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SCT - Sluggish Cognitive Tempo / CDS - Cognitive Disengagement Syndrome

SCT - Sluggish Cognitive Tempo / CDS - Cognitive Disengagement Syndrome

Author: Ulrich Brennecke
Review: Waldemar Zdero, M.A. in Psychology

CDS (Cognitive Disengagement Syndrome) was referred to as SCT (Sluggish Cognitive Tempo) until 202212 and was previously considered a type of subtype or extreme case of ADHD-I. This view is now outdated. CDS/SCT is a distinct disorder and occurs in approximately 25 to 50% of people with ADHD, both with and without comorbid ADHD. CDS/SCT is not yet an official disorder according to the DSM.
In cases of ADHD comorbidity, CDS/SCT appears to occur just as frequently in people with ADHD-HI as in people with ADHD-I.
Among people with CDS, 40% do not have ADHD, while 62% of people with ADHD do not have CDS.3

We consider the terms “slowed thinking” or “sluggish cognitive processing” to be inaccurate and inappropriate in the context of CDS/SCT. Rather, we observe slowed decision-making. The ability to think quickly is fundamentally present; we consider—as an unverified hypothesis—the possibility of excessive inhibition of the PFC by norepinephrine and, possibly, other neurotransmitters via the alpha-1 adrenoceptor.

CDS/SCT is characterized by various symptoms, including fatigue, hypoactivity, daydreaming, difficulty concentrating, poorer sleep quality, increased daytime sleepiness, impaired memory, and slowed information processing speed.

CDS/SCT can be diagnosed using validated questionnaires and exhibits specific neurophysiological characteristics. CDS/SCT can affect various aspects of life, including occupational performance and social withdrawal, and is best treated with multimodal therapy. Atomoxetine has been shown to significantly improve CDS/SCT symptoms, whereas people with ADHD are more likely to be non-responders to methylphenidate.

1. Symptoms of CDS / SCT

In the following list of CDS/SCT symptoms, the numbers indicate how frequently each symptom occurs in CDS/SCT, according to Becker et al.4. Lee et al.5 also list several of these symptoms as typical of CDS/SCT:

  • Gets tired or exhausted quickly 1.02
  • Low activity level, hypoactivity 0.97
  • Stares into space 0.96
  • Drowsy, sleepy, yawning (during the day) 0.95
  • Forgets what he/she was going to say 0.94
  • Sluggishness, slow movements 0.92
  • Easily confused 0.91
  • Lost in the Fog 0.89
  • Daydreams 0.88
  • Loses the train of thought 0.86
  • Slow thinking 0.82
  • Gets confused easily 0.85
  • Lost in thought 0.81
  • Mental Relaxation 0.82
  • Difficulty expressing thoughts 0.78
  • Often significant difficulties in making decisions (sluggish—in our experience)
  • Social Withdrawal678

A comprehensive review article identified 13 distinct symptoms of CDS/SCT that can be distinguished from ADHD; however, these symptoms are not clear-cut enough to be used for diagnostic purposes.9

A study found the Adult Concentration Inventory (ACI) to be suitable for diagnosing CDS/SCT. 10 CDS/SCT was clearly associated with:

  • More severe internalizing symptoms
  • Difficulties with time management and self-organization
  • Poorer sleep quality
  • Shorter sleep duration
  • Lower sleep efficiency
  • Increased daytime sleepiness.

CDS/SCT is correlated (like ADHD) with a delayed circadian rhythm and internet gaming addiction.11

CDS/SCT is not synonymous with reduced cognitive ability. There are highly gifted people with ADHD. This is consistent with the finding that CDS/SCT does not correlate with slow processing speed.12

The slowed cognitive performance specific to the sluggish/underarousal subtype does not mean that intelligence is reduced to the same extent. This means that CDS/SCT is not merely the result of reduced intelligence. We know several people whom we perceive as having CDS/SCT who have earned doctorates or are otherwise highly intelligent or even gifted. Rather, it appears that decision-making processes are slowed down or made more difficult. Conversely, a high IQ could mitigate CDS/SCT symptoms. A study confirms this.13

The ADxS.org online SCT test (as of September 2022) clearly showed a negative correlation between CDS/SCT symptoms and the highest reported IQ test score.

