Advancing the Multi-Informant Assessment of Sluggish Cognitive Tempo: Child Self-Report in Relation to Parent and Teacher Ratings of SCT and Impairment

A Multi-Method Examination of Peer Functioning in Children with and without Cognitive Disengagement Syndrome

OBJECTIVE

Cognitive disengagement syndrome (CDS) includes excessive daydreaming, mental confusion, and hypoactive behaviors that are distinct from attention-deficit/hyperactivity disorder inattentive (ADHD-IN) symptoms. A growing number of studies indicate that CDS symptoms may be associated with ratings of social withdrawal. However, it is important to examine this association in children specifically recruited for the presence or absence of CDS, and to incorporate multiple methods including direct observations of peer interactions. The current study builds on previous research by recruiting children with and without clinically elevated CDS symptoms and using a multi-method, multi-informant design including recess observations and parent, teacher, and child rating scales.

METHOD

Participants were 207 children in grades 2-5 (63.3% male), including 103 with CDS and 104 without CDS, closely matched on grade and sex.

RESULTS

Controlling for family income, medication status, internalizing symptoms, and ADHD-IN severity, children with CDS were observed during recess to spend more time alone or engaging in parallel play, as well as less time involved in direct social interactions, than children without CDS. Children with CDS were also rated by teachers as being more asocial, shy, and socially disinterested than children without CDS. Although children with and without CDS did not differ on parent- or self-report ratings of shyness or social disinterest, children with CDS rated themselves as lonelier than children without CDS.

CONCLUSIONS

Findings indicate that children with CDS have a distinct profile of peer functioning and point to the potential importance of targeting withdrawal in interventions for youth with elevated CDS symptoms.

The relationships of neuropsychological factors and loneliness preference in children with attention deficit hyperactivity disorder and cognitive disengagement syndrome

This study aimed to examine emotion dysregulation and internalizing disorders mediating the relationship between selective and sustained attention and loneliness preference in children diagnosed with attention deficit hyperactivity disorder (ADHD) and Cognitive Disengagement Syndrome (CDS). This study included 176 children and adolescents between ages 8 and 12. The solitude scale for children, Difficulties in Emotion Regulation Scale, Child Behavior Checklist, Barkley Sluggish Cognitive Tempo Scale, and CNS Vital Signs test were used. The results suggest that difficulties in emotion regulation and having an internalizing disorder had a mediating effect between difficulties in selective attention and preference for the loneliness of children with ADHD + CDS. Also, it was likely that the association between sustained attention and preference for loneliness is mediated by internalizing disorders. The results suggest that the social problems commonly exhibited by children with ADHD + CDS may be related to deficits in sustained and selective attention.

Cognitive disengagement syndrome and depressive symptoms in early adolescents: Examining the moderating role of a negative interpretation bias

BACKGROUND

Despite previous research demonstrating an independent association between cognitive disengagement syndrome (CDS; previously termed sluggish cognitive tempo) and depressive symptoms, studies have yet to examine what factors may moderate this link. A negative interpretation bias (i.e., maladaptive information processing whereby emotionally aversive meaning is perceived in ambiguous situations) is associated with the development and maintenance of depression and may moderate the association between CDS and depression. Using a multi-informant, multi-method design, this study examined whether negative interpretation bias exacerbated the association between CDS and depressive symptoms.

METHODS

336 adolescents (ages 10-12 years; 52.7% female; 61.9% White) and their caregivers completed measures of CDS and depressive symptoms. Adolescents completed the Scrambled Sentences Test, a task-based measure of interpretation bias. Regression analyses were conducted to examine interpretation bias as a potential moderator of the association between CDS and depressive symptoms.

RESULTS

For adolescent-reported depressive symptoms, higher caregiver- and adolescent-reported CDS symptoms and interpretation bias scores were each independently associated with higher depressive symptoms (all ps < .01), but CDS and interpretation bias did not interact in predicting depression (ps > .05). By contrast, significant CDS symptoms × interpretation bias interactions were found in models using both caregiver- and adolescent-reported CDS symptoms in relation to caregiver-reported depressive symptoms (ps = .01 and .003, respectively), such that CDS was more strongly associated with depression at higher levels of interpretation bias.

CONCLUSIONS

Negative interpretation bias strengthens the association between CDS symptoms and depressive symptoms when depressive symptoms are rated by caregivers, but not by adolescents. Findings highlight the importance of multiple informants when examining CDS and internalizing symptoms, with a need for longitudinal research to examine CDS and interpretation bias in relation to the progression and maintenance of depression across adolescence.

Mindful Awareness Practices (MAPs) in Adolescents With ADHD and Cognitive Disengagement Syndrome (CDS): A Pilot Open Trial

Objective: Very few studies have investigated intervention approaches that may be efficacious for youth with ADHD and co-occurring cognitive disengagement syndrome (CDS) symptoms. This study examined the feasibility, acceptability, and preliminary efficacy of a mindfulness-based intervention for adolescents with ADHD and co-occurring CDS symptoms. Methods: Fourteen adolescents ages 13 to 17 years (35.71% female; 64.29% White, 7.14% Black, 28.57% Multiracial) with ADHD and elevated CDS symptoms completed the 8-week group-based Mindful Awareness Practices (MAPs) program developed for individuals with ADHD. We collected measures of CDS, ADHD, mind-wandering, mindfulness, and other difficulties and functioning at baseline, 1-month post-intervention, and 3-month post-intervention to examine preliminary efficacy. We measured participant session attendance, session engagement, at-home practice adherence, and satisfaction of adolescents and caregivers at 1-month post-intervention to examine feasibility and acceptability. We also collected qualitative feedback from adolescents and caregivers at 1-month post-intervention. Results: The intervention was overall feasible to administer, and caregivers and adolescents reported satisfaction with the intervention despite some difficulties with attendance and engagement. We observed improvements to both caregiver- and adolescent-reported CDS symptoms and ADHD-inattentive symptoms from pre-intervention to post-intervention time points, though findings across 1- and 3-month follow-up differed based on informant. We also observed improvements to some indices of adolescent-reported mind-wandering, mindfulness, brooding rumination, and academic functioning. For caregiver report, the only other noted improvement was for executive functioning. No improvements were reported by teachers. Conclusions: Findings support the initial feasibility, acceptability, and preliminary efficacy of MAPs for adolescents with ADHD and co-occurring CDS symptoms on a range of outcomes. Larger trials with a randomized design are warranted to further examine mindfulness-based interventions for adolescents with ADHD and co-occurring CDS symptoms.

Clinical distinction between cognitive disengagement syndrome and ADHD presentations in a nationally representative sample of Spanish children and adolescents

BACKGROUND

This study sought to determine whether cognitive disengagement syndrome (CDS, formerly sluggish cognitive tempo) has different external correlates relative to ADHD-inattentive presentation (INP), ADHD-hyperactive/impulsive presentation (HIP), and ADHD-combined presentation (CP).

METHODS

Parents of a nationally representative sample of 5,525 Spanish youth (ages: 5-16, 56.1% boys) completed measures of CDS, ADHD-inattention (IN), and ADHD-hyperactivity/impulsivity (HI) and other measures. Scores greater/less than the top 5% on CDS, ADHD-IN, and ADHD-HI were used to create control (n = 5,013, 90.73%), CDS-only (n = 131, 2.37%), ADHD-INP-only (n = 83, 1.50%), ADHD-HIP-only (n = 113, 2.05%), ADHD-CP-only (n = 48, 0.97%), CDS + ADHD-INP (n = 44, 0.80%), CDS + ADHD-HIP (n = 25, 0.45%), and CDS + ADHD-CP (n = 68, 1.23%) groups.

RESULTS

Forty-nine percent of youth with clinically elevated CDS did not qualify for any ADHD presentation, whereas 64% of youth with clinically elevated ADHD did not qualify for CDS. The CDS-only group was higher than the ADHD-INP-only, ADHD-HIP-only, and ADHD-CP-only groups on anxiety, depression, somatization, daytime sleep-related impairment, nighttime sleep disturbance, and peer withdrawal, whereas the CDS-only and ADHD-INP-only groups did not differ on ODD (ADHD-HIP-only and ADHD-CP-only higher) and academic impairment (ADHD-CP-only higher than CDS-only and ADHD-HIP-only lower than CDS-only). The CDS-only group also had higher rates of anxiety, depression, and bipolar disorder diagnoses than the ADHD-only group.

CONCLUSIONS

A distinction was found between CDS and each ADHD presentation, thus providing support for CDS as a syndrome that frequently co-occurs with yet is distinct from each ADHD presentation.

