NEW RESEARCH
Group Therapy for Adolescents With Attention-Deficit/
Hyperactivity Disorder: A Randomized Controlled Trial
Raquel Vidal, PhD, Jordi Castells, MSc, Vanesa Richarte, MD, Gloria Palomar,
Marta Garc
ıa, MD, Rosa Nicolau, MSc, Luisa Lazaro, MD, PhD,
Miguel Casas, MD, PhD, Josep Antoni Ramos-Quiroga, MD, PhD
Objective: To determine the efficacy of group cognitive-
behavioral therapy (CBT) on adolescents with attention-
deficit/hyperactivity disorder (ADHD) who were in
pharmacological treatment but still had persistent
symptoms.
Method: We conducted a multicenter, randomized, rater-
blinded, controlled trial between April 2012 and May 2014
in a cohort of 119 adolescents (15–21 years of age). Par-
ticipants were randomly assigned to 12 manualized group
CBT sessions (n ¼ 45) or a waiting list control group (n ¼
44). Primary outcomes were assessed by a blinded eval-
uator (ADHD Rating Scale [ADHD-RS], Clinical Global
Impression Scale for Severity [CGI-S], Global Assessment
of Functioning [GAF]) before and after treatment, as well
as by self-report and parent informant ratings.
Results: Of the initial 119 participants enrolled, 89
completed treatment. A mixed-effects model analysis
revealed that participants who were assigned to the group
CBT sessions experienced significantly reduced ADHD
symptoms compared to the control group (ADHD-RS
Adolescent: 7.46, 95% CI ¼ 9.56 to 5.36, p < .001,
A ttention-deficit/hyperactivity disorder (ADHD) is a
neurodevelopmental disability affecting between
3% and 5% of the general population during
childhood.1 The defining features of the disorder are inat-
tention, impulsivity, and hyperactivity, which impair func-
tioning. ADHD can also lead to associated features of the
disorder such as difficulties in anger management, low
frustration tolerance, and depressive and anxiety symptoms.
Although ADHD appears in childhood, 50% to 65% of
children continue to have symptoms and impairment during
adolescence,2 and 78% of patients show some form of
persistence of ADHD during adulthood.3,4 Persistence of
ADHD during adolescence is associated with low academic
achievement, interpersonal difficulties, risky sexual
behavior, risky driving, and substance use disorders.5,6
Furthermore, adolescents (15–21 years of age) have high
rates of treatment discontinuation,7 which may impair
function at a crucial developmental stage.
Clinical guidelines recommend psychological approaches
as the first-line treatment for adolescents with ADHD,8
drawing attention to adolescents who are in transition from
childhood to adult services.9 Nevertheless, compared with the
amount of research on psychosocial interventions in chil-
dren10 and adults,11 little is known regarding appropriate
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MD,
d ¼ 7.5; ADHD-RS Parents: 9.11, 95% CI ¼ 11.48
to 6.75, p < .001, d ¼ 8.38; CGI-S Self-Report: 0.68, 95%
CI ¼ 0.98 to 0.39, p < .001, d ¼ 3.75; CGI-S
Clinician: 0.79, 95% CI ¼ 0.95 to 0.62, p < .001;
d ¼ 7.71). Functional impairment decreased significantly
in the CBT group according to parents (Weiss Functional
Impairment Scale 4.02, 95% CI ¼ 7.76 to 0.29, p < .05,
d ¼ 2.29) and according to the blinded evaluator
(GAF: 7.58, 95% CI ¼ 9.1 to 6.05, p < .001, d ¼ 7.51).
Conclusion: Group CBT associated with pharmacological
treatment is an efficacious intervention for reducing
ADHD symptoms and functional impairment in
adolescents.
Clinical trial registration information—CBT Group for
Adolescents With ADHD: a Randomized Controlled Trial;
http://clinicaltrials.gov/; NCT02172183.
