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Behavior Therapy 54 (2023) 444–460

www.elsevier.com/locate/bt

Clinical Change Mechanisms in the Treatment of College Students

With ADHD: Trajectories and Associations With Outcomes
Joshua M. Langberg
Rutgers University
Melissa R. Dvorsky
Children’s National Hospital–George Washington University School of Medicine

Paul Silvia
Jeff Labban
Arthur D. Anastopoulos
University of North Carolina Greensboro

nificant gains in the use of behavioral strategies and trajec-

The purpose of this study was to evaluate trajectories of
response for the three theorized mechanisms of clinical
change (knowledge, behavioral strategies, and adaptive
thinking) associated with the Accessing Campus Connec-
tions and Empowering Student Success (ACCESS) interven-
tion for college students with attention-deficit/
hyperactivity disorder (ADHD) and their association with
treatment outcomes. Participants included 250 college stu-
dents comprehensively diagnosed with ADHD randomly
assigned to ACCESS or to a delayed-treatment control
who completed ratings at baseline, end of active treatment,
and end of the maintenance phase of treatment (after two
semesters). Growth mixture models (GMMs) were used
to evaluate trajectories. Participants in ACCESS made sig-
Conflict of Interest Statement: For co-authors Dvorsky, Green,
Silvia and Labban, there are no conflicts. Drs. Langberg and
Anastopoulos published the ACCESS treatment manual as part of
the intervention dissemination process. The manual was published
by Springer, entitled CBT for College Students with ADHD: A
Clinical Guide to ACCESS. As such, we receive royalties associated
with book purchases. The research reported here was supported by
the Institute of Education Sciences, U.S. Department of Education,
through grant R305A150207 awarded to the University of North
Carolina Greensboro. The opinions expressed are those of the
authors and do not represent views of the Institute or the U.S.
Department of Education.
Address correspondence to Joshua M. Langberg, Ph.D., Rutgers
University, 152 Frelinghuysen Road, Piscataway, NJ 08854.
e-mail: jl3079@gsapp.rutgers.edu.
0005-7894/Ó 2023 Association for Behavioral and Cognitive Therapies.
target for psychological Published by Elsevier Ltd.
tories were associated with large effect size improvements
in measures of symptoms and functioning. Participants also
made improvements in ADHD knowledge. However, only
the knowledge trajectory with rapid improvement dis-
played significantly better outcomes. Only one trajectory
group showed improvement in adaptive thinking with most
ACCESS participants remaining stable across time. How-
ever, adaptive thinking trajectories were strongly related
to both symptom and functional outcomes. ACCESS is
associated with large gains in two of the three theorized
clinical mechanisms of change, behavioral strategies and
ADHD knowledge. Rapid improvement in behavioral
strategies was associated with robust improvement in
symptoms and functioning. Although improvements in
the third mechanism, adaptive thinking, were small, they
were strongly associated with outcomes demonstrating
the importance of a cognitive-behavioral approach in treat-
ing college students with ADHD.
Keywords: ADHD; college; mechanisms; intervention; treatment
outcome
THE TRANSITION from high school to college poses
many unique developmental challenges. Emerging
adults attending college are faced with signifi-
cantly increased academic, interpersonal, and
financial management responsibilities (Arnett,
2007, 2013; Larose et al., 2019). At the same time,
the monitoring and structure provided by adults
 mechanisms of treatment response to access
during childhood is largely removed, and college
students are expected to autonomously self-
manage academic and extracurricular activities
(Lowe & Dotterer, 2018). The transition is partic-
ularly challenging for emerging adults with
attention-deficit/hyperactivity disorder (ADHD)
who exhibit deficits in planning and organization
behaviors, struggle with academic motivation,
and experience difficulties with impulsivity and
self-regulation of behavior (Canu et al., 2021;
Fleming & McMahon, 2012). In comparison to
their peers, college students with ADHD have
lower grades and are less likely to graduate, expe-
rience high rates of internalizing problems such as
anxiety and depression, and are more likely to
engage in high-risk behaviors such as binge drink-
ing (Anastopoulos et al., 2018; Baker et al., 2012;
DuPaul et al., 2021).
In the past 5 years, the field has witnessed a
rapid increase in the development and evaluation
of psychosocial interventions for college students
with ADHD. The college setting presents many
challenges for ADHD intervention development
given that it is not feasible to scale-up most child-
hood ADHD interventions for the college context.
Specifically, most childhood ADHD interventions
are behavioral in nature and enlist parents and
teachers to provide structure and skills implemen-
tation monitoring (Fabiano et al., 2021; Van der
Oord & Tripp, 2020). However, parents have lim-
ited knowledge of, or involvement with, their chil-
dren’s day-to-day college activities and classes are
often too large for professors to provide substan-
tial support (LaCount et al., 2019; Vasko et al.,
2020). In addition, comorbid symptoms of anxiety
and depression significantly increase during late
adolescence, and prevalence rates for internalizing
disorders approach 50% in college students with
ADHD (Anastopoulos et al., 2018). This suggests
that traditional childhood behavioral therapeutic
approaches alone may not be sufficient. Finally,
receiving services on a college campus requires
that the individual, rather than a caregiver, have
knowledge about ADHD and treatment options
and be willing to seek and self-advocate for ser-
vices (Pfeifer et al., 2021). Given this unique con-
text, ADHD interventions developed to date for
college settings have varied widely in the therapeu-
tic approach utilized, ranging from behavioral
skills-based approaches to cognitive treatments,
to a joint cognitive-behavioral treatment (Gu
et al., 2018; LaCount et al., 2018; Solanto &
Anouk, 2021; Van der Oord et al., 2020). Many
of these interventions have demonstrated promis-
ing effects. However, almost nothing is known
about the therapeutic mechanisms driving these
445
effects. Mechanistic information will form the
foundation for the next phase of intervention
development.
In 2014, the National Institutes of Mental Health
(NIMH) redefined clinical trials, placing a strong
emphasis on experimental therapeutics, or mecha-
nistic research. NIMH clarified that a successful
treatment outcome study should “evaluate not only
the clinical effect of the intervention, but also gener-
ate information about the mechanisms underlying a
disorder or an intervention response” (Insel &
Gogtay, 2014). This shift occurred in part because
receiving something (i.e., some service or interven-
tion) is often better than receiving nothing, and
for the field to advance, it is important to under-
stand whether theorized active ingredients are hav-
ing the intended effect. Psychosocial treatments are
frequently multifaceted. Treatment effects may be
driven by a small portion of the intervention com-
ponents or may simply be the result of increased
attention or a therapeutic relationship (Karver
et al., 2018). This is precisely where we find our-
selves with interventions for college students with
ADHD. It is clear that providing something is better
than nothing (e.g., waitlist control), but there is lim-
ited information on why this is the case and which
clinical change mechanisms are driving effects. It
is important to understand whether unique mecha-
nisms (e.g., cognitive v. behavioral) are linked with
specific outcomes (e.g., academic functioning v.
depression) so that the field can begin to develop
modular and personalized approaches to care.
The college ADHD intervention with the most
robust research evidence is Accessing Campus
Connections and Empowering Student Success
(ACCESS). ACCESS is a cognitive-behavioral
treatment with a published protocol that has been
evaluated through an open trial and a large multi-
site randomized trial with participants followed
over 1 year (Anastopoulos et al., 2021). ACCESS
consists of eight 90-minute group sessions com-
bined with brief weekly individualized mentoring
sessions. A randomized controlled trial (N = 250)
showed that relative to a waitlist control, partici-
pants in ACCESS made significant and reliable
improvements in executive functioning (EF) and
ADHD symptoms and multiple aspects of func-
tioning (e.g., academic skills and overall well-
being; Anastopoulos et al., 2021; Eddy et al.,
2021). Importantly, the sample was relatively
diverse and had high rates of comorbid conditions,
increasing the likelihood that the findings will
generalize.
