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Old 02-07-09, 11:59 PM
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Sluggish Cognitive Tempo: A seperate disorder from ADHD?

Sluggish cognitive tempo

From Wikipedia, the free encyclopedia

<!-- start content --> Sluggish Cognitive Tempo (SCT) is an unformalized descriptive term which is used to better identify what appears to be a homogeneous sub-subgroup within the formal subgroup ADHD predominantly inattentive (ADHD-I or ADHD-PI) classification in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. It has been roughly estimated that the SCT population may make up 30-50% of the ADHD-PI population.
In many ways, those who have an SCT profile have the opposite symptoms of those with classic ADHD: Instead of being hyperactive, extroverted, obtrusive, and risk takers, those with SCT are passive, daydreamy, shy, and "HYPO"-active in both a mental and physical way. They also don't have the same risk factors and outcomes. Their demeanor is sluggish, as if "in a fog" and logically they also process information more slowly. A key behavioural characteristic of those with SCT symptoms is that they are more likely to appear to be lacking motivation. They lack energy to deal with mundane tasks and will consequently seek things that are mentally stimulating because of their underaroused state. Those with SCT symptoms show a qualitatively different kind of attention deficit that is more typical of a true information input-output problem, such as memory retrieval and active working memory. Conversely, those with the other two subtypes of ADHD are characteristically excessively energetic and have no difficulty processing information.<sup id="cite_ref-schwablearning_0-0" class="reference">[1]</sup>
<script type="text/javascript">//<![CDATA[ if (window.showTocToggle) { var tocShowText = "show"; var tocHideText = "hide"; showTocToggle(); } //]]> </script>


Diagnosis
Since the symptoms of SCT are not recognized in any standard medical manuals, those who have significant SCT symptoms would likely receive an ADHD/PI diagnosis. Currently the APA will most likely include SCT in the DSM-V, which is scheduled to be released in 2012.<sup id="cite_ref-1" class="reference">[2]</sup> Diagnostic criteria will be determined.



Causes
Like ADHD, those with SCT symptoms have a condition that appears to be genetic in nature. Far less is known about this group yet the impairments seem to indicate the prefrontal cortex region of the brain and difficulties with working memory. The 7-repeat allele polymorphism of the DRD4 gene is also linked more strongly to this group than to ADHD/C and ADHD/PHI subgroups.<sup id="cite_ref-pubmedcentral_2-0" class="reference">[3]</sup>
It is thought that SCT, ADHD-PI, and ADHD are due to variations in the availability of dopamine and norepinephrine, and/or the efficiency of the large chemical structures of the specific receptors and re-uptake receptors. This would explain the efficacy of stimulants such as amphetamines on the treatment of ADHD and SCT.<sup class="noprint Template-Fact">[citation needed]</sup>



Treatment
Up to 90% of children with ADHD respond well to methylphenidate (Ritalin) at medium-to-high doses<sup id="cite_ref-3" class="reference">[4]</sup>, however, a sizable percentage of children with ADHD-PI do not gain much benefit from Ritalin, and when they do benefit, it is at a much lower dose. Tests in lab rats have demonstrated that low doses of Ritalin can increase norepinephrine levels.<sup id="cite_ref-autogenerated1_4-0" class="reference">[5]</sup>
Those with ADHD-PI often respond well to amphetamines, such as the prescription medication Adderall.<sup id="cite_ref-autogenerated1_4-1" class="reference">[5]</sup> While methylphenidate and amphetamines have many similar effects on patients (both inhibit reuptake of the neurotransmitters dopamine and norepinephrine, for example), amphetamines also promote release of those neurotransmitters. This positive effect appears to support the hypothesis that SCT is related to neurotransmitter deficiencies.



Prognosis
ADHD is a developmental disorder, meaning that certain traits will be delayed in the ADHD individual. These traits can and usually will develop in people with ADHD, but just at a much slower rate than the average person. With ADHD, it has been estimated that this lag could be as high as thirty to forty percent in the development of certain skill sets, such as selective attention. Symptoms of ADHD are often seen by the time a child enters preschool. Those with SCT symptoms typically show a later onset of symptoms in comparison to ADHD. They have greater difficulty with academic tasks and far fewer social difficulties when compared to those with combo and hyperactive ADHD.<sup id="cite_ref-5" class="reference">[6]</sup>
Selective attention difficulties of those with SCT manifests itself academically, in that they are prone to making more mistakes while working. Those with classic ADHD do not have this difficulty. Those with SCT have difficulty with verbal retrieval from long term memory, but may have greater visual spatial capabilities. They have deficits in working memory which has been described as the ability to keep multiple things in mind for manipulation, while simultaneously keeping this information free from internal distraction. Consequently, mental skills such as calculation, reading, and abstract reasoning are often more challenging for those with SCT. They also have a more disorganized thought process, a greater degree of sloppiness, and lose things more easily. They tend to have a greater degree of comorbid learning disabilities. Instead of having greater difficulty selecting and filtering sensory input, as is in the case of SCT, people with other types of ADHD have problems with inhibition.
Studies indicate that comorbid psychiatric problems are more often of the internalizing variety with SCT, such as anxiety, depression, and social withdrawal. Their typical shy nature and slow response time has often been misinterpreted as aloofness or disinterest by others. In social group interactions, those with SCT may be ignored. Those with the other types of ADHD are more likely to be rejected in social situations, because of more intrusive or aggressive behavior. Those with classic ADHD also show externalizing problems such as substance abuse, oppositional-defiant disorder, and, to a lesser degree, conduct disorder.<sup id="cite_ref-6" class="reference">[7]</sup><sup id="cite_ref-schwablearning_0-1" class="reference">[1]</sup>



