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JADXXX10.1177/1087054715616184Journal of Attention DisordersEddy et al.

Article

Longitudinal Evaluation of the


Cognitive-Behavioral Model of ADHD in a
Sample of College Students With ADHD

Journal of Attention Disorders


111
The Author(s) 2015
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DOI: 10.1177/1087054715616184
jad.sagepub.com

Laura D. Eddy1, Melissa R. Dvorsky1, Stephen J. Molitor1, Elizaveta Bourchtein1,


Zoe Smith1, Lauren E. Oddo1, Hana-May Eadeh1, and Joshua M. Langberg1

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

ADHD symptoms is the cognitive-behavioral therapy


(CBT) model described by Safren, Sprich, Chulvick, and
Otto (2004; Figure 1). In this model, the underlying deficits
that characterize ADHD (i.e., attention, inhibition, and selfregulation) lead to repeated failures and underachievement.
Over time, these experiences lead to the development of
negative thought patterns, low self-concept, and symptoms
of anxiety and depression, in a cyclical pattern. These
symptoms of anxiety and depression in turn result in an
increased likelihood of future impairment (e.g., I am no
good at this and will fail anyway so why try?). Therefore,
even in the absence of persistent ADHD symptoms, past
underachievement would continue to affect future functioning through increased negative cognitions and internalizing
symptoms.
The Safren etal. (2004) model suggests that as individuals with ADHD age and experience underachievement, they
begin to develop dysfunctional cognitions and beliefs.
These negative cognitions often take the form of negative
judgments about self-worth or value, reflecting a low
1

Virginia Commonwealth University, Richmond, USA

Corresponding Author:
Laura D. Eddy, Department of Psychology, Virginia Commonwealth
University, 806 West Franklin Street, Richmond, VA 23284, USA.
Email: eddyld@mymail.vcu.edu

Journal of Attention Disorders

Figure 1. A cognitive-behavioral model of ADHD.


Source. Reprinted with permission from the author.

self-concept. Some examples of negative thoughts related


to self-concept include, I am a loser and I always screw
up (Safren etal., 2004, p. 351), and adolescents with
ADHD have been found to exhibit lower self-concept as
related to their academic abilities in comparison with their
peers (e.g., Major, Martinussen, & Wiener, 2013). However,
as shown in Figure 1, these negative cognitions are not proposed to be directly related to impairment, but instead, lead
to impairment through the eventual development of symptoms of anxiety and depression.
The temporal association outlined in the CBT model of
ADHD is supported by research showing that depressive
disorders typically develop several years after the onset of
ADHD (Daviss, 2008). Indeed, the developmental literature
suggests that rates of internalizing disorders among young
adolescents with ADHD do not differ significantly from
rates among young adolescents without ADHD (Bagwell,
Molina, Kashdan, Pelham, & Hoza, 2006; Ruchkin,
Lorberg, Koposov, Schwab-Stone, & Sukhodolsky, 2008).
However, in emerging adult populations such as college students with ADHD, significantly higher levels of comorbid
internalizing disorders relative to peers without ADHD have
been reported (e.g., Chronis-Tuscano etal., 2010;
Heiligenstein & Keeling, 1995). Some of the most rigorous
evidence is provided by Anastopoulos etal. (in press), who
conducted a large, multi-site study of an emerging adult college population using a multi-method, comprehensive assessment (including clinical interviews) to diagnose both ADHD
and comorbid disorders. In a sample of 443 emerging adults

