Effectiveness of CBT Intervention for Students with ADHD

Executive dysfunction in ADHD involves deficits in cognitive processes like working memory, planning, organization, and self-motivation. These difficulties can lead to procrastination, inefficiency, underachievement, and emotional distress in students, fueling a cycle of frustration and impaired academic performance.

Notably, executive deficits often persist even when core ADHD symptoms are managed with medication, underscoring the need for targeted interventions to build compensatory skills and coping strategies to support academic success and well-being.

Solanto, M. V., & Scheres, A. (2021). Feasibility, acceptability, and effectiveness of a new cognitive-behavioral intervention for college students with ADHD. Journal of Attention Disorders, 25(14), 2068-2082. https://doi.org/10.1177/1087054720951865

Key Points

• ADHD significantly impairs academic performance and emotional well-being in college students, with higher rates of course withdrawal, lower GPAs, and increased likelihood of academic probation and failure to graduate.
• Executive dysfunction, particularly in time management, organization, and planning, is a strong predictor of academic and occupational impairment in individuals with ADHD.
• The study found a new 12-session cognitive-behavioral therapy (CBT) program targeting executive functioning deficits to be feasible, acceptable, and effective in reducing inattentive symptoms and enhancing executive functioning in college students with ADHD.
• While medication can reduce core ADHD symptoms, interventions beyond medication are needed to target executive dysfunction and optimize functioning in college students with ADHD.

Rationale

ADHD has a pronounced negative impact on academic performance and emotional well-being in college students (Ramsay & Rostain, 2015b; Thomas et al., 2013).

Studies indicate college students with ADHD have higher rates of course withdrawal (Advokat et al., 2011), lower GPAs (Blase et al., 2009), increased likelihood of academic probation (Heiligenstein et al., 1999), and lower graduation rates (Barkley et al., 2006).

Executive dysfunction, especially in time management, organization, and planning, strongly predicts academic impairment in those with ADHD (Biederman et al., 2004; Dvorsky & Langberg, 2014; Weyandt et al., 2013).

While medication can reduce core symptoms, research on its effects and adherence in college students is limited (Blase et al., 2009; Rabiner et al., 2008).

CBT interventions targeting executive dysfunction have proven effective in adults with ADHD (Safren et al., 2010; Solanto et al., 2010), but tailoring to the specific needs of college students is still at an early stage.

This study aimed to adapt an established adult CBT program to address the executive functioning deficits of college students in the specific contexts and demands of the academic environment.

Method

Open trial assessing feasibility, acceptability and effectiveness of a 12-session weekly group CBT intervention targeting executive functioning in college students with rigorously diagnosed DSM-5 ADHD.

Treatment response was assessed pre- and post-treatment with structured interviews of ADHD symptoms, self-report questionnaires of symptoms and executive functioning, and GPA.

Procedure

Two groups of 9 students received 12 weekly 2-hour group CBT sessions including in-session exercises and weekly home practice. Sessions focused on behavioral and cognitive strategies to improve time-management, organization, planning, and application to academic work.

Sample

18 college students (56% female, mean age 23.61) meeting DSM-5 criteria for ADHD-predominantly inattentive (56%) or combined type.

Most had prior ADHD diagnoses and psychiatric comorbidities. 28% took ADHD medication during study.

