Does Comorbid Anxiety Improve College Student Response to ADHD Coaching?
In November, 2016, my doctoral student Rachel L. Kininger presented the results of her Master's Thesis at the 50th Annual Convention of the Association for Behavioral and Cognitive Therapies in New York City. The content of that presentation is provided below. Special thanks to two other students, Samuel A. Faulkner and Lauren E. Gaither for assisting with the construction of the poster.
College students with ADHD are at an increased risk for comorbid anxiety disorders (Prevatt, Dehili, Taylor, & Marshall, 2015), but it is unclear whether anxiety hinders or enhances psychosocial treatment response. ADHD coaching—targeting time management, study skills, and organization—is a promising treatment option for college students (Prevatt & Levrini, 2015), but the majority of the research to date has been quasi-experimental or qualitative. As a result, researchers have not addressed the potential influence of comorbid anxiety (Prevatt & Yelland, 2015).
We conducted a small RCT to preliminarily estimate the influence of anxiety on the relationship between treatment status and outcomes. The purpose of this study was to:
(a) Develop an ADHD coaching model acceptable to college students.
(b) Examine the degree to which ADHD coaching improves psycho-educational outcomes when compared to a control condition.
(c) Estimate the degree to which anxiety moderates treatment response to inform sample size needs in future research.
Participants. We recruited 20 undergraduate students receiving accommodations for ADHD from the Office of Disability Support Services (DSS) at East Carolina University. Most participants were women (65%) and white (90%). There were no freshmen in the sample; instead, 4 participants were sophomores (20%), 10 were juniors, and the remaining 6 (30%) were either fourth or fifth year seniors.
Procedures. Participants were randomly assigned to an ADHD coaching condition (n = 10) or a psychoeducational control condition (n = 10). Participants in the coaching intervention continued DSS accommodations and received approximately six biweekly coaching sessions during the Fall 2015 semester. The skills targeted in the sessions included time management, organization, study strategies, and note taking strategies using materials adapted from the Challenging Horizons Program (CHP; Schultz & Evans, 2015) and the CBT Treatment for Adults with ADHD treatment manual (Solanto, 2011).
Participants in the control condition continued DSS accommodations and received six biweekly newsletters containing information about the skills taught in the coaching condition. At the end of 10 weeks, all participants completed post-treatment evaluations and received $75 for their participation.
• Beck Anxiety Inventory (BAI; Beck & Steer, 1993)
• Treatment Satisfaction Survey (TSS; Canu & Bearman, 2011)
• Behavior Intervention Rating Scale (BIRS; Elliott & Treuting, 1991)
• Conners’ Adult ADHD Rating Scale (CAARS; Conners et al., 1999)
• Behavior Rating Inventory of Executive Function—Adult Version (BRIEF-A; Roth, Isquith, & Goia, 2005)
• Grade Point Average (GPA): Spring 2015 and Fall 2015
(a) Acceptability/Satisfaction: Participants who received ADHD coaching were more satisfied (TSS; t = 2.77, p = .013) and found the procedures more acceptable (BIRS; t = 3.91, p = .001) than control participants.
(b) Treatment Outcomes: Using repeated measures ANOVAs, Time X Condition interactions were inconclusive, with effects in the small to medium range on GPA (r = .27), ADHD symptoms (CAARS Total; r = .21), and executive functioning (BRIEF-A; rs = .25 to .37).
(c) Moderation Analyses: Reliable change indexes (RCI; Jacobson & Truax, 1991) were calculated for the BRIEF-A global executive composite (GEC; consisting of a metacognition index [MI] and a behavior regulation index [BRI]) and CAARS subscales (Inattention, Hyperactivity). Simple difference scores were calculated for change in GPA from spring to fall 2015. We then conducted simple moderation analyses using the PROCESS plugin for SPSS (Hayes, 2013), testing the impact of anxiety on the relationship between treatment status and RCI/difference scores. All Condition X Anxiety interactions were statistically inconclusive and accounted for only small increases in variance explained (ΔR2 = 0.3% - 4.7%). To examine trends, the conditional effects of treatment status on each outcome variable was plotted by low (-1 SD), mean, and high (+1 SD) levels of anxiety. Participants with low anxiety in the treatment condition experienced the largest improvements in GEC—driven mostly by changes in MI (see Figure at the top of this post, where low, mid, and high refer to levels of anxiety)—while participants with low anxiety in the control condition experienced the largest deterioration. A similar pattern was found for inattention symptoms on the CAARS. For the BRI, participants with low anxiety in the control condition reported relatively large deterioration, but all levels of anxiety appeared to respond equally to treatment. For Hyperactivity symptoms, all participants reported improvements over time, with the lowest anxiety group experiencing the greatest relative gains. In terms of grades, participants with low anxiety in the control condition experienced the largest deterioration over time, whereas all treatment participants experienced improvements over time regardless of anxiety level. Based on the observed model effect sizes (f2), we estimated sample size requirements for an adequately powered clinical trial (Table 2).