(M age = 18.2), 32.3% of students with ADHD met criteria


for a depressive disorder, compared with only 5.4% in the
comparison group, and 28.6% met criteria for an anxiety
disorder, compared with 3.6% in the comparison group.
Studies using dimensional measures have also found higher
rates of depressive and anxiety symptoms in college students with ADHD compared with those without ADHD
(Rabiner, Anastopoulos, Costello, Hoyle, & Swartzwelder,
2008; Richards, Rosen, & Ramirez, 1999). These studies
support the CBT model of ADHD, as they demonstrate
internalizing symptoms are developing over time in many
individuals with ADHD. However, less is known about
whether these symptoms are then leading to future impairment, above and beyond the existing negative influence of
ADHD symptoms.
To date, longitudinal studies examining the implications
of comorbid internalizing symptoms in ADHD samples have
largely focused on depression-specific outcomes, such as
more severe psychopathology and increased risk for suicidal
ideation (e.g., Chronis-Tuscano etal., 2010). Furthermore,
this research has largely been limited to individuals who meet
full criteria for Major Depressive Disorder or Dysthymia
(e.g., Biederman etal., 2008). The CBT model of ADHD
postulates that past underachievement leads to negative cognitions and symptoms of depression and anxiety, and these
individuals may or may not meet full criteria for a depressive
or anxiety disorder. Furthermore, it is unknown whether
these symptoms are associated with impairment broadly, or if
the increased impairment is limited to depression-related

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

GPA as a metric to judge the quality of applicants and their


potential for future academic success, as well as the academic progress of current students, pathways leading from
prior GPA to future impairment are a highly relevant area of
study. We hypothesized that consistent with the Safren etal.
model, negative cognitions and symptoms of anxiety and
depression would act as serial mediators of the association
between prior achievement (i.e., past-year GPA) and future
impairment, above and beyond symptoms of ADHD.

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.

Journal of Attention Disorders


Completion of the measure results in the formulation of 16
individual scales for which t scores are calculated. The t
scores between 60 and 69 are considered to be in the borderline clinical range, and t scores of 70 or higher are considered to be clinically significant. The Sense of Inadequacy
Scale examines the endorsement of attitudes or beliefs
reflecting a general difficulty or inability to succeed or to
achieve. Higher scores reflect more negative perceptions of
individual abilities, and, thus, a more negative self-concept.
The scale is made up of nine items. Examples of items
include Even when I try hard, I fail, I fail at things, and
I never quite reach my goal. Scores on this subscale from
T1 were used in the mediation models. Five-week test
retest reliability for the Sense of Inadequacy Scale is strong
( = .73, Intraclass Correlation Coefficent [ICC] = .84;
Nowinski, Furlong, Rahban, & Smith, 2008), and there is
evidence for both convergent and discriminant validity
(Nowinski etal., 2008). Internal consistency was acceptable
( = .73).
Anxiety and depression.To measure symptoms of anxiety,
the Anxiety Scale of the BASC-2: SRP-College Version
(Reynolds & Kamphaus, 2004) was used. The Anxiety
Scale examines endorsements of frequent fears or worries,
including specific (e.g., tests) and nonspecific (e.g., the
future) events. Depression was measured using the Depression Scale of the BASC-2: SRP-College Version (Reynolds
& Kamphaus, 2004). The Depression Scale measures
endorsements of thoughts related to depressive symptoms,
such as feelings of anhedonia and hopelessness. Scores on
the Anxiety and Depression scales collected at T1 and T2
were used in the mediation model. As with the Sense of
Inadequacy Scale, t scores on the Anxiety and Depression
scales between 60 and 69 are considered to be in the borderline clinical range, and t scores of 70 or higher are considered to be clinically significant. There is evidence for the
5-week testretest reliability of the Anxiety Scale ( = .84,
ICC = .93) and the Depression Scale ( = .65, ICC = .62;
Nowinski etal., 2008). Furthermore, there is evidence for
convergent validity of the BASC Anxiety Scale (Schwanz,
Palm, Thackray, & Hill-Chapman, 2009) and the BASC
Depression Scale (Nowinski etal., 2008) with commonly
used measures of anxiety and depression such as the StateTrait Anxiety Inventory (STAI; Spielberger & Gorsuch,
1983) and the Adult Self-Report (Achenbach & Rescorla,
2003). Internal consistency for the Depression and Anxiety
scales in this sample was good ( = .81 and = .85,
respectively).
Overall functional impairment.Participants completed the
Barkley Functional Impairment Scale (BFIS; Barkley,
2011), which assesses psychosocial impairment in 15
domains of major life activities, at T1 and at T2. The BFIS
is a norm-referenced measure (N > 1,200) with high internal

Eddy et al.
Table 1. Means, Standard Deviations, and Intercorrelations of Predictor, Mediator, and Outcome Variables.

