Child Psychiatry & Human Development

https://doi.org/10.1007/s10578-019-00943-z

ORIGINAL ARTICLE

Sluggish Cognitive Tempo and Behavioral Difficulties in Children

with ADHD: Associations with Internalizing and Externalizing
Symptoms
Laura Stoppelbein1   · Elizabeth McRae2 · Shana Smith3 · Stephen Becker4 · Paula Fite5 · Aaron Luebbe6 ·
Leilani Greening7

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Sluggish cognitive tempo (SCT) appears to be distinct from attention-deficit/hyperactivity disorder (ADHD) and unique pat-
terns of association between SCT and comorbid symptoms have been reported in the literature. The current study examined
the relation between environmental supports and comorbid concerns among children with high SCT. Parents of children
(ages 6–12) with a diagnosis of ADHD and clinically elevated SCT (N = 126) completed measures of emotional/behavioral
functioning, child routines, and parental adjustment. Regression analyses revealed that after controlling for child age and
parental adjustment, Household and Daily Living routines were associated with lower levels of externalizing symptoms
while Discipline routines were associated with higher levels of these symptoms, accounting for nearly 20% of the variance
in the equation. The findings suggest that for children with ADHD and high SCT routines may play an important role as an
environmental support for externalizing symptoms.

Keywords  Routines · Internalizing · Externalizing · Sluggish cognitive tempo

Introduction disorder (ADHD), SCT appears to be statistically distinct

Over the past decade there has been increasing interest in
understanding the behavioral construct of sluggish cogni-
tive tempo (SCT). SCT is characterized by slowed behavior
and/or cognition, frequent daydreaming, and a general state
of seeming confused or in a “fog” [1]. Research has sug-
gested that although similar to attention-deficit/hyperactivity
from ADHD, despite frequent co-occurence [2]. There con-
tinues to be debate regarding the correct conceptualization
of SCT and its relation to ADHD. For example, Barkley
and colleagues [3–5] suggest that SCT is a disorder that
frequently co-occurs with ADHD. Other reviews of SCT
suggest that it may be better conceptualized as a possible
specifier diagnostic specifier for ADHD [6]. Other research

1
* Laura Stoppelbein Department of Psychology, University of Alabama, PO
lastoppelbein@ua.edu Box 870161, Tuscaloosa, AL 35487‑0061, USA
2
Elizabeth McRae University of Alabama at Birmingham, Birmingham, AL,
emcrae@uab.edu USA
3
Shana Smith Jacksonville State University, Jacksonville, AL, USA
sasmith@jsu.edu 4
Cincinatti Children’s Hospital, Cincinnati, OH, USA
Stephen Becker 5
University of Kansas, Lawrence, KS, USA
stephen.becker@cchmc.org
6
Miami University, Miami, OH, USA
Paula Fite
7
pfite@ku.edu Glenwood Autism and Mental Health, Birmingham, AL,
USA
Aaron Luebbe
luebbea2@MiamiOH.edu
Leilani Greening
lgreening@ua.edu

