1136216

research-article2022
JADXXX10.1177/10870547221136216Journal of Attention DisordersCerny et al.

Article
Journal of Attention Disorders

Cognitive Performance and Psychiatric

1­–12
© The Author(s) 2022
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DOI: 10.1177/10870547221136216
https://doi.org/10.1177/10870547221136216

Disengagement Syndrome and ADHD journals.sagepub.com/home/jad

Diagnostic Groups

Brian M. Cerny1,2 , Tristan P. Reynolds1, Fini Chang1,3, Lauren M. Scimeca1,2,

Matthew S. Phillips1,4, Caitlin M. Ogram Buckley1,5, Sophie I. Leib1,6 ,
Zachary J. Resch1, Neil H. Pliskin1, and Jason R. Soble1

Abstract
Objective: Cognitive disengagement syndrome (CDS) is characterized by inattention, under-arousal, and fatigue and
frequently co-occurs with attention-deficit/hyperactivity disorder (ADHD). Although CDS is associated with cognitive
complaints, its association with objective cognitive performance is less well understood. Method: This study investigated
neuropsychological correlates of CDS symptoms among 169 adults (Mage = 29.4) referred for outpatient neuropsychological
evaluation following inattention complaints. We evaluated cognitive and self-report differences across four high/low CDS
and positive/negative ADHD groups, and cognitive and self-report correlates of CDS symptomology. Results: There
were no differences in cognitive performance, significant differences in self-reported psychiatric symptoms (greater CDS
symptomatology, impulsivity among the high CDS groups; greater inattention among the positive ADHD/high CDS groups;
greater hyperactivity among the positive ADHD groups), significant intercorrelations within cognitive and self-report
measures, nonsignificant correlations between cognitive measures and self-report measures. Conclusion: Findings support
prior work demonstrating weak to null associations between ADHD and CDS symptoms and cognitive performance
among adults. (J. of Att. Dis. XXXX; XX(X) XX-XX)

Keywords
sluggish cognitive tempo, cognitive disengagement syndrome, ADHD, assessment

