research-article2015
Article
Abstract
Objective: The primary aim of this study was to evaluate longitudinal pathways to impairment as outlined in the cognitivebehavioral model of ADHD in a sample of 59 college students diagnosed with ADHD. Method: Serial mediation models
were used to test whether underachievement, defined as prior year GPA, would longitudinally predict self-reported
impairment at the end of the next school year, through negative self-concept and associated changes in symptoms of
anxiety and depression, while controlling for baseline impairment and changes in ADHD symptoms. Results: Findings
supported the cognitive-behavioral model of ADHD. The association between prior year GPA and overall impairment at
the end of the year was fully mediated through self-concept and symptoms of depression. Conclusion: These results help
explain why impairment often persists even when ADHD symptoms remit and suggests that internalizing symptoms may
be an important target for intervention in college students with ADHD. (J. of Att. Dis. XXXX; XX(X) XX-XX)
Keywords
ADHD, college students, cognitive-behavioral model, self-concept, anxiety, depression
ADHD is characterized by developmentally atypical levels
of inattention and/or hyperactivity and impulsivity
(American Psychiatric Association [APA], 2013). Although
once believed to be a disorder specific to childhood, it is
now apparent ADHD persists into adolescence and adulthood in the majority of cases (Biederman etal., 2010).
Prevalence estimates suggest approximately 4.4% of adults
between the ages of 18 and 44 years meet criteria for ADHD
(Kessler etal., 2006). Furthermore, the patterns of impairment and underachievement commonly associated with
ADHD in childhood (DuPaul & Langberg, 2014) persist
into adulthood (Molina etal., 2009). For example, in comparison with young adults without ADHD, those with
ADHD attain lower levels of educational and occupational
achievement (Biederman etal., 2008; Kuriyan etal., 2012).
Young adults with ADHD also report poorer interpersonal
skills (Shaw-Zirt, Popali-Lehane, Chaplin, & Bergman,
2005), more relationship problems (Canu & Carlson, 2007),
and lower overall quality of life (Canu & Carlson, 2007;
Shaw-Zirt etal., 2005).
Importantly, many individuals diagnosed with ADHD in
childhood continue to experience significant impairment
into adulthood, even when symptoms of ADHD have remitted to below the diagnostic threshold (Willoughby, 2003;
Wolraich etal., 2005). One theory designed to explain why
impairments persist or increase even after the remittance of
Corresponding Author:
Laura D. Eddy, Department of Psychology, Virginia Commonwealth
University, 806 West Franklin Street, Richmond, VA 23284, USA.
Email: eddyld@mymail.vcu.edu
Eddy et al.
impairment (e.g., hospitalization and suicidal ideation).
Given the high rates of internalizing symptoms during
emerging adulthood, college seems to be an ideal developmental period to study the dimensional effect of comorbid
symptoms on functional impairment.
The number of students with ADHD pursuing higher
education has risen dramatically in the past 30 years, with
current prevalence estimates for ADHD in college settings
ranging from 5% to 8% (DuPaul, Weyandt, ODell, &
Varejao, 2009; Wolf, Simkowitz, & Carlson, 2009). Most
students pursuing a college degree fall in the age range of
18 to 25 years of age, which has been described as emerging adulthood (Arnett, 2000). This time period has been
proposed to be a unique developmental stage for adults,
marked by exploration and change in terms of employment,
higher education, romantic relationships, and identity
(Arnett, 2000). For many emerging adults, attending college represents one of these critical developmental changes
in which individuals are faced with challenges such as a
significant decline in external supports (e.g., parental supervision, teacher support) and an increase in environmental
demands (e.g., academic independence, financial responsibility, maintaining personal health; Fleming & McMahon,
2012). These changes are particularly difficult for emerging
adults with ADHD to navigate, and many experience significant impairment in the years following the transition to
college (Weyandt etal., 2013). Relative to their non-ADHD
peers, college students with ADHD have significantly lower
GPA, are more likely to be placed on academic probation,
and are less likely to graduate (e.g., Advokat, Lane, & Luo,
2011; Blase etal., 2009; Weyandt & DuPaul, 2013).
However, it is not clear what role the development of
comorbid internalizing symptoms has on the functioning of
college students with ADHD as no longitudinal studies testing this association exist. Given that ADHD symptoms can
also negatively affect functioning in college (Bruner,
Kuryluk, & Whitton, 2015; Lewandowski, Lovett, Codding,
& Gordon, 2008; Rabiner etal., 2008), to fully evaluate the
CBT model of ADHD, it would be important to control for
the trajectory of ADHD symptoms.