Key Words: cognitive-behavioral therapy, psychological
treatment, group therapy, ADHD
J Am Acad Child Adolesc Psychiatry 2015;54(4):275–282.
psychological treatment for adolescents with ADHD. The
majority of psychological interventions in teens with ADHD
have focused on parent treatment programs12-15 and school
interventions,16-19 which essentially represent a continuation
of childhood treatments. However, numerous developmental
and environmental changes characterize adolescents, and,
consequently, treatments that are effective for children with
ADHD may not be appropriate for adolescents.20,21 Not sur-
prisingly, parent training programs have reported limited
clinical improvements in adolescents with ADHD. School
interventions have primarily focused on young adolescents,
leaving a lack of evidence regarding late adolescents.
Although cognitive-behavioral therapy (CBT) approaches
have not been proved to be efficacious in children,22,23 a pre-
liminary study has reported that individual CBT could be an
effective treatment for adolescents with ADHD.24
In relation to group formats, there is an ongoing discus-
sion as to whether group sessions could be effective in this
age range. Group CBT has been proved to benefit adults
with ADHD25; however, its usefulness in adolescents with
ADHD is uncertain. Only 1 noncontrolled study on rational-
emotive group therapy has been tested in adolescents with
ADHD.26 The treatment program, which focused on asso-
ciated symptoms such as difficulties in anger and frustration
www.jaacap.org 275
VIDAL et al.
management and depressive and anxiety symptoms,
obtained nonsignificant improvements at posttreatment
assessment. Some evidence of improvement has been
observed after mindfulness training in adolescents, albeit in
studies that have included participants with probable
ADHD.27 Thus, although clinical guidelines recommend in-
dividual CBT for older adolescents when a group format has
not been effective,8 there are insufficient data to support the
efficacy of CBT group treatments.
The rationale of this study was to test a psychological
intervention that consisted of a direct focus on the adoles-
cent. In view of the unclear effects of group therapy in this
age range,26,27 we designed a group CBT approach. The
main objective was to assess the efficacy of a CBT group in
relation to its effects on ADHD symptoms, functional do-
mains, anxiety and depression symptomatology, and asso-
ciated symptoms such as difficulties in anger management.
This objective was accomplished through a randomized
controlled study of group CBT for adolescents with ADHD.
We hypothesized that, at the end of treatment, compared
to the control group: the CBT group would exhibit reduced
ADHD symptoms and reduced severity of ADHD; the CBT
group would show a significant reduction in associated
symptoms such as anxiety, depression, and an improvement
in anger management; and the CBT group would show less
functional impairment related to ADHD.
METHOD
Study Design
The design was a multicenter, randomized, rater-blinded, controlled
trial that assessed the efficacy of a CBT group in adolescents with
FIGURE 1 Contents of the cognitive-behavioral therapy (CBT) group program.
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ADHD. Participants were randomly assigned either to a CBT group
(n ¼ 59) or to a waiting list control group (n ¼ 60).
Participants
Patients were recruited from the 2 ADHD units in university hos-
pitals in Barcelona, Spain. All participants were in psychopharma-
cological treatment before the study but still presented significant
symptoms of ADHD. We considered residual impairment after
medication if the patient obtained a Clinical Global Impression Scale
(CGI) score (clinician version) of 3 (mildly ill) or greater. The in-
clusion criteria were as follows: DSM-IV ADHD diagnosis; age be-
tween 15 and 21 years; stabilized doses of medication for ADHD for
at least 2 months before the study; and agreement not to seek out
any other psychiatric or psychological treatment during the study.
The exclusion criteria were the presence of the following: affective
disorders; anxiety disorders; psychotic disorders; personality disor-
ders; substance use disorders in the past 6 months; pervasive
developmental disorder (PDD); an IQ lower than 85; and concurrent
psychological intervention. The only comorbidities accepted were
oppositional defiant disorder (ODD) and learning disorders such as
dyslexia. Patients who had symptoms of depression and anxiety but
did not meet diagnostic criteria for anxiety and depressive disorders
were included in the study. Individuals who were not in pharma-
cological treatment or could not stay on stable medication were also
excluded from the study.