Introduction have revealed a 3-factor structure with CDS loading on a

Cognitive disengagement syndrome (CDS; previously
referred to as sluggish cognitive tempo [SCT]) is associated
with symptoms of inattention and characterized by under-
arousal, hypoactivity, and reduced motivation (e.g., Barkley,
2014). Proposals to change the name from SCT have existed
for nearly a decade (i.e., Barkley, 2014), largely due to the
stigmatizing nature of the previous name and a recent work-
ing group has proposed the current title of CDS to address
this (Becker et al., 2022). CDS was initially thought to be a
“pure” form of the attention-deficit/hyperactivity disorder-
predominately inattentive presentation (ADHD-I) absent the
hyperactive-impulsive symptoms found in other ADHD pre-
sentations (Barkley, 2001; Milich et al., 2001). However,
research has since consistently demonstrated that CDS is a
highly comorbid, albeit dissociable, construct from ADHD
(Barkley, 2012, 2014; Becker, 2021; Becker et al., 2016). In
fact, factor analytic studies of CDS and ADHD symptoms
separate factor than the inattentive and hyperactive-impul-
sive symptoms characteristic of ADHD (Lee et al., 2014;
Penny et al., 2009). Factor analytic studies of the CDS con-
struct itself have revealed 2 to 3 subfactors typically associ-
ated with inattention, including 2-factor models of
daydreaming/sleepiness and slow/sluggish/lethargy factors
1
University of Illinois College of Medicine, Chicago, USA
2
Illinois Institute of Technology, Chicago, USA
3
University of Illinois at Chicago, USA
4
The Chicago School of Professional Psychology, IL, USA
5
University of Rhode Island, Kingston, USA
6
Rosalind Franklin University of Medicine and Science, North Chicago,
IL, USA
Corresponding Author:
Brian M. Cerny, Department of Psychology, Illinois Institute of
Technology, 3424 S State St, Chicago, IL 60616-3717, USA.
Email: bcerny1@hawk.iit.edu
2 Journal of Attention Disorders 00(0)
(e.g., Barkley, 2013; Penny et al., 2009) and 3-factor models
including daydreaming/boredom, lethargy, and cognitive
complaints (Smith & Suhr, 2021). However, emergence of
subfactors is inconsistent across studies and most studies
examining correlates of CDS do so as a unitary construct
(Becker, 2021; Becker et al., 2022). Unlike ADHD-I symp-
toms, CDS symptoms have shown null or inverse associa-
tions with hyperactivity-impulsivity symptoms observed in
the predominately hyperactive (ADHD-H) or combined
(ADHD-C) presentations of ADHD (Barkley, 2014; Becker,
2021; Becker et al., 2018; Lee et al., 2014; Wåhlstedt &
Bohlin, 2010), further underscoring that CDS and ADHD
are dissociable constructs. However, this association is not
universal, and CDS has demonstrated positive associations
with hyperactivity-impulsivity symptoms among children,
adolescents, and college students, though of a smaller mag-
nitude than inattentive symptoms (e.g., Creque & Willcutt,
2021; Jarrett et al., 2017; Smith & Suhr, 2021; Willcutt et al.,
2014). Although the two are distinct, ADHD and CDS co-
occur at rates between 39% and 59% (Barkley, 2014). Due
to their high rate of co-occurrence and the historical link
between the constructs, the majority of extant CDS research
has been conducted among samples with formal ADHD
diagnoses and have included measurements of ADHD
symptoms. A likely contributing factor is that one of the
most commonly used self-report adult CDS scales is
included as part of a widely used measure of adult ADHD
symptoms, namely the Barkley Adult ADHD Rating Scale-
4th Edition (BAARS-IV; Barkley, 2011).
CDS is also positively associated with internalizing dys-
function (e.g., anxiety and depression) as well as self-
reported functional impairment and executive dysfunction
above and beyond ADHD symptoms (Barkley, 2012;
Becker et al., 2014; Combs et al., 2014; Jarrett et al., 2017;
Kamradt et al., 2018; Leikauf & Solanto, 2017). However,
unlike in children, few studies have explored CDS’s asso-
ciation with objective cognitive test performance in adults.
This is notable because measure of CDS symptoms in adults
relies primarily on subjective report, which has typically
been associated with greater ratings of impairment than
objective cognitive performance (e.g., Guo et al., 2021).
Significant associations have been observed between CDS
symptom severity and performance on select cognitive assess-
ments in adults, particularly within the domains of attention
and processing speed (Becker et al., 2016; Jarrett et al., 2017;
Kamradt et al., 2018; Smith & Suhr, 2021; Wåhlstedt &
Bohlin, 2010; Willcutt et al., 2014). However, the magnitude
and significance of associations have been equivocal across
studies. Among adults, individuals with clinically significant
CDS and ADHD demonstrated moderately poorer perfor-
mance on a task of sustained attention than healthy controls
(Jarrett et al., 2017). However, group differences were iso-
lated to sustained attention, and CDS symptoms were not
independently associated with task performance in any
cognitive domain (Jarrett et al., 2017). Another study showed
modest, non-linear differences on tasks of working memory
and processing speed across individuals with ADHD grouped
by minimal, moderate, or severe CDS symptoms (Kamradt
et al., 2018). Among a university sample, one subfactor of
CDS (daydreaming/boredom) significantly, albeit modestly,
predicted working memory performance after taking into
account nonverbal fluid intelligence and other CDS subfac-
tors (Smith & Suhr, 2021). Further investigations with college
students have demonstrated no association between CDS and
cognitive performance (Wood et al., 2017). In contrast, there
have been more significant and expansive associations
between CDS and cognitive performance in the pediatric
ADHD literature. For instance, CDS has demonstrated sig-
nificant correlations with cognitive performance across mul-
tiple domains among children with ADHD, and it selectively
predicted sustained attention after accounting for ADHD
symptoms (Wåhlstedt & Bohlin, 2010). Large community
samples of children with and without ADHD and clinically
significant CDS symptoms yielded significant univariate
associations between CDS symptoms and multiple cognitive
domains, as well as unique associations with sustained atten-
tion, processing speed, and working memory (Creque &
Willcutt, 2021; Willcutt et al., 2014). That said, a study exam-
ining Puerto Rican children found no association between
CDS and cognitive performance (Bauermeister et al., 2012).
Collectively, findings have been mixed regarding the associa-
tion between CDS and objective cognitive performance in
adults, with stronger associations typically found among pedi-
atric samples. No cognitive profile or central cognitive deficit
has been found to be associated with CDS (Becker et al.,
2022).
Taken together, the extant literature in adults with CDS
complaints suggests that CDS is reliably associated with
self-reported functional deficits, although its association
with cognitive performance is inconsistent, ranging from
null to moderate across studies and samples. This study
aimed to evaluate potential cognitive performance differ-
ences in adults across CDS and ADHD diagnostic groups
and to examine neuropsychological correlates of CDS
among a mixed sample of adult outpatients referred for neu-
ropsychological assessment of reported inattention. We
hypothesized that CDS symptoms would have a minimal
association with objective cognitive performance and a
modest to strong association with psychiatric self-reports
among this sample.
Method
Participants
This cross-sectional study used archival data from 444
outpatients referred for neuropsychological evaluation
services for the purposes of diagnostic clarification and
Cerny et al. 3

Table 1.  Descriptive Statistics for the Entire Sample. Scale-4th Edition (WAIS-IV; Wechsler, 2008), Trail
Making Test (TMT) Parts A and B (Heaton et al., 2004;
Mean (SD)
Variable n (%) Reitan & Wolfson, 1993), and Beck Depression Inventory-
2nd Edition (BDI-II; Beck et al., 1996). Validity status
Age (Range: 18–59 years) 29.4 (8.0) was established by evaluating patient performance on two
Sex (M/F) 103/66 (61/39) or more of five PVTs: Victoria Symptom Validity Test
Education (Range: 8–24 years) 15.7 (2.4) (VSVT; Resch et al., 2021), Test of Memory Malingering
Race/Ethnicity Trial 1 (TOMM-T1; Tombaugh, 1996; Denning, 2012),
  Non-Hispanic White 98 (58) CVLT-II Forced Choice (CVLT-II FC; Schwartz et al.,
 Hispanic 27 (16)
2016), Brief Visuospatial Memory Test-Revised
  Non-Hispanic Black 25 (14.7)
Recognition Discrimination (BVMT-R RD; Pliskin et al.,
  Asian/Pacific Islander 13 (7.7)
2021; Resch et al., 2022), and Stroop Color and Word Test
  Multiracial or Other Race/Ethnicity 6 (3.6)
Word T-Score (White et al., 2020). Among the overall
Clinically Significant CDS 81 (47.9)
ADHD Final Diagnosis (n = 163)
sample, 234 patients were missing one or more study mea-
  No ADHD 76 (46.6) sures and were thereby excluded from subsequent analy-
 ADHD 67 (41.1) ses. An additional 71 participants were excluded due to
  Undetermined/Equivocal Study 20 (12.2) invalid CAT-A profiles, not being administered two or
CVLT Trials 1–5 T-Score 51.0 (11.2) more PVTs, or failing one or more criterion PVTs. See
CVLT LDFR z-Score 0.0 (1.1) Table 1 for demographic details for the full sample. Final
WAIS-IV PSI Standard Score 103.3 (13.8) determination of ADHD diagnosis was available for 163
WAIS-IV WMI Standard Score 104.2 (14.9) individuals (Table 2). Validity status was determined by
Trail Making Test Part A T-Score 50.3 (12.7) PVT performance and final clinician determination based
Trail Making Test Part B T-Score 49.5 (10.5) on a comprehensive neuropsychological assessment.
Cognitive Disengagement Syndrome 22.2 (5.8) Individuals with CDS symptoms above the 92nd percen-
Raw Score tile were determined to have clinically significant CDS
BDI-II Raw Score 15.9 (10.5) symptoms and included in the high CDS groups, whereas
CAT-A Inattention T-Score 67.4 (10.7) those at or below the 92nd percentile were included in the
CAT-A Impulsivity T-Score 58.5 (10.6) low CDS groups (n = 81; Barkley, 2011).
CAT-A Hyperactivity T-Score 53.8 (12.3)