Validity of Cognitive Disengagement Syndrome with Mother and Father Ratings of Brazilian Children: Replication of Northern Hemisphere Findings in South America

Although the Child and Adolescent Behavior Inventory (CABI) cognitive disengagement syndrome (CDS) scale has demonstrated validity relative to the CABI attention-deficit/hyperactivity disorder-inattention (ADHD-IN) scale with parent ratings of youth from North America, Europe, East Asia, and Central Asia, no study has evaluated the validity of the 15 symptom CDS scale with children from South America. Our purpose was to examine for the first time the validity of the CABI CDS scale with Brazilian children. Latent variable modeling procedures were used to examine the validity of CDS scores. Mothers and fathers completed measures of CDS, ADHD-IN, ADHD-hyperactivity/impulsivity (HI), anxiety, depression, and academic impairment on 366 Brazilian children (Mage = 8.64, SDage = 1.39, 53.3% females). First, the CDS symptoms showed strong internal validity with the ADHD-IN symptoms. Second, within and across sources, ADHD-IN showed stronger first-order and unique associations than CDS with ADHD-HI, whereas CDS, especially across sources, showed stronger first-order and unique associations than ADHD-IN with anxiety and depression. CDS and ADHD-IN were similarly associated with academic impairment. This study is the first to support the validity of CABI CDS scores with Brazilian children, thus replicating the findings in North America, Europe, East Asia, and the Central Asia in South America.

Examining ADHD and Cognitive Disengagement Syndrome Symptoms in Relation to Food Insecurity in Early Adolescents

Approximately 13.8 million U.S. households face food insecurity, which severely affects child development, with more than half of these households including children. Research links food insecurity to cognitive deficits and mental health challenges, highlighting the need for thorough understanding and intervention. Although existing studies have explored the association between food insecurity and internalizing symptomatology, less research has examined food insecurity in relation to attention-deficit/hyperactivity disorder (ADHD) symptoms. Further, no studies have explored the connection between food insecurity and cognitive disengagement syndrome (CDS) symptoms, closely related to ADHD symptoms. Despite extant research linking CDS to environmental factors, empirical attention to its potential association with food insecurity is notably lacking. Additionally, adolescents, almost twice as likely as younger children to experience household food insecurity, are likely more aware and respond differently to challenges during this developmental period. Accordingly, this study investigated the unique associations of parent-, teacher-, and youth self-reported ADHD dimensions and CDS symptoms in relation to parent-reported food insecurity in early adolescents (N = 136, ages 10-12). Controlling for age, sex, race, and medication use, no informant's ratings of ADHD symptom dimensions were uniquely related to food insecurity. In contrast, higher parent-, teacher-, and youth self-reported CDS symptoms were uniquely associated with greater food insecurity. This finding was robust to additional control of family income for teacher- and youth self-reported CDS symptoms. These findings highlight the complex link between food insecurity and mental health, suggest a connection with CDS symptoms, and stress the need to address food insecurity as a public health priority, especially in early adolescence.

The Comparison of Psychological Factors and Executive Functions of Children with Attention Deficit Hyperactivity Disorder and Cognitive Disengagement Syndrome to ADHD and ADHD Comorbid with Oppositional Defiant Disorder

OBJECTIVE

The study aims to examine family functionality, emotion regulation difficulties, preference for loneliness, social exclusion, internalizing and externalizing disorders, and executive functions in children with Attention Deficit Hyperactivity Disorder (ADHD) and Cognitive Disengagement Syndrome (CDS) and compare with ADHD, and ADHD+ Oppositional Defiant Disorder (ODD).

METHOD

This study included 842 children aged 8-12 years. The subjects were categorized according to DSM-V as ADHD (n = 246), ADHD + ODD (n = 212), ADHD + CDS (n = 176), and Control group (n = 207). The solitude and social exclusion, difficulties in emotion dysregulation and Barkley SCT scales, Child Behavior Checklist, family assessment device, and Central Vital Signs (CNSVS) test were used.

RESULTS

According to the study, children with ADHD + CDS had higher rates of internalizing disorders. They also preferred being alone and experienced more difficulty communicating with their parents and solving problems within the family. Additionally, these children had difficulty recognizing and understanding the emotional reactions of others. The ADHD + ODD group presented a poorer performance on CNSVS domain tests except for the psychomotor speed test than other groups. Also, ADHD + CDS children had the lowest psychomotor speed scores and lower scores on reaction time and cognitive flexibility than pure ADHD children.

CONCLUSION

This study will contribute to the etiology, treatment, and clinical discrimination of ADHD + CDS.

Cognitive Disengagement Syndrome-Clinical Interview (CDS-CI): Psychometric support for caregiver and youth versions

Cognitive disengagement syndrome (CDS), formerly termed sluggish cognitive tempo, is a set of symptoms characterized by excessive daydreaming, mental confusion, and slowed behavior/thinking. CDS is distinct from symptoms of attention-deficit/hyperactivity disorder (ADHD) and other psychopathologies and uniquely associated with functional impairment. However, despite significant progress in developing and evaluating rating scale measures of CDS, no clinical interview of CDS exists with established psychometric properties that can facilitate a multimethod approach assessing CDS. Accordingly, the present study evaluated the psychometric properties of the semistructured Cognitive Disengagement Syndrome-Clinical Interview (CDS-CI). The CDS-CI and the ADHD inattention (ADHD-IN) and hyperactive-impulsivity (ADHD-HI) modules from the Kiddie Schedule of Affective Disorders and Schizophrenia for School-Age Children (K-SADS) were administered to a sample of early adolescents (N = 341, ages 10-12 years) and their caregivers. Adolescents and caregivers also completed rating scale measures of CDS and ADHD symptoms. The CDS-CI demonstrated high internal consistency and interrater reliability. CDS-CI scores showed excellent same-source discriminant validity from K-SADS, ADHD-IN, and ADHD-HI scores and encouraging convergent and discriminant validity with rating scale measures, especially for caregivers. Above and beyond K-SADS, ADHD-IN, and ADHD-HI scores, higher parent and adolescent CDS-CI scores were both significantly associated with greater functional impairment. A threshold of ≥ 6 out of 15 symptoms was selected as an initial threshold for determining clinically elevated CDS using the CDS-CI. Findings provide psychometric support for the CDS-CI as a tool in the multimethod assessment of CDS. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Emotional Regulation Problems in Cognitive Disengagement Syndrome (formerly Sluggish Cognitive Tempo), Attention Deficit and Hyperactivity Disorder, Anxiety and Depression

Parents have reported emotional regulation problems in cognitive disengagement syndrome (CDS) and attention deficit and hyperactivity disorder (ADHD). The first objective of this research was to explore the differences between the parents' ratings on CDS, ADHD, hyperactivity/impulsivity, inattention, anxiety, depression and emotional dysregulation. The second one was to compare the predictive capacity of CDS and ADHD over anxiety, depression and emotional regulation problems. The third one was to analyze the mediation of emotional dysregulation in CDS, ADHD, hyperactivity/impulsivity, inattention, and anxiety and depression. The sampling used was non-probabilistic. The final sample consisted of 1,070 participants (484 fathers and 586 mothers) who completed the Emotion Regulation Checklist (ERC) and the Child and Adolescent Behavior Inventory (CABI). In relation to the first objective, first, mothers reported more emotional regulation problems in children than in fathers. Second, emotional regulation problems were more strongly correlated with hyperactivity/impulsivity. Significant differences were found in all father scores, except for anxiety and the emotional regulation subscale. Regarding mothers, significant differences were only observed in ADHD scores, hyperactivity/impulsivity, and depression. Both parents reported more problems in older children, except for hyperactivity/impulsivity scores and ADHD rated by mothers. According to the second objective, CDS scores were found to significantly predict anxiety and depression scores, but not those of inattention or emotional regulation problems. Finally, in relation to the third objective, emotional regulation problems mediated the relationships between CDS, ADHD, and anxiety and depression. In conclusion, the data support the importance of emotional regulation problems in understanding CDS and its relationship with ADHD, anxiety, and depression.

Unified and distinct cognitive control deficits in adolescents with cognitive disengagement syndrome and learning burnout

Introduction

Cognitive disengagement syndrome (CDS) is a psychological disorder characterized by daydreaming, mental fogginess, and slow thinking, while learning burnout (LB) is characterized by a passive and inattentive attitude toward learning. These two disorders are closely related but can be challenging to differentiate from one another. The present study aimed to identify shared and distinct cognitive control deficits between CDS and LB.

