Co-Principal Investigator: Langberg, Joshua

Purpose: The purpose of this project was to evaluate a psychosocial intervention—Accessing Campus Connections and Empowering Student Success (ACCESS)—for postsecondary students with attention deficit hyperactivity disorder (ADHD). Many postsecondary institutions provide campus support services (e.g., disability accommodations) to help students with ADHD because these students are more likely to struggle and to drop out than students without ADHD. Because such campus support services often times do not address the full range of difficulties displayed by college students with ADHD, there is much need for the development of additional evidence-based treatment services for this population. ACCESS was developed to help fill this gap, by giving college students with ADHD the knowledge and skills necessary for self-regulating behaviors, thoughts, and emotions that affect academic success. Building on preliminary research suggesting that ACCESS has a positive impact on student functioning, the current study sought to examine its efficacy in a more rigorous experimental research design, using a randomized controlled trial format. Findings from the current study revealed improvements in ADHD symptoms, executive functioning, academic study skills, use of disability service accommodations, daily-life performance, and general personal well-being. Together, such results lend strong support to the efficacy of ACCESS as a campus-based intervention for college students with ADHD.

Project Activities: The research team conducted a large scale, multi-site randomized control trial to evaluate the efficacy of our ACCESS intervention, including 250 students with ADHD and comorbidity status assigned to receive ACCESS either immediately or on a 1-year delayed basis (Delayed Treatment Control group). Both groups were assessed on three occasions to evaluate potential changes in primary (i.e., ADHD, executive functioning, depression, anxiety, academic functioning, personal and social functioning) and secondary (i.e., clinical change mechanisms, service utilization) outcomes. The researchers assessed the effects of the intervention on the immediate treatment group 6-months after their participation in the complete ACCESS program ended.

Pre-registration site: Registered after this study began on CinicalTrials.gov. Trial number: NCT04186312.

Publicly available data: Publicly available data (encompassing all variables used in the publication of the two efficacy papers) may be found on the University of North Carolina at Greensboro Dataverse (NC DOCKS) platform. RCT Examining Efficacy of ACCESS Intervention (IES Grant R305A150207)—University of North Carolina at Greensboro Dataverse (unc.edu)

WWC Review: Currently under review

Key Outcomes: Listed below are the main findings from this clinical trial study:

• Relative to the Delayed Treatment Control (DTC) group, immediate ACCESS participants displayed significantly greater improvements in ADHD knowledge, behavioral strategy use, and adaptive thinking skills, thereby supporting our conceptualization of the mechanisms of clinical change within the ACCESS intervention (Anastopoulos, Langberg, Eddy, Silvia, & Labban, 2021).
• Relative to the DTC group, immediate ACCESS participants exhibited greater improvements in their ADHD symptom levels, executive functioning skills, self-reported study skills, use of disability service accommodations, daily functioning, and overall personal well-being (Anastopoulos et al., 2021; Eddy, Anastopoulos, Dvorsky, Silvia, Labban, & Langberg, 2021).
• Such improvements in functioning remained stable for the immediate treatment group six months after their participation in the complete ACCESS program ended (forthcoming).
• Contrary to expectations, there were no significant differences between the two groups with respect to semester grade point averages, semester credit hours earned, and interpersonal functioning (Eddy et al., 2021).
• Although treatment-induced improvements in depression and anxiety were not evident based on group level analyses, analyses of clinical significance at the individual level indicated that immediate ACCESS participants were significantly less likely to report a worsening in depression/anxiety symptoms (Anastopoulos et al., 2021). 
• Cost analysis findings indicated that it is relatively inexpensive to implement ACCESS in a college campus setting, requiring approximately $1,187 per student (Anastopoulos, Langberg, Besecker, & Eddy, 2020).

Products: Products included a book on the intervention and journal articles on the  impact of ACCESS on student outcomes and a cost analysis of the program. Researchers also presented results to the research community and others.

Structured Abstract

Setting: This study was conducted in two public universities situated in Greensboro, NC and Richmond, VA, both of which are urban settings.

