NEW RESEARCH

Group Therapy for Adolescents With Attention-Decit/

Hyperactivity Disorder: A Randomized Controlled Trial
Raquel Vidal, PhD, Jordi Castells, MSc, Vanesa Richarte, MD, Gloria Palomar,
Marta Garc
a, MD, Rosa Nicolau, MSc, Luisa Lazaro, MD, PhD,
Miguel Casas, MD, PhD, Josep Antoni Ramos-Quiroga, MD, PhD
Objective: To determine the efcacy of group cognitivebehavioral therapy (CBT) on adolescents with attentiondecit/hyperactivity disorder (ADHD) who were in
pharmacological treatment but still had persistent
symptoms.
Method: We conducted a multicenter, randomized, raterblinded, controlled trial between April 2012 and May 2014
in a cohort of 119 adolescents (1521 years of age). Participants were randomly assigned to 12 manualized group
CBT sessions (n 45) or a waiting list control group (n
44). Primary outcomes were assessed by a blinded evaluator (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 signicantly reduced ADHD
symptoms compared to the control group (ADHD-RS
Adolescent: 7.46, 95% CI 9.56 to 5.36, p < .001,

ttention-decit/hyperactivity disorder (ADHD) is a

neurodevelopmental disability affecting between
3% and 5% of the general population during
childhood.1 The dening features of the disorder are inattention, impulsivity, and hyperactivity, which impair functioning. ADHD can also lead to associated features of the
disorder such as difculties 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 difculties, risky sexual
behavior, risky driving, and substance use disorders.5,6
Furthermore, adolescents (1521 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 rst-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 children10 and adults,11 little is known regarding appropriate
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY
VOLUME 54 NUMBER 4 APRIL 2015

MD,

d 7.5; ADHD-RS Parents: 9.11, 95% CI 11.48

to 6.75, p < .001, d 8.38; CGI-S Self-Report: 0.68, 95%
CI 0.98 to 0.39, p < .001, d 3.75; CGI-S
Clinician: 0.79, 95% CI 0.95 to 0.62, p < .001;
d 7.71). Functional impairment decreased signicantly
in the CBT group according to parents (Weiss Functional
Impairment Scale 4.02, 95% CI 7.76 to 0.29, p < .05,
d 2.29) and according to the blinded evaluator
(GAF: 7.58, 95% CI 9.1 to 6.05, p < .001, d 7.51).
Conclusion: Group CBT associated with pharmacological
treatment is an efcacious intervention for reducing
ADHD symptoms and functional impairment in
adolescents.
Clinical trial registration informationCBT 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):275282.

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 surprisingly, 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 efcacious in children,22,23 a preliminary 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 discussion as to whether group sessions could be effective in this
age range. Group CBT has been proved to benet adults
with ADHD25; however, its usefulness in adolescents with
ADHD is uncertain. Only 1 noncontrolled study on rationalemotive group therapy has been tested in adolescents with
ADHD.26 The treatment program, which focused on associated symptoms such as difculties in anger and frustration

www.jaacap.org

275

VIDAL et al.

management and depressive and anxiety symptoms,

obtained nonsignicant 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 individual CBT for older adolescents when a group format has
not been effective,8 there are insufcient data to support the
efcacy of CBT group treatments.
The rationale of this study was to test a psychological
intervention that consisted of a direct focus on the adolescent. 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 efcacy of a CBT group in
relation to its effects on ADHD symptoms, functional domains, anxiety and depression symptomatology, and associated symptoms such as difculties 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 signicant 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 efcacy of a CBT group in adolescents with

FIGURE 1

ADHD. Participants were randomly assigned either to a CBT group

(n 59) or to a waiting list control group (n 60).

Participants
Patients were recruited from the 2 ADHD units in university hospitals in Barcelona, Spain. All participants were in psychopharmacological treatment before the study but still presented signicant
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 inclusion criteria were as follows: DSM-IV ADHD diagnosis; age between 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 disorders; 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 deant 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 pharmacological treatment or could not stay on stable medication were also
excluded from the study.