IQ ; Participants (n) ; CDS/SCT symptoms (out of 26)
150 and higher 7 13.6
140–149 54 13.9
130–139 158 15.2
120–129 162 15.5
110–119 88 15.8
100–109 33 16.1
90–99 15 16.9
80–89 8 16.3

A total of 78 (out of 381) participants with an IQ of 120 or higher had 20 or more CDS/SCT symptoms (out of 26).

Of a total of 2,039 participants, only the 1,640 who reported not having ADHD—or whose responses referred to how they are when not taking ADHD medication—were included. Of these, 524 had reported their highest IQ test score.
It can be assumed that participants with lower IQ scores were less likely to report them. The values in the two IQ groups below 100 should be interpreted with caution due to the small number of participants.
Overall, the results are limited by the fact that the participants took the SCT online test—which is linked on ADxS.org—of their own volition.
The significant overrepresentation of high IQ scores is likely due to a high participation rate among members of Mensa e.V. Germany, an association for highly gifted individuals (with an IQ of 130 or higher).
Data as of September 2022. (c) ADxS.org

The term “Sluggish Cognitive Tempo” therefore does not seem particularly apt. Barkley also disagrees with the term SCT.14 SCT was renamed CDS (Cognitive Disengagement Syndrome) in 2022. In our view, “ ” or “Sluggish Decisioning” Might be more appropriate.

Based on our observations, people with ADHD are particularly likely to fail as self-employed individuals.

2. CDS / SCT as a distinct disorder

CDS/SCT was previously described as an extreme form of the ADHD-I subtype or as an ADHD-I-like type with slowed cognitive functioning.15
Further supporting this view is the finding that emotional dysregulation did not correlate with CDS or with hyperactivity/impulsivity in ADHD.16

However, a growing number of studies have concluded that SCT is a distinct disorder that can be distinguished from ADHD.1718 19 20 21 22 23 24 25 26 27 28 29 For 13 of the 15 SCT symptoms, strong discriminative power from ADHD-I was found.3031

A meta-analysis of 9 studies found acceptable to excellent reliability as well as high structural validity (high loading on an SCT factor and low loading on an ADHD-HI inattention factor) for the majority of SCT items.19

The Sluggish Cognitive Tempo Self-Report Scale is a valid and reliable self-report scale for diagnosing SCT.32

As early as the 2010s, Barkley argued that SCT was a distinct disorder, a view that has since been confirmed. However, in the early 2000s, he had also argued that ADHD-I constituted a distinct Disorder from ADHD-HI, a claim that has not been borne out.

The results to date from the ADxS.org online questionnaire on SCT (as of September 2022) also suggest that, while SCT is highly correlated with ADHD overall, it is largely independent of the ADHD-HI/ADHD-C or ADHD-I subtypes. The average results for the n = 180 participants with ADHD-HI/ADHD-C and the n = 241 participants with ADHD-I are nearly identical (ADHD-HI/ADHD-C: 15.4; ADHD-I: 16.9 out of 26 possible SCT symptoms, when they assessed themselves as they are when not taking ADHD medication). When people with ADHD assessed themselves as they are while taking ADHD medication, people with ADHD-HI reported 13.5 symptoms (n = 52, a decrease of 12.3%), while people with ADHD-I reported 15.4 symptoms (n = 62, a decrease of 8.9%). This suggests that ADHD medications may also have a certain positive effect on SCT symptoms and that this effect is greater among people with ADHD who have hyperactivity.
In contrast, the n = 33 participants who stated that they were certain they did not have ADHD or SCT achieved an average SCT score of 12.5. To date, no participant has stated that they are certain they have SCT but not ADHD. This is not surprising, given the lack of awareness surrounding this disorder.

On average, men reported 15.7 symptoms (n = 713), and women reported 15.4 symptoms (n = 1,250) out of a possible 26 symptoms.