The structure of the ACCESS intervention is
ideal for mechanistic research as the three core
therapeutic ingredients are addressed with
446 langberg et al.
participants at each session. Specifically, each
ACCESS session has ADHD knowledge, behav-
ioral/skills, and adaptive thinking skills (i.e., cog-
nitive therapy) components. Briefly, for ADHD
knowledge, participants learn about the core
symptoms of ADHD and how they are evaluated,
the impact of ADHD on functioning, and
evidence-based treatment options and how to
access them on campus. The behavioral aspects
of the intervention include teaching skills for plan-
ning ahead and organizing materials and study and
time-management strategies. The cognitive ther-
apy strategies address identification and replace-
ment of maladaptive thinking patterns with
adaptive thinking, along with understanding and
coping with emotions. Findings from the RCT
show that participants in ACCESS made signifi-
cant group-level improvements in these clinical
change mechanisms relative to control. Reliable
change analyses revealed that ACCESS partici-
pants had a more robust response on the measures
of ADHD knowledge (43.6%) and behavioral
strategies (31.2%), with only 11.6% of partici-
pants showing a reliable clinical response on the
cognitive clinical mechanisms (Anastopoulos
et al., 2021). However, all of these analyses were
at the group level and do not provide information
about trajectories of response (e.g., rapid respon-
der v. slow and steady) or whether the clinical
change mechanisms are associated with outcomes.
present study
The purpose of the present study is to evaluate
trajectories of improvement for the knowledge,
behavioral, and adaptive thinking cognitive com-
ponents of ACCESS and whether these trajecto-
ries are differentially associated with outcomes.
A person-centered approach is utilized to provide
unique information about the pace of uptake for
the three core clinical change mechanisms as
well as the different levels of response. Specifi-
cally, growth mixture modeling is utilized to
provide information about longitudinal patterns
of individual response and intra-individual differ-
ences in response (Muthén et al., 2002). Trajec-
tories of response with the clinical change
mechanisms are then evaluated relative to out-
comes, to determine whether various patterns
of improvement are differentially associated with
gains on distal measures of symptoms and func-
tioning. Both symptom and functional impair-
ment outcomes are included given the potential
for therapeutic mechanisms to be linked with
some outcome domains and not others. For
symptoms, the present study evaluates the
impact on ADHD inattentive symptoms and
executive functions and impairment outcomes
include overall well-being and academic skills
use. Outcomes were assessed at baseline, end
of active treatment (i.e., end of the first seme-
ster), and at the end of the maintenance phase
of treatment (i.e., at the end of the second seme-
ster). We hypothesized that ADHD knowledge
response would be associated with all outcomes,
whereas behavioral/skills mechanisms would pre-
dict symptoms and skills outcomes and adaptive
thinking would only impact well-being.
Method
participants
Participants were recruited at two large, public
universities in urban areas of the southeastern Uni-
ted States with large numbers of first-generation
college students and diverse student bodies. Insti-
tutional Review Boards (IRB) at both institutions
reviewed and approved the study. All participants
were over the age of 18 and provided consent. See
“Study Procedures” section below for more details
on student recruitment. We report how we deter-
mined our sample size, all data exclusions, all
manipulations, and all measures in the study. A
target sample size of N = 250 was determined
using power analysis with the software package
nQueryÒ version 6 based upon preliminary open
trial estimates. A total of 361 students completed
informed consent procedures and were screened
for eligibility. Eighty-one participants were
deemed ineligible for reasons related to not meet-
ing diagnostic criteria for ADHD or having a con-
current active psychiatric condition outside of the
scope of treatment. Thirty eligible participants
randomly assigned to the immediate ACCESS
intervention could not participate due to work
and classroom scheduling conflicts that precluded
their involvement during the group portion of
the active treatment phase. Thus, the final sample
included 250 participants ranging in age from 18
to 30 years (M = 19.68; SD = 2.15). See
Anastopoulos et al. (2021) for a CONSORT dia-
gram showing participant flow through each of
the study timepoints. The majority of the sample
identified as female (N = 165; 66%) and repre-
sented a range of postsecondary education levels
(i.e., 47.6% first-year students, 16.4% sopho-
mores, 26.4% juniors, 9.6% seniors). Approxi-
mately 6.8% of the participants identified as
Hispanic/Latino; 66.3% identified as Caucasian,
14.2% as African American, 5.3% as Asian,
0.4% as Native American, 10.6% as multi-racial,
and 3.3% as other (see Table 1 for additional
demographic information).
 mechanisms of treatment response to access 447
Table 1
Pretreatment Demographic and Selected Clinical Characteristics by Group
Variable ACCESS (N = 119) DTC (N = 131) Total (N = 250)
M (SD) M (SD) M (SD)
Age 19.74 (2.24) 19.63 (2.07) 19.68 (2.15)
FSIQ 110.53 (10.72) 110.56 (12.34) 110.54 (11.57)
CAARS Total Score 34.43 (9.25) 34.73 (8.86) 34.59 (9.03)
(%) (%) (%)
Female 64.7% 67.2% 66%
Race
Caucasian 66.1% 66.4% 66.3%
Black/African American 11.9% 16.4% 14.2%
Asian 5.1% 5.5% 5.3%
More than one race 11.9% 9.4% 10.6%
Other/not reported 5.1% 2.4% 3.7%
Ethnicity/Hispanic 7.0% 6.6% 6.8%
First Year College Students 49.6% 45.8% 47.6%
Comorbidity Status 62.2% 58.0% 60%
Predominantly Inattentive Presentation 41.2% 42.0% 41.6%
Combined ADHD Presentation 58.8% 58.0% 58.4%
ADHD Medications 52.9% 41.9% 47.2%
Other Medications 26.1% 29.0% 27.6%
Note. DTC = Delayed Treatment Condition; no statistically significant group differences detected using chi-square for categorical variables
and t-tests for dimensional variables; CAARS Total Score = overall ADHD symptom severity; Comorbidity Status = presence of other
DSM-5 mental health disorders co-occurring with ADHD; CAARS Total Score is reported in raw score form. ADHD Medication Sta-
tus = reported use of medication to treat ADHD; Other Medication Status = reported use of a psychoactive medication to treat other mental
health conditions

A multi-method, multi-informant assessment presence of developmentally inappropriate symp-

was used to determine ADHD and comorbidity
status. An expert panel comprised of three licensed
clinical psychologists reviewed evaluation data
and confirmed ADHD eligibility status through
required unanimous agreement. Participants went
through a comprehensive evaluation procedure to
assess for a diagnosis of ADHD as defined in the
Diagnostic and Statistical Manual of Mental
Disorders–Fifth Edition (DSM-5; APA, 2013).
Participants were administered a semistructured
interview collecting information about ADHD
symptoms and impairment associated with symp-
toms. Further, parent-report of childhood symp-
toms of ADHD (i.e., symptoms present prior to
age 12) was collected by telephone interview.
Finally, evaluation procedures included a struc-
tured interview assessing for the presence of other
psychiatric conditions; further, information about
onset and duration of psychiatric conditions was
collected to inform differential diagnosis between
ADHD and other conditions. Background infor-
mation (e.g., history of ADHD diagnosis, past aca-
demic/social functioning) was also collected.