Note. n = 169. CDS = Cognitive Disengagement Syndrome; ADHD = At- Measures

tention-Deficit/Hyperactivity Disorder; CVLT = California Verbal
Learning Test Trials; LDFR = California Verbal Learning Test Long Delay
Free Recall z-Score; WAIS-IV PSI = Wechsler Adult Intelligence Scale-4th
Ed. Processing Speed Index Score; WAIS-IV WMI = Wechsler Adult
Intelligence Scale-4th Ed. Working Memory Index Score; BDI-II = Beck
Depression Inventory 2nd Ed.; CAT-A = Clinical Assessment of Atten-
tion Deficit.
T-Scores have a mean of 50 and SD of 10; Standard Scores have a mean
of 100 and SD of 15; z-scores have a mean of 0.0 and SD of 1.0.
treatment planning at a Midwestern academic medical
center from 2014 to 2021. All patients consented to includ-
ing their test scores as part of an ongoing, IRB-approved
database study. The primary inclusion criterion was
administration of the BAARS-IV. No formal exclusion
criteria were employed, although patients were excluded if
they were not administered all study variables of interest,
administered fewer than two performance validity tests
(PVTs), or failed one or more PVTs (see below). Patients
were administered the BAARS-IV, Clinical Assessment of
Attention Deficit-Adult (CAT-A; Bracken & Boatwright,
2005), California Verbal Learning Test-2nd (CVLT-II;
Delis et al., 2000) or -3rd Editions (CVLT-3; Delis et al.,
2017), Working Memory Index (WMI) and Processing
Speed Index (PSI) of the Wechsler Adult Intelligence
Barkley Adult ADHD Rating Scale-4th Ed. (BAARS-IV; Bark-
ley, 2011).  The BAARS-IV is a 27-item self-report mea-
sure of both childhood and current ADHD symptoms and
current cognitive disengagement syndrome (titled “slug-
gish cognitive tempo” [SCT] on the measure) symptoms
based on DSM-IV criteria. Participants indicate the
extent to which CDS symptoms apply to them over the
past 6 months, indicating 1 for “Never or rarely,” 2 for
“Sometimes,” 3 for “Often,” and 4 for “Very often.”
Scores are converted to age-corrected percentile ranks.
The nine-item BAARS-IV CDS scale was used in this
analysis.
Clinical Assessment of Attention Deficit-Adult (CAT-A; Bracken
& Boatwright, 2005).  The CAT-A is a self-report inven-
tory of childhood and adulthood ADHD symptoms with
embedded symptom validity scales (Leib et al., 2022;
White et al., 2022). Participants indicate the extent to
which symptoms of ADHD applied to them both during
childhood and currently. Scores are converted to age-
corrected T-scores. The CAT-A Current Attention, Impul-
sivity, and Hyperactivity scales were used in the present
analyses.
4 Journal of Attention Disorders 00(0)
Table 2.  Demographic Breakdown by CDS/ADHD Group.
High CDS/+ ADHD Low CDS/+ ADHD High CDS/− ADHD
n = 30 n = 37 n = 38
Age 27.8 (5.4) 30.4 (9.4)
Education 15.8 (2.1) 15.9 (2.2)
Sex M/F 21/9 24/13
Race/Ethnicity
  Non-Hispanic White 20 (66.7%) 24 (64.9%)
 Hispanic 4 (13.3%) 6 (16.2%)
  Non-Hispanic Black 4 (13.3%) 5 (13.5%)
 Asian 2 (6.7%) 1 (2.7%)
  Mixed/Other Race/Ethnicity 0 1 (2.7%)
Note. n = 143. All p values >.05. CDS = Cognitive Disengagement Syndrome; ADHD = Attention-Deficit/Hyperactivity Disorder.
The California Verbal Learning Test-2nd Editions (CVLT-II and
CVLT-3; Delis et al., 2000, 2017).  The CVLT is a measure of
auditory learning and memory. Participants are presented
five trials of a list of words that can be grouped into seman-
tic categories. Following a distractor list and delay, partici-
pants are asked to freely recall as many words as they can
remember. Scores are converted to age-corrected T-scores
(trials 1–5) or z-scores (delayed free recall). Trials 1 to 5
and delayed free recall performances were included in the
present analyses.
Wechsler Adult Intelligence Scale-4th Edition (WAIS-IV; Wechsler,
2008).  The WAIS-IV is a clinical assessment of intellectual
ability for adolescents and adults. It yields four index scales
that are combined to form a full-scale IQ (FSIQ). Two indi-
ces are the Working Memory Index (WMI) and the Process-
ing Speed Index (PSI). The WMI is comprised of two
subtests evaluating basic and complex auditory attention.
The PSI is comprised of two paper-and-pencil subtests
examining visual-motor coordination and psychomotor
speed. Scores on individual WAIS-IV subtests are converted
to age-corrected scaled scores, which are combined to create
index-level standard scores. The standard scores for WMI
and PSI were included in the present analyses.
Trail Making Test (TMT; Heaton et al., 2004; Reitan & Wolfson,
1993).  The TMT is a widely used paper-and-pencil measure.
TMT Part A (TMT-A) is a test of visual scanning and psycho-
motor speeded sequencing. TMT Part B (TMT-B) is a similar
measure with an additional component of cognitive flexibil-
ity/set-shifting. Completion times are converted to scaled
scores, which are then converted to race- (Black/White), sex-
(Male/Female), education-corrected T-scores. T-scores for
TMT A and TMT B were used in the present analyses.
Beck Depression Inventory-2nd Ed. (BDI-II; Beck et  al.,
1996).  The BDI-II is a widely used and validated measure of
depression symptoms for individuals over the age of 13.
Low CDS/− ADHD
n = 38 χ2 F
30.7 (9.4) 28.6 (7.9) 0.1
15.6 (2.6) 14.9 (2.4) 2.87
17/21 26/12 38.44  
38.2  
19 (50%) 21 (55.3%)  
9 (23.7%) 7 (18.4%)  
6 (15.8%) 4 (10.5%)  
1 (2.6%) 5 (13.2%)  
3 (7.9%) 1 (2.6%)  
Participants select statements that best describe their mood
and well-being over the past 2 weeks. The BDI-II total score
was used the present analysis.
Conners Continuous Performance Task-2nd Ed. (CPT-II; Conners,
2004).  The CPT-II is a widely used continuous perfor-
mance measure. Participants are required to attend to the
screen which presents varying target or non-target stimuli
for an extended span of several minutes. Respondents are
required to press a key in response to target stimuli and not
respond to non-target stimuli. The CPT-II yields several
indices related to response speed, accuracy, and variability.
Data were available for Omissions (missed targets), Com-
missions (non-target responses), Hit Rate (response speed
for correct targets), and Variability (response speed consis-
tency) and these indices were included in the supplemen-
tary analyses (Tables 5 and 6).
Statistical Analyses
Analyses were conducted in R Studio version 2022.02.3
“Prarie Trillium” (RStudio Team, 2020). Two multivariate
analyses of variance (MANOVAs) were conducted to deter-
mine whether individuals with high or low CDS and with
and without a diagnosis of ADHD differed in performance
across the cognitive and psychiatric variables. Groups
included: high CDS/positive ADHD (Group 1), low CDS/
positive ADHD (Group 2), high CDS/negative ADHD
(Group 3), and low CDS/negative ADHD (Group 4).
Follow-up one-way analyses of variance (ANOVAs) with
Tukey’s post hoc pairwise comparisons were then con-
ducted to determine differences in study variables across
groups. 20 individuals were excluded from multivariate
analyses due to missing or indeterminate ADHD diagnostic
status. Familywise error rate for multiple comparisons was
controlled using false discovery rate (FDR) procedure, with
a 0.05 maximum FDR (Benjamini & Hochberg, 1995).
Among the entire sample, bivariate Pearson correlations
Cerny et al. 5