Intervention
CBT Group. The CBT group program was based on cognitive-
behavioral principles and used motivational interviewing tech-
niques to facilitate skills implementation. The treatment comprised
12 manualized sessions.28 The first session consisted of psycho-
education of ADHD (symptom identification and myths and re-
alities of ADHD). The sessions in the impulsivity module were as
follows: session 2, self-control strategies (functional analysis);
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 GROUP THERAPY FOR ADOLESCENTS WITH ADHD

session 3, cognitive skills (self-instruction); session 4, anger regula- the frequency of each item on a 4-point Likert scale. This scale has
tion (identifying anger triggers and alarm signs); session 5, frustra- been validated on adolescents (12–17 years of age) and on adults
tion tolerance and motivation (decisional balance, long-term with ADHD. The clinician-administered version was used for the
thinking, positive self-reinforcement); and session 6, interpersonal adolescent and parent informant.
abilities (criticism management and assertiveness training). The Clinical Global Impression Scale for Severity. The Clinical Global
attention module included the following: session 7, planning stra- Impression Scale for Severity37 CGI-S is a 7-point scale
tegies; session 8, problem solving and decision making; session 9, (1 ¼ normal or not ill, and 7 ¼ extremely ill). We used the self-report
procrastination; session 10, reducing external distractions; and ses- and clinician version to evaluate symptom severity.
sion 11, reducing distracting thoughts (postponing distractions, Clinical Global Impression–Improvement. The Clinical Global
redirecting attention). The last session consisted of a review of the Impression–Improvement (CGI-I)38 was used to evaluate reported
contents and maintenance of gains (Figure 1). Parents were not changes by the participants and by the clinician in relation to ADHD
involved in treatment sessions. symptoms. This scale assesses the total improvement of the patient’s
Control Group. The control group was a waiting list group. symptoms since the beginning of treatment. CGI-I is rated on a
Participants were visited only to monitor their adherence and 7-point scale (1 ¼ very much improved, 4 ¼ no change, and 7 ¼ very
continuation on medications for ADHD as prescribed by their psy- much worse).
chiatrist. Inclusion and exclusion criteria were the same as for the Weiss Functional Impairment Scale. We used the self-report and
experimental group. Participants did not receive any CBT or other parent version of the Weiss Functional Impairment Scale
type of psychological treatment during the study period. Partici- (WFIRS).39,40 This scale is appropriate for measuring adolescent and
pants in the control group were evaluated at pretreatment assess- youth functional impairment associated with ADHD and for
ment and were scheduled for a posttreatment evaluation with the monitoring treatment efficacy. It assesses different environments
same rater. After the posttreatment assessment, these individuals such as family, work/studies, life skills, self-concept, social activ-
were offered the opportunity to enter a CBT group through the ities, and risky activities. The scale has been psychometrically
ADHD program outside the study. validated with an internal consistency of greater than 0.8.
Global Assessment of Functioning. The Global Assessment of
Functioning (GAF)41 is a clinician-administered measure to assess
Treatment Fidelity
clinical severity and functioning.
The intervention was manualized in a structured format with writ-
ten material summarizing the content of the sessions for the par-
ticipants and including methodology and key points to address
during each session for the therapists. The CBT groups were con-
ducted by 2 clinical psychologists, 1 at each center, who had pre- TABLE 1 Demographic and Clinical Characteristics of the
vious experience with CBT groups. Before the beginning of the Sample
study, the therapists were trained to adhere to the content of the
manualized intervention. The key points of the session were visu- CBT Group Control Group
alized with a Microsoft PowerPoint presentation during the group (n ¼ 59) (n ¼ 60)
sessions. The 2 centers involved in the study used the same Pow-
erPoint material. Therapist competence and adherence to the treat- Variable n (%) n (%) p
ment manual in the 2 centers were rated on a checklist. All treatment Gender
sessions were videotaped, and 5 sessions from each 12-session trial Male 39 (66.11) 42 (70) NS
at each center were randomly selected for rating by an outside Female 20 (33.89) 18 (30)
consultant (41% of sessions rated). All participants were monitored
Education Level
weekly to evaluate medication adherence and to verify that no other
Primary 30 (50.85) 43 (71.67) NS
type of psychological treatment was received.