13
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does not support SCT symptoms as a part of the DSM-5
diagnostic criteria for ADHD—Predominantly Inattentive
Presentation as was previously suggested regarding DSM-IV
diagnostic criteria [7]. Instead it has been argued that symp-
toms of SCT are best conceptualized outside of a bi-factor
model of ADHD [8].
SCT’s potential distinctiveness from other forms of
psychopathology is underscored by its unique relation to
comorbid disorders and associated outcomes, including
academic and peer difficulties, and emotion dysregula-
tion. Multiple cross-sectional studies have documented a
relation between SCT and higher levels of depression and
academic and social impairment, even after controlling for
inattention symptoms of ADHD [9–17]. SCT has also been
related to higher levels of suicidal ideation/behavior among
children [14]. More recently, longitudinal research revealed
that SCT is associated with later peer/social impairment, as
well as higher levels of depression, anxiety, and academic
impairment across 6-month to 10-year intervals [10, 12, 16,
19]. Most of the research to date suggests that SCT, unlike
ADHD, is not uniquely related to externalizing symptoms
such as Oppositional Defiant Disorder in cross-sectional or
longitudinal evaluations [19–21].
Regardless of whether SCT is conceptualized as a distinct
construct from ADHD, but one that frequently co-occurs
with ADHD, or as a part of a broader inattention subtype/
specifier for ADHD, it appears that SCT symptoms still
have potentially impairing outcomes for children and ado-
lescents across multiple domains. Thus, it is important to
examine factors that might assist researchers in developing
a greater understanding of and thus mitigate the negative
outcomes that are associated with SCT. One factor that has
been evaluated in the literature among children with ADHD
as and other diagnoses (e.g., Autism Spectrum Disorder,
sleep concerns) is child routines. Child routines are defined
as “observable, repetitive behaviors which directly involve
the child and at least one adult acting in an interactive and
supervisory role and which occur with predictable regular-
ity in the daily and/or weekly life of the child” [22, p. 243].
Child routines are considered important for the psychologi-
cal adjustment and well-being of all family members [23].
For example, parents who encourage regular routines adjust
more easily and feel more satisfaction and competent in their
role as a parent [24]. Furthermore parents with lower levels
of psychopathology also tend to engage in more routines,
suggesting a bidirectional relation between parental adjust-
ment and routines [25, 26].
Child routines are not only associated with positive paren-
tal adjustment but with child well-being, as well. Children in
families who have regular routines experience less stress and
anxiety, engage in fewer externalizing behaviors, and expe-
rience overall better psychological adjustment [27]. Recent
literature suggests that child routines are associated with
13
Child Psychiatry & Human Development
lower levels of inattention and hyperactivity among children
diagnosed with ADHD. Furthermore, they seem to play a
protective role against the development of both internalizing
and externalizing symptoms among children diagnosed with
ADHD, even when other environmental risk factors are at
play (e.g., low socioeconomic status) [28–31].
Taken together, existing research has established a
foundation for relations between parental adjustment,
child routines, and child behavior. Specifically, research
suggests that better parental adjustment is associated
with a parent’s ability to effectively establish routines in
the child’s environment [25, 26]. Although research has
investigated the role of child routines on internalizing and
externalizing symptoms among children with ADHD, no
study to date has explicitly examined the role that routines
might play in the development of internalizing or exter-
nalizing symptoms among children with SCT. Thus, the
purpose of the present study is to extend the current SCT
literature and test routines in relation to internalizing and
externalizing symptoms among children with ADHD and
high levels of SCT because these two sets of symptoms
frequently co-occur.
Method
Participants
Participants included children (N = 126) between the ages
of 6 and 12 years (M age = 9.26, SD = 1.93) who had been
diagnosed with ADHD and their primary caregiver(s). Par-
ent–child dyads were recruited from mental health facili-
ties (both outpatient and acute inpatient) in the southeast
United States. The diagnosis of ADHD was made by a
clinical psychologist who completed a comprehensive
assessment. Assessments included a clinical interview,
completing of parent and children reported rating scales,
behavioral observations, teacher ratings in some cases,
and the completion of semi-structured interviews based
on DSM-V criteria (e.g., Mini-Kid)”
Exclusion criteria included the child having a comorbid
traumatic brain injury, psychosis, or being in the custody
of Child Protective Services (n = 12). Only children with
a verified diagnosis of ADHD and with a T-score of 70 or
greater on the SCT scale of the Child Behavior Checklist
were included in the study. The majority of the children
were male (64%), and most of the caregiver respondents
were mothers (75%) or fathers (13%). Twelve percent
of respondents were another custodial family member