Table 3.  Multivariate Analyses of Variance of Cognitive and Psychiatric Variables.

Group 1 Group 2 Group 3 Group 4

High Low CDS/+ High CDS/− Low CDS/−
CDS/+ADHD ADHD ADHD ADHD
n = 30 n = 37 n = 38 n = 38 V F ηp2 Pairwise
Cognitive variables .02 0.65 .03  
  CVLT Trials 1–5 51.6 (11.3) 50.1 (10.3) 49.3 (11.0) 53.4 (11.9) 0.42 <.01  
  CVLT LDFR 0.0 (1.1) −0.2 (1.3) −0.2 (0.9) 0.2 (1.0) 0.80 <.01  
  WAIS-IV PSI 102.8 (14.8) 104.6 (13.9) 98.6 (13.0) 106.8 (13.7) 0.37 <.01  
  WAIS-IV WMI 105.1 (16.7) 104.3 (15.0) 100.6 (16.3) 106.6 (13.9) 0.02 <.01  
  TMT A 49.0 (13.0) 50.5 (13.5) 48.5 (11.4) 54.8 (11.5) 2.75 .02  
  TMT B 48.7 (8.8) 48.0 (9.6) 48.6 (11.3) 51.7 (10.0) 1.75 .01  
Psychiatric variables .36 15.26* .36  
 CDS 27.4 (3.7) 17.5 (3.7) 26.7 (3.6) 17.9 (4.2) 17.01* .61 1,3>4; 1,3>2
 BDI-II 19.4 (13.2) 9.8 (6.8) 20.2 (9.2) 14.8 (10.7) 0.04 .15  
  CAT-A Inattention 72.8 (8.2) 67.5 (9.2) 69.3 (9.9) 59.4 (10.7) 26.19* .21 1,2,3>4
  CAT-A Impulsivity 63.9 (10.5) 57.6 (10.7) 59.7 (10.2) 52.1 (7.1) 19.09* .16 1,3>4; 1>2
  CAT-A Hyperactivity 58.4 (10.0) 58.2 (13.0) 48.8 (8.2) 46.8 (8.7) 33.01* .22 1,2>3,4

