aged 3.0–5.9 years with a T-score ≥51 on the THASS—preschooler form, indicating ADHD risk (12). Children were excluded if they had previously received a confirmed diagnosis of ADHD or autism spectrum disorder. Confirmed ADHD diagnoses were determined by developmental-behavioral pediatricians according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) diagnostic criteria based on comprehensive clinical evaluation, including caregiver interviews, developmental history, and review of available medical records. The purpose of this exclusion was to focus specifically on preschool children identified as being at elevated risk for ADHD but who had not yet met full diagnostic criteria. Additional exclusions included developmental delay as indicated by the Developmental Surveillance and Promotion Manual (DSPM) or autism risk identified by (PDDSQ) and Modified Checklist for Autism in Toddlers (M-CHAT)/M-CHAT, Revised with Follow-Up (M-CHAT-R/F) (29,30). Caregivers were required to use internet-connected mobile devices with the LINE application for remote assessments. Those unable to communicate in Thai or attend group sessions were excluded. Information regarding family history of ADHD or other neurodevelopmental conditions and prior participation in parenting programs was collected at baseline to evaluate potential confounding influences. Participants attending less than 80% of the 6-hour session (i.e., <4.8 hours) were withdrawn to preserve intervention fidelity. The intervention materials were culturally adapted through linguistic translation, contextual modification of parenting examples, and integration of culturally relevant communication practices consistent with Thai family dynamics. Adaptation focused on aligning behavioral strategies with collectivist family structures and common caregiving practices in Thai households.

Randomization and allocation

Participants were randomized using stratified block randomization (block size =4), stratified by monthly family income to balance socioeconomic status across groups (31). A biostatistician generated the sequence using a computerized algorithm. Allocation concealment was maintained via sealed opaque envelopes, opened only after baseline assessment. Outcome assessors remained blinded throughout the trial. Sample size determination: using G*Power 3.1.9.7 (32), the required sample size was calculated based on an anticipated large effect size (d=0.85) drawn from meta-analyses of parent training interventions (13,14), with α=0.05 and 80% power. The minimum required sample was 46 (23 per group); 48 participants were recruited to allow for attrition. Primary outcomes were assessed using the THASS preschooler form, a standardized caregiver-reported instrument developed and validated in Thai populations. The THASS preschooler form consists of behavioral items assessing inattentive and hyperactive-impulsive symptoms across two subscales. Responses are converted into standardized T-scores based on normative data derived from Thai preschool populations. A T-score ≥51 indicates elevated ADHD risk relative to age-matched norms. The scale demonstrates excellent internal consistency (Cronbach’s α=0.94–0.98) and good construct validity in previous validation studies.

Intervention protocol: the intervention group received a 6-hour, single-session, group-based PMT program delivered by developmental pediatricians and psychologists. Content integrated Thai cultural values with evidence-based behavioral strategies (24), including psychoeducation, communication skills, positive reinforcement, discipline techniques, and quality time enhancement. Delivery included lectures, group discussions, case studies, role-play, and supervised practice (33,34). Although delivered as a single 6-hour session, the program incorporated interactive skill rehearsal, role-play, and case-based discussion to support caregiver mastery of behavioral strategies. Participants were also able to seek follow-up consultation through the LINE messaging platform during the post-intervention period. The control group received equivalent content in printed materials without group interaction or facilitation. Both groups had access to follow-up consultation via the LINE platform.

Secondary outcomes included positive parenting behaviors, and positive parenting practices were evaluated using a 16-item Positive Parenting Scale designed to assess caregiver behaviors related to supportive communication, reinforcement, and constructive discipline. Each item is rated on a Likert scale, with higher scores reflecting stronger positive parenting behaviors. Total scores are categorized into low, moderate, and high levels based on empirically derived thresholds. The instrument demonstrates good internal consistency (Cronbach’s α=0.84), strong content validity (0.81–0.94), and acceptable test-retest reliability in prior studies as shown in Figure 1.

Figure 1 Positive parenting scores of the intervention and control group. The red stars indicate.