Secondary 29 (49.15) 17 (28.33)
Employment
Diagnostic and Outcome Measures Unemployed 3 (5.08) 2 (3.33) NS
Diagnosis of ADHD was established by experienced senior psychi-
Working 4 (6.78) 0
atrists using semi-structured interviews. For participants between 15
Studying 52 (88.14) 58 (96.67)
and 17 years of age, the Schedule for Affective Disorders and
Schizophrenia (K-SADS-PL) was used.29 For participants between 18 ADHD Subtype
and 21 years of age, the Conners’ Adult ADHD Diagnostic Interview Combined 37 (62.71) 35 (58.33) NS
for DSM-IV (CAADID) was used.30 To assess comorbidities, we Inattentive 21 (35.59) 25 (41.67)
used the Structured Clinical Interview for DSM-IV Axis I (SCID-I)31 Hyperactive 1 (1.7) -
and the Structured Clinical Interview for DSM-IV Axis II (SCID-II).32 Comorbidity
The Autism Diagnostic Interview–Revised Version (ADI-R)33 was Without comorbidity 50 (84.75) 49 (81.67) NS
used to exclude patients with PDDs. Participants were administered ODD 7 (11.86) 8 (13.33)
the Vocabulary and Block Design subtests of the Wechsler Adult Learning disorder 2 (3.39) 3 (5)
Intelligence Scale (WAIS-III),34 and adolescents aged 15 years were
administered the Wechsler Intelligence Scale for Children–IV Mean (SD) Mean (SD) p
(WISC-IV)35 to obtain an estimated IQ score.
Age 17.47 (1.88) 16.9 (1.75) NS
Abbreviated IQ 98.5 (8.67) 97.46 (9.4) NS
Primary Outcomes: ADHD Symptoms, Severity,
Note: ADHD ¼ attention-deficit/hyperactivity disorder; CBT ¼ cognitive-
and Functional Impairment
36 behavioral therapy; NS ¼ not significant (no between group significant
ADHD Rating Scale. The ADHD Rating scale (ADHD-RS) is an 18-
differences); ODD ¼ oppositional defiant disorder.
item scale that assesses the diagnostic criteria for ADHD and rates

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VIDAL et al.
Secondary Outcomes: Associated Symptoms
Beck Depression Inventory. The Beck Depression Inventory (BDI)42 is a
21-item scale to test depression symptoms by asking respondents to
rate how they have been feeling during the past week on a 4-point
Likert scale (0–3). It can be used for patients more than 13 years of age.
State-Trait Anxiety Inventory. The State-Trait Anxiety Inventory
(STAI)43 is a 40-item scale that differentiates between the temporary
condition of “state anxiety” and the more general and long-standing
quality of “trait anxiety.” It has been validated on adolescents (12–17
years of age) and adults.
State-Trait Anger Expression Inventory–2. The State-Trait Anger
Expression Inventory–2 (STAXI-2) was used for participants be-
tween 16 and 21 years of age,44 and STAXI-Ni~ nos y Adolescentes
(NA)45 was used for 15-year-old participants. The STAXI-2 is a self-
report questionnaire that measures state anger, trait anger, and
expression and control of anger.
Procedure
The ethics committees of the 2 hospitals approved the study before
participant enrollment, which occurred between April 2012 and May
2014. During this period, patients who were visited through the 2
ADHD units and who met inclusion criteria were informed about the
study. Participants who agreed to take part signed an informed consent
document, or for underage participants, parents provided signed
informed consent. After the pretreatment assessment, the data man-
ager of the study randomized participants to the 2 treatment conditions
using a computerized random number generator (SPSS version
20 software). The raters of the study were blinded to the intervention
and were not involved in the trial except for interviewing the partici-
pants at pretreatment and posttreatment assessment. Participants in
the 2 groups were evaluated at the beginning of the study (T1) and, for
the CBT group, again after session 12 (T2). One CBT group (6–8 par-
ticipants) and 1 control group were run concurrently to control for
effects of environmental factors (e.g., examinations or holiday periods).