Methods

We recruited 136 adolescents (aged 14 to 17 years) from an initial screening of CDS and LB (N = 476) and divided them into four groups: CDS, LB, CDS + LB, and typically developing control. After a second screening, 129 adolescents completed two tasks to assess their attentional networks and cognitive control capacity (CCC).

Results

Adolescents with high CDS symptoms (both CDS group and CDS+LB group) exhibited impaired disengaging effect of attention and lower CCC, indicating deficits in orienting attention and the upper limit of information processing for cognitive control specifically. Furthermore, support vector machine modeling identified CCC as the most significant parameter differentiating the CDS and LB groups.

Discussion

Our findings suggest that while adolescents with high CDS and high LB symptoms have similar outward manifestations in the adolescent's school life, deficits in attention and cognitive control, particularly in the CCC, may distinguish between the two groups.

Multi-method examination of cognitive disengagement syndrome and ADHD inattentive symptoms in relation to early adolescents' academic functioning

Cognitive disengagement syndrome (CDS), previously referred to as sluggish cognitive tempo, is a set of symptoms characterized by excessive daydreaming, mental fogginess, and slowed behavior/thinking. Studies examining the association between CDS and academic functioning have reported mixed findings and have relied upon limited measures of CDS, broad ratings of academic impairment, and/or focused only on elementary-aged children. The current study examined the relationship between CDS and academic functioning in adolescents using a comprehensive, multi-informant, multi-method design. Participants were 302 adolescents (Mage = 13.17 years; 44.7% female; 81.8% White; 52% with ADHD) recruited in the fall of their 8th grade. Above and beyond ADHD inattentive symptoms, CDS symptoms were related to poorer homework performance, lower math fluency, and lower daily academic motivation across multiple informants, and teacher-reported CDS symptoms were related to lower grades. Findings were not moderated by ADHD diagnosis, suggesting that associations between CDS and academic outcomes do not differ for adolescents with and without ADHD. Findings demonstrate that CDS symptoms are uniquely associated with daily academic difficulties as well as global indices of academic performance. These findings have implications for assessing and monitoring CDS symptoms in interventions aiming to improve the academic functioning in adolescents with and without ADHD.

Assessing the mediating relationships between psychological factors in children with attention deficit hyperactivity disorder and cognitive disengagement syndrome

This study aims to investigate the predictive and mediating relationships between emotion dysregulation, internalizing disorders, family functionality, loneliness preference, and executive functions (EF) in children with attention deficit hyperactivity disorder and cognitive disengagement syndrome (ADHD + CDS). This study included 176 children and adolescents (92 boys, 84 girls) who were diagnosed with ADHD + CDS according to the Diagnostic and Statistical Manual of Mental Disorders, the Fifth Edition criteria by a fellowship-trained child and adolescent psychiatrist, between ages 8 -12 (M = 10, SD = 1.52) with a convenience sampling method. The solitude scale for children, difficulties in emotion dysregulation scale, Child Behavior Checklist, Barkley Sluggish Cognitive Tempo Scale, Family assessment device, and CNS Vital Signs test were used. The results showed that difficulty in emotion regulation, preference for loneliness, internalizing disorders and CDS symptom severity did not have a mediating effect between family functionality and EF. Still, emotion dysregulation mediates the relationship between EF and internalizing disorders by itself and through loneliness preference. Also, preference for loneliness and emotion dysregulation had a mediating effect between family functionality and internalizing disorders. Finally, it was found that the effect of emotion regulation difficulty, loneliness preference, and internalizing disorders had a mediating role between CDS symptom severity and family functionality. In conclusion, the information obtained from this study on the etiology of CDS may guide future studies.

Examining cognitive disengagement syndrome in a psychiatric outpatient sample: Psychometric support and associations with internalizing symptoms and sleep problems

OBJECTIVE

The internal (structural) and external validity of a self-report measure of cognitive disengagement syndrome (CDS, formerly sluggish cognitive tempo) relative to a self-report measure of attention-deficit/hyperactivity disorder-inattention (ADHD-IN) was evaluated with adults from university outpatient psychiatric clinics in Turkey.

METHODS

A total of 274 outpatients (75.9% women; ages 18-64 years; Mage  = 31.06; SDage  = 10.84; 50.4% anxiety disorders; 41.6% depressive disorders; 2.9% ADHD; 1.5% sleep disorders; 0.7% eating disorders; 2.9% no mental disorder) completed self-report measures of CDS, ADHD-IN, ADHD-hyperactivity/impulsivity (HI), sleep problems, depression, and stress.

RESULTS

All 15 CDS symptoms measured by the Adult Concentration Inventory (ACI) showed convergent (moderate to high loadings on the CDS factor) and discriminant (loading close to zero on the ADHD-IN factor) validity. CDS also showed stronger first-order and unique associations than ADHD-IN with sleep problems, depression, anxiety, and stress, whereas ADHD-IN showed stronger first-order and unique associations than CDS with ADHD-HI.

CONCLUSION

This is the first study to provide support for the scores from this 15 item self-report measure of CDS by the ACI in a clinical sample of adults, with findings consistent with previous studies examining parent and teacher rating scale measures with the same 15 CDS symptoms. These findings provide additional support for usefulness of these 15 CDS symptoms as measured by the ACI to study CDS across various cultures.

Cognitive disengagement syndrome in pediatric spina bifida

The primary aim of this study was to characterize Cognitive Disengagement Syndrome (CDS) symptomatology in youth with spina bifida (SB). One hundred and sixty-nine patients aged 5-19 years old were drawn from clinical cases seen through a multidisciplinary outpatient SB clinic at a children's hospital between 2017 and 2019. Parent-reported CDS and inattention were measured using Penny's Sluggish Cognitive Tempo Scale and the Vanderbilt ADHD Rating Scale. Self-reported internalizing symptoms were measured with the 25-item Revised Children's Anxiety and Depression Scale (RCADS-25). We replicated Penny's proposed 3-factor structure of CDS with slow, sleepy, and daydreamer components. The slow component of CDS overlapped heavily with inattention, while the sleepy and daydreamer components were distinct from inattention and internalizing symptoms. Eighteen percent (22 of 122) of the full sample met criteria for elevated CDS, and 39% (9 of 22) of those patients did not meet criteria for elevated inattention. Diagnosis of myelomeningocele and presence of a shunt were associated with greater CDS symptoms. CDS can be measured reliably in youth with SB and can be discriminated from inattention and internalizing symptoms in this population. ADHD rating scale measures fail to identify a substantial portion of the SB population with attention-related challenges. Standard screening for CDS symptoms in SB clinics may be important to help identify clinically impairing symptoms and design targeted treatment plans.

Psychometric Properties of the Turkish version of the Child and Adolescent Behavior Inventory Sluggish Cognitive Tempo Scale (CABI-SCT) in Children and Adolescents

Sluggish cognitive tempo (SCT) (cognitive disengagement syndrome) (CDS) describes a cluster of symptoms including slowness, lethargy, and daydreaming. This study aims to evaluate the psychometric properties of the Turkish version of the Child and Adolescent Behavior Inventory (CABI-SCT) scale and its relationship to other psychological difficulties. A total of 328 children and adolescents aged between 6-18 years were included in the study. CABI-SCT, Revised Child Anxiety and Depression Scale (RCADS), Barkley Child Attention Scale (BCAS), ADHD Rating Scale-IV, and Strengths and Challenges Questionnaire (SDQ) were administered to parents of participants. Reliability analysis demonstrated good internal consistency and reliability. Confirmatory factor analysis indicated that the one-factor model of the Turkish version of CABI-SCT is an acceptable construct. This study supports the validity and reliability of the Turkish version of CABI-SCT for use in children and adolescents providing initial data concerning the psychometric properties and difficulties associated with the Turkish version of the CABI-SCT.

Physical and Extracurricular Activity in Adolescents With and Without ADHD: Examining Group Differences and the Role of Cognitive Disengagement Syndrome Symptoms

OBJECTIVE

This study examined extracurricular and physical activity related to ADHD (diagnosis and symptoms) and cognitive disengagement syndrome (CDS) symptoms.

METHODS

Participants were 302 adolescents (ages 12-14) with and without ADHD and primary caregivers. ADHD diagnosis was determined with parent interview. Questionnaires provided information on parent-reported demographic characteristics, ADHD symptoms, and extracurricular activity involvement; and adolescent-reported ADHD and CDS symptoms and indices of physical activity.