Assessment schedule

Outcome assessments occurred at baseline, 2-week, and 6-week post-intervention via secure LINE: mobile messaging application messaging system, ensuring standardized data collection while minimizing participant burden and maximizing retention rates.

Statistical analysis

All analyses followed intention-to-treat principles using SPSS version 28.0 software. Baseline characteristics were compared using Chi-squared tests for categorical variables and independent t-tests for continuous measures. Primary efficacy analyses were conducted using generalized estimating equations (GEE) to account for within-participant correlations across repeated assessments. The primary estimand was the group × time interaction, representing differential symptom trajectories between intervention and control groups over time. An exchangeable correlation structure was specified. Model outputs included β coefficients, standard errors, and 95% confidence intervals (CIs). Statistical significance was set at P<0.05 for all analyses.

Results

From September to December 2024, 62 families were screened; 48 eligible caregivers were randomized equally to intervention and control groups (Figure 2). The trial achieved 100% retention across all timepoints, with no serious adverse events reported. Baseline demographics were comparable across groups (P>0.05). Most caregivers were mothers (79.2%), aged 30–39 years (62.5%), and held university degrees (70.8%). Families were evenly distributed between nuclear and extended structures. Children were predominantly male (77.1%) with a mean age of 4.71±0.80 years, reflecting typical ADHD-risk preschool demographics. Baseline demographic characteristics are summarized in Table 1.

Figure 2 CONSORT 2025 flow diagram.

Clinical outcome measures at baseline confirmed equivalent starting points between groups. Total ADHD symptom scores showed no significant differences (intervention: 58.62±10.60 vs. control: 56.71±14.03, P=0.60), with similar patterns for hyperactivity-impulsivity (28.96±6.77 vs. 28.17±8.24, P=0.72) and inattention subscales (29.71±6.35 vs. 28.54±7.05, P=0.55). Positive parenting scores demonstrated balanced distribution (intervention: 38.83±5.88 vs. control: 41.08±4.89, P=0.16), with the majority of participants demonstrating moderate to high positive parenting levels (79.2% combined), contrasting with previous studies reporting predominantly low-to-moderate levels in ADHD-affected families. Baseline clinical assessments are presented in Table 2.

Primary outcome of ADHD symptom trajectories

Participants in the intervention group demonstrated substantial reductions in total ADHD symptoms at both 2 weeks (mean change: −14.29; 95% CI: −19.09, −9.49; P<0.001) and 6 weeks (−15.33; 95% CI: −20.13, −10.54; P<0.001), with large effect sizes (Cohen’s d=1.24–1.31). Significant improvements were observed in both hyperactivity-impulsivity and inattention subdomains (all P<0.001). The control group showed smaller, though statistically significant, reductions in total and hyperactivity symptoms (P<0.01), while inattention scores remained unchanged (P>0.10). Between-group comparisons revealed consistently superior outcomes in the intervention group across timepoints and domains, exceeding minimal clinically important differences. These findings support the clinical utility of the group-based intervention for early ADHD symptom reduction. ADHD symptom trajectories over time are summarized in Table 3.

Longitudinal modeling using GEE assessed treatment effects while adjusting for baseline covariates and repeated-measure structure. Significant main effects were observed for time (Wald χ²=7.828; P=0.001) and group (Wald χ²=4.551; P=0.04), indicating overall symptom reduction and superior outcomes in the intervention group. Effect sizes were calculated using Cohen’s d and are presented with 95% CIs. Although large effect sizes were observed, these estimates should be interpreted cautiously given the relatively small sample size and short follow-up period. The time-by-group interaction did not reach significance (Wald χ²=2.199; P=0.12), suggesting that improvements were maintained rather than differentially accelerated. Subdomain analyses showed significant time effects for hyperactivity (Wald χ²=7.856; P=0.001) and inattention (Wald χ²=5.485; P=0.005). Notably, inattention demonstrated a significant group effect (Wald χ²=5.459; P=0.02), while hyperactivity trends favored the intervention without reaching statistical significance (Wald χ²=2.395; P=0.12). These findings underscore the sustained advantage of the group-based intervention across symptom domains. Between-group comparisons are presented in Table 4, and the results are illustrated in Figure S1.