(12%). The racial distribution within the overall sample
was considered representative of the health-seeking popu-
lation in the region with 55% identifying as Caucasian,
Child Psychiatry & Human Development
40% identifying as African-American, and the remainder
identifying as Hispanic (2%) or biracial (3%). Overall, the
sample is considered representative and diverse in terms
of sex, age, and racial composition for the region in which
the study was conducted.
Procedure
Procedures were approved by the Institutional Review
Board. Informed consent was obtained from all participants
in this study and caregivers provided consent for their child’s
data to be used as a part of the research database. Caregiver
reports were collected as a part of the clinical services pro-
vided at the facility. Caregivers independently completed
packets of questionnaires assessing parental adjustment,
child emotional/behavioral concerns, and routines in the
home. Children were diagnosed by clinical psychologists
using a comprehensive diagnostic assessment process. After
the child’s admission to the clinical facility was complete,
caregivers were asked if they would be interested in pro-
viding consent to allow their child’s data to be used in the
current study. Caregivers were informed that their decision
regarding consent for research would not impact their child’s
treatment. The psychologists who diagnosed the children in
the present study were independent of the researchers.
Measures
The child behavior checklist (CBCL) [32] is a caregiver-
report measure of behavioral and emotional problems for
children ages 6–18 and was used in this study to measure
internalizing and externalizing child behavior problems.
T-scores based on age and sex are obtained; T-scores of 70
or above are considered clinically significant. The CBCL has
reported test–retest reliabilities of .73 − .94 (Internalizing
and Externalizing scales) and internal consistency of α = .88
[32]. Internal consistency for the current sample ranged from
α’s = .78 to .85. The SCT subscale of the CBCL was also
used in the present sample to identify children with high
or low levels of SCT. The SCT subscale has been used in
numerous studies that examine SCT in children and adoles-
cents and is considered reliable and distinct from measures
of ADHD and as having good face validity with other meas-
ures of SCT [7, 8, 33]
The child routines questionnaire (CRQ) [18] is a 39-ques-
tion caregiver-report measure of children’s daily routines
and activities in the home. Child routines, in this context,
are understood as predictable routines that are interactive
between the parent and the child. The CRQ provides a Total
score and four domain scores: daily living routines, house-
hold responsibilities, discipline routines, and homework
routines. Respondents rate statements such as “My child
wakes up at the same time every day” on a scale of 0–4,
which sum to a total score. Higher scores indicate more child
routines. The CRQ has strong internal consistency (α = .90)
and test–retest reliability (r = .86; Sytsma et al. [22]) and
has been validated in ADHD populations [29, 34]. The cur-
rent sample also demonstrated strong internal consistency
(α = .92).
The Hopkins Symptom Checklist-25 (HSCL-25) [35]
is a self-report measure of adjustment. The measure was
included to control for overall parental adjustment and its
relation to child internalizing and externalizing symptoms.
The HSCL-25 has 25 statements such as “feeling tense or
keyed up” and “feeling no interest in things” that are rated
on a 1–4 scale. This measure has strong internal consistency
and test–retest reliability in both clinical and non-clinical
adult populations [36] with higher scores indicating more
clinical symptoms and thus poorer parental adjustment. The
HSCL-25 has successfully been used to examine parental
adjustment in parents of both clinical and non-clinical popu-
lations of children [29, 34, 37]. In the present study, internal
consistency for the measure was high at α = .92.
Results
Sample Characteristics
The average levels of internalizing (M T-score = 71.89,
SD = 9.04) and externalizing behaviors (M T-score = 74.19,
SD = 8.73) fell in the clinical range of severity for the sam-
ple. Additionally, average scores on the Attention Deficit
Subscale of the CBCL fell in the Borderline Clinical range
(M T-scores = 69.73 and 72.33, SD’s = 7.97 and 5.79,
respectively). The mean score on the HSCL-25 was 23.50
(SD = 15.37) suggesting that parents in the present sample
were reporting average, non-clinical levels of adjustment
compared to normative samples. The mean total score for the
CRQ was 87.60 (SD = 26.61), which is significantly lower
than the average for control groups used in existing child
routines literature (M =112.44, SD =16.52; Jordan, 2003)
based on results of single-sample t-tests [t(125) = − 10.65,
p < .01].
Bivariate Correlations
Bivariate correlations (see Table 1) indicated that age was
significantly negatively related to the total routines score
(r =− .27, p = .01), CBCL externalizing symptoms (r =− .20,
p = .05), and the HSCL-25 score (r =− .22, p = .05). The
sex of the child was not significantly related to any study
variables. CBCL Internalizing symptoms were related to
CBCL Externalizing symptoms (r =.48, p = < .01), Home-
work Routines (r =.19, p = .05), and the total HSCL-25 score
(r =.30, p =< .01), such that higher levels of internalizing
13
 Child Psychiatry & Human Development