Prevention
There is no known way to prevent ADHD/PI. Some studies indicate an association between mothers who smoke during pregnancy and a higher rate of ADHD in their children. Avoiding smoking, alcohol, and drugs during pregnancy may help reduce the risk of developing ADHD or similar behaviour in offspring.



History of the term SCT and its relationship to the DSM
Sluggishness, drowsiness, and daydreaming were the characteristics listed in the DSM-III (in use from 1980-1987) that were to also be present in the diagnosis of Attention Deficit Disorder (ADD) without Hyperactivity. In a study looking at these symptoms (Lahey et al., 1988) the authors stated, "these symptoms were statistically extracted as a distinct factor", coined, Sluggish Cognitive Tempo. The Sluggish Tempo factor was found to correlate significantly to the Inattention factor, but only when Hyperactivity-Impulsivity symptoms were absent.
Sluggish Cognitive Tempo symptoms were removed from the Inattention symptom list in 1988 because of poor negative predictive power for the inattentive subgroup, and because DSM contributors and editors wanted the inattentive symptoms to be identical for all ADHD subgroups. The presence of the SCT symptoms tended to predict inattention, but the absence of these symptoms did not predict the absence of inattention.<sup id="cite_ref-7" class="reference">[8]</sup> This analysis did not take into account the possibility that the SCT symptoms could help predict a distinct grouping within the ADHD/PI subgroup and that the ADHD/PI subgrouping could be heterogeneous in nature.<sup id="cite_ref-8" class="reference">[9]</sup>
In the DSM-IV, with its new classification of symptoms for predominately inattentive ADHD, 50 to 70% of those with a ADHD-PI diagnosis have subclinical levels of hyperactivity-impulsiveness symptoms. People with ADHD combined type (ADHD-C) and predominantly hyperactive–impulsive type (ADHD-PHI) may outgrow some, or most of their hyperactive symptoms during or after childhood, while inattentive symptoms typically remain into adulthood. In contrast, those with SCT have had only inattentive features from a young age with little to no history of hyperactivity-impulsiveness. Dr. Russell Barkley has proposed that the DSM-IV designation of ADHD-PI be used only for those displaying purely inattentive symptoms and that those who have had a history of any hyperactivity be designated as ADHD combined subtype. Currently, one can have a few hyperactive symptoms and still receive a diagnosis ADHD-PI. Others believe that SCT should be classified as a new separate disorder when the DSM is next updated.<sup id="cite_ref-pubmedcentral_2-1" class="reference">[3]</sup>



Relationship to dysexecutive syndrome
The Executive system of the human brain coordinates actions and strategies for everyday tasks. Dysexecutive syndrome is defined as "cluster of impairments generally associated with damage to the frontal lobes of the brain" which includes "difficulties with high-level tasks such as planning, organising, initiating, monitoring and adapting behaviour."<sup id="cite_ref-9" class="reference">[10]</sup>
Adele Diamond has recently postulated that the core cognitive deficit of those with ADHD-PI (ADD), is working memory, or, as she coined in her recent paper on the subject, "childhood-onset dysexecutive syndrome". She states:
  • "Instructional methods that place heavy demands on working memory will disproportionately disadvantage individuals with ADD".
  • "language problems often co-occur with ADD, and it is suggested that part of the reason might be that linguistic tasks, especially verbal ones, tax working memory so heavily. Spatial and artistic skills, however, are often preserved or superior in individuals with ADD."
  • "The working memory deficit in many children with ADD is accompanied by markedly slowed reaction times, a characteristic that covaries with poorer working memory in general".
  • "Individuals with ADD have difficulty maintaining a sufficiently high level of motivation to complete a task...They go looking for something else to do or think about because they are bored...to remedy a general lower arousal level.."<sup id="cite_ref-pubmedcentral_2-2" class="reference">[3]</sup>