1. Prior year GPA


2. T1 functional impairment
3. T2 functional impairment
4. T1 ADHD symptom severity
5. T2 ADHD symptoms severity
6. T1 negative self-concept
7. T1 depressive symptoms
8. T2 depressive symptoms
9. T1 anxious symptoms
10. T2 anxious symptoms
M
SD

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

*p < .05. **p < .01. ***p < .001.

consistency ( = .97; Barkley, 2011) and 2-week testretest


reliabilities range from .47 to .72, according to domain
(Barkley, 2011). Participants rated impairment in each
major life activity on a 10-point Likert-type scale ranging
from 0 (not impaired) to 9 (severely impaired). A total
impairment score (sum of all 15 domains of functioning)
was examined in the present study ( = .96). Total impairment scores may range from 0 to 135. The mean impairment score in this sample was 50.14 (SD = 23.32) at T1 and
47.58 (SD = 24.58) at T2, respectively. Scores on this measure collected at T2 were used as an outcome measure in the
two mediation models, and T1 was controlled as a
covariate.
Prior year GPA. Participants GPA was used as a measure of
academic achievement and was coded based on a system
developed and refined in past work with adolescents and
young adults (Molina etal., 2009). Prior GPA was evaluated
at baseline. For freshmen participants, GPA from their
senior year of high school was used in the analyses. Similarly, for sophomores, juniors, and seniors, GPA from the
prior academic year was included in the analyses. For all
students, A = 4.0, B = 3.0, C = 2.0, D = 1.0, and F = 0.

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

T1 depressive/anxious symptoms T2 depressive/anxious


symptoms T2 functional impairment). Separate serial
mediation models were run for depression and anxiety
symptoms as mediators. Baseline functional impairment
(T1) and change in ADHD symptoms from T1 to T2 were
controlled for as covariates in both models. Process modeling strategies, as recommended by Hayes and Preacher
(2010) were used to assess the mediation pathway. The
PROCESS macro for SPSS (Hayes, 2012) allows for testing
of serial mediation models including both direct and indirect effects. For smaller samples, bootstrapping tests of
mediation are recommended over other tests of mediation
such as Baron and Kenny (1986), because bias-corrected
bootstrapped estimates of the confidence intervals (CIs) for
indirect effects do not assume normality of the distribution
of sampled indirect effects (Preacher, Rucker, & Hayes,
2007). For this study, 95% CIs are considered significant if
they do not include zero and 10,000 replications (bootstrapping tests) were used.

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.

Serial Mediation Analyses


Two separate mediation analyses were conducted to test the
serial mediators for GPA predicting later functional

Journal of Attention Disorders

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.

impairment (see Figures 1 and 2). Anxiety and Depression


at T1 and T2 were included as the mediators after T1 negative self-concept.
The first model tested whether negative self-concept and
depression over time (entered as serial mediators) mediates
the relationship between prior year GPA and later functional
impairment (T2), after controlling for baseline functional
impairment (T1) and ADHD symptom severity as covariates in the model. Specifically, this model tested the following causal chain: prior year GPA negative self-concept
(T1) depression (T1) depression (T2) functional
impairment (T2). A total effect from prior year GPA to T2
functional impairment was not present (c = .12, SE = .10,
p = .26), primarily due to a strong and significant association between T1 and T2 functional impairment (b = .56, SE
= .10, p < .001), and current mediation guidelines are clear
that an indirect effect may exist in the absence of a direct
effect (see Hayes, 2012; Preacher etal., 2007). In line with
this possibility, and as shown in Figure 1, the total indirect
effects of the serial mediators were significant (p < .001).
Examination of the specific indirect effects shows that there
was a significant indirect effect of the serial mediators, ab =
.03, SE = .02, 95% bootstrap CI = [.105, .008] (see
Figure 1) indicating that negative self-concept and depression from T1 to T2 serve as serial mediators of the effect of
prior year GPA on later functional impairment (T2). An
examination of the specific path coefficients demonstrated
that prior year GPA was negatively associated with negative
self-concept (T1), which positively predicted T1 depression,
which in turn positively predicted T2 depression, and depression (T2) was positively associated with functional impairment (T2). No mediation was found for negative self-concept

