CBT for College Students with ADHD: A Clinical Guide to ACCESS [1st ed.] 9783030331689, 9783030331696

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Arthur D. Anastopoulos Joshua M. Langberg Laura Hennis Besecker Laura D. Eddy

CBT for College Students with ADHD A Clinical Guide to ACCESS

CBT for College Students with ADHD

Arthur D. Anastopoulos • Joshua M. Langberg Laura Hennis Besecker • Laura D. Eddy

CBT for College Students with ADHD A Clinical Guide to ACCESS

Arthur D. Anastopoulos Department of Human Development and Family Studies University of North Carolina Greensboro Greensboro, NC, USA

Joshua M. Langberg Department of Psychology Virginia Commonwealth University Richmond, VA, USA

Laura Hennis Besecker Department of Human Development and Family Studies University of North Carolina Greensboro Greensboro, NC, USA

Laura D. Eddy Department of Human Development and Family Studies University of North Carolina Greensboro Greensboro, NC, USA

ISBN 978-3-030-33168-9    ISBN 978-3-030-33169-6 (eBook) https://doi.org/10.1007/978-3-030-33169-6 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To our families

Preface

College students with attention-deficit hyperactivity disorder (ADHD) commonly display clinically significant impairment in their academic, personal, social, and emotional functioning. Many such difficulties are evident as early as the first year of college, thereby placing students with ADHD at increased risk not only for taking longer to earn their degrees, but also for dropping out of school. For these and many other reasons, college students with ADHD need to have access to evidence-based treatments and support services. Unfortunately, very little treatment research has been conducted with the ADHD college student population. What research is available suggests that psychosocial interventions, especially those emphasizing cognitive-­behavioral therapy (CBT) approaches, can be very helpful. In addition to addressing their needs during college, CBT programs have great potential for providing students with the skills and knowledge that can facilitate their transition into new adult roles after they leave college. Over the past 8 years, our research teams at the University of North Carolina Greensboro (UNC Greensboro) and Virginia Commonwealth University (VCU) have been actively engaged in programmatic research to develop an evidence-based treatment for college students with ADHD.  Our program, known as ACCESS  – Accessing Campus Connections and Empowering Student Success – is a CBT intervention using group treatment and individual mentoring to give college students with ADHD the knowledge and skills necessary for bringing about improvements in their academic, personal, social, and emotional functioning. Our research findings provide strong support for the  efficacy  of the ACCESS program. Our purpose in writing this treatment manual is to provide guidance and assistance to others who may wish to implement ACCESS with postsecondary students with ADHD. The first chapter provides important background information about ADHD in college students; a review of treatment studies for this population; an overview of the rationale for the development of the ACCESS program; and a summary of the empirical evidence that we have generated attesting to its efficacy. Chapter 2 provides general guidance about the implementation of the group and mentoring components of ACCESS, as well as a discussion of qualifications necessary for delivering the program; student characteristics and scheduling issues that need to be taken into vii

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consideration; confidentiality issues; and suggestions for inviting guest speakers to provide information about the campus services they represent. Presented in Chaps. 3 through 11 is a detailed description of the steps necessary for implementing the group and mentoring components of ACCESS throughout treatment. This includes a clear statement of the goals for each session and the topics to be covered; guidance for implementing both the basics and nuances of the program; and handouts that are distributed to students to facilitate their understanding and mastery of information and skills targeted by the ACCESS program. At both UNC Greensboro and VCU, we have had great success in using ACCESS to help students with ADHD meet many of the challenges they face while attending college. Our program has been very well received by others on campus who serve this same population. Our hope is that ACCESS can be used as successfully by professionals who provide services to college students with ADHD, as it has been for us. It is in this spirit that we have written this treatment manual – as a guide for those who share our commitment to improving the daily lives of emerging adults with ADHD as they progress through college and begin their transition into postcollege adulthood. Greensboro, NC, USA  Arthur D. Anastopoulos Richmond, VA, USA   Joshua M. Langberg Greensboro, NC, USA   Laura Hennis Besecker Greensboro, NC, USA   Laura D. Eddy

Acknowledgments

The conceptualization and development of the ACCESS program would not have been possible without the assistance of many individuals, organizations, and agencies. Special thanks go to Kristen A. King, whose passion, tireless effort, and clinical expertise helped guide ACCESS from its earliest beginnings to what it has become today. We are also very grateful for the substantial contributions made by the various members of our research teams who served as group leaders, mentors, clinical evaluators, and support staff. This includes Erin Spence, Kaicee Beal, Rachel Reid, Jessica Goodman, Sophie Burke, Elizabeth Carter, Loren Ranson, Allison Bray, Sarah O’Rourke, Naomi Chatley, Michele Stewart, and Lydia Jodrey from the University of North Carolina Greensboro, as well as Lauren Oddo, Melissa Dvorsky, Stephen Molitor, Elizaveta Bourchtein, Zoe Smith, Hana-May Eadeh, Annie Wright, Farah Aslanzadeh, Nour Al Ghriwati, Rosanna Breaux, and Natalie Buchen from Virginia Commonwealth University. Additional thanks go to Kevin Murphy for his contribution as a clinical consultant and to Jeff Labban and Paul Silvia from the University of North Carolina Greensboro for their data management assistance and statistical expertise. Appreciation is also extended to the disability service offices, student health services, and counseling centers on both campuses for their ongoing assistance and support throughout the development and testing of the ACCESS program. We are especially grateful to the Institute of Education Sciences/US Department of Education for their generous grant award, without which our efficacy trial would not have been possible. Similarly, we would like to thank the College STAR Project and the funding agencies that supported our initial efforts to create and develop ACCESS, including the Oak Foundation, GlaxoSmithKline, and the Bryan, Weaver, Cemala, Tannenbaum Sternberger, and Michel Family Foundations in Greensboro, North Carolina. Finally, to all the students who participated in ACCESS, it was an honor and privilege to serve you – we are immensely grateful for your assistance in developing a program that can now be used to help other college students with ADHD.

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  1 ADHD in Emerging Adults Attending College������������������������������������     1 ADHD Overview ������������������������������������������������������������������������������������     1 Epidemiology��������������������������������������������������������������������������������������     2 Functional Impairment������������������������������������������������������������������������     2 Conceptual Understanding������������������������������������������������������������������     3 Summary����������������������������������������������������������������������������������������������     3 Assessment Issues������������������������������������������������������������������������������������     4 Diagnosing ADHD������������������������������������������������������������������������������     4 Co-occurring Conditions����������������������������������������������������������������������     5 Additional Assessment Considerations������������������������������������������������     5 Summary����������������������������������������������������������������������������������������������     7 Treatment ������������������������������������������������������������������������������������������������     7 Disability Accommodations and Pharmacotherapy ����������������������������     7 Psychosocial Interventions������������������������������������������������������������������     8 Critique of Psychosocial Treatment Literature������������������������������������     8 Summary����������������������������������������������������������������������������������������������     9 ACCESS��������������������������������������������������������������������������������������������������    10 Impetus for Developing ACCESS��������������������������������������������������������    10 College STAR Project��������������������������������������������������������������������������    11 Description of the ACCESS Program��������������������������������������������������    12 Empirical Support��������������������������������������������������������������������������������    14 Summary & Conclusions ��������������������������������������������������������������������    16 References������������������������������������������������������������������������������������������������    17   2 General Guidelines for Planning and Implementing ACCESS ��������    23 Planning ACCESS������������������������������������������������������������������������������������    23 Provider Qualifications������������������������������������������������������������������������    23 Student Characteristics������������������������������������������������������������������������    25 Scheduling Considerations������������������������������������������������������������������    26 Implementing ACCESS ��������������������������������������������������������������������������    27 Group Sessions������������������������������������������������������������������������������������    27 xi

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Mentoring Sessions������������������������������������������������������������������������������    27 Socratic Questioning����������������������������������������������������������������������������    28 Allocation of Time to Topics During Group and Mentoring Sessions ����������������������������������������������������������������������    29 Coordinating Delivery of Group and Mentoring Components������������    29 Confidentiality Issues��������������������������������������������������������������������������    30 Guest Speakers������������������������������������������������������������������������������������    31 Missed Meetings����������������������������������������������������������������������������������    31 Handouts����������������������������������������������������������������������������������������������    33 Using Components of ACCESS����������������������������������������������������������    33   3 Active Phase – Week 1 ��������������������������������������������������������������������������    35 Week 1 – Group ��������������������������������������������������������������������������������������    35 Introduction to ACCESS Program ������������������������������������������������������    35 ADHD Knowledge������������������������������������������������������������������������������    38 Behavioral Strategies ��������������������������������������������������������������������������    40 Adaptive Thinking Skills ��������������������������������������������������������������������    41 Ending Group Session��������������������������������������������������������������������������    42 Week 1 – Mentoring��������������������������������������������������������������������������������    42 Introduction & Confidentiality������������������������������������������������������������    42 Check-In����������������������������������������������������������������������������������������������    43 Collaborative Agenda Setting��������������������������������������������������������������    44 Learn More about the Mentee��������������������������������������������������������������    44 Clarify What Mentoring Is and Is Not ������������������������������������������������    45 Discuss Information Presented in Group ��������������������������������������������    45 Assess Mentee’s Strengths, Needs, and Goals������������������������������������    47 Ending Mentoring Session������������������������������������������������������������������    49 Week 1 – Group Agenda��������������������������������������������������������������������������    50 Week 1 – Group Handouts ����������������������������������������������������������������������    51 Week 1 – Mentoring Agenda ������������������������������������������������������������������    57 Week 1 – Mentoring Handouts����������������������������������������������������������������    58   4 Active Phase – Week 2 ��������������������������������������������������������������������������    63 Week 2 – Group ��������������������������������������������������������������������������������������    63 Beginning Group Session��������������������������������������������������������������������    63 ADHD Knowledge������������������������������������������������������������������������������    64 Behavioral Strategies ��������������������������������������������������������������������������    66 Adaptive Thinking Skills ��������������������������������������������������������������������    71 Ending Group Session��������������������������������������������������������������������������    73 Week 2 – Mentoring��������������������������������������������������������������������������������    73 Check-In����������������������������������������������������������������������������������������������    73 Collaborative Agenda Setting��������������������������������������������������������������    73 Review Between-Session Practice ������������������������������������������������������    74 Discuss Information Presented in Group ��������������������������������������������    74 Ending Mentoring Session������������������������������������������������������������������    76

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Week 2 – Group Agenda��������������������������������������������������������������������������    77 Week 2 – Group Handouts ����������������������������������������������������������������������    78 Week 2 – Mentoring Agenda ������������������������������������������������������������������    83 Week 2 – Mentoring Handouts����������������������������������������������������������������    84   5 Active Phase – Week 3 ��������������������������������������������������������������������������    87 Week 3 – Group ��������������������������������������������������������������������������������������    87 Beginning Group Session��������������������������������������������������������������������    87 ADHD Knowledge������������������������������������������������������������������������������    88 Behavioral Strategies ��������������������������������������������������������������������������    89 Adaptive Thinking ������������������������������������������������������������������������������    93 Ending Group Session��������������������������������������������������������������������������    95 Week 3 – Mentoring��������������������������������������������������������������������������������    95 Check-In����������������������������������������������������������������������������������������������    95 Collaborative Agenda Setting��������������������������������������������������������������    95 Review Between-Session Practice ������������������������������������������������������    96 Discuss Information Presented in Group ��������������������������������������������    96 Ending Mentoring Session������������������������������������������������������������������   100 Week 3 – Group Agenda��������������������������������������������������������������������������   101 Week 3 – Group Handouts ����������������������������������������������������������������������   102 Week 3 – Mentoring Agenda ������������������������������������������������������������������   108 Week 3 – Mentoring Handouts����������������������������������������������������������������   109   6 Active Phase – Week 4 ��������������������������������������������������������������������������   111 Week 4 – Group ��������������������������������������������������������������������������������������   111 Beginning Group Session��������������������������������������������������������������������   111 ADHD Knowledge������������������������������������������������������������������������������   112 Behavioral Strategies ��������������������������������������������������������������������������   113 Adaptive Thinking Skills ��������������������������������������������������������������������   116 Ending Group Session��������������������������������������������������������������������������   118 Week 4 – Mentoring��������������������������������������������������������������������������������   118 Check-In����������������������������������������������������������������������������������������������   118 Collaborative Agenda Setting��������������������������������������������������������������   118 Review Between-Session Practice ������������������������������������������������������   119 Discuss Information Presented in Group ��������������������������������������������   119 Ending Mentoring Session������������������������������������������������������������������   123 Week 4 – Group Agenda��������������������������������������������������������������������������   125 Week 4 – Group Handouts ����������������������������������������������������������������������   126 Week 4 – Mentoring Agenda ������������������������������������������������������������������   130   7 Active Phase – Week 5 ��������������������������������������������������������������������������   131 Week 5 – Group ��������������������������������������������������������������������������������������   131 Beginning Group Session��������������������������������������������������������������������   131 ADHD Knowledge������������������������������������������������������������������������������   132 Behavioral Strategies ��������������������������������������������������������������������������   133 Adaptive Thinking Skills ��������������������������������������������������������������������   137 Ending Group Session��������������������������������������������������������������������������   138

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Week 5 – Mentoring��������������������������������������������������������������������������������   138 Check-In����������������������������������������������������������������������������������������������   138 Collaborative Agenda Setting��������������������������������������������������������������   139 Review Between-Session Practice ������������������������������������������������������   139 Discuss Information Presented in Group ��������������������������������������������   140 Ending Mentoring Session������������������������������������������������������������������   145 Week 5 – Group Agenda��������������������������������������������������������������������������   146 Week 5 – Group Handouts ����������������������������������������������������������������������   147 Week 5 – Mentoring Agenda ������������������������������������������������������������������   151   8 Active Phase – Week 6 ��������������������������������������������������������������������������   153 Week 6 – Group ��������������������������������������������������������������������������������������   153 Beginning Group Session��������������������������������������������������������������������   153 ADHD Knowledge������������������������������������������������������������������������������   153 Behavioral Strategies ��������������������������������������������������������������������������   156 Adaptive Thinking ������������������������������������������������������������������������������   159 Ending Group Session��������������������������������������������������������������������������   160 Week 6 – Mentoring��������������������������������������������������������������������������������   160 Check-In����������������������������������������������������������������������������������������������   160 Collaborative Agenda Setting��������������������������������������������������������������   160 Review Between-Session Practice ������������������������������������������������������   161 Discuss Information Presented in Group ��������������������������������������������   161 Ending Mentoring Session������������������������������������������������������������������   166 Week 6 – Group Agenda��������������������������������������������������������������������������   167 Week 6 – Group Handouts ����������������������������������������������������������������������   168 Week 6 – Mentoring Agenda ������������������������������������������������������������������   172 9 Active Phase – Week 7 ��������������������������������������������������������������������������   173 Week 7 – Group ��������������������������������������������������������������������������������������   173 Beginning Group Session��������������������������������������������������������������������   173 ADHD Knowledge������������������������������������������������������������������������������   173 Behavioral Strategies ��������������������������������������������������������������������������   174 Adaptive Thinking Skills ��������������������������������������������������������������������   178 Ending Group Session��������������������������������������������������������������������������   179 Week 7 – Mentoring��������������������������������������������������������������������������������   179 Check-In����������������������������������������������������������������������������������������������   179 Collaborative Agenda Setting��������������������������������������������������������������   179 Review Between-Session Practice ������������������������������������������������������   179 Discuss Information Presented in Group ��������������������������������������������   180 Ending Mentoring Session������������������������������������������������������������������   185 Week 7 – Group Agenda��������������������������������������������������������������������������   186 Week 7 – Group Handouts ����������������������������������������������������������������������   187 Week 7 – Mentoring Agenda ������������������������������������������������������������������   192 Week 7 – Mentoring Handouts����������������������������������������������������������������   193

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10 Active Phase – Week 8 ��������������������������������������������������������������������������   195 Week 8 – Group ��������������������������������������������������������������������������������������   195 Beginning Group Session��������������������������������������������������������������������   195 ADHD Knowledge������������������������������������������������������������������������������   196 Behavioral Strategies ��������������������������������������������������������������������������   197 Adaptive Thinking Skills ��������������������������������������������������������������������   198 Ending Group Session��������������������������������������������������������������������������   199 Week 8 – Mentoring��������������������������������������������������������������������������������   200 Check-In����������������������������������������������������������������������������������������������   200 Collaborative Agenda Setting��������������������������������������������������������������   201 Review Between-Session Practice ������������������������������������������������������   201 Discuss Information Presented in Group ��������������������������������������������   201 Ending Mentoring Session������������������������������������������������������������������   205 Week 8 – Group Agenda��������������������������������������������������������������������������   206 Week 8 – Group Handouts ����������������������������������������������������������������������   207 Week 8 – Mentoring Agenda ������������������������������������������������������������������   211 Week 8 – Mentoring Handouts����������������������������������������������������������������   212 11 Maintenance Phase��������������������������������������������������������������������������������   217 Group Booster Session����������������������������������������������������������������������������   217 Beginning Group Booster Session ������������������������������������������������������   218 ADHD Knowledge������������������������������������������������������������������������������   218 Behavioral Strategies ��������������������������������������������������������������������������   219 Adaptive Thinking Skills ��������������������������������������������������������������������   220 Ending Group Booster Session������������������������������������������������������������   221 Mentoring������������������������������������������������������������������������������������������������   221 Initial Maintenance Phase Mentoring Session����������������������������������������   221 Check-In����������������������������������������������������������������������������������������������   222 Collaborative Agenda Setting��������������������������������������������������������������   222 Collaborative Planning Based on Current Needs and Goals����������������   223 Ending Mentoring Session������������������������������������������������������������������   227 Mid-Maintenance Phase Mentoring Session(s) ��������������������������������������   227 Check-In����������������������������������������������������������������������������������������������   228 Collaborative Agenda Setting��������������������������������������������������������������   228 Collaborative Planning Based on Current Needs and Goals����������������   228 Ending Mentoring Session������������������������������������������������������������������   230 Final Maintenance Phase Mentoring Session������������������������������������������   230 Check-In����������������������������������������������������������������������������������������������   230 Collaborative Agenda Setting��������������������������������������������������������������   231 Collaborative Planning Based on Current Needs and Goals����������������   231 Ending Mentoring Session������������������������������������������������������������������   232 Group Booster Session Agenda ��������������������������������������������������������������   234 Booster Group Handouts��������������������������������������������������������������������������   235

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Initial Maintenance Phase Mentoring Session Agenda����������������������������   238 Initial Maintenance Phase Mentoring Handouts��������������������������������������   239 Mid-Maintenance Phase Mentoring Session Agenda������������������������������   246 Final Maintenance Phase Mentoring Session Agenda ����������������������������   247 Index����������������������������������������������������������������������������������������������������������������   249

About the Authors

Arthur D. Anastopoulos, PhD  received his doctorate in clinical psychology from Purdue University and currently holds the position of Professor in the Department of Human Development and Family Studies at the University of North Carolina Greensboro, where he also directs an ADHD Clinic. Throughout his career, Dr. Anastopoulos has maintained clinical and research interests in the assessment and treatment of attention-deficit/hyperactivity disorder across the life span, with a current focus on emerging adults with ADHD attending college. Joshua M. Langberg, PhD  received his doctorate in clinical/community psychology from the University of South Carolina and currently holds the position of Professor in the Department of Psychology and serves as the Associate Dean for Research for the College of Humanities and Sciences at Virginia Commonwealth University. Throughout his career, Dr. Langberg has focused on the development and dissemination of interventions for adolescents and emerging adults with attention-­deficit/hyperactivity disorder that are feasible to implement in community and school settings. Laura Hennis Besecker, PhD  is a research scientist in the Department of Human Development and Family Studies at the University of North Carolina Greensboro, where she completed her doctorate in clinical psychology. In addition to her clinical work within the ADHD Clinic, Dr. Besecker is an instructor teaching graduate and undergraduate courses at both the University of North Carolina Greensboro and Elon University. Dr. Besecker’s clinical and research interests are focused on resilience and protective factors among youth with ADHD, anxiety, disruptive disorders, and health needs. Laura D. Eddy, PhD  is a research scientist in the ADHD Clinic in the Department of Human Development and Family Studies at the University of North Carolina Greensboro. She completed her doctorate in clinical psychology at Virginia

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About the Authors

Commonwealth University. Dr. Eddy’s clinical and research interests include cognitive-­ behavioral theory as applied to the treatment of individuals with ­attention-­deficit/hyperactivity disorder (ADHD), the overlap between comorbid internalizing conditions and ADHD, and the experiences of pregnant women with ADHD.

List of Figures

Fig. 1.1 ACCESS timeline ������������������������������������������������������������������������������  12 Fig. 1.2 Active phase content by week������������������������������������������������������������  13

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List of Tables

Table 1.1 Unique features of ACCESS������������������������������������������������������������  13

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Chapter 1

ADHD in Emerging Adults Attending College

Attention-Deficit Hyperactivity Disorder (ADHD; American Psychiatric Association [APA], 2013) is a mental health condition characterized by developmentally deviant levels of inattention, impulsivity, and hyperactivity that first arise in childhood, persist across the life span, and cause significant impairment in many domains of daily life functioning. Although much has been written about the impact of ADHD on young children, adolescents, and adults (Barkley, 2015), relatively less attention has been directed to its clinical presentation among individuals 18 to 25-years of age, transitioning through the developmental period known as emerging adulthood (Arnett, 2007). Recently, however, there has been a surge of research and clinical interest in this subgroup of the ADHD population, primarily focused on individuals attending college (Green & Rabiner, 2012; Prevatt, 2016; Weyandt & DuPaul, 2012). Because up-to-date knowledge of ADHD is one of the keys to successful clinical management of this disorder, this chapter begins with an overview of ADHD, after which its clinical presentation, assessment issues, and co-occurring conditions are discussed. This is followed by a review of published research studies that have examined the therapeutic impact of various treatment approaches for college students with ADHD. The remainder of this chapter focuses on ACCESS – Accessing Campus Connections and Empowering Student Success - addressing our rationale for its development, the iterative steps taken to pilot test and refine it, a detailed description of the program’s major treatment components, and a brief summary of research findings that our research team has generated attesting to its efficacy.

ADHD Overview ADHD is a neurodevelopmental disorder with symptoms first presenting in childhood (APA, 2013). The two major symptom categories, inattention and hyperactivity-­ impulsivity, include behaviors such as forgetfulness, trouble sustaining attention,

© Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_1

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difficulties with organization, fidgeting, talking excessively, and interrupting others. Although anyone may display these behaviors at times, individuals with ADHD do so much more frequently, to a degree that exceeds what might reasonably be expected relative to those of the same age and gender (APA, 2013). The presence of ADHD symptoms reflects an overarching, brain-based deficit in the ability to self-­ regulate, leading to a host of problems in everyday life (Barkley, 2015). Commonly, individuals with ADHD also experience problems with executive functioning, which involves the ability to plan, organize and monitor one’s own behavior in order to meet goals (Barkley & Murphy, 2011; see Solanto, 2015 for an in-depth discussion of this topic).

Epidemiology Prevalence estimates suggest that from 3.5% to 7% of children meet criteria for ADHD (Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015; Thomas, Sanders, Doust, Beller, & Glasziou, 2015; Willcutt, 2012). An estimated 65% of children and adolescents with ADHD continue to meet full diagnostic criteria for ADHD in adulthood (Barkley, Murphy, & Fischer, 2008), albeit at slightly lower prevalence rates (2.8–5%; Fayyad et  al., 2017; Kessler et  al., 2006; Matte et  al., 2015). Consistent with these findings, prevalence estimates for ADHD among college students range from 5–8% (Eagan et al., 2014; Wolf, Simkowitz, & Carlson, 2009). Individuals with ADHD also represent a substantial percentage of the students requesting disability accommodations on college campuses (DuPaul, Weyandt, O’Dell, & Varejao, 2009).

Functional Impairment The impairment that ADHD can cause is a serious matter, both to the student and to institutions concerned with graduation rates and retention issues. Compared to their peers, college students with ADHD demonstrate significantly lower grade point averages (GPA; DuPaul et al., 2018; Gormley, DuPaul, Weyandt, & Anastopoulos, 2016), are more likely to withdraw from courses (DuPaul et al., 2018), and are at increased risk for dropping out of college (Barkley et al., 2008; DuPaul et al., 2018; Hechtman, 2017). Even when students with ADHD remain in college, it is often the case that they take longer to complete their degrees compared to college students without ADHD (Hechtman, 2017). Moreover, the difficulties experienced by college students with ADHD are not limited to academics. Of additional clinical significance is the fact that college students with ADHD are at increased risk for displaying co-occurring mental health problems, including depression and anxiety disorders (Anastopoulos et al., 2018a), as well as histories of suicidal ideation and attempts (Eddy, Eadeh, Breaux, & Langberg, 2019). Students with higher levels of

ADHD Overview

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ADHD symptoms also report more problems in their relationships with others (Sacchetti, & Lefler, 2017), such as trouble handling conflicts (McKee, 2017) and poor relationship quality (Bruner, Kuryluk, & Whitton, 2015). Deficits in the ability to regulate emotions occur at higher rates among children and adults with ADHD and are associated with more psychosocial difficulties in this group (Anastopoulos et al., 2011; Surman et al., 2013). Although rates of substance use are high within the general college student population (O’Malley & Johnston, 2002), college students with ADHD are even more likely than peers to engage in dangerous or problematic patterns of substance use (Baker, Prevatt, & Proctor, 2012; Rooney, Chronis-Tuscano, & Yoon, 2012). Given such challenges, it should come as no surprise that college students with ADHD also report an overall lower quality of life than their peers (Pinho, Manz, DuPaul, Anastopoulos, & Weyandt, 2019).

Conceptual Understanding The fact that deficits in self-regulation are inherent in ADHD helps to explain why emerging adults with this condition are particularly prone to struggle in comparison with their college peers (Fleming & McMahon, 2012). This explanation stems in part from a consideration of a “perfect storm” of life circumstances that converge during this developmental period (Anastopoulos & King, 2015). For any individual, enrollment in college places increased demands for self-regulating a much wider range of responsibilities than was the case during high school, often encompassing academic, personal, social, health, and financial matters. For example, students arriving on a college campus for their first semester are expected to attend classes on time, successfully manage and prioritize the multiple academic assignments of each class, while at the same time also managing their money, doing laundry, taking charge of their meals, and making new friendships. For many if not most college students, this is the first time they have taken on this amount of responsibility without immediately available support from parents, and this adjustment can be quite challenging. For students with ADHD, this developmental challenge is even greater due to a diminished capacity for self-regulation that is inherent in having ADHD. Further complicating matters is that, as these demands for self-regulation increase, support from parents, academic accommodations, and other types of ADHD treatments (e.g., stimulant medication therapy) are often discontinued.

Summary Even though many students with ADHD are successful enough during high school to be accepted into college, they are at increased risk for experiencing significant educational and psychosocial difficulties throughout their college years. The mismatch that exists between their diminished capacity for self-regulation and the

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increased demands for self-regulation that arise during college sets the stage for these difficulties to occur. As parental support and other ADHD treatments are withdrawn, such problems intensify. Because large numbers of individuals with ADHD are currently attending college and these enrollments are continuing to grow (Wolf et al., 2009), there is much need for developing evidence-based interventions for this population.

Assessment Issues Diagnosing ADHD Although it may not be necessary for professionals providing treatment services to be responsible for conducting the initial assessment documenting the presence of ADHD, it nevertheless is important for them to be familiar with the process. Being aware of the assessment process allows them to share this information with students under their care, thereby helping them become more informed consumers of ADHD assessment services. A “gold-standard” assessment for an adult with ADHD includes information gathered using multiple methods, from multiple informants (see Ramsay, 2015 for a thorough discussion of assessment of ADHD in adults). Clinicians conducting an assessment should aim to gather data on ADHD symptoms, co-occurring conditions, and functional impairment using clinical interviews, rating scales, and available records, such as prior evaluation reports. As much as possible, clinicians should also gather information from other informants, such as parents, significant others or even roommates, as the combination of information gathered via self-report and other-report has been shown to optimize the ability to accurately detect ADHD and avoid false positive diagnoses (Sibley et al., 2012). The amount and type of clinical assessment data needs to be sufficient to thoroughly and accurately address the five major criteria for diagnosing ADHD that are listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; APA, 2013). An especially important criterion is whether there is current impairment in functioning associated with ADHD symptoms. DSM-5 also requires the frequent presence of at least 5 out of 9 inattention symptoms and/or 5 out of 9 hyperactive-impulsive symptoms, which deviate significantly from developmental expectations. Although it is not uncommon to use frequency counts to identify ADHD, research findings have clearly indicated that it is essential to assess for both impairment and symptoms, because the presence of one does not necessarily guarantee the presence of the other (DuPaul, Reid, Anastopoulos, & Power, 2014; Gathje, Lewandowski, & Gordon, 2008; Gordon et al., 2006). An equally important DSM-5 requirement is that the presence of other mental health and medical conditions must be ruled out, before a diagnosis of ADHD can be established. Thus, information about other conditions that might better account for observed impairments should be routinely collected. To establish a formal diagnosis, DSM-5 also

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requires clear evidence that ADHD symptoms occur in 2 or more settings and that the onset of these symptoms first appeared prior to 12-years of age. A commonly occurring assessment challenge arises when two or more mental health conditions are suspected of being present. To help make a differential diagnosis, it is important to consider the age at which symptoms of ADHD and the other conditions initially appeared. While ADHD symptoms typically present for the first time in childhood, the onset of depression and anxiety disorders, for example, generally occurs during adolescence (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). Thus, by examining the timeline for when ADHD and co-­occurring disorders first arise, it becomes possible to get a clearer diagnostic picture. For example, in situations where there is compelling evidence that ADHD occurred years before the onset of clinically significant depression or anxiety issues, that would bolster the evidence in favor of establishing an ADHD diagnosis. In addition to timeline issues, considering whether symptoms are episodic or chronic can be helpful in making a differential diagnosis. To this point, in contrast with symptoms of ADHD that are chronic, symptoms of depression are most prevalent and impairing during distinct depressive episodes. Thus, for a college student who has difficulty concentrating only during periods of depression, one would be disinclined to attribute these symptoms to ADHD.  Conversely, if concentration problems exist whether depression is present or not, this would be evidence pointing towards a possible ADHD diagnosis.

Co-occurring Conditions After determining that other mental health conditions do not better account for the presence of ADHD symptoms and impairments, it then becomes necessary to consider whether other psychiatric disorders may be present in addition to ADHD. In combination with ADHD, co-occurring conditions can intensify the overall severity of an individual’s psychosocial difficulties and therefore should also be addressed as part of an overall clinical management plan. Other mental health concerns commonly co-occur with ADHD across the life span (Pliszka, 2015) and emerging adulthood is no exception. In a recent study of first year college students, 55% of those with ADHD were also diagnosed with another mental health condition, most often Major Depressive Disorder or Generalized Anxiety Disorder (Anastopoulos et al., 2018a). Accordingly, comprehensive assessment of ADHD should routinely include an evaluation of co-occurring conditions.

Additional Assessment Considerations College students with ADHD represent a unique group, due to their age and the distinctive aspects of the college environment. As part of the transition to college, students often move out of their parents’ home for the first time. As a result, they

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have less access to the major sources of support typically utilized to be successful in high school. College students must also balance long-term planning about careers, choosing a major, and meeting course requirements with day- to-day responsibilities. Of additional significance is that college students typically have irregular schedules (e.g., classes on some days but not on others, classes at different times each day) and varying workloads (e.g., light at the beginning and heavy at the end of the semester). This irregularity is particularly challenging in the presence of ADHD, as it requires students to adjust to a changing daily routine and interferes with coping techniques used to manage symptoms, such as consistent routines. Thus, the college environment can serve to exacerbate, or make it more difficult to manage, ADHD symptoms. Sometimes, ADHD symptoms that were present but subclinical during adolescence, move into the clinical range in college, due in part to the nature of the environment. For this reason, it is not uncommon for ADHD to be diagnosed for the first time during college. Clinicians assessing ADHD in college students should also bear in mind that the assessment of this population relies primarily on information provided by the students themselves. This represents a change from the assessment process typically used to diagnose ADHD in childhood or adolescence, which relies primarily on information provided by others (e.g., parents, teachers). This shift in emphasis from an assessment approach that relies on other report to one that instead relies on self-­ report can also help explain why some individuals with ADHD come to clinical attention for the first time as young adults. In childhood and adolescence, parents and teachers initiate referrals for ADHD assessments when the behaviors displayed by a child are outwardly observable and sufficiently disruptive to the environment. In adulthood, individuals may seek out assessments and treatment due to concerns about ADHD symptoms that are primarily internal and harder for others to observe, such as restlessness and distractibility. Another important assessment issue is the need for having historical information that can accurately document the onset, course, and associated impairments of ADHD from childhood to the present. Emerging adults are often not reliable reporters of this type of information, thereby highlighting the importance of obtaining reports from parents. Although most college students with ADHD are comfortable consenting to obtaining parental input, there can be many obstacles to this happening. For example, college students with ADHD frequently live away from home; thus, it may be difficult to collect rating scale information from parents. For a variety of reasons, some college students may not be willing to include their parents in the assessment process, or their parents may no longer be available. In the absence of parental input, getting information from an older sibling or someone else who knew the student as a child can sometimes suffice. It can also be very helpful to obtain information from a spouse, partner, close friend, or roommate to get a perspective on the individual’s current functioning, in addition to that available from the individual’s self-report.

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Summary Accurate identification of ADHD and its co-occurring features is an important first step that guides the selection and implementation of appropriate evidence-based treatments. Multi-method, multi-informant assessments are well suited to gathering the types of clinical evaluation data that allow for a determination of whether all DSM-5 criteria for ADHD have been met. Due to their age and the distinctive aspects of a college environment, emerging adults pose unique assessment challenges that need to be taken into consideration to ensure diagnostic accuracy.

Treatment Disability Accommodations and Pharmacotherapy On many college campuses, disability services are the primary mechanism by which students with ADHD receive assistance, most often in the form of extended time on tests and various other accommodations (Wolf et al., 2009). Unfortunately, many college students choose not to use such services (Fleming & McMahon, 2012). Of additional concern is that when used alone, accommodations appear to produce minimal long-term benefits (e.g., Lewandowski, Gathje, Lovett, & Gordon, 2013; Miller, Lewandowski, & Antshel, 2015; Pariseau, Fabiano, Massetti, Hart, & Pelham, 2010) and do not address co-occurring difficulties, such as executive functioning deficits (Antshel, Hier, & Barkley, 2014; Dvorsky & Langberg, 2014) and emotional distress (Anastopoulos et al., 2018a). Although stimulant medications and other forms of pharmacotherapy have been shown to be effective and relatively safe for children and adults (Barkley, 2015; Faraone & Glatt, 2010), their use with emerging adults attending college has been understudied. To date, only one well-controlled stimulant medication trial has focused specifically on college students (DuPaul et  al., 2012). The results of this study demonstrated that lisdexamfetamine dimesylate (e.g., Vyvanse) significantly reduced ADHD symptoms and improved executive functioning. Despite the promising nature of these findings, additional medication trials are necessary to address the efficacy and safety of these medications, as well as concerns regarding the risk for misuse, abuse, and diversion on college campuses (Benson, Flory, Humphreys, & Lee, 2015; Kaye & Darke, 2012; Rabiner et al., 2009). Future clinical trial researchers should also take into consideration the unique aspects of a college ­environment and how that might impact the way in which medications are prescribed. To this point, although most prescribers generally advise a daily medication regimen with medication administered at the same time each day, this schedule of treatment may be far less realistic for a college student who may not have classes every day, whose classes may start at different times each day, and who experiences fluctuating academic demands at different times in the semester (e.g., final exam week). In addition,

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1  ADHD in Emerging Adults Attending College

college students often face challenges with getting medication refilled and dosages changed as their primary care physician may be in a location far from campus. In sum, there are many unanswered questions about best practices for the use and prescription of stimulants and other medications for college students with ADHD.

Psychosocial Interventions Although disability accommodations and pharmacotherapy have historically been the main forms of treatment available to college students with ADHD, their use with this population has not been well established empirically. Of further concern is that these treatments do not adequately address the broad range of co-occurring features and functional impairments displayed by college students with this condition. Such limitations make clear the need for additional treatment options. In response to this situation, a small but growing number of studies has recently investigated the use of psychosocial interventions to treat ADHD in college students (see He & Antshel, 2016 for a review). One line of research has investigated a coaching approach, utilizing goal setting, organization, and time management (Field, Parker, Sawilowsky, & Rolands, 2013; Prevatt & Yelland, 2015; Swartz, Prevatt, & Proctor, 2005). Other research groups have tested interventions using cognitive-behavioral therapy (CBT; Eddy, Canu, Broman-Fulks, & Michael, 2015; LaCount, Hartung, Shelton, Clapp, & Clapp, 2015), dialectical behavior therapy (DBT, Fleming, McMahon, Moran, Peterson, & Dreessen, 2015), mindfulness-­ based cognitive therapy (Gu, Xu, & Zhu, 2018), self-monitoring (Scheithauer & Kelley, 2017), and organization, time management, and planning (OTMP) skills training (LaCount, Hartung, Shelton, & Stevens, 2018). Findings from these initial psychosocial investigations revealed significant improvements in primary ADHD symptoms, most often related to reduced inattentiveness (Eddy et al. 2015; Gu et al., 2018; Fleming et al., 2015; LaCount et al., 2015; LaCount et al., 2018). Improvements in self-reported executive functioning have also been noted (Fleming et al., 2015). Although not routinely assessed, gains in self-reported learning strategies and educational functioning have been found (LaCount et al., 2015; LaCount et al., 2018; Prevatt & Yelland, 2015). Notably, corresponding increases in GPA have not been reliably demonstrated (Fleming et al., 2015; Gu et al., 2018; LaCount et al., 2018). Likewise, reduced levels of depression and anxiety symptoms have been reported in some (Gu et al., 2018) but not all studies (Fleming et al., 2015).

Critique of Psychosocial Treatment Literature Results from this emerging literature offer much promise for the role that psychosocial interventions may ultimately play in the overall clinical management of college students with ADHD. At the same time, however, it is necessary to acknowledge

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that findings have been inconsistent across extant studies, which limits conclusions about efficacy. Because programmatic research in this area has been lacking, many of these inconsistent findings are likely attributable to methodological and conceptual differences across studies (He & Antshel, 2016). This includes, for example, cross-study differences in the rigor used to identify ADHD and the degree to which comorbid psychiatric conditions were addressed. Additional cross-study differences are evident with respect to the conceptual underpinnings of treatment (e.g., CBT, DBT, coaching, OTMP), which can impact what is targeted for treatment. For example, DBT and mindfulness-based cognitive therapy approaches typically do not include a strong emphasis on the concrete academic skills needed to succeed in a college environment, such as planning a schedule, studying effectively, or managing long-term projects. Conversely, interventions focused on organization and time management skills, as well as coaching approaches, may not sufficiently address commonly occurring struggles associated with depression and anxiety (e.g., maladaptive thoughts and beliefs). These types of mental health concerns, which have been found to occur in up to 55% of first year college students with ADHD (Anastopoulos et al., 2018a), are associated with significant impairment, including lower graduation rates (Salzer, 2012). Moreover, they can interfere with the efficacy of traditional ADHD treatments if not directly addressed. In most of the reported psychosocial treatment studies, the number of treatment sessions offered has been short-term in nature (i.e., 3–10 sessions across 1–3 months), which runs counter to the prevailing view that treatment of ADHD must be more intensive and sustained over longer periods of time to have lasting impact (Smith, Barkley, & Shapiro, 2006). Relatedly, in only one of the above studies was a follow­up outcome assessment included, 3 months after treatment was completed (Fleming et al., 2015). Thus, much remains to be learned about the persistence of therapeutic gains once participation in psychosocial treatment has been completed. Finally, in none of the above interventions was there a focus on accessing outside support and resources  – e.g., disability offices, counseling centers, student health services  – which are readily available on college campuses and can be used together with psychosocial interventions.

Summary Although disability accommodations and stimulant medication are commonly used to treat ADHD in college students, empirical support for their use is minimal or lacking. For this reason and because these treatments do not address many of the co-occurring features and functional impairments that are often displayed by college students with ADHD, there has been a recent surge of research interest in developing psychosocial treatments to fill this void. Initial results from these investigations are promising but definitive conclusions about the efficacy of many of these psychosocial treatment approaches cannot be drawn at this time, due to conceptual differences, methodological limitations, and the dearth of programmatic

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research addressing this topic. One exception to this situation is the ACCESS intervention, which was developed systematically and addresses many of the limitations in previously reported treatment programs.

ACCESS Impetus for Developing ACCESS The need for developing an evidence-based intervention for college students with ADHD initially came to our attention through our clinical services. Beginning in 2008, the ADHD Clinic at UNC Greensboro saw a steady increase in referrals requesting evaluations of college students for ADHD concerns. Although some of these referrals were initiated by the students themselves, the vast majority emanated from the disability services office, Student Health Services, and the Counseling Center, all of whom needed current documentation of the students’ ADHD status before providing accommodations, medication, and counseling, respectively. It was through this ongoing process of conducting comprehensive diagnostic evaluations that we became keenly aware of the struggles that these emerging adults were experiencing in college. Particularly noteworthy were three important observations. For a substantial number of these students, their clinical presentations were seldom limited to ADHD; co-occurring depressive disorders, anxiety disorders, and other mental health conditions were quite common. Another prominent feature of their clinical presentations was the pervasive impact of their ADHD symptoms, interfering not only with their academic functioning, but also with their personal, social, emotional, and vocational functioning. Even though many of these students were receiving disability accommodations and other campus support services, they were continuing to struggle. Collectively, these observations suggested that something more was needed to address the clinical needs of the ADHD college population. To address this issue, we first turned to the research literature for guidance. Consistent with reviews of this literature at that time (DuPaul & Weyandt, 2009; Green & Rabiner, 2012), we found very little to guide us, apart from a limited number of published findings regarding the use of coaching (Reaser, Prevatt, Petscher, & Proctor, 2007; Swartz et  al., 2005). We then shifted our attention to the adult ADHD literature and identified two psychosocial treatment approaches with evidence of efficacy (Safren, Perlman, Sprich, & Otto, 2005; Solanto, 2011). Inherent in both approaches was an emphasis on the use of CBT strategies, including psychoeducation about ADHD, behavioral strategies, and cognitive therapy techniques. In the Safren protocol (Safren et  al., 2005), treatment was delivered individually, whereas in the Solanto (2011) program, a group format was utilized. Although both approaches seemed promising, neither had been evaluated empirically in the context of an ADHD college student population.

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College STAR Project In the spring of 2011, we were very fortunate to become part of the College STAR (Supporting Transition, Access, & Retention) Project, which is a University of North Carolina (UNC) System project focused on meeting the needs of college students with learning challenges. During our involvement from 2011 through 2014, a total of three UNC System campuses comprised College STAR, including East Carolina University (ECU) as the lead institution and Appalachian State University (ASU). Funding for the project at that time was provided through the generous support of the Oak Foundation, the GlaxoSmithKline Foundation, and several Greensboro North Carolina private foundations, including the Bryan Foundation, Weaver Foundation, Cemala Foundation, Tannenbaum Sternberger Foundation, and Michel Family Foundation. Across all three College STAR campuses, efforts were directed towards creating faculty development and student support programming to address the needs of college students with ADHD (UNCG), learning disabilities (ECU), and executive functioning difficulties (ASU). Our research team at UNC Greensboro was responsible for developing the student support piece, which is how ACCESS was initially conceptualized, developed, and pilot tested. Although many elements of the Safren (Safren et al., 2005) and Solanto (2011) programs were appealing, we were not certain if they could be implemented in their current form to students with ADHD attending college, given the very different developmental needs of this population versus the adults for whom these approaches had been developed. In the summer of 2011, we devoted a great deal of time and energy to conceptualizing a more developmentally appropriate adaptation of these approaches. Based on our analysis of these adult CBT programs, we decided that it was important to include developmentally appropriate psychoeducation about ADHD, behavioral strategies, and cognitive therapy skills in ACCESS. Rather than make a forced choice between individual (Safren et al., 2005) versus group formats (Solanto, 2011), we opted to use both. In light of research showing that treatment of ADHD must be sustained over longer periods of time to have lasting impact (Smith et  al., 2006), we also determined that it would be best to increase the length of ACCESS beyond the typical 8–12 weeks in which most treatments are delivered. To address this latter issue, we envisioned an initial active treatment phase, during which intensive treatment would be provided, followed by a maintenance phase that allowed for gradual withdrawal of treatment. Although these general parameters of ACCESS were clear in our minds, the exact details of how they would take shape were not. We initially considered active treatment phases ranging from 6 to 10 weeks in length, as well as a maintenance phase spanning anywhere from one to three semesters. During our involvement in the College STAR Project from 2011–2014, we implemented and evaluated these options, along with many other treatment delivery details. This iterative process of reviewing and refining our treatment approach is what ultimately allowed us to optimize ACCESS for its current use with the ADHD college student population.

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Description of the ACCESS Program ACCESS incorporates elements of the empirically supported adult CBT programs (Safren et al., 2005; Solanto, 2011), adapted to the developmental needs of emerging adults with ADHD in college. As shown in Fig. 1.1, 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 of these semesters, treatment is delivered in both a group and individual mentoring format. The active phase of the intervention includes eight

Semester 1 - Active Phase Month 1

Month 2

Semester 2 - Maintenance Phase Month 3

|----------8 Group Sessions-----------|

|---------8 to 10 Mentoring Sessions-----|

Month 1

Month 2

Month 3

Group Booster Session

|----Up to 6 Mentoring Sessions----|

Fig. 1.1  ACCESS timeline

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. As part of the process of fading treatment, only one 90-minute booster group session is offered during the maintenance phase, along with up to six 30-minute individual mentoring sessions distributed across the semester. Both treatment delivery formats are used to address the overall purpose of the ACCESS program – namely, to give college students with ADHD the knowledge and skills necessary to be successful in their daily life functioning. In line with the adult CBT programs (Safren et  al., 2005; Solanto, 2011), ACCESS is designed to increase knowledge of ADHD; to improve organization, time management, and other behavioral skills that address executive functioning deficits; and to increase adaptive thinking skills via cognitive therapy strategies. The underlying premise of ACCESS is that treatment-induced changes in these three domains will facilitate improvements in multiple areas of daily life functioning that are commonly impacted by ADHD. As such, ADHD knowledge, behavioral strategies, and adaptive thinking skills are conceptualized as the clinical change mechanisms inherent in the ACCESS program. Because ACCESS is fundamentally a CBT program, it has features in common with several of the other psychosocial treatment programs for adults and college students with ADHD. At the same time, however, built into the ACCESS program are many unique therapeutic elements (see Table 1.1). For example, in contrast with

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Table 1.1  Unique Features of ACCESS Unique Features of ACCESS Includes both an active phase and maintenance phase – New material is presented in active phase – Maintenance phase provides opportunities for continued practice – Maintenance phase facilitates mastery of new material and skills Both group and individual components – Group encourages social support and connections – Mentoring provides one-on-one attention and support Therapeutic components delivered concurrently – Helps address needs of multiple group members – Helps address problems with attendance Emphasis on psychoeducation (ADHD knowledge) – Greater knowledge leads to greater acceptance of ADHD diagnosis – Facilitates insight and use of treatment

the Safren (Safren et al., 2005) and Solanto (2011) programs that deliver their main treatment components sequentially – i.e., starting with an ADHD knowledge module, followed by a behavioral strategy module, and ending with an adaptive thinking skills module – ACCESS delivers these same treatment components concurrently. The decision to take this approach was inspired by clinical observations. Some students require more ADHD knowledge, others have great need for the behavioral strategies, while for still others, the adaptive thinking piece is critical. To maintain the interest and participation of every student in the group, each active phase group session (see Fig. 1.2) addresses ADHD knowledge, behavioral skills, and adaptive thinking skills in an integrated fashion, focused on a common theme (e.g., academic Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

ADHD Knowledge

Primary Symptoms

Causes

Assessment

School & Emotions and Medication Psychosocial Daily Risk-Taking Management Treatment Functioning

Behavioral Strategies

Campus Resources

Planners and To-Do Lists

Getting Organized

Attending Classes

Effective Studying

Long-Term Social Long-Term Projects Relationships Goals

Adaptive Thinking

Basic Principles

Maladaptive Thinking

Adaptive Thinking

Managing Schoolwork

Handling Emotions

Adhering to Social Treatment Relationships

Long-Term Outlook

Relapse Prevention

Fig. 1.2  Active phase content by week

functioning). In a complimentary fashion, concurrent mentoring sessions create opportunities for tailoring ACCESS to the needs of individual students by focusing on those components (i.e., knowledge, behavioral strategies, and adaptive thinking) discussed in group that are most relevant and meaningful for the student.

