Sluggish Cognitive Tempo in Adults Referred for an ADHD Evaluation: A Psychometric Analysis of Self and Collateral Report

Journal of Attention Disorders 1 –10 © The Author(s) DOI: 10.1177/1087054718787894

Jessica R. Lunsford-Avery, Scott H. Kollins, and John T. Mitchell

Sluggish cognitive tempo is a constellation of symptoms including sluggishness, daydreaming, being slow to react, easily bored and fogginess in thinking, which has been shown to exist in several disorders, but commonly in children with ADHD (Barkley 2014). This investigation is important as the authors characterize the psychometric properties of self and collateral report of the Barkley SCT scale (BAARS-IV: SCT subscale – nine items) versus the Conners Adult ADHD Scale in 124 adults (80 of whom had ADHD). The Barkley SCT scale had high internal consistency (self-report Cronbach’s α = .79, collateral-report Cronbach’s α = .82). The self and collateral versions of the Barkley SCT scale were significantly, moderately correlated after covarying for age and sex (r = .41, p < .001). Factor analyses supported the same three factors generally found in studies of childhood SCT: Slow/Daydreamy, Sleepy/Sluggish and Low Initiation/Persistence Symptoms. The Barkley SCT scale was fairly highly correlated with ADHD symptoms in the CAARS, except for the Sleepy/Sluggish factor not correlating with Hyperactivity/Restlessness or Impulsivity and lower association with Emotional Lability. The lack of association of the Sleepy/Sluggish factor with Restlessness and Impulsivity appears to have some face validity given the differential nature of the symptoms. This article is important to clinicians because it highlights the importance of assessing adult ADHD patients for symptoms of sluggish cognitive tempo and how these SCT symptoms may relate to DSM-5 ADHD symptoms.

Barkley, R. A. (2014). Sluggish cognitive tempo (concentration deficit disorder?): Current status, future directions, and a plea to change the name. Journal of Abnormal Child Psychology, 42, 117-125. doi:10.1007/s10802-013-9824-y

Emotional Dysregulation in Adult ADHD

This article reviews the phenomenology of emotional dysregulation in adult ADHD. The article discusses whether symptoms of emotional dysregulation (ED) are co-traveling symptoms that travel with symptoms of adult ADHD or whether they are part of the core symptoms of the condition.

Symptoms of ED include rapidly shifting affect, changeable mood, mood lability, impulsivity and emotional overactivity. Barkley et al. (7 from article) have posited that ED symptoms are part of a set of executive function deficits which are critical to the core of ADHD symptomtology (8).

In contrast, Wender (13) and co-workers have posited that ED symptoms should be part of the diagnostic criteria of adult ADHD and are included in the Utah criteria they defined and the Wender-Reimherr Adult Attention-Deficit Disorder Scale (WRAADS). Work from Adler and Kessler and co-workers (21) found that ED symptoms tracked separately from symptoms of inattention, hyper-activity impulsivity and executive function and were more likely to load on the Combined presentation of ADHD and be present in sub-threshold cases. The article also reviews a number of scales which have been used to assess ED, including the WRAADS, the expanded Adult ADHD Clinician Diagnostic Scale (ACDS) v.1.2, expanded Adult ADHD Self-Report Scale (ASRS) v1.1 Symptom Checklists and the Brown Adult ADD Scale (BAADS).

This article is important to clinicians because: 1) it defines and highlights the importance of recognizing symptoms of ED, 2) describes assessment methods and 3) notes the lower efficacy of standard adult ADHD pharmacotherapies of stimulants and atomoxetine than on core ADHD symptoms and 4) highlights the potential utility of cognitive behavioral therapy in treating ED symptoms in adults with ADHD.


ADHD and Eating Disorders

ADHD Affects the Efficacy of Treatment for Eating Disorders in Adult Women

Swedish researchers examined outcomes for adult women who sought treatment at the Stockholm Centre for Eating Disorders over a period of two years and nine months. Out of 1,517 women who came to the clinic 1,143 remained eligible for the study, after excluding women whose symptoms did not fulfill the DSM-IV criteria for eating disorders or had incomplete records.

Of these, seven hundred patients could not be reached or declined to participate, leaving 443 for follow-up. To guard against the possibility that the follow-up group might not be representative of the overall treatment group, researchers compared age, body mass index, and scores on tests for depression, anxiety, compulsivity, inattention, and hyperactivity. The only statistically significant differences were small ones. The median age of the group lost to follow-up was one year younger, they were less likely to be living alone, and on average scored a single point higher on the depression test. Otherwise they were broadly similar.

The one-year follow-up on the study group found a substantial difference in rate of recovery from eating disorders between those with and without comorbid ADHD. Almost three out of four patients (72%) who scored lower (between 0-17) on the World Health Organization adult ADHD self-report scale had recovered from their eating disorder. Among those scoring 18 and higher, on the other hand, it was less than half (47%). This difference was extraordinarily unlikely (one chance in one thousand) to be due to chance (p=.001).

Another way of expressing this is through odds ratios. Those scoring 18 and up on the ADHD self-report scale were about two and a half times less likely to recover from their eating disorders following treatment. More specifically, they were about three times less likely to recover from loss of control and binging, and almost three and a half times less likely to recover from purging.

To improve outcomes, the researchers suggest “identifying concomitant ADHD symptoms and customizing treatment interventions based on this.” They specifically propose controlled clinical trials to explore the effect of combining stimulant medications with standard treatment for eating disorders.