Measures

• Adult ADHD Investigator Symptom Rating Scale (AISRS): A structured interview assessing the 18 DSM symptoms of ADHD in adulthood. The number of inattentive symptoms endorsed and total inattentive symptom score served as primary outcome measures.
• Conners Adult ADHD Rating Scale-Self-Report (CAARS-S): A self-report scale measuring ADHD symptoms in adults. The DSM-IV Inattentive Symptoms and Inattention/Memory subscales were used as secondary outcome measures.
• Barkley Deficits in Executive Functioning Scale (BDEFS): A self-report measure of executive function in daily life. Subscales of Self-Management to Time, Self-Organization, Self-Motivation, and Total Executive Function were selected to measure changes in targeted domains.
• Learning and Study Strategies Inventory (LASSI): A self-report measure of students’ awareness and use of learning and study strategies. Subscales of Time-Management, Concentration, Motivation, and Anxiety were used to assess changes in academic-specific executive functions.
• Beck Depression Inventory-II (BDI-II): A self-report questionnaire measuring severity of depressive symptoms.
• State-Trait Anxiety Inventory (STAI): A self-report scale measuring both current (state) and general (trait) levels of anxiety.
• Penn State Worry Questionnaire (PSWQ): A self-report measure assessing tendency to engage in excessive, uncontrollable worry.

Analysis

Repeated measures ANOVA and MANOVA assessed pre-post changes on outcome measures. Effect sizes calculated as partial eta squared.

Results

84% attended ≥9/12 sessions. Significant reductions found in inattentive symptoms on AISRS (ES=0.65) and CAARS-S (ES=0.64). 39% no longer met symptom criteria post-treatment.

Significant improvements seen in time-management, organization and total executive functioning on BDEFS and LASSI. No change in GPA.

Insight

This study provides preliminary evidence that a CBT intervention tailored to the specific executive functioning deficits and academic demands of college students with ADHD is feasible, acceptable, and effective in reducing inattention and enhancing EF in key domains.

Participants found time-management strategies, “chunking” overwhelming tasks, and cognitive restructuring most helpful.

While no GPA change was seen, improved EF and reduced inattention, as found here, have predicted better academic and occupational outcomes in previous studies. Future controlled trials should evaluate the maintenance of gains and elucidate mechanisms of change.

Strengths

Below are some of the strengths of this study:

• The study utilized rigorous diagnostic procedures, including structured clinical interviews (ACDS, AISRS) to establish ADHD diagnosis and the corroboration of self-reported childhood and current symptoms with validated rating scales (CSS, CAARS-S).
• The CBT intervention was carefully manualized and tailored specifically to the needs and context of college students with ADHD, incorporating both behavioral and cognitive strategies to target executive functioning deficits relevant to academic demands.
• The study included the application of learned strategies to real-world academic tasks like reading, note-taking, and writing papers, promoting the generalization of skills.
• Outcomes were assessed using a combination of clinician-rated (AISRS), self-report (CAARS-S, BDEFS, LASSI), and objective (GPA) measures capturing a range of symptom, executive functioning, and functional domains.
• Participant evaluations provided additional data on the perceived helpfulness and acceptability of treatment components.
• The open-label design allowed for evaluation of feasibility and acceptability of the intervention in a real-world college campus setting.

Limitations

Below are some of the limitations of this study:

• As an open trial, the study lacked a control group, so the impact of time, attention, or other non-specific factors cannot be definitively ruled out. Randomized controlled trials will be necessary to establish efficacy.
• The sample size was relatively small (N=18) and demographically limited (mostly White, all fluent English speakers), reducing generalizability. Larger and more diverse samples should be studied.
• Longer-term outcomes were not evaluated, so the durability of reported improvements is unknown. Future studies should include follow-up assessments to determine if gains are maintained.
• The study did not assess comorbid learning disorders like dyslexia which could impact academic performance and treatment response. Future research should evaluate the impact of comorbidities.
• Medication usage was not controlled, and adherence was not assessed, so its impact could not be determined. Studies comparing and combining medication and CBT will help clarify best practices.
• Some academic outcomes like GPA are impacted by many factors beyond ADHD symptoms and thus may require more sensitive measures of change. More direct assessments of academic productivity, strategy use, and efficiency may be helpful.

Implications

Provides preliminary empirical support for a potentially scalable intervention to enhance functioning in college students with ADHD and executive deficits not fully addressed by medication alone.

May help improve critical academic and occupational outcomes. Suggests specific EF domains and skills to prioritize. Colleges should consider screening for ADHD and offering such support.

