Cognitive Disengagement Syndrome: The Opposite Of ADHD?

Editor's note: This text-based course is a transcript of the webinar, Cognitive Disengagement Syndrome: The Opposite Of ADHD?, presented by Tere Bowen-Irish, OTR/L.
*Please also use the handout with this text course to supplement the material.
Learning OutcomesAfter this course, participants will be able to differentiate between a diagnosis of ADHD and cognitive disengagement.After this course, participants will be able to analyze the daily impact that the characteristics of this diagnosis have on overall functioning at school, home, and community.After this course, participants will be able to evaluate interventions and treatment based on signs, symptoms and challenges with daily life skills.IntroductionWelcome, everyone. I’m thrilled to present this topic today as it feels incredibly relevant and reflects the beginnings of a shift in how we understand something we’ve observed and questioned for years. As we move through this session, we’ll reserve time for questions at the end. 
Many of us have encountered children who, for years, we’ve casually labeled as having ADD without the hyperactivity component. However, recent research is prompting us to reconsider this approach. It’s leading us toward interventions we might not typically associate with this group of children if we rely solely on an ADHD or ADD diagnosis framework.
Dr. Russell Barkley was one of the first to identify a subset of children who didn’t respond to medication in the typical way and seemed to exhibit a unique set of characteristics. These children often had a daydreamy quality, appeared disengaged, and struggled with processing input. For instance, when given directions in class, they might freeze or appear unsure—almost like a deer in headlights. Dr. Barkley coined the term "sluggish cognitive tempo" several years ago to describe this phenomenon, and it has been a topic that has intrigued me ever since. I’ve followed its progression closely to see how the research and thinking around it have evolved.
Today, we’re moving into a new understanding phase with the emergence of what is now called Cognitive Disengagement Syndrome. This evolving concept reflects the growing recognition of these children’s unique challenges and opens the door for more tailored and effective interventions. I look forward to exploring this further with you.
Diagnosis Not in the DSMIt’s important to note that this diagnosis has not yet been added to the DSM, though significant lobbying is underway to change that. The clinical signs are compelling, and I hope to share them with you today in a way that highlights why this emerging concept warrants attention. Considering these signs, the accommodations and modifications for children with these traits might look quite different from the standard approaches we’ve traditionally used.
Personally, I find this topic fascinating. It represents an opportunity to deepen our understanding and refine how we support these children daily.
Cognitive Disengagement Syndrome: Understanding the Opposite of ADHDI’ve referenced a particular article for this discussion because I found it especially insightful, even though it’s quite lengthy. The article poses the question of whether this condition is the “opposite of ADHD.” I find that phrasing intriguing, though not entirely accurate, as there are numerous similarities between the two diagnoses. Both ADHD and Cognitive Disengagement Syndrome (CDS) share overlapping characteristics, particularly in areas like attention and self-regulation, but they manifest these difficulties in distinct ways.
I want to highlight a quote from the article that resonates with me:
"The relationship between CDS and ADHD is very complex. While they may appear to be opposites at first glance, both conditions involve difficulties with attention and self-regulation, albeit in different ways."
This complexity underscores why it’s so important to ensure accurate diagnosis. With clarity about what a child is experiencing, we can design accommodations and modifications that truly address their needs and help them access the classroom more effectively.
The article also comprehensively explores these conditions' differences, causes, and risk factors. It is a robust resource for understanding the nuances of CDS and how it diverges from ADHD. I highly recommend it for anyone seeking a deeper dive into this topic.
Differences Between ADHD and CDSConsidering the relationship between ADHD and Cognitive Disengagement Syndrome (CDS) is important, but it’s equally vital to understand their significant differences.
Let’s begin with ADHD, which many of us are already familiar with, as it’s a common diagnosis on our caseloads. ADHD is fundamentally a developmental delay. Children with ADHD often face challenges with skills governed by the prefrontal cortex, such as emotional control, organization, anticipation, prioritizing, and planning. They tend to be highly distractible and frequently struggle with working memory and impulse control.