Nils Erik Svedlund, Claes Norring, Ylva Ginsberg, Yvonne von Hausswolff‐Juhlin, “Are treatment results for eating disorders affected by ADHD symptoms? A one‐year follow‐up of adult females,” European Eating Disorders Review (2018).

Identifying and Treating Persons with Comorbid ADHD and Substance Use Disorders

An international group of twelve experts recently published a consensus report examining the state of the evidence and offering recommendations to guide screening, diagnosis, and treatment of individuals with ADHD-SUD comorbidity.1

In a clear sign that we are still in the early stages of understanding this relationship, five of the thirteen recommendations received the lowest recommendation grade (D), eight received the next-lowest (C), and none received the highest (A and B).

The lower grades reflected the absence of the highest level of evidence, obtained from meta-analyses or systematic reviews of relevant randomized controlled trials (RCTs).

Nevertheless, with these limitations in mind, the experts agreed on the following points:

ADHD Diagnosis

  • The strongest recommendation, the only one based on a 2+ level of evidence (well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal) is that the “Short Version of the Adult ADHD Self-Report Scale (ASRS-SV) screener is currently the most widely used and investigated screening tool in individuals with ADHD and comorbid SUD, with good sensitivity and specificity across studies.”
  • Two other recommendations were graded C: The diagnostic process should include current and past substance abuse and seek to involve partners and relatives in evaluating symptoms and functional impairments.
  • Four recommendations got the lowest grade, D. The experts suggested starting the diagnostic process as soon as possible and focusing on drug- and alcohol-free periods in the patient’s life during history taking. They also recommended that physicians and clinical psychologists should only make diagnoses if they have extensive training in diagnosing ADHD, as well as experience with adults with ADHD and with addiction care, and that they should consider treating adults with sufficiently severe ADHD symptoms.

ADHD Treatment

  • In general, evidence was stronger in this area, and only one of the six recommendations was graded D. The other five recommendations were graded C, with the highest level of evidence being 2 (cohort or case and control studies with undetermined risk of bias), although in three cases it was level 3 (non-analytical studies, such as case reports and case series).
  • The grade D recommendation was to always consider a combination of psychotherapy and pharmacotherapy.
  • The grade C recommendations included considering adequate medical treatment of both ADHD and SUD; integrating ADHD treatment with SUD treatment as soon as possible; considering psychotherapy targeting both; use of long-acting methylphenidate, extended-release amphetamines, and atomoxetine because of their low potential for abuse; and careful clinical management to avoid abuse and diversion of prescribed stimulants.

Note: Andrew Reding is a co-author on this post.

1Cleo L. Crunelle at al., “International Consensus Statement on Screening, Diagnosis and Treatment of Substance Use Disorder Patients with Comorbid Attention Deficit/Hyperactivity Disorder,” European Addiction Research, published online March 6, 2018, DOI: 10.1159/000487767.

Is Cognitive Behavioral Therapy Effective for Older Adults with ADHD?

Though there have been numerous studies of the efficacy of cognitive behavioral therapy (CBT) for ADHD symptoms in children, adolescents, and adults, few have examined efficacy among adults over 50. A new study begins to fill that void.

Psychiatric researchers from the New York University School of Medicine, Massachusetts General Hospital, and Pfizer randomly assigned 88 adults diagnosed with elevated levels of ADHD to one of two groups. The first group received 12 weeks of CBT targeting executive dysfunction – a deficiency in the ability to properly analyze, plan, organize, schedule, and complete tasks. The second group was assigned to a support group, intended to serve as a control for any effects arising from participating in a group therapy. Each group was split into subgroups of six to eight participants. One of the CBT subgroups was run concurrently with one of the support-only subgroups and matched on the percent receiving ADHD medications.

Outcomes were obtained for different ADHD demographics, 26 adults aged 50 or older (12 in CBT and 14 in support) and compared with 55 younger adults (29 in CBT and 26 in support). The mean age of the younger group was 35 and of the older group 56. Roughly half of the older group, and 3/5ths of the younger group, was on medication. Independent (“blinded”) clinicians rated symptoms of ADHD before and after treatment.

In the blind structured interview, both inattentive scores and executive function scores improved significantly and almost identically for both older and younger adults following CBT. When compared with the controls (support groups), however, there was a marked divergence. In younger adults, CBT groups significantly outperformed support groups, with mean relative score improvements of 3.7 for inattentive symptoms and 2.9 for executive functioning. In older adults, however, the relative score improvements were only 1.1 and 0.9, and were not statistically significant.

Given the nonsignificant improvements over placebo, the authors’ conclusion that “The results provide preliminary evidence that CBT is an effective intervention for older adults with ADHD” is premature. As they note, a similar large placebo effect was seen in adults over 50 in a meta-analysis of CBT for depression, rendering the outcomes nonsignificant. Perhaps structured human contact is the key ingredient in this age group. It may also be, as suggested by the positive relative gains on six of seven measures, that CBT has a small net benefit over placebo, which cannot be validated with such a small sample size. Awaiting results from studies with larger sample sizes, it is for now impossible to reach any definitive conclusions about the efficacy of CBT for treating adults over 50.

Note: Andrew Reding is co-author on this post.

Mary V. Solanto, Craig B. Surman, Jose Ma. J. Alvir, “The efficacy of cognitive–behavioral therapy for older adults with ADHD: a randomized controlled trial,” ADHD Attention Deficit and Hyperactivity Disorders (2018)