2.1. Differences in Symptoms Between CDS and ADHD

Recent studies show that SCT differs from ADHD-I in the following ways:

  • SCT appears to correlate significantly more often than ADHD-I with
    • Subsequent drug withdrawal23
    • Internet Addiction and Internet Gaming Disorder33
    • Anxiety2223 34
      • In contrast, one study found no correlation between SCT and anxiety symptoms.28
    • Depression3522233428
    • Neuroticism36
    • Increased BIS36
    • Increased BAS fun-seeking36
  • SCT appears to be even more strongly associated with later internalizing behavior than ADHD-I.222330
  • SCT is said to correlate (differently or more strongly than ADHD-I) with later shyness2334 and internalizing symptoms22, as well as lower extraversion36.
  • While one study found that externalizing symptoms were associated with hyperactivity/impulsivity symptoms of ADHD-HI, internalizing symptoms in children and adolescents with ADHD correlated significantly with SCT. Although social withdrawal correlates statistically significantly with ADHD-I and inattention (compared to ADHD-HI), this relationship was mediated by the severity of SCT.37
  • SCT, like ADHD-I, is said to correlate with later social difficulties,2223 although other studies do not confirm this.34
  • According to a study, SCT is associated with even greater social withdrawal than ADHD,3839 , a finding that another study only partially confirms.34
  • ADHD-I was correlated with poorer mathematical performance and slower processing speed later on, while SCT was a more consistent predictor of poorer reading performance later on.23
  • SCT was correlated (unlike other ADHD symptoms) with suicidal tendencies, which in turn were correlated with depression.4030
  • SCT participants showed poorer memory performance than those with ADHD-I and those without ADHD.41
  • Motor Speed and Reaction Times
    • Compared to ADHD-I, SCT showed a slightly less reduced psychomotor speed and a better neurocognitive index.41
    • SCT showed faster reaction times than ADHD-I.41
    • Slower psychomotor speed and longer reaction times correlated with the degree of inattention.41
    • Unlike ADHD, the variance in reaction time is not increased in SCT42
    • The lack of impairment in reaction time variance is consistent, at least in general, with a report indicating that SCT was associated with less impairment in executive functions (such as reaction time variance, which is mediated by working memory) than ADHD.34
  • Unlike ADHD, SCT is supposed to
    • Occur with equal frequency in men and women43
    • Occur just as frequently in adults as in children and adolescents, even if they appear somewhat later than ADHD. Thus, there is no partial remission of symptoms in a subset of people with ADHD.43
    • In contrast, a 7-year longitudinal study of 639 twins found that SCT generally lasts only a short time (1–2 years) and has no lasting negative effects on academic achievement.22
  • SCT showed differences in HRV compared to ADHD that could indicate problems with arousal.44 Based on the symptoms of CDS, we suspect strong associations with impairments in arousal.
  • SCT showed reduced conscientiousness.36
  • People with SCT who also have ADHD are reportedly particularly likely to be MPH non-responders. In particular, elevated SCT Sluggish/Sleepy factor scores are said to indicate MPH non-responsiveness. However, neither elevated SCT “Daydreamy” symptoms nor the ADHD subtype (ADHD-HI or ADHD-I) differed in terms of the MPH response rate (which contradicts the hypothesis presented here that SCT is a subtype of ADHD-I).45
  • SCT begins in early childhood, similar to ADHD, although in SCT the symptoms increase moderately after age 5, while inattention remained more constant.46 SCT could subsequently be distinguished from ADHD, although the two were highly correlated. Lower parental education levels correlated with higher SCT ratings by teachers. African Americans had higher levels of inattention and lower SCT ratings from teachers.
  • Emotional Dysregulation
    • Unlike ADHD-I, SCT is not supposed to exhibit any signs of emotional dysregulation30
    • Participants with elevated CDS and ADHD symptoms also had the highest scores for emotional dysregulation and alexithymia. Regression analyses showed that CDS symptoms were better predictors of emotional dysregulation (47%) and alexithymia (32%) than ADHD scores (emotional dysregulation: 36%, alexithymia: 23%).47
  • CDS was correlated with symptoms of anxiety and depression, but not with inattention or emotional dysregulation16
  • In a comprehensive study, SCT symptoms were found to correlate with more frequent48
    • Daydreaming
    • Brooding
    • Daydreaming.
      The study also found initial empirical evidence of a unique and robust association between SCT symptoms and non-task-related thinking, while at the same time suggesting that the link between ADHD-HI and mind wandering may be less robust than previously assumed.
  • SCT is unremarkable in terms of time orientation, the repetition of non-words, and sentence recall. Instead, SGT appears to be more closely linked to features of a social (pragmatic) communication disorder.49
  • Circadian Rhythm and Sleep50
    • Duration of sleep
      • Children with ADHD had shorter sleep duration compared to children with SCT and healthy controls
      • There was no significant difference in sleep duration between the SCT group and the healthy control group
    • Eveningness
      • Was highest in SCT, but was also elevated in ADHD compared to the control group
    • Daytime sleepiness
      • What was highest in the SCT group and higher in the ADHD group than in the control group
      • The severity of SCT predicted daytime sleepiness and eveningness
  • CDS correlated significantly with51
    • Age
    • ADHD - Inattentive Type
    • Harm Avoidance
    • Insecure attachment
    • Age, ADHD inattentive subtype, and harm avoidance were significant predictors of CDS severity
  • CDS without comorbid ADHD showed52
    • During childhood
      • Higher values of
        • Anxiety Disorders
        • Depression
        • Somatization
        • Sleep disturbances that occur during the day
        • Nighttime Sleep Disturbances
        • Social Impairments
        • Withdrawal from peer groups,
      • No differences compared to ADHD-I or ADHD-HI with regard to
        • ODD
        • Academic difficulties (ADHD-C or higher only)
    • During adolescence
      • Higher values of
        • Somatization
        • Sleep disturbances that occur during the day
      • Lower values of
        • ODD as ADHD-I, ADHD-HI, and ADHD-C
        • School-related difficulties classified as ADHD-I and ADHD-C
      • No differences compared to ADHD-I, ADHD-HI, and ADHD-C with regard to
        • Depression
        • Social impairments
        • Withdrawal from peer groups