Participants were diagnosed with ADHD if the
panel determined they met DSM-5 criteria for
ADHD as evidenced by 5 or more symptoms of
inattention and/or hyperactivity/impulsivity,
impairment associated with symptoms, the
toms prior to age 12, and symptoms and impair-
ment not better explained by another ongoing
psychiatric condition. In the final sample
(N = 250), 58.4% met criteria for an ADHD Com-
bined presentation and 41.6% for ADHD Predom-
inantly Inattentive presentation. Furthermore,
60% of participants met DSM-5 criteria for at
least one co-occurring psychiatric diagnosis (i.e.,
29.6% met criteria for a depressive disorder and
31.6% met criteria for an anxiety disorder). The
final sample consisted of 119 immediate ACCESS
participants and 131 delayed treatment control
(DTC) participants. DTC participants received
ACCESS after two semesters in the control group.
As shown in Table 1, the two groups were statisti-
cally equivalent at pre-treatment across numerous
demographic and clinical variables.
description of intervention
ACCESS incorporates some elements of existing
adult CBT programs (Safren et al., 2005;
Solanto, 2011) adapted to the developmental
needs of emerging adults with ADHD in college.
ACCESS is delivered across two consecutive seme-
sters, the first of which is an 8-week active phase,
followed by a low-intensity semester-long mainte-
nance phase. Treatment is delivered in both a
group and individual mentoring format. During
448 langberg et al.
active treatment, participants received eight
weekly 90-min CBT group sessions with no more
than eight participants per group. The three
hypothesized clinical change mechanisms—ADHD
knowledge, behavioral strategies, and adaptive
thinking skills—were addressed in each of these
active phase group sessions (see Figure 1). Concur-
rent with the CBT group timeline, participants
received weekly 30-min individual mentoring ses-
sions. The objectives of individual mentoring are
to reinforce what the student learns in the CBT
group, to assist the student in setting personal
goals and monitoring progress, and to help the stu-
dent make connections with campus resources.
During the maintenance phase, participants
received a booster CBT group session and four to
six mentoring sessions. The treatment manual
has been published and is publicly available
(Anastopoulos et al., 2020). In the current study,
83.2% of the immediate treatment group attended
at least 6 group sessions, and 85.7% attended a
majority of mentoring sessions.
Study Procedures
Students were recruited from multiple sources,
including various campus support units (e.g., dis-
ability services, student health services), first-year
summer orientation sessions, and campus fliers.
E-mail advertisements announcing the study were
sent to students currently registered with disability
services at each respective campus. Interested stu-
dents were phone screened by study staff using
FIGURE 1 ACCESS Active Phase Weekly Content.
the ADHD Rating Scale-5. Students who endorsed
4 or more symptoms of either inattention or hyper-
activity/impulsivity on the phone screen were
scheduled for the comprehensive evaluation.
Participants meeting eligibility criteria were
randomly assigned to receive ACCESS immedi-
ately or after a 1-year delay (i.e., DTC group).
Random assignment was stratified by medication
status to ensure equivalent numbers of participants
taking ADHD medication in each group. Recruit-
ment was ongoing, and ACCESS was delivered
to five successive cohorts of participants across
consecutive semesters from the fall of 2015
through the spring of 2018. Fall cohorts ran from
early September through mid-November; spring
cohorts from early February into mid-April. While
waiting to participate in ACCESS on a 1-year
delayed basis, DTC participants were permitted
to receive treatment as usual.
Graduate student research assistants and one
licensed master’s-level professional counselor
served as ACCESS group leaders and mentors.
All group leaders received extensive training to
prepare them to implement the treatment protocol
with fidelity. Throughout the study, weekly super-
vision was provided by licensed doctoral-level clin-
ical psychologists experienced in the treatment
protocol; in addition, a detailed treatment manual
was provided to group leaders and mentors. Treat-
ment sessions were recorded, and 20% were ran-
domly selected and reviewed for fidelity. Overall
adherence to the content of treatment sessions
 mechanisms of treatment response to access
was excellent, with fidelity ratings of 96.4 and
95.6% obtained for the group and mentoring ses-
sions, respectively.
measures
Participants completed measures at baseline (T1),
end of the first semester (i.e., end of active treat-
ment; T2), and at the end of the second semester
(i.e., end of maintenance phase; T3).
clinical change mechanisms
Test of ADHD Knowledge (TOAK)
The TOAK is a 40-item questionnaire that mea-
sures general knowledge of ADHD. For each item,
participants respond to statements about ADHD
(e.g., “Hereditary factors play a major role in
determining if someone will develop ADHD”)
with “agree,” “disagree,” or “not sure.” Correctly
endorsed “agree” and “disagree” items are
summed to yield a total score, with higher scores
indicating greater knowledge of ADHD. Findings
based on the current sample indicate that the
TOAK possesses excellent internal consistency (co-
efficient a = .86) and demonstrates evidence of
convergent validity.
Strategies for Success (SFS)
The SFS contains 18 self-report items that assess
use of behavioral strategies for managing not only
academic work (e.g., using a planner) but also var-
ious personal responsibilities (e.g., keeping track
of keys/cell phone, organizing dorm room/apart-
ment, connecting with campus support services)
specifically targeted by the ACCESS intervention.
Respondents indicate how adeptly they use these
strategies on a 5-point scale, with 1 indicating
not well and 5 indicating very well. Items are
summed to yield a total score, with higher scores
indicating more frequent behavioral strategy use.
Findings from the current sample suggest that the
SFS possesses adequate internal consistency (coef-
ficient a = .84).
ADHD Cognitions Scale–College Version (ACS-
CV)
The ACS-CV is a 12-item self-report questionnaire
that assesses frequency of ADHD-related mal-
adaptive thinking patterns (e.g., “My work is bet-
ter if I wait until the last minute”). Each item is
rated on a 5-point scale, and ratings for all 12
items are summed to create a total ACS-CV score,
with higher scores reflecting more frequent engage-
ment in maladaptive thinking patterns (Knouse
et al., 2019). Treatment-related decreases in
ACS-CV scores indicate that targeted maladaptive
thinking patterns have been identified and replaced
with adaptive thinking patterns necessary for
449
improvements in emotional well-being and behav-
ioral functioning. The ACS-CV had satisfactory
internal consistency (coefficient a = .77).
outcome measures
The ADHD Impact Module-Adult (AIM-A;
Health Act CHQ Inc, 2007)
The AIM-A is a self-report measure designed to
assess the effects of ADHD symptoms and associ-
ated impairments on a number of life domains.
Scales include Living with ADHD, General Well-
Being, Performance and Daily Functioning, Rela-
tionships and Communication, Bothersomeness
and Concern, and Daily Interference. Scores range
from 0 to 100 with higher scores representing
higher functioning. The AIM-A has demonstrated
good internal consistency (a’s > .80) and concur-
rent and discriminant validity (Landgraf, 2007).
The Performance and Daily Functioning (a = .84)
and General Well-Being (a = .88) scales were uti-
lized in this study. The Performance and Daily
Functioning scale (11 items) measures self-
perceptions of performance in managing daily
responsibilities and engaging in general problem-
solving and decision making. Participants rate
their adeptness at “handling everyday hassles,”
and “ability to adapt to disruptions or unexpected
changes in routine.” For the General Well-Being
scale (10 items), respondents are rate frequency
of positive mood states, such as “accepting of
yourself” and “able to cope.”