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Another feature of ACCESS that distinguishes it from other CBT programs is the large amount of psychoeducation about ADHD that is provided. From clinical experience and our own research findings, we became aware of the fact that for many college students with ADHD, their knowledge and understanding of this disorder is extremely limited, often based on what their parents may have told them when they were first diagnosed as young children. For others, their acceptance and ownership of ADHD is limited due to a preference not to be publicly labeled with a diagnosis that can have negative social connotations. This is often the main reason why many college students with ADHD do not register with disability service offices, which require diagnostic disclosure. To address this apparent knowledge deficit, we incorporated a substantial ADHD psychoeducation component within ACCESS. Information about ADHD is discussed in every active phase group session. Our expectation was that by giving students a more developmentally appropriate understanding of their own ADHD, they would be more likely to accept the diagnosis, and therefore be more motivated to seek treatment and support services to help them cope. To facilitate their use of such services, time is also set aside in several active phase group sessions for guest speakers to provide information and to answer questions about campus units (e.g., disability services, counseling center) that may be of assistance to students. Yet another distinctive feature of ACCESS is its simultaneous use of group treatment and individual mentoring. Although each of these formats is commonly used alone to deliver treatment, both have limitations. For example, in a group treatment format it is not always possible to ensure that a participant fully understands or properly uses presented clinical information. Missing from individual mentoring are opportunities for connecting with and receiving support from others facing similar life challenges. By using group treatment and individual mentoring together, we believed that the advantages of one would help offset the disadvantages of the other, thereby providing a more effective overall delivery of treatment. The group portion of ACCESS is the primary vehicle for delivering new information during the active phase. The mentoring component of the active phase has three complimentary objectives: to monitor and fine-tune what the student learned in the group; to assess the student’s need for disability accommodations and other campus support services; and to work collaboratively with the student to identify and monitor attainment of personal goals. During the maintenance phase, group leaders and mentors help students refine and master the knowledge and skills acquired during the active phase. In addition, they guide students through a gradual process of taking on increasingly greater responsibility to help prepare them for functioning on their own after their participation in ACCESS ends.

Empirical Support During our involvement in the College STAR Project, we conducted an open clinical trial to begin the process of evaluating the therapeutic impact of ACCESS. Over a 4-year period, a total of 88 college students from UNC Greensboro with well-­

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15

defined ADHD received ACCESS. Outcome data were collected on three occasions – prior to the active phase, immediately after the active phase, and again at the completion of the maintenance phase. The results of this open clinical trial revealed improvements in multiple domains of functioning (Anastopoulos & King, 2015; Anastopoulos et  al., 2018b). Upon completion of the active phase, participants displayed statistically significant: reductions in the overall severity of their ADHD symptoms, encompassing both inattention and hyperactivity-impulsivity features; improvements in executive functioning; declines in the overall severity of anxiety and depression symptoms; increases in the number of semester credit hours attempted and earned; and increases in the use of both disability service accommodations and ADHD medications. Importantly, these improvements persisted throughout the maintenance phase of ACCESS, 5–7 months after active treatment ended. Our exploratory examination of the conceptual underpinnings of ACCESS further revealed significant increases in ADHD knowledge and behavioral strategies, along with reductions in maladaptive thinking. These results, while not confirmatory given the open clinical trial design, are nonetheless consistent with our hypothesis that knowledge of ADHD, behavioral strategies, and adaptive thinking skills are the mechanisms of clinical change within ACCESS. Although promising, findings from our open clinical trial alone cannot be used to establish the efficacy of ACCESS for several reasons. Foremost among these is the absence of a control group against which therapeutic improvements among participants can be gauged. Also limiting conclusions are the limited scope of assessed outcomes, the absence of a follow-up assessment to determine the persistence of treatment-induced improvements following completion of ACCESS, and the use of a smaller than desirable number of participants in the sample. To address efficacy more directly, we applied for and received a 4-year Goal 3 grant award (R305A150207) from the Institute of Education Sciences in the U.S. Department of Education. The purpose of this award was to conduct a multi-­ site randomized controlled trial (RCT) in collaboration with Dr. Joshua M. Langberg and his research team at Virginia Commonwealth University (VCU). Recruitment for this study began in the fall of 2015 and data collection for all participants was completed in the spring of 2019. Across five consecutive semesters, a total of 361 undergraduate students from UNC Greensboro and VCU were screened for the study. Of this number, 280 students met the study’s rigorous eligibility requirements and were randomly assigned either to a group that received ACCESS immediately or to a delayed treatment control (DTC) group that received ACCESS on a one-year delayed basis. Because 30 of those assigned to the immediate ACCESS group could not attend required group meeting times due to scheduling conflicts with their classes or part-time employment, the final sample for the project included 250 participants, with 119  in the immediate ACCESS group and 131 in the DTC condition. All participants met DSM-5 criteria for ADHD, determined on the basis of evaluation data drawn from a multi-method, multi-informant diagnostic assessment and confirmed by a panel of three ADHD experts. Approximately 58% of these students displayed an ADHD Combined presentation, with 42% meeting criteria for an

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ADHD Predominantly Inattentive presentation. In addition to their ADHD, 60% exhibited co-occurring psychiatric diagnoses, most often characterized by clinically significant depression and anxiety features. In terms of demographic features, the sample ranged in age from 18 to 30 years and was predominantly female (60%), Caucasian (66.3%), and comprised of first-year college students (47.6%). Participation in the group portion of active treatment was excellent: 83.2% of those who began ACCESS completed at least six of the eight weekly sessions; another 8.4% completed at least four. Participation in the mentoring portion of active treatment was equally strong, with 85.7% completing at least six of eight weekly sessions and another 7.6% completing at least four. All group and mentoring sessions were audio-recorded, and 20% of these were randomly selected for review to assess treatment fidelity. Results for both treatment modalities were excellent, with group leaders and mentors displaying high overall levels of adherence to the content of the treatment protocol (96.4% and 95.6%, respectively). Outcome data were collected at three time points for both groups – prior to the active phase, immediately after the active phase, and again at the completion of the maintenance phase. For the immediate ACCESS group, we also collected outcome data in a follow-up assessment that occurred 6 months after the maintenance phase ended. Initial statistical analyses of these outcome data have provided strong support for the efficacy of ACCESS. Relative to those in the DTC condition, participants in the immediate ACCESS group demonstrated significant post-active and post-maintenance phase improvements across multiple domains of functioning, including: ADHD (inattention) symptoms, executive functioning, academic learning and study strategies, general daily functioning, depression symptoms, anxiety symptoms, and use of campus-based disability service accommodations. Such changes were accompanied by improvements in the study’s hypothesized clinical change mechanisms addressing ADHD knowledge, behavioral strategies (e.g., organization, planning), and adaptive thinking skills. Of additional clinical significance is that the immediate ACCESS group continued to display these improvements 6 months after their participation in the maintenance phase ended. Finally, we also conducted a cost analysis that showed that implementation of the complete ACCESS program requires $1187 spent per student. Labor costs for all staff account for 83% of these expenses. Included in this total are per student costs of $367 for the group leader position and $419 for each mentor.

Summary & Conclusions The transition to college can be a challenging adjustment for any individual, due to the increased demands for self-regulation that occur during this developmental period. For emerging adults with ADHD, this challenge can be substantially greater because of their diminished capacity for self-regulation and the fact that previously received treatments and support systems are often removed. In line with this conceptualization, research findings consistently show that, relative to those without

References

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ADHD, college students with ADHD are at increased risk for co-occurring emotional difficulties, which together with ADHD, frequently impair performance in multiple domains of daily life functioning. Such findings make clear the need for evidence-based treatment services for this population. Unfortunately, relatively little research has addressed this issue to date. As part of a growing interest in developing psychosocial treatments for college students with ADHD (He & Antshel, 2016), we created the ACCESS program. From the beginning, our approach has been guided by real world clinical experience, conceptual considerations, and a systematic approach to research that is consistent with recommendations for treatment development (Rounsaville, Carroll, & Onken, 2001; Weisz, Jenson, & McLeod, 2004). To this latter point, we first pilot tested ACCESS in an open clinical trial, after which we conducted a large-scale multi-site RCT.  Results from both studies have consistently shown statistically significant improvements in functioning across multiple domains of functioning, thereby providing evidence of efficacy. Also noteworthy is the fact that these improvements in functioning continued 6 months after participation in ACCESS ended. In conclusion, ACCESS is a practical, low cost, evidence-based CBT intervention that can be used in conjunction with other treatment services to address the multitude of needs of college students with ADHD.  Our purpose in creating this treatment manual is to assist other professionals interested in implementing this approach, the details of which are described in the chapters that follow.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Anastopoulos, A. D., & King, K. A. (2015). A cognitive-behavior therapy and mentoring program for college students with ADHD. Cognitive and Behavioral Practice, 22, 141–151. https://doi. org/10.1016/cbpra.2014.01.002 Anastopoulos, A., Smith, T., Garrett, M., Morrissey-Kane, E., Schatz, N., Sommer, J., … Ashley-­ Koch, A. (2011). Self-regulation of emotion, functional impairment, and comorbidity among children with ad/hd. Journal of Attention Disorders, 15, 583–592. Anastopoulos, A. D., DuPaul, G. J., Weyandt, L. L., Morrissey-Kane, E., Sommer, J. L., Rhoads, L. H., … Gudmundsdottir, B. G. (2018a). Rates and patterns of comorbidity among first-year college students with ADHD. Journal of Clinical Child & Adolescent Psychology, 47, 236– 247. https://doi.org/10.1080/15374416.2015.1105137 Anastopoulos, A. D., King, K. A., Besecker, L. H., O’Rourke, S. R., Bray, A. C., & Supple, A. J. (2018b). Cognitive-behavioral therapy for college students with ADHD: Temporal stability of improvements in functioning following active treatment. Journal of Attention Disorders. https://doi.org/10.1177/1087054717749932 Antshel, K. M., Hier, B. O., & Barkley, R. A. (2014). Executive functioning theory and ADHD. In Handbook of executive functioning (pp. 107–120). New York, NY: Springer. Arnett, J. J. (2007). Emerging adulthood: What is it, and what is it good for? Child Development Perspectives, 1, 68–73. https://doi.org/10.1111/j.1750-8606.2007.00016.x Baker, L., Prevatt, F., & Proctor, B. (2012). Drug and alcohol use in college students with and without ADHD. Journal of Attention Disorders, 16, 255–263. https://doi. org/10.1177/1087054711416314

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Barkley, R.  A. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York, NY: Guilford Press. Barkley, R. A., & Murphy, K. R. (2011). The nature of executive function (EF) deficits in daily life activities in adults with ADHD and their relationship to performance on EF tests. Journal of Psychopathology and Behavioral Assessment, 33, 137–158. https://doi.org/10.1007/ s10862-011-9217-x Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York, NY: Guilford. Benson, K., Flory, K., Humphreys, K. L., & Lee, S. S. (2015). Misuse of stimulant medication among college students: A comprehensive review and meta-analysis. Clinical Child and Family Psychology Review, 18, 50–76. https://doi.org/10.1007/s10567-014-0177-z Bruner, M. R., Kuryluk, A. D., & Whitton, S. W. (2015). Attention-deficit/hyperactivity disorder symptom levels and romantic relationship quality in college students. Journal of American College Health, 63, 98–108. https://doi.org/10.1080/07448481.2014.975717 DuPaul, G. J., & Weyandt, L. L. (2009). College students with ADHD: Current status and future directions. Journal of Attention Disorders, 13, 234–250. 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. DuPaul, G. J., Weyandt, L. L., Rossi, J. S., Vilardo, B. A., O’Dell, S., Carson, K. M., … Swentosky, A. (2012). Double-blind, placebo-controlled, crossover study of the efficacy and safety of lisdexamfetamine dimesylate in college students with ADHD. Journal of Attention Disorders, 16, 202–220. DuPaul, G. J., Reid, R., Anastopoulos, A. D., & Power, T. J. (2014). Assessing ADHD symptomatic behaviors and functional impairment in school settings: Impact of student and teacher characteristics. School Psychology Quarterly, 29, 409–421. DuPaul, G. J., Franklin, M. K., Pollack, B. L., Stack, K. S., Jaffe, A. R., … Weyandt, L. L. (2018). Predictors and trajectories of educational functioning in college students with and without ADHD. Journal of Postsecondary Education and Disability, 31, 161–178. Dvorsky, M. R., & Langberg, J. M. (2014). Predicting impairment in college students with ADHD: The role of executive functions. Journal of Attention Disorders, 1624–1636. https://doi. org/10.1177/1087054714548037 Eagan, K., Stolzenberg, E. B., Ramirez, J. J., Aragon, M. C., Suchard, M. R., & Hurtado, S. (2014). The American freshman: National norms fall 2014. Los Angeles: Higher Education Research Institute, UCLA. Eddy, L. D., Canu, W. H., Broman-Fulks, J. J., & Michael, K. D. (2015). Brief cognitive behavioral therapy for college students with ADHD: A case series report. Cognitive and Behavioral Practice, 22, 127–140. Eddy, L.  D., Eadeh, H.  M., Breaux, R., & Langberg, J.  M. (2019). Prevalence and predictors of suicidal ideation, plan, and attempts in first-year college students with ADHD. Journal of American College Health, 1–7. https://doi.org/10.1080/07448481.2018.1549555 Faraone, S.  V., & Glatt, S.  J. (2010). A comparison of the efficacy of medications for adult attention-­deficit/hyperactivity disorder using meta-analysis of effect sizes. Journal of Clinical Psychiatry, 71, 754–763. Fayyad, J., Sampson, N.  A., Hwang, I., Adamowski, T., Aguilar-Gaxiola, S., Al-Hamzawi, A., … Gureje, O. (2017). The descriptive epidemiology of DSM-IV adult ADHD in the world health organization world mental health surveys. ADHD Attention Deficit and Hyperactivity Disorders, 9, 1–19. https://doi.org/10.1007/s12402-016-0208-3 Field, S., Parker, D. R., Sawilowsky, S., & Rolands, L. (2013). Assessing the impact of ADHD coaching services on university students’ learning skills, self-regulation, and Well-being. Journal of Postsecondary Education and Disability, 26, 67–81. Fleming, A., & McMahon, R. (2012). Developmental context and treatment principles for adhd among college students. Clinical Child and Family Psychology Review, 15, 303–329. https:// doi.org/10.1007/s10567-012-0121-z

References

19

Fleming, A. P., McMahon, R. J., Moran, L. R., Peterson, A. P., & Dreessen, A. (2015). Pilot randomized controlled trial of dialectical behavior therapy group skills training for ADHD among college students. Journal of Attention Disorders, 19, 260–271. Gathje, R., Lewandowski, L., & Gordon, M. (2008). The role of impairment in the diagnosis of adhd. Journal of Attention Disorders, 11, 529–537. https://doi.org/10.1177/1087054707314028 Gordon, M., Antshel, K., Faraone, S., Barkley, R., Lewandowski, L., Hudziak, J. J., … Cunningham, C. (2006). Symptoms versus impairment: The case for reporting DSM-IV’s criterion d. Journal of Attention Disorders, 9, 465–475. Gormley, M. J., DuPual, G. J., Weyandt, L. L., & Anastopoulos, A. D. (2016). First-year GPA and academic service use among college students with and without ADHD. Journal of Attention Disorders, 23, 1–14. https://doi.org/10.1177/1087054715623046 Green, A., & Rabiner, D. (2012). What do we really know about adhd in college students? Neurotherapeutics, 9, 559–568. https://doi.org/10.1007/s13311-012-0127-8 Gu, Y., Xu, G., & Zhu, Y. (2018). A randomized controlled trial of mindfulness-based cognitive therapy for college students with ADHD. Journal of Attention Disorders, 22, 388–399. https:// doi.org/10.1177/1087054716686183 He, J., & Antshel, K. (2016). Cognitive behavioral therapy for attention deficit / hyperactivity disorder (ADHD) in college students: A review of the literature. Cognitive and Behavioral Practice. https://doi.org/10.1016/j.cbpra.2016.06.001 Hechtman, L. (2017). Attention deficit hyperactivity disorder: Adult outcome and its predictors. New York: Oxford Press. Kaye, S., & Darke, S. (2012). The diversion and misuse of pharmaceutical stimulants: What do we know and why should we care?: Pharmaceutical stimulant diversion and misuse. Addiction, 107, 467–477. https://doi.org/10.1111/j.1360-0443.2011.03720.x Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., … Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. American Journal of Psychiatry, 163, 716–723. https://doi.org/10.1176/appi.ajp.163.4.716 Kessler, R.  C., Petukhova, M., Sampson, N.  A., Zaslavsky, A.  M., & Wittchen, H.-U. (2012). Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21, 169–184. https://doi.org/10.1002/mpr.1359 LaCount, P. A., Hartung, C. M., Shelton, C. R., Clapp, J. D., & Clapp, T. K. (2015). Preliminary evaluation of a combined group and individual treatment for college students with attention-­ deficit/hyperactivity disorder. Cognitive and Behavioral Practice, 22, 152–160. LaCount, P. A., Hartung, C. M., Shelton, C. R., & Stevens, A. E. (2018). Efficacy of an organizational skills intervention for college students with ADHD symptomatology and academic difficulties. Journal of Attention Disorders, 22, 356–367. Lewandowski, L., Gathje, R. A., Lovett, B. J., & Gordon, M. (2013). Test-taking skills in college students with and without ADHD. Journal of Psychoeducational Assessment, 31, 41–52. Matte, B., Anselmi, L., Salum, G. A., Kieling, C., Gonçalves, H., Menezes, A., … Rohde, L. A. (2015). ADHD in DSM-5: A field trial in a large, representative sample of 18- to 19- year-old adults. Psychological Medicine, 45, 361–373. https://doi.org/10.1017/S0033291714001470 McKee, T.  E. (2017). Peer relationships in undergraduates with ADHD symptomatology: Selection and quality of friendships. Journal of Attention Disorders, 21, 1020–1029. https:// doi.org/10.1177/1087054714554934 Miller, L. A., Lewandowski, L. J., & Antshel, K. M. (2015). Effects of extended time for college students with and without ADHD. Journal of Attention Disorders, 19, 678–686. O’Malley, P. M., & Johnston, L. D. (2002). Epidemiology of alcohol and other drug use among American college students. Journal of Studies on Alcohol, Supplement, 14, 23–39. Pariseau, M. E., Fabiano, G. A., Massetti, G. M., Hart, K. C., & Pelham, W. E., Jr. (2010). Extended time on academic assignments: Does increased time lead to improved performance for children with attention-deficit/hyperactivity disorder? School Psychology Quarterly, 25, 236–248.

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Pinho, T. D., Manz, P. H., DuPaul, G. J., Anastopoulos, A. D., & Weyandt, L. L. (2019). Predictors and moderators of quality of life among college students with ADHD. Journal of Attention Disorders, 23, 1736–1745. https://doi.org/10.1177/1087054717734645 Pliszka, S. R. (2015). Comorbid psychiatric disorders in children. In R. A. Barkley (Ed.), Attention-­ deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed., pp. 140–168). New York: Guilford Press. Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56, 345–365. https://doi.org/10.1111/ jcpp.12381 Prevatt, F. (2016). Coaching for college students with adhd. Current Psychiatry Reports, 18, 1–7. https://doi.org/10.1007/s11920-016-0751-9 Prevatt, F., & Yelland, S. (2015). An empirical evaluation of ADHD coaching in college students. Journal of Attention Disorders, 19, 666–677. Rabiner, D., Rabiner, D. L., Anastopoulos, A. D., Costello, E. J., Hoyle, R. H., McCabe, S. E., & Swartzwelder, H. S. (2009). Misuse and diversion of prescribed ADHD medications by college students. Journal of Attention Disorders, 13, 144–153. Ramsay, J. R. (2015). Psychological assessment of adults with ADHD. In R. A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (pp.  475– 500). New York: Guilford Press. Reaser, A., Prevatt, F., Petscher, Y., & Proctor, B. (2007). The learning and study strategies of college students with ADHD. Psychology in the Schools, 44, 627–638. Rooney, M., Chronis-Tuscano, A., & Yoon, Y. (2012). Substance use in college students with ADHD. Journal of Attention Disorders, 16, 221–234. https://doi.org/10.1177/1087054710392536 Rounsaville, B.  J., Carroll, K.  M., & Onken, L.  S. (2001). A stage model of behavioral therapies research: Getting started and moving on from stage I. Clinical Psychology: Science and Practice, 8, 133–142. Sacchetti, G.  M., & Lefler, E.  K. (2017). ADHD symptomology and social functioning in college students. Journal of Attention Disorders, 21, 1009–1019. https://doi. org/10.1177/1087054714557355 Safren, S., Perlman, C., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD: A cognitive behavioral treatment program therapist guide. Oxford: New York. Salzer, M. S. (2012). A comparative study of campus experiences of college students with mental illnesses versus a general college sample. Journal of American College Health, 60, 1–7. https:// doi.org/10.1080/07448481.2011.552537 Scheithauer, M. C., & Kelley, M. L. (2017). Self-monitoring by college students with ADHD: The impact on academic performance. Journal of Attention Disorders, 21, 1030–1039. Sibley, M. H., Pelham, W. E., Jr., Molina, B. S. G., Gnagy, E. M., Waxmonsky, J. G., Waschbusch, D. A., … Kuriyan, A. B. (2012). When diagnosing ADHD in young adults emphasize i­ nformant reports, DSM items, and impairment. Journal of Consulting and Clinical Psychology, 80, 1052–1061. https://doi.org/10.1037/a0029098 Smith, B. H., Barkley, R. A., & Shapiro, C. (2006). Combined child therapies. Attention-deficit Hyperactivity Disorder, 3, 678–691. Solanto, M. V. (2011). Cognitive-behavioral therapy for adult ADHD: Targeting executive dysfunction. New York: Guilford Press. Solanto, M. V. (2015). Executive function deficits in adults with ADHD. In R. A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (pp.  256– 266). New York: Guilford Press. Surman, C. B. H., Biederman, J., Spencer, T., Miller, C. A., McDermott, K. M., & Faraone, S. V. (2013). Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: A controlled study. ADHD Attention Deficit and Hyperactivity Disorders, 5, 273–281. https://doi.org/10.1007/s12402-012-0100-8

References

21

Swartz, S. L., Prevatt, F., & Proctor, B. E. (2005). A coaching intervention for college students with attention deficit/hyperactivity disorder. Psychology in the Schools, 42, 647–656. Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-­deficit/ hyperactivity disorder: A systematic review and meta-analysis. Pediatrics, 135, 995–001. Weisz, J. R., Jensen, A. L., & McLeod, B. D. (2005). Development and dissemination of child and adolescent psychotherapies: Milestones, methods, and a new deployment-focused model. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 9–39). Washington, DC: American Psychological Association. Weyandt, L. L., & DuPaul, G. J. (2012). College students with ADHD: Current issues and future directions. New York: Springer. Willcutt, E. G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: A meta-­ analytic review. Neurotherapeutics, 9, 490–499. https://doi.org/10.1007/s13311-012-0135-8 Wolf, L. E., Simkowitz, P., & Carlson, H. (2009). College students with attention-deficit/hyperactivity disorder. Current Psychiatry Reports, 11, 415–421.

Chapter 2

General Guidelines for Planning and Implementing ACCESS

This chapter provides general guidelines for planning and implementing ACCESS. The planning section includes a description of the qualifications necessary for serving as a group leader or mentor in the program. As with any other psychosocial treatment, it is important to ensure that ACCESS is clinically indicated for any given student. Thus, characteristics of students for whom ACCESS may or may not be appropriate are discussed. Because there can be variation in the academic calendar year from one college or university to the next, issues related to the timing of when to implement ACCESS are addressed. Featured in the implementation section of this chapter are clinical guidelines that can be applied to any portion of the treatment program. This includes a detailed description of the therapeutic process issues that guide a group leader or mentor through their respective treatment sessions. Also presented are detailed suggestions for allocating session time; coordinating delivery of the group and mentoring components; discussing confidentiality issues; scheduling guest speakers from campus support units; handling missed appointments; distributing session handouts; and using components of ACCESS.

Planning ACCESS Provider Qualifications As is true for any other type of psychosocial treatment, effective implementation of ACCESS requires a certain level of clinical skill and knowledge. Because ACCESS is fundamentally a CBT program, the group leader and mentor should have clinical experience, or at the very least familiarity, with the tenets of cognitive and behavioral theories and the basic techniques associated with these clinical orientations.

© Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_2

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Successful implementation of ACCESS also requires an in-depth knowledge and understanding of ADHD that is at least at a level greater than that of the students likely to be participating in the program. Although not a requirement, the more that the group leader and mentor know about the resources that are available on campus, the better. The same is true for having relevant professional experience working with college students, as well as background training in adolescent/emerging adult development. The role of group leader does not require a specific type of professional degree, but individuals serving in this capacity should have some training and experience in a clinical or applied field, preferably at a Masters degree level or higher. This preference stems in part from a consideration of the skills necessary for running groups. Having such training and experience also facilitates working with individuals presenting not only with ADHD, but with various other co-occurring mental health conditions as well. Over the years, our group leaders have included individuals who were Masters-level licensed professional counselors, advanced doctoral students in clinical psychology, and licensed doctoral-level psychologists. Presumably, individuals with advanced professional training in counseling, social work, and other applied fields would be equally well suited to taking on the group leader role in ACCESS. Similar applied training experience is desirable but not a requirement for individuals serving as a mentor in the ACCESS program. What is necessary are strong interpersonal skills that can be used to connect with and guide college students in the context of one-on-one mentoring sessions. In our experience with ACCESS, we have had great success using mentors from a variety of professional training backgrounds, including Masters-level graduate students in human development and family studies, counseling, developmental psychology, and clinical psychology. As was true for the group leader position, we have every reason to believe that Masters-level individuals from social work and other applied fields, as well as staff working in disability service offices and academic tutoring centers, have great potential for serving as mentors. It is important to point out that the individuals who have worked as group leaders and mentors in our program did not have the same levels of knowledge about ADHD or training in using cognitive and behavioral techniques and strategies prior to becoming part of ACCESS. Consequently, it is necessary to provide different types and amounts of training to ensure that all staff have acceptable and comparable levels of knowledge and expertise. Our training typically includes assigned readings on topics such as ADHD in college students and commonly used cognitive and behavioral strategies, group discussion, role playing, and observations. To assist others who may be interested in implementing ACCESS and would like to receive similar training, we are available to provide such consultation, tailored to the needs of the college, university, or agency seeking to implement ACCESS. For more information, please see our ACCESS webpage located at https://accessproject.uncg.edu/.

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Student Characteristics Because ACCESS is designed specifically for college students with ADHD, it is helpful but not completely necessary to have formal documentation of a student’s ADHD diagnosis before starting treatment. On our campus, it is often the case that a potential ACCESS participant has undergone a comprehensive psychological evaluation, for which there is a written report providing such documentation. Likewise, a student may have a written report from an off-campus provider that provides similar documentation from a past evaluation. In many cases, however, formal documentation is not available; instead, all that is available is the student’s self-report of having an ADHD diagnosis. In such situations, the group leader or mentor should, at a minimum, interview the student about the difficulties they are having to ensure that they seem consistent with a diagnosis of ADHD and are therefore likely to benefit from ACCESS.  In cases where there is greater uncertainty about the student’s ADHD status, the group leader or mentor could administer standardized ADHD rating scales to the student and/or the student’s parent to get a better feel for whether ADHD is present. When conducting such screening, it is important to use a scale that gathers information both about current symptoms and about childhood symptoms. An ADHD diagnosis alone, however, is not the only factor that must be taken into consideration. There must also be clear evidence that this intervention is clinically indicated. By that we mean, in part, that the student with ADHD must be having clinically significant difficulties in their academic, personal, social, and/or emotional functioning that would likely respond well to being in the ACCESS program. As noted in Chap. 1, approximately 55% of the college student ADHD population has a co-occurring secondary diagnosis, most often involving features of depression and anxiety. Many such co-occurring conditions in and of themselves do not preclude participation in ACCESS. Some mental health conditions do, however. This includes, for example, co-occurring autism spectrum disorders, bipolar disorder, obsessive-compulsive disorders, and active substance abuse conditions. The reason for not including students with these disorders in ACCESS is because such conditions typically require intervention strategies that are different than what is provided by ACCESS.  Moreover, there is no empirical evidence suggesting that ACCESS would be clinically appropriate for college students with any of these secondary conditions (e.g., autism spectrum disorder, bipolar disorder). Other student characteristics should also be taken into consideration to determine the appropriateness of providing ACCESS services. For example, ACCESS is less than ideal for a senior in their final college semester. To be maximally effective, ACCESS is delivered across two consecutive semesters; therefore, a senior in their final semester would not be able to participate in the maintenance phase of the program. ACCESS is also not appropriate for a student who is only taking on-line courses and unable to come to campus for regularly scheduled group and mentoring meetings. Another student characteristic to consider is one that often does not reveal itself until after the group portion of the ACCESS program has begun. We are

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s­ pecifically referring to students whose attitude, behavior, and comments may be inappropriate and disruptive to the group process. In one such situation that we experienced, several members of an ACCESS group independently contacted the group leader to inform them that they were withdrawing from the program because of a student’s disruptive behavior. Although we are certainly committed to understanding and helping students with difficult personality issues, we also have an obligation to the other students in the group. After much discussion of this situation between the group leader and the mentor, a decision was made to remove the student from the group portion of ACCESS but to allow the student to continue receiving ACCESS services through its mentoring component. This delicate situation was discussed in a meeting with the student, who accepted the proposed solution and ultimately completed the mentoring portion of the ACCESS program.

Scheduling Considerations While preparing to implement ACCESS, two important considerations are the scheduling of program start dates and the scheduling of group and mentor meetings. When determining an appropriate start date for the ACCESS program, it is necessary to ensure that there is enough time for students to receive the full course of group and mentoring meetings in the active phase, encompassing 8 weeks of group and up to ten weekly mentoring sessions. Hence, the start date of ACCESS should occur at a time that allows for its completion well before the end of the semester. Because class schedules for many students are in flux during the early part of a new semester, it is best not to set a firm ACCESS program start date until student schedules are set. The best time to finalize this would be after most students have solidified their course schedules, which generally happens 2–3 weeks after the semester has begun. A second major scheduling consideration is the timing of group and mentoring meetings. Our goal has always been to try to identify potential group times when all interested students could attend. We recognize, however, that this may not be feasible in settings with restrictions on both the times that group leaders are available and the availability of space for group meetings. Nevertheless, we encourage other providers to aim for scheduling group meetings at times that maximize the likelihood that the largest number of students will be able to attend. For example, scheduling groups for times in the late afternoon or early evening may allow students to attend after their classes conclude. The scheduling of mentoring sessions is somewhat easier, as mentoring sessions are typically 30 minutes in length (compared to 90 minutes for group sessions), and most students can fit a 30-minute meeting into their schedule. One constraint, however, is that mentoring sessions need to be scheduled a few days after the weekly group session with which it is associated. This allows students the opportunity to try out behavioral strategies and skills introduced in group sessions, which they can then review and refine with their mentor.

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Implementing ACCESS As described in Chap. 1, ACCESS is a CBT program 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 to give college students with ADHD the knowledge and skills necessary to be successful in daily life functioning.

Group Sessions The group portion of ACCESS is the primary vehicle for delivering new information during the active phase. Although some group content is presented in a lecture format, a back-and-forth, question-and-answer presentation style is used whenever possible to encourage active student participation. For example, when discussing how ADHD may affect students academically, students are invited to share their own perspectives on how ADHD has influenced their academic functioning. Invariably, stories told by one student spark an immediate, “that happened to me too” from other students who then share their stories with one another, thereby contributing to group cohesion. During the behavioral strategies portion of each session, the group leader often opens the discussion by asking students what strategies are working well, or not so well. When a student reports not having success with a given strategy, the group leader may ask the other members of the group to give feedback to that participant, emphasizing what they can do to use that strategy more effectively. A common example of this type of situation is when students show their planners to other group members, pointing out how their adaptations of the planner system (e.g., color highlighting) might also be of benefit to them. Similar strategies are used during the adaptive thinking skills portion of treatment, during which a white board or some other visual aid is used to guide students through adaptive thinking activities. During the maintenance phase there is only one booster group session. The primary objective of this session is to provide group members with an opportunity for addressing new questions about ADHD that may have arisen, for trouble-shooting their implementation of behavioral strategies, and for refining their use of adaptive thinking skills. Another important clinical benefit of the group booster session is that it provides an opportunity for group members to reconnect with one another and to receive support from fellow group members.

Mentoring Sessions During the active phase, the mentoring component of ACCESS has three complimentary objectives: to monitor and fine-tune what the student learned in the group; to assess the student’s need for disability accommodations and other campus ­support

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services; and to work collaboratively with the student to identify and monitor attainment of personal goals. Thus, mentors monitor student understanding of ADHD and help them apply behavioral strategies and adaptive thinking skills to situations that may occur outside of group treatment or perhaps are better suited to one-on-one rather than group discussion. As a way of addressing academic performance and personal success, mentors also provide referrals and guidance on accessing campus support units appropriate to student needs. In addition, mentors help students develop realistic goals, monitor their follow-through on achieving these goals, and provide students with ongoing support and personal coaching. All mentoring sessions occur within 1 week of the concurrent group session. During the initial mentoring session, mentors review a student’s current academic and personal functioning, use of campus resources, challenges, and goals for treatment. In subsequent sessions, mentors perform a brief check-in with the participant, collaborate with the student to set an agenda for that session, discuss information that was covered in group, review and fine-tune their efforts to practice newly acquired skills and strategies, set new goals and between-session practice assignments, and cover other topics as needed and as requested by the student. The actual amount of time spent on each of these areas varies according to the needs and interests of each student. Up to six mentoring sessions are also conducted during the maintenance phase. Such sessions are even more flexible than was the case during the active phase and are guided primarily by student needs and preferences. Thus, some students may choose to use these sessions to review and refine their use of behavioral strategies, whereas others may opt for using these sessions primarily for personal goal setting and support. To help prepare students for functioning on their own after their participation in ACCESS ends, mentors guide students through a gradual process of taking on increasingly greater responsibility for what happens both during and between mentoring sessions.

Socratic Questioning As is true in many other CBT applications, Socratic questioning plays an important role in both treatment delivery formats. In general terms, Socratic questioning is a form of questioning that encourages reflection and consideration of alternative points of view. In the context of ACCESS, the group leader and the mentor engage the student in Socratic questioning to get them to (1) think about any maladaptive thoughts they may be having, and (2) consider the possibility that there may be alternative ways of looking at the same situation. As awareness of their own ­maladaptive thinking patterns increases, students become better able to detect such thoughts in the moment and to replace them with more adaptive thinking, leading to more positive feelings and behavior. In the process, students gain confidence in their ability to do so on their own, which prepares them for functioning independently after their participation in ACCESS ends.

Implementing ACCESS

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 llocation of Time to Topics During Group and Mentoring A Sessions As outlined in Chap. 1, each active phase group session includes integrated coverage of ADHD knowledge, behavioral skills, and adaptive thinking skills, focused on a common theme (e.g., academic functioning). In theory, each of these three topics could be given equal time during the 90-minute group session. In practice, this seldom happens. In some weekly group sessions, relatively more time might be needed for covering behavioral strategies; in others, adapting thinking skills or information about ADHD may take precedence. There is no rigid formula for what proportion of time should be allocated to each of these three topics during a given group session. The actual amount of time allocated depends on the amount and complexity of the topic content, as well as the group’s interests, needs, and capacity to absorb presented information. Rather than specify an exact number of minutes for each topic in every group session, we think it best to defer to the group leader to make this determination based on their own assessment of their group’s unique circumstances and needs. The point to be made is that there is flexibility in allocating time to cover ADHD knowledge, behavior strategies, and adaptive thinking skills, as long as the content of all three topics is covered adequately in every group session. This issue of allocating time to these same topics is less problematic for mentors. This is because mentoring sessions provide opportunities for tailoring ACCESS to the needs of individual students by focusing on those components (i.e., knowledge, behavioral strategies, and adaptive thinking) discussed in group that are most relevant and meaningful for the student. Because mentors are working in a one-on-one format, they are in an excellent position to quickly assess a mentee’s understanding and need for further discussion of these topics, which can be addressed flexibly from one mentoring session to the next.

Coordinating Delivery of Group and Mentoring Components Although the guidelines for delivering the group and individual mentoring components of ACCESS are described separately, it is important to bear in mind that these are intertwined treatment components and therefore should delivered in a coordinated fashion. To achieve this goal, the group leader and mentor should meet weekly throughout the active phase. All such meetings should be scheduled prior to delivering the next ACCESS treatment session in sequence. During such meetings, the group leader can share with the mentor how their mentees performed in the group. Things that a mentee did well in group should be noted, which gives the mentor opportunities for acknowledging these successes during individual mentoring. Likewise, any concerns that the group leader has about a mentee can be shared with the mentor, who can then address these concerns more directly in an individual

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mentoring session than might otherwise be the case in a group. In a similar fashion, mentors can apprise the group leader of any strengths or concerns noted in an individual mentoring session that may be of some help in conducting subsequent group sessions.

Confidentiality Issues Although the exact boundaries of confidentiality may vary as a function of the setting in which ACCESS is implemented, it is important to make students aware of broadly accepted confidentiality guidelines. Thus, the group leader and the mentor have a responsibility to inform students that any and all information that they reveal during their participation in ACCESS will not be shared with their parents, school administrators, health care providers, or anyone else without their explicit written permission to do so. At the same time, however, students should be aware and accepting of the fact that the group leader and mentor will share information with each other in order to coordinate delivery of the ACCESS program. Students should also be apprised of what written records will be generated (e.g., mentoring session notes) and how such records will be stored and safeguarded to ensure confidentiality. Likewise, the steps that will be taken to ensure confidentiality during communications that take place between the student and ACCESS staff outside of group and mentoring sessions (e.g., phone, text, email) should be discussed. As is customary in clinical practice, it is also necessary to apprise students of the conditions under which confidentiality must be broken. Although the exact mandatory reporting standards can vary somewhat from state to state, it is generally the case that confidentiality must be broken if a participant is found to be imminently suicidal with a plan; if a participant is found to be homicidal, or: if a child is a victim of unreported physical or sexual abuse. Although the likelihood of any of these circumstances arising is low, it nevertheless is the responsibility of the ACCESS staff to have clear and specific plans in place to deal with them. In the case of a student revealing suicidal ideation, for example, the group leader and mentor should have some level of training that allows them to conduct an initial suicide risk assessment. If these initial efforts to resolve the situation are not successful, consultation from a licensed mental health care provider on staff should be obtained to determine appropriate next steps. To facilitate pursuing this option, the identity and contact information of the person responsible for providing this backup should be clear to the group leader and mentor prior to starting the ACCESS program. One additional point about confidentiality needs to be made. Because students might see each other outside of group or have mutual friends, it is critically important for establishing openness and trust that they do not talk about what they hear in group outside of group. Therefore, students should be strongly encouraged to refrain from sharing any personal information about other students revealed in group outside of the group.

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Guest Speakers One of the aims of the ACCESS program is to help college students effectively use the campus resources that are available to them. Most college campuses offer a wide variety of student support services that can aid college students with ADHD in successfully meeting academic demands; providing care for their physical and mental health needs; and offering career planning assistance. In our clinical and research activities, we have found that college students with ADHD are often unaware of the campus services available to them. Moreover, even when they are aware of such services, they may be hesitant to use them. To help students make better use of the campus resources available to them, we surmised that it might first be necessary to remove the mystery and misunderstanding that sometimes surround these resources. To this end, we routinely invite guest speakers from various support service units on campus to describe and answer questions about their services as part of a regularly scheduled group meeting. Anywhere from two to three such presentations will be given during the active phase of treatment, typically during the first 20–30 minutes of a group meeting. Some student services staff choose to do a brief presentation with slides, whereas others may choose to lead a brief informal conversation about their services. Either approach is acceptable, as simply providing students the chance to meet a staff member from a campus support service seems to help students with ADHD become more open to using these resources. Furthermore, these staff members can help answer common questions or concerns, which can reduce barriers to using services. For instance, some students incorrectly assume that registering with the disability support office means they would be required to use accommodations in every class. Correcting this misconception can help them connect with disability support and access accommodations, such as early course registration. Although the exact number and type of student support services can vary greatly across campuses, commonly available resource units include disability support services, student counseling, student health, academic support services (which often encompass tutoring and academic coaching), career counseling, and writing support centers. Because the group meeting time is often not finalized until the new semester has started, it may not be possible to schedule guest speakers until that decision has been made. In anticipation of that limitation, the group leader should contact several potential guest speakers in advance of starting ACCESS to determine their interest and availability to do a presentation. From that list, the group leader can then extend invitations to those campus staff whose schedule allows for their participation in the group.

Missed Meetings One problem behavior commonly displayed by college students with ADHD is being late for and missing meetings and other appointments. Given that one of the symptoms of ADHD is forgetfulness, this should not come as any surprise. In

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addition to forgetfulness, troubles with planning and organization can interfere with attendance in ACCESS group and mentoring sessions. This can happen when students double-book themselves, scheduling more than one appointment at the same time. Or students may decide not to attend a group or mentoring session because they need to complete an assignment or study for an exam at the last minute. In sum, despite their best intentions, students with ADHD are more likely than other individuals to arrive late for, and sometimes even miss, group and mentoring meetings. Although not a permanent solution, we do suggest providing students with meeting reminders and giving them an opportunity to attend a limited number of make­up sessions with either the group leader or mentor. Reminders can take the form of emails, texts, or phone calls. To facilitate communication, we often ask students to tell us the best way to reach them. Many students prefer texts, and there are several ways to schedule automatic recurring text reminders. It may be helpful to provide multiple reminders: one reminder the day of group, another reminder an hour before group, and sometimes even a final reminder 10 minutes before group. The exact amount, timing, and format of reminders can be determined in accordance with individual needs. To ensure that attendance is regular enough to derive benefits from ACCESS, we do encourage providing some sort of reminder, as this will increase attendance and punctuality. When a student misses an entire group or mentoring session, the group leader and mentor will need to discuss this and then decide whether to allow the student to complete a make-up group session or to reschedule the missed mentoring session as soon as possible. Although we strongly encourage the use of make-up sessions for the group (because each session builds upon the previous week), we recognize that in some university counseling centers, for example, there may be rules in place about how many times a student can reschedule a missed session. In keeping with this type of policy, one option might be to allow students to do so on a limited basis. To be clear, this does not mean that a group leader would meet with a student and conduct a 90-minute one-on-one make-up session. What we are instead suggesting is that the group leader meet individually with the student for no more than 20–30 minutes to provide an overview of the missed group meeting and to distribute the corresponding session handouts. In our research studies, for example, ACCESS participants were permitted to have a maximum of two such make-up sessions for missed group meetings. Another option for dealing with missed group meetings is to set a certain time each week for conducting a make-up session for any student who may have missed a group meeting. In sum, we encourage group leaders and mentors to consider a fairly lenient policy on makeup sessions, since problems with attendance are common in this group and are at least partly attributable to core ADHD symptoms. If attendance or tardiness is a recurring problem, a mentor can discuss this in session by identifying behavioral strategies and adaptive thinking skills that the mentee can use to address this.

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Handouts Throughout the active phase, handouts are provided to students in each group session and in many, but not all, mentoring sessions. These handouts are designed to serve as a resource that students can take with them as summaries of the information conveyed in group. These handouts also facilitate discussion within group. For instance, group leaders can direct students to look over the suggested behavioral strategies on the handouts and then elicit questions from group members about the use of different strategies, what strategies appeal to them and why, and so forth. Because of their importance in delivering ACCESS, the handouts for each session are included at the end of each chapter in which a treatment session is discussed.

Using Components of ACCESS As emphasized earlier, ACCESS is conceptualized as a two-semester long intervention in which group and individual mentoring are used to deliver the ADHD knowledge, behavioral strategies, and adaptive thinking skill components of treatment. In our clinical trial research studies, this is the version of ACCESS that we tested to demonstrate its efficacy. Therefore, we strongly recommend that others who wish to implement ACCESS do so using the full program as described in this treatment manual. We recognize that using ACCESS in its entirety may not be possible for many providers who wish to use it in their clinical work with college students with ADHD.  This raises an interesting practical dilemma. If a provider cannot implement ACCESS in its entirety, should they not use any of its treatment components, some of which intuitively may be of some therapeutic benefit to students with ADHD? We cannot definitively answer this question, because no research has been conducted to date to directly address this matter. At the same time, it is important to acknowledge that the absence of empirical evidence does not necessarily mean that certain components of the ACCESS program would not be helpful to students with ADHD. For this reason, we would defer any decision about using components of ACCESS, or a different delivery model, to those who may have need and reason to do so. This might apply, for example, to providers in college counseling centers, where it may be possible to offer the group portion of ACCESS but not the concurrent individual mentoring component. Conversely, because staff in college disability service offices typically work one-on-one with students, such staff might be better equipped and inclined to provide the mentoring portion of ACCESS but not its group component. To the extent that such campus services can be coordinated, it would create the possibility of delivering ACCESS in its complete form. This could occur, for example, with a counseling center providing the group piece in coordination with the disability service office handing the mentoring piece.

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Another situation in which it may not be possible to conduct ACCESS in its entirety is in the context of private practice. Not uncommonly, college students with ADHD receive treatment from private practitioners in the community located near university settings. Because the nature of the work that many private practitioners do is primarily one-on-one, the mentoring portion of ACCESS would seem well suited to being used by such providers. Because a typical therapy session, 50 minutes in length, is longer than the 30 minutes usually allocated to mentoring sessions in ACCESS, a private practitioner would have an opportunity to bring some of the content from the group portion of ACCESS into their individual session with the student. In sum, we believe that the best way to use ACCESS is in its entirety, which is what we evaluated to establish its efficacy. We recognize, however, that there are many circumstances that may limit use of the full ACCESS program. Under such circumstances, implementing components of ACCESS (e.g., group only) may be of some therapeutic benefit.

Chapter 3

Active Phase – Week 1

Content for Week 1 of the active phase of the ACCESS program is presented. Group content is presented first, followed by mentoring session content. The aims of the initial group meeting are to orient students to the program, to present information about ADHD symptoms and associated characteristics, to discuss resources available on campus, and to introduce the tenets of cognitive therapy and adaptive thinking skills. Group members first receive detailed information about the content, structure, and goals of ACCESS.  Expectations for participation and therapeutic progress are discussed as well. Information about the prevalence, developmental course, and situational variability of ADHD symptoms is presented next. As part of the review of available campus resources, students are encouraged to share their experiences with these resources. The group session concludes with students receiving an overview of the basic tenets of cognitive therapy and adaptive thinking techniques. In the initial mentoring session, students get to know their mentors and become acclimated to the mentoring process. Mentors also collect general background information about their mentees, review and clarify content that was covered in group, and gather information about mentee goals, strengths, and needs.