  1. ^ <sup>a</sup> <sup>b</sup> Dr. Russell Barkley: AD/HD Theory, Diagnosis, & Treatment Summary
  2. ^
  3. ^ <sup>a</sup> <sup>b</sup> <sup>c</sup> Diamond, Adele Attention-deficit disorder (attention-deficit/hyperactivity disorder without hyperactivity): A neurobiologically and behaviorally distinct disorder from attention-deficit/hyperactivity disorder (with hyperactivity) Development and Psychopathology 17: 807-825 Cambridge University Press (2005)
  4. ^ Diamond, Adele, "Attention-deficit disorder (attention-deficit/hyperactivity disorder without hyperactivity): A neurobiologically and behaviorally distinct disorder from attention-deficit/hyperactivity disorder (with hyperactivity)", (2006)
  5. ^ <sup>a</sup> <sup>b</sup> Diamond, 2006
  6. ^ NINDS Attention Deficit-Hyperactivity Disorder Information Page Oppositional and socially aggressive behavior is seen in 40-70 percent of children at this age.
  7. ^ Barkley, Russell Attention-Deficit/Hyperactivity Disorder: Nature, Course, Outcomes, and Comorbidity
  8. ^ Blackwell Synergy - Clin Psychol Sci & Pract, Volume 8 Issue 4 Page 463-488, December 2001 (Article Abstract)
  9. ^ Symptom properties as a function of ADHD type: an ...[J Abnorm Child Psychol. 2001] - PubMed Result
  10. ^ http://www.dwp.gov.uk/advisers/joped...t_review_2.pdf

Another great article on ADHD without hyperactivity
Attention-deficit disorder (attention-deficit/hyperactivity disorder without hyperactivity): A neurobiologically and behaviorally distinct disorder from attention-deficit/hyperactivity disorder (with hyperactivity)

Summary
The thesis that has been presented here is that (a) ADD (ADHD of the inattentive subtype without hyperactivity) is a different disorder from ADHD that includes hyperactivity. The two differ in their cognitive and behavioral profiles, patterns of comorbidities, responses to medication, and underlying neurobiological disorder. (b) ADD provides an instance of childhood-onset dysexecutive syndrome. (c) The core cognitive deficit of ADD is in working memory. Instructional methods that place heavy demands on working memory will disproportionately disadvantage individuals with ADD. Although many have remarked on an executive function deficit in ADHD broadly defined, the overwhelming emphasis has been on a core deficit in inhibition, especially response inhibition, rather than in working memory (e.g., Barkley, 1997; Nigg, 2001; Pennington & Ozonoff, 1996). An emphasis on response inhibition is appropriate for ADHD that includes hyperactivity, but it is argued here that that emphasis is inappropriate for ADD, where the primary deficit is in working memory. (d) The working memory deficit in ADD should be detectable by standardized testing if measures such as complex-span and/or divided-attention dichotic-listening tests are used. Examples of several complex-span working memory measures were provided as were reasons why earlier attempts to capture the cognitive deficit in ADD children using standardized measures were unsuccessful. (e) Language problems often co-occur with ADD, and it is suggested that part of the reason might be that linguistic tasks, especially verbal ones, tax working memory so heavily. Spatial and artistic skills, however, are often preserved or superior in individuals with ADD. (f) The working memory deficit in many children with ADD is accompanied by markedly slowed reaction times, a characteristic that covaries with poorer working memory in general. (g) Individuals with ADD have difficulty maintaining a sufficiently high level of motivation to complete a task and grow bored quickly, perhaps tiring because the working memory demands of the task exhaust them. They go looking for something else to do or think about because they are bored, rather than being unable to inhibit the pull of distractions. Their problem is not so much that are distractible as that they are easily bored. When engaged in an activity they enjoy they are fully able to successfully ignore even potent distractions. To remedy a general lower arousal level, they may seek risks that increase their level of arousal and attentiveness.

ADELE DIAMOND, University of British Columbia, Vancouver, and BC Children's Hospital, Vancouver.