Behavior Rating Inventory of Executive Function-
Adult (BRIEF-A; Roth et al., 2005)
The BRIEF-A is an 86-item self-report measure
designed to assess an individual’s behavioral appli-
cation of EF abilities and has shown good internal
consistency (coefficient a = .96). Responses gener-
ate three composite scale scores: the Behavioral
Regulation Index (BRI), which evaluates an indi-
vidual’s ability to appropriately inhibit and control
behaviors and emotions and shift between tasks
and environments; the Metacognition Index
(MCI), which measures their ability to self-
manage and monitor one’s own progress and per-
formance; and the overall Global Executive Com-
posite (GEC), which served as the primary
outcome in this study. Higher scores on this com-
posite scale indicates more difficulties with (EF).
Conners Adult ADHD Rating Scale, Long Version
(CAARS-S:L; Conners et al., 1999)
The CAARS-S:L is a widely used, psychometrically
sound (coefficient a from .73 to .84) measure of
ADHD in adults. The DSM–IV Inattentive (IN)
scores were used to assess treatment-related
changes in ADHD symptoms in the current study.
450 langberg et al.
The Learning and Study Strategies Inventory–
Second Edition (LASSI-2; Weinstein et al., 2002)
The LASSI-2 is a self-report measure designed to
assess the academic skills and strategies of college
students, in addition to attitudes and beliefs asso-
ciated with academic success. The LASSI-2 was
developed and normed using a large, nationally
representative college student population. It
includes 80 items rated on a 5-point Likert-style
scale to indicate the frequency of each behavior.
The present study included the Motivation
(a = .79), Time Management (a = .75), and Test
Strategies (a = .73) subscales. Higher scores on
Test Strategies and Time Management indicate
more frequent use of these skills. Higher scores
on the Motivation scale indicate willingness to
complete academic goals (Weinstein et al., 2002).
analytic approach
Growth mixture models (GMMs) were computed
in Mplus, Version 8.8 (Muthén & Muthén,
1998–2022)) to examine the differential trajecto-
ries of thinking, strategies for success, and ADHD
knowledge during the intervention and mainte-
nance periods. The GMMs also evaluated how
treatment condition (immediate vs. delayed) was
associated with differential change over time.
Instead of assuming that there is one underlying
population with a single change pattern, examin-
ing multiple latent subpopulations that differ in
model parameters (intercepts and slopes) allows
for variability around these parameters within
each class (Muthén & Muthén, 2000). GMMs
do not necessarily assume growth exists; rather,
latent classes may exhibit positive slopes, negative
slopes, or no change over time. A visual inspection
of individual trajectories indicated a high variabil-
ity between individuals, as well as a high number
of nonlinear trajectories. Specifically, for models
of strategies for success and ADHD knowledge,
trajectories exhibited periods of rapid acceleration
(i.e., skills acquisition) during the active phase fol-
lowed by a plateau during the maintenance phase.
To account for the rapid improvement that
occurred for many across baseline to postinterven-
tion, we used a freed loading growth model, where
the first time point was fixed to 0 and last time
point was fixed to 1, with all intermediate time
points freely estimated.
Consistent with recent studies using GMM to
examine treatment response heterogeneity (e.g.,
Breaux et al., 2019) we performed these analyses
in two steps each for thinking, strategies for suc-
cess, and ADHD knowledge. First, we evaluated
an unconditional GMM with classes K (in which
K = 1, 2, 3, 4). Following best practice (Muthén
& Muthén, 2000), we used a combination of
empirical criteria (i.e., [sample size adjusted] Baye-
sian Information Criterion [ssBIC], Akaike Infor-
mation Criteria [AIC], Lo-Mendell-Rubin [LMR]
adjusted likelihood ratio test for K-1 classes, boot-
strapped parametric likelihood ratio test [BLRT],
statistical significance of parameter estimates for
intercepts and slopes,) and substantive criteria
including classification probabilities greater than
.70 (i.e., how distinct each class is from the other
classes). We also examined class sizes, considering
classes with no less than 5% of the total sample
(Jung & Wickrama, 2008). Prior simulation stud-
ies support this sample size is sufficient for identi-
fying K = 1 to 4 classes (Lubke & Muthén, 2007;
Ram & Grimm, 2009). Once the best-fitting
model was determined, models were examined to
determine if trajectories had significant slopes
(i.e., indicating either improvement or worsening;
nonsignificant slopes indicated stable functioning).
To investigate the stability of each solution, we
reestimated the model with different starting val-
ues for the growth parameters. In each case, the
solution proved robust for different starting val-
ues, suggesting optimization was not achieved
through identification of a local maximum (Hipp
& Bauer, 2006).
Second, models were run with the auxiliary
function in Mplus using Vermunt’s three step pro-
cedure (Vermunt, 2010) with treatment condition
and baseline ADHD medication status as predic-
tors of class membership. Finally, we simultane-
ously included outcomes assessed at T3 (well-
being, daily functioning, EFs, inattention, time
management, test taking strategies, and motiva-
tion) to examine whether class membership was
differentially associated with outcomes at the end
of the maintenance phase. This approach involved
regressing treatment outcome variables, one at a
time, onto an indicator that represents an individ-
ual’s most likely GMM class membership (i.e., tra-
jectory that most closely approximated their data).
This minimizes potential bias in predictive models
by using information about classification probabil-
ities, obtained from the standard output of the
unconditional GMM to represent the measure-
ment error associated with forcing individuals into
a particular GMM class. To provide an estimate of
effect size for any significant predictors and out-
comes of class membership, Cohen’s d was calcu-
lated based on model estimated means and
standard errors for each class. As with the main
outcomes paper (Anastopoulos et al., 2021), an
intent-to-treat approach was utilized, including
any ACCESS participant who attended at least
one session. All participants were asked to com-
 mechanisms of treatment response to access
plete ratings, even if they didn’t consistently attend
treatment, and missing data were fairly low
(M = 15% across all three timpoints) and
addressed using full-information maximum likeli-
hood accommodated missing data (i.e., included
all available data for each participant). Intercorre-
lations and descriptive statistics for study variables
are presented in Table 2.
The study was registered at ClinicalTrials.gov
prior to publication of the initial efficacy manu-
scripts (NCT04186312). The dataset is publically
available and can be accessed at dataverse.unc.
edu.
Results
trajectories of treatment response
ADHD Knowledge
A three-class solution was the best-fitting model
for ADHD knowledge (see Table 3). Although
the adjusted LMR and bootstrapped LRT was
nonsignificant and both the 3-class and 4-class
solutions, the BIC increased in the 4-class solution,
supporting the 3-class model. Further, a visual
inspection of the 4-class solution demonstrated
two classes with parallel patterns (similar inter-
cepts and slopes) that were not qualitatively differ-
ent from the stable/low improving class in the 3-
class solution. Additionally, the smallest class size
for the 3-class model represented 15.9% of the
sample, however in the 4-class model there were
one class representing less than 2.5% of the sam-
ple. We retained the 3-class model solution as
the preferred unconditional model, which ade-
quately discriminated between classes with class
probabilities ranging from 0.80—0.84. All three
trajectories started with low levels of ADHD
knowledge (Figure 1a). The first trajectory had
low levels of ADHD knowledge (M = 18.02,
SE = 6.38), which increased significantly during
the intervention (low rapidly increasing class;
15.9%, lslope = 13.25, p = .003). A second class
(54.4%, moderate increasing class) started with
low ADHD knowledge (M = 22.32, SE = 0.95)
that increased moderately (lslope = 5.48,
p = .006). A third class (29.7%, low stable class)
had low initial levels of ADHD knowledge
(M = 19.68, SE = 0.89) that remained stable
throughout the intervention and follow-up
(lslope = 0.28, p = .906).