Week 1 – Group Introduction to ACCESS Program Beginning Group Session Group leaders should provide brief information about themselves and their role as leaders. Next, ask group members to introduce and share information about themselves. Sharing majors and class years (e.g., sophomore, junior) is also helpful for group cohesion, as this information can help students identify other group members

© Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_3

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who are at similar life stages or who share academic interests. This is also a time to discuss confidentiality. Although the exact boundaries of confidentiality may vary according to the setting in which ACCESS is implemented, it is important to make students aware of broadly accepted guidelines for confidentiality. Specifically, inform students that group leaders are bound to keep information shared in group confidential, unless it becomes clear that there is an imminent risk of harm to students in ACCESS or others. In this case, confidentiality may be broken to protect the welfare of the students or other people. Acknowledge that group members are not bound by the same confidentiality guidelines but emphasize that students should make every effort to keep private any and all information disclosed in group. Describe How ACCESS is Delivered During this discussion, direct students’ attention to Handout 1.2, which presents information about ACCESS. Inform students about the structure of group. ACCESS is delivered across 2 semesters  – an initial 8-week active phase followed by a semester-­long maintenance phase. Within the active phase, students will participate in eight 90-minute weekly group meetings and receive 30-minutes of individual mentoring per week. During the maintenance phase, students will meet once for a booster group session and receive 4–6 mentoring sessions. Explain the rationale for this format. Specifically, the group will present new material each week in three major areas: knowledge of ADHD, behavioral strategies, and adaptive thinking skills. Mentoring sessions will provide an opportunity for students to work one-on-­ one with a mentor to review group content, to assess their need for campus support services, and to set personal goals for using new knowledge and strategies in their own lives. Also make clear that, while the active phase of ACCESS focuses on presenting new information and skills, the maintenance phase provides a chance for students to continue practicing new skills while continuing to receive support in the form of ongoing mentoring sessions and one group “booster” session, which takes place toward the beginning of the semester. Set Expectations for Participation and Attendance Since new material will be presented in each group, strongly recommend that students attend all sessions. However, if students miss a group, they can be offered the chance to participate in a make-up session, either one-on-one with a group leader or by scheduling an extra session with their mentor. Emphasize that to benefit from ACCESS, students must be actively engaged in the program. Like many other real-­ life activities, the more students put into the group and mentoring, the more they will get out of the program. Encourage students to arrive on time; however, note that coming to group for part of the session is better than not coming at all.

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Tip Since being late for appointments or classes is common among individuals with ADHD, be as flexible as possible about tardiness, but at the same time encourage students to use their newly acquired skills to be on time for group and mentoring sessions.

Briefly Review Outline of Sessions and Discuss Expectations for Progress Go over Handout 1.3 listing the eight active treatment group sessions and the major topics covered in each session. This will help orient students to the knowledge, skills and techniques they will be learning. Discuss student expectations for progress over the course of the group and acknowledge the difficulty of changing behavior and starting new habits. It is important to provide validation for the fact that creating new habits is difficult, while at the same time instilling hope that creating these new habits is both possible and an important goal. This is an essential point to make, as it can serve as a reference point during weeks when students may feel frustrated with the difficulties of maintaining new behaviors and skills. It can be helpful to use a visual aid to demonstrate differences in one’s expectations for progress versus the reality of changing behavior. Direct the students’ attention to the Progress Chart shown in Handout 1.4. First, point out that from the beginning of treatment until the end of treatment, most individuals expect to see continuous improvement, represented by the straight line. Alert students to the fact that therapeutic progress seldom occurs in such a straight-line fashion. Instead, therapeutic progress is much more likely to have its ups and downs, as shown in the Progress Chart. In some weeks, improvements may be large, in others they may be small. Pointing this out to students goes a long way towards setting realistic expectations for therapeutic change. It is also critically important to mention that there may even be times when students have setbacks and they regress a bit. Acknowledge that this could lead to thoughts that ACCESS “isn’t working anymore.” Challenge this thought by showing students that while this may appear to be a setback, they are now functioning at a level much improved from when they started the program. To further combat the possibility of maladaptive negative thinking, encourage students to view such setbacks, not as evidence of failure but rather as opportunities for learning how to prevent such setbacks in the future. Therapeutic progress is typically gradual and variable; setbacks are opportunities for learning. Meet Mentors (Optional) If possible, invite mentors into group to introduce themselves. This allows students to briefly meet their mentors, which can get their mentoring sessions off to a fast start.

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ADHD Knowledge The main goal of this section is to provide students with accurate information about the core characteristics of ADHD; as well as to link this information to a discussion about how ADHD impacts daily life and behavior. Handout 1.5 provides detailed information about the symptoms, prevalence, and course of ADHD.  Rather than simply reading the information from the handout, it can be more engaging to start this section by asking students “What do you already know about ADHD?” As students answer this question, connect their responses to the information provided on the handout. What is ADHD The main point to be made here is that ADHD is a recognized diagnosis in the health care field, characterized by core symptoms of inattention, impulsivity, and hyperactivity. Provide examples of how these symptoms can be expressed in everyday life. To increase engagement in the discussion, ask students which symptoms they themselves display. In addition, inform students that symptom profiles can differ greatly between people with a diagnosis of ADHD. Some people may have only inattentive symptoms, while others may display a combination of inattentive and hyperactive-­ impulsive symptoms. Prevalence Start this section by asking students to estimate how many children out of 100 will have ADHD. Once students have made an estimate, inform them that the reported prevalence rate of ADHD is about 5–7 children out of 100. Explore whether students’ estimates were higher or lower than this number. Review other information about ADHD in this section, including differences in prevalence rates between males and females, and the fact that ADHD is found in all racial and ethnic groups, in all countries, regardless of income level. Developmental Course Guide students in a discussion about when ADHD symptoms first appear and how often they persist into adulthood. To increase engagement in this topic, ask students to share when their symptoms of ADHD first appeared. This sets the stage for noting that ADHD symptoms can arise anytime from infancy to 12 years of age, with an average of 3–4 years of age. Inform students that although ADHD was previously considered a childhood-­ limited disorder, we now know that ADHD persists into adulthood for most people.

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There is some evidence that hyperactive-impulsive symptoms decrease over time; however, this may be because hyperactive-impulsive symptoms can be less noticeable in adults. For example, adults may experience intense feelings of restlessness internally while remaining seated. Therefore, their restlessness is not observable to others. Situational Variability ADHD is a disorder of performance variability NOT inability Children and adults with ADHD are just as capable as their peers but may perform less well depending on certain contextual factors that can impact their behavior. Specifically, individuals with ADHD are better able to focus and sustain attention when a task is novel and interesting. Although everyone may have more difficulty concentrating during a boring task, it can feel nearly impossible for someone with ADHD.  Individuals with ADHD also perform better in one-on-one situations as opposed to large group settings, and when they receive frequent and immediate feedback about their performance. By recognizing the situational variability of ADHD, it becomes easier to understand why the behavior and performance of individuals with ADHD can vary greatly from one situation to the next and therefore appear inconsistent. Situational variability can also help explain why some people observe ADHD in an individual and others do not. For example, teachers may observe ADHD symptoms in a child because the classroom is a large group setting, whereas the child’s parents may  not see such symptoms because they typically interact with the child in one-to-one situations.

Tip One great technique to wrap up this section is to ask students if they’ve ever wondered why it’s easy for someone with ADHD to concentrate while playing video games. Prompt them to use what they just learned about situational variability to help understand this. As needed, explain that video games provide an ideal “environment” for enhancing focus and attention in someone with ADHD, because video games are inherently interesting, offer immediate and frequent feedback in the form of scoreboards, and are generally played individually or in small groups.

Neuropsychology of ADHD Emphasize that ADHD is the result of brain-based differences; that is, ADHD is the result of differences in the way the brain operates. These differences lead to difficulties with behavioral inhibition, which is the capacity to stop or delay a behavioral response. Practically speaking, what this means is that people with ADHD have a

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hard time inhibiting their behavior in a variety of ways – they may have problems pausing and thinking before acting, or they can have trouble preventing or stopping their mind from wandering. Behavioral inhibition, in turn, is linked to executive functioning abilities (depicted on the handout). People with ADHD tend to have more executive functioning difficulties, which make it harder to plan and complete goal-directed behavior. A good way to wrap up this portion of the group meeting is to offer students an opportunity to ask questions about the ADHD knowledge topics that were covered. Remind them that this is just the first in a series of steps to give them evidence-based knowledge of ADHD, designed to help them better understand and more effectively manage their ADHD.

Behavioral Strategies The primary goal of this section is to briefly review the variety of resources offered on campus. This will vary across colleges and universities; hence, this discussion will look slightly different depending on the specific campus resources available. Some common campus resources that are helpful to discuss are disability support services, tutoring, academic coaching, writing support, counseling, and student health offices from which ADHD medications may be prescribed. Remember to provide information about how to access these services in terms of specific locations, contact information, and any referral policies. Also, inform students that guest speakers from many of these offices will be invited to answer questions about their services during upcoming group sessions. An important point to emphasize is the fact that while these services are helpful, they may not be enough in and of themselves to help students with ADHD perform at their best. However, in combination with the support offered by the ACCESS program, they allow students to perform to the best of their abilities. Tip To increase student engagement in this section, ask students whether they have used any of the services reviewed in this section and ask them to share their impressions and experiences. Many students will have had positive experiences, and sharing can encourage other group members to try these services for themselves. To wrap up this section, note that support can also be provided by friends, family members, by ACCESS program mentors, and even by other group members. For example, signing up for a class with a friend can help support attendance in the class and provides a built-in “study buddy.”

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Assign Between-Session Practice Remind the students of the importance of meeting with assigned mentors before the next group. Also note that using a planner and a task list will be discussed in Week 2 and ask students to bring in any planner and task list system they may currently be using.

Adaptive Thinking Skills Direct students to Handout 1.6 to guide the discussion for this section. Introduce students to the basic principles of cognitive therapy, which provides the foundation for using adaptive thinking skills throughout the entire ACCESS program. The essential message is that thoughts can have an impact on how we feel and behave. This is commonly depicted via the “cognitive triangle,” which is displayed on the handout for this section. To keep students engaged, ask them whether they are familiar with this concept. If so, allow them to provide a description themselves. If they are not familiar with the cognitive triangle, ask them whether they have experienced a time when their thoughts about a situation or about themselves impacted how they were feeling. Use these examples to discuss the relationship between thoughts, feelings, and behaviors. For example, a student might report that they notice negative thoughts about themselves or their competence (e.g., “I’m so lazy, I’m terrible at school”). Point out that these types of thoughts are often not well-­ founded. For instance, a student may have the thought, “This is impossible, I will never be able to get this done” when thinking about a class project. Acknowledge that it may be the case that the project is difficult or challenging; however, to describe it as “impossible” is clearly an exaggeration that can reduce one’s motivation for taking on the task. Equally important is helping students understand the connection between their thoughts and their emotions and behavior. Ask them to identify some of the emotions that could occur along with such thoughts. Typical examples might include sadness, hopelessness, or frustration. Next, help students identify the behaviors that may be impacted by such thoughts. Some possible examples might be avoiding schoolwork or engaging in behaviors to “escape” negative emotions and thoughts such as playing video games, drinking alcohol, or spending money. Be sure to make clear the goal of learning adaptive thinking skills – to become better able to engage in more realistic, positive thinking. Note that thinking styles, like any other behavior, can become habitual. By learning adaptive thinking skills, students can identify unhelpful thinking habits and take steps to adjust or eliminate these habits. Ask students to think about a time when changing how they thought about a situation changed how they felt or acted. If students have trouble coming up with an example, ask whether they have ever misinterpreted a text message. Most students have examples of a time when they thought a friend was upset or annoyed with them, based on a brief text message or a delayed response by text. Since text

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messages are brief and lack the context of a face-to-face conversation, there are times when these messages are misinterpreted. Most students can relate to this experience, and it provides a useful example to discuss how faulty thoughts can lead to negative feelings. Make sure to get students to explain what happened once they realized they were misinterpreting the text – did their emotions change? Did their behavior change? Students generally report feeling relieved or happy. Often their behavior changed as well – they may have been avoiding a friend, or they may have been unable to focus on other things due to feeling upset. After their thoughts changed, they likely experienced a change in behavior as well. The way we think affects the way that we feel and the way we behave. Assign Between-Session Practice Ask students to try to notice their thoughts over the course of the next week. What types of thoughts do they notice when they are experiencing negative emotions, like sadness, fear, frustration, or anger? Remind students that practicing over the week in between group sessions is key to making progress with this skill.

Ending Group Session Conclude the session by reviewing the major points that were covered and by reminding the group of the importance of doing between-session practice assignments. Specifically, ask the students to meet with their mentor before the next group session and to bring in any current planner and task list system they may currently be using.

Week 1 – Mentoring Introduction & Confidentiality Brief Introduction Briefly greet the mentee and welcome them to the ACCESS program. Remind them about general confidentiality policies and issues, as well as those specific to the student’s campus. Be sure to consider these details when planning the start of the session. Mentor: “Hi! I’m Katherine Jones, but you can call me Kate. I’ll be your mentor for the ACCESS program. Today we’ll start just by getting to know each other and learning more about the ACCESS mentoring component. Let’s get started." Mentee: “Ok.”

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Tell them a bit about yourself and gather information about them. If desired, share with them your role at the institution or your organization/practice, your educational background, your pronouns, and some interesting facts, such as hobbies and where you are from. As you gather information about the mentee, make sure to ask how they like to be addressed (e.g., pronouns, nicknames, etc.). Mentor: “You may have already heard this in the group meeting, but it is important to remind you that what we talk about is confidential, which means that the ACCESS clinical staff will not discuss your personal information with other people without your consent. The ACCESS clinical staff consists of the group leader, myself, and our supervisor [if applicable]. The only time your information would be shared without your consent is in the case of an emergency such as a health emergency or if you were in immediate danger of hurting yourself or someone else. Does that make sense?” Mentee: “Yes, I’ve heard that before. Makes sense.” Mentor: “Ok, great. As I said, you can call me Kate. I use female pronouns like she and her. I am going to be your mentor – we’ll talk more about what that means in a few minutes. I have a master’s degree in Psychology, and I work as a service coordinator and a mentor, here in the Campus Resource Services Office. I am originally from Ohio and am a huge Cincinnati Reds fan. In my life outside of my job, I like playing recreational soccer and anything comic book related! Tell me a little about yourself – how you prefer to be addressed – like by a nickname or any preferences for pronouns, and anything else about you that you’d like to share.” Talking informally will help build rapport with the mentee. This is one of the most important aspects of this first session. Having a connection with the mentee will encourage them to continue participating in the program and coming to mentoring. Be sure to flag a few items of interest in the notes for the session as a cue for next time.

Check-In Briefly check in with the mentee about their experience at the first group session. In future sessions, the check-in will serve as a transitional time in the beginning of session. Questions to guide this discussion include: • How did the first group go for you? • Did you bring your ACCESS materials (i.e., Week 1 Handouts)?

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Collaborative Agenda Setting Briefly outline today’s session, letting the mentee know what to expect for the remainder of the time today: • Remind the mentee that this session will last about an hour, but all subsequent sessions will be about 30 minutes. • Continue getting to know each other and gather background information from the mentee. • Discuss the ACCESS program and the expectations for mentoring. • Review the content material from the first group meeting that outlined the basics of ADHD, discussed the importance of utilizing services on campus, and introduced the concept of adaptive thinking. • If topics from the check-in seem to generate more conversation pertinent to the needs of the mentee, suggest adding them to the agenda. Alternatively, directly ask the mentee if they would like to contribute to the agenda. Often the specific topics fit well into the existing agenda. Otherwise, plan to set aside a few minutes at the end to address the topic. Mentor: “I’ve given you our agenda for today. Each week I’ll do this  – but it’s important that our sessions are tailored to your needs. Is there anything else you would like to include on our agenda for today?” Mentee: “I just learned that my financial aid has not gone through. I am so stressed about it!” Mentor: “Ok, that topic will be very relevant when we discuss adaptive thinking in this session. After that, we can spend a few minutes problem solving about that situation, if needed.”

Learn More about the Mentee Use Handout 1.8 to gather more information about the mentee and their experiences with ADHD including: their ADHD clinical presentation type, when they were diagnosed, if they are taking medication or receiving other forms of treatment, what other psychological conditions they may have in addition to ADHD, and educational history information. Specifically ask about their major and academic standing to tailor mentoring to their needs. For example, different degrees may have different requirements. Additionally, determining mentees’ previous experiences on academic probation or suspension can make it easier to support their academic success. When completing the background information form, also gather information about communicating with the mentee. Do they prefer to be emailed or texted? How often would they like to receive reminders about mentoring? Many mentees like to receive multiple reminders for mentoring, often the day before and the morning of their scheduled session.

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Clarify What Mentoring Is and Is Not Begin by giving an overview of the program from the perspective of the mentor. Below is a sample of this description. Mentor: “As you heard in group, ACCESS services consist of two main components. The first is the group, in which you get the chance to learn information and skills that will help you reduce the impact that ADHD has on your day-to-day functioning. In addition to learning, you’ll be able to share stories and get support from others who have had similar struggles. I will work with you as a mentor for the next 8 weeks. Mentoring allows you to take skills you are learning in group and individualize them in a way that works best for you. By working with you one-on-­one, I can help you go into greater depth and discuss personal examples that are most relevant to your situation. I can also act as an accountability partner, following up and checking in with you each week as you try out skills. We can problem solve together and work as a team so that you get the most benefit from the program.” The description of mentoring can be mistaken for therapy or counseling. Be sure to discuss the differences and similarities between them. • Similarities: Mentoring and therapy both focus on reflective listening, empathy, and problem-solving skills. Like therapy, goals for mentoring include decreasing impairment and distress, establishing short- and long-term personal goals, and increasing motivation for change. • Differences: Unlike therapy, mentoring focuses specifically on issues related to ADHD symptoms or associated impairment. Mentoring occurs in brief and solution-­focused sessions (30-minutes). Any crises unrelated to ADHD are best handled by an individual counselor on campus or in the community. Briefly review the topics covered across all 8 group sessions and discuss the three main topics that will be covered each week: ADHD knowledge, behavioral strategies, and adaptive thinking.

Discuss Information Presented in Group The main objective of mentoring is to clarify, refine, and reinforce what is learned in the group sessions. Consider the following prompt to initiate this discussion: • Ok, let’s look over your handouts from group and go over each topic. As we go, we can focus more on the questions you have or ways that you would like to apply what you learned to your own situation.

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ADHD Knowledge Briefly introduce ADHD and discuss the core symptoms of inattention, impulsivity, and hyperactivity. Also briefly outline prevalence rates and the developmental course of ADHD.  Some mentees find it helpful to discuss how ADHD has often been thought about as a childhood disorder, but that it is known to persist across the lifespan. Clarify any confusion about this. For some mentees who understood most of the information presented in the group, open-ended questions may be enough to start a natural dialogue to easily address their questions and connect the information in a meaningful and personal way for them. Here are some potential questions to ask. • Was there any information that was new to you? • Was there anything that was especially interesting or surprising? For other mentees, repeating or reviewing specific information may be necessary because their knowledge of ADHD is limited or was not fully absorbed from the group. Below are some examples of helpful questions to prompt discussion. • Were you already familiar with the three types of ADHD symptoms? Do you feel you understand the differences between them and could explain them to someone else if they were curious to better understand you or your ADHD? • The symptoms can play out verbally, in your thinking, as well as physically – have you noticed different ways that you display ADHD symptoms? • Which ADHD symptoms do you experience that bother you the most? Discuss the concept of situational variability. Remind mentees that ADHD is a disorder of performance variability, not inability. Individuals with ADHD can thrive and be successful when they are able to find the situations and strategies that work for them. Questions to guide discussion include: • What are the situations in which you tend to function the best? • What strategies have you used in the past to reduce your ADHD symptoms and what strategies might be helpful in the future? Many mentees are unfamiliar with the concepts of behavioral inhibition and executive functioning. Briefly address any questions that mentees have about these topics. Mentees have often not thought about ADHD in this way and it can be extremely validating for them to discuss these concepts. Additionally, understanding these concepts can be key to developing a bigger picture understanding of themselves, ADHD itself, and importantly, how they can better understand how to adapt and cope for optimal functioning.

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Behavioral Strategies Discuss any resources that the student has utilized on or off campus, using Handout 1.9 to guide the discussion. Provide information about any relevant campus resources that the student might not know about. Address myths about campus services and encourage the mentee to utilize any services that might be beneficial. Tip Ask the mentee if they are registered with the disability office on campus. If they are not, discuss the benefits of using this service (e.g., priority registration, extended time on exams, etc.). Be prepared to outline the steps necessary to get connected with this resource on their campus.

Adaptive Thinking Introduce the concept of adaptive thinking with the mentee and ask if they have ever used these strategies before. At the most basic level, this strategy focuses on how thoughts, feelings, and behaviors are all interconnected. In other words, the thoughts an individual has impacts their feelings and behaviors (and vice versa). Discuss the cognitive triangle and provide basic examples of how this works.

Assess Mentee’s Strengths, Needs, and Goals Have a conversation with the mentee about what brought them to the ACCESS program. Questions to guide this discusion include: • How did you hear about the program? • What do you hope to gain from it? Ask the mentee what they believe are their strengths and weaknesses in relation to managing their ADHD. It is very important to ask about both strengths and weaknesses, as some who have a long history of challenges related to their ADHD may have difficulty identifying strengths and focus mainly on weaknesses. They may feel negatively and skeptical about their ability to manage their ADHD. Additionally, identifying strengths is often a good starting point for what may work to improve their weaker areas. This will help identify goals for the mentee. Mentee: “I don’t think I’m good at anything when it comes to my ADHD. That’s why I’m here.”

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Mentor: “Well, earlier when we talked about situational variability, you reflected that you do a better job paying attention in your art courses because that is a subject of high interest to you. You also said that periodically meeting with your professors one-on-one has helped you clarify information that you missed in class. Those are both strengths! What are some other ways you feel you are doing well coping with or managing your ADHD symptoms?” Mentee: “I am pretty good about taking my medication regularly. But I’m worried I rely on it too much because later in the day when it is out of my system, I feel like I don’t know what to do when I still need to get work done or study.” Mentor: “Ok. So, medication has helped, and you are good about taking it. Sounds like you have strengths complying with treatment and can establish a regular habit that is helpful! Through ACCESS, you’ll find other useful habits that you can start to implement regularly, just like taking medication. It also sounds like being focused and productive in the late afternoon and evening when your medication has worn off is a weaker area for you. Would that be a good goal for you this semester?” Mentee: “Yes – definitely!” Mentor:  “Great. We’ll include that in your personal goals for the program. What else?” Mentee: “Another weakness is that I’m late to everything and I know it affects my grades, my part-time job, and my friendships. I would like to improve being on time.” Mentor: “Another excellent suggestion. Let’s add that to your list of personal goals.” Tip Point out that it is a huge strength that they are seeking out support to learn new strategies! Also reflect on any other mentee strengths that emerged from talking with them in this first session.

Help the mentee identify at least two areas that they want to work on during their participation in ACCESS. Complete the Goal Setting Form (Handout 1.10). Discuss SMART goals – i.e., goals that are Specific, Measurable, Attainable, Realistic, and Timely. Discuss any barriers to reaching those goals and briefly discuss strategies that may be useful in achieving them. Mentees can create goals related to a wide variety of topics and situations, such as academics, social life, life balance, organization, healthy living, etc. Help mentees identify both short- and long-term goals.

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Inform the mentee that their Goal Setting Form will be used throughout mentoring to help monitor their progress, address any barriers, and to add new goals as needed. Tip When the mentee discusses a topic relevant to their goals, return to the goal sheet and discuss progress. Similarly, if a mentee mentions something that appears to be a goal, ask them if they would like to add it to the goal sheet so that they remember it and develop strategies to work toward that goal.

Ending Mentoring Session Check in about goals as needed. Is there anything that has been accomplished or needs to be modified? Any miscellaneous topics of discussion? This is where you can address any topics that did not fit into the prior discussion. Finally, review and clarify as needed the details of what you would like the mentee to do between now and the next mentoring session, including: • Bring all group materials to the next mentoring session, including all group session handouts and the planner that they will be using. • Research campus resources/services and consider what resources may be most useful to them. If the mentee identified that they wanted to connect with specific services (e.g., disability services), ask them to take steps toward connecting with that resource. Make sure to check-in about this in the next session. Confirm the date and time of next appointment. Ask the mentee to write down/set reminder and model similar behavior with your own planner/calendar.

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Week 1 – Group Agenda

Week 1 – Group Agenda

Introduction to ACCESS Program • Describe format used (8 group, 8+ mentoring sessions) and rationale • Set expectations for participation and attendance • Provide overview of topics covered across all 8 sessions • Introduce and meet mentors (preferred but optional)

ADHD Knowledge • Present information about core characteristics of ADHD including symptoms, prevalence, course, and neuropsychological explanation of ADHD • Discuss situational variability factors affecting performance of individuals with ADHD

Behavioral Strategies • Discuss list of services and offices on campus that provide academic, social, and emotional support to students • Provide contact information and guidance for accessing these services • Elicit feedback from group members about experiences using these resources

Adaptive Thinking Skills • Introduce basic tenets of cognitive therapy • Present the cognitive triangle model and emphasize connections between thoughts, feelings, and behaviors • Discuss the goal of cognitive therapy: more realistic thinking

Ending Group Session Handouts • 1.1 Week 1 Group Cover Sheet • 1.2 What is ACCESS • 1.3 Active Treatment Phase • 1.4 Progress Chart • 1.5 What is ADHD • 1.6 What is Adaptive Thinking

Handout 1.1

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ACCESS Accessing Campus Connections and Empowering Student Success

Week 1 – Group Handouts • • • • • •

1.1 Week 1 Group Cover Sheet 1.2 What is ACCESS? 1.3 Active Treatment Phase 1.4 Progress Chart 1.5 What is ADHD? 1.6 What is Adaptive Thinking?

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Handout 1.2

What is ACCESS? ACCESS = Accessing Campus Connections & Empowering Student Success

Program Description • Designed for college students with Attention-Deficit/Hyperactivity Disorder • Two-semester program including an eight-week active phase and a semester-­ long maintenance phase • Program includes a group component and an individual mentoring component • Group (Eight Weeks in Active Phase) ◦◦ Learn more about ADHD ◦◦ Learn behavioral strategies to cope with ADHD and help achieve success ◦◦ Learn adaptive thinking strategies • Individual Mentoring (Eight to Ten Sessions in Active Phase) ◦◦ Help apply what was learned in group ◦◦ Connect with campus resources ◦◦ Set and achieve personal goals ◦◦ Support/coaching ◦◦ Not psychotherapy • Second semester ◦◦ One Group booster session ◦◦ Meet with mentor up to six times Participation Goals • Attend all group sessions and individual meetings with mentor • Arrive on time (reminder will be provided) ◦◦ Participate! The more you put into this program, the more you will get out of it! • Importance of practice between sessions • Confidentiality: What happens in group stays in group ◦◦ Group leader/mentor exceptions to confidentiality to maintain safety

Primary symptoms

Campus resources

Basic principles

ADHD knowledge

Behavioral strategies

Adaptive thinking

Week 1

Maladaptive thinking

Planners and to-do lists

Causes

Week 2

Adaptive thinking

Getting organized

Assessment

Week 3

Managing schoolwork

Attending classes

School & Daily Functioning

Week 4

Handling emotions

Effective studying

Emotions and risk-taking

Week 5

Active Treatment Phase

Adhering to treatment

Long-term projects

Medication management

Week 6

Social relationships

Social relationships

Psychosocial treatment

Week 7

Relapse prevention

Long-term goals

Long-term outlook

Week 8

Handout 1.3 53

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Handout 1.4

Progress Chart

Improvement

Begin Treatment

End Treatment

Although we expect to make progress in a steady and predictable manner, progress is often variable. Remember that even if you are experiencing a “slump,” you have still made progress compared to where you started!

Handout 1.5



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What is ADHD? ADHD = Attention-Deficit/Hyperactivity Disorder (from Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition)

Inattention • Careless mistakes • Difficulty sustaining attention to task • Doesn’t listen • Does not finish things • Difficulty organizing • Avoids tasks requiring sustained mental effort • Loses things • Easily distracted • Forgetful

Hyperactivity-Impulsivity • Fidgets • Leaves seat • Runs about or climbs excessively • Difficulty playing quietly • “On the go” • Talks excessively • Blurts out answers • Difficulty waiting for turn • Interrupts or intrudes

Prevalence • 5–7% among children • Slightly lower rates among adolescents, with 70–80% still meeting criteria • 3–5% of adults • More males than females (2:1 … 6:1) in children and adolescents but closer to 1:1 among adults • Affects all income levels • Found in all ethnic/racial groups Developmental Course • Peak onset between years 3–4 • Hyperactive/impulsive symptoms often precede inattentive symptoms • Persists into adolescence and adulthood • Somewhat fewer problems with hyperactivity/impulsivity over time Situational Variability – A disorder of performance variability, not inability • Interesting vs. Boring • One-on-one vs. Group • Frequent vs. Infrequent Feedback • Immediate vs. Delayed Feedback

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Handout 1.6

What is Adaptive Thinking? Thoughts → Feelings & Behaviors What you think influences how you feel and what you do. Thought → I’ll never be able to do it.

Feeling Sad

&

Behavior Give up

The Cognitive Triangle Thoughts

Feelings

Behaviors

Often, the automatic thoughts that run through our minds and affect how we feel and act are either untrue or have just a grain of truth. Automatic thoughts can interfere with the ability to complete tasks and may contribute to feelings of depression, anxiety, and frustration. Goal of adaptive thinking = Realistic, balanced thoughts

Week 1 – Mentoring Agenda

Week 1 – Mentoring Agenda Introduction & Confidentiality Check-In Collaborative Agenda Setting Learn More about the Mentee Clarify What Mentoring Is and Is Not Discuss Information Presented in Group Assess Mentee Strengths, Needs, and Goals Ending Mentoring Session Handouts • 1.7 Week 1 Mentoring Cover Sheet • 1.8 Background Information Form • 1.9 Campus Resources Checklist • 1.10 Goal Setting Form

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Handout 1.7

ACCESS Accessing Campus Connections and Empowering Student Success



Week 1 – Mentoring Handouts • • • •

1.7 Week 1 Mentoring Cover Sheet 1.8 Background Information Form 1.9 Campus Resources Checklist 1.10 Goal Setting Form

Handout 1.8



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Background Information Form

When were you diagnosed with ADHD? Clinical presentation type? Have you been diagnosed with any other psychological or medical conditions? Do you take any medication for ADHD or other psychiatric conditions? Do you receive counseling for ADHD or other psychiatric conditions? What is your major? What year are you? What is your GPA right now? Are you in good academic standing? Have you ever been on academic probation or suspension? How do you prefer to be contacted (phone, email, text, etc.)? What are your preferred pronouns? Is there anything else you think is important for me to know about you right now?

Handout 1.9

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Campus Resource Checklist Campus resource

Disability support services/accessibility support

Counseling center

Tutoring

Academic coaching

Writing center

Career services center

Student health services

Other

Use?

Plan to use?

Notes

Handout 1.10

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Goal-Setting Form Goal & start date 1.

2.

3.

4.

5.

Target date

Progress

Chapter 4

Active Phase – Week 2

In Week 2, two key strategies are introduced in group: planners and To-Do lists. Additionally, group content also includes a discussion of the causes of ADHD, tips for finding helpful resources with accurate information about ADHD, prioritizing systems and strategies, and instruction on recognizing maladaptive thinking patterns. To supplement group content, mentors will help students with the implementation of planners and To-Do lists. Mentors will also review information about the causes of ADHD, available resources, and ways to recognize and manage maladaptive thinking patterns.

Week 2 – Group Beginning Group Session Ask Group Members to Reintroduce Themselves This is a friendly icebreaker and practical too. Because this is only the second group meeting, some students may have forgotten others’ names, and this spares them the awkwardness of asking. Address Any Carry-Over Issues from Week 1 First, briefly remind the group of what was covered in the first meeting. This creates an opportunity to answer any questions or to clarify any confusion that was not fully addressed previously. Taking time to do so is critically important because each treatment session is a building block for the following treatment session.

© Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_4

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Check to See If Connections Were Made with Mentors Encourage the students who did meet with their mentors to talk about how things went. Students typically describe very positive first meetings. Hearing about these positive experiences often serves to increase the motivation of anyone in the group who has not yet made a connection with their assigned mentor, to do so. As needed, provide encouragement and guidance to ensure that all group members are actively engaged with their assigned mentors prior to the next weekly meeting. To further highlight the importance of this connection, remind the students that the mentors will help them tailor what they learn from group to meet their individual needs. Remind the Group of the Importance of Between-Session Practice Ultimately, the goal is for students to successfully incorporate what they learn from ACCESS into their everyday lives. Between-session practice helps achieve this goal. To emphasize this point, it is often useful to re-state, “the more you put into it, the more you will get out of it.” Remind the group that between-session practice addressing the three major components of ACCESS – ADHD knowledge, behavioral strategies, and adaptive thinking skills – will be reviewed regularly. Make clear that the reason for doing so is completely constructive – after listening to how things went, give students feedback on how to do things even better the next time, as needed.

ADHD Knowledge Start the Knowledge Section Briefly review the ADHD knowledge covered in Week 1 and ask whether any questions have arisen. After answering these questions and dealing with any other carry-­ over concerns, transition into the new ADHD knowledge content, which is “what causes ADHD.” Encourage Group Discussion Remember that the more students talk and discuss the topic versus lecturing, the more engaging and successful the session will be. Start a good discussion by asking the group what they believe, or perhaps have heard, causes ADHD. Clarify the Roles of Nature Versus Nurture After students respond to initial questions about causes of ADHD, direct their attention to the figure in Handout 2.2. The first point to be made is that ADHD is likely caused by one or more biological factors, not environmental factors. Although poor parenting,

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chaotic home environments, excessive television watching, and many other such causes have been proposed, there is no evidence to support these theories. One way to convey this is to note that ADHD is sensitive to the environment; that is, ADHD symptoms may be more noticeable and problematic due to factors such as poor parenting, chaotic home life, and so forth. However, these factors do not cause ADHD. Environmental factors can exacerbate a pre-existing ADHD condition, but biological factors are primarily responsible for causing ADHD. Review What Brain Areas and Functions are Likely to Be Impaired Briefly describe how various neurotransmitters (e.g., dopamine), neurophysiological mechanisms (e.g., decreased blood flow), and neuroanatomical abnormalities in the prefrontal limbic area of the brain are thought to be involved in the expression of ADHD. Be sure to point out that, while what we currently know about the neurobiology of ADHD is based on evidence from numerous research studies, our understanding of this is far from complete and will continue to evolve over time. Discuss Pathways Impacting Prefrontal Cortex Given that prefrontal limbic abnormalities are involved in ADHD, the question remains, how did they get there? Raising this question provides an opportunity for discussing that there are multiple pathways by which the prefrontal area may be disturbed. To facilitate this discussion, once again direct the students’ attention to Handout 2.2; then state that, for most individuals, inborn biological factors, such as genetic factors and certain prenatal and birth complications, are the starting point for the pathway through the brain that leads to ADHD. In a smaller percentage of individuals, ADHD may be acquired after birth via head injury, lead poisoning, and other acquired biological mechanisms. Address the Genetics of ADHD Ask the group if anyone in their family has been diagnosed with ADHD or has symptoms of ADHD. This often leads to an enthusiastic description of parents, siblings, and other relatives with ADHD symptoms. Some students may express alarm or distress when they learn about the increased risk for ADHD that their own children will face. If this occurs, reassure students that an increased risk does not mean their children will have the disorder. Even if they do, ADHD is a manageable condition for which many treatments are available.

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 ncourage Students to Become Informed Consumers of ADHD E Information Point out that there is a great deal of misinformation about ADHD on the internet and elsewhere in the media, and so it is important to read critically and to carefully check sources. Websites aiming to sell “cures” for ADHD are particularly suspect. Because it unlikely that students will have the time to read a book about ADHD during the semester, encourage them to consider doing such reading in the future. The more accurate and evidence-based the information, the more likely it is to be of some help in managing ADHD. Direct Attention to Technology Tools Be sure to ask students to share with the group what apps and programs they have found most useful in coping with their symptoms. Because not all apps and computer programs are of equal quality, remind the group to take an informed consumer approach when selecting technology tools for their own use.

Behavioral Strategies Start the Behavioral Strategies Section Remind students that the topic covered last week was accessing campus resources. Briefly check-in to see if students have any questions about the resources discussed or if any students have connected with a new resource since the last session. Also survey the group to see who may have remembered to bring in planners and To-Do lists that they are currently using. Introduce the Planner and the To-Do List Throughout the discussion of planners and To-Do lists, refer students to Handouts 2.3 and 2.4. Some students will already be using some form of one or both tools at the start of the program. If a student already has a system working for them, they should be praised, invited to share it with the group, and then encouraged to make small improvements to that system, rather than starting anew. Many students are frustrated by planners and To-Do lists, and either have tried them in the past and have given up on them, or are using them now but in a halfhearted, ineffective way. Point out that barriers and issues with using planners are common, and can be managed through support from their peers, the group leader, and their mentor.

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Different Strokes for Different Folks Have each group member describe the types of planners they are using or have tried. Ask them to comment on what they like and don’t like about these planners. Be sure to praise students for their efforts and be reassuring if they complain about what is not successful – mention that adjustments can be made and that there is no “perfect” system. If there were, everyone would be using it! Deciding Which Type of Planner to Use When students share their current planner systems, the advantages and disadvantages of both will naturally arise. In our experience, written appointment-book type planners, preferably those that include time blocks for each day through the evening hours, tend to be the most helpful. Students can easily transfer their syllabi onto these planners by blocking off their class sessions each week (e.g., outlining them with rectangles) and writing assignments on those class times. After adding extracurricular activities, jobs, and other commitments to the planner, it becomes easy to eyeball the week to find “free time,” which can be blocked out as study time and time to dedicate to class assignments. Written planners can be used during class when phones are off limits. Perhaps more importantly, accessing a written planner will not lead to other distractions such as checking texts, emails, and social media. A disadvantage of written planners, however, is that it is often challenging to keep them nearby all the time. An advantage to using electronic planners is that students can set up classes and other recurring weekly events once rather than having to enter them manually for the whole semester. Students can also set alarms to remind them about classes and other activities. One disadvantage is that it is not as easy to view a whole week on a small phone screen. In addition, it is more difficult to access an electronic planner in class, as instructors tend to frown on or outright prohibit screen time during class. Getting distracted when checking a phone or computer planner is another very real problem. Bottom line: there is no right or wrong way, and what is ultimately selected should be what best meets the needs of a given student. Discuss Rules for Using Planners More Effectively First present the “Planner Laws” which are: 1 . Have only one planner at a time 2. Keep planners with you all the time 3. Enter all appointments into the planner Then ask for the group’s reactions. Most students will acknowledge that having multiple planners gets confusing; that you cannot consult or add items to a planner if it is not with you; and that it is challenging to rely on memory alone to keep track

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of all appointments and deadlines. Occasionally, a student will claim to have an excellent memory and does not need to write things down. Gently challenge this claim if this occurs. Some probing usually reveals that, in fact, tasks or events are forgotten at times because of not writing them down. Invite the Group to Share Helpful Hints Ask the group to volunteer strategies that have worked for them in their own planner use. This generally results in coverage of most of the suggested strategies. When needed, cover any techniques or strategies that were missed. One of the most important points to emphasize is the final one – a student should not become upset or catastrophize about their ability to use a planning system if they temporarily forget to use their planner. Students may give up prematurely on using a planner if they ignore it for a few days and then feel they have “failed.” Normalize this experience and emphasize that new habits take time to develop. If they stop for a few days, they can just pick up where they left off and try again! Remind them of the progress chart notion discussed in Week 1. Reminders to Facilitate Planner Use Start by sharing some examples of how visual and auditory reminders can be used. For example, posting lots of brightly colored sticky notes on a highly visible door to ensure tackling an item in the planner. Or maybe programming a device to sound a signal when it is time to address something else in the planner. Then ask the students what they are already using as visual and auditory reminders. They often have very creative ideas to share! Ask the Group to Practice Using the Planner Set the expectation that all students should test drive their planners to get a feel for what does and does not work. Acknowledge that challenges may arise as they attempt to implement a planner system and ask students to anticipate what barriers they may face in order to troubleshoot them in advance. A common issue is that students will simply forget to use their planner. Possible solutions include: • develop the habit of using the planner when engaged in other activities that already occur routinely (e.g., mealtime) • set an alarm to go off each morning and evening at a convenient time for reviewing the planner • review and update the contents of their planner while sitting in a hallway waiting for a class to start.

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Introduce the To-Do List The second behavioral strategy is using a To-Do list. Again, direct students to Handout 2.4 during the discussion of To-Do lists. First, ask the group to describe the types of To-Do lists they are currently using or have used. Because some students will be using To-Do lists and others will not, transition into discussing why it is even necessary to have a To-Do list if you are already using a planner. Be sure the group understands that certain tasks lend themselves better to the planner, whereas others are better suited for a To-Do list. Where students prefer to keep their To-Do list varies widely. This can be combined with the planner, such as when students create a To-Do list on brightly colored sticky notes that are placed within the planner. Sometimes it is more effective to keep a separate notebook dedicated for this purpose. Some students have a large white board at home that they continuously update. Others use electronic apps designed for this purpose. Still others use the weekend days, address section, blank pages, or other areas of their written planner that they are not otherwise using. Any of these systems might work successfully. However, discourage students from using individual sheets of loose paper that are easy to misplace. As with planners, students should consider the advantages and disadvantages of written versus electronic To-Do lists. Addressing Obstacles to Using To-Do Lists Anticipate the possibility that some students will reject the idea of using a To-Do list system because looking at a list of tasks causes anxiety or perhaps even makes them feel guilty for what they have not yet done. Use adaptive thinking techniques to explore and challenge faulty beliefs that may underlie this issue. Suggest alternative ways of thinking about this situation – e.g., “After all, you are not increasing the number of things you need to do by writing them down – you are just increasing your likelihood of actually getting them done!” In addition to addressing resistance with adaptive thinking strategies, encourage use of relaxation or mindfulness strategies for managing anxious thoughts. Yet another technique is to encourage students to create a daily task list limited to a few items, along with a longer To-Do list with a list of all on-going tasks. Some anxious students find that limiting the To-Do list to items that must be accomplished during the next few days is more palatable than a To-Do list that is lengthy in number and covers a long period of time. Suggestions for Completing Unpleasant Tasks Introduce the topic by asking students about tasks they may be avoiding. To increase the likelihood an avoided task will get done, the task should first be analyzed and then broken down into the smallest possible chunks that make practical sense. The To-Do list is a great place to display this breakdown, and the smaller chunks can then be transferred to the planner as actionable steps. To illustrate, if a student

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includes “write paper for English class” on a planner, the task may be avoided because it feels overwhelming and difficult. If, on the other hand, a student blocks off 15  minutes on the planner for “brainstorm topics for paper,” there is greater likelihood the task will be attempted and successfully accomplished. Completing the smallest step typically inspires a student to continue working and accomplish the next step in the larger task. The key is convincing oneself to get started, even if it means dedicating just 5  minutes to the unpleasant task, which most students acknowledge is tolerable for any task, even a strongly disliked one. Breaking down larger tasks into a series of more manageable smaller tasks is more likely to lead to completion of the larger task. Prioritizing Tasks within To-Do Lists Start this discussion by asking for a group member to voluntarily share items from their own To-Do list by writing them on a large dry erase board or by sending them to a Smartboard for display. Students typically will have long lists to share with the group and often readily acknowledge a tendency to attempt the easiest task first as their guiding principle for prioritizing tasks. Many students will also admit to suddenly feeling inspired at times do less important tasks before more important ones – such as cleaning a dorm room or making a grocery store run when they really need to be writing a paper. Encourage the group to discuss the obvious and subtle disadvantages of prioritizing in these ways. Using the sample list on the dry erase board, the group can then help the student prioritize every item. This can be done in a variety of ways, with some students preferring a ranking of each item as either lowest, medium, or highest importance (Safren et al., 2005), while other students may resonate with Covey’s (1989) time-management matrix (urgent/not urgent, important/not important). Still other students come up with their own, creative systems of how to prioritize tasks. The exact ranking system is completely a matter of personal preference. Assign Between-Session Practice Conclude this section by letting students know that they are encouraged to create a new To-Do list this week, incorporating many of the points discussed above. Remind them that their mentors will help them with this task, and that the goal is progress rather than perfection! As with planner use, brainstorm potential barriers and troubleshoot in advance.

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Adaptive Thinking Skills Start the Adaptive Thinking Section Begin by reminding the group of the general principles of cognitive therapy explained in Week 1. This can be introduced by saying, “Last week we discussed how thoughts influence both feelings and actions. The goal of learning adaptive thinking techniques is to increase your use of more balanced and realistic thinking, and to reduce episodes of maladaptive thinking.” Answer any lingering questions the students have about this approach. Review group members’ completion of the between-session practice assignment from Week 1. Specifically, ask if they have been more aware of their thoughts in the past week; if so, how might their thoughts have affected their feelings and behavior? Discuss Different Types of Maladaptive Thinking Direct students to Handout 2.5 during the discussion of maladaptive thinking patterns. There are several possible ways to discuss the different types of maladaptive thinking patterns that can occur. An especially effective approach is to tackle them one at a time, starting with a brief description, followed by an example from everyday life, and then asking the group to provide at least one additional example from their own experiences. Be sure to explore the feelings and behaviors associated with each maladaptive thought. To illustrate this process, you could define all-or-none thinking, provide an everyday example (“If I don’t get an A on the test, I’m a failure!”), discuss how this thought might make students feel (e.g., sad, anxious, fearful) and act (e.g., withdraw from a course, stop trying). Next, ask the group to think about how often they engage in each maladaptive thought pattern and to identify the types of maladaptive thinking that may cause them the most trouble.

Tip The professional term, maladaptive thinking patterns, can be used but for some students, labels such “thinking errors” or “cognitive distortions” sometimes resonate better. Students may even choose to invent a label that has special meaning for them, such as “brain fails” or “thought traps,” thereby increasing their engagement in using adaptive thinking techniques.

Most students enjoy all facets of the adaptive thinking section and readily identify with at least some of the maladaptive patterns. Some students will gain sudden insight into their own faulty beliefs and eagerly share examples with the group. Students’ reliance on text messages for communication provides a particularly rich

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field for mind-reading errors, given the absence of nonverbal cues in text messaging. Many students with ADHD engage in maladaptive thinking characterized by overly optimistic thinking rather than traditionally negative thoughts, which often sets the stage for procrastination and poor time management to occur. When the labeling error is discussed, many students with ADHD mention that they have been labeled by others, and sometimes even by themselves, as “lazy.” It is important to help students challenge this label! While problems with self-motivation are certainly part of ADHD, in our experience, college students with ADHD are often working much harder, and for much longer hours, than their peers, while earning poorer grades. This is hardly lazy. Removing Barriers to Adaptive Thinking Some students believe that they are “stupid” for having thought distortions. Gently challenge this labelling error and provide alternative thoughts for consideration. Evidence supporting these alternative thoughts can be presented by sharing genuine personal examples to make clear how common they are. Occasionally a student may claim that they never engage in any maladaptive thinking and that it would be “silly” to do so. This claim is itself, maladaptive thinking, and should be challenged (e.g., “Never in your life? Not once?”). An unwillingness to acknowledge ever engaging in maladaptive thinking is a potentially serious problem that must be addressed, so that the student does not miss out on benefitting from this clinically important component of the ACCESS program. If resistance persists, it is sometimes helpful to reframe all subsequent discussions of adaptive thinking as tools that, while not necessary at present, might prove useful in the future should they ever find themselves engaging in maladaptive thinking. Introduce the Three-Column Technique Either while working through student examples or after all the maladaptive thinking patterns have been discussed, draw students’ attention to the three columns at the bottom of Handout 2.5. These three columns address the following: a situation arises, this situation triggers automatic thoughts that frequently are negative and unrealistic, and negative feelings or behaviors ensue. Select a real example (e.g., “My professor unexpectedly e-mailed me to set up a meeting, I must have done something wrong, I am really scared and nervous”), and then demonstrate how to use the three columns as a tool for learning how to identify maladaptive thinking and its relationship to negative feelings and behaviors. Alert students to the fact that they will be learning how to challenge maladaptive thoughts and generate more adaptive thoughts in Week 3.

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Assign Between-Session Practice Ask students to use the 3-column technique to practice analyzing at least one situation in which negative feelings or behavior occurred. Remind them that their mentors will assist them as needed.