Note. n = 143. * p < .001. V = Pillai’s Trace; ηp2 = partial eta squared; CDS = Cognitive Disengagement Syndrome; ADHD = Attention-Deficit/ Hyper-
activity Disorder; CVLT = California Verbal Learning Test Trials; LDFR = California Verbal Learning Test Long Delay Free Recall z-Score; WAIS-IV
PSI = Wechsler Adult Intelligence Scale-4th Ed. Processing Speed Index Score; WAIS-IV WMI = Wechsler Adult Intelligence Scale-4th Ed. Working
Memory Index Score; TMT A = Trail Making Test Part A T-Score; TMT B = Trail Making Test Part B T-Score; BDI-II = Beck Depression Inventory 2nd
Ed. Raw Score; CAT-A = Clinical Assessment of Attention Deficit. T-Scores have a mean of 50 and standard deviation of 10; Standard Scores have a
mean of 100 and standard deviation of 15; z-scores have a mean of 0.0 and standard deviation of 1.0.

were used to evaluate directionality and magnitude of asso-
ciations between study variables.
A supplemental MANOVA was conducted including per-
formance on the Conners’ Continuous Performance Test-
2nd (CPT-II; Conners, 2004), along with the remaining
cognitive performance variables. Specifically, age-corrected
T-scores for CPT Omissions, Commissions, Hit Rate, and
Variability were available and included in the supplementary
analysis. CPT data was not included in the primary analysis
in order to preserve a larger sample size as not all partici-
pants included in the primary analysis were administered the
CPT. CPT data were available for 132 total individuals and
110 individuals who had complete CDS and ADHD diag-
nostic data. Supplementary Pearson correlations were simi-
larly repeated with the inclusion of the CPT variables.
Results
Descriptive statistics for the full sample and for the four
diagnostic groups are available in Tables 1 and 2, respec-
tively. Participants across the four diagnostic groups did
not significantly differ in age, education, sex, or racial/
ethnic background. All cognitive performance and psychi-
atric self-report variables were normally distributed
(skewness and kurtosis absolute values <0.45 and <0.50,
respectively).
The first MANOVA revealed no differences in cognitive
variables across the four high/low CDS and positive/nega-
tive ADHD diagnostic groups, V = 0.02, F(1, 141) = 0.65,
p = .69. Conversely, the second MANOVA revealed signifi-
cant differences in psychiatric variables across the four
groups, V = 0.36, F(1, 141) = 15.26, p < .001. Follow-up
ANOVAs revealed significant differences in CDS, inatten-
tion, impulsivity, and hyperactivity across the four groups.
See Table 2 for details on MANOVAs and follow-up pair-
wise comparisons.
Among the full sample, bivariate Pearson correlations
(Table 4) revealed that the cognitive performance vari-
ables (rs = .20–.79) and the self-report variables (rs = .26–
.52) were significantly positively intercorrelated, with
two exceptions: CDS and depressive symptoms were
independently uncorrelated with hyperactivity (ps > .05;
Table 3). CDS and WAIS-IV PSI were the only psychiat-
ric and cognitive performance variables that were sig-
nificantly correlated, albeit modestly (r = −.17, p < .05).
Correlations were repeated among individuals with con-
firmed ADHD, producing highly similar results.
The supplementary MANOVA conducted on the cogni-
tive variables across diagnostic groups was similar to the
results of the primary analysis (Table 5). Inclusion of the four
CPT variables did not reveal any significant differences
across groups, V = 0.11, F(1, 108) = 1.19, p = .30. For the sup-
plementary correlation analysis, all cognitive variables
remained intercorrelated, with select exceptions among the
four CPT variables (see Table 6). The psychiatric self-report
variable intercorrelations were highly similar as well. CDS
was no longer correlated with WAIS-IV PSI but had a modest
significant correlation with TMT-A (r = −.18, p < .05).
6 Journal of Attention Disorders 00(0)

Table 4.  Pearson Correlations Between Study Variables Among the Entire Sample.

CVLT T1-5 CVLT LDFR PSI WMI TMT A TMT B CDS BDI-II CAT-A ATT CAT-A IMP
CVLT LDFR .79*** -  
PSI .25** .23** -  
WMI .39*** .40*** .35*** -  
TMT A .20* .22** .50*** .30*** -  
TMT B .25** .23** .42*** .48*** .55*** -  
CDS −.04 −.07 −.17* −.10 −.15 .00 -  
BDI-II −.09 −.08 −.11 −.11 −.03 .06 .51*** -  
CAT-A ATT −.05 −.03 −.06 .10 −.08 .02 .47*** .27*** -  
CAT-A IMP −.05 −.02 −.07 .01 −.11 .02 .29*** .38*** .52*** -
CAT-A HYP −.11 −.07 −.03 −.10 −.09 −.12 .00 -.01 .26** .39***

Note. n = 169; *p < .05, **p < .01, ***p < .001. CVLT T1–5 = California Verbal Learning Test Trials 1–5 T-Score; CVLT LDFR = California Verbal Learning
Test Long Delay Free Recall Scaled Score; PSI = Wechsler Adult Intelligence Scale-4th Ed. Processing Speed Index Score; WMI = Wechsler Adult Intel-
ligence Scale-4th Ed. Working Memory Index Score; TMT A = Trail Making Test Part A; TMT B = Trail Making Test Part B; CDS = Barkley Adult ADHD
Rating Scale-4th Ed. Sluggish Cognitive Tempo (Cognitive Disengagement Syndrome) Raw Score; BDI-II = Beck Depression Inventory 2nd Ed. Raw
Score; CAT-A ATT = Clinical Assessment of Attention Deficit Attention T-Score; CAT-A IMP = Clinical Assessment of Attention Deficit Impulsivity
T-Score; CAT-A HYP = Clinical Assessment of Attention Deficit Hyperactivity T-Score.

