Exploring Sluggish Cognitive Tempo: Challenges and Treatment

October 21, 2021
Sluggish Cognitive Tempo Treatment


Sluggish cognitive tempo refers to when an individual lacks the motivation to socialize, learn new skills, or play. The symptoms are different for every person. For example, some people have trouble speaking or thinking quickly, while others might have difficulty maintaining attention.

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This article explores the condition often mistaken for ADHD, how it differs from the latter, and its diagnosis and treatment options.


1. What Is Sluggish Cognitive Tempo?

Sluggish cognitive tempo (SCT) is a condition characterized by slow mental and physical activity. It makes it hard to focus or follow conversations and may lead to coping mechanisms such as zoning out or daydreaming. SCT results from an overactive brain’s inability to distinguish between essential stimuli or insufficient energy allocation.

Even though sluggish cognitive tempo has been around for centuries, it is still not considered a clinical diagnosis or an individual disorder. Clinically, sluggish cognitive tempo (SCT) is suspected to be comorbid with attention deficit hyperactivity disorder (ADHD). But SCT patients have difficulty paying attention and maintaining focus—without hyperactive symptoms.


The History of Slow Cognitive Tempo

SCT was a common occurrence in populations in the early 1980s, characterized mainly by ‘low mental power’ and a tendency to daydream. The term SCT was first coined in 1984 by a clinical psychologist named Dr. Russell Barkley, who previously worked as a professor at the Medical University of South Carolina and Virginia Tech.

Barkley created the term SCT following an extensive investigation into attention problems that were not always associated with ADHD. He also proposed that the name “Attention-Deficit Disorder” be changed to “Attention-Deficit/ Concentration-Deficit Disorder.”

It’s important to note that very little research has focused on studying SCT as a distinct disorder. There is evidence of references to aspects of SCT in old nursery rhymes.  This shows that SCT symptoms and physical characteristics were also common in children at the time. 

For example, in 1865, a physician named Heinrich Hoffman published a book of short stories called “Der Struwwelpeter.” It was filled with rhymes that heavily cited ADHD and SCT attributes. The first half of the book describes proper behavior for children. The second half taught lessons through allegories, and every story ended with a rhyme that teaches a lesson about a particular character’s misbehavior.


Sluggish Cognitive Tempo
Causes of Sluggish Cognitive Tempo


In the 1980s, through contemporary research on SCT, the resemblances and differences between the two disorders became clear.  The American Psychiatric Association made a milestone contribution to the study, introducing two diagnostic frameworks for ADD, including the H (hyperactivity) in the name, while the other excludes it.

These diagnostic criteria gave professionals a precise method to diagnose certain disorders according to specific parameters that are important when choosing treatment options. Two similar-looking conditions were differentiated through numerous successful and failed approaches. But ADHD and SCT, however, are two separate conditions, so eventually, experts subtyped a condition known today as ADHD.

According to DSM-5 ADHD classification, there are three predominant subtypes: inattentive, hyperactive, and combined. The term Slow Cognitive Tempo was used in the 80s to describe how some children are not hyperactive but are still excessively slow or lazy (as in the case of  ADHD), with the condition later termed ‘sluggish cognitive tempo.’ Each disease manifests itself in different ways, although some people with SCT have also had ADHD.


Association of SCT and ADHD

Traditionally, ADD referred to people who had issues focusing and were inactive but did not have problems with hyperactivity. But does ADHD lead to cognitive sluggishness? In some examples of the inattentive type of ADHD, only some individuals experience symptoms of lethargy or sluggishness.

Most experience hyperactive behavior (and increased states of arousal). The general public may think that many individuals with ADHD tend to feel sleepy or tired periodically; this is an inaccurate assessment. Eventually, it became clear that these terms cannot be used in heterogeneous contexts because they describe different conditions.

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Similarities between Sluggish Cognitive Tempo and ADHD

The symptoms of SCT and ADHD are very similar. They both cause someone to have trouble paying attention, controlling their behavior, and managing time. However, they are not the same because SCT is just a personality trait while ADHD is a disorder. The similarities between cognitive sluggishness and attention hyperactivity disorder are evident in the below symptoms:

Symptoms SCT ADHD
A tendency to zone out/ daydream YES YES
Lethargy  YES YES
Problem remembering things YES YES
Inability to stay alert  in uninteresting situations YES YES
Slow information processing YES YES

There is a 50 % chance that patients with slow cognitive tempo develop attention deficit hyperactivity disorder.  The probability of patients with ADHD developing SCT is about 63 to 65%. Even though SCT shares many similarities with ADHD, some characteristics set these two conditions apart.