Secondary outcome of positive parenting behaviors

Positive parenting outcomes as shown in Figure 1, revealed mixed intervention effects with temporal variation. Intervention participants showed significant improvements at 2-week post-training (mean difference: 2.92 points; 95% CI: 0.78, 5.06; P=0.008; Cohen’s d=0.74), representing meaningful enhancement in positive parenting practices. However, the magnitude of improvement was reduced at 6-week follow-up compared with the early post-intervention assessment. (mean difference: 1.96 points; P=0.01; Cohen’s d=0.32). Changes in positive parenting outcomes are summarized in Table 5, and the results are illustrated in Figure S2, while GEE analyses are shown in Table 6.

When comparing the differences between the intervention and control groups at each time period using GEE analysis, it was found that there was no statistically significant difference in time, group, and time by group interaction. Control group positive parenting scores remained relatively stable across assessment periods, showing minimal deviation from baseline values. GEE analysis revealed no significant main effects for time (Wald χ²=1.073; P=0.35), group (Wald χ²=0.710; P=0.40), or time-by-group interaction (Wald χ²=0.948; P=0.39), suggesting insufficient intervention intensity for sustained parenting behavior modification.

Clinical significance and effect size interpretation

Observed ADHD symptom reductions surpassed clinical significance thresholds, with Cohen’s d values >1.2 indicating large, functionally meaningful effects. These exceeded outcomes from comparable parent training studies and typical pharmacologic interventions in preschool ADHD. The persistence of benefits through 6-week follow-up, despite non-significant time-by-group interactions, supports the efficiency of brief, group-based formats in reducing family burden while preserving efficacy. The LINE-based follow-up platform proved highly feasible, with 100% completion and no technical issues. No adverse events were reported, and all families completed the intervention without safety concerns. High participant satisfaction and engagement further reflect the success of cultural tailoring in aligning intervention content with Thai family dynamics, enhancing acceptability and potential scalability within national healthcare systems.

Discussion

This RCT provides compelling evidence that culturally-adapted, group-based parent training significantly reduces ADHD symptoms in at-risk Thai preschoolers, with sustained benefits persisting 6 weeks post-intervention. The magnitude of observed improvements substantially exceeded clinically meaningful thresholds, with effect sizes (Cohen’s d>1.2) surpassing those reported in recent meta-analyses of parent training interventions (13,14). These findings represent a significant advance in evidence-based treatment for Southeast Asian populations, where cultural factors substantially influence intervention acceptability and efficacy. The robust symptom reductions observed in our intervention group likely reflect multiple converging mechanisms. Enhanced parental self-efficacy in managing ADHD-related behaviors appears central to intervention success, consistent with social cognitive theory emphasizing the role of perceived competence in behavioral change (22). The group-based delivery format may have amplified these effects through peer support mechanisms, normalized problem-sharing experiences, and vicarious learning opportunities, particularly relevant within collectivistic cultural frameworks (33). The sustained 6-week benefits contrast with typical decay patterns observed in behavioral interventions, suggesting that brief, intensive group formats may offer advantages over extended treatment protocols (19). This durability likely reflects the comprehensive nature of our intervention, which integrated psychoeducation, skill-building, and practice opportunities within a culturally-sensitive framework that acknowledged Thai family values and communication patterns. Notably, the non-significant time-by-group interaction revealed parallel improvement trajectories rather than differential change rates between groups. While both groups demonstrated symptom improvements over time, intervention participants maintained consistently superior outcomes throughout follow-up. This pattern suggests that the intervention established an initial advantage that persisted rather than accelerating improvement rates, potentially reflecting the assessment effects and educational material exposure experienced by control participants (17).

Positive Parenting Outcomes and Interpretation: The mixed findings for positive parenting behaviors warrant careful interpretation within the broader context of intervention research. While significant short-term improvements emerged at 2 weeks post-intervention, these gains diminished by 6-week follow-up, suggesting insufficient intervention intensity for sustained parenting behavior change. This pattern may reflect several contributing factors, including ceiling effects among participants with initially high positive parenting scores, the brief intervention duration, or the complexity of modifying deeply ingrained parenting practices within a single-session format (16,33). The baseline positive parenting scores in our sample exceeded those reported in previous studies of ADHD-affected families, potentially reflecting developmental differences between preschool and school-aged populations (26). Parents of younger children may naturally demonstrate higher levels of warmth and positive engagement, as parenting stress and negative interaction patterns often escalate with persistent behavioral challenges over time. This age-related variation underscores the importance of early intervention approaches that capitalize on existing positive parent-child relationships while building behavioral management skills.