Accordingly, the present study uses a multi-method
approach to evaluate the pathway to impairment proposed
by the Safren etal. (2004) model. Specifically, we tested
whether prior year GPA (i.e., past achievement/underachievement) affects future self-reported functional impairment through a negative self-concept (i.e., negative
cognitions) and the subsequent trajectory of depressive and
anxiety symptoms. Consistent with a developmental
approach, this association was evaluated controlling for
baseline self-reported functional impairment as well as
changes in ADHD symptoms. In this study, we used prior
year GPA as a measure of past achievement and a broad
(i.e., multiple domain) self-report measure of functional
impairment. Because many universities and colleges use
Method
Participants
Participants were undergraduate students enrolled in a large
public university in Virginia. For the current study, 139 students initially expressed interest in the study and completed
the phone screen. In all, 101 families were eligible based on
the phone screen, 94 completed the inclusion/exclusion
evaluation, and 68 met full study-inclusion criteria and
were enrolled. We limited the sample for the current study
to full-time students (those taking 9 credit hr; N = 62), and
59 of these participants completed all the primary study
measures examined in this study. In comparing the demographic characteristics of those participants for whom full
data were available with those without complete data, no
differences were found for age, gender, ethnicity, year in
school, parent education level, family income, and ADHD
medication status (ps > .05). Similarly, no differences were
found for ADHD subtype, symptoms of ADHD, anxiety,
depression, negative self-concept, GPA, or functional
impairment ratings (ps > .05).
The final sample of 59 participants included in this study
ranged in age from 17 to 30 years (M = 19.90, SD = 2.75
years), and 32 (54.2%) were male. Forty-two participants
(71.2%) self-identified as Caucasian; the remaining were six
African American (10.2%), six Hispanic (10.2%), and five
multiracial (8.5%). Twenty-seven participants (45.7%) were
in their first year of college, with remaining participants in
their second (n = 13; 22.0%), third (n = 11; 18.6%), or fourth
(n = 8; 13.6%) year. Based on procedures described below,
30 participants (50.8%) were diagnosed with Diagnostic and
Statistical Manual of Mental Disorders (4th ed.; DSM-IV;
APA, 1994) ADHD, Predominantly Inattentive presentation,
and 29 (49.2%) were diagnosed with ADHD, Combined
Presentation. Thirty-five participants (59.3%) were taking
medication for ADHD, and four (6.8%) were taking medications for other psychological disorders. Fifty participants
(84.7%) had received an ADHD diagnosis prior to the study.
Procedure
The study was approved by the university Institutional
Review Board (IRB), and student participants signed
4
informed consent and their parents/guardians provided verbal consent. The inclusionary criteria included attendance at
the university where the research was being conducted and
meeting full DSM-IV diagnostic criteria for ADHD,
Predominantly Inattentive Type (ADHD-I) or ADHD,
Combined Type (ADHD-C). Diagnosis was determined
through separate administration of Part 1 and Part 2 of the
Conners Adult ADHD Diagnostic Interview for the DSM-IV
(CAADID; Epstein, Johnson, & Conners, 2000; Epstein &
Kollins, 2006) to students and their parent/guardian. The
CAADID assesses both current and childhood symptoms and
impairment, as well as age of onset and pervasiveness of
symptoms across time. Part 1 of the interview provides a
detailed history, and Part 2 is the ADHD diagnostic interview.
Strict diagnostic inclusion criteria were adhered to in this
study. Specifically, parents/guardians had to endorse at least
six symptoms in an ADHD domain on the CAADID as
present and impairing during childhood for a student to be
included. Furthermore, the student and their parents/guardians had to endorse a total of six symptoms in a domain as
currently present and impairing on the CAADID. For documentation of current ADHD symptoms, we allowed parent
interview data to be supplemented with student self-report
and vice versa. However, both the parent and student had to
endorse a minimum of four symptoms in a domain as currently present and impairing for supplementation to occur.
Flyers describing the study were included in the orientation
packets of all incoming freshman, e-mailed to all students
currently receiving ADHD accommodations, and posted in
the Disability Services Office, at Student Health, and in all
university dorms. The flyers stated that students with difficulties with attention and concentration and/or students
with a diagnosis of ADHD were eligible to receive a free
diagnostic evaluation. Students completed baseline measures at the start of the school year (T1) and follow-up measures at the end of the school year (T2; 9 months
post-baseline) and received a nominal monetary reimbursement for their time and effort completing the ratings at both
time points.
Measures
Negative self-concept. The Sense of Inadequacy Scale from
the Behavior Assessment System for ChildrenSecond Edition: Self-Report of PersonalityCollege Version (BASC-2:
SRP-College Version; Reynolds & Kamphaus, 2004) was
used to measure negative self-concept. This measure, which
was normed on a sample of 706 college students between
18 and 25 years of age, is designed to assess the frequency
or intensity with which an individual engages in a range of
internal thoughts and external behaviors. The BASC-2:
SRP-College Version consists of 185 total items, which are
rated on either a 4-point rating scale (1 = never; 2 = sometimes; 3 = often; 4 = almost always) or as true/false.