Table 5.  Supplementary Multivariate Analyses of Variance of Cognitive Variables.

Group 1 Group 2 Group 3 Group 4

High Low High CDS/− Low CDS/−
CDS/+ADHD CDS/+ADHD ADHD ADHD
n = 26 n = 22 n = 33 n = 29 V F ηp2 Pairwise
Cognitive variables .11 1.19 .11  
  CVLT Trials 1–5 51.3 (11.5) 52.5 (10.2) 49.2 (11.4) 55.0 (12.0) 0.66 <.01  
  CVLT LDFR −0.1 (1.1) 0.2 (1.2) −0.1 (1.0) 0.4 (0.9) 1.67 .02  
  WAIS-IV PSI 102.0 (15.7) 103.4 (15.3) 98.9 (12.4) 106.1 (14.1) 0.42 <.01  
  WAIS-IV WMI 103.1 (15.9) 103.5 (16.1) 101.8 (16.8) 106.6 (14.3) 0.42 <.01  
  TMT A 46.9 (12.1) 51.4 (13.6) 48.5 (11.7) 54.9 (11.6) 4.25 .04  
  TMT B 47.7 (8.9) 47.1 (9.4) 48.6 (11.8) 52.9 (10.5) 3.79 .03  
 Omissions 60.0 (23.3) 53.1 (19.5) 62.2 (39.3) 56.2 (36.1) 0.01 .03  
 Commissions 56.8 (9.2) 56.8 (10.7) 51.0 (9.9) 54.4 (11.3) 2.09 .03  
  Hit Rate 46.7 (9.7) 47.2 (8.2) 54.7 (12.3) 46.5 (10.1) 0.73 .03  
 Variability 55.6 (12.0) 55.0 (13.0) 58.4 (12.6) 48.8 (11.6) 2.60 .03  

Note. n = 110. All p values >.05. V = Pillai’s Trace; ηp2 = partial eta squared; CDS = Cognitive Disengagement Syndrome; ADHD = Attention-Deficit/
Hyperactivity Disorder; CVLT = California Verbal Learning Test Trials; LDFR = California Verbal Learning Test Long Delay Free Recall z-Score; WAIS-
IV PSI = Wechsler Adult Intelligence Scale-4th Ed. Processing Speed Index Score; WAIS-IV WMI = Wechsler Adult Intelligence Scale-4th Ed. Working
Memory Index Score; TMT A = Trail Making Test Part A T-Score; TMT B = Trail Making Test Part B T-Score; Omissions = CPT Omissions T-Score;
Commissions = CPT Commissions T-Score; Hit Rate = = CPT Hit Rate T-Score; Variability = CPT Variability T-Score. T-Scores have a mean of 50 and
standard deviation of 10; Standard Scores have a mean of 100 and standard deviation of 15; z-scores have a mean of 0.0 and standard deviation of 1.0.

Discussion
This cross-sectional study evaluated the associations
between subjective retrospective complaints of CDS, objec-
tive cognitive performance, and self-report psychiatric
measures in neuropsychiatric outpatients with and without
ADHD. Results revealed no statistically significant differ-
ences in cognitive performance across 4 ADHD and CDS
diagnostic groups. There were significant group differences
in self-reported psychiatric symptoms, although this was
unsurprising considering that self-reports were used to
establish the high/low CDS groups and additionally helped
inform diagnosis of ADHD. Among the full sample, all per-
formance-based cognitive measures were intercorrelated.
Most self-report measures were similarly intercorrelated,
with the exception of hyperactivity symptoms with CDS
and with depressive symptoms. Moreover, neuropsycho-
logical performance had weak to null correlations with psy-
chiatric symptoms.
Results of the present study support prior work demonstrat-
ing the weak to null associations between CDS symptoms and
objective cognitive performance among adults (Jarrett et al.,
2017; Kamradt et al., 2018; Smith & Suhr, 2021). Some prior
studies have demonstrated selective deficits in sustained
 Table 6.  Supplementary Pearson Correlations Between Study Variables Among the Entire Sample with Available Data.

CVLT CVLT CAT-A CAT-A

T1–5 LDFR PSI WMI TMT A TMT B Omissions Commissions Hit Rate Variability CDS BDI-II ATT IMP
CVLT LDFR .79*** -  
PSI .30*** .26** -  
WMI .45*** .43*** .34*** -  
TMT A .24** .25** .49*** .24** -  
TMT B .27** .23** .43*** .47*** .57*** -  
Omissions −.30*** −.28** −.15 −.15 −.17* −.21* -  
Commissions −.19* −.17* −.13 −.14 −.12 −.08 .08 -  
Hit Rate −.15 −.14 −.25** −.14 −.22* −.25** .35*** −.50*** -  
Variability −.29** −.25** −.32*** −.23** −.27** −.31*** .52*** .16 .40*** -  
CDS −.10 −.15 −.12 −.09 −.18* −.04 .07 −.03 .16 .19* -  
BDI-II −.11 −.07 −.06 −.06 −.01 .07 .04 .13 .00 .13 .44*** -  
CAT-A ATT −.08 −.06 .02 .14 −.08 .07 −.12 .14 −.15 −.04 .43*** .22* -  
CAT-A IMP −.07 −.01 .02 .06 −.09 .05 .14 .23 −.06 .10 .22* .34*** .44*** -
CAT-A HYP −.10 −.03 .02 −.12 −.09 −.06 .08 .15 −.07 .04 −.03 .00 .19* .40***