Sample: Of the 361 students who volunteered to participate, 280 met the study's rigorous eligibility requirements and were randomly assigned to either the immediate ACCESS group (n=149) or the Delayed Treatment Condition (DTC; n=131). Because 30 of those assigned to the immediate ACCESS group could not attend the required CBT group meetings due to classroom and/or employment scheduling conflicts, the final sample (n = 250) included 119 immediate ACCESS participants and 131 DTC participants. Included in the final sample were 165 females (66 percent) and 85 males (34 percent), ranging in age from 18 to 30 years (M = 19.7) and representing a cross-section of postsecondary education levels (47.6 percent first-year students, 16.4 percent sophomores, 26.4 percent juniors, 9.6 percent seniors). Approximately 6.8 percent of the participants reported having Hispanic/Latino backgrounds; 66.3 percent  identified as Caucasian, 14.2 percent as African American, 5.3 percent as Asian, 10.6 percent as multiracial, and 3.3 percent as other or not reported. In terms of clinical characteristics, 58.4 percent received an ADHD Combined presentation diagnosis; 41.6 percent displayed an ADHD Predominantly Inattentive presentation; 60 percent also met DSM–5 criteria for at least one psychiatric diagnosis co-occurring with ADHD, most often involving a current anxiety or depressive disorder; nearly half (47.2 percent) were taking medication for ADHD.

Intervention: ACCESS incorporates elements of empirically supported adult cognitive-behavioral therapy (CBY) programs, adapted to the developmental needs of emerging adults with ADHD in college. ACCESS is delivered across two consecutive semesters, the first of which is an intensive 8-week active phase, followed by a less intensive semester-long maintenance phase in which treatment is gradually faded. In each phase, treatment is delivered in both a group and individual mentoring format. The active phase includes 8 weekly group sessions, each of which is 90 minutes in length. Concurrent with these group sessions are weekly individual mentoring sessions, each of which is approximately 30 minutes in length. The purpose of individual mentoring is threefold: to reinforce what the student learns in the group, to assist the student in establishing personal goals and monitoring progress, and to help the student make connections with campus resources as needed. Both treatment delivery formats are used to (1) give college students a developmentally appropriate understanding of their own ADHD; (2) improve organization, time management, and other behavioral strategies that target executive functioning deficits commonly found among individuals with ADHD; and (3) increase adaptive thinking skills via cognitive therapy strategies to address co-occurring depression and anxiety features that are frequently comorbid with ADHD. The underlying premise of ACCESS is that improvement in ADHD knowledge, behavioral strategies, and adaptive thinking skills—that is, the hypothesized clinical change mechanisms—will facilitate improvements in multiple domains of daily life functioning negatively impacted by ADHD.

Research Design and Methods: Students were recruited from disability services, student health services, first-year summer orientation sessions, and campus fliers. All potential participants were initially screened for study eligibility by phone. Potentially eligible participants subsequently underwent a more comprehensive in-person evaluation, during which information pertinent to determining eligibility for the study, as well as pretreatment outcome data, were collected. The five successive cohorts of participants received ACCESS from the fall of 2015 through the spring of 2018. The researchers collected treatment outcome data from both groups on three occasions: within 2 weeks prior to beginning active treatment, immediately after active treatment, and in the final 2 to 3 weeks of the maintenance phase. They also collected data on the stability of treatment-induced improvements for the immediate treatment groups 6-months after their participation in the complete ACCESS program ended. While waiting to participate in ACCESS on a 1-year delayed basis, DTC participants could receive treatment as usual. Group and mentoring sessions were conducted in campus-based clinic settings. Mentoring sessions were generally conducted in person within a few days following the corresponding group session. Graduate student research assistants and one master's-level licensed professional counselor served as group leaders and mentors with supervision throughout the study by licensed doctoral-level clinical psychologists. In addition to receiving monetary compensation for completing measures, participants were given a written summary of their screening evaluation results, which could be used as documentation for receiving campus support and treatment.

Control Condition: Participants assigned to the DTC group received ACCESS on a 1-year delayed basis. For ethical reasons, DTC participants were allowed to receive other treatments as usual during the waiting period.