Intervention
CBT Group. The CBT group program was based on cognitivebehavioral principles and used motivational interviewing techniques to facilitate skills implementation. The treatment comprised
12 manualized sessions.28 The rst session consisted of psychoeducation of ADHD (symptom identication and myths and realities of ADHD). The sessions in the impulsivity module were as
follows: session 2, self-control strategies (functional analysis);

Contents of the cognitive-behavioral therapy (CBT) group program.

JOURNAL
276

www.jaacap.org

OF THE

AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY

VOLUME 54 NUMBER 4 APRIL 2015

GROUP THERAPY FOR ADOLESCENTS WITH ADHD

session 3, cognitive skills (self-instruction); session 4, anger regulation (identifying anger triggers and alarm signs); session 5, frustration tolerance and motivation (decisional balance, long-term
thinking, positive self-reinforcement); and session 6, interpersonal
abilities (criticism management and assertiveness training). The
attention module included the following: session 7, planning strategies; session 8, problem solving and decision making; session 9,
procrastination; session 10, reducing external distractions; and session 11, reducing distracting thoughts (postponing distractions,
redirecting attention). The last session consisted of a review of the
contents and maintenance of gains (Figure 1). Parents were not
involved in treatment sessions.
Control Group. The control group was a waiting list group.
Participants were visited only to monitor their adherence and
continuation on medications for ADHD as prescribed by their psychiatrist. Inclusion and exclusion criteria were the same as for the
experimental group. Participants did not receive any CBT or other
type of psychological treatment during the study period. Participants in the control group were evaluated at pretreatment assessment and were scheduled for a posttreatment evaluation with the
same rater. After the posttreatment assessment, these individuals
were offered the opportunity to enter a CBT group through the
ADHD program outside the study.

Treatment Fidelity
The intervention was manualized in a structured format with written material summarizing the content of the sessions for the participants and including methodology and key points to address
during each session for the therapists. The CBT groups were conducted by 2 clinical psychologists, 1 at each center, who had previous experience with CBT groups. Before the beginning of the
study, the therapists were trained to adhere to the content of the
manualized intervention. The key points of the session were visualized with a Microsoft PowerPoint presentation during the group
sessions. The 2 centers involved in the study used the same PowerPoint material. Therapist competence and adherence to the treatment manual in the 2 centers were rated on a checklist. All treatment
sessions were videotaped, and 5 sessions from each 12-session trial
at each center were randomly selected for rating by an outside
consultant (41% of sessions rated). All participants were monitored
weekly to evaluate medication adherence and to verify that no other
type of psychological treatment was received.

Diagnostic and Outcome Measures

Diagnosis of ADHD was established by experienced senior psychiatrists using semi-structured interviews. For participants between 15
and 17 years of age, the Schedule for Affective Disorders and
Schizophrenia (K-SADS-PL) was used.29 For participants between 18
and 21 years of age, the Conners Adult ADHD Diagnostic Interview
for DSM-IV (CAADID) was used.30 To assess comorbidities, we
used the Structured Clinical Interview for DSM-IV Axis I (SCID-I)31
and the Structured Clinical Interview for DSM-IV Axis II (SCID-II).32
The Autism Diagnostic InterviewRevised Version (ADI-R)33 was
used to exclude patients with PDDs. Participants were administered
the Vocabulary and Block Design subtests of the Wechsler Adult
Intelligence Scale (WAIS-III),34 and adolescents aged 15 years were
administered the Wechsler Intelligence Scale for ChildrenIV
(WISC-IV)35 to obtain an estimated IQ score.