Eddy et al.
Table 1. Means, Standard Deviations, and Intercorrelations of Predictor, Mediator, and Outcome Variables.
10
.22
.32*
.56***
.14
.49***
.37**
.18
.40**
.71***
.45***
.44**
.51**
.52***
.26*
.40**
.16
.23
.38**
.21
.31*
.60***
.14
.31**
.52***
.06
.39**
.48***
.57***
.12
.46***
.49***
.18
.52***
.49***
.54***
.54***
.08
.43**
.54***
.19
.57***
.44**
.37**
.59***
.80***
54.29
11.69
2.94
0.67
50.14 47.58
23.32 24.58
46.68
8.66
40.20
8.49
57.71
11.50
51.70
11.92
50.27
9.38
55.22
12.12
Analytic Plan
The primary aim of this study was to test the indirect and
direct pathways between a history of past underachievement and later functional impairment. Accordingly, serial
mediation was used, as it assumes a causal chain linking
the mediators, with a specified direction of causal flow
(Hayes, 2012, p. 14). For example, prior academic underachievement may contribute to a more negative self-concept,
which leads to increases in symptoms of anxiety or depression, which ultimately contributes to increased functional
impairment (i.e., prior GPA T1 negative self-concept
Results
Participant age, gender, race, employment status, living status, and current and childhood treatments including medication were not significantly correlated with functional
impairment outcome and are not considered further.
Correlations between all predictor, mediator, and outcome
variables are displayed in Table 1. T1 functional impairment, ADHD symptoms, prior year GPA, negative self-concept, and symptoms of depression and anxiety were each
significantly associated with T2 overall impairment.
Figure 2. Indirect effects model of prior year GPA predicting T2 functional impairment via T1 negative self-concept leading to T1
depression to T2 depression.
Note. Standardized coefficients shown outside parentheses; standard errors are shown inside parentheses. Dashed paths are nonsignificant (ps > .05).
Analyses controlled for baseline functional impairment (T1), which in the final model were significantly positively associated with T2 functional impairment (b = .43, SE = .11, t = 3.85, p = .003). Analyses also controlled for change in ADHD symptoms from T1 to T2, which in the final model were not
associated with T2 functional impairment (b = .22, SE = .13, t = 1.77, p = .08). CI = confidence interval.
*p < .05. **p < .01. ***p < .001.
Eddy et al.
Figure 3. Indirect effects model of prior year GPA predicting T2 functional impairment via T1 negative self-concept to T1 anxiety to
T2 anxiety.
Note. Standardized coefficients shown outside parentheses; standard errors are shown inside parentheses. Dashed paths are nonsignificant (ps > .05).
Analyses controlled for baseline functional impairment (T1), which in the final model were significantly positively associated with T2 functional impairment (b = .37, SE = .11, t = 3.24, p = .002). Analyses also controlled for change in ADHD symptoms from T1 to T2, which in the final model were not
associated with T2 functional impairment (b = .23, SE = .11, t = 1.79, p = .09).
*p < .05. **p < .01. ***p < .001.
Discussion
The purpose of this study was to longitudinally evaluate the
pathways outlined by the cognitive-behavioral model of adult
ADHD (Safren etal., 2004) in a sample of college students
with ADHD. The primary aim was to determine whether negative self-concept and associated changes in symptoms of
anxiety and depression longitudinally mediated the association between prior academic achievement and later levels of
impairment. Overall, the results of this study provide support
for the validity of the cognitive-behavioral model of adult
ADHD. Specifically, in this sample of college students with
ADHD, negative self-concept and symptoms of depression
fully mediated the association between prior GPA and selfreport of overall functional impairment more than a year later.
Although not statistically significant, the magnitude of the
association between anxiety and functioning was similar to
that of depression, and the lack of statistical significance may
have been associated with sample size and power to detect
effects. Notably, as outlined in the cognitive-behavioral model
of ADHD (see Figure 1), prior GPA was not directly associated with symptoms of depression but was significantly associated with self-concept, which in turn led to depressive
symptoms. In terms of clinical implications, these finding
suggest that negative self-concept is an important precursor to
depressive symptoms in emerging adults with ADHD and
should be assessed along with depressive symptoms.
Furthermore, given that the association between depression
and impairment held even when controlling for changes in
ADHD symptoms, it seems likely that interventions for college students with ADHD will need to include cognitive strategies to counter maladaptive thinking patterns.