RESULTS

Although ADHD diagnosis and symptom dimensions were correlated with less extracurricular and physical activity involvement, CDS symptoms were most often independently associated with these outcomes. Females and adolescents from lower income homes also often had less involvement in extracurricular and physical activity.

CONCLUSIONS

Findings point to the need for more research in this area, careful assessment of risk factors (i.e., CDS symptoms, economic burden), and interventions that address inactivity in adolescents with ADHD, including those that address inequity related to income and sex.

Comparing Cognitive Disengagement Syndrome Growth in Youth With and Without Spina Bifida

OBJECTIVE

Cognitive disengagement syndrome (CDS; formally known as sluggish cognitive tempo), difficulties with social engagement, and lower levels of autonomy have been identified as maladaptive comorbidities in youth with spina bifida (SB). This study compared growth curves of CDS for youth with and without SB and examined whether these trajectories were associated with later functioning.

METHODS

Longitudinal data spanning 8 years included youth with SB (n = 68, Mage = 8.34) and a demographically matched sample of typically developing (TD) peers (n = 68, Mage = 8.49). Adolescents, along with their caregivers and teachers, reported on youth social skills, behavioral functioning, and CDS. Growth curve models were examined by comparing CDS trajectories by SB status.

RESULTS

Growth curves indicated that youth with SB had higher levels of teacher-reported CDS at ages 8 and 9, but growth curves were relatively stable for both groups. When predicting social skills, higher levels of teacher-reported (but not mother-reported) CDS at baseline predicted worse social functioning for both youth with and without SB in adolescence. For the slope findings, higher rates of mother-reported CDS over time predicted worse social skills (β = -0.43) and lower levels of youth decision-making (β = -0.43) for the SB group, while higher rates of teacher-reported CDS predicted worse social skills for the TD group.

CONCLUSION

Next steps include understanding the impact that impaired social functioning and restricted autonomy have on youth with and without SB due to CDS to inform interventions. Additionally, advocacy for increased awareness of CDS-related impairment is needed, particularly for youth with chronic health conditions.

Cognitive Disengagement Syndrome and Child Sleep Problems in ADHD, Anxiety and Depression

The main objective of this study was to analyse the relationship and differential contribution of Cognitive Disengagement Syndrome (CDS) and sleep problems in children in different psychopathological measures. A total of 1133 participants (612 fathers/mothers and 521 children aged 7-13 years in Years 3-6 of Primary Education) completed the scales on CDS, sleep problems, depression (DEP), anxiety (ANX) and attention deficit and hyperactivity disorder (ADHD). Similar and significant correlations were identified in the measures of CDS and sleep problems between fathers and mothers, obtaining a high coefficient between the two parents. However, weak correlations were found between fathers/mothers and children. The scores of CDS and the sleep disturbance scale for children (SDSC) significantly predicted the internalising measures and ADHD, especially between SDSC and DEP. It was confirmed that sleep problems had a greater presence in the group of children with the highest ADHD scores, and especially in CDS and ADHD jointly. To conclude, the data indicate the importance of sleep problems in understanding CDS and its relationship with other psychopathological measures, especially ADHD, although to a greater extent with internalising symptoms, especially DEP.

Report of a Work Group on Sluggish Cognitive Tempo: Key Research Directions and a Consensus Change in Terminology to Cognitive Disengagement Syndrome

OBJECTIVE

The aim of this work was 2-fold: (1) to evaluate current knowledge and identify key directions in the study of sluggish cognitive tempo (SCT); and (2) to arrive at a consensus change in terminology for the construct that reflects the current science and may be more acceptable to researchers, clinicians, caregivers, and patients.

METHOD

An international Work Group was convened that, in early 2021, compiled an online archive of all research studies on SCT and summarized the current state of knowledge, noted methodological issues, and highlighted future directions, and met virtually on 10 occasions in 2021 to discuss these topics and terminology.

RESULTS

Major progress has been made over the last decade in advancing our understanding of SCT across the following domains of inquiry: construct measurement and stability; genetic, environmental, pathophysiologic, and neuropsychological correlates; comorbid conditions; functional impairments; and psychosocial and medication interventions. Findings across these domains are summarized, and potential avenues to pursue in the next generation of SCT-related research are proposed. Following repeated discussions on terminology, the Work Group selected "cognitive disengagement syndrome" (CDS) to replace "SCT" as the name for this construct. This term was deemed to best satisfy considerations that should apply when selecting terms for a condition or syndrome, as it does not overlap with established terms for other constructs, is not offensive, and reflects the current state of the science.

CONCLUSION

It is evident that CDS (SCT) has reached the threshold of recognition as a distinct syndrome. Much work remains to further clarify its nature (eg, transdiagnostic factor, separate disorder, diagnostic specifier), etiologies, demographic factors, relations to other psychopathologies, and linkages to specific domains of functional impairment. Investigators are needed with interests and expertise spanning basic, clinical, and translational research to advance our understanding and to improve the lives of individuals with this unique syndrome.

Pharmacologic Management of Cognitive Disengagement Syndrome (CDS) and Implications for Attention-Deficit/Hyperactivity Disorder (ADHD) Treatment: Emerging Treatments and Recommendations for Future Research

Although the study of cognitive disengagement syndrome (CDS; previously called sluggish cognitive tempo) first emerged in the 1980s, very little is known about treating CDS or its impact on evidence-based interventions for attention-deficit/hyperactivity disorder (ADHD) with which it frequently co-occurs. The objective of this leading article was to investigate the existing evidence on medication treatment and CDS, including studies that have examined CDS response to medication and CDS as a moderator of ADHD treatment response. A total of seven studies were identified. At present, the limited existing literature suggests that psychostimulants such as methylphenidate and lisdexamfetamine, as well as atomoxetine, may improve CDS symptoms, although replication and research on related medications is needed. However, there are indications that CDS symptoms may predict a reduced response to methylphenidate in children with ADHD. Although untested, research on the neurobiological, neuropsychological, and behavioral correlates of CDS point to a possible benefit of other ADHD medications (e.g., guanfacine), medications that treat narcolepsy (e.g., modafinil), and medications traditionally used to treat depression and anxiety (e.g., viloxazine, bupropion, fluvoxamine), some of which have also recently been used in ADHD management. The article concludes with recommendations for future research on pharmacologic treatment and CDS.

Sluggish Cognitive Tempo Self Report Scale (SCT-SR): Development and Initial Validation Study

OBJECTIVE

Sluggish Cognitive Tempo (SCT) is a psychological construct consisting of daydreaming, confusion, slowness in movements, lethargy, and low motivation. It is important to develop a self-report scale to evaluate SCT symptoms in children and adolescents in order to meet the following needs; (1) Considering the closeness of SCT symptoms with internalized symptoms, it can provide more reliable information, (2) It allows information to be obtained from multiple informants, and (3) The main symptoms of SCT include subjective experiences such as daydreaming and mind wandering that may be difficult to observe from the outside. Therefore, it was aimed to develop a self-report SCT scale.

METHOD

A total of 467 adolescents and 178 parents participated in the study. Data were collected with scales.

RESULTS

The scale consists of 20 items and a single factor. Factor loadings were between 0.60 and 0.81.

CONCLUSION

Sluggish Cognitive Tempo Self-Report Scale is a valid and reliable self-report scale.

Sluggish Cognitive Tempo (Cognitive Disengagement Syndrome) and Academic Functioning: A Systematic Review and Agenda for Future Research

The past two decades have witnessed substantial interest in sluggish cognitive tempo (SCT), a set of symptoms (e.g., excessive daydreaming, mental confusion, slowed behavior) distinct from attention-deficit/hyperactivity disorder (ADHD) and other psychopathology symptoms. Despite evidence linking SCT to a range of functional outcomes, findings for academic functioning are unclear. The current review summarizes the literature on SCT and academic functioning and offers an agenda for future research. A systematic review was conducted to identify studies assessing SCT and academic outcomes, including academic impairments and performance, in childhood, adolescence, and young adulthood. Sixty studies were retained (53 cross-sectional, 7 longitudinal) from 44 separate samples, with the majority (n = 32, 53%) assessing global ratings of academic impairment and fewer measuring specific academic domains or standardized achievement test scores. Findings were generally consistent in showing SCT to be correlated with global ratings of academic impairment, lower grades, and inconsistently associated with poorer math and reading scores. Findings were more mixed when controlling for ADHD symptoms, intelligence, and/or demographic factors. Overall, SCT is associated with poorer academic functioning, although inconsistencies and key limitations are common across studies. Ten directions for future research are offered to advance understanding of how SCT may be associated with or impact academic functioning.