Primary Outcomes: ADHD Symptoms, Severity,

and Functional Impairment
36

ADHD Rating Scale. The ADHD Rating scale (ADHD-RS) is an 18item scale that assesses the diagnostic criteria for ADHD and rates
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY
VOLUME 54 NUMBER 4 APRIL 2015

the frequency of each item on a 4-point Likert scale. This scale has
been validated on adolescents (1217 years of age) and on adults
with ADHD. The clinician-administered version was used for the
adolescent and parent informant.
Clinical Global Impression Scale for Severity. The Clinical Global
Impression Scale for Severity37 CGI-S is a 7-point scale
(1 normal or not ill, and 7 extremely ill). We used the self-report
and clinician version to evaluate symptom severity.
Clinical Global ImpressionImprovement. The Clinical Global
ImpressionImprovement (CGI-I)38 was used to evaluate reported
changes by the participants and by the clinician in relation to ADHD
symptoms. This scale assesses the total improvement of the patients
symptoms since the beginning of treatment. CGI-I is rated on a
7-point scale (1 very much improved, 4 no change, and 7 very
much worse).
Weiss Functional Impairment Scale. We used the self-report and
parent version of the Weiss Functional Impairment Scale
(WFIRS).39,40 This scale is appropriate for measuring adolescent and
youth functional impairment associated with ADHD and for
monitoring treatment efcacy. It assesses different environments
such as family, work/studies, life skills, self-concept, social activities, and risky activities. The scale has been psychometrically
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
clinical severity and functioning.

TABLE 1
Sample

Demographic and Clinical Characteristics of the

CBT Group
(n 59)

Variable
Gender
Male
Female
Education Level
Primary
Secondary
Employment
Unemployed
Working
Studying
ADHD Subtype
Combined
Inattentive
Hyperactive
Comorbidity
Without comorbidity
ODD
Learning disorder

Age
Abbreviated IQ

(%)

Control Group
(n 60)
n

(%)

39
20

(66.11) 42
(33.89) 18

(70)
(30)

30
29

(50.85) 43
(49.15) 17

(71.67) NS
(28.33)

3
4
52

(5.08)
2
(6.78)
0
(88.14) 58

(3.33) NS

37
21
1

(62.71) 35
(35.59) 25
(1.7)
-

(58.33) NS
(41.67)

50
7
2

(84.75) 49
(11.86)
8
(3.39)
3

(81.67) NS
(13.33)
(5)

Mean

(SD)

Mean

17.47
98.5

(1.88) 16.9
(8.67) 97.46

NS

(96.67)

(SD)

(1.75) NS
(9.4)
NS

Note: ADHD attention-deficit/hyperactivity disorder; CBT cognitivebehavioral therapy; NS not significant (no between group significant
differences); ODD oppositional defiant disorder.

www.jaacap.org

277

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 (03). 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 (1217
years of age) and adults.
State-Trait Anger Expression Inventory2. The State-Trait Anger
Expression Inventory2 (STAXI-2) was used for participants between 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 selfreport 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 manager 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 participants 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 (68 participants) 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 signicance 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 signicant at the 5%
level. Cohens d was calculated to estimate the effect size of treatment outcomes.

RESULTS
Sample Characteristics
Table 1 shows participant characteristics. No statistically
signicant differences between groups were detected with
respect to demographic characteristics or baseline measures
of the participants. No signicant differences were detected
between the 2 groups in the type and doses of medication for
ADHD (Table 2).

TABLE 2 Mean Daily Doses of Medications Among

Participants
ADHD Medication and
Treatment Group
Methylphenidate
CBT group, n 54
Control group, n 47
Atomoxetine
CBT group, n 5
Control group, n 13

www.jaacap.org

Mean

(SD)

Daily Dose (mg)

Range

46.05
47.07

(17.28)
(18.36)

18e72
10e80

51.31
53.45

(19.08)
(17.05)

40e80
40e80

Note: ADHD attention-deficit/hyperactivity disorder; CBT cognitivebehavioral therapy.