Ending Group Session Conclude the session by reminding the group of the recommended activities for between-session practice. Specifically, students will start using their planners and To-Do lists, and to practice using the three-column technique. Caution them that attempting these new activities may seem overwhelming at first, but that they should not feel discouraged because: • they are working together with fellow group members to test out new strategies to make positive changes in their lives, which is why they decided to participate in ACCESS • their group leader and mentors will be assisting them in adopting these new strategies • they have already thought about what could interfere with their efforts to practice and have developed a plan to overcome these obstacles.

Week 2 – Mentoring Check-In Briefly get an update on how the mentee has been doing since the last mentoring session. What is important in this check-in is to foster rapport-building. So, transition the mentee into the session in a comfortable way. For most mentees, a brief and light conversation about  recent events on campus or other topics of interest is sufficient.

Collaborative Agenda Setting This is the first week using the “standard” agenda format, the basics of which will be consistent from weeks 2–8. Although the outline from week to week is essentially the same, the content within each week will vary according to the content of the group session and the individual mentee’s needs. If topics from the check-in

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seem to generate more conversation pertinent to the needs of the mentee, suggest adding them to the agenda. Mentor: “This week I’ll check in about your ACCESS materials and your thoughts about campus resources. We’ll also discuss what you learned in group. This week you covered the causes of ADHD, the tools of a planner and To-Do list, and how to recognize maladaptive thoughts. Is there anything else you would like to discuss today?” Mentee: “Sounds good. I’d also like to talk about a situation going on with my roommate right now that is really stressing me out.” Mentor: “Ok, I’ll make sure we save some time for that. That might also be a good situation for us to generate examples when we talk about adaptive thinking.”

Review Between-Session Practice Follow up briefly on any “To-Do” or practice items that were discussed the prior week. This is important for two reasons: (1) those items are tools for treatment and will help the mentee improve their functioning, and (2) accountability is something that helps reinforce behaviors that you do want in your mentee. For this session, the following are the main items to check: • Did the mentee get a planner and To-Do list? Did they bring them to session? • Did the mentee consider which campus resources may be useful? If so, which ones? • Did the mentee bring handouts from group to this mentoring session? Give enthusiastic and positive feedback for any follow through on these tasks. Be neutral and do not over-respond to missed practice. Encourage mentees to complete missed practice as needed.

Discuss Information Presented in Group ADHD Knowledge The more engaged the mentee is, the better their learning experience. So, instead of lecturing, consider beginning this discussion with any of the following questions: • What is your reaction to learning about the causes of ADHD? • Do others in your family have ADHD? • Do you have any questions about this material? Occasionally mentees pose questions of a personal nature that are beyond the professional boundaries of the mentor. Mentee: “Let me tell you about my family member, and you can tell me if they have ADHD.”

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Mentor: “I think that is a good question to ask but it is not within my role as a mentor to diagnose a family member. If your family member is interested in finding out if they have ADHD, I can direct you to a qualified healthcare provider to address that.” Behavioral Strategies Any of the questions below would be a good way to begin this portion of the mentoring session: • Where will you keep your planner? • How will you remember to use your planner each day? • Will your cell phone work, or would a paper planner work better? Next, review the three planner rules and make sure that the mentee has a clear understanding for why it is important to follow these rules: 1 . Have only one planner. 2. Keep your planner with you always. 3. Enter every appointment and task into your planner; if it’s not written in your planner, it won’t happen. Discuss the importance of recording everything in the planner: classes, study time, socializing with friends, work, exercise, dates like birthdays, etc. Recording everything promotes effective time management and facilitates remembering ­ appointments. Some mentees may inform their mentor that: “I don’t need a planner. I can remember everything. What I’m doing now works for me.” Should this occur, first point out that “remembering everything” is likely faulty thinking. Also mention that in every semester (and even after college), there will be times when scheduling gets more complicated, or life is more stressful making it harder to remember as many details. Emphasize the importance of getting into the habit of using a planner so that when stressful situations arise, it is easier to stay organized and focused on important tasks. Finally, be sure to discuss the importance of getting started, and keeping in mind that the goal is progress, not perfection. Help the mentee make their first To-Do list using Handout 2.7, if they have not done so already. After generating the list of tasks, encourage the mentee to identify A, B, and C priority tasks or demonstrate the alternative Urgent/Important Matrix. If the mentee is registered with the campus disability office, help them schedule test taking times for classes. If not registered, have the mentee pick a time this week to do so.

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Adaptive Thinking Begin this section by asking the mentee to identify the types of thinking errors they make most often. It is important to help the mentee see that initially having maladaptive thoughts is normative and something everyone does at least some of the time. What is most important about these adaptive thinking skills is recognizing faulty thoughts before you let your emotions spin out of control or make unhealthy/ unproductive decisions.

Tip Remind the mentee that spending time memorizing the names of the different types of maladaptive thinking is not necessary. What is necessary is understanding and remembering what each type of maladaptive thinking does.

Give the mentee practice using the 3-column approach by helping them complete Handout 2.8. To facilitate this discussion, consider using one or more of the following examples: • You’re walking to class. Somebody you know walks by without saying hello. You think to yourself, “How rude!” • You get a D on your first test of the semester. You think to yourself, “I’m going to fail this class!” Also consider using an example from comments the mentee has made earlier in the session. When doing this, be sure not to sound critical or judgmental.

Ending Mentoring Session Check in about goals as needed. Is there anything that has not been accomplished or needs to be modified? Any miscellaneous topics of discussion? This is an opportunity to address any topics that did not fit into the prior discussion. Review and clarify as needed the details of what you would like the mentee to do between now and the next mentoring session, including: • Bring all group materials to next mentoring session • Use planner and To-Do List over the next week and bring to next mentoring session • Practice 3-column approach at least one time Confirm the date and time of next appointment. Ask the mentee to write down/set reminder and model similar behavior with your own planner/calendar.

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Week 2 – Group Agenda

Beginning Group Session ADHD Knowledge • Provide accurate, up-to-date information about what does and does not cause ADHD • Recommend books and on-line resources for obtaining reliable ADHD information • Point out potentially helpful phone apps and computer programs

Behavioral Strategies • Discuss the advantages and disadvantages of written and electronic planners • Identify a specific planner to use • Describe ways to maximize the effectiveness of the planner • Provide tips to break down and prioritize tasks in To-Do Lists

Adaptive Thinking Skills • Describe common types of maladaptive thinking • Illustrate how negative thoughts affect feelings and behavior • Discuss how to use a 3-column strategy to help recognize maladaptive thinking

 nding Group Session E • Address any questions that may arise • Review the details of completing the between-session practice assignments

Handouts • 2.1 Week 2 Group Cover Sheet • 2.2 What Causes ADHD • 2.3 Using Your Planner • 2.4 Using Your To-Do List • 2.5 Recognizing Maladaptive Thinking Patterns

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Handout 2.1

ACCESS Accessing Campus Connections and Empowering Student Success



Week 2 – Group Handouts • • • • •

2.1 Week 2 Group Cover Sheet 2.2 What Causes ADHD? 2.3 Using Your Planner 2.4 Using Your To-Do List 2.5 Recognizing Maladaptive Thinking Patterns

Handout 2.2



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What Causes ADHD?

Neurobiology of ADHD • Neurochemical, neurophysiological, and/or neuroanatomical abnormalities in the pre-frontal-limbic areas of the brain Possible causes • Genetic transmission • Prenatal and birth complications • Neurological illness or injury

ADHD runs in families • If a child has ADHD ◦◦ 15–20% of mothers ◦◦ 25–30% of fathers ◦◦ 25% of siblings ◦◦ 30–40% fraternal twin, 70% + identical twin • If a parent has ADHD ◦◦ 50% risk for the child Genetic markers • Many genes linked to ADHD identified – not just one gene • Many of these genes associated with dopamine system • Our understanding of the genetics of ADHD is far from complete

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Handout 2.3

Using Your Planner

What type of planner should I use? • Written planner • Cell phone/digital planner

3 Planner Laws • Have only ONE planner • Keep your planner with you at all times • Enter every appointment and task into your planner

Tips for using your planner • Review and update your planner daily at a set time • Enter class, work, and personal commitments in the same planner • For each of your classes, enter class times, test dates, assignment due dates, and blocks of study and homework time • Set up regular weekly time slots for recurring tasks (e.g., laundry) • Schedule larger blocks of time for things that require more focus • Plan to do the most difficult things when you will be most alert • Plan to do the easiest things when you will be more tired • Schedule more enjoyable and easier things after harder things • Schedule relaxation time • Don’t get upset if you forget to use your planner for a while – just start again as soon as possible!

Using visual and auditory reminders to remember appointments • Visual reminders — ◦◦ Post-it notes on bathroom mirror, inside of front door, on class binder, on cell phone ◦◦ White board or bulletin board used as daily “reminder board” • Auditory reminders— alarm clocks or cell phone alarms, set to give you plenty of time to get where you need to be (e.g., 15 minutes before appointment)

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Using Your To-Do List

Why do I need a To-Do list? • A place to write down all tasks • Helps you: ◦◦ Remember things ◦◦ Organize your time more effectively • A place to record information not tied to a date (therefore, not in planner) • Replaces little sheets of paper that are easy to lose

Using your To-Do list • Have only one To-Do list at a time • Break down large tasks into manageable “chunks” • Cross off tasks after completion • Review and revise your list at the beginning and end of each day • When list gets messy, recopy unfinished tasks onto a new list

Prioritizing tasks • Systematically prioritize tasks • Prioritize based on urgency/deadlines and both short- and long-term goals • Do MOST important tasks first • After making a To-Do List, assign A, B, and C ratings to each task: ◦◦ A = Highest importance, need to do today or tomorrow ◦◦ B = Medium importance, need to start on these soon ◦◦ C = Lowest importance, might be easy but isn’t critical to do • Do all A tasks before any B tasks and all B tasks before any C tasks

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Handout 2.5

Recognizing Maladaptive Thinking Patterns Goal of Adaptive Thinking = Realistic, Positive Thinking

Maladaptive Thinking Patterns • All-or-None Thinking: You see things in black and white categories. For example, if your performance falls short of perfect, you see it as a total failure. • Jumping to Conclusions: You make a negative interpretation even though there are no facts that convincingly support your conclusion. ◦◦ Mind Reading: You arbitrarily conclude that someone is reacting negatively to you. ◦◦ Fortune Telling: You anticipate that things will turn out badly. • Overgeneralization: You see a single negative event as part of a never-ending pattern. • Catastrophizing: You expect extreme consequences and outcomes. • “Should” Statements: You try to motivate yourself with “should” and “shouldn’t” as if you need to be punished before you can be expected to do anything. • Mental Filtering: You pick out a single negative detail and dwell on it exclusively, overlooking other, positive, aspects of the situation. • Disqualifying the Positive: You reject positive experiences by insisting they “don’t count” for some reason or other. • Labeling: An extreme form of overgeneralization. You attach a broad negative label to yourself or others. • Personalization: You see negative events as indicative of some negative characteristic of yourself or others, or you take responsibility for events that were not your fault. • Emotional Reasoning: You assume that your negative emotions necessarily reflect the way things really are: “I feel it, so it must be true.”



Thought Record Situation

Automatic thoughts

Feelings/Behavior

Week 2 – Mentoring Agenda

Week 2 – Mentoring Agenda Check-In Collaborative Agenda Setting Review Between-Session Practice Discuss Information Presented in Group Ending Mentoring Session Handouts • 2.6 Week 2 Mentoring Cover Sheet • 2.7 To-Do List • 2.8 Thought Record

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Handout 2.6

ACCESS Accessing Campus Connections and Empowering Student Success



Week 2 – Mentoring Handouts • 2.6 Week 2 Mentoring Cover Sheet • 2.7 To-Do List • 2.8 Thought Record

Handout 2.7



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To-Do List Priority Rating

To-Do

Target Completion Date

Priority Ratings A = Highest importance, need to do today or tomorrow B = Medium importance, need to start on these soon C = Lowest importance, might be easy but isn’t critical to do

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Handout 2.8



Thought Record Situation

Automatic thoughts

Common Maladaptive Thinking Patterns All-or-None Thinking Jumping to Conclusions Mind Reading Fortune Telling Overgeneralization Catastrophizing “Should” Statements Mental Filtering Disqualifying the Positive Labeling Personalization Emotional Reasoning

Feelings/ Behaviors

Chapter 5

Active Phase – Week 3

Group and mentoring content for Week 3 of the active phase of treatment is presented. During the group session, students receive information about the DSM-5 criteria for ADHD and the components of a comprehensive ADHD assessment. Next, detailed guidance on the use of organizational techniques and time management strategies is provided. Group members participate in an interactive dialogue about causes of procrastination and ways to control procrastination tendencies. An important new adaptive thinking skill is also introduced, with group members receiving step-by-step instruction in how to challenge maladaptive thinking patterns. During mentoring, mentors engage students in a detailed review of their use of a planner and To-Do lists over the past week. Mentors also review new information presented in group to ensure student understanding and discuss implementation of new behavioral strategies and adaptive thinking skills. As needed, mentors monitor, support, and provide guidance to refine student use of previously learned behavioral strategies and adaptive thinking skills.

Week 3 – Group Beginning Group Session Ask students if they have any general questions that they would like to ask at this time. Answer these questions as time permits. If this discussion becomes excessively long, refer students to their mentors to address further questions.

© Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_5

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ADHD Knowledge Start the Knowledge Section Briefly review the ADHD knowledge covered in Week 2 and ask whether any questions have arisen. After answering these questions and dealing with any other carry-­ over concerns, transition into the new ADHD knowledge content, which is the assessment of ADHD. Direct students to Handout 3.2 for an overview of this topic. Assessment of ADHD Begin by informing the group that there is currently no simple test that can determine whether someone has ADHD. Instead, assessment and diagnosis of ADHD is completed by gathering information about an individual’s current and past functioning to determine whether criteria for ADHD as outlined in DSM-5 are met. Because most students are not familiar with how an ADHD diagnosis is established, present a brief summary of the five criteria that must be met by noting that: • 5 or more symptoms from either the inattention list or the hyperactivity-­impulsivity list must be present to a degree that is developmentally inappropriate • ADHD symptoms must be present before age 12 • ADHD symptoms must be associated with impairment in daily life functioning • functional impairment must be evident in at least 2 settings • symptoms and impairment are not better explained by another mental health or medical condition An extremely important point to make here is that these criteria exist for a reason – although many people may meet one or two of these criteria, far fewer will meet all the criteria listed above. This helps explain why some people may think they have ADHD, when in fact they do not. This also serves to emphasize the point that an ADHD diagnosis is only made when a person’s clinical presentation deviates significantly from what would be expected of someone of the same age. This information can be highly validating for individuals diagnosed with ADHD, who have often heard other people make statements such as “I’ve never been diagnosed, but I know I have ADHD.” Hearing such statements from other people can result in doubt of one’s own diagnosis, as it appears that “everyone has ADHD.” Therefore, providing information about how ADHD is accurately diagnosed reiterates the fact that ADHD is a valid diagnosis, which is assessed in a systematic, careful way. Remind students that symptom presentations can vary greatly from person to person, as noted in Week 1. Some people may primarily display inattentive symptoms, for which a diagnosis of ADHD Predominantly Inattentive presentation would be made, whereas others may demonstrate a combination of inattentive and hyperactive-­impulsive symptoms, for which a diagnosis of ADHD Combined presentation would be appropriate. Such differences in clinical presentation are important to recognize because they can be associated with different patterns of co-occurring clinical conditions, types of treatment, and prognosis.

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Acknowledge for the group that there is a great deal of variability in the way that ADHD is assessed, and that many of these approaches can lead to faulty diagnostic conclusions. Point out that the “gold-standard” for evaluating ADHD is a multi-­ informant, multi-method assessment approach to ensure diagnostic accuracy. That is, information should be gathered from multiple informants as much as possible (e.g., the parent and teacher of a child, or a parent, spouse, or friend of an adult). Information should also be collected using multiple types of assessment measures. For instance, information should be collected via interviews and rating scales. School records may also provide helpful information. Together, such information paints a more complete picture of an individual’s current and past functioning, thereby allowing for a more accurate determination of not only ADHD, but also its co-occurring features. Explain to group members that knowing what constitutes a thorough assessment of ADHD can be helpful not only to themselves, but also for friends or members of their family who ask them about diagnosing ADHD. By being well-informed, they can identify health care providers who conduct high-quality, comprehensive ADHD assessments. Tip Some group members may express concerns about how they were diagnosed with ADHD.  If this question arises, remind students that although a multimethod assessment is the “gold-standard” for ADHD assessment, it is possible to receive a valid diagnosis of ADHD without undergoing this process. As needed, make students aware of local health care providers who conduct comprehensive multi-informant, multi-method assessments.

Behavioral Strategies Start the Behavioral Strategies Section Conduct a brief check-in with students regarding between-session practice. Students were asked to start or to continue using a planner system as well as a To-Do list. Encourage students to share successes as well as challenges or barriers they experienced while using their planner and To-Do list. As time permits, spend a few minutes making suggestions about how to handle any issues or problems students encountered. If this discussion becomes lengthy, refer students to their mentors for more discussion of between-session practice. If some students did not attempt between-session practice, encourage them to try again this week. As needed, remind the group that the goal is progress, not perfection. For someone who wasn’t using a planner at all, using a planner even once over the course of the week is progress.

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Next, introduce today’s behavioral strategies: managing procrastination and organization techniques. It can be helpful to note here that there are many types of organization, including the organization of time, materials and home environment. Remind students that they will be asked to choose at least one technique to implement as between-session practice, so that they can be thinking about which strategies might be the most helpful for them. Addressing Procrastination Remind students to follow along using Handout 3.3 during this portion of the group meeting. The initial goal of this discussion is to encourage students to reflect on common reasons for procrastination and to identify factors contributing to their own procrastination. This in turn will help guide students in choosing strategies to help manage procrastination. In general, students are quick to acknowledge struggling with procrastination and are open to discussing how to manage this common difficulty. It can be helpful to normalize their experience by pointing out that “everyone procrastinates sometimes.” At the same time, encourage students to identify the major downsides of procrastination to emphasize the importance of managing procrastination tendencies. Such disadvantages include increased stress as deadlines approach, less time to review and catch errors, and the increased possibility of missing a deadline entirely. Next, ask students to generate a list of reasons why people procrastinate. Common reasons include wanting to do something more interesting instead, feeling overwhelmed or unsure of where to start, becoming distracted by other tasks or assignments, or deciding to wait until they feel ‘inspired’ or ‘ready.’ After students have identified reasons for procrastinating, engage them in a discussion about what strategies or techniques might help counter their reason for procrastinating. For example, if someone procrastinates because they want to do something more interesting, they might instead use the interesting activity as a “reward” for starting the task they are avoiding. Hence, they might set a goal of working on the task for 45  minutes before taking a break to do the more interesting task, which provides immediate reinforcement for completing their work. In contrast, to manage “feeling overwhelmed,” it can be more helpful to break tasks down into smaller steps, which feel less overwhelming or aversive. Another possible approach is to identify potential maladaptive thinking patterns. Students can then use adaptive thinking techniques (discussed in more detail later in this session) to challenge counterproductive thoughts that lead to procrastination. Students often describe “feeling overwhelmed.” This tends to come up a lot when discussing procrastination, so be prepared to address this. To help students better understand and deal with procrastination using adaptive thinking strategies, it can be helpful to first point out that, technically speaking, “overwhelmed” is not an emotion. It is, however, an indication of high levels of stress, which is often ­associated with feeling anxious or worried. Moreover, the experience of “feeling overwhelmed” can signal the presence of thoughts or beliefs such as “I can’t do

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this,” “It’s too much for me,” “I’ll never get this done” or even “This is going to be so boring, frustrating, or unpleasant.” Many students commonly report that they procrastinate when faced with large projects or long-term papers. This can reflect feeling unsure about where to begin, or feelings of stress or anxiety. To help manage this type of procrastination, encourage students to break down large tasks into smaller, more manageable pieces. If maladaptive thoughts are contributing to procrastination (e.g., waiting to feel ‘inspired’ or ‘ready’), urge students to consider whether this is a “helpful” or “unhelpful” thought. This often assists the student in recognizing that this type of thinking sets the stage for waiting until the last minute, which in turn increases stress as the deadline approaches and diminishes the quality of their work. If students report procrastinating because they are distracted by other tasks, distractibility delay is an excellent technique to use. This technique will be discussed in detail in a later session, but it can be helpful to provide students with a quick overview to begin the process of addressing procrastination. Briefly, this technique involves keeping a notebook at hand while working on a task. When students have the urge to work on something else, they should make a written note of what was distracting them and then come back to it after their current task is complete. This helps students avoid jumping from task to task without completing anything. Organizational Techniques To facilitate the discussion of organization techniques, direct students’ attention to Handout 3.4. Keep in mind that the relevance of certain organizational topics may differ among group members. For example, students who are further along in their college career and closer to graduating may be particularly interested in discussing financial management, whereas first year college students may find this topic less pertinent. Hence, it is not necessary to spend the same amount of time on each of the organizational topics below. Instead, adjust the time spent on each section to meet the needs of the group.

Tip To encourage group discussion and avoid merely “lecturing” to students about organization techniques, ask students to discuss strategies they already use, or techniques they find helpful. Organizing Time  Present students with information about techniques to improve time awareness. Note that there is research evidence to suggest individuals with ADHD may have more difficulty estimating time. As a result, using strategies to improve time awareness can help students be on time for appointments, social ­meetings, and classes. Also encourage students to begin observing how long it takes

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them to complete tasks. This awareness can help students use their planner more effectively, since they will be able to more accurately block time for tasks. Discuss techniques for arriving on time to appointments and classes. Some useful techniques include planning to arrive early, setting reminders or alarms that go off when it is time to depart, and timing how long it takes to get from one place to another. In addition, wearing a watch or placing a clock in clear view are other methods to increase awareness of time. Organizing Class Materials  Encourage students to discuss how they currently organize class materials and start a discussion about how to improve organization. One technique is to create a binder or folder for each class, which will hold notes from class, syllabi, assignment instructions, and so forth. This can be an actual physical binder or even a folder on their computer. The idea is to put all class materials into one place, rather than having notes scattered around in multiple places (e.g., stuffed into textbooks, mixed in with notes from other classes). Organizing and Managing Paperwork and Email  Begin a discussion about managing paperwork such as bills and important documents, as well as managing email. Encourage students to consider creating an organizational system or filing system to keep track of important documents. Note that this system can look quite different from person to person and encourage them to talk to their mentors about what system might work best for them. Organizing Your Home  The main point here is to emphasize the benefits of keeping personal space organized and clutter-free. Potential techniques include establishing a place where each object is kept and designating a specific area where particularly important items are placed (e.g., putting keys in a bowl on the kitchen counter). Scheduling a regular time to complete chores is another way to encourage organization. Organizing Finances  Managing personal finances can be very difficult for individuals with ADHD. Forgetfulness can interfere with paying bills on time; impulsivity may lead to unnecessary and excessive spending; and problems with planning and organization can prohibit effective budgeting. Direct students to review some of the financial management strategies listed on the handouts, such as setting up automatic bill payments, creating a monthly budget using a spreadsheet or an app, or even letting a trusted family member help with managing finances. This discussion about finances can lead students to feel anxious or concerned about managing finances, particularly for those who do not yet have much experience doing so. Discussing topics such as what credit is, what it is used for, and how to build good credit may be especially helpful in this situation. Although this general topic of managing money may not be immediately relevant for some students, increasing their awareness of these financial issues helps them prepare for the future, as they will eventually be taking on this responsibility themselves.

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Tip To keep students engaged, ask them to brainstorm ways in which ADHD symptoms may get in the way of managing one’s finances. Students generally enjoy this activity, which sets the stage for discussing techniques to handle these issues.

Assign Between-Session Practice To wrap up this section, ask students to choose at least one organizational technique they would like to implement as between-session practice. Have students verbally identify the technique they want to try and remind them that mentors will be checking in with them about their experiences.

Adaptive Thinking Start the Adaptive Thinking Section Briefly remind students about the topic of last week’s adaptive thinking discussion—maladaptive thinking patterns. Students were asked to complete a 3-column thought record as a part of their between-session practice. Ask about experiences using this technique and provide encouragement and support as needed. Next, inform students that today’s topic is challenging maladaptive thinking patterns and using a 6-column thought record. Challenging Maladaptive Thinking Patterns Direct student’s attention to Handout 3.5, which provides a list of questions to help challenge maladaptive thinking patterns. Inform students that using these questions to challenge their maladaptive thoughts will help reduce the strength of their belief in the maladaptive thought and can help lead to less negative emotions associated with these thoughts. Also emphasize that the additional columns are designed to systematically help students learn how to replace maladaptive thinking with adaptive thinking, leading to more positive feelings and more adaptive behaviors. Working through an example is generally the best way to teach this material, as it provides students a chance to observe the process of challenging a maladaptive thought. Group leaders can choose to use a hypothetical example, or they can refer to examples provided in the prior group session. Alternately, group leaders can ask for a volunteer who would be willing to allow the group to use their between-­session

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practice as an example. Using a real-life example provided by a student can be particularly impactful. However, group leaders should be sensitive to the fact that discussing maladaptive thinking can be an emotional discussion. If group leaders are concerned that a student may be too uncomfortable to discuss their thoughts with the group, they should refrain from encouraging the student to do so. Guide students through the process of using the questions listed on the handout to challenge an example of a maladaptive thinking pattern and complete a 6-column thought record. Use a whiteboard or smartboard to visually display the questions and answers for all group members to see. Furthermore, encourage students to generate as many of the answers as possible, to increase engagement. Depending on the situation, some questions may be more helpful than others. For example, working through Question 3 (What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome?) can be especially appropriate to challenge a “catastrophizing” thought such as “I’m going to fail the exam.” Tip Remind the group that some thoughts do not necessarily reflect reality. Unhelpful thoughts should be tested and challenged – they are often untrue or distortions of the truth.

Generate Alternative Thoughts Use the process of questioning maladaptive thoughts to inform the creation of alternative thoughts, which are more realistic and typically more positive than maladaptive thoughts. For example, if the maladaptive thought is “I’m going to fail my exam,” an alternative thought could be, “I may not get the grade I want on this exam, but it is highly unlikely that I will fail since I’ve been studying for it.” Rate Degree of Belief Next, demonstrate rating the degree of belief in alternative thoughts. This is a critically important step, because if you do not have confidence in generated alternative thoughts, you are not likely to experience desired changes in your emotions or actions. Ask the group to estimate the degree of belief in alternative thoughts. Most students will rate their belief in alternative thoughts as less than 100%. Reassure the group that this is normal — we do not expect that anyone will immediately believe these thoughts absolutely, particularly the first time they go through this process. Instead, the goal is to increase the degree of belief in the alternative thoughts over time. As the student gathers more evidence to support these alternative thoughts, their degree of belief will increase, and this will be associated with more positive emotions and adaptive behaviors.

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Identify New Feelings and Behaviors Finally, ask students to list the emotions or behaviors that may be associated with the alternative thoughts. This again serves to highlight the connections between thoughts, feelings, and behaviors. Assign Between-Session Practice Ask students to use the 6-column technique to practice analyzing at least one situation in which negative feelings or behavior occurred. Remind them that their mentors will assist them as needed.

Ending Group Session Provide students with a quick summary of between-session practice assignments, which include using at least one new organizational technique and completing a 6-column thought record. Encourage students to remember that their mentor will be providing support by checking in about the between-session practice and trouble-­ shooting problems or barriers that may arise.

Week 3 – Mentoring Check-In Get an update on how the mentee has been doing since the last mentoring session. Remember to review your individual notes for each mentee prior to seeing them to ensure that you are recalling individualized information that is relevant and important to that person. This kind of personal connection will increase mentees’ desire to participate in mentoring, as well as create a feedback loop that encourages the student to follow through on between-session practice.

Collaborative Agenda Setting Briefly outline the content and outline of the session, including a check-in about between-session practice and reviewing material from the week 3 group meeting, which addressed the assessment of ADHD, strategies for getting organized, and a new strategy for challenging maladaptive thinking patterns. If topics from the check-in seem to generate more conversation pertinent to the needs of the mentee, suggest adding them to the agenda.

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Review Between-Session Practice Follow up briefly on any practice items that were discussed in the prior week. For this session, it is particularly helpful to address: • Did the mentee enter events and tasks into their planner? • Did the mentee practice the 3-column adaptive thinking log? • Did the mentee bring handouts from group to this mentoring session? Give enthusiastic and positive feedback for any follow through on these tasks. Be neutral and do not respond overly negatively to missed practice. However, you may choose to ask the mentee to follow up in the next week on important items. Be sure to remind them of this at wrap-up.

Discuss Information Presented in Group ADHD Knowledge Briefly discuss the DSM-5 criteria and assessment processes that were discussed in the group session. Questions to consider asking to facilitate discussion include: • What was interesting to you about how ADHD is assessed? • Did anything surprise you? • What was your reaction to being diagnosed with ADHD? Discuss future needs for assessment with mentee. Additional evaluation may be needed to address a variety of circumstances, including fine tuning a treatment regimen, a worsening of daily life difficulties, the onset of depression or other co-­occurring psychological problems, planning for major transitions (e.g., graduate school), or needing updated documentation for receiving disability accommodations.

Tip Because disability services on college campuses may require different types of documentation, be sure to review with the mentee the specific documentation needed for receiving accommodations at their school.

Behavioral Strategies Review strategies for getting organized in at least two areas that are most relevant for the mentee. Difficulties with organizing class materials and finances are especially common. Additional organization strategies can be discussed as time permits.

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Consider using the following prompt to get things started: • Several behavioral strategies are available for organizing time, class materials, and items you tend to lose. Which of these ideas would be most useful for you? Which of these areas do you need to work on? Organizing Time  It is often difficult for those with ADHD to manage their time effectively. Help the mentee organize their time better by practicing time management strategies. Depending on the rapport with the mentee, it may be useful to discuss their history of tardiness and respectfully discuss real-life consequences for running late. Mentees often find it helpful to time how long it takes them to get places or to do certain routine tasks. This information can be used to better plan and schedule tasks in their planner! Organizing Class Materials  Here are some potential questions to help initiate the discussion of organizing class materials. • How do you typically try to organize your materials for class? • What aspects of this are harder for you? Most students need help organizing their class materials. Organizing class materials is therefore likely to be a skill the mentee may select for further discussion. Discuss entering all important dates from course syllabi into the planner at the beginning of each semester. If the mentee has not already done this for this semester, consider including this as an assigned task for this week. Remind mentees that staying organized makes it easier to study. Discuss options for organizing class materials, such as keeping separate binders for each class and organizing digital files on their laptop. Some students may express feeling overwhelmed by the idea of having to spend additional time getting organized when they are already quite busy. Discuss the pros and cons of their existing system to determine if it can be modified rather than changed entirely. Mentee: “I don’t want to change my organizational system because it is already half-way through the semester. I don’t have time to deal with this now.” Mentor: “I get it, it feels like too much in the middle of all the things you need to do. Using your current system would take less time to set up, but how is it affecting your time in the long run?” Mentee: “Well, I do spend a ridiculous amount of time trying to figure out what assignments I need to do and when they are due. Plus, the not knowing makes me stress out and sometimes I miss deadlines completely because I didn’t realize anything was due at all!” Mentor: “Would starting small, like pulling out your syllabi and entering all of the assignments that will soon be due into one place, like your planner, be a reasonable first step? Maybe you could do it in the hour between your math and biology classes when you tend to sit on a bench in the hall before class.” Organizing Paperwork  To begin and guide the discussion of paperwork, consider asking the following:

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• How do you keep track of things you need like bills, mail, medical reports, or school related documents? • What about documents on your computer, laptop, or phone  – how are they organized? Discuss the mentee’s strategies for organizing important paperwork, such as bills and school documents. Many individuals utilize paperless billing, so make sure to discuss organizing electronic files and email as well. Organizing Your Home  Here are some options to prompt the discussion of keeping track of things at home: • What are items that you tend to misplace? Cell phones, wallets, IDs, and keys are frequently misplaced items. • What kind of systems have you tried for keeping track of these items? Many mentees express concern about losing items, such as their phone, keys, student ID, wallet, etc. Help mentees build strategies to keep track of important items. Finding a “home” for all important items can be a useful way to keep track of items. For example, many mentees hang a hook by their door for their keys. Remind mentees to get into the habit of putting items away as soon as they are home or done using them. This is a good opportunity to discuss how the planner can be used to help schedule regular life tasks as well, such as laundry.

Tip Keep in mind that many college students may live in residential campus housing and therefore have fewer options for organizing their personal belongings.

Organizing Finances  Consider using many of the questions below as part of this discussion of finances: • • • •

Do you keep track of your spending, and if so, how? Are you late paying bills? Do you tend to buy things on impulse? Do you have a plan for saving money?

Some mentees may need help organizing their finances. Creating a budget can help mentees track and manage their money. Many students express concern for “impulse purchases.” Explore what type of impulse buys your mentee makes and discuss strategies to limit unnecessary spending. Using cash instead of a credit/debit card can be extremely useful way to monitor one’s spending. For example, some mentees choose to keep “spending money” in cash. It is often more difficult to monitor

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spending with cards! Also discuss the importance of monitoring debt (e.g., student loans), understanding credit scores, and strategies for timely bill pay. You may also wish to explore the use of apps to keep a budget and monitor spending. Adaptive Thinking Begin this section by prompting mentees to report on their use of adaptive thinking skills. Look over the thought record assigned as between-session practice and provide suggestions as needed. Did they identify realistic situations, thoughts and feelings? If the mentee did not complete the record, do one in session. Try to use a thought that the mentee has expressed in session. For example, during the organizational strategies, there is a good chance they may have expressed a maladaptive thought (e.g., “I can never keep track of paperwork,” “I lose everything,” “Planners just won’t work for me”). Using the mentee’s between-session practice example or the one just generated in session, complete Handout 3.7, which presents a 6-column thought record. Help the mentee fill out the additional columns that walk them through how to challenge their initial maladaptive thought and replace it with a more realistic and often less upsetting alternative thought. Next, guide them through the process of rating their degree of belief in the alternative thought and identifying any new feelings/ behaviors. Time permitting, give the mentee additional practice using the full 6-column approach using one or more of the following hypothetical examples: • You have a test tomorrow and you are just now getting around to studying. You think to yourself, “I’m going to fail!” • You just realized you forgot to turn in your financial aid paperwork. You think to yourself, “Now, I can’t go to school this semester  – I’ll never amount to anything.” Often one maladaptive thought leads to another. In the second example above, help the mentee recognize that before jumping to conclusions about the first part of the thought (they can’t go to school), they could simply adjust the thought – “This could affect school, but I first need to find out what it means for this semester and what options I have.” Changing the first part of the thought likely prevents the second part (that they will never amount to anything). Again, help the mentee see that even if the first part of the thought is true, it does not mean the second part is: “Even if I have to take a break this semester, I can do something like a job, internship, or other experience that helps me work toward my bigger goals for the future. My path might change, but I can still have a promising future.” Some mentees may easily identify distortions but have difficulty identifying alternative cognitions. An adaptive thought is not necessarily a positive or complete opposite thought from the cognitive distortion. It is simply more realistic.

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Ending Mentoring Session Check in about goals as needed. Is there anything that has been accomplished or needs to be modified? Any miscellaneous topics of discussion? Address any topics that did not fit into the prior discussion. Review and clarify as needed the details of what you would like the mentee to do between now and the next mentoring session, including: • Bringing all group materials to the next mentoring session • Bringing in a notebook or binder for a class so that mentor can see and help with organizational strategies (and note-taking in advance of session 4). Ask the mentee to enter all major deadlines from syllabi into their planner. If the mentee is struggling with a class, ask them to bring the materials for that class. • Practice 6-column system to record at least one example of a maladaptive thinking. Confirm the date and time of next appointment. Ask the mentee to write down/set reminder and model similar behavior with your own planner/calendar.

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Week 3 – Group Agenda Beginning Group Session ADHD Knowledge • Present information about assessment of ADHD • Emphasize importance of multi-method assessment

Behavioral Strategies • Discuss procrastination and techniques for managing procrastination • Present and discuss strategies for time management • Present and discuss strategies for organizing class materials • Present and discuss strategies for organizing physical environment and completing home chores • Present and discuss strategies for organizing finances

Adaptive Thinking Skills • Ask group members to identify examples of maladaptive thinking • Discuss how to challenge automatic thoughts • Present and discuss questions that help challenge maladaptive thinking • Work through an example of challenging a maladaptive thought with a six-­column thought record

 nding Group Session E • Address any questions that may arise • Review the details of completing the between-session practice assignments

Handouts • 3.1 Week 3 Group Cover Sheet • 3.2 Assessment of ADHD • 3.3 Addressing Procrastination • 3.4 Get Organized • 3.5 Challenging Maladaptive Thinking

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Handout 3.1

ACCESS Accessing Campus Connections and Empowering Student Success



Week 3 – Group Handouts • • • • •

3.1 Week 3 Group Cover Sheet 3.2 Assessment of ADHD 3.3 Addressing Procrastination 3.4 Get Organized 3.5 Challenging Maladaptive Thinking

Handout 3.2



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Assessment of ADHD

Diagnostic criteria • 5 or more symptoms from either list (inattention or hyperactivity-impulsivity) present to a degree inconsistent with developmental level • Some symptoms before age 12 • Some impairment from symptoms occurs in 2 or more settings • Evidence of impairment in academic, occupational, or social functioning • Symptoms not better accounted for by some other condition

ADHD presentations • Combined • Predominantly Inattentive • Predominantly Hyperactive/Impulsive • Other Specified ADHD or Unspecified ADHD • In Partial Remission

Factors affecting assessment of ADHD • Adherence to diagnostic criteria vs. only counting symptoms • ADHD symptoms and impairment vary from setting to setting • ADHD impacts multiple domains of functioning • Other conditions mimic ADHD symptoms ◦◦ Inattention may be caused by depression, anxiety, learning disorders, psychosis, trauma ◦◦ Hyperactivity-impulsivity may be caused by anxiety, bipolar disorder, tic disorder, borderline personality disorder

Multi-method assessment strategy is best! • Multiple informants/sources (e.g., self-report and other report) • Multiple measures used with each informant/source (e.g., interview, rating scales, records)

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Handout 3.3

Addressing Procrastination Short-­term

Pros Get to do something else Decreased anxiety

Long-­term None

Cons Don’t make progress on task Feel guilty/anxious Increased stress Have to give up other things (sleep, self-care, time with friends, etc) to do work Not able to do best work Risk of not completing task

• Understand why you procrastinate so that you can address the underlying issue (Anxiety? The sense that a task is overwhelming? Waiting for inspiration?) • Think about ways other ACCESS strategies could help with procrastination (Using a planner, making a To-Do list, breaking down tasks, changing thoughts) • Make positive changes! (But recognize that changing habits will take time)

Handout 3.4



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Get Organized!

Organizing Time • Increasing time awareness ◦◦ Wear a watch; place clocks in clear view ◦◦ Estimate/ time how long everyday tasks actually take ◦◦ Helps improve ability to estimate time • Being on time ◦◦ Time how long it really takes to get to class/work ◦◦ Use visual/auditory reminders to help adhere to departure time ◦◦ Aim to be early — this provides a time “buffer” ◦◦ For early classes — sign up with a friend who can support your attendance • Sleeping through alarms ◦◦ Set multiple alarms ◦◦ Include one that requires getting out of bed to turn it off

Organizing Class Materials • Consider a separate binder for EACH class • Consider creating electronic folders for each class • Each class binder or folder should include: ◦◦ Syllabus ◦◦ Assignment instructions ◦◦ Notes from lecture and readings ◦◦ Handouts and supplemental materials • Review and clean out binder/folder regularly

Organizing Paperwork and Emails • Set up a filing system for important papers ◦◦ Simpler is better. ◦◦ Keep important items only • Organize “e-paperwork” ◦◦ Create folders in email inbox ◦◦ Create labels • Create a designated location for important papers requiring action

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Handout 3.4

Get Organized! (Page 2)

Organizing Your Home • An organized environment helps: ◦◦ Maintain a sense of order ◦◦ Minimizes distractions • To avoid losing things: ◦◦ Decide upon a specific set place for important items ◦◦ Example: place a basket or bowl by door for keys ◦◦ Put items in designated spot IMMEDIATELY upon arriving at home ◦◦ For items carried with you, designate a specific place in your backpack/bag/ purse • Household chores ◦◦ Consider scheduling regular chore time (e.g., laundry every Sunday afternoon) ◦◦ Make chores more enjoyable ◦◦ Example: Play music; Watch TV while folding laundry; Complete chores with roommates

Organizing Finances • Keep track of bills: put in designated location or folder • Consider setting up online banking and automatic bill payments ◦◦ Reduce risk of forgetting to pay ◦◦ Ensure there are sufficient funds in your account to cover payments • Avoid impulsive purchases: use cash instead of cards! ◦◦ Using cash helps increase awareness of spending • Consider creating a monthly budget ◦◦ Many apps are available to help track spending • Maintain a good credit score ◦◦ Pay bills on time ◦◦ Minimize debt ◦◦ Check your credit report for errors • Be fully aware of the terms of financial aid/student loan • Consider consulting with trusted family member to help manage finances

Handout 3.5



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Challenging Maladaptive Thinking

Types of Maladaptive Thinking • All-or-None Thinking • Jumping to Conclusions ◦◦ Mind Reading ◦◦ Fortune Telling • Overgeneralization • Catastrophizing

• • • • • •

“Should” Statements Mental Filtering Disqualifying the Positive Labeling Personalization Emotional Reasoning

Questions to Help You Challenge Maladaptive Thinking Patterns (1) What is the evidence that the automatic thought is true? What is the evidence that the automatic thought is not true? (2) Is there an alternative explanation? (3) What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome? (4) What’s the effect of believing the automatic thought? What could be the effect of changing my thinking? (5) If a friend was in the situation and had this thought, what would I tell them?



Expanded Thought Record Situation

Automatic thoughts

Feelings/ Behaviors

Alternative thoughts

Degree of belief in alternative thoughts

New feelings/ Behaviors

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Week 3 – Mentoring Agenda

Check-In Collaborative Agenda Setting Review Between-Session Practice Discuss Information Presented in Group Ending Mentoring Session Handouts • 3.6 Week 3 Mentoring Cover Sheet • 3.7 Challenging Maladaptive Thinking – Individual Practice

Handout 3.6

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ACCESS Accessing Campus Connections and Empowering Student Success



Week 3 – Mentoring Handouts • 3.6 Week 3 Mentoring Cover Sheet • 3.7 Challenging Maladaptive Thinking: Individual Practice

Degree of belief in alternative thoughts

New feelings/ Behaviors

1) What is the evidence that the automatic thought is true? What is the evidence that the automatic thought is not true? 2) Is there an alternative explanation? 3) What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome? 4) What’s the effect of believing the automatic thought? What could be the effect of changing my thinking? 5) If a friend was in the situation and had this thought, what would I tell them?

Alternative thoughts

• All-or-None Thinking • Jumping to Conclusions ◦◦ Mind Reading ◦◦ Fortune Telling • Overgeneralization • Catastrophizing • “Should” Statements • Mental Filtering • Disqualifying the Positive • Labeling • Personalization • Emotional Reasoning

Feelings/ Behaviors

Questions to help you challenge automatic thoughts

Automatic thoughts

Maladaptive Thinking Patterns

Situation

Challenging Maladaptive Thinking: Individual Practice

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Chapter 6

Active Phase – Week 4

Week 4 of the active phase of the ACCESS program focuses on treatment issues related to  the impact of ADHD on academic performance in college. During the group session, the group leader engages students in a discussion of the processes by which ADHD and its associated features impact academic performance. Next, group members receive instruction in the use of behavioral strategies to help improve academic performance, including strategies for selecting and scheduling classes, methods to sustain attention during classes, and note-taking tips. Finally, guidance in using adaptive thinking skills to manage negative thoughts related to academic performance is provided. Mentors begin their meeting with a review of the student’s ongoing use of previously learned behavioral strategies and adaptive thinking skills; suggestions for helping the student work through difficulties in implementation are provided as needed. Mentors also review and clarify information covered in group, with the goal of ensuring that students understand this information fully and provide guidance in the use of newly presented behavioral strategies targeting academic performance. Mentors similarly aid students in refining their use of adaptive thinking skills to help manage maladaptive thoughts associated with academic performance.

Week 4 – Group Beginning Group Session As is customary, ask students if they have any general concerns. Address these as time permits and defer longer responses to questions or issues to the student’s mentor as needed.

© Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_6

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ADHD Knowledge Start the Knowledge Section Briefly review the ADHD knowledge covered in Week 3 and ask if there are any further questions about the assessment of ADHD. After answering these questions and dealing with any other carry-over concerns, transition into the new ADHD knowledge content, which is a discussion of how ADHD affects academics and other areas of daily life. Direct the group’s attention to Handout 4.2, which serves as a guide for this discussion. Discuss Risk and Protective Factors Before discussing the various ways that ADHD can impact students’ life negatively, take a moment to set the stage for discussing this topic. Remind students that although ADHD increases risk for some negative outcomes, this does not mean that every single person with ADHD will experience these. Emphasize the fact that there are many factors other than ADHD that play a role in determining whether an outcome will be favorable or negative. Point out that clinicians and researchers refer to these as “risk” and “protective” factors. List several examples of protective factors, such as a strong social support system, the use of coping strategies, awareness or insight about ADHD, a strong sense of personal goals, and so forth. Also point out that two of these protective factors - awareness of ADHD and coping strategies – are areas targeted by the ACCESS program. The Developmental Challenge of ADHD in College To help students understand how ADHD might affect performance in college, first point out the increased number of demands for self-regulation that college places on any student. For example, college students are expected to create and follow their own schedules, which will be different from the schedules of other students. They are expected to complete much of their academic work outside of class time (e.g., reading, writing assignments and various projects). They are also expected to keep track of deadlines and academic assignments themselves. Although some professors provide reminders, this is not standard practice across different courses. Many professors provide the deadlines on syllabi and leave the rest up to the students themselves. Another academic challenge is registering for classes. For any student, registering for classes requires a great deal of organization and planning, including being aware of registration dates, meetings with advisers, and selecting classes in accordance with timelines that fulfill degree requirements. For any student, meeting these increased demands for self-regulation can be challenging. For students with ADHD, this challenge is even greater because of the deficits in self-regulation that are inherent in ADHD.

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Along with increased demands on self-regulation, students entering college also generally experience a decrease in assistance and support from others. Most students are living away from home, and as a result they can no longer benefit from the reminders or support provided by their parents or other family members. For example, if a high school student oversleeps, their parents may wake them up, thereby serving as a safety net. In college, this safety net is removed. If students oversleep, they are likely to be late for class or miss it entirely. Many parents also make sure that studying occurs before tests and that long-term papers and other projects are submitted on time. Additional support may come from high school teachers who may allow students to turn in assignments late without penalty. Emphasize that the combination of increased demands for self-regulation and decreased support can be thought of as a “perfect storm” of circumstances that make it more difficult for college students with ADHD to perform to the best of their abilities. Note that this perfect storm is likely the reason that many college students with ADHD experience educational difficulties. In addition to schoolwork, college students must take on increased responsibility for managing many other areas of their daily functioning that previously may have been handled by parents and others. This includes, for example, shopping for groceries, preparing meals, doing laundry, managing finances, and keeping track of meetings and appointments. Encourage the group to discuss these and other aspects of daily life requiring greater self-regulation. Invite the group to think about how ADHD might make it more difficult to manage not only these activities, but also things like driving, social relationships, and jobs.

Tip Ask the group to describe their first semester in college – was it difficult to adjust? Did they find it difficult to make their own schedules, get themselves to class and manage all their academic work? Many students will share examples illustrating their own personal “perfect storm.”

Behavioral Strategies Start the Behavioral Strategies Section Conduct a brief check-in with students regarding between-session practice. Students were asked to implement at least one organizational technique presented in Week 3. Ask students to report individually on their use of these techniques. Make sure to praise any use of organizational techniques, no matter how small.