Treatment condition significantly predicted tra-
jectories of ADHD knowledge, v2(2) = 480.84,
p < .001. Specifically, individuals in the immediate
ACCESS intervention were significantly more
likely to be in the low rapidly increasing (100%)
relative to those in the delayed treatment condition
451
(0.0%) and were significantly less likely to be in
the moderately increasing (10.7%) and low/stable
(2.6%) classes relative to those in the delayed
treatment condition (89.3% and 97.4%, respec-
tively). The proportion of individuals in the
ACCESS condition was significantly greater in
the low rapidly increasing trajectory relative to
the moderately increasing, v2(1) = 59.42,
2
p < .001, and low/stable, v (1) = 301.75,
p < .001, trajectories. Medication status at base-
line was also significantly associated with trajecto-
ries of ADHD knowledge, v2(2) = 14.54, p = .011,
such that those in the low rapidly increasing trajec-
tory were much less likely to be taking medication
for ADHD at baseline (5.3%) relative to the mod-
erate increasing (42.2%; v2(1) = 8.45, p = .004)
and low/stable (51.2%; v2(1) = 13.40, p < .001)
classes. There were no differences between the
low/stable and moderately increasing trajectories
for either treatment condition (v2(1) = 0.33,
p = .569) or medication (v2(1) = 0.57, p = .452).
Being in the low rapidly increasing trajectory of
ADHD knowledge was significantly associated
with fewer inattention problems (ds = 0.42-.53)
and better time management skills (ds = 0.38-
0.54) at T3 compared to the moderate increasing
class and low/stable class (see Table 4). The low
rapidly increasing trajectory of ADHD knowledge
was also significantly associated with better daily
functioning (d = 0.44) and greater motivation
(d = 0.41) after treatment compared to those in
the low/stable class. There were no differences
between individuals in the low/stable and moder-
ate increasing trajectories at T3.
Behavioral Strategies
A three-class model was determined to be the best
fit for strategies for success (see Table 3). Although
the adjusted LMR and bootstrapped LRT was
nonsignificant for both the 3-class and 4-class
solutions, the AIC and BIC increased in the 4-
class solution, supporting the 3-class model. Fur-
ther, a visual inspection of the 4-class solution
demonstrated two classes with parallel patterns
(similar intercepts and slopes) that were not qual-
itatively different from the stable/low improving
class in the 3-class solution. The 4-class model also
contained one class representing less than 5% of
the sample (2.5%, n = 6). We retained the 3-class
model solution and this model adequately discrim-
inated between classes with class probabilities
ranging from 0.78—0.83. The first trajectory (Fig-
ure 1b) started with a relatively low frequency of
using behavioral strategies (M = 41.46,
SE = 4.06), which rapidly increased throughout
the active period and continued to increase during
 452
Table 2
Intercorrelations Between Study Variables
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1. Treatment Group –
2. ADHD Medication Status .04
3. T1 Cognitions .02 .10
4. T2 Cognitions .18*** .10 .57***
5. T3 Cognitions .21** .13 .57*** .73***
6. T1 Strategies .09 .11 .47*** .21** .24***

langberg et al.
7. T2 Strategies .46*** .07 .21** .40*** .34*** .42***
8. T3 Strategies .41*** .05 .22** .35*** .38*** .46*** .75***
9. T1 ADHD Knowledge .01 .15 .12 .02 .01 .03 .08 .02
10. T2 ADHD Knowledge .48*** .02 .23*** .01 .02 .05 .24*** .19** .53**
11. T3 ADHD Knowledge .57*** .001 .20** .04 .09 .07 .28*** .21** .48*** .81***
12. T3 AIMS Well-being .08 .04 .24*** .29*** .34*** .23** .33*** .45*** .002 .01 .02
13. T3 AIMS Daily Functioning .27*** .06 .23** .33*** .31*** .35*** .55*** .74*** .03 .16* .13 .65**
14. T3 BRIEF EF .19*** .15* .45*** .58*** .61*** .41*** .48** .61*** .04 .001 .01 .56** .65***
15. T3 CAARS Inattention .26*** .16* .38*** .51*** .58*** .39*** .48*** .54*** .10 .05 .07 .42*** .51*** .81***
16. T3 LAS Time Management .24** .09 .15* .28*** .29*** .35*** .42*** .63*** .02 .11 .06 .37*** .56*** .50*** .45***
17. T3 LAS Motivation .24** .06 .16* .28*** .30*** .35*** .46*** .62*** .01 .11 .07 .37*** .57*** .49*** .44*** .64***
18. T3 LAS Test Strategies .21** .08 .21** .39*** .40*** .29*** .33** .42*** .003 .13 .08 .33** .42** .60*** .62*** .51*** .44***
Ms .48 36.14 34.37 33.80 45.69 54.97 55.06 20.85 25.95 26.36 53.85 53.52 145.37 16.51 19.39 26.48 24.84
SDs .50 8.08 8.02 8.65 11.05 13.40 14.25 6.22 6.11 6.41 15.91 20.79 25.29 5.46 6.12 6.33 5.59
Note. T1 = baseline, T2 = immediate post intervention, T3 = 6 months follow-up/maintenance. AIMS = ADHD Impact Module-Adult. BRIEF = Behavior Rating Inventory of Executive Function–
Adult Version. CAARS = Conners Adult ADHD Rating Scale, Self-Report. LAS = Learning and Study Strategies Inventory.
* p < .05, ** p < .01, *** p < .001.
 mechanisms of treatment response to access 453
Table 3
Model Fit Statistics for Growth Mixture Models
Model AIC BIC ssBIC LMR p BLRT P
ADHD Knowledge
1 Class 4082.64 4107.26 4085.07 – – – –
2 Class 4083.26 4118.44 4086.74 5.07 .37 5.38 .38
3 Class 4083.04 4128.76 4087.55 5.87 .75 6.23 .31
4 Classa 4082.92 4139.20 4088.48 5.77 .05 6.12 .50
Strategies for Success
1 Class 5125.24 5149.89 5127.70 – – – –
2 Class 5114.43 5149.65 5117.94 5.43 .11 5.76 .33
3 Class 5110.27 5156.04 5114.83 9.59 .33 10.17 .08
4 Classa 5116.20 5172.55 5121.83 .06 .83 .06 .99
Maladaptive Cognitions
1 Class 4494.63 4519.28 4497.09 – – – –
2 Class 4494.80 4530.02 4498.32 5.49 .48 5.82 .26
3 Class 4489.23 4535.01 4493.70 10.91 .04 11.57 .07
4 Classa 4488.15 4544.49 4493.77 6.68 .25 7.09 .22
Note. Bolded row represents the best fitting model. AIC = Akaike Information Criterion. BIC = Bayesian Information Criterion.
ssBIC = sample size adjusted Bayesian Information Criterion. LMR = Lo-Mendell-Rubin adjusted likelihood ratio test. BLRT = boot-
strapped parametric likelihood ratio test. For the LMR and BLRT, tests are comparing the fit of one model to the previous (k-1 class)
model.
a
Four class solution had at least one class with fewer than n = 10 or (less than 4% of the sample).

the maintenance phase (18.1%, lslope = 28.51, inattention (ds = 0.99-1.03), as well as greater
p < .001; low rapidly increasing). A second trajec- time-management skills (ds = 0.87-1.32), motiva-
tory started with a moderate level of behavioral tion (ds = 0.79-1.21), and testing strategies
strategy use (M = 50.59 SE = 1.64) that increased (ds = 0.45-0.62) following treatment (Table 4).
particularly during the active phase of intervention There were no significant differences between indi-
(51.0%, lslope = 7.62, p < .001; moderate increas- viduals in the low rapidly increasing and moderate
ing). A third trajectory started with low use of increasing trajectories, except for daily function-
behavioral strategies (M = 40.09, SE = 1.74) that ing, which was significantly higher in the low
remained fairly stable (31.9%, lslope = 0.61, rapidly increasing group, v2(1) = 4.33, p = .038,
p = .794). d = 0.40.