Program Completion Rate

A ow 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
classied as noncompleters. Noncompleters were dened as
individuals participating in less than 75% of the sessions.
There were no signicant differences in demographic characteristics or baseline measures between completers and
noncompleters. In relation to treatment delity, checklists
revealed no differences between the 2 centers in mean ratings 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 signicantly reduced ADHD core
symptoms (ADHD-RS Adolescent scores: magnitude 7.46,
95% CI 9.56 to 5.36, d 7.5; ADHD-RS Parents: 9.11,
95% CI 11.48 to 6.75, d 8.38), revealing large effect
sizes. Severity of ADHD symptoms decreased signicantly
more in the CBT group (CGI Self-Report: 0.68, 95%
CI 0.98 to 0.39, d 3.75; CGI Clinician: 0.79, 95%
CI 0.95 to 0.62, d 7.71). Functional impairment
decreased signicantly more in the CBT group according to
the blinded evaluator (GAF: 7.58, 95% CI 9.1 to 6.05,
d 7.51; WFIRS Parents version: 4.02, 95% CI 7.76
to 0.29, d 2.29). However, no signicant differences were
observed between groups according to WFIRS self-report.
Anxiety, Depressive Symptomatology, and Difculties in
Anger Management. Results indicated a main effect of time in
depressive symptomatology (BDI: F4.15 22.02, p .000)
and anger management (STAXI State: F2.4 4.58, p .03;
STAXI Trait: F2.5 4.16, p .04; STAXI Expression:
F3.34 9.89, p .002). Nevertheless, no signicant interaction of time  group or effect of group was found.
Global Improvement. An independent t test was performed 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
JOURNAL

278

Daily Dose (mg)

OF THE

AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY

VOLUME 54 NUMBER 4 APRIL 2015

GROUP THERAPY FOR ADOLESCENTS WITH ADHD

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 0.001, p .000); the clinician
version also reported signicant differences between groups
(CGI-I Clinician: F13.02 2.45, p .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 subtype, and comorbidity). No signicant differences were
detected in relation to interactions among clinical and demographic 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 signicant differences were seen in treatment effects between participants
who continued medication and participants who discontinued pharmacological treatment. A nonparametric test
for independent samples detected no signicant 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
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY
VOLUME 54 NUMBER 4 APRIL 2015

anxiety, depression, and difculties in anger management;

and reduced functional impairment.
As our rst hypothesis predicted, the CBT group achieved large effect sizes in reduction of ADHD symptoms and
severity. Previous studies on individual CBT obtained
similar results but with smaller effect sizes (d 0.410.61 for
impulsivity and d 1.021.39 for inattention)24 according to
parents and teachers. School interventions also obtained
smaller effect sizes than the current study (d 0.160.9 for
impulsivity symptoms and d 2.612.84 for inattention).16
However, our trial exhibited a similar tendency toward
smaller effect sizes on impulsivity (d 4.94.95) compared
to inattention improvements (d 8.579.62) according to
adolescents and parents.
Contrary to the prediction of our second hypothesis, group
CBT intervention did not signicantly reduce symptoms of
anxiety and depression. These ndings 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
efcacy 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 difculties in anger management demonstrated a lack of signicant change in these features.26 In contrast, studies on
psychological treatment in childhood demonstrated that

www.jaacap.org

279

VIDAL et al.

Mixed-Effect Analysis of Primary and Secondary Outcomes

TABLE 3

CBT Group
(n 59)
Baseline

Control Group
(n 60)
Outcome

Measure

Mean

(SD)

Mean

ADHD-RS Adolesc
Inattention
Impulsivity
ADHD-RS Parents
Inattention
Impulsivity
CGI-S Self-report
CGI-S Clinician
GAF
WFIRS-S
WFIRS-P
BDI
STAI
STAXI State
STAXI Trait
STAXI Control
STAXI Expression

27.28
15.47
11.83
29.05
17.27
12
3.54
3.69
63.25
39.31
32.92
7.42
21.49
16.13
21.95
27.41
24.53

(1.04)
(0.57)
(0.69)
(1.05)
(0.57)
(0.78)
(0.12)
(0.06)
(0.79)
(2.81)
(2.46)
(0.82)
(0.64)
(2.18)
(1.1)
(1.19)
(1)

18.47
10.14
8.29
19.05
11.31
7.72
2.9
2.86
70.83
31.48
28.24
4.71
20.56
15.5
19.99
29.23
22.2