In the classroom, these difficulties are often glaring. You might observe them struggling to sustain time on task due to external distractors—a custodian mowing the lawn, a pencil dropping, or a recent announcement they can't stop thinking about. Their ability to return focus to their work is notably impaired. These children are also at risk for conditions like depression and anxiety, and they often display poor self-regulation, which can lead to temper and angry outbursts.
On the other hand, children with CDS present a very different picture. They are more hypoactive, often foggy or confused, as though unsure of what’s happening around them. Tasks take them much longer to complete, and they may seem almost sleepy or zoned out during the day. This internal distractibility often leads them to focus on things like the discomfort of their chair, the sound of their stomach growling, or memories of playing with their dog in the snow yesterday. As a result, they may daydream excessively. Like children with ADHD, those with CDS are also at risk for depression and anxiety, but their social challenges are particularly pronounced. They often struggle with peer relationships and social skills, making engaging in play or connecting with others difficult.
Neurologically, ADHD is marked by underactivity in the prefrontal cortex. Dr. Russell Barkley emphasizes that this developmental delay can be as much as 30%. For example, a 10-year-old child with ADHD might function more like a 7-year-old in terms of prefrontal skills. ADHD also involves imbalances in dopamine and norepinephrine, further contributing to difficulties with attention and impulse control.
In contrast, CDS is associated with differences in the brain’s default mode network and problems with neurotransmitter balance. Procrastination and difficulty initiating attention are hallmark features. While both conditions share challenges with attention regulation, these challenges manifest in distinct ways. ADHD tends to involve external distractions, whereas CDS often involves internal distractions and a struggle to engage with the task at hand mentally.
Understanding these distinctions allows us to scaffold interventions better. Strategies for children with ADHD may focus on managing external stimuli and building prefrontal skills. For those with CDS, the focus might shift toward addressing internal disengagement and fostering sustained task engagement. Both require tailored approaches that reflect the unique ways their challenges present in daily life.
Let's Set the Scene: Case StudiesLet’s set the scene: Sarah, diagnosed with ADHD, and Colby, diagnosed with ADD without the hyperactivity component, are in a fourth-grade classroom. We’re standing at the door, observing, with our “therapy eyes” on.
The teacher announces: "We need to clean off our desks, take out our blue folders for language arts, and grab our haiku homework from last night." Sarah, the child with ADHD, immediately rushes to her backpack in the cubby to grab her homework. What did she hear? Likely just the last part of the instructions—the haiku homework. She returns to her desk, kneels on her chair with her chest over the desk, knocking off math cards, a pencil, and scissors, and then yells, “What else do we need?”
The teacher responds with a simple reminder: “Blue folder and clean desk.” Sarah begins pulling out all her folders, scattering them onto the floor. She’s probably not even considering that the haiku homework could already be in the blue folder. Her impulsive actions are disconnected from working memory, leaving her off track.
Meanwhile, Colby reacts differently to the same set of instructions. After hearing the teacher’s directions, she stays seated, looking around and asking, “What’s going on?” When the teacher simplifies the command to “Clean off your desk,” Colby starts stacking the math cards, pencil in one hand and scissors in the other. But she has to start over as the cards start to splay out. She turns to a classmate, asking, “Where do the cards go?”
Four minutes into this, the other 21 students in the class are ready to move on. The teaching assistant approaches Sarah and gently directs her: “Please pick up the other folders and stuff on the floor. Put them in your desk. We are starting.” Then she moves to Colby and asks, “What do you need to do next?” Colby looks around and notices her peers’ blue folders and the assistant prompts her with “Yes.” Still uncertain, Colby glances at her desk, then toward the cubby, and blurts, “I have no idea where it is. Can I go to the bathroom?”
These two children demonstrate vastly different responses to the same set of directions. Both face challenges with attention, focus, following directions, and initiating tasks, but their approaches are quite different. Observing these dynamics in an inclusive classroom highlights where scaffolds, accommodations, and strategies can be tailored...