Differences between Sluggish Cognitive Tempo and ADHD

Symptoms SCT ADHD
Aggression NO YES 
Poor conduct NO YES 
Social impairments  YES  NO
Strange behavior NO YES
Anxious YES NO
Lack of guilt NO YES
Executive functioning problems  NO YES
Socially withdrawn YES  NO
Impaired physical performance YES NO
Inability to wait for your turns in a conversation NO  YES

In the past few years, studies have uncovered an active resurgence of SCT among those with ADHD. In addition to ADHD, other conditions also show strong associations with SCT, discovered by extensive research. A recent study proved that children with autism are much more likely than other children to show signs of SCT.

Experts in this field concluded that 49% of autistic children showed signs of inferior complex thinking skills. In contrast, 40% of inattentive type ADHD and 31% with combined-type ADHD showed similar symptoms. This study led the researchers to conclude that SCT is much more common among kids on the autism spectrum than those with ADHD.


Sluggish Cognitive Tempo
Treatment Options for Sluggish Cognitive Tempo


2. Understanding the Symptoms of Sluggish Cognitive Tempo

Identifying the symptoms of sluggish cognitive tempo is not an easy job for any health practitioner especially considering its strong resemblance with the subtypes of ADHD. Although there is still no official list of symptoms developed for SCT, potential symptom markers can help identify SCT in individuals.


What Are the Symptoms of Sluggish Cognitive Tempo?

As defined in Reihman’s (2005) study, sluggish cognitive tempo syndrome is an “abnormality of basic or general cognition, affective behavior, and behavioral regulation that is considered to share symptoms with ADHD.” Other traits could be highlighted in Sluggish Cognitive Tempo syndrome as further analyzed by Russel A. Barkley and colleagues:

A-List of SCT symptoms

  • looking/ feeling spacy
  • Lethargic
  • Feeling mentally foggy
  • Staring a lot
  • Slow-moving/ sluggish
  • Easily confused
  • Slow in completion of tasks
  • Unable to process questions or explanations accurately
  • Lost in thoughts
  • Appearing drowsy/ sleepy
  • Lack of initiative and effort fades
  • Trouble staying awake/ alert
  • Appearing apathetic/ withdrawn
  • Daydreaming
  • Underactive

Generally, SCT is often accompanied by ADHD-related symptoms such as hyperactivity, mood swings, impulsive behavior, difficulties concentrating, lack of impulse control, irritability, and poor performance in school. In addition to the mentioned characteristics, SCT is closely connected with behavioral problems and autism spectrum disorders. Hence it can be very challenging for specialists to form a precise differential diagnosis between them.

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3. How Do I Know if I Have Sluggish Cognitive Tempo?

When people feel like they cannot stay on task or that their mind is distracted on an ongoing basis, this could suggest that they are dealing with some degree of sluggish cognitive tempo. But there are different degrees of SCT (slow cognitive tempo), and, what is more, it has symptoms that overlap with ADHD.

The Barkley 12 symptom manual for diagnosing SCT has been instrumental in determining the cause of many cases. No definitive diagnosis is issued when symptoms such as needing to stay busy and having restlessness occur in patients because these symptoms can also be attributed to patients who have both SCT and ADHD. Nonetheless, the manual is beneficial in helping treat case studies when SCT is suspected. 


New Approaches to SCT Diagnosis

Becker, Leopold, and colleagues published a meta-analysis in 2016 after conducting a literature review. According to the study, thirteen symptoms can be used to diagnose and assess sluggish cognition. Children were the primary focus of this study.


Adult Diagnostic Criteria

Throughout his lifetime, Becker developed with Burns and Garner a symptom rating scale specific to adult SCT. Sixteen more signs were studied, which they thought could be helpful in the Adult Concentration Inventory (ACI). The ten robust markers were taken into account for the study to distinguish between SCT and ADHD.


Is There Any Sluggish Cognitive Tempo Test?

The Adult Concentration Inventory (ACI) is used in conjunction with these questionnaires to measure SCT:

  • The Barkley Adult ADHD Rating Scale IV (BAARS-IV)
  • The Beck Depression Inventory-Second Edition (BDI-II)
  • The Beck Anxiety Inventory (BAI)
  • The Revised Attention Network Test (ANT-R)

The term Sluggish cognitive tempo (SCT) may be a new phenomenon in the United States. Still, like many things which happen globally, this phenomenon has been reported in other countries too. Interestingly enough, many said SCT symptoms have been present in people from different countries, such as Canada, Spain, Korea, Nepal, and Chile.

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4. Sluggish Cognitive Tempo Causes and Risk Factors

There is still a lot that needs to be studied further to understand the risk factors for slow cognitive tempo, and so far, that data has not been available. The theorized causes of SCT include:


Brain Structure and Chemistry

Toward the end of the last century, it was believed that sluggish cognitive tempo was associated with reduced activity in the left superior parietal lobe. The reduced activity might be one cause of SCT.