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Tip Help students reframe statements such as “I did it for one day then forgot about it.” Most students will tend to speak as though this reflects a “failure.” Encourage them to reframe experiences like this as a success by restating it as “I did it for one day, which is more than I did the previous week.”

Strategies for Getting the Most Out of Classes Direct students to Handout 4.3, which provides detailed information about the strategies presented in this section. The goal of this behavioral strategies section is to encourage students to consider different approaches and techniques that can improve their ability to efficiently absorb and retain information during classes. The following strategies are designed to improve students’ ability to sustain attention during lectures, as well as their ability to organize and retain information presented in lectures. A key point to discuss is that “just showing up” to class is generally not enough to achieve a passing grade, much less a high grade. Instead, thoughtful preparation and active engagement are essential steps to succeeding in each class. Choosing and Scheduling Classes Students can take steps to maximize their success in classes before each class begins. Scheduling classes thoughtfully will help students perform to the best of their abilities. Encourage students to consider the type of schedule that might work best for them. Individuals with ADHD typically have a harder time sustaining their attention; accordingly, classes that take place once per week for 3 hours at a time are generally a poor fit. Instead, students may wish to find classes that meet for a shorter amount of time multiple days per week. Also advise the group to consider scheduling more difficult and demanding classes for the time of day when they are most alert. Further encourage them to build breaks into their daily schedule. This will allow them time to get food, water, and rest before their next class. It is difficult for anyone to concentrate when they are hungry, thirsty or tired, so planning breaks is one way to prevent these situations. Paying Attention During Class There are numerous techniques to help students sustain their attention throughout classes and lectures. Urge the group to think about what techniques might benefit them. Some commonly used techniques include sitting at the front of class, bringing water, coffee, or gum. Taking notes (discussed below) can also help students sustain attention in class.

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Taking Notes As with many of the techniques discussed in this manual, there is no “one-size-fits-­ all” approach to note taking. Instead, help students consider the pros and cons of the different approaches listed on the handout. For example, there is evidence that handwriting notes improves retention of material. On the other hand, typed notes can be more easily reorganized later and may be easier to read for students with messy handwriting. Another consideration is the use of a recording device to record lectures, which allows students to go back and double check their notes or fill in information they may have missed. Some students may report relying on outlines provided by their professors prior to class. Students should be encouraged to make use of whatever materials and resources their professors provide. If a student reports relying exclusively on these outlines, it can be helpful to prompt them to think about how they manage a class in which no outlines or supplemental materials were provided. Most students will acknowledge that there is no universal standard in terms of whether professors provide this material. Generally, other students will speak up to offer their own experiences with classes in which little to no supplemental material was provided. The Cornell system of note taking is a highly structured approach in which students use a standard template to organize their notes. Most students have heard of this method, and in our experience, many will have strong opinions, both positive and negative, about this method. Again, the goal is not to sell this approach. Instead, it is best to focus on the benefits of this method, such as better organization and the ability to easily study notes organized in this manner. Remind students that the overall goal is to consider improving their note taking. Using a template such as the one used in the Cornell method is just one of many ways to do this. It is often useful to address the topic in a group discussion by asking what methods students already use to keep their notes organized. This allows students to offer one another suggestions about organizational note-taking methods. This is particularly helpful when students report actively disliking the Cornell system, often due to being “forced” to use this method during middle school classes. Getting Help From Instructors Another way to get the most out of classes is to make use of the office hours offered by instructors. Emphasize the benefits of seeking out instructors during office hours, such as demonstrating interest and engagement and making connections with instructors who may serve as references or write letters of recommendation in the future. It is entirely possible that some students will report negative interactions or experiences with instructors. For instance, students may report that their instructors appeared impatient, or did not offer the level of support students expected. If this occurs, validate their experiences while also encouraging the use of strategies and adaptive thinking to cope with such situations. For example, students may have

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maladaptive thoughts in response to these experiences (e.g., “Professors are not interested in helping students”). Students should be encouraged to use adaptive thinking strategies to manage these situations. Alternately, students may need to consider using planning and organization techniques to better prepare for meeting with professors. For instance, students may have better experiences when they prepare specific questions to ask their instructors, or when they email professors ahead of time to set up a meeting. At the very least, if students report a negative experience interacting with a professor, it can be helpful to point out that this is generally an isolated incident, rather than a common experience. Be sure to encourage students to avoid jumping to the conclusion that all interactions will be unpleasant by pointing out that this assumption is a prime example of two types of maladaptive thinking, known as negative fortune telling and overgeneralizing. Assign Between-Session Practice Ask students to choose one of the above techniques to try as between-session practice. As usual, remind them that their mentor will be checking in with them about their experiences.

Adaptive Thinking Skills Start the Adaptive Thinking Section Provide a brief reminder about last week’s topic, which was challenging maladaptive thinking patterns, and introduce the new topic for this session - ways to use adaptive thinking to manage ADHD and improve schoolwork. Begin by checking on students’ use of adaptive thinking techniques by asking about experiences with challenging maladaptive thinking over the course of the week. When checking on students’ use of maladaptive thinking, it is important to keep in mind the personal and sometimes sensitive nature of these thoughts. Some students are perfectly comfortable sharing their experiences of identifying upsetting maladaptive thoughts with the group, but others may not be. Hence, it can be best to check in briefly on the completion of the between-session practice (i.e., “Were you able to use the adaptive thinking strategies we discussed last week?”) without requiring each student to discuss their experience in detail. In our experience, some students will voluntarily share more details. If necessary, group leaders can gently prompt students to share voluntarily by making a statement such as “Would anyone be willing to discuss their experience using adaptive thinking skills last week?” Keep in mind that students also discuss between-session practice with their mentors, thereby allowing them to get one-on-one feedback about their use of adaptive thinking strategies. From this point onward in the program, the adaptive thinking section of group will follow a specific structure. Each week, group leaders will initiate discussion about

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how maladaptive thoughts might interfere with functioning in different areas of life. Students will engage in discussion, followed by in-session practice using the column analysis/thought record technique to challenge maladaptive thoughts and to replace them with alternative thoughts that lead to more positive feelings and behavior. Using Adaptative Thinking to Improve School Performance Students should be directed to Handout 4.4 for this portion of the group, which focuses on how maladaptive thoughts might interfere with managing academic work. Provide students with examples of maladaptive thoughts that are commonly associated with ADHD (e.g., “There’s no way I’ll ever stick to a schedule”) and ask them to generate other thoughts that might occur for someone with ADHD. Use this same process to generate discussion about maladaptive thoughts that could interfere with academic work. Examples of thoughts commonly reported by students with ADHD include: “I’m just terrible at math and I always will be,” “I do better work when I wait until the last minute,” “I always work better under pressure,” “This is going to take so long, it’s going to be terrible for me,” and “Even if I study for a test, what difference will that make?” Another common maladaptive thought that impacts academic performance is associated with class attendance. Many students report having the thought “There’s no point in going” when they are running late for class. This is an easy thought to challenge – point out that attending class for a shorter amount of time (even just 15 minutes) is still more useful than not attending class. Encourage them to gather evidence using this approach. After this discussion, work through an academically related thought record as a group. There are multiple approaches to this exercise. Either select a hypothetical example to work through as a group or ask for a volunteer to share an experience that seems to fit the session’s topic. The goal of this exercise is to allow group members to practice their adaptive thinking skills in session with guidance and support. Thus, students are learning the process, regardless of which maladaptive thought they are engaged in challenging. At this point in the program, students may require a good deal of support in terms of identifying maladaptive thoughts and using adaptive thinking strategies. As the program continues, students will grow more familiar and adept at these skills. Plan to provide more support and direct guidance in these early sessions. Later in the program, it is appropriate to put more responsibility on students to identify, challenge, and replace maladaptive thinking patterns on their own. Assign Between-Session Practice Ask students to continue using the thought record/column analysis approach and the questions to help challenge maladaptive thoughts as between-session practice. Remind them that their mentors will be checking on their use of these techniques as well.

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Ending Group Session As in previous sessions, provide a quick summary of between-session practice assignments. Students will practice using at least one strategy to get the most out of classes. They are also expected to continue to use the adaptive thinking techniques by challenging their maladaptive thought patterns with the column analysis approach and/or the use of the challenge questions. Remind students that the goal is progress, not perfection, and encourage them to bring back questions or concerns about problems or barriers that may arise as they engage in these between-session practice activities.

Week 4 – Mentoring Check-In Get a brief update on how the mentee has been doing since the last mentoring session. Feel free as part of the check-in to include informal questions about things that the mentee may have previously disclosed about their interests or events in their life. Mentor: “Hi, good to see you! Your team was on TV last night – did you watch it? What a game!” Or you might follow up on a topic that you noted at the end of Week 3 that may not naturally come up during the regular agenda. Mentor: “You mentioned that your mom was coming into town over the weekend, How was her visit?” In some cases, the latter check-in might lead to agenda-relevant conversation. Mentee: “Well, I got a good dinner out of it, but seeing her just reminds me that I can never live up to her expectations, especially now that I’m an art major.” Mentor: “A good dinner out can be a great benefit to a parent visit! But sounds like there are some negative thoughts that crept in with her visit. They might be good to work on when we get to the adaptive thinking section today. I’ll note it for our agenda.”

Collaborative Agenda Setting Briefly describe the content and outline of the session, including a check on how the between-session practice went. Also review the material that was covered in the most recent group session, which addressed how ADHD affects school and other

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everyday life activities, tips for getting the most out of classes, and how adaptive thinking can help manage ADHD and improve academic functioning. If topics from the check-in seem to generate more conversation pertinent to the needs of the mentee, suggest adding these to the agenda.

Review Between-Session Practice To ensure that the mentee is using and beginning to gain skill in implementing recently presented strategies, be sure to check on the following items: • Did the mentee bring the planner to session and are they using it for a range of tasks including academic, social, and other appointments? • Did the mentee practice the 6-column adaptive thinking log? • Did the mentee bring handouts from group to this mentoring session? • If the mentee chose anything else to practice between sessions, be sure to follow up on that. Give enthusiastic and positive feedback for any follow through on these tasks. Be neutral and do not over-respond to missed practice. However, you may choose to ask the mentee to follow up in the next week on important items. Be sure to remind them of these items at wrap-up.

Discuss Information Presented in Group ADHD Knowledge To initiate this discussion, consider asking any one or combination of the following questions: • • • •

What was interesting to you about how ADHD affects school? Did anything surprise you? How has ADHD impacted your school performance, in the past and currently? How did having ADHD impact your transition to college?

Discuss the “perfect storm” of life circumstances that make the transition to college particularly difficult for students with ADHD. Describe the increased demands for self-regulation that are placed on all students and highlight how those with ADHD have deficits related to self-regulation that can make meeting these demands difficult. Also, discuss changes in the amount of support that students receive from teachers, parents, high school counselors, and individualized education plans as students transition to college. Students are expected to be more autonomous. Together, these factors create a perfect storm of life circumstances that may increase risk for academic difficulties. Providing such an explanation gives students with ADHD a better understanding of the nature of their academic difficulties, which in turn can

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serve to increase their motivation to seek appropriate treatment and campus support services. Mentee: “ADHD always made it hard for me to sit through classes and remember my homework. My parents would literally make me sit at the kitchen table every day until my homework was done. I barely ever took notes in class or studied because it was boring to me. But I didn’t need to because I tested well. So, I managed to pull off decent grades in school. But college is different – I can’t get by without notes or studying now. And I’m doing a terrible job of keeping up with my readings and assignments.” Mentor: “You have just described that “perfect storm” that often happens to students with ADHD when they get to college. It sounds like ADHD affected you, but you had some factors in your favor that helped you do well. You had parents who provided a structure and oversight to ensure you got your work done. Also, because you are very intelligent, after doing homework and going to class, you could still do well on high school level tests.” Mentee: “But now I’m in college and everyone was smart enough to get here! And the classes are at a higher level. There is less practice and more material to know for the tests.” Mentor: “Yes, there is more expected of you and no parent to make you sit down and do it.” Discuss other areas of everyday life that may be affected by ADHD. Highlight the developmental challenge and discuss other areas of life that require self-­regulatory skills. Many mentees feel validated when they learn that individuals with ADHD often have difficulties with sustaining relationships, driving, employment, and money management. It is often useful to briefly assess which of these areas the mentee struggles with and discuss their previous experiences. For example, many mentees have not connected their driving difficulties with their ADHD symptoms, such as being easily distracted.

Tip End this portion of the session by emphasizing two important points: (1) that having ADHD does not automatically mean an individual will have academic problems, which are also determined by various risk and protective factors, and (2) the impact of ADHD can and often does extend to areas beyond academics (e.g., relationships) that may need to be included in treatment planning.

Behavioral Strategies Because it is not possible to cover all topics within the time constraints of the mentoring session, be sure to review at least two of the following strategies for getting the most from classes.

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Choosing and Scheduling Classes Strategically  Briefly discuss degree and major requirements for the mentee. Most mentees have never reflected on how best to schedule classes. Reflect with the mentee on what time(s) of day they can focus best, if they prefer breaks between classes, and other aspects of scheduling courses. This information can be used to tailor their schedule to their needs (e.g., scheduling hardest classes and tasks when they are most alert and focused). Also reflect on the type of class settings that the mentee prefers. Many students with ADHD do better in smaller discussion-based courses as opposed to big lecture courses. Of course, big lecture courses may not always be avoided, which is a perfect transition to discussing paying attention in courses. Be sure to be familiar with the mentee’s specific degree and major requirements. Also be aware of registration windows and deadlines—make sure to remind the mentee about the process of obtaining accommodations for priority registration, if available. This may involve connecting with specific support service offices on campus, submitting disability documentation, etc. If the mentee is unaware of this process, help them connect with these support services. This is a great time to have the mentee practice entering a “To-Do” task into their planner. Paying Better Attention in Class  Discuss strategies for staying alert and focused in class. Mentees have likely heard many of the common strategies, such as being well-rested, bringing snacks (e.g., gum, water, coffee), taking detailed notes, sitting in the front of the class, etc. Although many mentees have heard that it is beneficial to sit in the front of classes, they may not completely understand why. Discuss common distractions when sitting in the back of a classroom. This may include, for example, the many students sitting in front of them who may be texting, surfing the internet, fidgeting, or engaging in other activities that pull the mentee’s attention away from the professor’s lecture. In contrast, sitting near the front limits those distractions and provides an additional level of accountability (e.g., it is harder to “get away” with texting right in front of the professor). Another strategy that may be new to mentees is setting a vibrating alarm to go off mid-lecture for them to “check-in” with themselves about their attention. When the silent alarm goes off, mentees can remind themselves to pay attention. Yet another way to personalize effective strategies for paying attention in class is to help the mentee identify times when they have been able to pay attention in class (or at least do better). Mentor: “Can you think of times in classes when you have been able to pay better attention? What were they like?” Mentee: (laughs) “Well, in most situations, I’m pretty easily distracted. But I tend to focus best in classes when I really like the subject, the instructor, or if it’s a more interactive class. I’m a chemistry major and in those classes I usually like the information and solving the problems can be a fun challenge for me. The labs are great because they are hands on and interactive. But even in chemistry, if it’s a big lecture class – I’m usually more interested in the

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web browsing of the guy in front of me or I’m watching the girl next to me write super-organized multi-color notes instead of taking my own notes.” Mentor: “Ok, so classes that are interesting to you is important  – that’s great to recognize. You might remember that’s part of the situational variability of ADHD. But sometimes you still must fulfill requirements with classes that are not as interesting. I did hear two things in what you said. One, is that you do better when you are actively engaged. The other is that in large lecture classes, part of the challenge is the disconnect from the professor – including all the people in between. What are some ways you can make a large class or boring topic something you are more engaged with?” Mentee: “Well, in a large class, I could move to closer to the front. I stopped doing that when I went to college because my teachers always made me do it when I was a kid, but I guess it would help with all the other distractions going on in the room.” Mentor: “Ok, good. What else?” Mentee: “I’ve noticed that my philosophy class holds my attention pretty well even though it’s not a subject I usually would be interested in. That class is smaller and very interactive. The professor never lectures, he’s tells great illustrative stories, and he asks us questions and we discuss and debate as a group. I’m really into that class!” Mentor: “So, when you can interact you are more engaged. How can you make that happen in classes that aren’t naturally like that for you?” Mentee: “Well, if I’m sitting near the front, I’ll be more likely to ask questions or answer the professor when a question is asked of the class. It’s harder to be anonymous when you are up front… I guess that’s the point, huh?” Mentor: “Exactly! You could also challenge yourself to be really engaged in your notetaking. Let’s talk some about the best ways to do that.” Taking Notes  Discuss the pros and cons of taking notes on a laptop or writing in a notebook. Briefly determine how the mentee currently takes notes and if it works well for them. Discuss strategies for effective note taking, such as utilizing all or some of the Cornell System, recording lectures for reviewing later, taking notes on PowerPoint notes from lecture slides, and comparing and discussing notes with classmates. These strategies can be used to help mentees make sure they are getting the important information from lectures. Tip If mentees are registered with the disability services office, one accommodation that may be available to them is access to smart pens or other support services (e.g., note taker).

Getting Help from Professors  Clarify the purpose of office hours and challenge or dispel any myths the mentee may have. For example, many mentees believe that going to office hours is wasting the professors’ time or can only be used if they are

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struggling in the course. Discuss the benefits of office hours and reflect on the mentee’s comfort level utilizing this support. Mentee: “I always feel like I’m bothering them.” Mentor: “Most professors really enjoy interacting with students. One easy way to start is with that plan you had earlier to move to the front of the class. Then you’ll more naturally have opportunities to interact with the professor before or after class.” Mentee: “That makes sense. I never thought of it that way. And then, if there was something in class that confused me or that I missed, I can ask and get feedback on it right away by following up as soon as class is over.” Mentor: “Right! Also, if a professor knows who you are earlier in the semester… before you are having problems… they are going to be more likely to give you the benefit of the doubt than if you are suddenly showing up at a point of desperation.” Adaptive Thinking To begin this section, review the between-session practice assignment. If the mentee completed their practice thought log, look over the thought record and provide any suggestions if needed. Did they identify realistic situations, thoughts and feelings? If the mentee did not complete the record, practice once in session. Try to use a thought that the mentee has expressed in session. (e.g., “I can never focus in large classes,” or “I don’t want to learn a new way to take notes mid-way through a semester…it won’t work for me.”). Help the mentee challenge their initial thought and replace it with a more realistic and often less upsetting alternative thought. Also present one or two additional hypothetical examples to discuss that are related to the content of this session. This might include, for example: • You’re taking a test. You look at the first question and you don’t know how to solve it. You think to yourself, “I am going to fail the test.” • Your professor asks to speak to you after class. You think to yourself, “I’m in trouble.”

Ending Mentoring Session Check in about goals as needed. Is there anything that has been accomplished or needs to be modified? Any miscellaneous topics of discussion? This is where topics can be addressed that did not fit into the prior discussion.

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Finally, review and clarify as needed the details of what the mentee is expected to do between now and the next mentoring session, including: • Bring all group materials to next mentoring session • If the mentee indicated that they would be connecting with support services on campus to get accommodations, remind them to do this before the next session. • Make an adjustment to current note taking strategies for 1 week. This may be using one aspect of the Cornell System, getting a smart pen, etc. • If relevant, look up courses for next semester and create schedule options that align with the discussion on getting the most from classes. • Practice the 6-column system with at least one example of a maladaptive thinking pattern. Confirm the date and time of next appointment. Ask the mentee to write down/set reminder and model similar behavior with your own planner/calendar.

Week 4 – Group Agenda



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Week 4 – Group Agenda

Beginning Group Session ADHD Knowledge • Discuss academic demands of college and increased need for self-regulation • Discuss how the demands of college may be particularly challenging for college students with ADHD • Discuss how ADHD may affect other daily life activities • Emphasize the role of risk and protective factors in determining outcomes

Behavioral Strategies • Present and discuss strategies for choosing and scheduling classes • Present and discuss strategies for paying attention during class and decreasing distractibility • Present and discuss note-taking strategies • Discuss benefits of meeting with professors

Adaptive Thinking Skills • Present examples of maladaptive thinking patterns that may be more frequent for those with ADHD • Present and discuss examples of how maladaptive thinking patterns may interfere with successful academic performance • Work through examples of challenging maladaptive thinking patterns (either challenging ADHD-related thoughts or thoughts that interfere with academic performance)

 nding Group Session E • Address any questions that may arise • Review the details of completing the between-session practice assignments

Handouts • 4.1 Week 4 Group Cover Sheet • 4.2 How ADHD Affects College Performance • 4.3 Get the Most from Classes • 4.4 Manage ADHD-Related Thoughts to Improve Academics

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Handout 4.1

ACCESS Accessing Campus Connections and Empowering Student Success



Week 4 – Group Handouts • • • •

4.1 Week 4 Group Cover Sheet 4.2 How ADHD Affects College Performance 4.3 Get the Most from Classes 4.4 Manage ADHD-Related Thoughts to Improve Academics

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How ADHD Affects College Performance How Does ADHD Affect College Performance? The “perfect storm” • Entry into college brings increased demands for self-regulation • Simultaneously, assistance and support from others is withdrawn This “perfect storm” of life circumstances increases the risk for: • • • •

Not being able to register for preferred courses Withdrawing from or dropping courses more often than others GPA below expectations and capabilities Taking longer amounts of time to graduate and/or not graduating

Does ADHD Only Affect Academic Performance? With diminished self-regulation, there is increased risk for: • • • • •

Difficulties sustaining friendships/dating relationships Driving difficulties Frequent job changes Money management difficulties Family conflict, especially with parents

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Handout 4.3

Get the Most from Classes

Choosing and scheduling classes strategically • Be aware of requirements • Schedule difficult classes for when most alert • Alternate harder classes with fun classes/activities • Avoid lengthy lecture courses (i.e., three-hour classes) • Leave breaks in schedule between classes ◦◦ Provides time to review notes/reading between classes ◦◦ Provides time to get to next class ◦◦ Provides a brief break • Don’t overload • Consider smaller classes

Paying better attention during class • Be well-rested • Brief exercise before class may increase alertness • Bring gum/candy/coffee/water according to preference • Sit up front • Take notes • Taking notes can help with staying focused • Consider setting a vibrating alarm for mid-lecture as a cue for checking your attention

Taking the best notes • Writing vs. typing • Put header on every page of notes (class, date, page #) • Cornell System of note taking • Recording and reviewing lectures ◦◦ Allows you to fill in gaps in your notes ◦◦ Consider smartpen • Use your instructor’s PowerPoint notes – print these out before class • Compare notes with those of a classmate

Getting help from professors • Take advantage of office hours

Handout 4.4



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Manage ADHD-Related Thoughts to Improve Academics

What are some maladaptive thoughts associated with ADHD?

What are some maladaptive thoughts that impact academic performance?

• “There’s no way I’ll ever stick to a schedule.” • “It’s better when I just go with the flow.”

• “I work better at the last minute” • “I’m just no good at math!” • “I got a low grade on this test; I’m going to fail out of college!”

Maladaptive Thinking Patterns • All-or-None Thinking • Jumping to Conclusions ◦◦ Mind Reading ◦◦ Fortune Telling

• • • •

Overgeneralization Catastrophizing “Should” Statements Mental Filtering

• Disqualifying the Positive • Labeling • Personalization • Emotional Reasoning

Questions to Help You Challenge Automatic Thoughts (1) What is the evidence that the automatic thought is true? a. What is the evidence that the automatic thought is not true? (2) Is there an alternative explanation? (3) What’s the worst that could happen? Could I live through it? a. What’s the best that could happen? b. What’s the most realistic outcome? (4) What’s the effect of believing the automatic thought? a. What could be the effect of changing my thinking? (5) If a friend was in the situation and had this thought, what would I tell them? Situation

Automatic thoughts

Feelings/ Behaviors

Alternative thoughts

Degree of belief in alternative thoughts

New feelings/ Behaviors

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Week 4 – Mentoring Agenda Check-In Collaborative Agenda Setting Review Between-Session Practice Discuss Information Presented in Group Ending Mentoring Session Handouts – none

Chapter 7

Active Phase – Week 5

In Week 5 of the active phase of ACCESS, information about the increased risk for depression, anxiety, emotion regulation issues, low self-esteem, and risky behaviors is presented in the group. In addition, the group session introduces strategies for effective studying and the use of a distractibility delay technique to increase attention. The group session concludes with the group leader engaging the students in a discussion of how to manage emotional distress and reduce engagement in risky behavior through adaptive thinking techniques. Mentors begin their session by monitoring student efforts to use more effective note taking strategies, as well other assigned between-session practice activities. Mentors next engage their mentee in a discussion of the increased risk for co-occurring emotional problems and risky behaviors associated with ADHD. Mentors also work closely with their mentees to tailor their use of effective studying strategies and the distractibility delay technique to their individual needs. One-on-one mentoring guidance is also provided to facilitate mentee use of adaptive thinking skills to reduce emotional distress and engagement in risky behaviors.

Week 5 – Group Beginning Group Session Conduct a brief check-in by asking students if they have any questions about the program they would like to ask. Answer questions that arise, but feel free to defer some questions to mentors if longer, more in-depth responding is needed.

© Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_7

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ADHD Knowledge Start the Knowledge Section Briefly review the ADHD knowledge covered in Week 4, addressing how ADHD affects academic performance and other areas of life. Next, introduce the topic of the current session: increased risk for depression, anxiety, other mental health concerns, and risky behavior. Refer students to Handout 5.2 during this discussion. Other Mental Health Concerns Inform students that research findings on college students with ADHD indicate that ADHD is associated with an elevated risk for other mental health concerns. These include depression, anxiety, emotion regulation issues, low self-esteem, and substance use. In fact, up to 55% of college students with ADHD also meet formal diagnostic criteria for another mental health disorder. Most commonly, college students with ADHD report co-occurring depression or anxiety. Ask group members to think about and discuss why ADHD might be associated with an increased risk for these other conditions. Students will typically be able to quickly identify reasons for increased risk of other mental health concerns, such as frustration associated with ADHD symptoms, increased self-doubt about one’s competence, conflict in relationships, and sadness or frustration associated with poor performance at school or work. If students neglect to mention the role of emotion regulation, identify it as a potential factor contributing to high rates of co-occurring emotional conditions. Remind students that emotion regulation refers to the ability of individuals to identify and manage their own emotions and note again that this is an area of self-regulation that is often more challenging for those with ADHD.  Students are generally able to quickly grasp the concept that trouble regulating emotion increases risk for disorders such as depression and anxiety, and may even explain increased risk of substance use, as individuals may use substances to try to cope with painful emotions. Impulsivity may be another risk factor for substance use that increases risk for college students with ADHD. Be sure to identify this if students do not raise it themselves. It is equally important to emphasize that increased risk for these conditions does not mean that all students with ADHD will experience co-occurring mental health concerns. Remind students that protective factors (e.g., social support, positive relationships with others, receiving treatment, insight) can help reduce this risk. To increase their engagement in this topic, ask students to identify several other potential protective factors that can help reduce the risk for other mental health concerns. Not uncommonly during such discussions, students may self-disclose their own struggles with depression, anxiety, and other co-occurring mental health conditions. Because of the personal and potentially sensitive nature of this information, remind group members to respect one another’s privacy by not sharing such information outside of group. Many options are available for responding to such self-­disclosures,

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including: validating students’ struggles (e.g., “It sounds like that was a difficult time for you”), thanking group members for being willing to share (e.g., “I really appreciate you sharing this experience with the group”), and noting that these experiences are demonstrations of how ADHD increases risk for mental health concerns (e.g., “It seems like your frustration with school led to that depressive episode”). If the discussion becomes overly lengthy, gently wrap up the discussion and signal a move to the next topic by stating “Thank you so much for being willing to share your experiences. These are all examples of how ADHD can affect emotions and lead to an increased risk for other mental health concerns. However, in the interest of time, we do need to move on to the next topic.” Remember that due to difficulties with self-regulation, college students with ADHD are particularly likely to become sidetracked by sharing their experiences and stories; therefore, it is frequently necessary to provide this type of gentle but firm redirection. Another difficult situation that can arise is when a student’s disclosure reveals a potentially serious emotional difficulty that would best be discussed privately rather than in the group. Should this occur, acknowledge the seriousness of this disclosure and offer to meet individually with the student after the group to discuss this more thoroughly and to determine if referral to a mental health professional is needed.

Behavioral Strategies Start the Behavioral Strategies Section Remind the group of the previous session addressing strategies to get the most out of classes and ask them to discuss their use of these strategies over the past week. Assist the group as needed by suggesting ways to overcome barriers to using such strategies. Next, transition to the new topic for the current session: studying effectively. Direct students to Handout 5.3 for this discussion. Studying Effectively Depending on their major, students may or may not have frequent exams. Explain to the group that regardless of their major, most students will need to study for an exam at some point, which is the reason why this topic is being addressed. Distributing Study Time To introduce these techniques, ask students about their general study patterns. Do they start preparing for exams a week in advance, or the night before? Many students will report putting off studying until the last minute, typically the night before or morning before their exam. Ask students to identify their perceptions of the

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benefits and drawbacks of waiting until the last minute or “cramming.” Some commonly identified drawbacks are increased feelings of stress, getting less sleep the night before an exam, and not being able to cover all the material. Sometimes students will report no benefits to cramming, but occasionally one or two students will identify a belief that the material is “fresh” in their mind. Should this arise, ask the students to consider whether this belief could be an example of maladaptive thinking, which could be challenged using adaptive thinking techniques. The purpose of this discussion is to help students more thoughtfully consider the impact of waiting until the last minute to study. This is an extremely common behavioral pattern for college students with ADHD – many students with ADHD report they “never” start studying early, or “always” wait until the last minute. Since this is a long-standing pattern for such students, it is likely that they have not reflected on the drawbacks of this behavior in any systematic way for a long time. At the same time, students have undoubtedly been instructed by former teachers, parents, advisors, counselors and so forth to start assignments and studying early. As a result, they may be in the habit of “tuning out” this advice. It is important to avoid falling into the trap of coming across as yet another authority figure lecturing students about the importance of getting an early start on studying. Thus, it is critically important to get the students to take ownership of this problem by articulating their own reasons for why it might be important not to procrastinate and to get an earlier start on studying. Once students have identified and reconsidered their own reasons, present the strategies for creating and using a study schedule. Students can use their planner for scheduling study time, and they can use behavioral reinforcement to reward their own behavior. For example, students may schedule a study session immediately before doing something reinforcing, such as watching a movie or going to dinner with friends. Thus, the fun activity serves as a reward for completing the study session. Developing a Study Space Ask students to identify where they prefer to study and why. Some students prefer studying in a dorm room or at their apartment, while others will report a preference for studying at a library or a coffee shop. Regardless of where they study, students should be encouraged to take proactive steps to limit distractions. This may be accomplished by turning off their phone or phone ringer, limiting their access to email or distracting websites, or even by notifying friends or significant others that they plan to study during a specific time. Students can also consider choosing a quiet location with limited distractions, such as a library, or using noise-cancelling headphones or a white noise machine or app. Although some students report that they work best with silence, others will adamantly report that total silence is distracting in and of itself. In anticipation of this possibility, be sure to acknowledge for the group that each student should consider what level of background noise they prefer. Some students report working best in environments with muted background noise, such as a coffee shop. Others enjoy

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listening to music while studying. The goal is for students to identify and then create the type of environment that is most conducive to studying for themselves. This may not be the same from student to student. Using Distractibility Delay Most students are not familiar with the concept of distractibility delay. Introduce this technique as a method to increase work efficiency and note that there are two major parts to it, which can be used independently or alone. The first part is assessing the length of one’s own average attention span, with the goal of breaking studying time into chunks that fit this attention span. To gauge their own average attention span, students should observe how long they stay focused while studying or working. After repeating this exercise several times, they can calculate the average length of time they were able to focus before becoming distracted. This is an estimate of their attention span. In order to study or work on long, monotonous tasks most efficiently, students should aim to work in chunks of time matching this attention span, which can be labeled as focus times or focus periods. For example, if a student measures their ability to focus while studying on four occasions and finds that they were paying attention for 25 minutes, 20 minutes, 10 minutes and 25 minutes, their average attention span is 20 minutes. This student should plan accordingly to study for 20 minutes at a time during their next studying session, which can be facilitated by using a timer. After studying for 20 minutes, a brief rewarding break can be taken, after which the timer should be re-set for the next 20 minutes of studying. The second component of this distractibility delay technique ensures that students make the most of their focus times and avoid becoming sidetracked by other tasks or activities, which is a common complaint among college students with ADHD. To achieve this, first inform students that they should keep a notebook or piece of paper close by during the focus period. Should they find themselves distracted by the lure of another task or activity, they should instead write down whatever extraneous tasks or activities come to mind, so as not to forget them, and then put this written list aside in order to re-focus their attention on the task at hand. Upon completing their scheduled studying, they can review the list and decide whether any of the potential distractions are urgent matters requiring their attention. If so, they can act on them during their break. This technique addresses the tendency for students to become distracted by tasks or matters that seem important in the moment. This tendency is often driven by the fear that “if I don’t do this now, I will forget about it and it won’t get done.” Although this thought is not entirely unrealistic, it is not helpful when it results in the student becoming sidetracked repeatedly while studying. College students with ADHD report that this type of pattern happens quite often, with the result being that their studying time is frequently interrupted. By keeping a list of these potentially distracting thoughts and tasks (e.g., “I need to pay my cell phone bill,” “I haven’t texted my best friend in a week,” “When does registration for next semester start?”), students can feel assured that they will not forget these tasks. At the same time, returning their attention to the task at hand will result in improved efficiency when doing

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academic tasks and activities. Use of this technique also helps build student confidence in their own ability to take control over directing their attention, instead of feeling helplessly pulled from distraction to distraction.

Tip Many apps and browser extensions are now available to aid students in implementing distractibility delay. Ultimately, a simple timer is all that is needed; however, many students enjoy using a dedicated app that supports this approach. Also ask the group for any suggestions that they might have for this purpose.

Other Study Tips This section describes other techniques that can help students study effectively. For example, an awareness of the information that will likely appear on the exam is important. Some professors clearly indicate what proportion of exam questions will come from lecture material and reading, respectively. This can help students prioritize their studying. Other helpful techniques include making flashcards or study guides to organize the material. Students sometimes report that creating their own flashcards or study guides “takes too much time.” Be sure to point out that the time spent creating flashcards or study guides should be considered studying, because rewriting material is a great way to increase retention of the information. Studying in a group and periodically testing one another with questions is another strategy that can be helpful for some students. Other students benefit from creating visual diagrams that organize the information or concepts presented in lectures or classes. Students should also consider techniques to get the most out of reading dense textbook material. Some helpful strategies include periodically summarizing what they read, either aloud or by writing a summary. Taking notes while reading and color highlighting important information are other strategies that can be used to increase retention of material. To wrap up this section, note that the common thread among these study techniques is increased engagement with the material. Whether students choose to make flashcards, study guides or diagrams, they are engaging with the material in an active way. Active engagement with material increases retention of material. This can be contrasted to passive studying – reading and rereading the text with no effort to engage with the material in a new way. Generally, students are quick to recognize and agree that active engagement with class material results in improved knowledge of the material and as a result, better exam grades. The key to effective studying is active engagement with the material. The exact method of engagement can vary. Encourage students to pick one or two techniques to try as between-session practice and remind them that their mentors will be checking on their use of these techniques.

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Adaptive Thinking Skills Start the Adaptive Thinking Section Provide a brief summary of last week’s topic (using adaptive thinking to manage unhelpful thoughts associated with academics and ADHD) and introduce the new topic for this session: using adaptive thinking to cope with negative emotions and impulsive urges. As usual, check on use of adaptive thinking techniques and provide praise and guidance. At this point, students should demonstrate improvements in terms of recognizing maladaptive thinking patterns. However, they may continue to struggle with challenging maladaptive thoughts, as this skill often takes more time and practice to master. If students report difficulties with challenging thoughts, normalize this experience and encourage them to continue working on this skill. Coping with Negative Emotions and Maladaptive Behavior This focus for this session is a discussion of how maladaptive thought patterns may contribute to negative, upsetting emotions, thus increasing risk for some of the conditions discussed in the ADHD Knowledge section (depression, anxiety, emotion regulation difficulties). Refer students to Handout 5.4 to guide this discussion. Provide examples of situations and thoughts that might lead to upsetting emotions. For instance, a student who ends a relationship with a significant other may have thoughts such as “My relationships never last. No one can put up with me for very long. I’ll never have a lasting relationship.” These thoughts are likely associated with an assortment of emotions, such as sadness, fear, disappointment, anxiety, frustration, resentment and so forth. Encourage discussion of other common situations that could lead to negative emotions and ask students to generate ideas about the types of thoughts that may come up in these situations. Some helpful examples include failing a class, getting into a fight with a family member, friend, or roommate, dealing with financial difficulties, and so forth. Next, engage students in a discussion of how thoughts may influence risk-taking behavior. Due to the sensitive nature of this topic, start this discussion by providing a hypothetical example and encouraging group discussion, rather than by asking group members to share their experiences. Ask the students, for example, to name some maladaptive thoughts that may occur when someone considers driving home after having too much to drink. It is helpful to frame this discussion by directing students to identify thoughts that increase the likelihood of risky behavior (driving home) and thoughts that decrease the likelihood of risky behavior. For example, thoughts such as “I’ve only had a few drinks, and I feel fine” and “I only live 10 minutes away” may increase the likelihood of driving home, while thoughts such as “Getting a ticket for driving while intoxicated would cause me a lot of problems” and “I may unintentionally get into an accident and harm myself or someone else” may decrease the likelihood of driving home.

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Next, have students consider how to use adaptive thinking skills to cope with the types of thoughts identified above. Group leaders can choose to focus on challenging thoughts associated with negative emotions, or thoughts associated with risk-­ taking behavior. If time permits, it is helpful to discuss both. When guiding students to challenge these thoughts, focus more on whether thoughts are helpful, as opposed to focusing on the accuracy of the thoughts. For instance, for a student considering driving home after drinking, the thought “I only live 10 minutes away” is accurate, but not helpful. Similarly, for students coping with tough situations such as break-ups, failing classes, or financial difficulties, thoughts such as “this is so hard” or “this feels terrible” are accurate, but often not helpful. Encourage students to consider whether thoughts are increasing their distress – are these thoughts making an already tough situation feel worse? If so, students should challenge these thoughts. Remind students again that the goal of adaptive thinking is not to ignore reality, but to replace maladaptive thinking with more balanced, realistic and helpful thoughts. Assign Between-Session Practice Encourage students to continue using the column analysis and questions to help challenge maladaptive and unhelpful thoughts as between-session practice. As in previous sessions, remind them that their mentors will be checking on their use of these techniques as well.

Ending Group Session To end the session, provide a quick summary of between-session practice assignments. Over the upcoming week, students will try to implement at least one study technique and will continue to use adaptive thinking techniques. Remind students once more that the goal is progress, not perfection.

Week 5 – Mentoring Check-In Get a brief update on how the mentee has been doing since the last mentoring session. When possible, follow up on a topic that you noted at the end of the previous session that was important to the mentee, but may not naturally come up during the regular agenda. Remember that more personalized check-ins might lead to agenda-­ relevant conversation.

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Mentor: “Hi Jordan, good to see you! How was that Psychology exam? I know you were concerned about it and had a plan of attack when we last met.” Mentee: “I’m glad it is behind me. I think I did okay, actually! Following the study plan we came up with helped. I don’t know my grade yet because I haven’t gotten it back. In the past, on big tests like that I’d basically have a panic attack before or during the exams. My mind would totally go blank and even if I had studied, I would forget everything.” Mentor: “Do you think preparing in a different way made you feel less anxious going into this test?” Mentee: “Definitely! I felt more confident and because I studied small amounts of information over a longer period rather than  all in one night, I felt like even if I got nervous, I wouldn’t forget it.” Mentor: “That’s great to hear! A little bit of anxiety before a test can help motivative you to study, but too much anxiety can be debilitating. As you heard in group this week, anxiety, including test anxiety and other problematic thoughts and feelings are common in people who have ADHD.  Let’s remember this example when we talk more about that in a few minutes.”

Collaborative Agenda Setting Briefly outline the content for this session, including a check on between-session practice, reviewing material from the group session, and any topics from the check­in that are pertinent to the needs of the mentee.

Review Between-Session Practice Follow up briefly on any practice goals that were discussed the prior week. Specific items to monitor include: • Did the mentee connect with any support services on campus? • Did the mentee adjust their current note taking strategies? • Did the mentee look up course offerings for next semester and create schedule options that will help them get the most from their classes? • Did the mentee practice the 6-column adaptive thinking log? • Did the mentee bring handouts from group to this mentoring session? • Also follow up on anything else the mentee chose to practice between sessions. Give enthusiastic and positive feedback for any follow through on these tasks. Be neutral and do not over-respond to missed practice. However, the mentee may be asked to follow up in the next week on important items. Be sure to remind them of these items at wrap-up.

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Discuss Information Presented in Group ADHD Knowledge Discuss the ways in which ADHD may lead to other mental health concerns, such as depression, anxiety, and substance abuse. Specifically, emphasize the fact that over time the symptoms of ADHD may create frustration and self-doubt, which can increase risk for depression and anxiety. Call to the attention of the mentee the way in which impulsive tendencies can increase risk for substance use. Review any questions that the mentee may have. Also engage the mentee in further discussion by asking: • Have you had problems with low self-esteem, mood, worry, frustration, or anger along with your ADHD? • Which came first, your ADHD or these other problems? How do you think they relate to one another? • What do you think has helped protect you from some of the additional difficulties that individuals with ADHD can have? What has protected you? Tip Remind the mentee that having ADHD does not automatically lead to clinical depression, anxiety, anger, etc. Discuss the need for being aware of this possibility and the importance of using adaptive thinking skills to reduce the risk of experiencing emotional problems.

Mentee: “Just hearing about all the things that people with ADHD have in addition to ADHD was depressing… If I wasn’t depressed before, I am now, ha!” Mentor: “I can see what you mean. The other conditions may not be fun to hear about – but knowing about them can be helpful. First, it you have experienced one or more of these, it helps to know you aren’t alone in your experience. Second, if you don’t have one of these other conditions, knowing about them can help prepare you for that possibility. Knowledge can help improve your response, which can help reduce the severity or the duration of symptoms.” Mentee: “Yeah, I can see that. So, I suppose I should feel good about it.” Mentor: “Well, one way to feel is resilient! Equipping yourself with information is very powerful. So, now that you know what the odds are for having emotional problems, what are some of the things that may have helped you avoid such difficulties?” In addition to emotional distress, also discuss risky behaviors that have been associated with having ADHD. Highlight how behavioral inhibition and impulsivity

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may set the stage for risky behavior to occur. The following questions can help prompt this discussion: • Have you ever noticed that having ADHD makes you do things without thinking them all the way through? Or makes you do things that are risky? • Some students with ADHD find that they use substances more, or engage more often in risky sexual behavior Have any of these things been problematic for you? • If not, what has been helpful to you in refraining from risky activities? Behavioral Strategies Review at least two of the following strategies for studying effectively. Students may wish to explore creating and sticking to a study schedule, developing a great study space, improving their attention span with the distractibility delay, or other general studying tips. Allow the mentee to indicate which areas are most important to them to discuss. Creating and Sticking to a Study Schedule  Discuss how the mentee currently studies, including how often and when they study. Consider asking the following questions to start this discussion: • How do you use your planner to create a study schedule? • How far in advance do you usually start studying? How has that been working for you? For many mentees, creating a study schedule is an entirely new concept that they have never done before, especially to the extent of entering it into their planner. Discuss the benefits of scheduling a regular study time to review course material each week, which may limit the need for cramming before big tests. Also, reinforce that studying on a regular basis leads to longer-lasting retention of the knowledge. Address any barriers that may keep the mentee from sticking to the study schedule and remind them of the importance of rewarding themselves for doing this successfully. Help the mentee find meaningful rewards that they can use to reinforce their behavior. Creating external reinforcement can help when what they are doing (e.g., studying) is not naturally holding their attention. Mentor: “What can you do to reward yourself for good studying behavior?” Mentee: “I could meet friends at the café or watch an episode of this show I’m really into right now.” Mentor: “Ok, those are good! Would either of those options potentially derail your study flow if you still have quite a bit left to do?” Mentee: “Definitely – either of them could become a “time suck” where I end up hanging out with my friends all night or the next thing I know, I’ve binge watched 6 episodes.”

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Mentor: “Consider making a list of both brief and long rewards. During a busy time, having a few quick rewards can help keep you motivated without becoming a time suck. For example, you could go play your guitar, play with your dog, or text a friend – especially a friend who wants you to do well and is likely to be on board with encouraging you to “keep up the good work!” Mentee: “Yes, social media, YouTube, and video gaming could all be on my list. But I would need to set a timer for those!” Mentor: “Good thinking. Also, a longer binge tv-watching session could be a bigger reward for completing a goal, like after studying for and taking a test or finishing a paper.” Developing a Great Study Space  Discuss strategies for creating a study space that helps mentees study effectively. Remember, everyone has individual preferences about level of background noise, studying at a library or coffee shop, and so forth. Encourage mentees to identify what factors are important for them. In the course of this conversation, discuss common distractions with the mentee. What typically distracts them when they are studying? Common distractions include clutter in their room or on their desk, cell phones, people around them talking, etc. Mentees often benefit from limiting both social and sensory distractions. This often includes closing out all internet tabs other than the one they are using to study, silencing or turning off phones (or even placing it across the room), and choosing a quiet place to study (e.g., library). Point out small distractions that students may not have noticed before, such as getting distracted looking out the window, choosing to clean their room before studying, or talking with friends in their study group. Lastly, remind mentees that it is important to have all course materials with them before they start studying so that they don’t need to leave to go find them, which may result in stumbling across more distractions. This connects well with previous session strategies about keeping class materials organized! Here are some questions to guide discussion: • Where do you usually study? How is that working for you? • What things usually distract you in your study space? • Do you have all the needed supplies for studying? Mentee: “This one is easy – my phone is my biggest distraction!” Mentor: “Ok. What can you do?” Mentee: “I can silence it and put it away in my bag.” Mentor: “Ok, good. Is that realistic?” Mentee: “Well, it will be hard. I’ll feel like I’m missing out on something.” Mentor: “If you feel that way, what can you tell yourself?” Mentee: “I know that feeling will pass. There won’t be much important happening and I can hear about it later.”

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Mentor: “Right, that kind of delayed gratification is hard! But it’s also key trait for being successful. It sounds like this one is highly reinforcing and so would be a great choice for one of the rewards we discussed earlier.” Mentee: “I like that!” Improving Attention Span through Distractibility Delay  For most mentees this is an entirely new concept, but one they enjoy very much! The distractibility delay allows individuals to measure their attention span, which may help them schedule tasks in blocks of time that aligns with their attention span and work toward improving their attention over time. Remember to discuss (a) how to measure attention, (b) how to schedule study time and other tasks to fit with this attention span, (c) how to use a notebook to limit distractions that pop into one’s head, and (d) how monitoring attention over time may help mentees lengthen their attention spans. Here are some questions to initiate the conversation: • How long can you pay attention before getting distracted? Does this depend on what activity you are doing (e.g. listening to a lecture, studying, writing a paper, reading, etc.)? • How do you feel about using a distractibility delay technique to help you focus better? General Studying Tips  Address any general aspects of studying effectively that the mentee may wish to discuss. For example, discuss the importance of knowing what information will be on the exam, address types of studying that are most difficult for the mentee (e.g., textbook reading), and discuss strategies that may be especially relevant to the mentee. Many mentees struggle to read and retain material in their textbooks. The overall goal is to encourage mentees to consider ways to increase their engagement with the material. To do this, mentees can use any number of techniques, such as highlighting, creating flashcards, or taking notes while reading. Discuss what techniques mentees have tried before and any techniques they may be willing to try. Help mentees troubleshoot barriers to using these techniques. Mentee: “I try to highlight as I go, but I still feel like I get to the bottom of the page and have no idea what I just read.” Mentor: “This is really common. It is difficult to read and retain information that may be dense. Using an engaging technique such as making flash cards or taking notes while reading will help you actually store the information in your brain.” Mentee: “It just seems so time consuming.” Mentor: “I can see that. Think of it this way – is it possible that reading once in a more engaged way takes the same or even less time than if you reread multiple times?” Mentee: (laughs) “Yes! And its wasted time because I usually still don’t remember it. I’m just not sure I will do this.”