8
the mean overall impairment score on the BFIS suggests
minimal impairment (M = 50.14, SD = 23.32 on a scale from
0 to 135), a more detailed examination of individual domain
scores (which range from 0 to 9) reveals that participants
reported significant impairment in multiple domains of
functioning. For example, the mean impairment score was
6.11 (SD = 2.49) in the Educational Activities domain and
5.68 (SD = 2.52) on the Organization of Daily Responsibilities
domain, respectively. Accordingly, although college students with ADHD are clearly a unique group, there is evidence of impairment in the sample in multiple domains of
functioning.
Limitations
There are several limitations to the current study that should be
noted. First, the sample size in the current study was moderate
Eddy et al.
and replication of the findings in other college samples is
needed. Second, the measures utilized in this study were
almost exclusively self-report, with the exception of prior
year GPA. Although this is a common assessment strategy
for college students and adults with ADHD, a multi-informant measurement is considered optimal, particularly for
the assessment of impairment (Sibley etal., 2012). Third, it
could be argued that past-year GPA too narrowly measures
past failure/underachievement as conceptualized by the
Safren etal. (2004) model. Future research could improve
on this by utilizing additional measures of past academic
success or achievement such as high school ranking, college entrance exam scores, or number of failing grades
experienced per year. In addition, it may be useful to gather
measures related to students perceptions of what constitutes underachievement or failure, because these perceptions may not always correspond exactly with external
assessment of academic success such as grades, class rankings, or exam scores. Another limitation is the college student sample used in this study, which inherently limits the
generalizability of the findings. The degree to which the
results will generalize to a population of young adults with
ADHD who are not attending college is unknown. Finally,
no control group was collected, and it is important to
acknowledge that that CBT model may not be unique to
college students with ADHD.
Conclusion
Overall, the findings from this study support the pathways
outlined by the Safren etal. (2004) cognitive-behavioral
model of impairment for adults with ADHD. The development of a negative self-concept leading to depressive symptoms seems to be important in explaining the recurring
cycle of impairment witnessed in individuals with ADHD,
above and beyond the trajectory of ADHD symptoms. The
findings from this study suggest that interventions for college students with ADHD will need to include both cognitive and behavioral strategies (e.g., Anastopoulos & King,
2015) and that behavioral only approaches are unlikely to
be successful.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Laura D. Eddy, M.A., is a third-year graduate student in the clinical psychology program at Virginia Commonwealth University.
11
Her research interests include ADHD in emerging adults and the
testing and implementation of cognitive-behavioral treatments for
ADHD.
Melissa Dvorsky, M.S., is a fourth-year graduate student in the
doctoral program for clinical psychology at Virginia
Commonwealth University. Her research interests include the
development and evaluation of effective assessment and treatment
strategies for youth with ADHD, particularly in the school setting.
She is also interested in promotive and protective factors related to
successful outcomes among adolescents with ADHD.
Stephen J. Molitor, M.S., is a third-year graduate student in the
doctoral program for clinical psychology at Virginia
Commonwealth University. His research interests are centered on
the cognitive abilities of youth and adults with ADHD. He is also
interested in how cognitive abilities of youth are assessed by psychologists, and how these abilities link with academic and social
outcomes.
Liza Bourchtein, B.A. is a second-year graduate student in the
doctoral program for clinical psychology at Virginia
Commonwealth University. Her research interests include schoolbased interventions for children with attentional difficulties, as
well as the influence of parental factors on the trajectories of their
offspring.
Zoe Smith, B.A., is a first-year graduate student in the doctoral
program for clinical psychology at Virginia Commonwealth
University. Her research interests include school-based interventions for adolescents with ADHD, as well as the relationship
between sleep problems and sluggish cognitive tempo in an
ADHD population.
Lauren Oddo, B.A., is the research coordinator at the Center for
ADHD, Education and Service. She has research interests in
ADHD in adults and the co-occurrence of depression in adults
with ADHD.
Hana-May Eadeh is an undergraduate research assistant at the
Center for ADHD, Education and Service. Her research interests
include internalizing disorders among adolescents and the overlap
between ADHD and internalizing disorders and symptoms.
Joshua Langberg, Ph.D., is an associate professor at Virginia
Commonwealth University. Dr. Langberg and his students are currently conducting research in a wide variety of areas related to
ADHD including alcohol use and comorbid disorders in college
students with ADHD, sleep problems in adolescents with ADHD
and their impact on behavior and school functioning, written
expression abilities in adolescents with ADHD, assessment and
treatment of ADHD in primary care settings, executive functions
in ADHD and the association with academic and social performance, and factors that may predict successful academic trajectories in youth with ADHD.