Baseline
(SD)

(1.01)
(0.51)
(0.7)
(1.11)
(0.58)
(0.77)
(0.12)
(0.07)
(1.05)
(2.43)
(2.51)
(0.79)
(0.62)
(11)
(0.91)
(1.4)
(0.82)

Outcome

Mean

(SD)

Mean

(SD)

Cohens d

27.45
14.83
12.36
29.32
17.03
12.06
3.3
3.78
63.4
33.36
34.57
6.36
19.86
18.76
20.88
26.47
22.54

(1.03)
(0.5)
(0.68)
(1.06)
(0.58)
(0.78)
(0.12)
(0.06)
(0.75)
(2.71)
(2.38)
(0.82)
(0.63)
(8.52)
(1.06)
(1.14)
(0.97)

26.09
14.47
11.72
28.44
16.99
11.56
3.35
3.4
63.12
29.42
33.92
4.7
20.34
17.15
20.62
27.25
21.76

(1.02)
(0.5)
(0.7)
(1.13)
(0.6)
(0.78)
(0.12)
(0.07)
(1)
(2.36)
(2.44)
(0.8)
(0.63)
(6.25)
(0.9)
(1.38)
(0.82)

7.5***
8.57***
4.9***
8.38***
9.62***
4.95***
3.75***
7.71***
7.51***
0.13 (NS)
2.29*
0.0 (NS)
0.35 (NS)
0.36 (NS)
0.1 (NS)
0.21 (NS)
0.08 (NS)

Note: ADHD-RS Attention-Deficit/Hyperactivity Disorder (ADHD) Rating Scale; Adolesc Adolescents; BDI Beck Depression Inventory; CGI-S Clinical Global
Impression Scale for Severity; GAF Global Assessment of Functioning; NS not significant (no between-group significant differences); STAI State-Trait Anxiety
Inventory; STAXI State-Trait Anger Expression Inventory; WFIRS-P Weiss Functional Impairment ScaleeParents; WFIRS-S Weiss Functional Impairment
ScaleeSelf-Report.
*p < .05; ***p < .001.

combined treatment was effective for comorbid and associated 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 signicant
improvements compared to participants in the control
group. Prior results from individual CBT have shown that
although ADHD symptoms were reduced after the psychological 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 participants without pharmacological treatment were not assessed.
It would be of value to conduct trials that include participants 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 (1214 years of age). Third, our program
demonstrated signicant 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
inuenced 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 specicity of group CBT effects. Nevertheless, previous studies on adults with ADHD
compared CBT to supportive therapy25,52 or a discussion
group,53 obtaining signicant differences favoring CBT in
decreasing ADHD symptoms. Despite these limitations, all
of the participants in our trial were receiving pharmacological 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
benet 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 difculties 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 benet these patients. Indeed, given the
JOURNAL

280

www.jaacap.org

OF THE

AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY

VOLUME 54 NUMBER 4 APRIL 2015

GROUP THERAPY FOR ADOLESCENTS WITH ADHD

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
signicance 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 sufcient for reducing
certain domains of impairments or associated features.21
According to Barkleys model of decient emotional selfregulation in ADHD, greater gains in certain domains of
impairments and associated or comorbid symptoms may be
achieved through more emotion-based treatments. &

Biomediques August Pi i Sunyer (IDIBAPS) and with the University of Barcelona.

Drs. Richarte and Palomar are with Hospital Universitari Vall dHebron, ADHD
Program, Barcelona, Spain.
Financial support was received from the Agencia de Salut P
ublica de Barcelona 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 dHebron, served as the
statistical expert for this research.
Disclosure: Dr. Casas has received travel grants from Eli Lilly and Co., JanssenCilag, 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., JanssenCilag, Shire, Rovi, and Rubi

o in the past two years. Drs. Vidal, Castells,
Richarte, Palomar, Garc
a, Nicolau, and Lazaro report no biomedical nancial interests or potential conicts of interest.
Correspondence to Josep Antoni Ramos-Quiroga, Department of Psychiatry
CIBERSAM, Hospital Universitari Vall dHebron, Universitat Aut
onoma
Barcelona, Passeig Vall dHebron, 119 e 129 08035 Barcelona; e-mail:
jaramos@vhebron.net

Accepted January 21, 2015.