Cultural Adaptation and Implementation Considerations: All randomized participants completed follow-up assessments at all scheduled timepoints, resulting in a 100% retention rate. However, formal satisfaction measures were not collected and should be included in future implementation studies. The group-based format aligned with collectivistic values emphasizing community support and shared problem-solving, while the content integration acknowledged Thai communication styles and disciplinary approaches (20,25). These adaptations likely enhanced intervention acceptability and engagement compared with individually-delivered or culturally-generic approaches. The successful implementation within Thailand’s healthcare infrastructure demonstrates the feasibility of integrating evidence-based parent training into existing clinical services. The single-session format offers particular advantages for resource-limited settings, minimizing family burden while maintaining therapeutic efficacy. However, our findings suggest that booster sessions or extended support may be necessary to sustain positive parenting improvements, representing an important consideration for program refinement (22,23). These findings have immediate implications for clinical practice within Thai pediatric healthcare systems and broader relevance for developing nations facing similar challenges in providing evidence-based mental health services. The demonstration of intervention efficacy supports the integration of group-based parent training as a first-line treatment for preschoolers with ADHD risk, potentially serving as bridge intervention while families await specialized evaluation or as primary treatment for subclinical presentations. The cost-effectiveness advantages of group delivery, combined with demonstrated cultural acceptability, position this intervention as a scalable approach for addressing the growing recognition of preschool ADHD symptoms. Healthcare systems could implement such programs within existing developmental pediatric services, leveraging trained personnel and established infrastructure to maximize population-level impact (27,28).

Several limitations warrant acknowledgment. A relatively high proportion of participating caregivers held university degrees. This demographic profile may reflect healthcare access patterns in tertiary referral settings and could limit the generalizability of findings to populations with lower educational attainment. Future studies should include more socioeconomically diverse samples to better represent the broader population. The reliance on parent-report measures introduces potential bias, although this reflects real-world clinical practice were parental observations guide treatment decisions. The 6-week follow-up period, while demonstrating sustained short-term benefits, provides limited information regarding long-term maintenance. Future studies should incorporate extended follow-up assessments and multiple informant perspectives to comprehensively evaluate intervention durability and generalizability. The single-session intervention format, while demonstrating efficacy, may benefit from modification to include booster sessions or technology-enhanced support to maintain positive parenting improvements. Investigation of optimal intervention dosing, delivery modalities, and cultural adaptation strategies represents important directions for future research. Additionally, examination of intervention effectiveness across diverse socioeconomic and educational backgrounds would enhance generalizability and inform targeted implementation approaches. Additionally, the relatively short follow-up duration limits conclusions regarding long-term sustainability of treatment effects and parenting behavior changes.

Conclusions

This RCT demonstrates that a culturally adapted, group-based parent training program significantly reduces ADHD symptoms in at-risk Thai preschoolers, with sustained effects and large effect sizes. The intervention’s brief, single-session format proved feasible, well-accepted, and effective, offering a scalable model for resource-limited settings. While improvements in positive parenting were less durable, the robust behavioral outcomes justify clinical integration into early childhood services. These findings advance the global evidence base on culturally responsive ADHD interventions and highlight the importance of aligning treatment models with local family values. Future refinements, including booster sessions, may further enhance long-term parenting outcomes and implementation impact.

Acknowledgments

We would like to thank the Queen Sirikit National Institute of Child Health for institutional support that enabled successful completion of this study. We would also like to thank all participating children and their caregivers for their cooperation and invaluable contribution.

Footnote

Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-898/rc

Trial Protocol: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-898/tp

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-898/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-898/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-898/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Queen Sirikit National Institute of Child Health (IRB No. 00007346). Informed consent was obtained from all caregivers prior to participation.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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