Treatment condition significantly predicted tra-
Adaptive Thinking
jectories of behavioral strategies, v2(2) = 56.97,
A three-class model was determined to be the best
p < .001. Relative to the delayed treatment condi-
fit for the ACS-CV (see Table 3). The AIC and BIC
tion, individuals who received the ACCESS inter-
evidenced diminishing gains in estimating beyond
vention immediately were significantly more
a 3-class model. A nonsignificant adjusted likeli-
likely to be either in the group that started low
hood ratio statistic for the 4-class model and sig-
and made rapid improvements (86.4%; v2(1)
nificant adjusted Lo-Mendell-Rubin likelihood
= 53.72, p < .001) or in the moderate increasing
ratio test (LMR) test statistic for the 3-class model
group (59.2%; v2(1) = 19.90, p < .001), and less
provide further support for the 3-class model.
likely to be in the low/stable class (7.4%
Additionally, the smallest class size for the 3-
= ACCESS; 92.6% = delayed treatment). Individu-
class model represented 19.0% of the sample;
als in the ACCESS intervention condition were also
however, in the 4-class model there was one class
more likely to be in the group that started low and
representing less than 5% of the sample. We
rapidly improved relative to the moderate increas-
retained the 3-class model solution as the preferred
ing class, v2(1) = 4.75, p = .029. There were no sig-
unconditional model. This 3-class model ade-
nificant differences in medication status between
quately discriminated between classes with class
the trajectories, v2(2) = 0.48, p = .785. Being in
probabilities ranging from 0.82–.91. The trajecto-
either the group that started with low scores and
ries (Figure 1c) consisted of a class that started
increased or the group that started with moderate
with high impairment (M = 44.97, SE = 1.07) and
strategies use and increased was significantly asso-
remained high (“high stable” class; 19.0%), repre-
ciated with greater well-being (ds = 0.75-0.79),
senting more frequent engagement in maladaptive
better daily functioning (ds = 1.11-1.52), fewer
thinking patterns throughout the intervention
EF problems (ds = 1.10-1.12), less severe
 454
Table 4
Follow-up Treatment Outcomes by Trajectory Class Membership for Each Treatment Response Domain
Follow-up Treatment Class Specification Means Wald v2 Tests of Mean Equality
Outcomes
ADHD Knowledge Class 1: Low- Class 2: Mod- Class 3: Low-Stable Class 1 v. 2 d Class 1 v. 3 d Class 2 v. 3 d
Increasing Increasing
M (SE) M (SE) M (SE)
AIMS Well-being 57.41 (4.56) 53.21 (2.07) 53.08 (2.44) .56 .17 .72 .18 .01 .01
AIMS Daily Functioning 61.09 (4.92) 53.90 (2.87) 49.07 (3.01) 1.25 .22 4.47* .44 1.04 .16
BRIEF EF 135.59 (5.59) 147.54 (3.43) 146.47 (3.96) 2.61 .31 2.63 .32 .03 .03
CAARS Inattention 13.54 (1.12) 16.97 (.74) 17.28 (.84) 5.16* .42 7.42** .53 .06 .04
LAS Time Management 22.55 (1.08) 19.00 (.86) 18.50 (.92) 5.13* .38 8.55** .54 .12 .05
LAS Motivation 28.68 (1.31) 26.42 (.91) 25.56 (.87) 1.56 .22 4.16* .41 .37 .09
LAS Test Strategies 26.07 (1.31) 25.50 (.76) 23.18 (.87) .11 .07 3.49+ .38 3.10+ .28
Strategies for Success Class 1: Low- Class 2: Mod- Class 3: Low-Stable Class 1 v. 2 D Class 1 v. 3 d Class 2 v. 3 d

langberg et al.
Increasing Increasing
M (SE) M (SE) M (SE)
AIMS Well-being 59.90 (3.27) 58.94 (2.02) 41.63 (2.75) .05 .04 18.44*** .79 20.31*** .75
AIMS Daily Functioning 71.40 (4.00) 60.47 (2.43) 29.85 (3.20) 4.33* .40 64.65*** 1.52 50.11*** 1.11
BRIEF EF 131.77 (6.09) 135.70 (2.97) 172.61 (3.88) .27 .11 31.40*** 1.12 50.10*** 1.10
CAARS Inattention 14.03 (1.32) 14.42 (.69) 21.65 (.75) .06 .05 24.90*** 1.03 43.16*** .99
LAS Time Management 23.81 (1.24) 20.96 (.81) 13.54 (.86) 2.93+ .32 45.71*** 1.32 33.06*** .87
LAS Motivation 30.84 (1.00) 28.11 (.86) 20.60 (1.07) 3.36+ .30 49.47*** 1.21 24.28*** .79
LAS Test Strategies 26.92 (1.19) 25.83 (.74) 21.69 (1.01) .48 .13 11.35** .62 8.35** .49
Maladaptive Cognitions Class 1: High Class 2: Mod- Class 3: Low- Class 1 v. 2 D Class 1 v. 3 d Class 2 v. 3 d
Stable Decreasing Decreasing
M (SE) M (SE) M (SE)
AIMS Well-being 44.32 (2.72) 54.84 (1.75) 59.32 (2.54) 9.14** .52 16.95*** .78 1.83 .22
AIMS Daily Functioning 44.17 (4.25) 52.12 (2.17) 64.17 (3.50) 2.41 .30 13.98*** .72 7.58** .46
BRIEF EF 167.07 (4.50) 149.74 (2.36) 118.87 (3.66) 10.14** .60 69.89*** 1.64 43.22*** 1.10
CAARS Inattention 21.49 (.75) 17.05 (.53) 11.30 (.89) 20.38*** .74 78.57*** 1.65 26.42*** .89
LAS Time Management 15.98 (1.05) 18.74 (.61) 23.66 (1.23) 4.49* .38 23.09*** .90 10.90** .62
LAS Motivation 24.30 (1.35) 26.02 (.67) 29.30 (1.10) 1.13 .21 8.45** .57 5.42* .40
LAS Test Strategies 21.60 (1.14) 24.32 (.57) 28.65 (.92) 3.99* .39 23.69*** .95 13.32*** .63
Note. +p < .10. *p < .05. ** p < .01. *** p < .001; LAS = LASSI-2nd edition.
 mechanisms of treatment response to access
period (lslope = 0.41, p = 0.77). Two additional
classes demonstrating less frequent maladaptive
thinking were also observed: a “moderate decreas-
ing” class (56.7%) that started with moderate mal-
adaptive thoughts (M = 36.62, SE = 0.69) that
significantly decreased (lslope = -2.55, p = .002);
and a “low decreasing” class (24.3%) that started
with relatively lower maladaptive thoughts
(M = 28.25, SE = 0.98) that significantly decreased
after the active phase with continued improve-
ments through the maintenance phase (lslope = -
3.87, p = .001).