Drs. Vidal, Casas, and Ramos-Quiroga are with Hospital Universitari Vall
dHebron, ADHD (Attention-Decit/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
nic of Barcelona. Dr. L

azaro are
with Hospital Clinic of Barcelona, (CIBERSAM), Institut dInvestigacions

0890-8567/$36.00/2015 American Academy of Child and Adolescent

Psychiatry
http://dx.doi.org/10.1016/j.jaac.2014.12.016

REFERENCES
1. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of
adult ADHD in the United States: results from the National Comorbidity
Survey Replication. Am J Psychiatry. 2006;163:716-723.
2. Langley K, Fowler T, Ford T, et al. Adolescent clinical outcomes for young
people with attention-decit hyperactivity disorder. Br J Psychiatry. 2010;
196:235-240.
3. Biederman J, Petty CR, Clarke A, Lomedico A, Faraone SV. Predictors of
persistent ADHD: an 11-year follow-up study. J Psychiatr Res. 2011;45:
150-155.
4. Biederman J, Petty CR, Evans M, Small J, Faraone SV. How persistent is
ADHD? A controlled 10-year follow-up study of boys with ADHD.
Psychiatry Res. 2010;177:299-304.
5. Barkley RA, Fischer M, Smallish L, Fletcher K. Young adult outcome of
hyperactive children: adaptive functioning in major life activities. J Am
Acad Child Adolesc Psychiatry. 2006;45:192-202.
6. Thompson AL, Molina BSG, Pelham W, Gnagy EM. Risky driving in
adolescents and young adults with childhood ADHD. J Pediatr Psychol.
2007;32:745-759.
7. McCarthy S, Asherson P, Coghill D, et al. Attention-decit hyperactivity
disorder: treatment discontinuation in adolescents and young adults. Br J
Psychiatry. 2009;194:273-277.
8. National Institute for Health and Clinical Excellence. Attention decit
hyperactivity disorder diagnosis and management of ADHD in children,
young people and adults. London: National Institute for Health and
Clinical Excellence; 2008. NICE guidelines CG72.
9. Nutt DJ, Fone K, Asherson P, et al. Evidence-based guidelines for management of attention-decit/hyperactivity disorder in adolescents in
transition to adult services and in adults: recommendations from the
British Association for Psychopharmacology. J Psychopharmacol. 2007;
21:10-41.
10. Chronis AM, Jones HA, Raggi VL. Evidence-based psychosocial treatments for children and adolescents with attention-decit/hyperactivity
disorder. Clin Psychol Rev. 2006;26:486-502.
11. Vidal R, Bosch R, Nogueira M, Casas M, Ramos-Quiroga JA. Psychological treatment of attention decit hyperactivity disorder in adults: a
systematic review. Actas Espa~
nolas Psiquiatr. 2012;40:147-154.
12. Barkley RA, Guevremont DC, Anastopoulos AD, Fletcher KE.
A comparison of three family therapy programs for treating family

JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY

VOLUME 54 NUMBER 4 APRIL 2015

13.

14.

15.
16.

17.

18.

19.

20.

21.

22.

23.

conicts in adolescents with attention-decit hyperactivity disorder.