Age and Gender  

The results of several studies published to date indicate that slow cognitive tempo is independent of age, ethnicity, or gender. Researchers found that males had slightly more symptoms in childhood than females, but the symptom prevalence in adulthood was not sex-specific.


Acute Lymphoblastic Leukemia (ALL) and SCT

Acute lymphoblastic leukemia is a cancer of the white blood cells. It is not one specific thing, but a group of cancers that include myelomas, leukemias, and lymphomas in children and adults.

All of these cancers share several things in common. However, there is a broad distinction between the two, with lymphoma as a different kind of cancer in white blood cells. ALL and the other types are the common type of lymphoma that affects all major types of white blood cells.

According to research in this regard, individuals who survive acute lymphoblastic leukemia are likely to experience SCT at high rates. According to the study, a higher dose of radiation therapy is responsible for the close correlation of SCT with ALL. Radiation exposure causes neurocognitive impairments such as slow processing speed, difficulty concentrating, and impairments in motor skills in these individuals.


Sluggish Cognitive Tempo
Common Symptoms of Sluggish Cognitive Tempo


Parental Factors in Developing SCT

SCT may have some parental influences. Barkley conducted a national survey in 2013 which revealed that the following parental factors are linked to an increased risk of SCT:

  • Lower parental education
  • Lower annual household income
  • Parents with a disability


Alcohol Poisoning in Prenatal Life

According to research, a fetus exposed to alcohol during intrauterine life can be more likely to develop the sluggish cognitive function. Alcohol affects unborn babies in significant ways, including causing problems with impairments in motor functions, memory deficits, speech problems, low intelligence levels, difficulty following instructions, visual-spatial trouble, and others.



As previously discussed, there is a strong association between ADHD and SCT.  According to a review study, SCT and ADHD patients suffer more severely than patients with ADHD. The neuropsychological characteristics of sufferers caught in the SCT and ADHD trap include problems in controlling attention and impulses, cognitive challenges such as planning, lack of knowing emotions and their regulation, over-reactivity to the environment, sleep problems such as abnormally long sleep latency or parasomnia/ hypersomnia during childhood or adolescence.


SCT and Neuropsychological Deficits

While some mental illnesses may lead to or may develop neuropsychological problems, SCT does not cause these issues. The development of SCT is not associated with a low intelligence quotient or low IQ.


Sluggish Cognitive Tempo
Medications Used for Sluggish Cognitive Tempo


5. How Does Sluggish Cognitive Tempo Affect Individuals?

There have been several complications linked to the SCT in children and adults, including the following:


Sleep Problems

Researchers have explored sleep disturbances in relation to sluggish cognitive tempo as its possible complication. Study results show that behavioral symptoms such as sleep disturbance contribute to SCT and ADHD. Scientists collected parent reports and analyzed them to create an understanding of the sleep disorders-SCT relationship. The study also considered the children’s age, medication, mental health, and physical health status.

Findings from research revealed that children with difficulty waking up tend to be sluggish and lethargic.


Suicidal Behaviors

It appears that sluggish cognition is uniquely associated with suicidal behavior. 1704 college students were involved in a planned research study. Suicidal behaviors and mental health status were taken into consideration in all the measures.

These were the results:

  • A total of 4% of students reported having previously considered suicide.
  • 2.2% said they planned to commit suicide someday.
  • 7.5% have thought about and attempted suicide several times over the last year.
  • In 41.4% of cases, individuals never discussed their intention to attempt suicide with anyone.

About one-quarter of the participants had suicidal behavior and SCT. In most participants, suicidal behaviors were reported, establishing the first empirical link between SCT and suicidal behavior. 


Slow Processing Speed

It is not tricky for SCT patients to sort and analyze information. A study of college students’ test-taking abilities and reading abilities supports these findings. The study used additional tests, including:

  • Processing speed
  • Reading fluency
  • Reading comprehension

The study results indicated that symptoms of SCT pose the greatest difficulties in time-related tasks and adversely affect processing speed. A comprehensive study is needed to determine whether SCT symptoms are related to low academic performance.

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Sluggish cognitive performance is often accompanied by confusion and wandering thoughts.

What Is Mind-Wandering?

Mind-wandering is when people drift off into their thoughts or become disconnected from external stimuli and fixate on their internal thoughts instead. They often do not realize that these thoughts are unconditioned. Mind-wandering is a really big problem for a lot of people.

It can cause you to stress out because it makes it very difficult to focus on anything important. In fact, the more you try to get your mind off of something, the more difficult it can be to get rid of it from your thoughts! Mind-wandering hinders one’s working memory and inhibits one’s ability to focus on goals and many other life-related issues, ideas, concerns, and objects.