(T1) alone in that the indirect effect of prior GPA negative


self-concept (T1) functional impairment (T2) was nonsignificant, ab = .02, SE = .04, 95% CI = [.120, .060], but
only significant when considered in the indirect path with T1
depression T1 depression as serial mediators. Similarly,
no mediation was found for depression (T1) alone in that the
indirect effects of prior GPA depression (T1) functional impairment (T2) was nonsignificant, ab = .01, SE =
.03, 95% CI = [.022, .106], as well as the indirect effects of
prior GPA negative self-concept (T1) depression (T1)
functional impairment (T2) was nonsignificant, ab =
.01, SE = .04, 95% CI = [.109, .042].
The second model tested whether negative self-concept
and anxiety over time (entered as serial mediators) mediates
the relationship between prior year GPA and later functional
impairment (T2), after controlling for baseline functional
impairment (T1) and change in ADHD symptom severity as
covariates in the model. Specifically, this model tested the
following causal chain: prior year GPA negative selfconcept (T1) anxiety (T1) anxiety (T2) functional
impairment (T2). As depicted in Figure 3, although prior
GPA demonstrated an effect to negative self-concept (T1)
that predicted anxiety (T1) and this predicted later anxiety
(T2), only a marginally significant effect was present from
anxiety (T2) to functional impairment (T2), b = .23, SE =
.17, p = .11. Furthermore, examination of the specific indirect effects shows that there was not a significant indirect
effect of the serial mediators, ab = .02, SE = .03, CI =
[.120, .002] (see Figure 2) indicating that negative selfconcept and anxiety over time do not serve as serial mediators of the effect of prior year GPA on later functional
impairment (T2), unlike the depression model.

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.

It is important to note that the measure of impairment


used in this study taps difficulties with multiple areas of
life, such as daily responsibilities, relationships with friends
and family, maintaining physical health, academic functioning, and driving. As noted in the introduction, previous
studies examining the impact of depression in ADHD samples have focused on depression-specific outcomes such as
increased suicidal ideation. Although such measures are
undoubtedly meaningful, it is also critical to consider functioning more broadly. These findings indicate that depressive symptoms in college students with ADHD may affect
multiple distinct aspects of functioning. Indeed, symptoms
of depression predicted overall functioning, whereas there
was not a significant direct path from prior year GPA to
overall functioning. These findings are congruent with past
research showing that the emotional and social functioning
of college students is more predictive of attrition than is
academic functioning (Gerdes & Mallinckrodt, 1994).
It is important to acknowledge that emerging adults with
ADHD who attend college are a unique group, by virtue of
the fact that they have functioned at a high-enough level in
high school to be accepted by a college or university.
However, although they may be functioning relatively well
compared with young adults with ADHD who are not
attending college, they are certainly not functioning as well
as their non-diagnosed peers. For instance, in the present
sample, 70% of participants had received a D or an F in a
core class during the second academic semester (T2). In
addition, 54% endorsed clinical levels of anxiety or depression symptoms on the BASC-2, suggesting that many might
meet criteria for an internalizing disorder. Finally, although

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.