J Consult Clin Psychol. 1992;60:450-462.
Barkley RA, Edwards G, Laneri M, Fletcher K, Metevia L. The efcacy of
problem-solving communication training alone, behavior management
training alone, and their combination for parent-adolescent conict in
teenagers with ADHD and ODD. J Consult Clin Psychol. 2001;69:926-941.
Svanborg P, Thernlund G, Gustafsson PA, Haggl
of B, Poole L, Kadesj
o B.
Efcacy and safety of atomoxetine as add-on to psychoeducation in the
treatment of attention decit/hyperactivity disorder: a randomized,
double-blind, placebo-controlled study in stimulant-nave Swedish children and adolescents. Eur Child Adolesc Psychiatry. 2009;18:240-249.
McCleary L, Ridley T. Parenting adolescents with ADHD: evaluation of a
psychoeducation group. Patient Educ Couns. 1999;38:3-10.
Evans SW, Axelrod J, Langberg JM. Efcacy of a school-based treatment
program for middle school youth with ADHD: pilot data. Behav Modif.
2004;28:528-547.
Evans SW, Schultz BK, Demars CE, Davis H. Effectiveness of the challenging horizons after-school program for young adolescents with
ADHD. Behav Ther. 2011;42:462-474.
Molina BSG, Flory K, Bukstein OG, et al. Feasibility and preliminary efcacy of an after-school program for middle schoolers with ADHD: a
randomized trial in a large public middle school. J Atten Disord. 2008;12:
207-217.
Sibley MH, Pelham WE, Evans SW, Gnagy EM, Ross JM, Greiner AR. An
evaluation of a summer treatment program for adolescents with ADHD.
Cogn Behav Pract. 2011;18:530-544.
Young S, Amarasinghe JM. Practitioner review: non-pharmacological
treatments for ADHD: a lifespan approach. J Child Psychol Psychiatry.
2010;51:116-133.
Antshel KM, Barkley R. Psychosocial interventions in attention decit
hyperactivity disorder. Child Adolesc Psychiatr Clin North Am. 2008;17:
421-437.
Storeb OJ, Skoog M, Damm D, Thomsen PH, Simonsen E, Gluud C.
Social skills training for attention decit hyperactivity disorder (ADHD)
in children aged 5 to 18 years. Cochrane Database Syst Rev. 2011;12:
CD008223.
Sonuga-Barke EJS, Brandeis D, Cortese S, et al. Nonpharmacological
interventions for ADHD: systematic review and meta-analyses of

www.jaacap.org

281

VIDAL et al.

24.
25.
26.

27.

28.

29.

30.

31.

32.

33.

34.
35.
36.

37.
38.

randomized controlled trials of dietary and psychological treatments. Am

J Psychiatry. 2013;170:275-289.
Antshel KM, Faraone SV, Gordon M. Cognitive behavioral treatment
outcomes in adolescent ADHD. J Atten Disord. 2012;18:483-495.
Solanto MV, Marks DJ, Wasserstein J, et al. Efcacy of meta-cognitive
therapy for adult ADHD. Am J Psychiatry. 2010;167:958-968.
Morris GB. A rational-emotive treatment program with conduct disorder
and attention-decit hyperactivity disorder adolescents. J Ration Cogn
Ther. 1993;11:123-133.
Zylowska L, Ackerman DL, Yang MH, et al. Mindfulness meditation
training in adults and adolescents with ADHD: a feasibility study. J Atten
Disord. 2008;11:737-746.
Vidal R, Casas M, Ramos-Quiroga JA. Manual de Tratamiento CognitivoConductual Para Adolescentes Con TDAH y Consumo de Cannabis.
Madrid: Editorial Selene; 2014.
Kaufman J, Birmaher B, Brent D, et al. Schedule for Affective Disorders
and Schizophrenia for School-Age ChildrenPresent and Lifetime
Version (K-SADS-PL): initial reliability and validity data. J Am Acad
Child Adolesc Psychiatry. 1997;36:980-988.
Epstein JN, Johnson DE, Conners CK. Conners Adult ADHD Diagnostic Interview for DSM-IV. North Tonawanda, NY: Multihealth System; 2001.
Spitzer R, Robert L, Gibbon M. SCID-I, Versi