Table 1  Bivariate correlations 1 2 3 4 5 6 7 8 9 10
+
1. Age – .17 .03 − .20* − .22* − .27 − .15 .02 .23* − .23*
2. Sex – − .07 − .08 − .05 − .08 − .11 − .08 − .12 .03
3. CBCL internalizing – .48+ .30+ − .05 − .07 − .10 − .03 .19*
4. CBCL externalizing – − .33+ − .20* − .19* − .25* − .08 − .18
5. HSCL-25 – − .05 − .01 − .16 − .01 − .04
6. CRQ total – .85+ .84+ .88+ .69+
7. CRQ daily living – .68+ .69+ .56+
8. CRQ household – .68+ .43+
9. CRQ discipline – .55+
10. CRQ homework –

CBCL child behavior checklist, HSCL Hopkins symptom checklist, CRQ child routines questionnaire
*p < .05; +p < .01

symptoms were associated with higher levels of externaliz-
ing symptoms, homework routines, and parental adjustment
concerns. Externalizing symptoms were related to two CRQ
subscales—Daily Living Routines and Household Responsi-
bilities—and the Total Routines score, such that lower lev-
els of Externalizing symptoms were related to higher levels
of Daily Living Routines, Household Routines, and Total
routines (r’s =− .19 to − .25, p ≤ .05). Finally, Externalizing
symptoms were significantly related to HSCL-25 symptoms
(r =.33, p < .01).
Regression Analyses
Separate step-wise regression analyses were completed with
Internalizing and Externalizing symptoms entered as the
dependent variable. In Step 1 of the regression, the child’s
age and the HSCL-25 Total score were entered as predictor
variables. In the second step, the subscales of the CRQ were
entered as predictor variables after controlling for age and
the HSCL-25 Total score.
For Internalizing Symptoms, Step 1 of the regression
was statistically significant [F(2, 123) = 10.08, p < .001,
R2=.14; see Table 2) with only the HSCL-25 emerging as
a significant predictor of Internalizing symptoms. When
the subscales of the CRQ were entered in Step 2, the equa-
tion remained statistically significant, but there was no sig-
nificant change in R2 [F(6, 119) = 4.28, p = .001, R2=.18].
While the HSCL-25 continued to be a significant predictor
of Internalizing Symptoms, the child’s age also emerged as
a significant predictor. None of the subscales of the CRQ
significantly predicted Internalizing Symptoms.
Step 1 of the regression equation predicting Externalizing
Symptoms was only marginally significant [F(2, 123) = 2.55,
p = .08, R2=.04; see Table 2] with only the HSCL-25 emerg-
ing as a significant predictor of Externalizing symptoms.
The subscales of the CRQ were entered at Step 2, and the
equation became statistically significant with a significant
change in R2 [F(6, 119) = 4.35, p = .001, R2=.19]. While the
HSCL-25 continued to be a significant predictor of External-
izing Symptoms, Daily Living, Household, and Discipline

Table 2  Summaries of Internalizing Externalizing

hierarchical regression analyses
for CBCL internalizing and Predictor β P β P
externalizing scales in children
with SCT Step 1 F (2, 123) = 10.08, p < .001 F (2, 123) = 2.55, p = .08,
R2 = .14 R2 = .04
 Age .13 .13 .04 .68
 HSCL-25 .36 < .001 .20 .03
Step 2 F (6, 119) = 4.28, p = .001 F (6, 119) = 4.35, p = .001,
R2= .18, Δ R2 = .04 R2= .19, Δ R2 = .15
 Age .17 .05 .01 .92
 HSCL-25 .34 < .001 .18 .04
 Daily living − .03 .85 − .27 .05
 Household − .12 .30 − .34 .003
 Discipline .09 .54 .51 .001
 Homework .20 .07 − .09 .41

CBCL child behavior checklist, HSCL Hopkins symptom checklist, CRQ child routines questionnaire