One study found no dimensional differences in symptoms between CDS and ADHD-I, apart from the CDS symptoms. The neurocognitive test profiles for CDS and ADHD-I were comparable, with the exception of the neurocognitive index and reaction time, which were impaired in ADHD-I. Executive dysfunction was somewhat more specific to ADHD-I compared to pure CDS, while depressive symptoms and ASD symptoms occurred with equal frequency.53

2.2. Comorbidity of CDS and ADHD

However, SCT and ADHD appear to be significantly comorbid. One report states that 30 to 63% of people with ADHD-I are said to also exhibit significant SCT symptoms.5455
A study involving n = 1,024 participants found that 40% of those with ADHD exhibited increased CDS symptoms, while 60% of those with CDS had an increased risk of ADHD.47
A large study of over 2,000 families found that among children, only 48% of people with SCT also had ADHD, and only 35% of people with ADHD-HI also had SCT. People with SCT but without ADHD had higher levels of anxiety, depression, shyness, and sleep disturbances than people with ADHD but without SCT. In contrast, people with ADHD but without SCT exhibited greater deficits in executive functions and more frequent ODD than people with SCT. SCT and ADHD did not differ in terms of friendships or social or academic impairments.34
One study found elevated CDS symptoms in 10% of participants and elevated ADHD symptoms in 9.2%. Of the probable ADHD cases, 40% had elevated CDS symptoms, while 60% of the cases with elevated CDS symptoms had an elevated risk of ADHD.47