More information can be found here:
http://www.pubmedcentral.nih.gov/art...?artid=1474811
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Old 02-08-09, 09:47 AM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

I have this, and it sucks bigtime.
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Old 02-08-09, 01:08 PM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

Might be useful to separate them. But I wish these articles wouldn't keep using ADHD-PI (which I think is what I'll most likely be diagnosed with because my hyperactivity had a late onset so 'shouldn't exist') and SCT (which doesn't apply to me) interchangeably. I don't know if some of that is supposed to apply to me or not, such as the bit about lower doses of stimulants being better.
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Old 02-08-09, 02:00 PM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

i have found this to be confuisssing witch dont happen often

can you expaiane the subsets plz ie

more strongly to this group than to ADHD/C and ADHD/PHI subgroups.<SUP class=reference id=cite_ref-pubmedcentral_2-0>[3]</SUP>
It is thought that SCT, ADHD-PI, and ADHD are due to variations in the availability

i was not awere there was more than one subtype????

knew there was attive and in ataivecetive but what your saying i was not frmeiler with is this new rescurch? and dose this work the same with sdyicalxa???? the same way????????????? dorm

by the way it was good therd
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Old 02-08-09, 02:01 PM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

yankees440:

I've just recently joined as you have. I started a social group for Sluggish Cognitive Tempo. Please join us! (Anybody, of course!) Maybe we've got some research to swap! I would like to include the video of Dr. Barkley you have, but I didn't know how.
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Old 02-09-09, 01:44 AM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

Yeah, i'll join your group. What's the name of your group and where can i find it?
Also, here are a couple links to Dr. Barkley's conferences which include Sluggish Cognitive Tempo and future directions of this particular subtype


Here is another conference that Dr. Barkley spoke at, also contains a lot of good info on ADHD


Let me know what you think of these videos
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Old 02-09-09, 02:19 PM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

yankees440 Yeah, i'll join your group. What's the name of your group and where can i find it?

yankees440,
This link should get you there... http://www.addforums.com/forums/group.php?groupid=60

I have watched both of these videos numerous times! Dr. Barkley is quoted often in the more scientific threads of this forum. I sent Dr. Barkley an e-mail in December after discovering the vids. I received a prompt and graciously helpful reply. I'll probably send one more before I see a neurologist.

I am presently reading through Dr. B's Attention-Deficit Hyperactivity Disorder: a handbook for diagnosis and treatment 3rd edtion (2006). I'm not going cover to cover (it's a textbook the size of a college dictionary!) but sifting through the stuff that is relavant to SCT.
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Old 02-09-09, 02:36 PM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

dormammau: i was not awere there was more than one subtype????

Hey, Dorm,

Check out the first of the two videos in yankee440's reply. Most of what pertains to SCT is in the first and last twenty minutes or so. I hope it helps!
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Old 02-09-09, 07:27 PM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

Hey firstdesserts.. So you mentioned in this forum that your going to see a neurologist. Is it to get diagnosed or to get medications. If it's to get medications i could tell you that the medications i'm on for ADHD have greatly improved my life.
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Old 02-09-09, 07:34 PM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

Yankee440,

I'm hoping to get a more accurate diagnosis than ADHD. I'm not hyperactive, but hypoactive. I'm not too impulsive either. The symptoms Dr. Barkley describes as Sluggish Cognitive Tempo in your first video fits me like a glove - even the part about not being helped by Ritalin or Welbutrin.
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Old 02-09-09, 11:09 PM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

Quote:
Originally Posted by firstdesserts View Post
Yankee440,

I'm hoping to get a more accurate diagnosis than ADHD. I'm not hyperactive, but hypoactive. I'm not too impulsive either. The symptoms Dr. Barkley describes as Sluggish Cognitive Tempo in your first video fits me like a glove - even the part about not being helped by Ritalin or Welbutrin.
Hi Firstdesserts,
I have the SCT symptoms as well and I take Vyvanse. It works great for me. Medications in the amphetamine class such as Adderall and Vyvanse usually work better for those who have inattentive ADHD or SCT symptoms.

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Old 02-10-09, 12:19 AM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

ADDMAGNET!
Yeah! That's the stuff I'm looking for! Thank you for your reply!
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Old 02-10-09, 05:00 AM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

Theres really no difference between SCT and ADHD-I.
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Old 02-10-09, 08:42 AM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

Quote:
Originally Posted by D.B. Cooper View Post
Theres really no difference between SCT and ADHD-I.
ADHD-PI (short for predominantly inattentive, not exclusively) means you didn't meet at least six of the hyperactive-impulsive symptoms for ADHD in the DSM-IV for at least six months before age 7. Not everyone in this category fits the SCT profile. There are many possible behaviour patterns in between those two extremes - for example the patterns of everyone who doesn't have ADHD at all. Personally I don't (according to my own best judgement) meet the criteria for ADHD-C, which were written for children, but all the same I'm more hyperactive than most people my age to an extent that is mildly impairing and distressing. For people like me, who are thought to make up the majority of those with ADHD-PI, SCT doesn't apply.
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Old 02-10-09, 11:41 AM
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Re: Sluggish Cognitive Tempo: A seperate disorder from ADHD?

D. B. & Rose,

You've both brought up issues I need to define. The first is where I am on the DSM-IV, and what symptoms deviate from it.
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