We designed a brief ADHD coaching treatment for college students and piloted it in a small, pilot RCT. Participants found the intervention acceptable and experienced small to medium improvements in GPA, ADHD symptoms, and executive functioning when compared to a control condition. It is important to note that our results could have occurred by chance (ps > .05), but treatment effects trended in the expected direction across multiple outcomes, consistent with previous research on ADHD coaching.
Exploratory analyses of the potential moderating effect of anxiety on the relationship between treatment status and outcomes suggest that anxiety may be an important consideration in the treatment of college students with ADHD. Although the moderating effect of anxiety only accounted for small changes in the relationship between treatment status and outcomes, a consistent pattern emerged: Participants with relatively low anxiety experienced the largest treatment gains across most outcomes, including executive functioning and inattention symptoms. Without treatment, participants with ADHD and relatively low comorbid anxiety generally experienced worse outcomes over time. In contrast, participants with the highest relative levels of anxiety generally experienced little change over time, regardless of treatment status, suggesting a protective benefit of comorbid anxiety. We estimate that to test these trends with adequate statistical power would require a sample size ranging from 39 to 279 participants, depending on the outcome of interest.
There were several limitations to this study, including our reliance on self-report measures for the majority of outcomes and the limited representativeness of the sample. In particular, we noted that participants reported a low level of anxiety (M = 10.25, SD = 8.30; range = 0 - 29) on the BAI, contrary to our expectations. These limitations point to the need to replicate this study with a larger and more diverse sample.
Overall, the results of this pilot study suggest that comorbid anxiety may have meaningful implications for college students receiving ADHD coaching. Specifically, it may be critical to target services for college students with ADHD and little or no comorbid anxiety. Students with low comorbid anxiety do not appear to benefit under treatment-as-usual conditions, but may respond well to ADHD coaching.
Beck, A. T., & Steer, R. A. (1993). Beck anxiety inventory. San Antonio, TX: The Psychological Corporation.
Canu, W. H., & Bearman, S. K. (2011). Community-clinic-based parent intervention addressing noncompliance in children with attention-deficit/hyperactivity disorder. Cognitive and Behavioral Practice, 18, 491-501.
Conners, C. K., Erhardt, D., Epstein, J. N., Parker, J. D. A., Sitarenios, G., & Sparrow, E. (1999). Self-ratings of ADHD symptoms in adults I: Factor structure and normative data. Journal of Attention Disorders, 3, 141-151.
Elliott, S. N., & Treuting. M. V. B. (1991). The behavior intervention rating scale: Development and validation of a pretreatment acceptability and effectiveness measure. Journal of School Psychology, 29, 43-51.
DuPaul, G. J., Weyandt, L. L., O'Dell, S. M., & Varejao, M. (2009). College students with ADHD: Current status and future directions. Journal of Attention Disorders, 13, 234-250.
Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press.
Prevatt, F., Dehili, V., Taylor, N., & Marshall, D. (2015). Anxiety in college students with ADHD: Relationship to cognitive functioning. Journal of Attention Disorders, 19, 222-230.
Prevatt, F., & Levrini, A. (2015). ADHD coaching: A guide for mental health professionals. Washington, DC: American Psychological Association.
Prevatt, F., & Yelland, S. (2015). An empirical evaluation of ADHD coaching in college students. Journal of Attention Disorders, 19, 666-677.
Roth, R. M., Isquith, P. K., & Gioia, G. A. (2005). Brief rating inventory of executive function-adult version (BRIEF-A). Lutz, FL: Psychological Assessment Resources.
Schultz, B. K., & Evans, S. W. (2015). A practical guide to implementing school-based interventions for adolescents with ADHD. New York: Springer.
Solanto, M. V. (2011). Cognitive-behavioral therapy for adult ADHD: Targeting executive dysfunction. New York, NY: The Guildford Press.