Two studies found evidence that SCT could be considered a group of symptoms that occurs in various mental Disorders.56 When ADHD, depression, anxiety disorders, sleep disorders, and alcohol and cannabis abuse were excluded, fewer than 5% of the participants remained who had shown high SCT scores.57
Children with ADHD, ASD, or ASD+ADHD (AuADHD) showed similar CDS symptom scores. However, children with AuADHD exhibited more severe cognitive CDS symptoms than children with ADHD alone. Both the general CDS characteristics and the cognitive CDS symptom subgroup were associated with greater social difficulties—regardless of diagnosis—particularly social withdrawal, a higher degree of repetitive behaviors, and greater sensory sensitivities.58

3. Neurophysiological Characteristics of SCT / CDS

  • The specific SCT symptoms (sluggishness, underarousal) could be caused by a noticeable deficit in the uptake of dopamine and norepinephrine.15
  • SCT is thought to correlate with inactivity in the superior parietal lobe (SPL).54
  • Sluggish Cognitive Tempo is said to be associated with attention problems, but not with hyperactivity or aggression. Sleep problems are also said to be less common.59
  • Unlike ADHD, Sluggish Cognitive Tempo does not show any abnormalities in the frontal and fronto-central theta-beta ratio on the EEG.60
  • According to a study, SCT is associated with impaired information processing capacity and a slowed (visual) information processing speed.61
    Another study found no correlation between SCT and reduced information processing speed, but did find a correlation with reduced working memory speed as well as increased inhibition speed. A combination of slowed working memory and accelerated inhibition was therefore hypothesized.62
  • A high workload on working memory significantly impairs information processing speed. Nevertheless, in ADHD, it was found that manipulating working memory had no effect on information processing speed, nor did information processing speed affect working memory. This suggests that impairments in working memory and information processing speed in ADHD are caused by different areas of brain function.63
  • In patients with CDS, blood flow volume was reduced in the internal carotid artery (particularly on the right side), but not in the vertebral arteries. Reduced blood flow volume in the internal carotid artery correlated slightly with increased CDS symptoms. This suggests reduced cerebral blood flow in CDS.64
  • An interesting report cites “partial sleep” in the brain as a possible cause of some SCT symptoms or mind wandering.65
  • Sleep problems are strongly correlated with SCT/CDS66
  • Adolescents with SCT completed the Wechsler Symbol Search and Coding subtests and the Grooved Pegboard Test. Their parents reported no symptoms in the people with ADHD that would affect symbol search or coding scores, while the people with ADHD themselves reported significantly lower coding scores. Both parents and people with ADHD consistently reported symptoms that correlated significantly with slower Grooved Pegboard times. The resulting hypothesis is that SCT correlates more clearly with performance on the processing speed task as motor demands increase.67
  • A study of children with ADHD aged 8 to 12 measured SCT symptoms in relation to autonomic nervous system responses under social and cognitive stress. Respiratory sinus arrhythmia (RSA) and skin conductance reactivity (SCL). SCT symptoms did not correlate with RSA reactivity under any stress condition. Under social stress caused by rejection, more severe SCT symptoms correlated with greater SCL reactivity. This pattern was independent of ADHD-HI symptoms, internalizing symptoms, medication status, or gender. The authors conclude that there is a link between SCT symptoms and sympathetic nervous system reactivity, as well as greater activation of the BIS.68
  • A magnetoencephalography (MEG) study found:69
    • A correlation between CDS symptoms and larger changes in the root mean square (ΔRMS) (incongruent-congruent trials) in M2 and M3, suggesting that greater mental effort may be required to overcome distractions during incongruent trials
    • A negative correlation between CDS symptoms and ΔM2 performance (incongruent-congruent trials) in the medial prefrontal cortex (mPFC), suggesting insufficient performance distribution in a region critical for attentional processing; however, this association was no longer significant after controlling for ADHD status.
    • No significant correlation was found between CDS symptoms and alertness or orientation.