Treatment condition was not significantly asso-
ciated with trajectories of maladaptive thinking
patterns, v2(2) = 4.33, p = 0.115. However, indi-
viduals in the delayed treatment condition were
more likely to be in high stable maladaptive think-
ing trajectory (69.5%) relative to those in the
immediate ACCESS intervention (30.5%), v2(1)
= 3.71, p = 0.054. The proportion of individuals
in the ACCESS condition was not significantly dif-
ferent across the moderate decreasing trajectory
(50.4% delayed, 49.6% ACCESS) or the low
decreasing trajectory (43.4% delayed, 56.7%
ACCESS). Treatment condition was not associated
with any significant differences between the low
decreasing trajectory and the moderate decreasing
trajectory, v2(1) = 0.22, p = .642, or the high/
stable trajectory (v2(1) = 2.45, p = .117). There
were no significant differences in medication status
between the trajectories, v2(2) = 1.44, p = .488.
Being in the moderate decreasing trajectory rela-
tive to the high/stable trajectory was associated
with greater well-being (d = .52), fewer EF prob-
lems (d = .60), less inattention (d = .74), greater
time management (d = .38), and more effective
testing strategies (d = .39; see Table 4). Those in
the low decreasing trajectory had significantly bet-
ter outcomes than those in the high/stable trajec-
tory across all areas (ds from 0.57-1.65).
Relative to those in the moderate decreasing class,
participants in the low decreasing trajectory also
had significantly higher functioning at follow-up
across outcomes (ds from 0.40-1.10), except for
well-being (d = 0.22).
Discussion
Increased academic expectations and demands for
behavioral self-regulation combined with
decreased structure and monitoring make the col-
lege environment challenging for emerging adults
with ADHD. Promising psychosocial interventions
have been developed and vary widely in therapeu-
tic approach, ranging from organizational skills to
mindfulness to cognitive-behavioral therapy (e.g.,
Fleming et al., 2015; Gu et al., 2018). It is
455
important for the field to begin to identify core
clinical change mechanisms so that these interven-
tions can be refined and best-practice recommen-
dations established. The ACCESS intervention
provides psychoeducation about ADHD diagnosis,
co-occurring features, impairments, and treatment
(i.e., ADHD knowledge), behavioral skills strate-
gies (e.g., organizational skills), and adaptive
thinking strategies (e.g., identifying, challenging,
and replacing maladaptive thinking each session).
The present study evaluated trajectories of
response for these clinical change mechanisms
and whether they were associated with improve-
ment in symptoms and functional impairment.
Participants in ACCESS made robust improve-
ments in ADHD knowledge and behavioral strate-
gies. Improvement in behavioral strategies was
associated with moderate to large effect size
improvement on all outcomes, whereas ADHD
knowledge was primarily associated with moder-
ate improvements in symptoms of inattention
and time management. Adaptive thinking skills
displayed only small improvements over the course
of treatment and these improvements could not be
attributed to treatment condition. However, tra-
jectories of thinking were significantly associated
with both symptom and functional outcomes at
the follow-up assessments. Implications of these
findings for the treatment of college students with
ADHD and for intervention development and
refinement are discussed.
As shown in Figure 2, approximately 70% of
the sample made moderate to large improvements
in the knowledge and behavioral strategies clinical
change mechanisms. Participants in the ACCESS
intervention were far more likely to be in the tra-
jectory classes that made rapid gains on these mea-
sures relative to the delayed treatment control.
Contrary to hypotheses, improvement in behav-
ioral strategies was not only associated with aca-
demic outcomes but was also linked with
moderate to large effect size improvements in
well-being and overall functioning. It is notewor-
thy that significant improvement is what seems
to matter, not the magnitude of that improvement.
Specifically, both the moderate and high improv-
ing behavioral strategies trajectories significantly
outperformed the low and stable group, but differ-
ences between the moderate and high classes were
small in terms of effect sizes. This was different for
ADHD knowledge, where incremental improve-
ments seemed to matter more, with the high
improving class outperforming the moderate
improving class for both symptoms of inattention
and time management. It is important to note that
a wide variety of behavioral strategies are taught
456 langberg et al.
FIGURE 2 Trajectories of response from baseline (T1), post active phase (T2) and end maintenance phase (T3).
in ACCESS and assessed on the Strategies for Suc-
cess measure. For example, one session targets
accessing campus resources and self-advocacy,
another session targets strategies for consistently
attending class, and another session targets inter-
personal relationships. This is in addition to the
organizational skills and study strategies often
included in interventions for college students with
ADHD (e.g., Hartung et al., 2020; LaCount et al.,
2018).
The college environment is in some ways unique
in that disability and mental health services are
often readily available. However, many students
are not aware of the services, feel stigma about
pursuing services, are not comfortable self-
advocating for services, and/or find the documen-
tation requirements (e.g., a report) cumbersome
and costly. ACCESS directly addresses each of
these barriers to care. In fact, as part of ACCESS
sessions, college service providers (e.g., disability
services, writing support) come to group meetings
to provide brief, 20- to 30-minute introductions to
the services they offer and how to access them. As
demonstrated in the ACCESS RCT manuscript
(Anastopoulos et al., 2021), at baseline, partici-
pants in the treatment and control groups were
statistically equivalent with the types of services
they were receiving. However, at follow-up, 61%
of ACCESS participants were receiving disability
services (i.e., accommodations) as compared to
38% of the control (both groups less than 25%
at baseline). Interestingly, both ACCESS and
delayed participants increased ADHD medication
use from baseline to follow-up with no significant
 mechanisms of treatment response to access
differences (ACCESS baseline = 53% and
post = 67%; Delayed baseline = 42% and
post = 71%). Accordingly, it may be that provid-
ing documentation (i.e., the study initial evalua-
tion report) is sufficient for helping college
students with ADHD obtain medication services,
but that better understanding ADHD as a disor-
der, existing laws and regulations, and how to
self-advocate (i.e., ACCESS knowledge and behav-
ioral components), is necessary for students to
overcome stigma and to pursue accommodations.
As shown in Table 3, maladaptive thinking pat-
terns were strongly associated with symptom and
functional outcomes, and there were even substan-
tial incremental differences between each of the
classes (i.e., as opposed to just high v. low differ-
ences). Figure 2 shows that approximately 80%
of participants displayed reductions in maladap-
tive thinking. However, unlike the behavioral
strategies and knowledge clinical mechanisms
where classes that improved were almost all par-
ticipants represented in the ACCESS group, each
maladaptive thinking class had roughly equal
numbers of ACCESS and delayed treatment partic-
ipants. The only significant difference was that
69% of individuals in the group with the highest
level of maladaptive thinking were in the delayed
treatment compared to 31% in ACCESS. The mal-
adaptive thinking findings are novel and highlight
the benefits of this type of class trajectory
approach. Unlike a group or mean-based approach
where we might conclude that adaptive thinking
strategies don’t matter, our analyses show that
they are strongly associated with outcomes. How-
ever, the ACCESS treatment did not lead to a
robust change in maladaptive thinking. In some
ways this makes sense given that over 50% of
the sample had a diagnosed internalizing condi-
tion. The ACCESS intervention is relatively brief,
with maladaptive thinking only being addressed
for 30 minutes at a time for 8 group sessions. This
is in comparison to cognitive or cognitive-
behavioral therapy for depression which typically
includes 10–12, 50-minute sessions focused on
identifying, challenging, and replacing maladap-
tive thinking patterns with adaptive thinking pat-
terns that lead to improvements in emotional
well-being and functioning (Kazantzis et al.,
2018; Luo et al., 2020). It is important to note that
maladaptive thinking was most strongly associated
with the symptom outcomes (i.e., EF and inatten-
tion), which may be partially explained by similar-
ities across the constructs (see Table 3). However,
associations with well-being, overall functioning,
time-management, and test strategies were also
large and clinically meaningful effects when com-
457
paring the class with the highest level of maladap-
tive thinking to the class with the lowest. Further,
to our knowledge the ACCESS RCT was the first
to study the impact of intervention on overall
well-being with other studies focusing solely on
improvement in EF and ADHD symptoms and
academic functioning. Emerging adults with
ADHD have often experienced patterns of per-
ceived repeated failures by the time they reach col-
lege and struggle with self-esteem (Shaw-Zirt
et al., 2005). It is encouraging that both adaptive
thinking skills and behavioral strategies were asso-
ciated with moderate to large effects on well-being
when comparing the high versus low trajectories.
clinical implications and future
directions
This study provides important insights into the
clinical change mechanisms associated with symp-
toms and functioning in college students with
ADHD. The large (ds over 1.0) effects for the
behavioral strategies mechanisms suggest that
future interventions should focus on providing a
wide variety of behavioral strategies, rather than
limiting to academic or organizational strategies.