Clinical Implications and Future Directions


These findings have several potential implications for
ADHD interventions focused on emerging adults and college
students. Adolescents with ADHD are at risk for developing
negative self-concepts (Major etal., 2013), and the findings
from this study link a negative self-concept to the development of symptoms of anxiety and depression. Evidencebased treatments commonly used to treat ADHD in childhood
(e.g., pharmacological interventions, behavioral parent training, school interventions) do not directly target either comorbid internalizing symptoms or negative self-concepts.
Furthermore, CBT intervention efforts with younger children
and adolescents that have focused mostly on changing maladaptive cognitions have largely been ineffective in improving both ADHD symptoms and impairment (Antshel &
Olszewski, 2014). In contrast, there is accumulating evidence
for the effectiveness of CBT for adults (Knouse & Safren,
2010) and college students (Anastopoulos & King, 2015)
with ADHD. This provides evidence that targeting maladaptive cognitions and associated symptoms of anxiety and
depression in individuals with ADHD is important, but several important unanswered questions remain.
First, it is currently unclear when in development failure
experiences begin to have a detrimental impact on the selfconcepts of adolescents with ADHD and when a negative
self-concept spills into clinical symptoms of depression and
anxiety. Longitudinal studies tracking the development of
self-concept in ADHD could inform when cognitive strategies might be most usefully incorporated into ADHD interventions. One possibility is that negative self-concepts do
not develop until later adolescence because a significant
portion of children with ADHD exhibit a positive illusory
bias (PIB) and may not be aware of their deficits or that
their performance is worse than their peers (Hoza, Pelham,
Dobbs, Owens, & Pillow, 2002; Owens, Goldfine,
Evangelista, Hoza, & Kaiser, 2007). Alternatively, it may be
that prior to adolescence, youth with ADHD have not yet
experienced enough failure experiences and underachievement to have developed a pervasive negative selfconcept. As failure experiences accumulate, there may be a
tipping point in adolescence when self-concept suffers,

Journal of Attention Disorders


and the path to the development of symptoms of anxiety
and depression is initiated. Furthermore, it may be the case
that this tipping point occurs later in development for some
individuals, with the effects of this shift observed first during emerging adulthood.
An alternate theory may be that a PIB does extend into
adulthood, but perhaps exists only in limited areas. Research
on PIB in adults has demonstrated that adults with ADHD
overestimate their competence with regard to driving abilities (Knouse, Bagwell, Barkley, & Murphy, 2005); however, there is no other compelling evidence that suggests
that adults with ADHD overestimate their academic skills
or functioning broadly. In fact, there is evidence that adults
with ADHD rate their overall impairment levels significantly higher (worse) than the ratings of their impairment
provided by spouses or close friends (Barkley, Knouse, &
Murphy, 2011). Thus, it seems more likely that adults with
ADHD are more cognizant of their own difficulties than
children or adolescents with ADHD.
Second, it is unknown whether the development of
comorbid symptoms of anxiety and depression can be prevented or minimized by including cognitive strategies into
behavioral interventions implemented during adolescence.
Most CBT research with children and adolescents with
ADHD has focused on short-term outcomes, and future
studies could be designed to assess for long-term preventive
effects. Furthermore, there has been almost no intervention
research focused on high school students with ADHD (see
Evans, Langberg, Egan, & Molitor, 2014, for an exception),
and it seems likely that self-concept and negative thoughts
would increase in salience during this late adolescent
period. Regardless, it seems likely that a purely behavioral
approach would not be successful in a college student with
ADHD population, given the high rates of comorbid depression and anxiety. Specifically, college students with ADHD
and comorbid internalizing symptoms would likely struggle
with apathy and lack of motivation to implement new
behavioral strategies.
Specific to the Safren etal. model, the findings from this
study have the potential to be extended by evaluating the
remaining pathways described by the model. For instance,
the model suggests that negative self-concept and symptoms
of anxiety and depression contribute to impairment by interfering with the use of compensatory strategies (e.g., organizational techniques, prioritizing) used to manage ADHD
symptoms. This was not evaluated in the current study, and
future research in college samples might use a measure such
as the Learning and Study Strategies Inventory (LASSI;
Weinstein & Palmer, 2002) to evaluate the impact of depression and anxiety on academic skills and strategies.

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.