Statistical Analysis and Sample Size
Changes in ADHD symptoms after CBT programs have been shown
to average 5 to 10 points on the ADHD-RS. Thus, power analysis
indicated that the study required a sample size of a minimum of 45
participants per group to detect a difference in ADHD-RS scores of 6
or more points with an SD of 9, assuming a risk a of 5% and risk b of
less than 2% 2-sided significance level. All participant data were
analyzed using a mixed-effect model design. Variables included in
the assessment of possible interactions in treatment effects were age,
gender, level of studies, ADHD subtype, and comorbidity. An
exploratory analysis to assess possible baseline differences between
groups was applied using t tests for continuous variables and
c2 tests for categorical variables. All analyses were conducted with
SPSS version 20, and all reported results were significant at the 5%
level. Cohen’s d was calculated to estimate the effect size of treat-
ment outcomes.
RESULTS
Sample Characteristics
Table 1 shows participant characteristics. No statistically
significant differences between groups were detected with
respect to demographic characteristics or baseline measures
of the participants. No significant differences were detected
between the 2 groups in the type and doses of medication for
ADHD (Table 2).
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TABLE 2 Mean Daily Doses of Medications Among
Participants
Daily Dose (mg)
ADHD Medication and Daily Dose (mg)
Treatment Group Mean (SD) Range
Methylphenidate
CBT group, n ¼ 54 46.05 (17.28) 18e72
Control group, n ¼ 47 47.07 (18.36) 10e80
Atomoxetine
CBT group, n ¼ 5 51.31 (19.08) 40e80
Control group, n ¼ 13 53.45 (17.05) 40e80
Note: ADHD ¼ attention-deficit/hyperactivity disorder; CBT ¼ cognitive-
behavioral therapy.
Program Completion Rate
A flow diagram of the study is shown in Figure 2. Low
dropout rates were observed; 10.16% of the participants in
the CBT group dropped out. The treatment completion rate
was high; only 8 participants (13%) in the CBT group were
classified as noncompleters. Noncompleters were defined as
individuals participating in less than 75% of the sessions.
There were no significant differences in demographic char-
acteristics or baseline measures between completers and
noncompleters. In relation to treatment fidelity, checklists
revealed no differences between the 2 centers in mean rat-
ings of therapists’ adherence to the CBT content, and 95% of
the sessions were rated as adherent.
Primary and Secondary Outcomes
Table 3 shows the primary and secondary outcomes
of the study.
ADHD Symptoms, Severity, and Functional Impairment. At
posttreatment evaluation, participants who received CBT
group therapy exhibited significantly reduced ADHD core
symptoms (ADHD-RS Adolescent scores: magnitude 7.46,
95% CI ¼ 9.56 to 5.36, d ¼ 7.5; ADHD-RS Parents: 9.11,
95% CI ¼ 11.48 to 6.75, d ¼ 8.38), revealing large effect
sizes. Severity of ADHD symptoms decreased significantly
more in the CBT group (CGI Self-Report: 0.68, 95%
CI ¼ 0.98 to 0.39, d ¼ 3.75; CGI Clinician: 0.79, 95%
CI ¼ 0.95 to 0.62, d ¼ 7.71). Functional impairment
decreased significantly more in the CBT group according to
the blinded evaluator (GAF: 7.58, 95% CI ¼ 9.1 to 6.05,
d ¼ 7.51; WFIRS Parents version: 4.02, 95% CI ¼ 7.76
to 0.29, d ¼ 2.29). However, no significant differences were
observed between groups according to WFIRS self-report.
Anxiety, Depressive Symptomatology, and Difficulties in
Anger Management. Results indicated a main effect of time in
depressive symptomatology (BDI: F4.15 ¼ 22.02, p ¼ .000)
and anger management (STAXI State: F2.4 ¼ 4.58, p ¼ .03;
STAXI Trait: F2.5 ¼ 4.16, p ¼ .04; STAXI Expression:
F3.34 ¼ 9.89, p ¼ .002). Nevertheless, no significant interac-
tion of time  group or effect of group was found.
Global Improvement. An independent t test was per-
formed to detect differences between groups in relation to
improvement perceived by the participants (CGI-I). It was
found that participants from the CBT group perceived more
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FIGURE 2 Flow diagram through the phases of the study, comparing cognitive-behavioral therapy (CBT) group and a waiting list
control group for attention-deficit/hyperactivity disorder (ADHD).
improvement than participants from the control group
(CGI-I Self-Report: F9.21 ¼ 0.001, p ¼ .000); the clinician
version also reported significant differences between groups
(CGI-I Clinician: F13.02 ¼ 2.45, p ¼ .000).