13
Child Psychiatry & Human Development
Routines also emerged as statistically significant predic-
tors such that higher levels of Daily Living and Household
routines were associated with lower levels of Externaliz-
ing Symptoms. However, higher levels of Discipline Rou-
tines were associated with higher levels of Externalizing
Symptoms.
Discussion
Results of the present study yield implications for helping to
understand the comorbid emotional and behavioral difficul-
ties that may occur with high levels of SCT. Research to date
has established links between SCT and internalizing but not
externalizing behaviors when controlling for ADHD [e.g.,
15, 37, 38]. However, results of the present study suggest
that children with high levels of SCT tend to exhibit clini-
cally significant levels of both internalizing and externaliz-
ing behavioral concerns. Additionally, child routines appear
to be related to externalizing but not internalizing behavior
in children with high SCT, providing further information
about the unique pattern of associations observed specifi-
cally among those with high levels of SCT. Finally, results of
the present study could also assist in further distinguishing
SCT as a unique, albeit overlapping, construct from ADHD,
given that the pattern of associations between child routines
and comorbid emotional and behavioral concerns in children
with ADHD and high SCT differs from these associations
reported in samples of children with ADHD only.
Child Routines and Internalizing Behavior
Child routines have been shown to buffer against the effects
of daily life stressors and internalizing and externalizing
behaviors in children and are associated with better overall
psychological adjustment in both clinical and non-clinical
populations of children [29, 31]. However, child routines
were not associated with internalizing behaviors in children
with high SCT in the present study. Instead, parental adjust-
ment and age emerged as predicting internalizing behav-
iors even after accounting for child routines. Although not
within the primary scope of the study, these findings provide
important information regarding emotional and behavioral
functioning in children with high SCT. Children with high
levels of SCT might be uniquely sensitive to this type of
parental distress. It may be that the influence of genetics or
genetic phenotypes associated with anxiety/depression may
have a particularly significant impact on the development of
these symptoms within an SCT population. Alternatively,
other parenting behaviors (e.g., monitoring, support) may
be more important in mitigating or predicting internalizing
symptoms among children with SCT.
Child Routines and Externalizing Behavior
Three subscales of the CRQ—Discipline routines, daily
living routines, and household responsibilities—emerged
as significant associations of externalizing behaviors in
children with high SCT, with higher levels of Discipline
Routines predicting higher levels of externalizing behaviors
and higher levels Daily Living Routines and Household
Responsibilities predicting fewer externalizing behavior.
Discipline routines on the CRQ refers to consistency with
rules and methods of discipline (e.g., a child knows what
will happen if he/she does not follow the rules, is praised/
punished for specific behaviors, etc.), and structured fam-
ily activities [22]. Although this scale has been associated
with fewer externalizing behaviors in other child populations
[39], including children with ADHD in which SCT levels
were not addressed [29], Discipline Routines were predictive
of higher levels of externalizing behaviors for children with
high SCT in the present study. It might be that high levels
of Discipline Routines are more stressful than supportive
for children with high SCT due to an inflexible adherence to
rules that does not account for the ways in which symptoms
of SCT might impact one’s ability to comply with behavioral
expectations. This type of parental rigidity could potentially
lead to frustration in the child with SCT that could present
as externalizing behaviors (e.g., aggression, oppositional
behavior, or noncompliance). However, this finding may
not be unique to children with SCT and may also occur in
children who have ADHD without high levels of SCT. It
might also be that high levels of Discipline Routines are
associated with a more authoritarian parenting style (i.e.,
parenting style that is defined by high and rigid expectations,
punitive responses to misbehavior, and low levels of warmth
and responsiveness) [40], which has been implicated as a
psychosocial factor associated with higher levels of external-
izing behaviors in children with ADHD [e.g., 41] and with
poorer executive functioning [42], which is also an associ-
ated feature of SCT [43]. Alternatively, children with higher
levels of externalizing problems may simply elicit higher
levels of discipline and Discipline Routines, thus accounting
for this relation.
The daily living routines scale of the CRQ primarily
refers to routines around meals and bedtime, with questions
about bedtime routines primarily driving this scale [22].
Therefore, in addition to the support provided by knowing
what to expect from their parents and environment during
these times of transition, children with high SCT might par-
ticularly benefit from bedtime routines. Individuals with
SCT have been shown to experience a range of sleep dif-
ficulties [12], which have been associated with externalizing
behaviors, particularly for children with poorer self-regula-
tion skills [44], such as those with SCT. Therefore, Daily
13