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Mentor: “Are you open to experimenting with just one technique this week? What if this week you just tried to write down some of the major points after reading a chapter in your textbook? If you find that works, we can experiment the following week with taking more detailed notes.” Adaptive Thinking If the mentee completed their practice thought log, look over the thought record and provide any suggestions if needed. Did they identify realistic situations, thoughts and feelings? If the mentee did not complete the record, practice once in session. Try to use a thought that the mentee has expressed in session. For example, during the discussion about ADHD and dealing with emotions or when discussing study strategies, there is a good chance they made a maladaptive statement such as: • Great… so if I have ADHD, I’m basically doomed. • Not being on my phone while studying is going to kill me. Help the mentee challenge the initial thought and replace it with a more realistic, adaptive thought. Generate two new examples related to this session’s content. One example should relate to how adaptive thinking can help manage difficult emotions, such as depression, anxiety, or anger. The other should focus on how adaptive thinking can help the mentee refrain from engaging in potentially harmful behaviors, such as risky sex, excessive drinking, and driving while intoxicated. Questions to help guide this discussion include: • How might maladaptive thinking lead to doing risky things? • What adaptive thoughts could be helpful in helping you refrain from risky behavior? Students may have trouble generating personal examples or may feel uncomfortable discussing risky behaviors more generally. It can be helpful to work through one of the following hypothetical examples to provide the mentee with additional practice. This allows them to practice adaptive thinking skills without disclosing information about their own private behavior. • You go to a party with lots of drinking the night before an exam. You think to yourself, “You only live once!” • You are leaving a party and think to yourself, “I don’t have the time or money to deal with getting a ride. I need to drive home.”

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Ending Mentoring Session Check in about goals as needed. Is there anything that has been accomplished or needs to be modified? Any miscellaneous topics of discussion? This is a good place to address any topics that did not fit into the prior discussion. Finally, review and clarify as needed the details of what the mentee will do between now and the next mentoring session, including: • Bring all group materials to the next mentoring session • Use their planner to block out study time for 1  week and follow their new schedule. • Adjust their current study space and study strategies as needed. • Practice the 6-column system. Confirm the date and time of the next appointment. Ask the mentee to write down/ set reminder and model similar behavior with your own planner/calendar.

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Week 5 – Group Agenda

Week 5 – Group Agenda

Beginning Group Session ADHD Knowledge • Present and discuss information about increased risk for depression, anxiety, emotion regulation issues, low self-esteem and substance use • Discuss and identify various protective factors

Behavioral Strategies • General discussion of importance of effective studying • Use of a study schedule • Creating a study space • Improving attention span using distractibility delay • Other study tips

Adaptive Thinking Skills • Group discussion of relationship between maladaptive thinking and depression, anxiety, and anger/frustration • Group discussion of relationship between maladaptive thinking and risky behavior • Work through examples of how to challenge maladaptive thinking patterns associated with depression, anxiety, anger/frustration, and risky behavior

 nding Group Session E • Address any questions that may arise • Review the details of completing the between-session practice assignments

Handouts • 5.1 Week 5 Group Cover Sheet • 5.2 ADHD, Emotional Functioning, and Maladaptive Behaviors • 5.3 Studying Effectively • 5.4 Using Adaptive Thinking to Cope with Emotions and Maladaptive Behaviors

Handout 5.1

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ACCESS Accessing Campus Connections and Empowering Student Success



Week 5 – Group Handouts • 5.1 Week 5 Group Cover Sheet • 5.2 ADHD, Emotional Functioning, and Maladaptive Behaviors • 5.3 Studying Effectively • 5.4 Using Adaptive Thinking to Cope with Emotions and Maladaptive Behaviors

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Handout 5.2

ADHD, Emotional Functioning, and Maladaptive Behaviors

Research on college students with ADHD suggests increased risk for: • Emotion regulation issues • Low self-esteem • Depression, anxiety, and other psychological distress • Increased risk for suicidal thoughts and attempts • Substance abuse –– More likely to smoke cigarettes –– More problems associated with alcohol/drug use, although rates of use do not differ significantly • Risky sexual behavior –– Increased risk of unintended pregnancy –– Increased risk of STDs

Protective Factors • Protective factors are strengths, skills, resources, supports, or coping strategies • Help you deal more effectively with stress • Lower your risk of negative outcomes

Handout 5.3



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Studying Effectively

Creating and Sticking to a Study Schedule –– Create a study schedule; put your schedule in your planner –– Multiple short study sessions are more effective than single long sessions (“cramming”) –– Consider scheduling regular study periods for each class –– Reward yourself for following your study schedule

Developing a Great Study Space • Limit social distractions –– Hang a “do not disturb” sign –– Turn off your phone ringer; avoid looking at email –– Tell your friends/roommates/significant other when you will be studying • Limit sensory distractions –– Choose a quiet location/use ear plugs –– Do not study by a window or in a high traffic area –– Have all materials at hand

Improving Your Attention Span Through Distractibility Delay • Measure how long you can pay attention • Break down study time into chunks that fit this attention span • Have a notebook nearby during your “focus” period; write down distracting thoughts instead of acting on them • After the focus period ends, review the thoughts you wrote down and determine if anything needs your immediate attention • Gradually increase the length of your focus period

Studying Tips • Know what information you are responsible for learning –– Increase retention of dense reading material –– Skim text before reading and develop questions –– While reading, look for answers to your questions • Summarize the reading after each section (verbally and/or in writing) • Use study techniques that increase your engagement with the material –– Create diagrams –– Test yourself –– Create flashcards • Develop mnemonics • Set an alarm for halfway through a study session; use as a cue to ask yourself if you are still on-task

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Using Adaptive Thinking to Cope with Emotions and Maladaptive Behaviors What thoughts make it more likely that you will engage in maladaptive behaviors? What thoughts help you avoid these behaviors? • “I’m never going to get better” • “Everyone drinks a lot in college” Types of Maladaptive Thinking • • • • •

• All-or-None Thinking • Jumping to Conclusions –– Mind Reading –– Fortune Telling • Overgeneralization • Catastrophizing

“Should” Statements Mental Filtering Disqualifying the Positive Labeling Personalization

Questions to Help You Challenge Automatic Thoughts (1) What is the evidence that the automatic thought is true? What is the evidence that the automatic thought is not true? (2) Is there an alternative explanation? (3) What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome? (4) What’s the effect of believing the automatic thought? What could be the effect of changing my thinking? (5) If a friend was in the situation and had this thought, what would I tell them?

Situation

Automatic thoughts

Feelings/ Behaviors

Alternative thoughts

Degree of belief in alternative thoughts

New feelings/ Behaviors

Week 5 – Mentoring Agenda

Week 5 – Mentoring Agenda Check-In Collaborative Agenda Setting Review Between-Session Practice Discuss Information Presented in Group Ending Mentoring Session Handouts - none

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Chapter 8

Active Phase – Week 6

In the Week 6 group session, the knowledge piece focuses on a description of medications for ADHD that is intended to help students become more informed about this form of treatment. Additionally, test-taking strategies and techniques for managing long-term projects and papers are presented. Group participants also receive guidance in using adaptive thinking skills to increase their adherence to ADHD treatments. Mentors review and refine student efforts to create a study schedule, to adjust their study space, and to practice their adaptive thinking skills as applied to emotional distress/risky behavior. Mentors also clarify any questions about the new information presented in group and assist mentees in tailoring strategies for test-­taking and long-term projects to their individual needs. Similar assistance is provided with respect to using adaptive thinking skills to increase adherence to treatment.

Week 6 – Group Beginning Group Session Again, check for general questions related to the ACCESS program and defer questions requiring longer responses to the mentor.

ADHD Knowledge Medication for ADHD The topic for this session is the use of medication to treat ADHD. Because this is a very popular topic for students that can engage them in extensive conversation, it is often necessary to set a specific time limit for this discussion to ensure that the other agenda items are addressed. © Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_8

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For non-medical staff serving as group leaders, it is also necessary to disclose the limitations of your professional boundaries, offering a statement such as “I am not a medical doctor and cannot provide medical advice. The information we will discuss is based on published research findings and is not intended to be medical advice.” One way to start the discussion is by asking group members to share their experiences with medications they have taken for ADHD. In general, students enjoy sharing their experiences with different medications and often have strong opinions and numerous questions. Thus, it is important to be informed as much as possible about ADHD medications to conduct this session. An excellent way to facilitate further discussion of this topic is by distributing a printed version of an up-to-date chart of medications for ADHD that is available online through the National Resource Center for ADHD (https://chadd.org/for-parents/medications-used-in-the-treatment-of-adhd/). This chart provides information about various stimulant medications used to treat ADHD, including generic and brand names for each, duration of each, dosage options and common side effects. Rationale The goal of the discussion is to provide accurate and detailed evidence-based information about ADHD medications so that students feel empowered to make medication informed decisions in collaboration with their prescribing health care professional. Whether or not students choose to take medication, they can benefit from learning about what medications are available, the pros and cons of each, how medication works, realistic expectations for medications, and how to optimize use of medication. This knowledge, combined with their knowledge of themselves and their needs, will allow them to make well-informed decisions about their own treatment. Medication Basics Begin this discussion by emphasizing that there is extensive research support for the use of medication to treat ADHD, especially stimulant medication. Inform the group that stimulant medication has been shown to be effective for at least 80–90% of individuals who take it. For this reason, stimulant medications are often the first type of medication a health care professional will recommend. Next, provide a very basic explanation for the way that stimulant medications, which are the most frequently prescribed medications for ADHD, work. Note that stimulants increase the availability of the neurotransmitter, dopamine, in that area of the brain that is involved in the process of behavioral inhibition. With more dopamine available, the behavioral inhibition area of the brain is better able to function, improving an individual’s capacity to pause before acting and to better focus attention.

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When ingested orally, stimulant medications are fast acting and begin to work within 30 minutes. Their therapeutic effectiveness also wears off relatively quickly, lasting for as little as 4  hours (short-acting preparation) and up to 10–12  hours (long-acting preparations). Also point out that, unlike many other medications, stimulant medications do not need to build up in the blood stream to be effective. Because they are fast acting, they can, if need be, be stopped for brief periods of time (e.g., 1 day, a weekend) and resumed without difficulty. In addition to addressing the distinction between short- and long-acting stimulant medications, be sure to mention many of the other ways in which stimulant medications can differ. Direct the group’s attention to the National Resource Center medication chart to facilitate this discussion, For example, alert the group to the fact that there are two general classes of stimulant medications – methylphenidate products (e.g., Ritalin) and amphetamine salt products (e.g., Adderall). Other ways in which stimulant medications can differ include their mode of delivery (pill vs. patch) and their different modes of release (i.e., bimodal vs. continuous). The general point to be made is for students to understand that there are lots of stimulant medication options available to them, which they should discuss with their prescribing health care professional to determine which one might be best suited for them. As part of this discussion, also emphasize that stimulant medications are most effective when taken on a schedule recommended by prescribers. For a variety of reasons, many college students find it difficult to stick to a medication regimen. For example, many students report changing bedtimes and wake times throughout the week. As a result, they do not take their medication at the same time each day. Further, students may have irregular class schedules, making it difficult to match their schedules to their medication regimen. For example, a student who has a class from 4:00 to 5:30 on Tuesdays and Thursdays may take medication later in the day on those days so that they are able to better focus during class. Unfortunately, this may result in more difficulty sleeping on those evenings. Ideally, students should discuss medication options with their prescribing physician and together identify a medication that best meets their individual medical, behavioral, and lifestyle needs. Adjusting Medications and Coping with Side Effects Individuals with ADHD often require adjustments to their medication choice and dosage before finding their optimal medication regimen. Normalizing this experience for students can help prevent frustration caused by trying multiple medications and premature discontinuation of medication. Review the most common side effects of stimulant medications with students, which include sleep problems and appetite suppression. Identify ways to manage these side effects, such as taking medication in the morning so that its effects will wear off well before bedtime. Another strategy is eating a healthy, filling breakfast in the morning prior to taking medication so that appetite suppression does not

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interfere with eating a meal prior to starting their day. Additional tips might include setting reminders on a smart phone to eat snacks or eat lunch or bringing healthy snacks to campus so that students have access to healthy food even if they do not eat a full meal during the day. Students may spontaneously volunteer to disclose their own personal experience with potential side effects. Should this occur, acknowledge the importance of their observation while at the same time, recommending that they share their concerns about potential side effects with their prescribing health care professional. Realistic Goals for Change Finally, discuss realistic expectations for therapeutic change with students. In other words, it is reasonable to expect medications to increase attention span. In contrast, medications will not make a student, who dislikes math, enjoy doing their math assignment. Similarly, medications do not in and of themselves impact motivation. A student who feels no motivation at all to complete academic work is not more likely to complete their work when taking medication. It is the case, however, that medications allow students to focus longer, which can lead to feelings of accomplishment and confidence, thereby improving motivation. Hence, many students experience increased motivation after starting an effective medication regimen. The topic of medication often brings up a discussion of the maladaptive belief that medication is “cheating” or makes things “easy” for students. College students with ADHD frequently report some degree of belief in this thought. Learning about the mechanism of action for medication can be a helpful way to correct this faulty belief. Accordingly, emphasize that medication provides a correction to brain functioning, helping the brains of individuals with ADHD function more like the brains of those without ADHD.  Furthermore, point out that although medication helps improve focus, it is still necessary to focus on the right thing. In other words, while medication can treat the symptoms of ADHD, students are the ones who make the decision to focus on schoolwork, chores, or other important activities.

Behavioral Strategies Start the Behavioral Strategies Section Check on the group’s use of strategies for studying effectively over the past week. Help them problem-solve ways to overcome barriers and provide support and encouragement as needed. Next, introduce the behavioral strategies topic for the current session: test-taking tips and managing papers and long-term projects.

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Taking Exams: General Test-Taking Tips To engage students, ask them to read over the test-taking tips listed on Handout 6.2 and then discuss ones they already use or find helpful. Alternately, ask them to identify strategies they have not heard of or tried before. This allows group leaders to avoid lecturing students by listing strategies one by one. As part of this discussion, be sure to highlight the importance of several test-taking tips, including: reading directions carefully, answering easier questions first and returning to harder questions later, and reviewing answers before turning the exam in for grading. Strategies for True/False Questions Again, direct students’ attention to the handouts while reviewing this topic. Emphasize that “for a statement to be true, all parts of the statement must be true” and “if any part of a statement is false, the entire statement is false.” Also point out that qualifying words (e.g., often, probably, might, seldom, sometimes) tend to make a statement true, whereas absolute words (e.g., always, never, all, everyone) tend to make a statement false. Strategies for Multiple Choice Questions Begin by asking the group how they approach multiple choice questions. In addition to whatever approach they might mention, be sure to address the following guidelines: reading the question carefully and circling tricky words and phrases such as “except for;” developing an answer to the question prior to reading the answer choices; reading all the answer choices before selecting one; crossing off the answer choices known to be incorrect, and; using information from questions with known answers to help answer other questions. Strategies for Essay Questions Discuss strategies for answering essay questions including: reading the prompt or directions carefully, organizing thoughts before beginning the writing process, paraphrasing the original prompt or question to create an introductory statement, outlining major points that need to be covered, and budgeting time to address each essay question before beginning the writing process. Managing Papers and Long-Term Projects Begin by encouraging students to think back to the discussion of procrastination in Week 3, since procrastination is often the biggest barrier that students identify in completing long-term projects and papers. As a reminder, ask students to identify

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their own reasons for procrastination. This in turn will help guide students in choosing strategies to help manage this procrastination. Throughout the following discussion, refer students to Handout 6.3 for a list of strategies to manage long-term projects and papers. Break it Down Students frequently report that they put off working on a project because it feels overwhelming, or they describe “not knowing where to start.” To address these barriers, encourage students to break down larger projects into smaller steps, which can be listed on a task list or written in a planner with reasonable deadlines for each step. Often, these smaller steps feel less overwhelming. In addition, by breaking tasks down into smaller steps, students can visually monitor their progress toward completing a project, which can serve as motivation to continue working. A related strategy involves setting “time goals” to work on larger projects. For example, instead of setting a goal to “write two pages” of a paper, students can set a goal of working on the paper for 30 minutes, or whatever amount of time they previously determined was within their typical focus period. Some students may be less likely to avoid working on a large project when they set clearly defined time goals. Other Tips Encourage students to consider rewarding themselves for completing smaller steps of their project. For instance, they can plan a fun activity to do after completing their target goal or buy themselves a snack or treat. Specific tips for writing papers include reading papers aloud to catch typos, grammatical errors or awkward phrasing; getting help from the writing center or from professors; and using voice recognition software. Dictation software may be especially helpful for students who find it difficult to express themselves through writing, as it allows them to verbally express their ideas to be converted into text. If students report “writer’s block,” encourage them to try starting the process by freely writing their ideas and thoughts without initially worrying about editing or punctuating. This can help jump start the writing process, and they can subsequently go back and edit their writing. Finally, remind students of the importance of using adaptive thinking strategies to manage unhelpful thoughts associated with procrastination on large projects. Some common thoughts that students might report include, “This is too much for me,” “I can’t do this,” “This will never get finished,” or “I never start papers ahead of time.” Students may also report neutral or overly positive thoughts such as “I work better at the last minute” or “I’ll just do it later.” Remember to help students assess whether these thoughts are helping or hurting them. Adaptive thinking strategies can be used to manage these types of thoughts as well.

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Assign Between-Session Practice Conclude the behavioral strategies section by asking students to identify a tip or technique they would be willing to attempt over the next week. Remind them that their mentors will check on their progress.

Adaptive Thinking Start the Adaptive Thinking Section After providing a brief review of using adaptive thinking to cope with negative emotions and harmful temptations, introduce the new topic for today’s group: using adaptive thinking to stick with treatment for ADHD.  Conduct a brief check-in regarding students use of adaptive thinking outside of session. Troubleshoot difficulties with challenging thoughts and encourage students to continue using adaptive thinking outside of session to develop greater mastery. Using Adaptative Thinking to Stick with Treatment Direct students’ attention to Handout 6.4. Initiate a group discussion of ways in which ADHD symptoms and associated behaviors may interfere with treatment (e.g., medication, counseling, academic accommodations). Some examples include forgetting to take medication or to refill medication, forgetting appointments or being late for appointments, or impulsively stopping medication or therapy. Students with ADHD are often tempted to impulsively switch to new treatment strategies. For example, students may suddenly report they would like to switch from a paper planner to a new online scheduling system after using a paper planner for a few weeks. Help students assess whether such a change is a smart decision, or whether this change reflects an impulsive need for something new and different, which is inherently more exciting than maintaining a previous strategy. Although the decision ultimately lies with the student, help the students recognize their underlying motivation and the potential pros and cons of their decision. Next, encourage group members to identify some maladaptive thoughts that might interfere with sticking with treatment. Possible examples could include “I don’t have time for this” or “I’ve tried this treatment strategy and it didn’t work” or “I’m never going to be able to change.” Use a column analysis approach to help students work through the process of challenging these sorts of maladaptive thoughts. Remind them to identify the maladaptive thinking pattern reflected in these thoughts and guide them in using the suggested questions to generate more realistic alternative thoughts. Students sometimes find it helpful to consider how their future selves might appreciate their progress in treatment. For instance, ask students to consider how

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they might feel if they completed treatment, or if they achieved a personal goal. Students generally predict that they will feel confident, accomplished, and proud. Helping them tap into these anticipated future emotions can increase their commitment to treatment. This is particularly important for students with ADHD, who often have trouble accomplishing long-term goals. A related strategy is helping students identify times in the past when they did not follow-through on a goal and perhaps experienced negative consequences as a result. Reflecting on these experiences can also be an important source of motivation for students. Assign Between-Session Practice Encourage students to continue using the adaptive thinking column analysis and questions to help challenge and replace maladaptive thoughts as between-session practice. As in previous sessions, remind them that their mentors will be checking on their use of these techniques as well.

Ending Group Session End the session by summarizing the between-session practice assignments for this session, which include trying out at least one of the behavioral strategies for taking exams, managing papers and long-term projects. Students should also continue to practice adaptive thinking skills.

Week 6 – Mentoring Check-In Get an update on how the mentee has been doing since the last mentoring session. When relevant, follow up on a topic that you noted at the end of the previous session that was important to the mentee, but may not naturally come up during the regular agenda.

Collaborative Agenda Setting Briefly outline the content of the session, including a check on the between-session practice assignment and reviewing material from the group session. In the group session, students learned about medications used to treat ADHD, strategies for taking exams and managing papers and long-term class projects, and how adaptive thinking can help individuals stick with treatment. If topics from the check-in seem

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to generate more conversation pertinent to the needs of the mentee, suggest adding them to the agenda.

Review Between-Session Practice Follow up briefly on any To-Do or practice items that were discussed the prior week. For this session, be sure to check the following items: • • • • •

Did the mentee use their planner to create a study schedule for the week? Did the mentee identify and make any adjustments to their study space? Did the mentee practice the 6-column adaptive thinking log? Did the mentee bring handouts from group to this mentoring session? Be sure to follow up on anything else the mentee chose to practice between sessions.

Give enthusiastic and positive feedback for any follow through on these tasks. Be neutral and do not over-respond to missed practice; however, ask the mentee to follow up in the next week on important items. Be sure to remind them of these items at wrap-up.

Discuss Information Presented in Group ADHD Knowledge A good way to kick off this discussion about ADHD medications is to inquire about the mentee’s personal experience with this type of treatment. Questions to guide this discussion include: • Have you ever taken medication for your ADHD? • Have you ever wondered why it is even necessary to take ADHD medications? • Are you satisfied with the ADHD medication that you are currently taking? This topic may elicit distorted thinking (e.g., “I shouldn’t have to take mediation.”) or erroneous thinking (e.g., “ADHD medication is bad.”). Be prepared to provide evidence-based information and dispel common myths about ADHD medication. Mentee: “I used to take medication for ADHD, but I just didn’t feel like ‘me’ when I was on it. It seemed like my parents’ little helper… not mine.” Mentor: “That is a common experience among teens with ADHD who were diagnosed in childhood. The difficulties that resulted in an ADHD diagnosis were first recognized by adults and likely not by you.” Mentee: “Yeah, I think by the time I was a teenager, I was ‘over it.’ I didn’t want to deal with ADHD anymore. Now I can see how my symptoms are affecting me. I’m just not sure I want to take a pill every day.”

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Have a conversation about using medication to treat ADHD during college. Many college students have varied schedules and may not need ADHD medications for the same hours each day. Talk with the mentee about their needs and discuss how to be an advocate for themselves when meeting with prescribing health care professionals. Many mentees find it useful to write down information and questions to take to their prescriber to help them remember to discuss these topics. This information may include their history with ADHD medications (e.g., what they have taken, dosages, what they liked/disliked), their needs for ADHD medications, questions about side effects, etc. Mentor: “This is the advantage of being an adult. You are now in the driver’s seat and can use information as well as your self-awareness to work with your doctor to find the best fit. You can give your doctor feedback about what your needs are.” Mentee: “That’s true. I don’t remember having much input. My mom would talk and then I’d end up getting whatever she and the doctor came up with. I remember it lasted from about breakfast until the afternoon.” Mentor: “Good observation. Your schedule in college is probably different than it was in your earlier school years. Some college students prefer short-acting medication that they can use for tasks and activities that require more intense concentration and use behavior strategies the rest of the time. Others use a combination of short- and long-acting to meet a variety of needs.” Mentee: “That’s pretty cool. It makes sense. I think I’m ready to try it again. Which medication do you think I should take?” Mentor: “That’s a great question to ask your health care professional. Let’s talk about some of your priorities when it comes to medication. We can get some ideas about what’s out there from this list that compares the different types available. You can share your priorities and medication preferences when you talk to your doctor.”

Tip Know what options are available to receive a prescription for ADHD on campus and in the community. What documentation is needed to receive ADHD medications on campus? Will the mentee need to get an updated evaluation? Be prepared to walk mentees through required steps.

Behavioral Strategies Taking Exams  Discuss the mentee’s experiences with exams and provide general test-taking tips. Determine what aspects of taking exams are most difficult for the mentee and discuss individualized strategies that may be relevant to the mentee. Discuss different strategies for different types of exam questions, including true/

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false, multiple-choice, and short answer or essay questions. Also address general test-taking hints, including the pros and cons of procrastinating and studying at the last minute (i.e., cramming). To facilitate this discussion, consider asking: • What types of tests do you generally take in your classes? • What types of exams or questions do you perform best on? Which are hardest for you? • What are some things you do the day before taking a test? The morning of? • What are things you can do when sitting down to begin taking a test?

Tip Know what accommodations are available on campus, such as extended time on exams and private testing rooms. Many mentees are averse to using this service, so it may be useful to discuss the benefits of these services and address any maladaptive thoughts or misconceptions.

Managing Papers and Long-Term Projects  Discuss what strategies the mentee currently uses to manage the big projects that are typically due at the end of the semester. Address issues related to procrastination. Emphasize the importance of breaking down large projects into small, manageable steps. For example, if a mentee puts “final paper” on their To-Do list, they may feel overwhelmed and not know where to start on that task. Instead, if the mentee breaks this paper down into smaller steps – research paper topics, create outline, write introduction, write body, write conclusion, review and edit, and take to the writing center – it may feel easier to get started on those tasks. Help mentees estimate how long it will take to complete each task and schedule times in their planner to work on each task. Remind mentees to give themselves plenty of time to complete tasks before the due date. Questions to guide this portion of the discussion include: • What are some difficulties you have had when writing papers? • What are some strategies that seem to work well for you when writing papers? • Do you sometimes put off getting started on a task or assignment? Is it worse for some classes or tasks than others? Mentee: “Literally, every paper I ever write, whether it’s one page or fifteen pages, gets done the day before or the day its due. And sometimes not even then. I get extensions and turn them in late all the time.” Mentor: “What are you telling yourself when this happens?” Mentee: “I don’t know! I’m just in freak out mode at that point. I know I need to start sooner, but I just can’t motivate myself to get going until the deadline is imminent.” Mentor: “Well, stress or anxiety is our body’s natural signaling system telling us that we need to problem solve or choose an action. How well are you doing on your papers when you have this amount of stress?”

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Mentee: “Some of my best work has been completed at the last minute!” Mentor: “Is it really your best work?” Mentee: “Probably not. I feel like I do ok on the content. But I know I could do better. Especially because I don’t have time to edit or proofread. I make a lot of careless mistakes on grammar and spelling or my writing is jumbled.” Mentor: “And how are you feeling?” Mentee: “Irritable and super stressed. Then exhausted afterwards. I hate myself when I function like that.” Mentor: “I’m wondering if there is a way to set some earlier deadlines for yourself for completing steps of your paper. You can write them into your planner and even create some rewards for yourself for meeting those smaller deadlines. The smaller goals won’t require as much of your attention span so that may not seem as daunting.” Mentee: “Yeah, I could do that. I will probably still blow it off because I’ll know it isn’t the real deadline.” Mentor: “Would accountability help? You involve a good friend, one of your parents, or even me as an accountability partner who will be expecting an update at each deadline. Another helpful approach is to set up an appointment with the professor and plan to go over your outline or a draft of part of your paper.” Mentee: “Now that might work for me! I would feel awkward showing up with nothing, so that would help me get pieces of it done earlier. And I would get feedback and maybe actually produce what they are looking for.”

Tip Students often enjoy the “just 5 minutes” exercise to help get them started on a task that they have been avoiding. For example, a mentee may tell themselves that they just need to work on something for 5 minutes and then they can stop. Set a timer for 5 minutes and start working. Not uncommonly, mentees find that once they start working, they can keep going for much longer than 5 minutes and get a lot of work done. Help the mentee identify all remaining large tasks for the semester by creating a master To-Do list. Creating this list helps the mentee keep track of multiple tasks and responsibilities so that nothing is forgotten. Seeing the list can feel daunting and overwhelming, so remind mentees that if they had created the same list at the beginning of the semester, it would have been much longer. Encourage the mentee by reminding them of how much they have already accomplished this semester and how they can use their strategies to tackle these remaining tasks. It may also be helpful to suggest prioritizing this master To-Do list and use their planner to schedule times to work on these tasks. Be sure to make a copy of the master To-Do list for future reference.

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Adaptive Thinking If the mentee completed their practice thought log, look over the thought record and provide any suggestions if needed. If the mentee did not complete the record, practice one in session, using something mentioned by the mentee. For example, during the discussion about taking exams, the mentee may have expressed: Mentor: “When we were talking about taking exams, you mentioned how you feel anxious as soon as you get your test. Tell me about that situation.” Mentee: “Yes, even when I feel like I have studied well and I know the information, as soon as I read that first question, it’s like all the information just leaves my brain and I think I’m going to fail this exam.” Help the mentee challenge their initial thought and replace it with a more realistic alternative thought that leads to more adaptive behavior. Mentor: “Ok, so looking at the columns, we’ve identified the situation and your initial thought. Let’s go through the rest of the steps. In that moment, how do you feel?” Mentee: “Anxious. Sometimes like I’m going to have a panic attack.” Mentor: “Ok, you are now in that moment and you are going to use that feeling as a signal to take your Adaptive Thinking tool out of your mental toolbox. What’s next?” Mentee: “I’m going to stop and come up with an alternative thought that reflects a more realistic outcome. I know that is a pretty dramatic outcome based on one question.” Mentor: “Ok, good. Yes, it sounds like catastrophic thinking. So, what is your reframed thought?” Mentee: “I would tell myself:‘I have studied, I might not know this first question, but there are plenty of other questions. I probably won’t fail.’ Then I would take a deep breath and look over the whole test and start by answering something I do know.” Mentor: “Good! Now, using your adaptive thinking what’s next?” Mentee: “How much I believe the thought and how I feel now. I believe that thought about 80% and now I’m still keyed up but I’m not nearly as anxious. I’m ready to tackle the test.” Mentor: “Great – that’s the kind of energy you want for the test! Not the kind that makes your brain stop retrieving all that good information you studied!” Generate a new example related to the content of this session. The following prompts may be helpful in guiding the mentee to come up with a relevant example: • Have you noticed any thoughts that get in the way of sticking with ACCESS, your medication regimen, or other treatment services? • How might adaptive thinking skills help you manage such situations?

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If the mentee has trouble coming up with an example to use for practice, consider presenting the following hypothetical examples: • You forget to refill your stimulant medication before an upcoming exam. You think to yourself, “I’ll just wait until the exam is over, the damage is already done.” • You feel like the commitments of going to group and mentoring each week are too time-consuming. You think to yourself, “I don’t have time for this, I’ll just drop out.”

Ending Mentoring Session Check in about goals as needed. Is there anything that has been accomplished or needs to be modified? Any miscellaneous topics of discussion? This is where you can address any topics that did not fit into the prior discussion. Finally, review and clarify as needed the details of what you would like the mentee to do between now and the next mentoring session, including: • Bring all group materials to next mentoring session • If the mentee has a test coming up, try using recommended test-taking strategies. • Look at the syllabus or assignment details for one paper or project and use behavioral strategies to break it down into manageable steps on To-Do list. • Practice 6-column system to record to address at least one example of a maladaptive thinking that interferes with test-taking, completing long term projects or papers, or sticking with treatment. Confirm the date and time of next appointment. Ask the mentee to write down/set reminder and model similar behavior with your own planner/calendar.

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Week 6 – Group Agenda

Beginning Group Session ADHD Knowledge • Facilitate group discussion about experiences with medication • Present and discuss information about how medication for ADHD works, different types of ADHD medications, and medication options (e.g., immediate vs. extended release) • Present and discuss information about potential benefits and side effects

Behavioral Strategies • Present and discuss general test-taking tips and strategies • Present and discuss strategies for managing long-term projects and papers

Adaptive Thinking Skills • Facilitate group discussion of how ADHD symptoms can interfere with treatment • Facilitate group discussion of how maladaptive thinking patterns can interfere with treatment • Work through examples of challenging maladaptive thinking patterns associated with treatment for ADHD

 nding Group Session E • Address any questions that may arise • Review the details of completing the between-session practice assignments

Handouts • 6.1 Week 6 Group Cover Sheet • 6.2 Taking Exams • 6.3 Managing Papers and Long-Term Projects • 6.4 Using Adaptive Thinking to Stick with Treatment

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Handout 6.1

ACCESS Accessing Campus Connections and Empowering Student Success



Week 6 – Group Handouts • • • •

6.1 Week 6 Group Cover Sheet 6.2 Taking Exams 6.3 Managing Papers and Long-Term Projects 6.4 Using Adaptive Thinking to Stick with Treatment

Handout 6.2



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Taking Exams

General Test-taking Hints • Get a good night’s sleep and make sure to eat before the exam • Sit at the front to reduce distractions • Read all directions carefully • Do the easiest items first • Don’t leave items blank! Make a guess, do first step, write down some information • Review your exam before handing it in • Review incorrect answers once exam is graded to help prepare for next exam

Strategies for True/False Questions • For a statement to be true, ALL parts must be true • Qualifying words (often, probably, might, seldom, etc.) tend to make statement true • Absolute words (always, only, absolutely, never, etc.) tend to make statement false • Watch out for negative words/prefixes (un-, non-, mis-, etc.) that alter meaning

Strategies for Multiple-choice Questions • Circle tricky words/phrases like “except for” and “not true” • Develop an answer BEFORE reading choices, then look for the choice that best matches • Read ALL the answer choices • Cross off answer choices that are clearly incorrect • Use information from questions you know to help answer questions you don’t know

Strategies for Essay Questions • Read the directions carefully • Organize your thoughts before writing - Consider creating a brief outline • Paraphrase the original question to create an introductory statement • Budget your time carefully

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Handout 6.3

Managing Papers & Long-Term Projects

Break It Down! • Use your planner and To-Do list to manage long-term projects –– Break down project into small, manageable steps –– If a step looks overwhelming, break it down more –– Estimate how long it will take to complete each step –– Use your planner to block out chunks of time to complete each step –– It may also be helpful to create your own deadlines for each step • Getting started is often the hardest part! If you’re feeling stuck, do something towards your goal, however small • Reward yourself after you complete each step (e.g., call a friend, have a snack)

Hints for Papers • Break down writing process into smaller, more manageable steps • Start early • Take a break between writing and proofreading —it helps to return with “fresh eyes” • Read your final paper aloud to catch grammatical errors, awkward sentences, and careless mistakes –– Consider having a friend read your paper aloud • Consider getting help from on-campus resources –– Tutors/academic coaches may help with brainstorming, organizing, writing, editing –– Tutor can be external support to help meet deadlines for progress • Consider getting help from professors –– Set up meetings to discuss progress if possible –– Some may be willing to review draft (be sure to ask well in advance of the deadline) • Consider dictation software • Got writer’s block? –– Try freely writing down ideas without stopping to judge format/organization

Handout 6.4



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Using Adaptive Thinking to Stick with Treatment

What types of maladaptive thoughts get in the way of treating ADHD? • “I’ve always been like this—I can’t change” • “I never finish anything” • “I forgot to look at my planner this morning — there’s no point in doing it now” Types of Maladaptive Thinking • All-or-None Thinking • Jumping to Conclusions –– Mind Reading –– Fortune Telling • Overgeneralization • Catastrophizing

• • • • •

“Should” Statements Mental Filtering Disqualifying the Positive Labeling Personalization

Questions to Help You Challenge Automatic Thoughts (1) What is the evidence that the automatic thought is true? What is the evidence that the automatic thought is not true? (2) Is there an alternative explanation? (3) What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome? (4) What’s the effect of believing the automatic thought? What could be the effect of changing my thinking? (5) If a friend was in the situation and had this thought, what would I tell ­them?

Situation

Automatic thoughts

Feelings/ Behaviors

Alternative thoughts

Degree of belief in alternative thoughts

New feelings/ Behaviors

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Week 6 – Mentoring Agenda Check-In Collaborative Agenda Setting Review Between-Session Practice Discuss Information Presented in Group Ending Mentoring Session Handouts – none

Chapter 9

Active Phase – Week 7

In Week 7, group members receive information about evidence-based psychosocial treatments for ADHD.  Behavioral strategies that support a healthy lifestyle and strong relationships with others are also discussed, as are adaptive thinking strategies for maintaining positive relationships. The mentoring session provides an opportunity for addressing any questions about psychosocial treatments for ADHD, for helping students implement and adapt healthy lifestyle and relationship strategies, and for refining use of adaptive thinking techniques pertinent to relationship issues.

Week 7 – Group Beginning Group Session Begin the group by addressing any questions or carry-over concerns from the last group meeting in which test-taking strategies, suggestions for doing long-term projects and papers, and sticking to treatment were discussed.

ADHD Knowledge Provide the group with accurate, evidence-based information about psychosocial treatments for ADHD.  To facilitate this discussion, direct the group’s attention to Handout 7.2. Introduce this topic by emphasizing that, while numerous treatments for ADHD exist, many of these have yet to be proven effective. By learning which treatments have been supported by rigorous research findings, students will become informed consumers, should they choose to seek psychosocial treatment in the future.

© Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_9

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Remind the group why it is important to seek treatment services that are evidence-­ based. Practically speaking, this means that significantly more people “get better” and show improvements in their daily life functioning after receiving treatment, relative to those who do not receive the treatment. Although this does not mean it works for everyone, one’s chances of benefitting from an evidence-based psychosocial treatment are greater than would be the case for a psychosocial treatment lacking research support. Against this background, provide an overview of existing evidence-based treatments for ADHD in adults and college students. Specifically note that there is evidence to support the use of cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and mindfulness for adults. ADHD coaching may also be helpful. Briefly identify the major differences between CBT, DBT, and coaching. As part of this discussion, note that practitioners who administer CBT and DBT are typically trained in the delivery of mental health services, whereas ADHD coaches may or may not possess training in mental health. Lacking this training, ADHD coaches may not be fully prepared to handle co-occurring depression, anxiety, or other mental health issues that may be present. Conclude this knowledge portion of the group session with a summary of the status of the field. Specifically, state that, despite the limited research on psychosocial treatments for college students with ADHD, currently available findings consistently indicate that CBT is a useful treatment for this population. Remind students of the fact that ACCESS is a CBT program with strong evidence for efficacy, based on the results of the large multi-site randomized controlled trial recently completed by our research team.

Behavioral Strategies Start the Behavioral Strategies Section Conduct a brief check-in with students regarding between-session practice. This week, students were to try out a test-taking tip or a technique for managing papers and long-term projects. Ask students to discuss their use of these techniques and provide encouragement and trouble-shooting tips as needed. Healthy Lifestyles Distribute Handout 7.3 and introduce the topic of healthy lifestyles by providing the rationale for discussing this. Note that most people perform better in their daily lives when they maintain healthy lifestyle habits, such as getting enough sleep, eating nutritious meals, and exercising regularly. Some students may ask whether ADHD symptoms can be treated through diet and exercise. Although there is no hard evidence that ADHD symptoms are effectively managed by diet and exercise, individuals with ADHD will likely feel better

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and be better able to cope with ADHD if they have healthy habits. Therefore, maintaining a healthy lifestyle can play a substantial role in improving quality of life and performance for those with ADHD. Staying Healthy Ask students to describe what they do to stay healthy. Examples might include choosing nutritious meal options, exercising regularly, or getting adequate and consistent sleep. Encourage students to eat regular, nutritious meals and to drink plenty of water. Discuss the importance of healthy sleep habits, including keeping a regular wake and bedtime and establishing consistent bedtime and morning routines. Inform students that waking up at the same time every day and going to bed around the same time helps regulate sleep patterns, making it easier to fall asleep and wake up. Establishing regular routines associated with bedtime and mornings can also be helpful. Routines can act as cues to signal that it is time to wake up or fall asleep. Students often report a great deal of difficulty waking up in the morning. Encourage discussion around potential methods to make waking up easier. One option is to put an alarm clock across the room from the bed, so that it is necessary to get out of bed to turn off an alarm. For students who report sleeping through alarms, many alarm apps are available that may be helpful. Some apps require individuals to do a task such as a math problem or trivia question before the alarm will shut off. Also ask students if they have any other ideas or suggestions for addressing this issue. Relaxation Discuss techniques to combat and reduce stress. This includes identifying early signs of stress and using strategies to cope with stress effectively. Ask students to list some of their own early signs of stress. Emphasize that the sooner they can address stress, the more effective they will be. Help students identify strategies that may be helpful in coping with stress. This might include, for example, deep breathing exercises, yoga, progressive muscle relaxation, mindfulness exercises, and positive imagery exercises.

Tip Leading students in a deep breathing or muscle relaxation exercise is a fun way to increase engagement in this session. Students also enjoy discussing mindfulness and deep breathing apps.

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Using Medication Effectively Initiate a conversation about using ADHD medication in a manner that maximizes effectiveness. Remind students that ADHD medication works best when taken as prescribed and help them identify strategies to keep a consistent medication regimen. For instance, if students report trouble remembering to take medication, the use of visual reminders or a pill organizer can be helpful. Many students report that they forget to refill their prescriptions before they run out. Another complication that arises in the college student population is that the health care provider who prescribes the student’s medication often works in the student’s hometown far from campus, and the student has not yet transferred their treatment to a local provider. This situation creates logistical challenges that can be particularly difficult for students with ADHD to manage. To facilitate this transfer of care, provide the group with a listing of health care providers on campus (e.g., Student Health Services) and in the community who are available to address their medication management needs. Handling Relationships Begin by asking the group to talk about the importance of maintaining a balance in the amount of time spent on academics versus relationships and other social activities. Encourage students to consider the drawbacks of focusing too much on academics and neglecting relationships, and vice versa. Reflecting on this topic can help students consider whether they have achieved a healthy balance regarding academics and relationships. This is a great way to begin discussing strategies for building and maintaining relationships, which are enumerated in greater detail in Handout 7.4. Ask students whether they find it more difficult to make friends or maintain friendships. Some students find it more difficult to initiate friendships, while others find it more challenging to maintain friendships. Encouraging students to consider this question is another way to set the stage for discussing relationship strategies. Present strategies for making new friends, emphasizing the need for planning and time management. Students can attend social events on campus and join student clubs or groups in order to meet people and make new friends. Point out that students can plan for these events by recording them in their planners, which will increase the likelihood they will attend. Next, introduce strategies for interacting with others. For instance, if students are shy or uncomfortable in social situations, they may benefit from identifying conversation topics or conversation starters before attending a social event. This can help them feel more comfortable and prepared during such events. Next, initiate a discussion of how to maintain relationships. It can be helpful here to remind students of the ways in which ADHD symptoms negatively impact

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r­ elationships. For instance, forgetting events or important dates can cause relationship conflict, and impulsive statements and interruptions can lead to arguments or hurt feelings. Again, emphasize how planning, organization, and time management skills can reduce such problems. For example, students can record friends’ birthdays or other important events in their planner. Using a planner can also help students remember to attend social events. They can even set reminders to prompt them to check in with friends regularly. Another strategy is to plan a recurring activity to do with friends, such as a weekly game night or movie night. Planning and organizational strategies are not just for academic tasks. They can be helpful in maintaining strong relationships as well! Working in Groups Introduce this section by noting that most students will at some point be required to work with partners or groups in their college classes. Given some of the relationship problems that can be associated with ADHD symptoms, it is helpful to consider ways to effectively work with others. Aid students in identifying strategies for managing group projects. Examples of helpful strategies include keeping a record of the multiple steps and duties involved in the project, the person assigned to each one, and a listing of due dates and deadlines. Encourage the students to enter all such information into their planners. In addition, remind students to avoid overcommitting themselves, as it can be difficult to estimate the amount of time required to complete tasks. Students may unintentionally take on an unreasonable amount of work. Encourage students to take time to carefully assess how much time a task might take. Being Professional Discuss the importance of being professional in certain situations and the various ways in which students can convey a professional attitude in their interactions with co-workers, supervisors, and faculty members. Encourage students to speak more formally when talking to a supervisor or faculty member and to use a more formal writing style (e.g., using correct spelling and punctuation, avoiding informal abbreviations) when communicating with faculty or supervisors. Also, encourage students to maintain appropriate boundaries with co-workers and faculty. Discussing appropriate boundaries can be difficult, as different individuals are likely to have different ideas about what constitutes an “appropriate” boundary. One way to manage this is to help students consider the potential consequences of sharing too much information. For example, ask students to identify the pros and cons of sharing information such as “I missed class because I was hungover” with a faculty member.

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Assign Between-Session Practice Ask students to choose one or two healthy lifestyle strategies and at least one strategy for improving relationships to practice over the next week. Remind them that their mentors will be checking in with them regarding their use of strategies.

Adaptive Thinking Skills Start the Adaptive Thinking Section Briefly review the topics covered in the last group session (e.g., using adaptive thinking to stick with treatment) before introducing the new topic – using adaptive thinking to improve relationships. Ask students to discuss their level of confidence in using adaptive thinking skills. At this point in ACCESS, most students feel confident in their ability to identify, challenge, and replace maladaptive thinking with adaptive thoughts. Using Adaptive Thinking to Improve Relationships The goal of this discussion is to help students identify how their relationships may have been impacted by ADHD, and then to consider how these experiences may have influenced their thoughts about relationships.  To introduce this topic, encourage students to discuss how the symptoms and difficulties associated with ADHD can affect relationships. Examples might include interrupting others during conversations, losing track of the conversation due to trouble focusing, forgetting events, or missing time with friends due to poor planning. Direct students’ attention to Handout 7.5 during this section. Encourage students to identify maladaptive thoughts that might get in the way of relationships (e.g., “I can’t make friends, keeping up with friendships is too hard for me,” “I don’t have time for relationships”). Help the group work through a column analysis exercise using a maladaptive thought about relationships. For example, if a student reports the thought “Keeping up with friendships is too hard,” group leaders can help students challenge this thought using the question “What is the impact of believing this thought?” Students will often mention feeling hopeless or frustrated, and giving up on potential friendships easily. Encourage students to consider the benefits of changing this thought, including having more friendships, improving the quality of existing friendships, and feeling more confident. Identifying these potential benefits can increase motivation to replace the maladaptive thought with adaptive thinking (e.g., “Maintaining friendships does take time, but it isn’t impossible.”). Also point out that previously discussed behavioral strategies can be used in conjunction with adaptive thinking skills to address this type of situation. For instance, students can set reminders to text a friend as a strategy to keep in touch and maintain the friendship.

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Assign Between-Session Practice Ask students to continue to practice challenging maladaptive thoughts using adaptive thinking techniques. Make sure to praise progress in using these techniques and remind them that using adaptive thinking becomes easier and more effective over time.

Ending Group Session Remind the group of the recommended between-session practice assignments. Specifically, encourage the group to practice using at least one healthy lifestyle strategy and one improving relationships strategy, and to apply their use of adaptive thinking techniques to relationship situations. Also, remind students that the next group session, which will be the eighth and final group meeting during the current semester, will focus on planning for the future and discussing how to maintain progress.

Week 7 – Mentoring Check-In Get a quick update on how the mentee has been doing since the last mentoring session. Follow up on any topics noted at the end of the previous session that were important to the mentee that may not be part of the planned agenda.

Collaborative Agenda Setting Briefly outline the goals for this session, including a check on between-session practice efforts and a review of the newly presented information from the recent group meeting addressing evidence-based psychosocial treatments for ADHD, healthy lifestyles, and healthy relationships.

Review Between-Session Practice Follow up on any “To-Do” or practice items that were discussed the prior week. For this session, be sure to address the following items: • Did the mentee try using new test-taking strategies? • Did the mentee bring their end of semester “master To-Do list”?

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• Did the mentee use behavioral strategies to break down a large task into manageable steps and add those steps to their To-Do list? • Did the mentee practice the 6-column adaptive thinking log? • Did the mentee bring handouts from group to this mentoring session? • If the mentee chose anything else to practice, be sure to follow up on that. Give enthusiastic and positive feedback for any follow through on these tasks. Be neutral and do not over-respond to missed practice; however, ask the mentee to follow up in the next week on important items. Be sure to remind them of these items at wrap-up. Tip Encourage the mentee to continue to utilize the To-Do list that summarizes the remaining tasks for the semester. In addition to facilitating completion of these tasks, this To-Do list will provide concrete evidence of the progress they are making progress as they cross off completed items.