Mind-Wandering Vs. Daydreaming

Daydreaming and mind-wandering may appear to be synonymous, but they are two very different mental states. The main difference is that daydreaming happens when you are conscious of your thoughts, whereas mind-wandering is an unconscious detachment from reality. Daydreams are often positive vibes, whereas mind-wandering tends to lead on a more negative path.

Also, on daydreaming, there are visuals, imaginations, and sometimes hallucinations. You can daydream in a conscious state, still connected to the present world.


Lack of Self-Esteem

People who have a slow cognitive tempo tend to get stressed out easily. According to a study with published findings in the Journal of Attention Disorders, their tasks take them longer to complete, negatively affecting their self-esteem.


Relationship Difficulties

Mind-wandering disorders cause patients to spend most of their time daydreaming, being distracted, and frustrated. You might find that your relationships with others suffer when you cannot take responsibility, fulfill your obligations, and communicate effectively. Thus, the symptoms of SCT often lead individuals to feel lonely.

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6. How Do You Treat Sluggish Cognitive Tempo?

Because sluggish cognitive tempo isn’t a clinical diagnosis yet, there aren’t any specific treatment protocols developed to treat it. Because of this, it’s hard to determine whether or not a stimulant medication is the best choice for treating SCT in children and teenagers. In regards to SCT and symptoms that overlap with ADHD, stress, and anxiety, the following options are considered:

(Note: It is vital to obtain instructions and prescriptions from your certified health practitioner before taking a medication or treatment option. Please inform your doctor if you experience any side effects or unusual symptoms.)


Stimulant Medication

In addition to treating the SCT symptoms of inattentiveness, stimulants such as Ritalin may also improve focus and concentration.


Non-Stimulant Medication 

Treatment of SCT symptoms may also involve non-stimulant medications like Axotomine and norepinephrine reuptake inhibitors. Common non-stimulant medications include:

  • Atomoxetine (Strattera)
  • Guanfacine
  • Clonidine

Several studies have shown that Axotomine is effective in controlling symptoms of SCT. But some researchers deny methylphenidate’s effectiveness for treating the symptoms of daydreaming in individuals in some studies.


Sluggish Cognitive Tempo Supplements

Natural supplements can be helpful in different ways for SCT as they are for ADHD. One of the most effective natural supplements is L-tyrosine. For example, this supplement is beneficial when finding brain stimulation—other valuable supplements include:

Omega-Fatty Acids:  They are found plenty in fish like sardines. The fatty acids are mainly responsible for the improvement of cognitive and behavioral skills.

Zinc:  Zinc deficiency is believed to lead to inattention. You can prevent SCT side effects by fulfilling your zinc body requirements.

Magnesium:  Magnesium soothes the brain by promoting relaxation when present in the body at the right amount.


Sluggish Cognitive Tempo
Therapies for Sluggish Cognitive Tempo


Selective Serotonin Reuptake Inhibitors  

Anecdotally, individuals with SCT and other conditions like social anxiety and PTSD (post-traumatic stress disorder) tend to self-diagnose and self-treat by using SSRIs (selective serotonin reuptake inhibitors). However, some health care providers believe that current research regarding the efficacies of SSRIs for individuals exhibiting cognitive slowness is inconclusive.


Therapy for SCT 

You can look into psychotherapy as an option to treat symptoms of SCT. There are many different types of psychotherapy but find one that focuses on treatment via behavioral therapies or operant procedures. Some important considerations are duration, adjuncts, efficacy, culture sensitivity, accessibility/ availability & economic factors. Among the best therapies to consider include:

In light of your symptoms and prognosis, your doctor will recommend the best option for you.


Lifestyle Changes

People with SCT should eat right, get ample sleep each night, and moderately work out. A diet plan that avoids high-fat foods is of the utmost importance here. Also, being more aware of your sleeping habits can be highly effective in helping relieve symptoms.

Always remember to go to bed around the same time every evening, so you get the rest you need at night. Getting an adequate amount of daily exercise – every day – can also help improve quality-of-life for people with SCT.


Eye-Feedback Training

Eye-feedback is a task-based study that involves aspects of the Unity 3-D game. Researchers used this technique to develop a training program with feedback from an eye tracker about where participants were looking. The experiment would show people with SCT-specific cues to direct their attention versus other cues meant to distract them. The results revealed that the eye-feedback technique was successful in engaging and disengaging attention.

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Sluggish Cognitive Tempo Future Direction

Sluggish cognitive tempo is a condition that has been recognized and known in the past three decades and has been compared to attention deficit hyperactivity disorder in terms of symptoms and treatment. People with SCT often deal with a variety of challenges because of its adverse symptoms. 

Treatments range from individual approaches, such as supplements that boost serotonin levels, to cooperative efforts with several professional support systems, such as tutors or therapists. In the future, the condition may get a new name, a new classification as a disorder, and new diagnostic and therapeutic prescription frameworks.

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