Moderators of Change
Clinical and demographic characteristics were included in
the mixed-effect model to explore possible interactions in
treatment effects (age, gender, level of studies, ADHD sub-
type, and comorbidity). No significant differences were
detected in relation to interactions among clinical and de-
mographic characteristics on treatment effects in any of the
different outcome measures. No differences were observed
between completers and noncompleters in any of the
outcome measures, and no statistically significant differ-
ences were seen in treatment effects between participants
who continued medication and participants who dis-
continued pharmacological treatment. A nonparametric test
for independent samples detected no significant effect of
type of ADHD medication used (methylphenidate versus
atomoxetine) on response to CBT.
DISCUSSION
We predicted that 12 sessions of CBT group therapy would
result in the following: reductions in ADHD symptoms and
severity; lower scores on associated symptoms such as
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GROUP THERAPY FOR ADOLESCENTS WITH ADHD
anxiety, depression, and difficulties in anger management;
and reduced functional impairment.
As our first hypothesis predicted, the CBT group ach-
ieved large effect sizes in reduction of ADHD symptoms and
severity. Previous studies on individual CBT obtained
similar results but with smaller effect sizes (d ¼ 0.41–0.61 for
impulsivity and d ¼ 1.02–1.39 for inattention)24 according to
parents and teachers. School interventions also obtained
smaller effect sizes than the current study (d ¼ 0.16–0.9 for
impulsivity symptoms and d ¼ 2.61–2.84 for inattention).16
However, our trial exhibited a similar tendency toward
smaller effect sizes on impulsivity (d ¼ 4.9–4.95) compared
to inattention improvements (d ¼ 8.57–9.62) according to
adolescents and parents.
Contrary to the prediction of our second hypothesis, group
CBT intervention did not significantly reduce symptoms of
anxiety and depression. These findings could be explained on
the basis of the low baseline scores for symptoms of anxiety
and depression in the sample. Similar results have been
observed in mindfulness programs27 that have demonstrated
efficacy in diminishing ADHD core symptoms in adolescents
but not anxiety and depression symptomatology. Along the
same lines, a rational-emotive group therapy focused on
associated symptoms such as anxiety, depression, and diffi-
culties in anger management demonstrated a lack of signifi-
cant change in these features.26 In contrast, studies on
psychological treatment in childhood demonstrated that
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VIDAL et al.

TABLE 3 Mixed-Effect Analysis of Primary and Secondary Outcomes

CBT Group Control Group
(n ¼ 59) (n ¼ 60)

Baseline Outcome Baseline Outcome

Measure Mean (SD) Mean (SD) Mean (SD) Mean (SD) Cohen’s d
ADHD-RS Adolesc 27.28 (1.04) 18.47 (1.01) 27.45 (1.03) 26.09 (1.02) 7.5***
Inattention 15.47 (0.57) 10.14 (0.51) 14.83 (0.5) 14.47 (0.5) 8.57***
Impulsivity 11.83 (0.69) 8.29 (0.7) 12.36 (0.68) 11.72 (0.7) 4.9***
ADHD-RS Parents 29.05 (1.05) 19.05 (1.11) 29.32 (1.06) 28.44 (1.13) 8.38***
Inattention 17.27 (0.57) 11.31 (0.58) 17.03 (0.58) 16.99 (0.6) 9.62***
Impulsivity 12 (0.78) 7.72 (0.77) 12.06 (0.78) 11.56 (0.78) 4.95***
CGI-S Self-report 3.54 (0.12) 2.9 (0.12) 3.3 (0.12) 3.35 (0.12) 3.75***
CGI-S Clinician 3.69 (0.06) 2.86 (0.07) 3.78 (0.06) 3.4 (0.07) 7.71***
GAF 63.25 (0.79) 70.83 (1.05) 63.4 (0.75) 63.12 (1) 7.51***
WFIRS-S 39.31 (2.81) 31.48 (2.43) 33.36 (2.71) 29.42 (2.36) 0.13 (NS)