Cognitive Disengagement Syndrome (Sluggish Cognitive Tempo) and Social Withdrawal: Advancing a Conceptual Model to Guide Future Research

OBJECTIVE

Cognitive disengagement syndrome (CDS, previously referred to as "sluggish cognitive tempo") is a set of symptoms defined by excessive mind-wandering, mental confusion, and slowed behaviors separable from ADHD inattention.

METHOD

Of the studies examining CDS in relation to psychosocial outcomes, one of the most established correlates of CDS is social withdrawal. However, studies have yet to test mechanisms or moderators of the link between CDS and social withdrawal.

RESULTS

As a parallel body of literature exists in developmental psychopathology on predictors and outcomes of social withdrawal, this review merges these literatures to identify themes and advance a conceptual model on mechanisms (e.g., task-unrelated thought, poorer social skills, social anxiety) and moderators (e.g., behavioral inhibition, sex, parenting) of the CDS and social withdrawal link.

CONCLUSION

This model provides researchers and clinicians with testable hypotheses to better understand the link between CDS and social withdrawal and to identify treatment targets to improve the social engagement of youth with CDS.

A multi-method examination of sluggish cognitive tempo in relation to adolescent sleep, daytime sleepiness, and circadian preference

BACKGROUND

The field's understanding of the association between sluggish cognitive tempo (SCT) and sleep is severely limited by the lack of multi-method and multi-informant research designs that move beyond global ratings, often focused on a limited number of sleep-related domains, such as daytime sleepiness. The current study begins to address these limitations by using actigraphy, daily sleep diary, and self- and parent-report global ratings of sleep in adolescents, a developmental period marked by changes in SCT, sleep, and circadian function. As SCT and sleep are also associated with ADHD symptoms, we tested these associations in a sample of adolescents with and without ADHD.

METHODS

Adolescents (N = 302; M age = 13.17 years, 44.7% female) with (n = 162) and without ADHD (n = 140) and parents completed global ratings of sleep and daytime sleepiness, and adolescents completed a measure of circadian preference. Adolescents also wore actigraphs for approximately two weeks, during which daily diaries were completed.

RESULTS

Above and beyond demographic characteristics (i.e., sex, race, and family income), pubertal development, medication use, and ADHD group status, adolescents' self-reported SCT symptoms were uniquely associated with shorter sleep duration and later sleep onset per both actigraphy and daily diary. SCT symptoms were also uniquely associated with longer sleep onset latency and poorer overall sleep (per daily diary), more sleep/wake problems and daytime sleepiness (per adolescent rating), more difficulties initiating and maintaining sleep (per parent rating), and later eveningness preference (per adolescent rating). Nearly all significant effects remained in sensitivity analyses controlling for adolescent- or parent-reported ADHD symptom dimensions.

CONCLUSIONS

Findings provide the strongest evidence to date for SCT being uniquely linked to poorer sleep, greater daytime sleepiness, and a later evening circadian preference across subjective and objective measures. Longitudinal studies are needed to evaluate predictive and bidirectional associations.

Low School Support Exacerbates the Association between Peer Difficulties and Sluggish Cognitive Tempo in Adolescents

OBJECTIVE

Although peer difficulties and sluggish cognitive tempo (SCT) are related, studies have yet to examine environmental factors that may advance further understanding of this association. The current study tested whether peer difficulties, specifically social competence and peer victimization, interacted with school support, a component of school climate, in relation to adolescents' SCT symptoms. Further, we explored whether these relations would be differentially associated with SCT in adolescents with and without attention-deficit/hyperactivity disorder (ADHD).

METHOD

Adolescents (N = 288; Mage = 14.08, 45% female, 82.6% White; 52% with ADHD) completed measures of social competence, peer victimization, school climate support, and SCT and ADHD inattentive (IN) symptoms. Parents also reported on adolescents' social competence, SCT, and ADHD-IN symptoms.

RESULTS

Results indicated that adolescent and parent ratings of lower social competence were both associated with higher adolescent-reported SCT symptoms in the context of low, but not high, school support. Relational and nonphysical victimization were associated with higher self-reported SCT symptoms in the context of low school support. Lower adolescent- and parent-reported social competence were also related to higher parent-reported SCT symptoms, with these associations not moderated by school support. These results remained after controlling for demographics and ADHD-IN symptoms and were similar across adolescents with and without ADHD.

CONCLUSIONS

Findings from the current study are the first to provide evidence that peer difficulties and school climate are jointly related to adolescents' self-reported SCT and underscore the importance of continued research investigating social adversity and environmental factors in relation to SCT.

The Associations Between Sluggish Cognitive Tempo, Internalizing Symptoms, and Academic Performance in Children With Reading Disorder: A Longitudinal Cohort Study

OBJECTIVE

To investigate whether sluggish cognitive tempo (SCT) was associated with anxiety, depression, and academic performance (AP) in children with reading disorder (RD), and whether ADHD-Inattention (ADHD-IN) moderated these relationships.

METHOD

Parents and teachers of children with RD (N = 147, ages 6-18) completed evaluations of SCT, ADHD, anxiety, depression, and AP, every 3 months for 18 months. Baseline and longitudinal associations between SCT and outcomes, and effect moderation of ADHD-IN, were assessed.

RESULTS

Teacher-rated SCT was positively associated with teacher-rated anxiety (p < .001) and negatively associated with AP (p < .001) cross-sectionally and longitudinally, with significant effect modification by ADHD-IN for both outcomes. SCT was not associated with depression in adjusted cross-sectional and longitudinal analyses. There were no significant findings for any parent-reported measures.

CONCLUSION

SCT has negative effects on anxiety and AP in children with RD among individuals with low ADHD-IN according to teacher report. Targeted treatment of SCT may provide substantial benefits.

Impact of a Behavioral Sleep Intervention in Adolescents With ADHD: Feasibility, Acceptability, and Preliminary Effectiveness From a Pilot Open Trial

OBJECTIVE

An open trial tested the feasibility, acceptability, and preliminary effectiveness of a behavioral sleep intervention in adolescents with ADHD.

METHOD

Fourteen adolescents (ages 13-17 years; 50% male) with ADHD and co-occurring sleep problems received the cognitive-behavioral-based Transdiagnostic Sleep and Circadian Intervention for Youth (TranS-C). Adolescent, parent, and teacher ratings, actigraphy, and daily sleep diaries were collected at pre-intervention, post-intervention, and 3-month follow-up.

RESULTS

Adolescents experienced moderate to large improvements in sleep, mental health symptoms, and daily life executive functioning from pre-treatment to post-treatment, and improvements were generally maintained at 3 months. Pre-intervention, 71.4% of adolescents were classified as poor sleepers and this was reduced to 21.4% and 28.6% at post-treatment and follow-up, respectively.

CONCLUSION

This study provides strong preliminary evidence that TranS-C improves sleep and associated outcomes in adolescents with ADHD and co-occurring sleep problems. A randomized controlled trial is needed to rigorously test the efficacy of TranS-C in this population.

Longitudinal Association of Sluggish Cognitive Tempo with Depression in Adolescents and the Possible Role of Peer Victimization

It is unknown whether sluggish cognitive tempo (SCT) is prospectively associated with depression in adolescence, and possible processes linking SCT to depression remain unexamined. Using a longitudinal study with three timepoints over a two-year period, the current study tested the indirect effects of SCT on depression via peer victimization, specifically physical, relational, and verbal victimization. Participants were 302 adolescents (M_age = 13.17 years; 44.7% female participants; 81.8% White; 52% with ADHD). In the fall of 8th grade, adolescents and parents completed measures of adolescents' SCT and ADHD symptoms. Adolescents completed a measure of peer victimization in spring of 8th grade and a measure of depressive symptoms in 10th grade. Models examining indirect effects were conducted with and without control of baseline ADHD and/or depressive symptoms. Across analyses, adolescent and parent ratings of SCT symptoms uniquely predicted greater depressive symptoms two years later when controlling for adolescent sex, study site, and either 8th grade depressive or ADHD symptoms. Further, adolescents' self-reported 8th grade SCT symptoms predicted 10th grade depressive symptoms via verbal victimization when controlling for 8th grade ADHD symptoms, but not in analyses incorporating 8th grade depressive symptoms. Findings underscore the predictive association of SCT on depressive symptoms, the possible role of adverse peer relationships as a mechanism linking SCT to depression, and the importance of considering ADHD and depressive symptoms in research on longitudinal correlates of SCT.