on Cl
nica. Entrevista Cl
nica
Estructurada Para Los Trastornos Del Eje I Del DSM. Barcelona: Masson; 1996.
First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. Entrevista
Cl
nica Estructurada Para Los Trastorno de Personalidad Del Eje II Del
DSM-IV. Barcelona: Masson; 1999.
Lord C, Rutter M, Le Couteur A. Autism Diagnostic InterviewRevised: a
revised version of a diagnostic interview for caregivers of individuals
with possible pervasive developmental disorders. J Autism Dev Disord.
1994;24:659-685.
Wechsler D. Wechsler Adult Intelligence Scale III. 3rd ed. San Antonio,
TX: Psychological Corporation; 1997.
Wechsler D. Wechsler Intelligence Scale for Children. 4th ed. San Antonio, TX: Harcourt Assessment; 2003.
Dupaul GJ, Power T, Anastopoulos A. ADHD Rating ScaleIV:
Checklists, Norms, and Clinical Interpretation. New York: Guilford; 1998.
National Institute of Mental Health. CGI (Clinical Global Impression)
Scale. Psychopharmacol Bull. 1985;21:839-844.
Guy W. Assessment Manual for Psychopharmacology. Rockville, MD:
US Department of Heath, Education and Welfare Public Health Service;
Alcohol, Drug Abuse, and Mental Health Administration; 1976.

39. Canadian Attention Decit Hyperactivity Disorder Resource Alliance

(CADDRA). Weiss Functional Impairment Rating ScaleParent Report
(WFIRS-P); 2000.
40. Canadian Attention Decit Hyperactivity Disorder Resource Alliance
(CADDRA). Weiss Functional Impairment Rating Scale (WFIRS); 2000.
41. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.
42. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for
measuring depression. Arch Gen Psychiatry. 1961;4:561-571.
43. Spielberger CD, Gorsuch RL, Lushene RE. Cuestionario de Ansiedad
Estado-Rasgo. Madrid: TEA Ediciones; 1986.
44. Spielberger CD. Inventario de Expresi

on de Ira Estado-Rasgo. Barcelona:
TEA Ediciones; 1999.
45. Spielberger CD. Inventario de Expresi

on de Ira Estado-Rasgo En Ni~
nos Y
Adolescentes. Barcelona: TEA Ediciones; 1999.
46. MTA Cooperative Group. A 14-month randomized clinical trial of treatment
strategies for attention-decit/hyperactivity disorder. Multimodal treatment
study of children with ADHD. Arch Gen Psychiatry. 1999;56:1073-1086.
47. Conners CK, Epstein JN, March JS, et al. Multimodal treatment of ADHD
in the MTA: an alternative outcome analysis. J Am Acad Child Adolesc
Psychiatry. 2001;40:159-167.
48. Fabiano GA, Pelham WE, Coles EK, Gnagy EM, Chronis-Tuscano A,
OConnor BC. A meta-analysis of behavioral treatments for attentiondecit/hyperactivity disorder. Clin Psychol Rev. 2009;29:129-140.
49. Weiss M, Murray C, Wasdell M, Greeneld B, Giles L, Hechtman L.
A randomized controlled trial of CBT therapy for adults with ADHD
with and without medication. BMC Psychiatry. 2012;12:30.
50. Larson K, Russ SA, Kahn RS, Halfon N. Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics.
2011;127:462-470.
51. Murphy KR, Barkley RA, Bush T. Young adults with attention decit
hyperactivity disorder: subtype differences in comorbidity, educational,
and clinical history. J Nerv Ment Dis. 2002;190:147-157.
52. Safren SA, Sprich S, Mimiaga MJ, et al. Cognitive behavioral therapy vs
relaxation with educational support for medication-treated adults with
ADHD and persistent symptoms: a randomized controlled trial. JAMA.
2010;304:875-880.
53. Hirvikoski T, Waaler E, Alfredsson J, et al. Reduced ADHD symptoms in
adults with ADHD after structured skills training group: results from a
randomized controlled trial. Behav Res Ther. 2011;49:175-185.
54. Knouse LE, Safren SA. Current status of cognitive behavioral therapy for
adult attention-decit hyperactivity disorder. Psychiatr Clin North Am.
2010;33:497-509.

JOURNAL
282

www.jaacap.org

OF THE

AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY

VOLUME 54 NUMBER 4 APRIL 2015