WFIRS-P 32.92 (2.46) 28.24 (2.51) 34.57 (2.38) 33.92 (2.44) 2.29*
BDI 7.42 (0.82) 4.71 (0.79) 6.36 (0.82) 4.7 (0.8) 0.0 (NS)
STAI 21.49 (0.64) 20.56 (0.62) 19.86 (0.63) 20.34 (0.63) 0.35 (NS)
STAXI State 16.13 (2.18) 15.5 (11) 18.76 (8.52) 17.15 (6.25) 0.36 (NS)
STAXI Trait 21.95 (1.1) 19.99 (0.91) 20.88 (1.06) 20.62 (0.9) 0.1 (NS)
STAXI Control 27.41 (1.19) 29.23 (1.4) 26.47 (1.14) 27.25 (1.38) 0.21 (NS)
STAXI Expression 24.53 (1) 22.2 (0.82) 22.54 (0.97) 21.76 (0.82) 0.08 (NS)
Note: ADHD-RS ¼ Attention-Deficit/Hyperactivity Disorder (ADHD) Rating Scale; Adolesc ¼ Adolescents; BDI ¼ Beck Depression Inventory; CGI-S ¼ Clinical Global
Impression Scale for Severity; GAF ¼ Global Assessment of Functioning; NS ¼ not significant (no between-group significant differences); STAI ¼ State-Trait Anxiety
Inventory; STAXI ¼ State-Trait Anger Expression Inventory; WFIRS-P ¼ Weiss Functional Impairment ScaleeParents; WFIRS-S ¼ Weiss Functional Impairment
ScaleeSelf-Report.
*p < .05; ***p < .001.

combined treatment was effective for comorbid and associ-
ated symptoms but improved ADHD core symptoms to a
lesser degree than did pharmacological treatment.46-48
As predicted by our third hypothesis, functional
impairment decreased in participants in the CBT group,
according to parents and the clinician ratings. However,
adolescents in the CBT group did not report significant
improvements compared to participants in the control
group. Prior results from individual CBT have shown that
although ADHD symptoms were reduced after the psy-
chological treatment,24 many of the adolescents remained
functionally impaired in at least 1 domain (reported by
parents and teachers).
There are a number of limitations to this study. First, we
included medicated adolescents; effects of CBT in partici-
pants without pharmacological treatment were not assessed.
It would be of value to conduct trials that include partici-
pants without pharmacological treatment.49 Second, the
participants studied were between 15 and 21 years of age;
future research could test our CBT program in young
adolescents (12–14 years of age). Third, our program
demonstrated significant short-term gains; however, the
maintenance of these achievements was not assessed. The
patient sample in the current trial included participants
with comorbid ODD and learning disorders but no other
comorbidities such as anxiety, affective, or substance use
disorders, which are associated with ADHD. The validity of
this treatment in patients with additional comorbidities is
uncertain. However, ODD and learning disorders are the
2 most common comorbid disorders in adolescents with
ADHD.50,51
Given the waitlist control group design, participants were
aware of the condition to which they had been assigned, and
expectations from parents and adolescents could affect their
reports on the outcome ratings. Psychological factors such as
contact with a therapist or meeting in a group could have
influenced treatment effects. For these reasons, future
research on CBT for adolescents with ADHD needs to
include a comparison group, such as support therapy or a
discussion group, to assess the specificity of group CBT ef-
fects. Nevertheless, previous studies on adults with ADHD
compared CBT to supportive therapy25,52 or a discussion
group,53 obtaining significant differences favoring CBT in
decreasing ADHD symptoms. Despite these limitations, all
of the participants in our trial were receiving pharmacolog-
ical treatment. Thus, the study begins to answer whether a
group CBT add-on to pharmacological treatment should be
recommended.