Discuss Information Presented in Group ADHD Knowledge Discuss information regarding other evidence-based psychosocial treatment options for ADHD. Dispel any myths related to treatment options that have not been supported in the research literature, such as dietary management. Discuss any other strategies that the mentee has previously used to treat their ADHD and how it has worked for them. Mentor: “Mike, I know you have used medication, but what else have you done to manage your ADHD?” Mentee: “Well, I saw a therapist when I was a kid, but we just talked and played games. I don’t think it helped much.” Mentor: “Ok, that’s consistent with what research tells us  – that traditional talk therapies like you have described are not very effective at reducing symptoms or the effects of ADHD.” Mentee: “Yes, we talked in group about how it could help with the other conditions that someone might have like depression, but not ADHD.” Mentor: “Right. You are in a non-medication form of treatment right now with the ACCESS program. How is that different than regular therapy?” Mentee: “Well, it’s more like learning skills and strategies I can use.” Mentor: “Yes, exactly! You are learning cognitive and behavioral strategies. You are also getting information about ADHD, which is what we call psychoeducation.” Mentee: “I definitely think this has been more helpful than what I did as a kid!”

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Behavioral Strategies Address the topic of making and maintaining friendships and at least two other topics from this section. Staying Healthy  Have a discussion with the mentee about staying healthy. Address some broad categories of health that may be difficult to maintain on a college campus, such as eating well, sleeping well, and regularly exercising. Many mentees feel validated after discussing how it can be difficult to maintain a healthy lifestyle while in college. Normalize this as a challenge for many college students. For example, a variable class schedule and dorm life make it difficult to stick to a routine sleep schedule. It may also be beneficial to discuss habits that are generally considered unhealthy that may be difficult to resist in college, such as the use of alcohol and drugs. The following questions may help guide the discussion. • In what areas of your life do you already practice healthy habits? • Are there areas of your life where your habits could be healthier? Do you wish to add any goals related to healthy living? Tip Remain non-judgmental about any unhealthy habits the mentee may disclose. Discussing healthy habits as “shoulds” would be modeling poor adaptive thinking language. Instead, keep the conversation strength-based and help the mentee identify what they are already doing well and areas of desired growth.

Relaxation Discuss relaxation techniques, such as deep breathing, progressive muscle relaxation (PMR), body-scan meditation, visualization meditation, yoga, tai-chi, etc. Determine which strategies the mentee has used in the past and what strategies they may wish to try in the future. Discuss how relaxation strategies are an important aspect of everyday life but may be particularly useful during stressful times, such as finals week. Consider using the following questions to initiate the discussion. • How do you generally handle stress? • What are some things that you find help you relax? • Have you ever tried any of the relaxation strategies that you learned in group? As part of this relaxation discussion, ask the mentee to create a list of healthy habits and coping strategies that can be used in times of stress. Using Handout 7.7, encourage them to add 5–10 strategies that they think would help them relax during stressful times. Examples may include meditation, PMR, sticking to a sleep schedule, exercise, utilizing campus resources, calling a friend or family member, going for a walk, etc. Be sure they are identifying strategies they would realistically try. Remind the mentee to keep their list of stress reduction strategies close at hand for the next time they are feeling overwhelmed.

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Using Medication Effectively Address issues related to using medication effectively. Discuss strategies to improve medication adherence with the mentee, such as setting daily auditory or visual reminders. Also remind mentees that using their planner and cell phone to remind them when it is time to refill their prescription may be a useful strategy. Make sure to individualize these strategies to address any difficulties the mentee experiences. To begin, consider asking: • Do you ever have trouble with missing doses or taking the medication on time? • Do you have trouble remembering to fill your medication?

Tip A useful tactic for getting into a habit of taking medication is to pair it with an already established habit. For example, if the mentee is supposed to take medication when they first wake up in the morning, find out what they tend to do first. If they begin the day by looking at their phone, suggest putting their medication and a glass of water next to their phone before they go to bed at night. Making and  Maintaining Friendships Mentees often express difficulty with making and maintaining friendships once they get to college. Discuss friendships with the mentee and determine if they struggle in these areas. Normalize these difficulties for most students transitioning to college even when ADHD is not a factor. Discuss strategies and provide recommendations, such as using their planner and To-Do list to block out time for social events and trying to reduce distractions in social situations (e.g., studying with friends in a private room in the library rather than at the busy coffee shop). Mentees may also find it useful to discuss how their ADHD symptoms may impact their interactions with friends. Here are some questions to engage mentees in the discussion. • Do you ever have trouble making or keeping friends? • Have your ADHD symptoms ever impacted your friendships? • Do you ever have trouble balancing your social life with your academic life? The planner can be a useful tool for promoting healthy relationships. For example, if a friend mentions that they have an important event coming up (e.g., big test, job interview, birthday, etc.), adding it to the planner can help mentees remember to ask about it. These small details can go a long way in maintaining friendships. The planner can similarly be used to remind mentees to keep in touch with friends and family members who aren’t on campus. For example, mentees may find it useful to set dates in their planner to video chat with friends in their hometown or friends who went to different schools.

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Working in Groups  Many mentees dread working in groups for school projects. Discuss strategies for staying organized and communicating with group members, such as using the planner and To-Do list, and maintaining communication with group members. For example, it is often useful to create a shared document in the first group meeting that clearly outlines who is doing what tasks for the project with specific deadlines. Discuss common experiences in group projects relevant to the mentee and problem solve as needed. For example, some mentees feel like they do more work than other group members. Alternatively, some mentees may experience difficulties working in groups because of their ADHD. Explore this possibility and make suggestions for addressing any disclosed problems in this area. Being Professional  Discuss professionalism with the mentee. This conversation will differ depending on the mentee’s current and previous work experience. Determine how comfortable the mentee is interacting with teachers, professors, managers, co-workers, and peers. Provide strategies and recommendations for maintaining professionalism in settings that are relevant to the mentee. For example, many mentees benefit from discussing how to interact with their professors via email – provide recommendations about how to address professors, proof reading emails prior to sending, and maintaining professional boundaries. Encourage mentees to use professors’ preferred method of communication, use their professional titles, and to make appointments ahead of time, which might require adding these to the planner, so they aren’t forgotten. Here are some additional questions to prompt further discussion. • Have your ADHD symptoms affected you at work? • Have your ADHD symptoms impacted your interactions with teachers, professors, or work supervisors? Adaptive Thinking If the mentee completed their practice thought log, look over the thought record and provide any suggestions if needed. If not, practice one in session using a maladaptive thought that the mentee has expressed in session. Mentor: “When we were talking about healthy habits, I noticed you kept saying ‘I should exercise more. I’m so out of shape compared to high school.’ How did saying that make you feel?” Mentee: “Guilty…and pathetic. I already feel like such a slacker because I’m so behind in my academic work, thinking about how out of shape I am makes me feel worse.” Mentor: “You compared yourself to high school. What was different then?” Mentee: “Well, I played sports. Also, my parents made sure I got my assignments done and fed me (laughs). So, I guess it was easier for me to do it all.”

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Mentor: “Ok, so was your first thought accurate? If not, how could you modify or replace it?” Mentee: “No, it’s not really accurate. I could instead say, ‘I want to exercise more. It was easier for me to get regular exercise in high school.” I can get in shape again, but I might need a new approach.” Mentor: “Great – you just went through all the steps of the thought record except the last two. How does this new thought make you feel and how much do you believe it?” Mentee: “It makes me feel much better and more motivated. I am being too hard on myself. Things have changed, but they are not insurmountable. I do believe that, 100 percent!” Generate a new example related to the content of the current topic. A useful area to address is maladaptive thinking about maintaining friendships and how ADHD affects their relationships. Mentor: “Let’s explore how adaptive thinking may help you improve relationships with friends and family members. What is a thought you have when you are around other people?” Mentee: “I’m constantly worried that I’m annoying people because I talk too much and interrupt them or don’t listen. Sometimes, I don’t even try to interact because I’ll just drive them crazy eventually anyway.” Mentor: “So, there are times you have bothered people. Is that true all the time?” Mentee: “No, my close friends like to be around me and know I am funny and that I’d do anything for them. They get me. My best friends will put their hand on my arm when they need me to focus on what they are talking about.” Mentor: “It sounds like you are a good friend to the people you have gotten to know well.” Mentee: “I am! I just know I really annoy some people. I don’t have to be best friends with everyone – but I could use a few more good friends.” Mentor: “Ok, well how did those first friendships begin?” Mentee: “I have a lot in common with my closest friends. It’s easier for me to pay attention to what they are saying because I’m interested in what they are interested in, too. And once I got to know them better, then I was comfortable letting them know I have ADHD and how they can get my attention when they need me to listen.” Mentor: “Finding common ground sounds like a great way to get to know someone better AND for you to be a better listener. Let’s put this into the thought log to see how this situation plays out.” In addition to examining a situation specific to the mentee, additional practice in using the thought log for social situations can be achieved using the following examples: • Your friend doesn’t call you back. You might think to yourself, “They don’t care about me.” • You walk by someone you know on campus and they don’t acknowledge you. You think to yourself, “They must be mad at me.”

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Ending Mentoring Session Check in about goals as needed. Is there anything that has been accomplished or needs to be modified? Any miscellaneous topics of discussion? Address any topics that did not fit into the prior discussion. Remind the mentee that their next session is scheduled to be the final mentoring session of the semester, unless they decide to use 1–2 optional mentoring sessions that are tailored more specifically to their needs without a group outline. Ask the mentee to think about this and to decide whether to use these additional mentoring sessions before the next regularly scheduled weekly meeting. Finally, review and clarify as needed the details of what the mentee will do between now and the next mentoring session, including: • Bring all group materials to next mentoring session • Continue to use the To-Do List including crossing off items as the semester progresses. • Try two new healthy habits or coping strategies. • Analyze at least one example of a maladaptive thinking pattern using the thought record. Confirm the date and time of next appointment. Ask the mentee to write down/set reminder and model similar behavior with your own planner/calendar.

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Week 7 – Group Agenda

Beginning Group Session ADHD Knowledge • Present and discuss information about evidence-based psychosocial treatments for ADHD

Behavioral Strategies • Discuss rationale for starting or maintaining healthy lifestyle habits • Present and discuss strategies for healthy lifestyle habits, including: ◦◦ Nutrition, sleep and exercise ◦◦ Relaxation and stress management ◦◦ Using medication effectively • Present and discuss strategies to form and maintain healthy relationships, including: ◦◦ Making new friends ◦◦ Keeping in touch with friends to maintain relationships ◦◦ Setting healthy boundaries in relationships • Present and discuss strategies to manage working with a group or team • Present and discuss strategies for professionalism in the workplace and in school

Adaptive Thinking Skills • Facilitate group discussion of how ADHD symptoms and maladaptive thinking patterns can interfere with relationships with friends and family • Work through examples of how to challenge maladaptive thinking patterns that negatively impact relationships

 nding Group Session E • Address any questions that may arise • Review the details of completing the between-session practice assignments

Handouts • 7.1 Week 7 Group Cover Sheet • 7.2 Is Medication the Only Way to Treat ADHD • 7.3 Healthy Lifestyles • 7.4 Handling Relationships • 7.5 Improving Relationships with Adaptive Thinking

Handout 7.1

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Week 7 – Group Handouts • • • • •

7.1 Week 7 Group Cover Sheet 7.2 Is Medication the Only Way to Treat ADHD? 7.3 Healthy Lifestyles 7.4 Handling Relationships 7.5 Improving Relationships with Adaptive Thinking

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Handout 7.2

Is Medication the Only Way to Treat ADHD?

For adults with ADHD: • Cognitive-Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) also supported by research evidence • Some evidence that ADHD coaching and mindfulness may be helpful as well

For college students with ADHD: • Research on the impact of psychosocial treatments is in the early stages • Promising treatments/resources for college students with ADHD include: CBT, DBT, campus-based services and accommodations, ADHD coaching, ­organization, time management, & planning

For children and adolescents with ADHD: • CBT has not been effective • Family-based and parent-focused behavioral treatments most effective • School-based interventions and summer treatment programs also effective • MTA study (large, landmark study with rigorous research methods) ◦◦ For most children/adolescents with ADHD, multi-modal treatment best ◦◦ Multimodal = using evidence-based treatments (i.e., medication and behavioral treatments in combination)

Handout 7.3



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Healthy Lifestyles

Staying Healthy • Eating well, getting enough sleep, and exercising regularly protects from the effects of stress • Eat well to support mood and attention ◦◦ Eat regularly and drink plenty of water ◦◦ Make healthy food choices • Sleep well to improve daily performance  ◦◦ Keep a regular bedtime and wake time to set your internal clock and make waking easier ◦◦ Establish an evening routine to help wind down ◦◦ Establish a morning routine to combat morning fog ◦◦ If spacing out in the morning is a significant problem, consider using a written checklist • Exercise regularly to combat stress and reduce feelings of restlessness ◦◦ Desire to exercise is not enough — put it in your planner ◦◦ Set a small, manageable goal at first and then build momentum ◦◦ Monitor your progress ◦◦ Make it fun! (Exercise partner, classes)

Relaxation • Become aware of your earliest symptoms of stress so you can act early to combat it • Find a relaxation method that works well for YOU. Some techniques to explore: ◦◦ Deep breathing ◦◦ Progressive muscle relaxation ◦◦ Body-scan meditation ◦◦ Visualization meditation ◦◦ Yoga/Tai Chi

Using Medication Effectively • Medication helps the most when taken regularly as prescribed • Communicate with your doctor to find the best fit medication • Remembering to take your medication ◦◦ Use visual and auditory reminders (put it in your schedule, set an alarm) ◦◦ Put a refill reminder in your schedule ◦◦ If your prescribing physician is out  of  town and this causes difficulty with obtaining refills, consider seeing a local physician or psychiatrist

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Handout 7.4

Handling Relationships

Making New Friends • Making friends takes planning ◦◦ Block out time for social events in your planner ◦◦ Join student clubs or groups ◦◦ The more people you come into contact with, the better the chances of making a friend • Work on social skills ◦◦ Prep for social encounters: Rehearse some conversation starters ◦◦ Develop questions to ask others about themselves ◦◦ Feeling overwhelmed? Pick one or two people to talk to ◦◦ Nonverbal communication is important ◦◦ Maintain eye contact ◦◦ Nod or smile to show interest

Maintaining Friendships • Put friends’ birthdays or important life events in your planner • Use your planner to remind yourself to check in with friends • Plan regular activities with friends to help maintain friendships (e.g., weekly jog, coffee every Friday) • Set healthy boundaries

Working in Groups • Keep track of the multiple steps involved in group projects ◦◦ Write down each step and indicate whose responsibility it is • Record all deadlines in your planner • Don’t over-commit

Being Professional • Be professional with boss/supervisor ◦◦ Keep things formal • Communicating with professors ◦◦ Use their preferred method of communication (e.g., email, voicemail) ◦◦ Use formal writing conventions in your emails (e.g., correct title, spelling and punctuation) • Maintain boundaries with coworkers

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Improving Relationships with Adaptive Thinking

What are some maladaptive thoughts that might affect relationships? • “I can never keep up with friends” • “I don’t have time to have friends” • “I always screw up my relationships — there’s no point in even trying” Types of Maladaptive Thinking • All-or-None Thinking • Jumping to Conclusions ◦◦ Mind Reading ◦◦ Fortune Telling • Overgeneralization • Catastrophizing

• • • • •

“Should” Statements Mental Filtering Disqualifying the Positive Labeling Personalization

Questions to Help You Challenge Automatic Thoughts 1) What is the evidence that the automatic thought is true? What is the evidence that the automatic thought is not true? 2) Is there an alternative explanation? 3) What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome? 4) What’s the effect of believing the automatic thought? What could be the effect of changing my thinking? 5) If a friend was in the situation and had this thought, what would I tell them?

Situation

Automatic thoughts

Feelings/ Behaviors

Alternative thoughts

Degree of belief in alternative thoughts

New feelings/ Behaviors

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Week 7 – Mentoring Agenda Check-In Collaborative Agenda Setting Review Between-Session Practice Discuss Information Presented in Group Ending Mentoring Session Handouts • 7.6 Week 7 Mentoring Cover Sheet • 7.7 Stress Reduction Strategies

Handout 7.6

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Week 7 – Mentoring Handouts • 7.6 Week 7 Mentoring Cover Sheet • 7.7 Stress Reduction Strategies

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Handout 7.7

Stress-Reduction Strategies

 Strategy

1

2

3

4

5

Date tried?

How did it go?

Rate helpfulness (0–10)

Chapter 10

Active Phase – Week 8

Guidelines for implementing the final group and mentoring sessions during the active phase are presented. The primary goal for these sessions is to prepare students for the transition from the current active phase semester to  the start of the maintenance phase next semester. The group session begins with a brief review of previously presented ADHD knowledge, followed by a discussion of how this knowledge can be used to improve daily life functioning. The group session also focuses on a review and refinement of newly acquired behavioral strategies, along with suggestions for their continued use in the future. Likewise, there is a review and refinement of acquired adaptive thinking skills and recommendations for their continued use. During the mentoring session there is a review of the information covered in the final group and planning for next steps. This includes a discussion of the option for conducting two additional mentoring sessions during the current active phase. The mentoring session also addresses any additional questions about ADHD. Additional time is spent reviewing and refining the mentee’s implementation of learned behavioral strategies and adaptive thinking skills. A description of how mentoring is conducted during the upcoming maintenance phase is also provided.

Week 8 – Group Beginning Group Session Address any general questions and then introduce the topics to be covered in this final group meeting during the active phase session: understanding how ADHD might affect life after college, long-term goal setting, and a summary of adaptive thinking skills. Make clear to the group that the skills learned in the ACCESS program are helpful for many aspects of adult life that occur after college, including careers, money management, relationships, and even parenting. © Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6_10

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Be sure to consider the age composition of the group when leading this session. When working with a group of first year college students, spend more time discussing how ADHD could affect them during the remainder of their college careers. Alternatively, when working with a group composed mainly of juniors and seniors, shift the focus to a discussion of how ADHD might affect future jobs, relationships, and so on.

ADHD Knowledge Begin this session by encouraging the group to reflect on what they have learned about ADHD and to think about how ADHD may affect them in the future. Such a discussion promotes greater student insight into how ADHD has impacted, and may continue to impact, their daily behavior, relationships, employment, and other areas of life. Refer students to Handout 8.2 for this discussion. Employment To engage the group in a discussion of how ADHD might impact career planning, first ask students to talk about their experiences with jobs that were a good fit versus a bad fit. By identifying the characteristics of jobs that they preferred, students can begin to consider how to account for those preferences, as well as how to plan around ADHD symptoms and associated difficulties when applying for and accepting jobs. Tie this notion of a good fit back to the earlier discussion of the situational variability of ADHD symptoms. Encourage students to reflect on what job characteristics might be challenging for them, given their ADHD symptoms. For example, a student who experiences high levels of restlessness when sitting still may wish to seek jobs that allow them to be more active and avoid traditional office jobs that require them to sit still for hours on end. Those who struggle with distractibility might want to choose job settings that are quieter and allow the opportunity for working in a distraction-reduced environment, such as private office space rather than one with a high level of ongoing activity and distractions (e.g.,  communal office spaces). Students who thrive when working as a part of a team may wish to avoid jobs that require them to work independently most of the time. It is extremely important for students to pursue job situations and careers that provide a good fit with their personality and how their ADHD impacts them. Money Management Encourage students to think about how to minimize the negative impact of ADHD on money management. Remind them that common ADHD symptoms, such as planning difficulties, forgetfulness, and impulsive decisions, can lead to difficulties

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with creating and sticking to a budget. Being aware of this possibility helps students anticipate and have plans for dealing with these challenges. For instance, students can set aside time each month to work on a budget. They may wish to use money management apps on their devices or meet with a financial advisor at their bank. They might also consider working with a trusted family member or friend to review their financial decisions and plans. Personal Relationships Because ADHD symptoms can lead to difficulties in relationships, help students consider ways to anticipate and consciously manage this challenge. Suggest several strategies to address this, including disclosing their ADHD diagnosis to individuals close to them, using organization techniques to keep track of social obligations and events, and applying their adaptive thinking skills to potentially problematic social situations. Parenting Although parenting is not an activity affecting most college students, it is something that many of them will face in the future. With that caveat in mind, call attention to this issue and briefly highlight some important points for students to keep in mind for the transition into post-college adulthood. Emphasize that parenting calls for a great deal of organization and planning, which can be quite challenging for adults with ADHD. Many of the strategies discussed in the ACCESS program, such as the planner and To-Do lists, can be helpful for managing the demands of parenting.

Behavioral Strategies Start the Behavioral Strategies Section Conduct a brief check-in with the group regarding their between-session practice. Over the past week, students were asked to try out a healthy lifestyle technique or a technique for handling and maintaining relationships. Ask students about their use of these techniques and provide encouragement and trouble-shooting tips as needed. Setting and Achieving Goals Give the students a reminder that they will be asked to identify a goal at the end of this section. Next, review techniques for setting and achieving goals. Note that many of the strategies from earlier sessions of ACCESS are relevant for setting and achieving goals, even long-term goals or non-academic goals. Direct students’ attention to Handout 8.3 for this discussion.

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Some of the techniques for goal setting include writing down short-term and long-term goals, breaking goals down into manageable steps, monitoring progress toward goals, sharing goals with family and friends to keep oneself accountable, and posting written goals in a highly visible area, such as on a bathroom mirror or refrigerator. Students can also start with a small goal to build their confidence before working up to a larger goal. For example, a student who wants to eventually work up to a goal of running a marathon might want to start by setting the goal of running a few miles three times in a week. Setting and achieving this smaller goal can help students feel more confident and prepared to achieve a bigger goal. Encourage students to consider potential barriers to achieving goals and brainstorm ways to overcome these barriers. Spending time thinking about how to deal with these barriers is an important problem-solving skill and will better prepare students to manage potential pitfalls. Finally, help students consider how to build flexibility into their goals. For instance, instead of setting a goal of working for one specific company, students may set a goal of obtaining a position in their field. Maintaining New Skills Ask students to reflect on the behavioral strategies learned over the course of the program and encourage them to share the ones they found most helpful. Remember, these skills will likely vary from person to person. Remind students that practice is key – over time, using skills repeatedly will help make these skills more advanced and more automatic. In addition, spend time discussing how to handle challenges and setbacks. It is important to normalize setbacks and challenges for students, so that they are prepared to manage these effectively rather than giving up on skills the first time they experience a setback. To facilitate discussion of the above points, remind students of things that were covered earlier in the program, such as “the more you put into it, the more you will get out of it.” It is also very helpful to revisit the progress chart to help set realistic expectations for change during the upcoming maintenance phase.

Adaptive Thinking Skills Start the Adaptive Thinking Section The purpose of this section is to review and summarize adaptive thinking skills. Aim to provide an overview of the goals of adaptive thinking as well as helpful tips for continued use and implementation of these skills. Refer students to Handout 8.4 to facilitate the discussion. One way to encourage discussion in this section is to ask students for their opinions about the adaptive thinking skill portion of the program. Such a discussion can

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be prompted by asking, “Why do you think we have spent so much time talking about thoughts?” Generally, students are quick to respond that maladaptive thinking patterns lead to frustration and negative emotions and interfere with daily life in a myriad of ways. They may also comment on the importance of catching themselves engaging in negative thinking and the need for replacing such thoughts with more adaptive, realistic thinking. Adaptive Thinking Summary Begin by reminding students that the goal of adaptive thinking is not to be unrealistically positive or oblivious to hard truths. Rather, the aim is to generate thoughts that are more realistic and balanced. Furthermore, adaptive thinking is a habit that can be learned – the more someone practices adaptive thinking, the more effective it will become. Encourage students to be aware of their own tendencies regarding maladaptive thinking patterns. Ask students to identify the faulty thinking patterns to which they are most prone. For instance, some students may be likely to engage in “fortune telling,” while others are most likely to notice “labeling” thoughts. Knowing their own tendencies can help students more quickly identify and challenge thoughts that are unhelpful. On a similar note, ask students to share which questions from the thought record were most helpful to them when challenging maladaptive thoughts. If a certain question was typically helpful, encourage them to write it down or find a way to keep this question in mind. As needed, help students reframe thoughts about past frustrations or failure experiences. Point out that when ADHD is not identified or effectively managed, it can interfere with daily life in a major way. Just because students have struggled in the past does not necessarily mean they will continue to struggle in the future. Emphasize that their chances for future success have improved greatly because of their active involvement in the ACCESS program. Building on this last statement, transition to providing guidance for implementing adaptive thinking skills in the future. Instruct students to be alert for negative emotions or unproductive behavior, and to use these experiences as cues to examine automatic thoughts associated with these emotions and behaviors. Emphasize the utility of writing thoughts down and completing a thought record – this process can help students confront their thoughts in an organized manner.

Ending Group Session Spend a few minutes discussing the shift to the maintenance phase during the upcoming semester. Remind students that there will be one group booster session scheduled towards the beginning of the semester, along with up to six individual mentoring sessions that can be spread across the semester on whatever schedule

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works best for the student. Remind the group that the purpose of the maintenance phase is to support students as they continue to implement and achieve mastery of the skills and strategies presented during the active phase of treatment. Providing such support will make it easier for students to continue using these skills and strategies on their own when their participation in ACCESS concludes at the end of the next semester.

Week 8 – Mentoring Check-In This is the last of the planned eight mentoring sessions. This is an important milestone, and it is useful to greet the mentee with enthusiasm for reaching this point of the program. If the decision has already been made that the mentee will not be needing the optional additional mentoring sessions for this semester, a celebratory favorite soda, snack or fun “I did it!” certificate might be a good way to greet the mentee. A celebration, of course, can also take place even if the optional mentoring sessions are requested. As usual, briefly get an update on how the mentee has been doing since the last mentoring session. When relevant, follow up on a topic that you noted at the end of Week 7 that was important to the mentee, but may not naturally come up during the regular agenda. Keep in mind that at this point in the program, the mentee will be getting close to the end of an academic semester and may have a specific project, paper, or important event that has been weighing on their mind. Checking in about this provides feedback in a caring way. Mentor: “Welcome to the last official mentoring session for this semester. Can you believe it?” Mentee: “No, it’s gone really fast! Are we still planning to meet the extra two times?” Mentor: “Yes, absolutely! But today is an important milestone. It marks your completion of the core part of the program! I think that’s quite an achievement – especially in the middle of a busy college semester.” Mentee: “Ha! Me, too. There are lots of things I never finish… so I guess this IS something to celebrate!” Mentor: “Here is your official Yay Me! Certificate to mark this event.” Mentee: “Aww! Eight pictures of puppies for my eight sessions. You know me so well!” Mentor: “Even as adults, it’s good to celebrate achievements. Just like you’ve been celebrating completion of your ECON assignments with celebratory dance breaks with your roommate. Speaking of ECON, how is that final project going?”

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Mentee: “Pretty well. I’ve done the three of steps on my Final To-Do list and made an appointment with my professor to look over what I have so far and give me feedback.” Mentor: “Great! We’ll look at that list today in addition the other agenda items. Let’s go over that now.”

Collaborative Agenda Setting Briefly outline the content of this session. This includes a check on between-session practice and reviewing material from the final group session, which addressed wrapping up treatment, looking to the future, setting long-term goals, and maintaining new skills. If topics from the check-in seem to generate more conversation pertinent to the needs of the mentee, suggest adding these to the agenda.

Review Between-Session Practice Follow up briefly on any To-Do or practice items that were discussed the prior week. Be sure to address the following items: • Did the mentee try relaxation or any other coping strategies, such as PMR, meditation, sleep, exercise, calling a friend, or going for a walk? • Is the mentee still using strategies to break down large tasks into manageable steps and add those steps to their To-Do list? Have they added or crossed off items from their end of semester To-Do List? • Did the mentee practice the 6-column adaptive thinking log? • Did the mentee bring handouts from group to this mentoring session? • Follow up on anything else the mentee chose to practice between sessions. Give enthusiastic and positive feedback for any follow through on these tasks. Be neutral and do not over-respond to missed practice.

Discuss Information Presented in Group The topics for today’s session flow more naturally as an integrated discussion rather than three distinct topics. Integrating the three areas of this program is the next level thinking that is the aspirational goal for the participants of the program. As the discussion flows, stay mindful of what areas are being addressed through the conversation and what areas may be left to cover.

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ADHD Knowledge Have a discussion with the mentee about the future. Discuss education, employment, money management, intimate relationships, and parenting. Provide information about how ADHD may impact these areas of life and remind the mentee that many of the strategies they now have in their tool kit can be modified for use in these new situations. Make sure to point out areas of growth and improvement observed in the mentee. To promote greater self-awareness, consider posing the following questions: • In what ways have you shown academic improvements, as well as improvements in other areas of your daily life? • What skills have you learned thus far that you think will be helpful as you transition into these other areas of adult life? • What goals do you have for yourself 5 years from now? Tip Many mentees struggle to identify areas of growth and may need assistance reflecting on their strengths. Be prepared to reflect on the mentee’s specific areas of improvement.

Behavioral Strategies Review the goals that the mentee identified in the very first mentoring session. Provide encouragement for how the mentee has made improvements in these areas and achieved specific goals. Help the mentee identify specific accomplishments or areas of improvement of which they can be proud. Remind the mentee of their many strengths and knowledge of resources available. Refer to Handout 8.6 to facilitate this discussion. Discuss setting and achieving goals in the context of preparing for the next semester or next stage of life. Ask the mentee to identify specific strategies that they wish to continue using as they finish this phase of the ACCESS Program. To facilitate this discussion, refer to Handout 8.7 (ACCESS Content Summary) as a prompt to help the mentee remember the knowledge, skills and strategies covered in the active phase of the ACCESS program. Next, ask the mentee to come up with three short-term and two long-term goals that they wish to continue pursuing. These goals may relate to finishing the semester strong, longer term academic goals such as graduation, or general life goals. As part of this overall discussion, it is often helpful to ask the following questions. • Which of your skills can help you meet these short- and long-term goals? • Which campus resources will you continue to use? Which resources have you not used that may be helpful to you in the future (e.g., career services)?

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Mentor: “Ok, we’ve identified some of your areas of growth and your five-year plan. Let’s look at the short- and long-term goals we set earlier in the semester.” Mentee: (Reads and comments on goals and any progress.) Mentor: “Great, so looks like we can update Goal 2. You completed your capstone project on time. I know this was a huge task for you and you did really well, breaking it down into smaller, more manageable pieces across the semester and knocking it out one step at a time. Mark that one as complete!” Mentee: “That feels really good. It really helped to do things differently this time.” Mentor: “Ok, so looking at your other goals, are there any that you want to continue as on-going? And are there any that you feel are inconsistent with the five-­year plan you just shared?” Mentee: “Yes, I’d like to have the goal about using organizational tools like my planner as an on-going goal. When I come back next semester, I want to keep myself accountable for continuing to use those tools and not letting them drop mid-­semester when I get busier. But I feel like the goal of getting all A’s and B’s so that I qualify to rush a sorority was the wrong goal. I still want to rush, but it is not as important to my future as I used to think it was. Good grades are still important, but now getting good grades is more for getting into graduate school and for feeling satisfied that I am achieving closer to my potential.” Mentor: “That’s great. And you have already modified that goal once, do remember how?” Mentee: “Yes, I changed it from all A’s to A’s and B’s. I was being too hard on myself to be perfect. A’s are great and I’ll be extra happy when I get them, but A’s and B’s will be enough for the program I am interested in. I can be proud of both grades.” Mentor: “Yes, you’ve done a nice job with adapting your thinking to be more realistic and I can tell it has helped your outlook and motivation. These goals sound reasonable and fit well with your target long range plan. Is there anything else you’d like to add?” If there are more weeks left in the semester, additional mentoring sessions can be offered. These additional mentoring sessions would have no new content, but would allow for continued accountability, problem solving, and coaching. Mentor: “Do you want to meet with me for another session or two this semester to continue to check in and keep trying out the tools you’ve learned?” Mentee: “You mean, just come to mentoring but not to group? Mentor: “Yes. You’ve filled up your tool belt with all kinds of options and so now we would focus on everyday problem solving with whatever comes your way as you wrap up this semester. You’ve got the skills. I would work with you as a coach – helping to select the tools you want to use as well as an accountability partner to check in with as you keep knocking out your final tasks of the semester!”

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Mentee: “That sounds good, but I am feeling really good about how things are going with everything we’ve done this semester. I’d like to try it on my own.” Mentor: “That is a great to hear! I agree that you have made so much progress that you are ready to go it alone for the rest of this semester. You likely will not need it, but if you change your mind, feel free to set up another mentoring session before the end of this semester.”

Tip Some mentees may decline additional mentoring sessions because they feel overwhelmed as the semester closes. Anticipate this possibility and be prepared to discuss an alternative view of this same situation. Point out that additional sessions, instead of being a burden, more typically are a way to reduce feelings of being overwhelmed.

Adaptive Thinking If the mentee completed their between-session practice, look over the thought record and provide any suggestions if needed. If the mentee did not complete this, practice one in session using a maladaptive thought that the mentee has previously expressed. For example, during the discussion about continuing to use learned strategies and skills, the mentee may have expressed a maladaptive thought about not being able to maintain progress without group and mentoring. Mentor: “When we were talking about wrapping up the program, do you remember what you said to me?” Mentee: “Yes, I said. ‘I can’t do this without you!’ (Laughs) Ok, I know what you want me do with that.” Mentor: “Ok, let’s hear it!” Mentee: “Well, that thought makes me feel helpless and scared that I’m going to fail at adulting. It makes me feel like my future looks grim.” Mentor: “Ok, is that a fair and accurate thought for you to have after all you’ve done this semester? Keep going....” Mentee: “No, I can be kinder to myself. Instead, I can say that I have enjoyed working with you and I wish I didn’t have to do this without you… but I have the skills now and I can tackle each thing as it comes. Even if I trip and fall sometimes, I can do this!” Mentor: “And?” Mentee: “I believe this. It makes me feel better… proud.”

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Ending Mentoring Session Remind the mentee that this can be the last mentoring session of the semester, or they may opt to use one or two additional mentoring sessions that are tailored more specifically to their needs without a group outline. Briefly discuss what will happen in the maintenance phase that will occur next semester. • Determine if the mentee wishes to use the additional two mentoring sessions available to them. If the mentee wishes to use the remaining sessions this semester, schedule the next session and ask mentee to enter the date and time into their planner. • If the mentee does not wish to use the remaining mentoring sessions, remind them that you will reach out to them at the beginning of next semester to schedule the first maintenance mentoring session. • Make a copy of the mentee’s goal setting and maintaining new skills handout for the mentee to take with them. • Make a copy of the updated To-Do List for the mentee to take with them.

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Week 8 – Group Agenda

Beginning Group Session ADHD Knowledge • Facilitate group discussion of how knowledge about ADHD can improve future functioning in multiple areas of life, including employment, relationships, parenting, and money management

Behavioral Strategies • Present and discuss strategies for setting and achieving long-term goals • Facilitate group discussion of skills learned in group and encourage continued use of strategies and skills • Emphasize availability of campus resources as sources of ongoing support

Adaptive Thinking Skills • Summarize adaptive thinking strategies • Facilitate group discussion of usefulness of adaptive thinking skills and maintaining adaptive thinking skills

 nding Group Session E • Discuss goals and format of maintenance phase • Answer any questions about maintenance phase

Handouts • 8.1 Week 8 Group Cover Sheet • 8.2 ADHD Knowledge Summary • 8.3 Looking to the Future • 8.4 Adaptive Thinking Summary

Handout 8.1

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ACCESS Accessing Campus Connections and Empowering Student Success

Week 8 – Group Handouts

 • • • •

8.1 Week 8 Group Cover Sheet 8.2 ADHD Knowledge Summary 8.3 Looking to the Future 8.4 Adaptive Thinking Summary

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Handout 8.2

ADHD Knowledge Summary

Knowing about ADHD • Increases insight • Reminds you to use strategies to cope more effectively

Employment • Try to find jobs that match your personality, your temperament, and the fact that you have ADHD • Many of the same strategies used for managing schoolwork (e.g., planners) can be adapted for use in work settings

Money management • Make an extra effort to manage spending and save money

Intimate relationships/marriage • The more that your partner understands, accepts, and supports you as an adult with many qualities, including ADHD, the more likely it is that you will have a mutually satisfying relationship

Parenting • Raising children requires a lot of organization, planning, and consistency • Many of the same strategies that you used for managing your schoolwork (e.g., use of a To-Do list) can be adapted for use in parenting

Handout 8.3



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Looking to the Future

Setting and Achieving Goals • Write down goals • Decide what goals you want to take action on –– Consider starting with a small goal to practice and build your confidence • Break down goals into manageable steps to move to your To-Do list • Write deadlines for each step in your planner • Think about what tends to get in the way -- how can you address these barriers • Monitor progress toward goals –– Each day, assess: • How much time did you spend working towards your goals • Identify what worked well • Identify what got in your way and what can you do differently tomorrow • Share your goals with family and friends to keep yourself accountable • Write your goal on a notecard and tape it somewhere you will see it each day • Spend time visualizing your goal and how good it will feel to achieve it • Build flexibility into your goals to allow for the unexpected

Maintaining Your New Skills • Identify the skills you found most helpful • Maintain progress by continuing to use skills • New skills need to be practiced regularly to become automatic • Everyone experiences challenges and setbacks –– Challenges are opportunities to work on problem solving –– Use adaptive thinking strategies • Take advantage of campus resources Remember, the goal is progress, not perfection! Recognize the progress you have made!

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Handout 8.4

Adaptive Thinking Summary

If you find yourself feeling distressed or doing counterproductive things: • Think back to events preceding these circumstances and analyze the thoughts that followed • Be on guard for maladaptive thinking patterns that can lead to emotional distress or counterproductive behavior

Remember, there is always more than one way to think about any situation. • Generate alternative thoughts that are realistic and believable to better manage emotions and behaviors

As you move forward, it may be helpful to reframe the past. • If you experienced past ADHD difficulties, remind yourself that these difficulties were the result of living with an untreated ADHD condition • Just because you have had past difficulties related to ADHD does not mean you will have the same difficulties in the future To maintain progress and keep improving, continue to use the skills and knowledge you have learned in ACCESS.

Week 8 – Mentoring Agenda

Week 8 – Mentoring Agenda Check-In Collaborative Agenda Setting Review Between-Session Practice Discuss Information Presented in Group Ending Mentoring Session Handouts • 8.5 Week 8 Mentoring Cover Sheet • 8.6 Planning for the Future • 8.7 ACCESS Content Summary

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Handout 8.5

ACCESS Accessing Campus Connections and Empowering Student Success



Week 8 – Mentoring Handouts • 8.5 Week 8 Mentoring Cover Sheet • 8.6 Planning for the Future • 8.7 ACCESS Content Summary

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Handout 8.6

Planning for the Future Think of examples of your progress from the past semester. This may include particular skills, achievements, or general broad areas where you showed improvement or progress. List examples of progress during ACCESS Active Phase 1.

2.

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List some of the important skills that helped you make progress. 1.

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Handout 8.7

ACCESS Content Summary ADHD Knowledge • What is ADHD –– Core Symptoms: Inattention, Impulsivity, Hyperactivity –– Situational Variability –– Behavioral Inhibition and Executive Functioning Deficits • What Causes ADHD? –– Neurobiological basis –– Genetics –– Dopamine • Assessment of ADHD –– Criteria for ADHD –– Different ADHD presentations –– Multiple Measures –– Multiple Sources • How ADHD Affects College Performance –– Increased demand for self-regulation –– Decreased external support • ADHD, Emotional Functioning and Maladaptive Behaviors –– Depression, anxiety, low self-esteem –– Emotion regulation issues; suicidal ideation –– Increased risk for substance abuse; some risky sexual behaviors –– Importance of protective factors • Medications Used in the Treatment of ADHD –– Stimulant and non-stimulant medications –– How medication works –– Common side effects • Is Medication the Only Way to Treat ADHD? –– CBT, DBT, Mindfulness –– ADHD Coaching, Campus Resources • ADHD Knowledge –– Why is ADHD Knowledge important? –– Finding employment that is a “good fit” –– Money management –– Personal relationships –– Parenting

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ACCESS Content Summary Behavioral Strategies • • • • •

•

•

• • •

•

• •

Use Campus Resources Use a Planner Use a To-Do List Prioritizing Strategies Organizational Strategies –– Organizing Time –– Organizing Class Materials –– Organizing Home Environment –– Organizing Finances Address Procrastination –– Know Why –– Break It Down –– Reward Yourself Get the Most From Classes –– Scheduling Classes Strategically –– Paying Attention During Class –– Note Taking Skills –– Getting Help From Professors Taking Exams –– Test-Taking Strategies and Tips Manage Papers and Long-Term Projects –– Break it Down and Start Early Healthy Lifestyles –– Staying Healthy (Eat, Sleep, Exercise) –– Stress Management –– Use Medication Effectively Handling Relationships –– Making and Maintaining Friendships –– Working in Groups –– Being Professional Goal Setting –– Strategies for Setting and Achieving Goals Maintaining Progress

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Handout 8.7

ACCESS Content Summary Adaptive Thinking • What is Adaptive Thinking –– Thoughts ➔ Feelings and Behaviors –– Goal of Adaptive Thinking: Realistic and Balanced Thoughts • Recognizing Maladaptive Thinking –– Types of Maladaptive Thinking • All-or-none • Jumping to conclusions (Mind Reading; Fortune Telling) • Overgeneralization • Catastrophizing • Mental filtering • Labeling • Personalization • Emotional reasoning • Should statements • Disqualifying the positive • Challenging Maladaptive Thinking –– Questions to Help Challenge Maladaptive Thinking • What is the evidence for and against the thought? • Is there an alternative explanation? • What is the worst that could happen? Could I live through it? • What is the effect of believing the thought? What is the effect of changing my thinking? • What would I tell a friend? • Manage ADHD-Related Thoughts to Improve Academics –– “I do better when I wait until the last minute” –– “I can never keep things organized” • Using Adaptive Thinking to Cope with Emotions and Maladaptive Behaviors –– “I’m never going to get better” –– “Everyone drinks a lot in college” • Using Adaptive Thinking to Stick with Treatment –– “I never finish anything” –– “I’ve always been like this—I can’t change” • Using Adaptive Thinking to Improve Relationships –– “I can never keep up with friends” –– “I don’t have time to have friends”

Chapter 11

Maintenance Phase

Although many students show numerous improvements in functioning at the end of the active phase, clinical trial research has shown that there can be slippage in these therapeutic gains following termination from treatment. For this reason and because ADHD is a chronic condition that persists across time, a semester-long maintenance phase was built into the ACCESS program. During the maintenance phase, students once again receive group treatment and individual mentoring. Both components, however, are scaled down from what they were during the active phase, such that only one group session and no more than six mentoring sessions are offered. The rationale for reducing the number of sessions is to help students successfully transition from the weekly support and guidance offered in the active phase to a state of greater autonomy by the end of the maintenance phase. This shift allows students to develop confidence in their ability to maintain progress and continue to improve after their participation in the maintenance phase of ACCESS has ended. Greater emphasis is also placed on reviewing and refining previously learned knowledge and skills rather than on presenting new information, with the mentoring component of ACCESS assuming primary responsibility for achieving this objective. By continuing to work with mentors throughout a second semester, students have an opportunity to achieve greater mastery using the skills and knowledge they learned during the active phase. Such mastery increases the likelihood that students will continue to display improvements in their daily functioning after they complete the ACCESS program.

Group Booster Session This booster session will be the only group session during the maintenance phase. It is described as a booster session because the focus is on reviewing and refining knowledge and skills from the active phase. The group booster session also serves

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the purpose of allowing students to reconnect with other members of their group and prompting them to plan for the new academic semester. For this reason, this 90-minute session is typically scheduled early in the new semester. During the session, students are asked to reflect on what knowledge, skills, and strategies were helpful last semester and to discuss their plans for maintaining their progress. As needed, a portion of the booster group time can be focused on troubleshooting – that is, identifying barriers to success and ways to remove such barriers. In addition, students are reminded to reconnect with their mentors and prompted to make use of other campus resources.

Beginning Group Booster Session Enthusiastically welcome the students back to the ACCESS program and conduct a brief check-in. Be sure to praise the group for resuming their participation in ACCESS during the maintenance phase. In addition to being reinforcing, such encouragement is a reminder that the ACCESS program staff, as well as the other group members, are a source of ongoing support. When conducting the check-in, consider asking: • • • •

How have you been doing since we saw you at the end of the last semester? How are you feeling about the upcoming semester? Have you finalized your class schedule? Are you excited about the courses you will be taking?

ADHD Knowledge Check for Questions about ADHD This section may be brief, depending on whether students have questions or concerns they want to discuss. Begin by providing an opportunity for the group to bring up any questions they may have about anything that was covered last semester, as well as any new questions about ADHD that may have arisen. No new material need be introduced. Remind the group that an important reason for including an ADHD knowledge component as part of ACCESS was to give them a better understanding of their own ADHD and to help them become more informed consumers of any future ADHDrelated assessment and treatment services. Time permitting, briefly highlight some of the major points of ADHD knowledge that were discussed during the active phase (e.g., situational variability of symptoms). To further engage students, ask the group to share what types of ADHD knowledge were especially helpful to them, and how it may have helped them.

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Behavioral Strategies Discussion of Strategies Begin by directing the group’s attention to Booster Handout 1.2 for a listing of many of the behavioral strategies presented in the active phase group sessions. Then ask the students to identify which strategies were most helpful and encourage them to elaborate on their use of these strategies. To facilitate this discussion, consider asking the following questions: • In what context did you use these strategies (e.g., academic tasks, social relations)? • How did using them improve daily life? • Did you encounter obstacles that made using them more difficult? • What did you do to overcome these obstacles? • Do you need any suggestions for improving your use of these strategies? Remind the group of the importance of continuing to use these behavioral strategies. Emphasize that the more they do so, the more mastery they will achieve and the more likely it is that these skills will become automatic. Also prompt the group to reflect on this learning process and to indicate whether some of these behavioral strategies have already become automatic. Conclude this section by reminding the group that continued behavioral strategy use is key to maintaining progress towards their academic, personal, and social goals. Planning Strategy Use Help students with their plans to implement behavioral strategies again this semester. First, start a conversation about what they have already done or plan to do in the current semester. Use the information students provided about their favorite strategies to guide this dialogue. For example, if students report using a planner was helpful, ask if they have purchased a planner or set up a digital planner already. The following prompts may be useful in starting this discussion: • What are your plans for using some of the behavioral strategies this semester? • Has anyone already begun using some of the strategies they found helpful last semester? If so, what strategy are you using? How is it going so far? Consider Potential Barriers In addition to discussing their successful use of behavioral strategies, ask the group to identify what might get in the way of continuing to use these newly acquired skills. Remind them that by considering this possibility, it will allow them to anticipate and have plans in place to overcome barriers, thereby increasing their chances

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for continued success. For example, if a student is concerned that they may forget to bring their planner to campus every day, prompt them to think of ways to remember this. This could include posting reminder notes on the refrigerator, bathroom mirror, or any other place where they would see it every day. Similarly, a student who frequently procrastinates could create a written procrastination plan with a list of steps to take to overcome the urge to procrastinate. This list could include “break the task into smaller steps,” “work on it for 15 minutes,” and “use adaptive thinking to deal with maladaptive thoughts.”