Working memory and cognitive flexibility predict growth trajectories of sluggish cognitive tempo in youth with spina bifida

As sluggish cognitive tempo (SCT) shows similar inattention and neuropsychological dysfunction as youth with spina bifida (SB), it is important to examine whether neuropsychological functioning may affect the development of SCT in this population. Participants were 140 youth with SB and their parents who participated in five waves of a longitudinal study across eight years (ages 8-15 years at Time 1). At Time 1, teacher-, mother-, and father-report of SCT showed 9%, 8.3%, and 5.3% impairment in SCT respectively compared to other youth in the sample. Growth curves were used to examine changes over time in mother-, father-, and teacher-reported SCT. Four neurocognitive variables were included (attention, working memory, cognitive flexibility, plan/organize) as predictor variables of SCT growth and intercepts. Mother, father, and teacher-report of SCT were included in separate models. Age and shunt status were included as covariates in the growth models. Inattentive symptoms were also included as a covariate in working memory, shift, and plan/organize models. Worse working memory at Time 1 predicted an increase in mother-reported SCT symptoms over eight years (β = -.28) and poorer cognitive shifting skills predicted higher rates of teacher-reported SCT over time (β = -.61). All other neurocognitive variables predicted the intercept, but not the slope of SCT symptoms. Results indicate that worse neurocognitive functioning is associated with higher levels of SCT symptoms and that worse working memory and cognitive flexibility at baseline predicted an increase in SCT symptoms as youth with SB age. It may be important for clinicians to monitor and assess levels of SCT in youth with SB.

Depression and learning problems in children: Executive function impairments and inattention as mediators

This study examines the relationship between depression and learning problems in children, focusing on the mediating role of executive function impairments and inattention. A sample of 115 children, aged 7 to 12 years, who had difficulties in school activities, were tested over the past three years, with different measures assessed by different raters. Regression analyses were employed in analyzing the data. The psychometric tests used were Child Depression Inventory (CDI) and Conners 3rdEdition. Children with a high level of depressive symptoms have also a very high level of learning problems, executive function impairments and inattention. Executive function impairments and inattention add significant explanatory variance for learning problems in school-aged children over and above depression. Executive function impairments and inattention have a partial mediating effect on the relationship between depression and learning problems. The assessment of the executive functions and attention is an important part in the assessment of children with depression; intervention and treatment programs for depression should include components focused on executive functions and attention.

Sluggish Cognitive Tempo and Daytime Sleepiness Mediate Relationships Between Sleep and Academic Performance

OBJECTIVE

Sleep difficulties, daytime sleepiness, and sluggish cognitive tempo (SCT) are associated with impairments in academic performance. SCT refers to symptoms of sluggishness, tiredness/lethargy, and slowed thinking/processing, but despite symptom overlap with sleepiness, research examining interrelations of SCT with sleep and daytime sleepiness is limited. The aims of this study were to evaluate the relationship between SCT and daytime sleepiness and to examine pathways between sleep, daytime sleepiness, SCT, and academic performance.

METHOD

Participants were a community sample of 1628 parents/caregivers of children aged between 6 and 10 years who completed questionnaires about their child's behavior, sleep, and academic performance. Confirmatory factor analysis was used to examine whether SCT was distinct from daytime sleepiness. Then, structural equation modeling was used to examine direct and indirect pathways between sleep (sleep-disordered breathing [SDB] symptoms, sleep duration, and latency), daytime sleepiness, SCT, and academic performance in reading, writing, and math.

RESULTS

SCT and daytime sleepiness were distinct but moderately correlated (r = 0.33, p ≤ 0.001). Sleep, in particular SDB symptoms, predicted increased SCT and daytime sleepiness. SCT was directly and negatively associated with all domains of academic performance, daytime sleepiness was associated with poorer reading performance, and longer sleep duration was directly associated with poorer math performance. SCT and, to a lesser extent, daytime sleepiness mediated effects of sleep on academic performance.

CONCLUSION

SCT symptoms are important for understanding how sleep difficulties affect academic performance in children. Sleep, daytime sleepiness, and SCT are interrelated but distinct factors that affect children's academic performance.

Sluggish Cognitive Tempo Symptoms, But Not ADHD or Internalizing Symptoms, Are Uniquely Related to Self-Reported Mind-Wandering in Adolescents With ADHD

Objective: The purpose of this study was to test the relation between sluggish cognitive tempo (SCT) symptoms and self-reported mind-wandering in a sample of adolescents with ADHD. Method: Adolescents (N = 79; aged 13-17 years; 70% male) diagnosed with ADHD completed measures of SCT, ADHD, anxiety, and depression symptoms, in addition to mind-wandering. Parents also provided ratings of adolescents' ADHD symptoms. Results: All adolescent-reported psychopathology dimensions, including ADHD, internalizing, and SCT, were significantly bivariately correlated with greater mind-wandering. However, in regression analysis that considered psychopathologies simultaneously, SCT was the only dimension uniquely associated with greater mind-wandering. This finding was unchanged when parent-reported ADHD symptoms were included in the model. Conclusion: These findings are the first to show that SCT symptoms are uniquely related with self-reported mind-wandering in adolescents with ADHD and underscore the importance of considering co-occurring SCT symptoms when testing the interrelations between ADHD and mind-wandering. Replication is needed in larger samples and with other measures of mind-wandering.

Prospective impact of COVID-19 on mental health functioning in adolescents with and without ADHD: protective role of emotion regulation abilities

BACKGROUND

The impact of chronic stressors like the COVID-19 pandemic is likely to be magnified in adolescents with pre-existing mental health risk, such as attention-deficit/hyperactivity disorder (ADHD). This study examined changes in and predictors of adolescent mental health from before to during the COVID-19 pandemic in the Southeastern and Midwestern United States.

METHODS

Participants include 238 adolescents (132 males; ages 15-17; 118 with ADHD). Parents and adolescents provided ratings of mental health symptoms shortly before the COVID-19 pandemic and in spring and summer 2020.

RESULTS

Adolescents on average experienced an increase in depression, anxiety, sluggish cognitive tempo, inattentive, and oppositional/defiant symptoms from pre-COVID-19 to spring 2020; however, with the exception of inattention, these symptoms decreased from spring to summer 2020. Adolescents with ADHD were more likely than adolescents without ADHD to experience an increase in inattentive, hyperactive/impulsive, and oppositional/defiant symptoms. Adolescents with poorer pre-COVID-19 emotion regulation abilities were at-risk for experiencing increases in all mental health symptoms relative to adolescents with better pre-COVID-19 emotion regulation abilities. Interactive risk based on ADHD status and pre-COVID-19 emotion regulation abilities was found for inattention and hyperactivity/impulsivity, such that adolescents with ADHD and poor pre-COVID-19 emotion regulation displayed the highest symptomatology across timepoints. Lower family income related to increases in inattention but higher family income related to increases in oppositional/defiant symptoms.

CONCLUSIONS

The early observed increases in adolescent mental health symptoms during the COVID-19 pandemic do not on average appear to be sustained following the lift of stay-at-home orders, though studies evaluating mental health across longer periods of time are needed. Emotion dysregulation and ADHD increase risk for sustained negative mental health functioning and highlight the need for interventions for these populations during chronic stressors. Results and clinical implications should be considered within the context of our predominately White, middle class sample.

Systematic Review: Assessment of Sluggish Cognitive Tempo Over the Past Decade

OBJECTIVE

To conduct a systematic review of the measures designed to assess sluggish cognitive tempo (SCT) since the first SCT scale using careful test-construction procedures was published in 2009.

METHOD

MEDLINE (PubMed), Embase, PsychINFO, and Web of Science databases were searched from September 2009 through December 2019. Articles reporting on reliability (internal consistency, test-retest, and interrater reliability), structural validity (an aspect of construct validity focused on items' convergent and discriminant validity), concurrent and longitudinal external validity, invariance, or intervention/experimental findings were included.

RESULTS

Full criteria for data extraction and inclusion were met by 76 studies. Nine measures for assessing SCT were identified (7 assessing parent report, teacher report, and/or self-report in children and 2 assessing self-report and/or collateral informant report in adults). Each measure demonstrated acceptable to excellent reliability. All or at least the majority of SCT items on each measure also had structural validity (high loadings on an SCT factor and low loadings on an attention-deficit/hyperactivity disorder [ADHD] inattention factor). Studies have supported the invariance of SCT across sex and time, and there is initial evidence of invariance across informants, youths with ADHD and youths without ADHD, and ADHD presentations. The Child and Adolescent Behavior Inventory (CABI), Child Concentration Inventory, Second Edition (CCI-2), and Barkley Adult ADHD Rating Scale-IV (BAARS-IV) have particularly strong support for assessing parent/teacher-reported, youth self-reported, and adult self-reported SCT, respectively.