Our research suggests that CBT group therapy could
benefit adolescents in reducing ADHD symptoms and the
severity of the disorder. It is important to note that the
completion rate of the program was high and that low rates
of dropout were observed, despite the difficulties of
engaging this population in treatment. Thus, CBT group
therapy would appear to be an acceptable approach in this
age range. The results support the rationale of the present
research, indicating that a more direct intervention on older
adolescents could benefit these patients. Indeed, given the

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peer pressures during this age, a group format could be an
approach that might provide reinforcement and motivation
to change. Another important result is that at the end of the
treatment, the ratings of participants on the ADHD-RS were
typically correlated with remission of ADHD symptoms.
Because of this, the intervention obtained not only statistical
significance but clinical relevance. Finally, this CBT group
program achieved similar results in different centers.
Future research should focus also on functioning as a
primary outcome of psychological approaches54 and should
ascertain why, despite improvements in ADHD symptoms,
some teens continue to perceive functional impairment. CBT
programs tend to focus only on ADHD symptoms (skills
programs), and this may not be sufficient for reducing
certain domains of impairments or associated features.21
According to Barkley’s model of deficient emotional self-
regulation in ADHD, greater gains in certain domains of
impairments and associated or comorbid symptoms may be
achieved through more emotion-based treatments. &
Accepted January 21, 2015.
Drs. Vidal, Casas, and Ramos-Quiroga are with Hospital Universitari Vall
d’Hebron, ADHD (Attention-Deficit/Hyperactivity Disorder) Program, Centro
de Investigaci

on Biom
edica En Red de Salud Mental (CIBERSAM), Barcelona,
Spain, and Universitat Aut
onoma de Barcelona. Mr. Castells, Dr. Garcia and
Ms. Nicolau are with the Hospital Cl
ınic of Barcelona. Dr. L
azaro are
with Hospital Clinic of Barcelona, (CIBERSAM), Institut d’Investigacions
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GROUP THERAPY FOR ADOLESCENTS WITH ADHD
Biomediques August Pi i Sunyer (IDIBAPS) and with the University of Barcelona.
Drs. Richarte and Palomar are with Hospital Universitari Vall d’Hebron, ADHD
Program, Barcelona, Spain.
Financial support was received from the Agencia de Salut P
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lona and the Department de Salut, Government of Catalonia, Spain; Instituto
de Salud Carlos III FIS (PI 11/01629), and a grant from the Agressotype
Research Program. Raquel Vidal, PhD, is a recipient of a Rio Hortega contract
from the Instituto Carlos III.
Sergi Valero, PhD, of the Hospital Universitari Vall d’Hebron, served as the
statistical expert for this research.
Disclosure: Dr. Casas has received travel grants from Eli Lilly and Co., Janssen-
Cilag, Shire, and Laboratorios Rubi
o. He has received grant research support
from Janssen-Cilag, Shire, Laboratorios Rubi
o, and Eli Lilly and Co. He has
been on the advisory board for Janssen Cilag, Shire, Laboratorios Rubi
o, and
Eli Lilly and Co. He has served as a consultant for Janssen-Cilag, Shire,
Laboratorios Rubi
o, and Eli Lilly and Co. Dr. Ramos-Quiroga has served on the
speakers’ bureau and acted as consultant for Eli Lilly and Co., Janssen-Cilag,
Novartis, Lundbeck, Shire, and Rubi
o. He has received travel awards from
Janssen-Cilag, Shire, and Eli Lilly and Co. for participating in psychiatric
meetings. The ADHD Program chaired by Dr. Ramos-Quiroga has received
unrestricted educational and research support from Eli Lilly and Co., Janssen-
Cilag, Shire, Rovi, and Rubi
o in the past two years. Drs. Vidal, Castells,
Richarte, Palomar, Garc
ıa, Nicolau, and Lazaro report no biomedical finan-
cial interests or potential conflicts of interest.
Correspondence to Josep Antoni Ramos-Quiroga, Department of Psychiatry
CIBERSAM, Hospital Universitari Vall d’Hebron, Universitat Autonoma
Barcelona, Passeig Vall d’Hebron, 119 e 129 08035 Barcelona; e-mail:
jaramos@vhebron.net
0890-8567/$36.00/ª2015 American Academy of Child and Adolescent
Psychiatry
http://dx.doi.org/10.1016/j.jaac.2014.12.016
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