Adaptive Thinking Skills Check in on Use of Skills Check in with students about their use of adaptive thinking. Specifically, ask students if they have been able to recognize and label their own maladaptive thoughts, and assess whether they have been able to effectively challenge these thoughts and replace them with more adaptive thinking. Students generally report a variety of experiences—some students report a great deal of progress, whereas others may indicate they have struggled to continue using adaptive thinking. Praise any progress and remind students that continuing to use these skills will help them become more effective and automatic. Review and Refine Adaptive Thinking Skills Begin by asking students to discuss any difficulties they have experienced when using adaptive thinking skills. Some of the challenges that students commonly report include recognizing when they are engaging in maladaptive thinking and becoming too focused on whether a thought is true or not. To help students with the former issue, encourage students to look for emotions that are particularly strong as a cue that a maladaptive thought could be present. To address the latter, remind students that a more important question is whether the thought is helpful or unhelpful. To ensure that the group has a clear understanding of the adaptive thinking approach, work through one more example of the process of recognizing, challenging, and replacing maladaptive thoughts, using either a hypothetical example or a situation volunteered by a student. To facilitate this discussion, refer the group to Booster Handout 1.3. Wrap up this portion of the group session by reminding the group that recognizing and challenging maladaptive thinking patterns can help them cope with negative emotions and lead to positive changes in behavior.

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Ending Group Booster Session Because this is the final time the group will meet, it is important to end on a positive note. Set the tone for this discussion by congratulating students for attending group sessions during both semesters and by praising their commitment to self-­improvement and their participation in the ACCESS program. Next, prompt the group to take a step back and reflect on the things they may have gained from this group experience, whether it be ADHD knowledge, behavioral strategies, or adaptive thinking skills. To help students reflect on this, ask them to name one group-­related accomplishment from the past semester of which they are particularly proud. Students often mention using a planner consistently or learning to recognize and control maladaptive thoughts. If a student has trouble recognizing their own accomplishments, mention one or two examples of the progress they have made and then ask them to elaborate on these achievements. This helps to ensure that this discussion will be a positive experience for all.

Mentoring For most students, four to six mentoring sessions are generally enough to meet their needs during the maintenance phase. Scheduling of these sessions, as well as what is discussed in each session, is flexible and driven primarily by student preferences. The mentoring component of ACCESS is primarily responsible for achieving the objectives pertaining to (1) the fine tuning of previously learned knowledge and skills and (2) helping the mentee make the transition to greater independence. To this latter point, mentors intentionally assume a more Socratic style, allowing mentees to take on increasingly greater responsibility for what happens both during and between mentoring sessions.

Initial Maintenance Phase Mentoring Session The goal of this session is to orient mentees to maintenance phase mentoring. It is essential to devote time to discussing structure and expectations for maintenance phase mentoring, as these differ substantially from active phase mentoring. After orienting mentees to the changes, focus on collaboratively identifying the needs and goals of the mentees and engaging them in their planning to accomplish these goals.

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Check-In Take a few minutes to get a brief update on how the mentee has been doing since the final mentoring session of the active phase last semester. As needed, follow up on any topics previously noted as important to the mentee. Mentor: “Well, I know you were ready to reward yourself with some serious sleeping in over the winter break. Did you get a chance to rest like you wanted to?” Mentee: “Yes! I slept until noon for about 3 days straight. After that I caught up with friends and family and just ate a lot of my grandma’s cooking.” Mentor: “That’s great! I know you also had a short-term goal over the break of filling out paperwork to apply to study abroad next fall. Any updates on that?” Mentee: “My break went faster than I expected. I did print out the forms and filled out some of them, but I still need to finish up.” Mentor: “Ok, we can include planning for that in our agenda today.”

Collaborative Agenda Setting Before getting into the details of the agenda for this session, be sure that the mentee has a clear understanding of the purpose of mentoring during the maintenance phase and how this differs from the active phase last semester. Guide the mentee to a better understanding of how the program shifts as they continue to grow, improve, and integrate their newly acquired skill sets. Remind them that they can receive up to six mentoring sessions. The rationale for offering fewer sessions than was the case during active treatment is to help them gradually develop confidence in their ability to continue making progress after their participation in ACCESS has ended. Be sure to point out that maintenance phase mentoring will focus on providing them with ongoing opportunities to fine-tune the skills and knowledge that they learned during the active phase in order to achieve greater mastery. Also mention that an important shift that will take place, with the mentee taking on increasingly greater responsibility for what happens both during and between mentoring sessions. Make clear that all such changes are intended to give mentees the confidence and skill mastery necessary for continuing to display improvements in their daily functioning after they complete their participation in ACCESS. Mentor: “Last semester you developed a huge tool bag full of all kinds of tools. You learned information and tons of strategies  – organizational, study, emotional, social, thought, health, etc. Now we will make a shift – instead of the program dictating the topics and direction of mentoring, we can focus on the topics most important to you to an even greater degree.” Mentee: “So, I’m supposed to set the agenda now?” Mentor: “Well, yes…sort of! We can still do that together. We’ll tackle your goals and problem solve and strategize anything that is getting in the way of them. So, plan to bring ideas of what you would like to work on each time we meet. The

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idea now is to help you decide which tools to use and for you to get better at using them on your own. You are becoming the expert on your own needs. I will help by serving as resource and part of your support system.” Mentee: “Okay. Sounds good! Well, like I mentioned when I first got here, I decided to change my major over the break but now I’m feeling overwhelmed with making sure I know what credits I need.” Mentor: “Okay. We can include finding resources for that when we talk about your schedule for the semester. We will also review your current needs and goals. What other topics would you like to include today to help get your semester started on the right foot?”

Collaborative Planning Based on Current Needs and Goals The mentee may have a strong sense of their priorities for mentoring during the maintenance phase. In such a scenario, follow the mentee’s lead and help them address their goals by assisting in planning and trouble-shooting skills and strategy use. Some mentees, however, may be unsure about their goals and what would be most helpful to them. For such students, the topic headings listed below can serve as a guide for assessing areas of focus that may be most relevant. Daily Schedules Briefly review what the mentee has planned for the new semester. Identify classes they are taking, jobs they may be working, and other time commitments they may have. Determine if the mentee is still using a planner. If so, ask them to get out their planner and review their planner habits. If the mentee is struggling to use the planner this semester, this is a topic to return to throughout maintenance mentoring. It may also be beneficial to add this to the mentee’s goal sheet. Tip Focus on identifying and organizing tasks rather than executing these in the session. If the mentee has not started their planner, help them schedule a time to do that themselves.

Resources Determine what campus resources the mentee is using this semester. As needed, remind them of the process to connect with the disability office, student health, and other pertinent campus resources. Also bring to the mentee’s attention any campus resources that may be relevant for the first time this semester. For example, for a

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student nearing graduation, it may be helpful to explore the need for connecting with career services. Other questions to ask include: • Are you currently registered with the campus disability service office? –– If yes: Is there anything that needs to be done to follow up with services (e.g. give letter to professors, etc.) –– If no: What is the first step that can be done this week to do that? • Is there anything that needs to be done to continue care (e.g. schedule an appointment to renew medication prescription, schedule appointment to resume counseling)? • What other campus resources are you continuing to use? • Are there any other campus resources that might be good for you to begin using? Current Needs and Goals Review the notes from the previous semester before starting this session. Pay special attention to the Planning for the Future Handout 8.6 that was completed at the end of the last semester. Given that 1–2 months may have passed, revisiting this material will serve as a helpful reminder of the mentee’s strengths, challenges, goals, and use of strategies and resources, thereby getting this portion of the initial session off to a good start. Begin by giving enthusiastic and positive feedback for any follow-through on goals during the break. Next, follow up briefly on any strategies that the mentee planned to work on during the semester break. Remember, this session will primarily focus on identifying goals, with the mentee taking the lead. Throughout this discussion, help the mentee update their goals using the Goal Setting Handout 1.10. Specific questions to consider asking to address these issues include: • Are there any other new goals you would like to include for this semester? • You mentioned ____________ as areas of concern – what is a realistic goal in this area? • Are there any longer-term goals that you might want to include in your planning? For example, steps toward applying to graduate school, job hunting, internship planning, studying abroad, etc. • What goals do you have for this semester? For the next year? For the next 5 years? • How are you planning to balance various academic, social, and/or work demands on your time this semester? • What are some things that might get in the way of accomplishing your goals? • What strategies can you use to help you maintain progress towards your goals? Mentor: “Earlier you mentioned your semester-break goal of completing the paperwork for studying abroad. You said that you partially completed that but have more to do. What does that look like?”

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Mentee: “I need to finish the health form, order a transcript, and contact my French instructor to provide a reference for me.” Mentor: “Ok. Thinking about your strategies from last semester, what do you need to do?” Mentee: “I need to add it to my To-Do list and put time into my planner for when I will set time aside to do those things. Should only take me about 30 minutes. I can add that into my planner this afternoon!” Mentor: “Great, sounds like you can knock that goal out quickly. I’ll check in with you about it next time. You’ve got a good handle on how to use your tools to schedule your ‘To-Dos.’ Now, let’s think about your other short and long-term goals.” Identify ACCESS Content Areas Requiring Further Refinement Begin by asking the mentee if there are any aspects of the ADHD knowledge, behavioral strategies, or adaptive thinking information that they learned last semester that they would like to discuss over the course of maintenance mentoring. To facilitate this discussion, refer the mentee to the ACCESS Content Summary Handout 8.7. Because of time constraints, it may not be possible to discuss these at length in this first session. Acknowledge this time limitation and ask the mentee for their input on how best to prioritize the order in which these issues will be discussed, either in this initial session or in subsequent mentoring meetings. Regardless of when these issues are addressed, the following topic outlines can be used to guide these discussions. ADHD Knowledge  Address any areas of ADHD knowledge that the mentee may wish to discuss. This may include revisiting something they learned from the active phase or perhaps addressing something new that they read or heard about in between semesters. Pay attention to and clarify any misconceptions or myths about ADHD that the mentee may express throughout the session. Examples of questions that can be asked to guide this discussion include: • Do you have any lingering questions about any of the information you learned about ADHD last semester? • Have you read any articles or heard things from friends or family members that raise any new questions about ADHD? • Do you recall how being aware of the situational variability of ADHD symptoms can help you make decisions about course selections, jobs, etc.? • How might ADHD be impacting your academic performance, your relations with family and friends, or your emotional functioning? • Are you taking any medications for ADHD this semester; if so, how are things going? Behavioral Strategies  Determine which behavioral strategies the mentee is still using from the previous semester (e.g., planner, To-Do list), and help them identify which

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behavioral strategies they may wish to discuss and fine-tune during the current semester. Also, consider asking any of the following questions to guide this discussion: • What tasks do you have left from the To-Do list we created last semester? • What strategies have you been using to continue making progress towards your goals? • What are some challenges you anticipate as you continue working towards your goals? • How far in advance do you plan to start long term papers/projects? • Have you thought about how are you going to deal with procrastination this semester? • Have you looked into receiving tutoring? • Who else can be your support person? Do you have an accountability buddy? Adaptive Thinking  Briefly assess the mentee’s retention and continued use of adaptive thinking skills during the break. Help them identify which aspects of adaptive thinking they may wish to discuss, clarify, and continue working on this semester. Be sure to acknowledge their successes. Provide support and suggestions for improvement. To facilitate general discussion of adaptive thinking skills, consider asking: • Overall, how successful have you been in continuing to use adaptive thinking skills? • Have you continued to notice how your thoughts affect your feelings and your behavior? • Have you been able to catch yourself engaging in maladaptive thinking as it is happening or later as you reflect on the situation? • Is there a certain maladaptive thinking pattern you find yourself using most often? • Have you had any trouble generating more realistic alternative thoughts to replace maladaptive thinking? • Have you used your thought record to help you work through a difficult situation? • Can you think of an example of how using adaptive thinking helped you successfully resolve a difficult situation? If needed, use the thought record in Handout 3.7 to work through an example brought forward by the mentee (e.g., “I cannot do well this semester without the level of support provided by the ACCESS program last semester”). Mentor: “Did you notice what you just said as we were talking about talking about planning for this semester?” Mentee: “I know, I know… I said, I’ll probably go back to all my old habits and not do well this semester.” Mentor: “And how does a thought like that make you feel?” Mentee: “Totally unmotivated and down about myself.” Mentor: “Yes, and what can you do with that kind of thought?”

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Mentee: “I can replace it, so that my mood doesn’t get sabotaged with negative thinking.” Help the mentee challenge their initial thought and replace it with a more realistic and less upsetting thought. Now that they are in the maintenance phase, they will likely need very little prompting to do this and should be encouraged to take the lead. Mentor: “Ok, let’s hear it, then! What could you have said?” Mentee: “I could have said, ‘I feel stressed about getting back into these habits again without the group and seeing you as often. But I know how to do this, and I can still check in with you for pointers.’” Mentor: “All true statements. How does saying it that way feel?” Mentee: “It’s more motivating and makes me feel more optimistic. It reminds me that I have the tools I need, and I can be patient with myself as I get into a new semester. You are still a support and I have friends and family who can also help me be accountable to myself. Also, I’ve shown that I can do this, and I can do it again.” Mentor: “That’s great! You got it!”

Ending Mentoring Session Be sure to address any topics that did not fit into the planned discussion. Collaboratively schedule future sessions. As part of the process of fading out treatment, mentoring ideally should no longer occur weekly. To help the mentee develop greater confidence in their ability to be successful on their own, aim for scheduling up to six mentoring sessions every other week or every few weeks, at time points in the semester that will be most helpful to the mentee. Confirm the date/time of next appointment and ask the mentee to enter this information into their planner.

Tip The idea is to allow for more independent practice and for the mentee to shift to having accountability partners other than the mentor. This may be a topic to address if the mentee is struggling to identify friends, family members, appropriate university personnel, or other professionals who could serve in this role and provide ongoing support and encouragement.

Mid-Maintenance Phase Mentoring Session(s) As noted earlier, up to six mentoring sessions can be provided during the maintenance phase of the ACCESS program. The initial and final mentoring sessions require relatively more structure, and outlines for each are presented in this chapter. Because

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mentoring sessions that take place between the initial and final meetings are highly similar in purpose, they do not require unique descriptions and therefore a single generic session description is used for all mid-maintenance phase mentoring sessions.

Check-In After the initial maintenance mentoring session, each subsequent maintenance session should have a friendly and brief check-in that helps transition the mentee into the session. Whenever possible, include a personalized follow up on a topic that is pertinent to the mentee.

Collaborative Agenda Setting Collaboratively create an agenda for each session, including getting an update on how things have gone since the most recent mentoring session, and reviewing ongoing efforts to use previously learned knowledge and skills. If topics from the check­in seem to generate more conversation pertinent to the needs of the mentee, suggest adding these to the agenda. Tip Remember that one of the goals of the maintenance phase is to facilitate the transition from the mentor being the expert to the mentee having more mastery. Whenever possible, encourage the mentee to take a leadership role in the session while providing support, asking questions, and adding ideas as needed.

Collaborative Planning Based on Current Needs and Goals Check-in about any To-Do or practice items that were discussed in the previous mentoring session. Because mentoring sessions occur less frequently this semester, it may be useful to discuss new strategies for accountability and monitoring of progress. For example, many mentees may need to develop new strategies for monitoring their own progress toward their goals, completing items on their To-Do lists, and practicing new strategies. Mentee: “I really want to continue to schedule study and homework sessions like I did last semester. It saved my GPA!” Mentor: “Sounds good. What do you need to do to make that happen again?”

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Mentee: “Well, I know I can start by including it in my planner. I’ve already put in my class schedule, work-study job hours, and the due dates for major assignments.” Mentor: “That’s great. Is there anything else that would make sure that happens?” Mentee: “It helped knowing I was coming in to see you and you’d hold me accountable. Also, my reward system of watching the next episode of a TV show with my roommate after a study session made it fun. She said it even made her study better.” Mentor: “Sounds like she might be open to partnering with you on accountability by being a part of the reward. Instead of checking in with me, perhaps you can include her or other friends as study buddies.” Mentee: “I’ve tried studying with friends, but it’s too distracting.” Mentor: “Understandable. Instead, you can buddy up by agreeing to do your coursework at the same time. Then you can check in by text message to encourage each other, challenge each other to do ‘just 5 more’ minutes, and celebrate when you’ve met your goal by doing something fun for a little while.” Mentee: “Yes, that could work! She’ll like being a part of this. She got inspired last semester watching me make all these changes.” Topics that were not discussed during the initial maintenance mentoring session due to time constraints (e.g., ADHD knowledge, behavioral strategies, adaptive thinking) should be addressed during any one or combination of these mid-­ maintenance meetings. This may include reviewing information pertaining to knowledge of ADHD, helping the mentee fine-tune and practice behavioral strategies, and/or continuing to assist the mentee in refining their use of adaptive thinking skills. Not uncommonly, a mentee may spontaneously ask questions that clearly relate to ADHD knowledge, behavioral strategies, or adaptive thinking skills, creating a mentee-initiated opportunity to discuss them in greater detail. To promote greater independence, initially use a Socratic style of questioning to encourage the mentee to recall and utilize the tools and information they have previously used to be able to answer the question themselves. Should this approach not work, provide the answer for them on this occasion but do not be discouraged from trying this Socratic approach again. The more practice of this type given to the mentee, the better able they will be to answer similar questions on their own in the future. Mentee: “I’m doing pretty well staying on top of my assignments and other responsibilities. But the semester isn’t even halfway through and I’m already feeling burnt out.” Mentor: “What do you mean by burnt out?” Mentee: “Tired. But also, like I’m working all the time and I know that might make me lose motivation to stay on top of things.” Mentor: “You have been working really hard. It’s paying off but can take a toll. Do you remember what we talked about last semester related to maintaining a healthy lifestyle and some balance?”

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Mentee:  “You mean like getting sleep, getting exercise, planning time with friends… Stuff like that?” Mentor: “Yes, exactly. Why don’t we get out that handout and go over those for some refreshers on what you can do? You can identify a few things to help provide a healthy balance and prevent burnout.” Set New Goals Based on conversations with the mentee, identify activities and tasks for them to practice prior to the next mentoring session. This may include some of the same between-session tasks that were practiced during the active phase (e.g., using the planner, organization, etc.), or it may involve new practice items that are tailored to the needs of the mentee in the current semester. Regularly review the mentee’s goals on the Goal Setting Handout 1.10 throughout the semester to assess progress, to revise existing goals, and to add new goals as appropriate. As part of this review, be sure to refer to what the mentee learned about setting goals during the active phase (e.g., S.M.A.R.T goals). Also, be sure to remove any goals that the mentee has accomplished and to commend them on their progress.

Ending Mentoring Session Address any topics that did not fit into the planned discussion. Remind the mentee of how many mentoring sessions have been completed and how many remain. Confirm the date/time of next appointment and ask the mentee to enter this information into their planner. Maintain flexibility and reschedule upcoming mentoring sessions as needed to accommodate mentee priorities (e.g., finals week, registering for classes) and unexpected events (e.g., changes in their part-time job schedule).

Final Maintenance Phase Mentoring Session Check-In This is the last of the planned maintenance mentoring sessions and the official end of the ACCESS program. This is an important milestone for the mentee, so remember to greet them with enthusiasm for finishing. A celebratory favorite soda, snack, or playful “I did it!” certificate might be a fun way to commend the mentee for their success.

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As usual, briefly get an update on how the mentee has been doing since the last mentoring session. When relevant, follow up on a topic that you noted at the end of the previous session that was important to the mentee, but may not naturally come up during the regular agenda. Keep in mind that at this point in the program, the mentee will be getting close to the end of an academic semester and may have a specific project, paper, or important event that has been weighing on their mind. Checking in about this provides feedback in a caring way.

Collaborative Agenda Setting Collaboratively outline the session, including a check-in about any prior skills or material from the ACCESS program that the mentee would like to revisit. If topics from the check-in seem to generate more conversation pertinent to the needs of the mentee, suggest adding it to the agenda. Include a final wrap-up of the ACCESS program in the agenda. This is the mentee’s last mentoring session in the ACCESS program. Make sure to set aside time to revisit goals and assess growth, strengths, and areas for continued practice.

Collaborative Planning Based on Current Needs and Goals Check-in about any To-Do or practice items that were discussed in the previous mentoring session. To wrap-up with mentoring, make sure to revisit any remaining questions the mentee has about the ACCESS program, including any information related to ADHD knowledge, behavioral strategies, or adaptive thinking. It is very likely that the final mentoring session will occur close to the end of the semester, which allows the mentee to think about creating their master To-Do list, registering for classes, and breaking down large tasks for the remainder of the semester. This is a useful time to check with the mentee about these end of semester strategies. Discuss strategies for maintaining skills learned in the ACCESS program across time. It is useful to discuss any barriers that the mentee may face in using their new skills and problem solve as needed. Mentor: “So, how can you keep up all the gains you have made? Next semester, when you are a college junior and no longer in ACCESS, what happens?” Mentee: “Hopefully I’ll keep doing what I’ve been doing. I’ll have a planner and To-Do lists… all that.” Mentor: “And what if you get stuck?” Mentee: “I might freak out. But hopefully only for a few minutes. Then I’ll adjust my thoughts and remind myself that I have the tools. Then, if I can’t think of what to do, I’ll pull out my ACCESS handouts and look at my options.”

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Mentor: “Excellent! And in 5 years, when you’ve accomplished the goal you have set of obtaining a job in marketing and your boss gives you a huge project that feels overwhelming? Then what?” Mentee: “Ha! Same thing, I guess. Right now, I can say I would break the project down into parts and set smaller goals, schedule time, reward myself… all the things I’m doing now. And if I forget, I’ll dust off my ACCESS handouts and figure it out.” Many mentees often express concern that they will not be able to continue using their new skills without the support of their mentor. Address their concerns and provide encouragement for their many improvements throughout ACCESS, including their strengths and ability to connect with additional resources. Pay attention to any maladaptive thinking patterns that come up during this discussion. As needed, prompt mentees to use adaptive thinking skills. Seting New Goals For the last time, revisit the mentee’s goals listed on the Goal Sheet Handout 1.10. Identify the specific strategies from the ACCESS program that they want to continue using to reach their ongoing goals. Write this down on the goal sheet to remind the mentee about everything they have in their toolbox to help them reach their goals. It is also useful to ask the mentee to identify some of their biggest strengths or accomplishments throughout the ACCESS program. If the mentee struggles, help them reflect on their progress throughout the program and be prepared to offer encouragement and examples of growth. Ask the mentee to review their current goals and come up with a few new goals. These may be short- or long-term goals and may relate to academics (e.g., finish the semester strong, apply for graduate school), general life goals (e.g., exercise more, maintain a healthy life balance), or other goals relevant to the mentee. Make a copy of the mentee’s goal sheet and give it to them at the end of the session.

Ending Mentoring Session • Congratulate the mentee for successfully completing ACCESS! Remind the mentee of all that they have accomplished throughout the program and highlight some of their biggest improvements. • If desired, provide the mentee with a congratulatory certificate or snack as a reward for their completion of the program. • Provide the mentee with any needed materials or documentation (e.g., lost session handouts, copies of their goal sheets, etc.).

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Mentor: “Congratulations on completing the ACCESS program! You have done a ton of work, acquired lots of tools to use now and in the future, and become an expert on YOU!” Mentee: “I definitely feel like I have what I need to keep going with my education and feel less daunted about ‘adulting,’ too. But what am I going to do without you?” Mentor: “Just keep doing what you are doing. You have nicely transitioned from learning and practicing to a level of mastery, with me shifting to providing support as you problem solve on your own and stay accountable to yourself. You have also successfully made the transition to having other people in your life as accountability partners. As you move forward, aspire to progress, not perfection, and do keep in mind that there will be ups and downs as you continue to work towards your goals. For times when you might get stuck, you can always dig out your handouts as reminders and use your list of resources for any extra support. You have worked hard over the past two semesters and have made numerous changes in your approach that have allowed you to be more successful. You are ready! It has been a pleasure working with you. Congratulations!”

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Group Booster Session Agenda

Group Booster Session Agenda

ADHD Knowledge • Check for questions about ADHD

Behavioral Strategies • Lead a discussion of strategies students found most helpful • Guide students in planning strategy use for the current semester • Help students consider potential barriers

Adaptive Thinking Skills • Check in on students’ use of adaptive thinking skills • Review and refine adaptive thinking skills as needed Ending Group Session Handouts • Booster Group Cover Sheet 1.1 • Booster Handout 1.2 Review of ACCESS Strategies • Booster Handout 1.3 Adaptive Thinking

Booster Handout 1.1

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ACCESS Accessing Campus Connections and Empowering Student Success



Booster Group Handouts • Booster 1.1 Booster Group Cover Sheet • Booster 1.2 Review of ACCESS Strategies • Booster 1.3 Adaptive Thinking

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 • • • • • • • •

• •

Booster Handout 1.2

Review of ACCESS Strategies Make use of campus resources Use a planner Use a To-Do list and prioritizing techniques Create a study schedule Reinforce/reward yourself to stay motivated Create an optimal study space –– Limit social and sensory distractions Use distractibility delay to sustain attention Manage procrastination –– Understand why you procrastinate and use an appropriate strategy –– Feeling overwhelmed? Break down papers/projects into smaller steps –– Unhelpful thoughts? Use adaptive thinking Use organization strategies in academic work and at home –– Helps prevent losing things –– Helps prevent distracting clutter Stay healthy –– Eat well, and get enough sleep –– Exercise regularly and use stress management techniques

Degree of belief in alternative thoughts

New feelings/ Behaviors

(1) What is the evidence that the automatic thought is true? What is the evidence that the automatic thought is not true? (2) Is there an alternative explanation? (3) What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome? (4) What’s the effect of believing the automatic thought? What could be the effect of changing my thinking? (5) If a friend was in the situation and had this thought, what would I tell them?

Alternative thoughts

• All-or-None Thinking: Seeing things in “black and white” • Jumping to Conclusions: Making a negative interpretation with little to no evidence –– Mind Reading: Assuming that someone is reacting negatively –– Fortune Telling: Expecting a negative outcome to events • Overgeneralization: Interpreting a single negative event as broad truth • Catastrophizing: Expecting extreme and horrible consequences • “Should” Statements: Statements that include “should”; often reflect unrealistic expectations • Mental Filtering: Dwelling on a single negative detail of a larger situation • Disqualifying the Positive: Rejecting positive experiences by insisting they “don’t count” • Labeling: Attaching a broad negative label to yourself or others (extreme form of overgeneralization) • Personalization: Viewing negative events as evidence of negative characteristics; assuming things are somehow “your fault” • Emotional Reasoning: Interpreting negative emotions as evidence; “I feel it, so it must be true.”

Feelings/ Behaviors

Questions to help you challenge automatic thoughts

Automatic thoughts

Maladaptive Thinking Patterns

Situation

Adaptive Thinking

Booster Handout 1.3 237

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Initial Maintenance Phase Mentoring Agenda

Initial Maintenance Phase Mentoring Session Agenda Check-In Collaborative Agenda Setting Collaborative Planning Based on Current Needs and Goals Ending Mentoring Session Handouts • Maintenance Mentoring Cover Sheet 1.1 • 8.6 Planning for the Future • 1.10 Goal Setting • 8.7 ACCESS Content Summary • 3.7 Challenging Maladaptive Thinking: Individual Practice

Initial Maintenance Phase Mentoring Handout 1.1

ACCESS Accessing Campus Connections and Empowering Student Success



Initial Maintenance Phase Mentoring Handouts • • • • •

Maintenance 1.1 Maintenance Mentoring Cover Sheet 8.6 Planning for the Future 1.10 Goal Setting Form 8.7 ACCESS Content Summary 3.7 Challenging Maladaptive Thinking: Individual Practice

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Handout 8.6

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Planning for the Future Think of examples of your progress from the past semester. This may include particular skills, achievements, or general broad areas where you showed improvement or progress. List examples of progress during ACCESS Active Phase 1.

2.

3.

4.

5.

List some of the important skills that helped you make progress. 1.

2.

3.

4.

5.

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Handout 1.10



Goal-Setting Form Goal & start date 1.

2.

3.

4.

5.

Target date

Progress

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Handout 8.7

ACCESS Content Summary ADHD Knowledge

• What is ADHD –– Core Symptoms: Inattention, Impulsivity, Hyperactivity –– Situational Variability –– Behavioral Inhibition and Executive Functioning Deficits • What Causes ADHD? –– Neurobiological basis –– Genetics –– Dopamine • Assessment of ADHD –– Criteria for ADHD –– Different ADHD presentations –– Multiple Measures –– Multiple Sources • How ADHD Affects College Performance –– Increased demand for self-regulation –– Decreased external support • ADHD, Emotional Functioning and Maladaptive Behaviors –– Depression, anxiety, low self-esteem –– Emotion regulation issues; suicidal ideation –– Increased risk for substance abuse; some risky sexual behaviors –– Importance of protective factors • Medications Used in the Treatment of ADHD –– Stimulant and non-stimulant medications –– How medication works –– Common side effects • Is Medication the Only Way to Treat ADHD? –– CBT, DBT, Mindfulness –– ADHD Coaching, Campus Resources • ADHD Knowledge –– Why is ADHD Knowledge important? –– Finding employment that is a good fit –– Money management –– Personal relationships –– Parenting

Handout 8.7



• • • • •

•

•

• • •

•

• •

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ACCESS Content Summary Behavioral Strategies Use Campus Resources Use a Planner Use a To-Do List Prioritizing Strategies Organizational Strategies –– Organizing Time –– Organizing Class Materials –– Organizing Home Environment –– Organizing Finances Address Procrastination –– Know Why –– Break it Down –– Reward Yourself Get the Most From Classes –– Scheduling Classes Strategically –– Paying Attention During Class –– Note Taking Skills –– Getting Help From Professors Taking Exams –– Test-Taking Strategies and Tips Manage Papers and Long-Term Projects –– Break it Down and Start Early Healthy Lifestyles –– Staying Healthy (Eat, Sleep, Exercise) –– Stress Management –– Use Medication Effectively Handling Relationships –– Making and Maintaining Friendships –– Working in Groups –– Being Professional Goal Setting –– Strategies for Setting and Achieving Goals Maintaining Progress

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Handout 8.7

ACCESS Content Summary Adaptive Thinking

• What is Adaptive Thinking Thoughts → Feelings and Behaviors –– Goal of Adaptive Thinking: Realistic and Balanced Thoughts • Recognizing Maladaptive Thinking –– Types of Maladaptive Thinking • All or none • Jumping to conclusions (Mind Reading; Fortune Telling) • Overgeneralization • Catastrophizing • Mental filtering • Labeling • Personalization • Emotional reasoning • Should statements • Disqualifying the positive • Challenging Maladaptive Thinking –– Questions to Help Challenge Maladaptive Thinking • What is the evidence for and against the thought? • Is there an alternative explanation? • What is the worst that could happen? Could I live through it? • What is the effect of believing the thought? What is the effect of changing my thinking? • What would I tell a friend? • Manage ADHD-Related Thoughts to Improve Academics –– “I do better when I wait until the last minute” –– “I can never keep things organized” • Using Adaptive Thinking to Cope with Emotions and Maladaptive Behaviors –– “I’m never going to get better” –– “Everyone drinks a lot in college” • Using Adaptive Thinking to Stick with Treatment –– “I never finish anything” –– “I’ve always been like this—I can’t change” • Using Adaptive Thinking to Improve Relationships –– “I can never keep up with friends” –– “I don’t have time to have friends”

Degree of belief in alternative thoughts

New feelings/ Behaviors

(1) What is the evidence that the automatic thought is true? What is the evidence that the automatic thought is not true? (2) Is there an alternative explanation? (3) What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome? (4) What’s the effect of believing the automatic thought? What could be the effect of changing my thinking? (5) If a friend was in the situation and had this thought, what would I tell them?

Alternative thoughts

• All-or-none thinking • Jumping to conclusions • Mind Reading • Fortune telling • Overgeneralization • Catastrophizing • “Should” statements • Mental filtering • Disqualifying the positive • Labeling • Personalization • Emotional reasoning

Feelings/ Behaviors

Questions to help you challenge automatic thoughts

Automatic thoughts

Maladaptive Thinking Patterns

Situation

Challenging Maladaptive Thinking: Individual Practice

Handout 3.7 245

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Mid-Maintenance Phase Mentoring Agenda

Mid-Maintenance Phase Mentoring Session Agenda Check-In Collaborative Agenda Setting Collaborative Planning Based on Current Needs and Goals Ending Mentoring Session

Final Maintenance Phase Mentoring Agenda

Final Maintenance Phase Mentoring Session Agenda Check-In Collaborative Agenda Setting Collaborative Planning Based on Current Needs and Goals Ending Mentoring Session

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Index

A Academic performance ADHD affect college performance, 127 group session adaptive thinking, 116, 117 ADHD developmental challenge, 112, 113 ADHD knowledge, 112 assign between-session practice, 116, 117 behavioral strategies, 113 column analysis approach, 118 instructors, 115, 116 paying attention during class, 114 risk and protective factors, 112 school performance, 117 students’ ability, 114 taking notes, 115 mentoring session adaptive thinking, 123 ADHD knowledge, 119, 120 check-in, 118 choosing and scheduling classes, 121 collaborative agenda setting, 118, 119 getting help from professors, 122, 123 handouts, 126 paying better attention in class, 121, 122 review between-session practice, 119 taking notes, 122 treatment issues, 111 Accessing Campus Connections and Empowering Student Success (ACCESS) active phase group session, 13, 14 ADHD knowledge module, 13

CBT, 12, 14 clinical experience, 14 College STAR Project, 11 development, 10 diagnostic disclosure, 14 domains, 12 empirical support, 14–16 group portion, 14 group treatment, 14 implementing (see Implementing ACCESS) individual mentoring, 14 introductions (see Introductions) maintenance phase, 14 mentoring sessions, 13 participation goals, 52 planning (see Planning ACCESS) program description, 52 program orientation (see Program orientation) semesters, 12 therapeutic elements, 12 treatment delivery formats, 12 Active substance abuse conditions, 25 Active treatment phase, 53 Adaptive thinking, 13, 27–29, 33 academic performance assign between-session practice, 117 in-session practice, 117 school performance, 117 ADHD medications assign between-session practice, 160 treatment, 159 assessment of ADHD group session, 93–95 mentoring session, 99

© Springer Nature Switzerland AG 2020 A. D. Anastopoulos et al., CBT for College Students with ADHD, https://doi.org/10.1007/978-3-030-33169-6

249

250 Adaptive thinking (cont.) distractibility delay technique assign between-session practice, 138 negative emotions and maladaptive behavior, 137, 138 maintenance phase check-in, 220 review and refine adaptive thinking, 220 planners and To-Do lists group session, 71, 72 mentoring session, 76 program orientation, 41–42 group session, 56 mentoring session, 47 psychosocial treatments assign between-session practice, 179 transition planning fortune telling, 199 habit, 199 negative emotions/unproductive behavior, 199 past frustrations/failure experiences, 199 ADHD features characteristics, 38 developmental course, 38, 39 diagnosis, 38 neuropsychology, 39, 40 prevalence, 38 program orientation mentoring session, 46 situational variability, 39 symptom profiles, 38 ADHD medications emotional distress/risky behavior, 153 group participants, 153 group session adaptive thinking, 159, 160, 171 assign between-session practice, 159, 160 behavioral strategies, 156 break it down, 158 coping with side effects, 155, 156 essay questions, 157 managing papers and long-term projects, 157, 170 multiple choice questions, 157 professional boundaries, 154 rationale, 154 realistic goals for change, 156 stimulant, 154, 155 taking exams, 169 test-taking tips, 157

Index tips, 158 true/false questions, 157 handouts, 168 mentoring session adaptive thinking, 165, 166 ADHD knowledge, 161, 162 check-in, 160 collaborative agenda setting, 160 goals, 166 managing papers and long-term projects, 163, 164 review between-session practice, 161 taking exams, 162 test-taking strategies, 153 Amphetamine salt products, 155 Anxiety, 2, 5, 10, 91, 131, 132, 137, 139, 140 Appalachian State University (ASU), 11 Assessment issues college environment, 5 college students, 6 co-occurring conditions, 5 diagnosing ADHD, 4–5 document, 6 emerging adults, 6 irregularity, 6 parental input, 6 self-report, 6 subclinical, 6 and treatment, 6 Assessment of ADHD group session adaptive thinking, 93 addressing procrastination, 90, 91, 104 alternative thoughts, 94 behavioral strategies, 89, 90 diagnosis, 88 diagnostic criteria, 103 factors affecting, 103 feelings and behaviors, 95 general questions, 87 hearing, 88 information, 89 knowledge, 88 maladaptive thinking, 93–94, 107 multi-method assessment, 89, 103 organizational strategies, 91–93 presentations, 103 rate degree of belief, 94 symptoms, 88 variability, 89 mentoring session adaptive thinking, 99 behavioral strategies, 96–99 check-in, 95

Index collaborative agenda, 95 knowledge, 96 maladaptive thinking, 110 review between-session practice, 96 Attention-deficit hyperactivity disorder (ADHD) assessment issues (see Assessment issues) characterization, 1 college (see College students) conceptual understanding, 3 developmental course, 55 epidemiology, 2 executive functioning, 2 functional impairment, 2, 3 prevalence, 55 research and clinical interest, 1 self-regulation, 3 situational variability, 55 symptoms, 1, 2 treatment (see Psychosocial treatment) up-to-date knowledge, 1 young children, 1 Auditory reminders, 80 Autism spectrum disorders, 25 B Behavioral inhibition, 39, 40, 46 Behavioral skills, 13, 29 Behavioral strategies, 27 academic performance adaptive thinking, 123 assign between-session practice, 116 choosing and scheduling classes, 114, 121 getting help from professors, 122, 123 instructors, 115, 116 paying attention during class, 114 paying better attention in class, 121, 122 students’ ability, 114 taking notes, 115, 122 ADHD medications assign between-session practice, 159 break it down, 158 essay questions, 157 managing papers and long-term projects, 157 multiple choice questions, 157 test-taking tips, 157 tips, 158 true/false questions, 157 assessment of ADHD group session, 89–93 mentoring session, 96–99

251 distractibility delay technique attention span, 135 distributing study time, 133, 134 study space development, 134, 135 study tips, 136 studying effectively, 133 tasks/activities, 135 maintenance phase barriers, 219 planning strategy, 219 planners and To-Do lists group session, 66–70 mentoring session, 75 program orientation group session, 40–41 mentoring session, 47 psychosocial treatments assign between-session practice, 178 being professional, 177 handling relationships, 176, 177 healthy lifestyles, 174, 175 medication, 176 relaxation, 175 working in groups, 177 transition planning setting and achieving goals, 197, 198 skills, 198 Bipolar disorder, 25 Brain-based deficit, 2 Brain-based differences, 39 C Campus Resource Services Office, 43 Campus resources, 35, 40, 47, 49, 52, 58, 60, 66, 74, 202, 206 Causes of ADHD brain areas and functions, 65 consumers, 66 encourage group discussion, 64 in families, 79 genetic markers, 79 genetics, 65 neurobiology, 79 prefrontal cortex, 65 roles of nature vs. nurture, 64, 65 technology tools, 66 CBT principles, 41 Challenging thoughts, 93, 95, 101, 102, 108 Clinical assessment data, 4 Clinical guidelines, 23 Clinical interviews, 4 Clinical orientations, 23 Coaching approach, 8

Index

252 Cognitive-behavioral therapy (CBT), 8–12, 14, 17, 174, 188 College environment, 9 College STAR Project, 11 College students with ADHD, 1, 2, 5 and adults, 12 clinical management, 8 clinicians assessing, 6 co-occurring features, 8 first year, 5 functional impairments, 8 general population, 3 learning challenges, 11 long-term planning, 6 medications, 8 parental input, 6 periods of depression, 5 population, 10 psychosocial treatments, 17 stimulant medication trial, 7 treatment, 8 UNC Greensboro, 14 Confidentiality issues, 23, 30 Co-occurring conditions, 25 Cornell system, 115, 122 D Delayed treatment control (DTC), 15 Depression, 2, 5, 131, 132, 137, 140 Depressive disorders, 10 Developmental course, 38, 39, 55 Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), 4 Dialectical behavior therapy (DBT), 8, 9, 174, 188 Disability accommodations, 7, 8 Distractibility delay technique group session adaptive thinking, 137, 150 ADHD knowledge, 132 assign between-session practice, 138 attention span, 135 behavioral strategies, 133 distributing study time, 133, 134 mental health concerns, 132, 133 negative emotions and maladaptive behavior, 137, 138 study space development, 134, 135 study tips, 136 studying effectively, 133, 149 tasks/activities, 135 handouts, 147

mentoring session adaptive thinking, 144 ADHD knowledge, 140, 141 attention span, 143 check-in, 138, 139 collaborative agenda setting, 139 creating and sticking, study schedule, 141, 142 review between-session practice, 139 study space development, 142, 143 studying tips, 143, 144 Distractions, 121 Documentation, 25 Dopamine, 154 E East Carolina University (ECU), 11 Educational history, 44 Emotion regulation, 131, 132, 137 Emotional functioning, 148 Empirical support, 14–16 clinical trial, 14, 15 cost analysis, 16 demographic features, 16 group and mentoring sessions, 16 immediately/DTC, 15 maintenance phase, 15 outcome data, 15, 16 participation, 16 RCT, 15 Environmental factors, 65 Evidence-based knowledge, 40 Executive functioning, 46 F Face-to-face conversation, 42 Feeling overwhelmed, 90 Final maintenance phase mentoring session check-in, 230 collaborative agenda setting, 231 goals, 232 skills, 231, 232 Fortune telling, 116 G Genetics of ADHD, 65 Group booster sessions, 27 Group content orient students, 35 Group leader, 23, 24 Group members, 35

Index Group sessions delivering, 29, 30 implementing ACCESS, 27 time allocation, 29 Guest speakers, 23, 31 H Handouts, 33 Hyperactivity-impulsivity, 1 I Implementing ACCESS CBT program, 27 confidentiality issues, 30 group sessions, 27 guest speakers, 31 handouts, 33 mentoring sessions, 27–28 missed meetings, 31–32 portions, 33–34 Socratic questioning, 28 time allocation, 29 Inattention, 1 Interpersonal skills, 24 Introduction ACCESS is delivered, 36 beginning group session, 35, 36 and confidentiality, 42–43 meet mentors (optional), 37 participation and attendance, 36 planners and To-Do lists, 66 group session, 69 student expectations for progress, 37 K Knowledge review, 195 L Long-term projects, 153, 157, 163, 164 M Maintaining progress, 219 Maintaining relationships, 176 Maintenance phase, 27, 28 adaptive thinking, 237 greater emphasis, 217 group session adaptive thinking, 220, 244–247 ADHD knowledge, 218, 242

253 behavioral strategies, 219, 220, 243 goal-setting, 241–247 maladaptive thinking, 245 mentoring session adaptive thinking, 226 ADHD knowledge, 225 behavioral strategies, 225 check-in, 222 collaborative agenda setting, 222 current needs and goals, 224 daily schedules, 223 resources, 223, 224 treatment and individual mentoring, 217 Major depressive disorder, 5 Maladaptive behaviors, 148 Maladaptive negative thinking, 37 Maladaptive thinking, 15, 93–94 assessment of ADHD group session, 107 mentoring session, 110 planners and To-Do lists group session, 71, 72 Maladaptive thoughts, 71, 72, 74, 76 Managing procrastination, 90, 101 Masters degree level, 24 Mental health conditions, 5 types, 9 Mentor, 23, 24 Mentoring sessions delivering, 29, 30 implementing ACCESS, 27–28 time allocation, 29 Methylphenidate products, 155 Mid-maintenance phase mentoring session(s) ADHD knowledge, 229 check-in, 228 collaborative agenda setting, 228 goals, 230 Mindfulness, 174 Mindfulness-based cognitive therapy, 8, 9 Missed appointments, 23, 31–32 N National Resource Center for ADHD, 154 Neuropsychology, 39, 40 Note taking, 115, 122 O Obsessive-compulsive disorders, 25 One-on-one mentoring sessions, 24 On-line courses, 25

254 Optional mentoring, 185 Organization, time management and planning (OTMP) skills training, 8, 9 Organizational strategies group session between-session practice, 93 class materials, 92, 105 finances, 92, 106 and managing paperwork and email, 92 paperwork and emails, 105 time, 91, 92, 105 your home, 92, 106 mentoring session class materials, 97 finances, 98, 99 paperwork, 97, 98 time, 97 your home, 98 Organizational techniques, 113 Overgeneralizing, 116 P Perfect storm, 113, 119, 120, 127 Pharmacotherapy, 7, 8 Physical abuse, 30 Planners and To-Do lists group session adaptive thinking, 71, 72 addressing, 69 ADHD knowledge (see Causes of ADHD) assign between-session practice, 70, 73 behavioral strategies, 66 between-session practice, 64 completing unpleasant tasks, 69, 70 connections, mentors, 64 different strokes, folks, 67 introduction, 66, 69 maladaptive thinking, 71, 72, 82 practice, 68 prioritizing tasks, 70 reminders, planner use, 68 rules, 67, 68 three-column technique, 72 types, 67, 80 mentoring session adaptive thinking, 76 ADHD knowledge, 74, 75 behavioral strategies, 75 check-in, 73 collaborative agenda setting, 73, 74 maladaptive thinking, 86 review between-session practice, 74

Index Planning ACCESS provider qualifications, 23–24 scheduling, 26 student characteristics, 25–26 Prefrontal cortex, 65 Private practice, 34 Professional degree, 24 Program orientation group session adaptive thinking, 41–42 ADHD knowledge, 38–40 behavioral strategies, 40–41 introduction (see Introduction) mentoring session adaptive thinking, 47 ADHD knowledge, 46 background information form, 59–61 behavioral strategies, 47 campus resources, 60 check-in, 43 collaborative agenda, 44 differences, 45 goal-setting form, 61 introduction, 42–43 learning more information, 44 similarities, 45 strengths, needs and goals, 47–49 Progress chart, 37, 54 Progressive muscle relaxation (PMR), 181 Provider qualifications, 23–24 Psychosocial difficulties, 3 Psychosocial interventions, 8 Psychosocial treatments disability accommodations, 7, 8 group session adaptive thinking, 178, 191 ADHD knowledge, 173, 174, 188 assign between-session practice, 178, 179 behavioral strategies, 174 being professional, 177 handling relationships, 176, 177, 190 healthy lifestyles, 174, 179, 189 medication, 176 relationships strategy, 179 relaxation, 175 staying healthy, 175 working in groups, 177 handouts, 187, 193 interventions, 8 literature, 8–9 mentoring session adaptive thinking, 183, 184 ADHD knowledge, 180

Index being professional, 183 check-in, 179 collaborative agenda setting, 179 making and maintaining friendships, 182 maladaptive thinking pattern, 185 medication, 182 relaxation, 181 review between-session practice, 179, 180 staying healthy, 181 working in groups, 183 pharmacotherapy, 7, 8 Q Qualifications necessary, 23 R Randomized controlled trial (RCT), 15 Real-life activities, 36 Reference point, 37 Refining skills, 217, 229 Risky behaviors, 131, 132, 137, 140, 144 S Scheduling, 26 Screening, 25 Selecting classes, 112 Self-esteem, 131 Self-monitoring, 8 Self-regulating, 3 Set expectations, 36 Sexual abuse, 30 Situational variability, 39, 46, 55 Skill refinement, 195 Socratic questioning, 28 Straight-line fashion, 37 Stress-reduction strategies, 194 Student characteristics, 23, 25–26 Substance abuse, 140 Suicidal ideation and attempts, 2 T Test-taking strategies, 153, 166 Text messages, 41–42 Therapeutic process, 23 Thinking errors, 71, 76 Thoughts, 41, 42

255 Time management, 87, 97, 101 Training experience, 24 Transition planning adaptive thinking, 198, 199 behavioral strategies healthy lifestyle technique, 197 setting and achieving goals, 197 skills, 198 behavioral strategies setting and achieving goals, 198 group session ACCESS program, 195 adaptive thinking, 210 ADHD knowledge, 196 age, 196 behavioral strategies, 206 employment, 196 general questions, 195 knowledge, ADHD, 206, 208 maintenance phase, 206 money management, 196, 197 parenting, 197 personal relationships, 197 setting goals, 209 skils, 209 mentoring agenda adaptive thingking, 204 adaptive thinking, 216 ADHD knowledge, 202, 214 behavioral strategies, 202–204, 215 check-in, 200 collaborative agenda setting, 201 review between-session practice, 201 mentoring session, 195 Treatment adherence, 153 Trouble-shooting, 27 U University of North Carolina (UNC), 11 V Virginia Commonwealth University (VCU), 15 Visual aid, 37 Visual reminders, 80 W Written report, 25