living routines, including consistent bedtime routines, might
predict fewer externalizing behaviors not only because of the
consistency associated with the routines but also by coun-
teracting the effects of poor sleep quality and its associated
cognitive and behavioral outcomes, many of which might
include increased severity of the core features of SCT.
Household responsibilities also emerged as a predictor of
externalizing symptoms, with more Household Responsibili-
ties, such as completing chores (e.g., cleaning up after meals,
putting away toys and clothes, etc.) and personal hygiene
tasks, predicting lower levels of externalizing behavior.
Daily chores and self-hygiene tasks might be difficult for
children with SCT to accomplish due to lower levels of task
initiation and completion, particularly with multi-step tasks.
When these expectations are in place without accompanying
environmental supports, such as consistency and remind-
ers, children with high SCT might have difficulty complet-
ing these tasks, resulting in externalizing behaviors such
as emotional outbursts (e.g., screaming, aggression, etc.)
and/or perceived oppositional-defiance. However, when the
expectations for Household Responsibilities are consistently
implemented and reinforced, children with SCT are better
able to rely on rote memory rather than working memory
and/or sustained memory, both of which are documented
deficits for individuals with SCT [43], to accomplish these
tasks. As such, Household Responsibilities might not only
directly affect externalizing behaviors in this way, but they
might also predict lower levels of externalizing behaviors by
increasing the child’s self-efficacy through routinely accom-
plishing tasks.
Taken together, the present study suggests that specific
types of child routines may serve as a buffer against external-
izing, but they may not be effective in reducing internalizing
symptoms in children with SCT. This finding has several
theoretical and clinical implications. First, this study further
distinguishes SCT as a distinct construct from ADHD and
other psychopathologies, as the relations between child rou-
tines and child behavior in a sample of children with ADHD
and high SCT differs from extant literature on these relations
in other clinical groups, including those with ADHD and no
SCT or unspecified levels of SCT. Second, results suggest
that within the domain of child routines, some types of struc-
ture and routines (e.g., chores, bedtime routines, etc.) appear
to serve as environmental supports that could mitigate some
of the negative effects of SCT and thus result in lower levels
of externalizing behaviors. However, other types of routines
(i.e., discipline) are associated with higher levels of exter-
nalizing behaviors. This pattern of associations not only fits
the continually emerging clinical profile of individuals with
high levels of SCT but further contributes to understanding
psychosocial and environmental supports that are unique to
individuals with SCT.
13
Child Psychiatry & Human Development
Findings of the present study should be interpreted in
light of some methodological limitations. The present study
is cross-sectional in nature and includes only treatment-seek-
ing parent–child dyads seeking mental health services, sug-
gesting that reported parent and child behaviors might not be
representative of their typical level of functioning. However,
the measures used in the present study assess for behaviors
across a broad range of time (e.g., the CBCL prompts par-
ents to rate their child’s behavior within the past 6 months)
and have strong psychometric properties, thus suggesting
that the findings of the present study are representative of
this clinical population. Furthermore, the sample was rep-
resentative of those seeking mental health services in the
southeast and provided a balanced sex representation. Future
research might consider examining these and other psycho-
social variables (e.g., income, education level) as they relate
to SCT longitudinally and in community samples to continue
to garner a more comprehensive understanding of SCT not
only as it relates to other psychopathologies but also as a
unique clinical construct. Additionally, comparisons of chil-
dren who are diagnosed with ADHD and also have high ver-
sus low levels of SCT may help further illuminate potential
mediating and moderating pathways. While the current study
did not include comparisons across groups, it did offer at
least initial support for the role of routines and their unique
association with externalizing behaviors among children
who have high levels of SCT. Finally, the present study
relied solely on parent-report of both the child’s adjustment
as well as their own adjustment. Thus, rating biases may
have influenced the parents’ ratings. Further research using
multi-informant and multi-method approaches could further
clarify relations among parental adjustment and behaviors
as they relate to internalizing or externalizing symptoms.
Summary
SCT has been identified as a related but clinically and sta-
tistically distinct construct from ADHD. As a part of this
distinctness, SCT has a unique pattern of associations with
other comorbid symptoms and outcomes. Given the short-
and long-term deleterious effects associated with SCT,
the current study sought to evaluate one specific type of
environmental support that could assist with preventing or
positively impacting the comorbid internalizing and exter-
nalizing symptoms often associated with SCT. The findings
suggest that certain types of routines, Daily Living routines
and Household routines, may be associated with fewer exter-
nalizing symptoms, but routines did not seem to have an
influence on the presence of internalizing symptoms. Thus,
treatment with clinical populations who present with high
levels of SCT and comorbid externalizing symptoms may
Child Psychiatry & Human Development
wish to incorporate the use of these types of specific routines
into the treatment process to help ameliorate the ongoing
impact of comorbid externalizing symptoms among those
with SCT.
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