Key Measures: Key measures included the Semi-Structured Interview for Adult ADHD (researcher-developed), the self-report and parent-report versions of the ADHD Rating Scale-5 (standardized), and the Structured Clinical Interview for DSM–5: Research Version (standardized) to evaluate ADHD diagnostic status and the presence of co-occurring and/or exclusionary psychiatric disorders. An expert review panel used these data to determine participant diagnostic status and eligibility. The researchers used the Test of ADHD Knowledge (researcher-developed), Strategies for Success (researcher-developed), and ADHD Cognitions Scale-College Version (researcher-developed) to assess treatment-induced changes in ADHD knowledge, behavioral strategies, and adaptive thinking skills respectively. They used the Conners Adult ADHD Rating Scale (standardized) and the Behavior Rating Inventory of Executive Function–Adult Version (standardized) to assess treatment-related changes in primary ADHD symptoms and associated executive functioning deficits. They used the Beck Depression Inventory (standardized) and the Beck Anxiety Inventory (standardized) served as emotional functioning outcome indices. For changes in academic functioning, they used self-reported responses to the Learning and Study Strategies Inventory – Second Edition (standardized) and semester grade point averages and semester credit hours earned collected from archival records (University Registrar). For changes in personal and social functioning, they used the ADHD Impact Module-Adult (standardized). They also gathered information about participant use of treatments other than ACCESS from the Services for College Students Interview (researcher-developed).

Data Analytic Strategy: The researchers estimated impact using latent growth curve models (LGCM) to evaluate how treatment condition (immediate vs. delayed) influenced change over time. They used a multiple-group framework to evaluate differential change over time.

Cost Study: The cost analysis  examined not only the overall cost of  implementing ACCESS but also the costs associated with each of its two modes of delivery (i.e., group and individual mentoring). Excluding costs specific to research (e.g., outcome data collection), implementation of the complete ACCESS program required $1,787 spent per student, or $1,187 if the initial diagnostic assessment to determine participant suitability to receive treatment is excluded. Labor costs account for 83% of the latter amount. Of this total, the cost of implementing the group component was $367 per student, whereas the cost of the individual mentoring component was $419 per student. Such findings indicate that it is relatively inexpensive to implement ACCESS in a college campus setting.

Related IES Projects: N/A.

Project website: Home | Access Project (uncg.edu)

Additional online resources and information: Twelve videos were created to facilitate training of others interested in implementing ACCESS. This includes 4 talking head videos that provide background information, along with 4 group sessions and 4 mentoring sessions depicting the process of implementing ACCESS. Each talking head video is approximately 10 minutes in length and publicly available using the following links. Topics include: The Treatment Needs of College Students with ADHD; ACCESS Program for College Students with ADHD; Maintenance Phase of the ACCESS Program; Practical Guidelines for Planning and Implementing ACCESS. In the 8 process-oriented videos, each of which runs approximately 5 minutes, hired student actors demonstrate the process by which ACCESS group and mentoring sessions are conducted during the active phase of the program. Topics covered by the four group videos include: Situational Variability and ADHD; Recognizing Maladaptive Thinking; Choosing a Planner; Managing Distractions. The four mentoring videos address: Getting to Know Your Mentee; Making To-Do Lists More Effective; Managing Procrastination; Using Thought Records to Increase Adaptive Thinking. Because these 8 videos contain clinical content, they are password protected. Individuals interested in viewing these may do so by requesting permission from Dr. Anastopoulos.

Products and Publications

Books

Anastopoulos, A.D., Langberg, J.M., Besecker, L.H., & Eddy, L.D. (2020). CBT for College Students with ADHD — A Clinical Guide to ACCESS. Springer.

Journal article, monograph, or newsletter

Anastopoulos, A.D., Langberg, J.M., Eddy, L.D., Silvia, P.J., & Labban, J.D. (2021). A randomized controlled trial examining CBT for college students with ADHD. Journal of Consulting and Clinical Psychology, 89 (1), 21–33.

Eddy, L.D., Anastopoulos, A.D., Dvorsky, M.R., Silvia, P.J., Labban, J.D., & Langberg, J.M. (2021). An RCT of a CBT intervention for emerging adults with ADHD attending college: Functional outcomes. Journal of Clinical Child and Adolescent Psychology, 1–14.