CONCLUSION

The SCT measures included in this review share numerous positive properties, have promising psychometric support, and have proven useful for examining the external correlates of SCT across the life span. Although substantial progress has been made over the last decade, work remains to be done to further improve the assessment of SCT and key directions for future research are provided.

Validity of Sluggish Cognitive Tempo in Turkish Children and Adolescents

The internal and external validity of sluggish cognitive tempo (SCT) relative to attention-deficit/hyperactivity disorder-inattention (ADHD-IN) was evaluated with Turkish children and adolescents. Parents completed the SCT, ADHD-IN, ADHD-hyperactivity/impulsivity (HI), oppositional defiant disorder (ODD), callous-unemotional (CU), anxiety, depression, social impairment, and academic impairment scales of the Child and Adolescent Behavior Inventory (CABI) on 1015 Turkish children and adolescents (56% girls; ages 6-15 years; M_age = 10.05, SD_age = 2.32), including 762 recruited from the community and 253 recruited from outpatient psychiatric clinics. SCT symptoms demonstrated excellent internal validity with the ADHD-IN symptoms. SCT symptoms also showed invariance across boys and girls as well as across community and clinical samples. SCT showed stronger first-order and unique associations than ADHD-IN with anxiety and depression whereas ADHD-IN showed stronger first-order and unique associations than SCT with ADHD-HI, ODD, and academic impairment. SCT and ADHD-IN showed equal associations with CU behaviors and social impairment. The current study is the first to support the validity of CABI SCT scores with Turkish children and adolescents and also replicates the findings from similar studies with children from South Korea, Spain, and United States. These findings thus further strengthen the transcultural validity of CABI SCT scale scores.

Examining the Role of Attention Deficits in the Social Problems and Withdrawn Behavior of Children With Sluggish Cognitive Tempo Symptoms

Previous studies have found that sluggish cognitive tempo (SCT) symptoms are often associated with social problems and withdrawn behavior. However, the possible neuropsychological mechanism underlying this relationship remains unclear. Some studies have also found that SCT symptoms are related to deficits in sustained attention and selective attention. However, no study has examined whether attention deficits are related to social problems and withdrawn behavior in children with SCT. This study was the first to examine the neuropsychological correlates of social problems and withdrawn behavior among children with SCT symptoms. The results showed that sustained attention measure (omission) predicted the severity of social problems and withdrawn behavior in children with SCT even after controlling for symptoms of attention-deficit hyperactivity disorder. Selective attention measure (response latency mean) was also found to predict the severity of social problems. These results suggest that the social problems commonly exhibited by children with SCT are related to deficits in sustained attention and attentional control. Thus, our results provide an initial support to the link between attention deficits and social problems among children with SCT.

Sluggish Cognitive Tempo and Depressive Symptoms in Children and Adolescents Predict Adulthood Psychopathology

Sluggish cognitive tempo (SCT) is characterized by behavioral symptoms reflecting slowness and lethargy (e.g., sluggishness, appearing sleepy) and inconsistent alertness/mental confusion (e.g., daydreaming, fogginess). SCT is substantially correlated with the inattentive symptoms of attention-deficit/hyperactivity disorder (ADHD) and may be part of that domain, but in cross-sectional data, SCT is also strongly associated with both inattention and depression. To date, no study has examined the prospective associations of SCT symptoms in childhood/adolescence with symptoms of ADHD and internalizing problems in adulthood. Using a sample of 449 twin children and adolescent pairs, prospective multiple regression analyses examined whether self- and parent-reported SCT, depression, and parent-reported symptoms of ADHD predicted symptoms in adulthood 12 years later. SCT and depression at time one were strongly correlated (self-reported SCT and depression r = 0.84; parent-reported SCT and depression r = 0.78). When adult outcomes were separately regressed on each youth symptom dimension, self-reported SCT (β = 0.26, p < 0.0001) and depression (β = 0.13, p < 0.0001) each predicted adult symptoms of depression and self-reported SCT predicted inattention (β = 0.12, p = 0.0026). Parent-reported depression, but not parent-reported SCT, predicted self-reported adult depression symptoms (β = 0.17, p = 0.0003). In contrast, when each adult outcome was regressed simultaneously on youth self-reported SCT and depression, neither predicted adulthood inattention or depression. These findings indicate that SCT in childhood and adolescence is strongly associated concurrently and predictively with both inattention and depression. Theoretical and clinical applications of the construct of SCT must take its robust association with both inattention and depression into account.

Sluggish cognitive tempo and processing speed in adolescents with ADHD: do findings vary based on informant and task?

Few studies have examined whether behavioral sluggish cognitive tempo (SCT) symptoms are related to speeded task performance. Mixed findings in existing research could be due to previous studies using a broad conceptualization of processing speed, not including self-report of SCT symptoms, and relying on non-optimal measures of SCT. Using a multi-informant design with both parent- and adolescent-reported SCT symptoms, the present study provides a preliminary test of the hypothesis that SCT symptoms would be associated with slower performance on tasks having greater graphomotor and fine motor demands. Participants were 80 adolescents (ages 13-17 years; 71% male) with attention-deficit/hyperactivity disorder (ADHD). Adolescents and parents completed ratings of SCT. Adolescents were administered the Wechsler Symbol Search and Coding subtests and the Grooved Pegboard Test. When adjusting for age, sex, and ADHD symptom severity, parent-reported SCT symptoms were not significantly associated with Symbol Search or Coding scores but were significantly associated with slower Grooved Pegboard time. Adolescent-reported SCT symptoms were not significantly associated with Symbol Search but were significantly associated with lower Coding scores and slower Grooved Pegboard time. Findings provide preliminary support for the hypothesis that SCT may be more clearly associated with processing speed task performance as motor demands increase and provide a potential explanation for the mixed literature on SCT in relation to processing speed by demonstrating that the presence and magnitude of associations vary by informant and task.

Do sluggish cognitive tempo symptoms improve with school-based ADHD interventions? Outcomes and predictors of change

BACKGROUND

Sluggish cognitive tempo (SCT) is a construct that includes symptoms of slowness, excessive daydreaming, and drowsiness. SCT is often comorbid with attention-deficit/hyperactivity disorder (ADHD), and SCT symptoms are associated with significant academic impairment above the influence of ADHD. Despite the overlap between ADHD and SCT and associated impairments, no studies have evaluated how evidence-based psychosocial interventions for adolescents with ADHD impact symptoms of SCT.

METHODS

This study examined whether SCT symptoms improved in a sample of 274 young adolescents with ADHD who were randomly assigned to an organizational skills intervention, homework completion intervention, or to a waitlist control. SCT intervention response was evaluated broadly in all participants and, specifically, for participants in the clinical range for SCT symptom severity at baseline. Change in ADHD symptoms of inattention, executive functioning, and motivation were examined as potential predictors of improvement in SCT.

RESULTS

The two intervention groups were collapsed together for analyses because there were no significant differences in change in SCT symptoms. Multilevel modeling results indicate that parent-reported SCT symptoms significantly decreased when comparing the intervention group to waitlist control (d = .410). For adolescents with parent-reported clinical levels of SCT, the decrease in symptoms was more pronounced (d = .517). Self-reported SCT symptoms produced null results, though effect size calculations showed small improvement for the full sample (d = .313) and for the high-SCT group (d = .384). Change in behavior regulation executive functioning (d = .247), metacognitive executive functioning (d = .346), and inattention (d = .230) predicted change in parent-reported SCT symptoms.

CONCLUSIONS

Although not specifically designed to decrease SCT symptoms, the ADHD interventions evaluated in this study resulted in significant improvements in parent-reported SCT with small to moderate effect sizes. Clinical implications and future directions are discussed, including development of interventions for adolescents with high levels of SCT.