Note. n = 129; *p < .05, **p < .01, ***p < .001. CVLT T1–5 = California Verbal Learning Test Trials 1–5 T-Score; CVLT LDFR = California Verbal Learning Test Long Delay Free Recall Scaled Score;
PSI = Wechsler Adult Intelligence Scale-4th Ed. Processing Speed Index Score; WMI = Wechsler Adult Intelligence Scale-4th Ed. Working Memory Index Score; TMT A = Trail Making Test Part A;
TMT B = Trail Making Test Part B; CDS = Barkley Adult ADHD Rating Scale-4th Ed. Sluggish Cognitive Tempo (Cognitive Disengagement Syndrome) Raw Score; BDI-II = Beck Depression Inventory
2nd Ed. Raw Score; CAT-A ATT = Clinical Assessment of Attention Deficit Attention T-Score; CAT-A IMP = Clinical Assessment of Attention Deficit Impulsivity T-Score; CAT-A HYP = Clinical As-
sessment of Attention Deficit Hyperactivity T-Score.

7
8 Journal of Attention Disorders 00(0)
attention (Jarrett et al., 2017), which were not observed in the
present study. Studies in adult samples have been sparse,
although they reliably demonstrate that CDS symptoms are
more strongly associated with self-report data than objective
cognitive performance (e.g., Jarrett et al., 2017). Existing
research on CDS and cognitive performance in children and
adolescents with ADHD is more consistent, with most studies
demonstrating widespread moderate associations across cog-
nitive domains (e.g., Creque & Willcutt, 2021; Wåhlstedt &
Bohlin, 2010; Willcutt et al., 2014) with few exceptions reveal-
ing no to minimal associations after controlling for ADHD
symptoms (e.g., Bauermeister et al., 2012). Taken together,
these results may suggest that CDS is more strongly associated
with cognitive performance in children than adults. However,
this difference may also be explained by CDS symptom mea-
surement. The majority of studies demonstrating similar results
to the present study utilized the 9-item SCT/CDS scale from
the BAARS-IV (Barkley, 2011; Jarrett et al., 2017; Kamradt
et al., 2018; Smith & Suhr, 2021; Wood et al., 2017), which is
validated for use among adults. Conversely, pediatric studies
drew items from the Child Behavior Checklist (CBCL-C;
Achenbach & Rescorla, 2001) to create a CDS composite with
4 to 12 items (Bauermeister et al., 2012; Creque & Willcutt,
2021; Wåhlstedt & Bohlin, 2010; Willcutt et al., 2014). As
such, the BAARS-IV SCT scale may capture a slightly differ-
ent construct than the CBCL-C composites, with the former
potentially being less strongly associated with objective cogni-
tive performance. Without more consistency in objective mea-
surement of CDS among children, it is not possible at this time
to determine whether differences in CDS correlates observed
in children versus adults are due to measurement-related or
construct-related factors (see Becker et al., 2022).
Conversely, the presence of relative cognitive deficits in
ADHD versus healthy controls has been well-established and
often include heterogenous impairments in attention, working
memory, executive functioning, and processing speed (e.g.,
Alderson et al., 2013; Hervey et al., 2004; Leib et al., 2021;
Mostert et al., 2015; Pievsky & McGrath, 2018; Willcutt
et al., 2005). The current study, however, did not reveal sig-
nificant between-group differences on cognitive performance
for patients with and without ADHD, regardless of CDS sta-
tus. ADHD is associated with inter-individual variability (e.g.,
Leib et al., 2021; Mostert et al., 2015) and, although relative
deficits are common, they are not universal.
Consistent with extant literature, this study’s self-reported
psychiatric outcomes support links between symptom com-
plaints of CDS, ADHD, and depression. Consistent with pre-
vious literature, CDS was associated with ADHD
symptomatology, with a stronger association observed with
inattention than impulsivity or hyperactivity (e.g., Becker
et al., 2016; Bernad et al., 2014; Kamradt et al., 2018).
Additionally, higher impulsivity observed in Group 1 (high
CDS/positive ADHD) than Group 2 (low CDS/positive
ADHD) and in Groups 1 (high CDS/positive ADHD) and 3
(high CDS/negative ADHD) than Group 4 (low CDS/nega-
tive ADHD) suggest a potential additive effect of comorbid
CDS and ADHD on self-reported symptomatology. Previous
literature has demonstrated similar additive effects, though
not exclusively in impulsivity or other forms of externalizing
behavior (e.g., Barkley, 2012; Kamradt et al., 2018; Wåhlstedt
& Bohlin, 2010). Previous studies that have found positive
associations between CDS symptoms and externalizing
behavior saw a reversal of these associations after controlling
for ADHD symptoms (see Becker et al., 2022). However, a
post hoc analysis of covariance (ANCOVA) controlling for
inattention and hyperactivity did not attenuate group differ-
ences in impulsivity among this sample. The majority of
extant literature combines hyperactive and impulsive symp-
toms into a single hyperactive/impulsive symptom cluster
(e.g., Becker et al., 2016, 2018; Capdevila-Brophy et al.,
2014; Kamradt et al., 2018; Smith & Suhr, 2021; Wåhlstedt
& Bohlin, 2010), with some exceptions (e.g., Jarrett et al.,
2017). Moreover, few, if any, previous investigations of CDS
have used the CAT-A as a measure of ADHD symptoms,
which separates hyperactivity and impulsivity into distinct
indices. It is possible that this separation produced group dif-
ferences in impulsive symptoms that would not be observed
had we used a measure with a unitary hyperactive-impulsive
index. Moreover, the CAT-A includes items on its Impulsivity
index that are more related to cognitive/attentional impulsiv-
ity than overt behavioral impulsivity (i.e., difficulty with self-
monitoring or planning; Bracken & Boatwright, 2005).
Additional CDS research using the validity-controlled CAT-A
to assess ADHD symptoms is required to better understand
the differential associations with hyperactivity and impulsiv-
ity. Finally, although between-group differences were not
observed, results demonstrated depressive symptoms were
significantly correlated with CDS and ADHD symptoms,