Among 169 children and adolescents with spina bifida (SB), 18% were found to have SCT. The study replicated the 3-factor structure of SCT proposed by Penny, with the components “slow,” “sleepy,” and “daydreamer.” “Slow” overlapped significantly with inattention, while “sleepy” and “daydreamer” differed markedly from inattention and internalizing symptoms. A myelomeningocele (a congenital malformation of the spinal cord caused by incomplete closure of the neural tube, with open vertebral arches and protrusion of the dural sac) and the presence of a shunt (a shunt is a short-circuit connection with fluid transfer between normally separate vessels or cavities) correlated with more severe SCT symptoms.70

4. Medication for SCT

  • A meta-analysis of k = 3 studies found evidence of a moderate improvement in CDS symptoms with methylphenidate (1 study, SMD = 0.51), atomoxetine (1 study, SMD = 0.42), and lisdexamfetamine (1 study, SMD = 0.38), although none of these values were statistically significant.71
  • In one study, atomoxetine significantly improved 7 out of 9 symptoms on the Kiddie-Sluggish Cognitive Tempo Interview (K-SCT) in children with SCT. The improvement in SCT symptoms was completely independent of ADHD symptoms.72 This also suggests that SCT is a distinct Disorder or has a distinct underlying cause and can coexist with ADHD.
  • According to a study, people with SCT are particularly likely to be MPH nonresponders; in contrast, ADHD-HI and ADHD-I did not differ in their MPH response rates in this study, a finding that is controversial.45
  • One study found that MPH improved SCT symptoms only in the school setting. Daydreaming and oppositional behavior were correlated with a weaker response to MPH in SCT.73
  • The results of the ADxS.org SCT online test suggest that ADHD medications may bring about some improvement in SCT symptoms (see above).
  • A study found significantly lower levels of B12 and D3 in patients with comorbid ADHD and CDS.74

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  6. Fredrick, Becker (2022): Cognitive Disengagement Syndrome (Sluggish Cognitive Tempo) and Social Withdrawal: Advancing a Conceptual Model to Guide Future Research. J Atten Disord. 2022 Aug 4:10870547221114602. doi: 10.1177/10870547221114602. PMID: 35927980. ↥

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  12. Cook, Braaten, Vuijk, Lee, Samkavitz, Doyle, Surman (2019): Slow Processing Speed and Sluggish Cognitive Tempo in Pediatric Attention-Deficit/Hyperactivity Disorder: Evidence for Differentiation of Functional Correlates. Child Psychiatry Hum Dev. 2019 Jun 21. doi: 10.1007/s10578-019-00904-6. ↥

  13. Tamm L, Epstein JN, Orban SA, Kofler MJ, Peugh JL, Becker SP (2023): Neurocognition in children with cognitive disengagement syndrome: accurate but slow. Child Neuropsychol. 2023 Mar 2:1-20. doi: 10.1080/09297049.2023.2185215. PMID: 36864603. n = 263 ↥

  14. Vortrag Barkley (2014) an der Lynn University, Minute 1:44 ↥

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  17. Fredrick JW, Jacobson LA, Peterson RK, Becker SP. Cognitive disengagement syndrome (sluggish cognitive tempo) and medical conditions: a systematic review and call for future research. Child Neuropsychol. 2023 Sep 15:1-35. doi: 10.1080/09297049.2023.2256052. PMID: 37712631. REVIEW ↥

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  24. Garner, Peugh, Becker, Kingery, Tamm, Vaughn, Ciesielski, Simon, Loren, Epstein (2017): Does Sluggish Cognitive Tempo Fit Within a Bi-Factor Model of ADHD? J Atten Disord. 2017 Jun;21(8):642-654. doi: 10.1177/1087054714539995. n=168 ↥

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  27. McFayden, Jarrett, White, Scarpa, Dahiya, Ollendick (2020): Sluggish Cognitive Tempo in Autism Spectrum Disorder, ADHD, and Their Comorbidity: Implications for Impairment. J Clin Child Adolesc Psychol. 2020 Feb 6:1-8. doi: 10.1080/15374416.2020.1716365. PMID: 32027539. ↥

  28. Brewe, Simmons, Capriola-Hall, White (2020): Sluggish cognitive tempo: An examination of clinical correlates for adults with autism. Autism. 2020 Feb 7:1362361319900422. doi: 10.1177/1362361319900422. PMID: 32028780. n = 57 ↥ ↥ ↥

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