Sluggish Cognitive Tempo in Adolescents with and without ADHD: Differentiation from Adolescent-Reported ADHD Inattention and Unique Associations with Internalizing Domains

A growing number of studies support the internal and external validity of youth self-reported sluggish cognitive tempo (SCT) symptoms. However, no study has examined SCT in adolescents without ADHD, examined whether adolescent self-reported SCT is distinct from adolescent self-reported ADHD inattention (ADHD-IN), or evaluated whether links between SCT and internalizing problems differ for adolescents with or without ADHD. The present study is the first to (1) determine the convergent and discriminant validity of self-reported SCT and ADHD-IN symptoms in both adolescents with and without ADHD, (2) test the invariance of SCT and ADHD-IN symptoms across ADHD and comparison groups, (3) examine SCT as uniquely related to a range of internalizing-relevant domains, and (4) evaluate if the association between SCT with internalizing correlates differs for adolescents with or without ADHD. Participants were adolescents (Mage = 13 years) with (n = 162) and without (n = 140) ADHD. Adolescents and parents completed measures of internalizing symptoms and emotion dysregulation; adolescents completed measures of rumination and suicidal ideation. Analyses indicated that 13 of the 15 SCT items demonstrated convergent and discriminant validity from ADHD-IN, and SCT and ADHD-IN demonstrated invariance across the ADHD and comparison groups and across sex. SCT, but not ADHD-IN, was uniquely associated with greater adolescent-reported internalizing symptoms and suicidal ideation. Both SCT and ADHD-IN were uniquely associated with adolescent-reported emotion dysregulation and parent-reported internalizing symptoms. Only ADHD-IN was uniquely associated with parent-reported emotion dysregulation. Findings support the differentiation of adolescent-reported SCT and ADHD-IN and demonstrate associations between SCT and increased internalizing problems in adolescents with and without ADHD.

Initial Examination of the Bidirectional Associations between Sluggish Cognitive Tempo and Internalizing Symptoms in Children

Few studies have examined the longitudinal association between sluggish cognitive tempo (SCT) symptoms and internalizing symptoms, and no study has examined the potentially bidirectional associations between SCT and internalizing symptoms. The present study used a short-term longitudinal design to examine the directionality of the associations between SCT, depressive, and anxious symptoms in children. Teachers of 188 children in 1st to 6th grades (6-13 years of age; 47% boys) provided ratings of children's SCT, anxiety, and depressive symptoms in the fall school semester (T1) and again 6 months later (T2). Children in 3rd to 6th grades (n = 133) provided ratings of anxiety and depressive symptoms at both time points. Cross-lagged panel models examining the longitudinal associations between SCT, anxiety, and depressive symptoms were conducted controlling for sex and grade, with separate models for teacher- and child-reported internalizing symptoms. SCT symptoms at Time 1 (T1) predicted increased depressive symptoms at T2, with findings consistent across teacher-rated depression and child-rated depression. Depression at T1 did not predict SCT at T2. SCT symptoms at T1 also predicted increased teacher-rated anxiety at T2 but not child-rated anxiety. Finally, child-rated anxiety at T1 predicted increased SCT at T2. Findings from this study provide the first evidence that SCT symptoms predict subsequent depressive symptoms and not the reverse. Associations between SCT and anxiety are more nuanced, with results differing based on the informant. Additional studies are needed to replicate and extend these findings across longer developmental periods with more time points and to examine mechanisms of the associations between SCT and internalizing symptoms in children.

Are Sluggish Cognitive Tempo, ADHD, and Oppositional Defiant Disorder Trait- or State-Like Constructs from Prekindergarten to Fourth Grade?

The objective was to determine the proportion of trait (consistency across occasions) and occasion-specific variance in sluggish cognitive tempo (SCT), attention deficit/hyperactivity disorder (ADHD)-inattention (IN), ADHD-hyperactivity/impulsivity (HI), and oppositional defiant disorder (ODD) symptom ratings. A single trait factor-multiple state factors model was applied to parent ratings of SCT, ADHD-IN, ADHD-HI, and ODD symptoms for 978 children (50% female) across prekindergarten (M = 4.90 years), kindergarten (M = 6.27 years), 1st-grade (M = 7.42 years), 2nd-grade (M = 8.45 years), and 4th-grade (M = 10.45 years) assessments. For the prekindergarten assessment, SCT, ADHD-IN, ADHD-HI, and ODD contained more occasion-specific than trait variance (54%, 64%, 56%, and 55% occasion-specific variance, respectively). In contrast, SCT, ADHD-IN, ADHD-HI, and ODD contained more trait than occasion-specific variance for the kindergarten through 4th-grade assessments (62%-72%, 65%-68%, 71%-75%, and 60%-69% trait variance, respectively). SCT, ADHD-IN, ADHD-HI, and ODD are slightly to moderately more state-like than trait-like during the prekindergarten developmental period but are more stable traits than fluctuating states from kindergarten to 4th grade. Findings indicate that, particularly after children start formal schooling, these psychopathology dimensions are primarily stable traits; implications for assessment are discussed.

Shortened Sleep Duration Causes Sleepiness, Inattention, and Oppositionality in Adolescents With Attention-Deficit/Hyperactivity Disorder: Findings From a Crossover Sleep Restriction/Extension Study

OBJECTIVE

Although poor sleep is often reported in adolescents with attention-deficit/hyperactivity disorder (ADHD), prior studies have been correlational. This study investigated whether sleep duration is causally linked to sleepiness, inattention, and behavioral functioning in adolescents with ADHD.

METHOD

A total of 72 adolescents (aged 14-17 years) entered a 3-week sleep protocol using an experimental crossover design. The protocol included a phase stabilization week, followed in randomized counterbalanced order by 1 week of sleep restriction (6.5 hours) and 1 week of sleep extension (9.5 hours). Sleep was monitored with actigraphy and daily sleep diaries, with laboratory visits at the end of each week. Analyses included 48 adolescents who had complete actigraphy data and successfully completed the sleep protocol (defined a priori as obtaining ≥1 hour actigraphy-measured sleep duration during extension compared to restriction). Parent and adolescent ratings of daytime sleepiness, ADHD symptoms, sluggish cognitive tempo (SCT), and oppositional behaviors were the primary measures. The A-X Continuous Performance Test (CPT) was a secondary measure.

RESULTS

Compared to the extended sleep week, parents reported more inattentive and oppositional symptoms during the restricted sleep week. Both parents and adolescents reported more SCT symptoms and greater daytime sleepiness during restriction compared to extension. Adolescents reported less hyperactivity-impulsivity during sleep restriction than extension. No effects were found for parent-reported hyperactivity-impulsivity, adolescent-reported ADHD inattention, or CPT performance.

CONCLUSION

This study provides the first evidence that sleep duration is a causal contributor to daytime behaviors in adolescents with ADHD. Sleep may be an important target for intervention in adolescents with ADHD.

CLINICAL TRIAL REGISTRATION INFORMATION

Cognitive and Behavioral Effects of Sleep Restriction in Adolescents With ADHD; https://clinicaltrials.gov/; NCT02732756.

Clinical differentiation of sluggish cognitive tempo and attention-deficit/hyperactivity disorder in children

This study (a) determined whether clinical elevations of sluggish cognitive tempo (SCT) and attention-deficit/hyperactivity disorder (ADHD) symptom distributions in a large community sample of children would allow for identifying SCT-only, ADHD-only, and SCT + ADHD clinical groups; (b) examined co-occurrence of clinically elevated SCT and ADHD; (c) evaluated whether these clinical groups differed in their gender distribution, co-occurring mental health symptoms, or impairment in academic and social functioning; and (d) explored patterns of independence and overlap when clinically elevated depressive symptoms were considered in tandem with SCT and ADHD. Participants were mothers, fathers, and teachers of 2,142 children (50.51% boys, ages 8-13 years) from 32 schools in Spain. All three groups of informants completed measures of SCT, ADHD, oppositional defiant disorder (ODD), anxiety, depression, shyness, social impairment, and academic impairment. Cut-off scores for the top 5% of the sample were used to create SCT-only, ADHD-only, SCT + ADHD, and comparison groups. Across informants, 4.97%-5.53% met criteria for clinically elevated ADHD-only, and 2.30%-2.80% met criteria for clinically elevated SCT-only; 27%-35% of the ADHD group also met the criteria for the SCT group, whereas 44%-54% of the SCT group met the criteria for the ADHD group (primarily based on inattentive symptoms). The ADHD-only group had higher ODD scores than the SCT-only group, whereas the SCT-only group generally had higher shyness and internalizing scores (particularly depression) than the ADHD-only group. Additional analyses that also included clinically elevated depression revealed that 28-46% of the children with elevated SCT had elevations in neither ADHD nor depression. This study moves the field toward examining both the empirical and clinical differentiation of SCT and ADHD. Findings are discussed regarding how SCT may fit in diagnostic nosologies and models of psychopathology. (PsycINFO Database Record (c) 2018 APA, all rights reserved).