References

Advokat, C., Lane, S. M., & Luo, C. (2011). College students with and without ADHD: Comparison of self-report of medication usage, study habits, and academic achievement. Journal of Attention Disorders, 15(8), 656-666. https://doi.org/10.1177/1087054710371168

Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2006). Young adult outcome of hyperactive children: Adaptive functioning in major life areas. Journal of the American Academy of Child & Adolescent Psychiatry, 45(2), 192-202.

Biederman, J., Monuteaux, M. C., Doyle, A. E., Seidman, L. J., Wilens, T. E., Ferrero, F., Morgan, C. L., & Faraone, S. V. (2004). Impact of executive function deficits and attentiondeficit/hyperactivity disorder (ADHD) on academic outcomes in children. Journal of Consulting and Clinical Psychology, 72, 757–766

Blase, S. L., Gilbert, A. N., Anastopoulos, A. D., Costello, E. J., Hoyle, R. H., Swartzwelder, H. S., & Rabiner, D. L. (2009). Self-reported ADHD and adjustment in college: Cross-sectional and longitudinal findings. Journal of Attention Disorders, 13(3), 297-309. https://doi.org/10.1177/108705470933444

Dvorsky, M. R., & Langberg, J. M. (2014). Predicting impairment in college students with ADHD: The role of executive functions. Journal of Attention Disorders. https://doi.org/10.1177/1087054714548037

Heiligenstein, E., Guenther, G., Levy, A., Savino, F., & Fulwiler, J. (1999). Psychological and academic functioning in college students with attention deficit hyperactivity disorder. Journal of American College Health, 47(4), 181-185.

Rabiner, D. L., Anastopoulos, A. D., Costello, J., Hoyle, R. H., & Swartzwelder, H. S. (2008). Adjustment to college in students with ADHD. Journal of Attention Disorders, 11(6), 689–699. https://doi.org/10.1177/1087054707305106

Ramsay, J. R., & Rostain, A. L. (2015). College students with ADHD. In L. Adler, T. Spencer, & T. Wilens (Eds.), Attention-deficit hyperactivity disorder in adults and children. Cambridge University Press.

Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves, M., & Otto, M. W. (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. Journal of the American Medical Association, 304(8), 875-880.

Solanto, M. V., Marks, D. J., Wasserstein, J., Mitchell, K., Abikoff, H., Alvir, J. M. J., & Kofman, M. D. (2010). Efficacy of meta-cognitive therapy for adult ADHD. American Journal of Psychiatry, 167(8), 958-968. https://doi.org/10.1176/appi.ajp.2009.09081123

Thomas, M., Rostain, A., & Prevatt, F. (2013). ADHD diagnosis and treatment in college students and young adults. Adolescent medicine: state of the art reviews, 24(3), 659.

Weyandt, L. L., DuPaul, G. J., Verdi, G., Rossi, J. S., Swentosky, A. J., Vilardo, B. S., … & Carson, K. S. (2013). The performance of college students with and without ADHD: Neuropsychological, academic, and psychosocial functioning. Journal of Psychopathology and Behavioral Assessment, 35(4), 421-435. https://doi.org/10.1007/s10862-013-9351-8

Keep Learning

Some Socratic questions for a college class to discuss based on this review paper could include:

1. How could colleges better identify students struggling with undiagnosed ADHD and connect them to supports? What barriers currently exist?
2. What unique challenges do college students with ADHD face compared to children or adults with ADHD? How can interventions be tailored to address these?
3. If you were designing a study to further evaluate this CBT program, what would an ideal control group be? What additional outcome measures might be important to include?
4. How might this CBT program need to be adapted for online/remote delivery? What opportunities and challenges would a virtual format present?
5. How could strategies from this program be implemented in a stepped-care model, where some components are offered more broadly and intensively than others based on need? What would be important to consider?