The ACCESS model is unique because after a brief
review of group content at the beginning of each
mentoring session, the participant picks which
strategies resonate with them and what they want
to work on. Participants develop both short- and
long-term goals to work towards for the strategies
they pick. In this way, the ACCESS model allows
treatment to be personalized, which may be
important given the diversity of clinical presenta-
tions and needs associated with ADHD in college
students. Additional work is needed to evaluate
the behavioral strategies data at the item level, to
determine which specific skills and strategies par-
ticipants are choosing to focus on and whether
effects can be parsed at the individual skill level.
Maladaptive thinking patterns were relatively
stable over the course of treatment. However,
being in the high, moderate, or low thinking
groups had significant implications for both func-
tional and symptom outcomes. These data suggest
that the ACCESS intervention may need to be
refined further, perhaps to utilize a modular
approach that provides additional content for col-
lege students who present with low self-esteem
and/or symptoms of depression. One option would
be for the mentors to dictate a focus on maladap-
tive thinking when participants score above a cer-
tain level at baseline. Another option would be to
have a separate three to five session ACCESS mod-
ule focused specifically on identifying and chal-
lenging maladaptive thinking that participants
458 langberg et al.
could enroll in during the maintenance phase of
treatment. Finally, the current ACCESS session
content and structure could be maintained, with
mentors making additional efforts to connect par-
ticipants with internalizing comorbidities with
campus-provided CBT. Regardless, it is important
for future treatment outcome research with college
students with ADHD to either take a CBT
approach (versus skills/behavioral only) or to
ensure that participants in strictly behavioral and
skills-based treatments are connected with a thera-
pist with expertise in internalizing conditions.
The present study highlights the importance and
utility of carefully identifying and frequently mea-
suring theorized mechanisms of change as recom-
mended by NIMH (Insel & Gogtay, 2014). In
this study, each mechanism (knowledge, behav-
ioral, cognitive) was addressed during every ses-
sion. The trajectory approach revealed some
interesting trends that will be important to study
further. For example, for behavioral strategies,
one group showed rapid uptake of skills (18% of
all study participants; 86% ACCESS participants),
starting lower than the moderate improving group
but ending up significantly higher than the moder-
ate improving group. In contrast, only 7% of the
group that did not make improvements in behav-
ioral strategies were ACCESS participants. Given
the large impact of behavioral strategies on out-
comes, it will be important to explore the charac-
teristics of participants who made such large and
rapid gains. Moderator analyses are warranted to
evaluate whether the ACCESS intervention bene-
fits a diverse range of participants across sex,
age, race/ethnicity, and comorbidity status. It
may be that the intervention needs to be tailored
to more fully meet the needs of students in certain
groups (e.g., freshman college students). The pro-
cess of treatment development for college students
with ADHD is still in the early stages. As such,
most of the studies published to date are pilot stud-
ies with fewer than 80 total participants, which
can make moderation analyses challenging from
a power perspective. RCTs as large as the ACCESS
study and larger will be needed to develop an ade-
quate understanding of what works for whom.
limitations
This study aimed to measure outcomes in a com-
prehensive manner, covering symptoms, function-
ing, and academic skills/strategies. However, it is
important to note that the scales used in this study
(e.g., BRIEF-A and LASSI-2) have many additional
subscales that could provide different or clinically
relevant information. Further, as with most studies
of college students, the outcome assessments were
self-report. This is typical in that in many classes
(e.g., large lecture) teachers may not know stu-
dents individually or observe behavior in a manner
sufficient to provide ratings. Further, parents are
no longer in a position to provide ratings and
not all students have friends who could accurately
rate their behavior (e.g., freshman) and/or they
may be uncomfortable asking friends or room-
mates to rate behavior. As a result, the findings
reported in this paper are subject to bias, in that
they are single informant, the informants were
aware whether they were in treatment or control,
and studies have shown some groups of students
with ADHD have difficulty rating their own
behavior accurately (Bourchtein et al., 2017).
The only non-self-report assessment collected in
the RCT was grade point average (GPA). How-
ever, as reported in (Eddy et al., 2021), no signif-
icant effects were found for GPA and slopes
between the treatment and control did not differ.
In both conditions, GPAs were stable and in the
mid-C range. Accordingly, GPA was not included
as a more objective outcome as it did not change
over time.
The ACCESS sample is fairly diverse, but lack of
detailed assessment of factors related to race/ethnic-
ity and gender is a limitation. Given the importance
of emerging adulthood for identity exploration and
formation, future studies should move beyond ask-
ing about sex and race, to ask about gender identity
and racial identity and centrality. In addition, con-
sidering the significant negative impact that struc-
tural and systemic racism has on college campuses
(Harwood et al., 2018; Squire et al., 2018), it is crit-
ical to begin to measure the impact of these factors.
Treatments such as ACCESS may need to be cultur-
ally adapted to acknowledge the importance of
these factors and the daily impact that they have
on access to care, stigma, and mental health inequi-
ties. It is worth noting that consistent with the col-
lege campuses where the study took place, 60% of
the sample identified as female. Accordingly, the
findings may not generalize to a sample with a more
typical 3:1 male to female ADHD ratio. Further,
since not all individuals ADHD attend college, it
would be important to evaluate whether the
ACCESS intervention is effective for emerging
adults with ADHD transitioning from high school
into the workplace.
conclusion
This was the first study to evaluate mechanisms of
clinical change in the psychosocial treatment of col-
lege students with ADHD. This study evaluated tra-
jectories of clinical change mechanisms—ADHD
knowledge, behavioral strategies, and adaptive
 mechanisms of treatment response to access
thinking—and their impact on symptoms and func-
tional outcomes. Participants in ACCESS made
large gains in behavioral strategies and ADHD
knowledge. In contrast, maladaptive thinking was
largely stable across the intervention period, with
the only treatment difference being that individuals
in the delayed treatment condition were more likely
to be in high stable maladaptive thinking trajectory
(69.5%) relative to those in the immediate ACCESS
intervention (30.5%). Behavioral strategies and
adaptive thinking trajectories displayed large and
significant associations with symptom and func-
tional outcomes with clinically meaningful effect
sizes differences. Knowledge trajectories displayed
small to moderate associations with improvement
on ADHD symptoms on inattention and use of
time-management strategies. The findings from this
study lend support to the conceptual foundation for
the ACCESS intervention; that ADHD knowledge,
behavioral skills and strategies, and adaptive think-
ing are important components in the treatment of
college students with ADHD. However, the results
of this study suggest that brief cognitive interven-
tion is unlikely to be sufficient given the high levels
of internalizing comorbidities found in college
ADHD samples. This study also highlights the
importance of teaching a broad range of behavioral
success strategies to include self-advocacy skills and
how to access available services.
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