consistent with prior studies indicating that CDS is related to
internalizing symptoms (Becker, 2021; Becker et al., 2014;
Becker & Langberg, 2013; Becker et al., 2016; Capdevila-
Brophy et al., 2014; Kamradt et al., 2018).
This study had several methodological strengths, includ-
ing a large sample that was demographically diverse with
objective controls for performance and symptom validity.
However, there were several limitations. First, all partici-
pants were referred for ADHD evaluation in the context of
inattention complaints, thereby making this a convenience
sample. Participants who did not yield clinically significant
symptoms of CDS or ADHD still experienced subjective
problems with inattention, which can introduce bias and
limits the conceptual and clinical dissociation of CDS and
ADHD (Barkley, 2014). Second, the study may have been
underpowered to detect differences across groups. A post
hoc power analysis revealed that the MANOVA was under-
powered. However, a second post hoc power analysis on the
supplementary MANOVA revealed adequate power, sug-
gesting that the observed primary analysis results were not
Cerny et al. 9
due to lack of power. Third, item-level data for the
BAARS-IV SCT scale was not available for analysis.
Although a unitary factor structure is most commonly seen
in extant research, select previous studies support a 2- or
3-factor structure for the BAARS-IV SCT scale, and sub-
factors have demonstrated differential associations with
neuropsychological functioning (Barkley, 2013; Becker
et al., 2022; Smith & Suhr, 2021). As such, future research
would benefit from analyzing convergence between cogni-
tive performance and CDS subfactors. Fourth, information
on FSIQ and medication status were not available for most
individuals in this sample, precluding direct examination.
This is notable as factors such as FSIQ and medication sta-
tus have previously been linked to attenuated cognitive per-
formance among persons with ADHD (e.g., Fuermaier
et al., 2017; Keezer et al., 2021). Future research would
benefit from including such relevant demographic and
treatment-related information when assessing cognitive dif-
ferences between CDS and ADHD diagnostic groups. Fifth,
final diagnostic status was not available for all participants,
limiting our sample size. This includes the 20 individuals
for whom ADHD diagnostic status was not available.
Moreover, diagnostic information regarding presence of
other neurocognitive disorders was not available for any
participants in the sample, which precludes control or
examination of other disorders which may be associated
with cognitive impairment (e.g., specific learning disorders,
history of moderate to severe brain injury). Moreover, addi-
tional diagnostic information such as co-occurring psychi-
atric or learning disorders was not available for all patients.
Co-occurring disorders could affect cognitive performance,
so conclusions about cognitive performance without this
information are incomplete. However, the sample per-
formed largely in the intact/average range, suggesting that
co-occurring disorders likely had a minimal influence on
cognitive performance. Lastly, future research would bene-
fit from assessing CDS symptom correlates in a more diag-
nostically diverse clinical population referred for cognitive
complaints other than inattention.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Brian M. Cerny https://orcid.org/0000-0003-2678-1207
Sophie I. Leib https://orcid.org/0000-0002-7708-9352
Jason R. Soble https://orcid.org/0000-0003-3348-8762
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Author Biographies
Brian M. Cerny is a clinical psychology graduate student at
Illinois Institute of Technology specializing in rehabilitation psy-
chology. Clinical and research interests broadly include neuropsy-
chology, rehabilitation psychology, performance validity assess-
ment, psychosocial outcomes in chronic disability, and
neurocognitive performance in ADHD.
Tristan P. Reynolds, MBA, is a Consultant in Capgemini Invent’s
Life Sciences Practice. Prior to joining Capgemini, Tristan served
as the co-founder for a biotechnology startup aimed at commer-
cializing a novel, rapid, point-of-care diagnostic test for autoim-
mune and infectious diseases. Tristan has an interest in improving
patient outcomes.
Fini Chang is a clinical psychology doctoral student at the
University of Illinois at Chicago. Her clinical focus lies in neuro-
psychology, and her program of research investigates interrelations
12 Journal of Attention Disorders 00(0)
of emotion and cognitive processing, along with the effects of
problematic sleep, in depression and anxiety.
Lauren M Scimeca is a clinical psychology graduate student at
Illinois Institute of Technology specializing in rehabilitation psy-
chology. Her clinical and research interests broadly include pedi-
atric neuropsychology, neuropsychological evaluation outcomes,
and neurocognitive performance in ADHD.
Matthew S. Phillips is a clinical psychology graduate student.
Clinical and research interests include neuropsychological assess-
ment, psychometric properties of performance and symptom
validity tests, ADHD, and health literacy.
Caitlin M. Ogram Buckley, PhD, earned her doctorate from the
University of Rhode Island in 2022, and is currently a postdoctoral
fellow in clinical rehabilitation neuropsychology at Bancroft
NeuroRehab. Clinical and research interests include development
of interventions for executive dysfunction.
Sophie Leib is a clinical psychology doctoral student at Rosalind
Franklin University of Medicine and Science. She is currently the
pediatric neuropsychology intern at Nationwide Children’s
Hospital. Clinical and research interests include pediatric popula-
tions, psychometrics, and ADHD.
Dr. Pliskin is a Professor of Clinical Psychiatry and Neurology
at the University of Illinois-Chicago and Chicago Electrical
Trauma Rehabilitation Institute. He is a board-certified clinical
neuropsychologist and past president of the Society for Clinical
Neuropsychology.