Psychological Assessment

Are Sluggish Cognitive Tempo and Daytime Sleepiness

Distinct Constructs?
Joshua M. Langberg, Stephen P. Becker, Melissa R. Dvorsky, and Aaron M. Luebbe
Online First Publication, March 10, 2014. http://dx.doi.org/10.1037/a0036276

CITATION
Langberg, J. M., Becker, S. P., Dvorsky, M. R., & Luebbe, A. M. (2014, March 10). Are Sluggish
Cognitive Tempo and Daytime Sleepiness Distinct Constructs?. Psychological Assessment.
Advance online publication. http://dx.doi.org/10.1037/a0036276
 Psychological Assessment 2014 American Psychological Association
2014, Vol. 26, No. 2, 000 1040-3590/14/$12.00 DOI: 10.1037/a0036276

Are Sluggish Cognitive Tempo and Daytime Sleepiness

Distinct Constructs?

Joshua M. Langberg Stephen P. Becker

Virginia Commonwealth University Miami University

Melissa R. Dvorsky Aaron M. Luebbe

Virginia Commonwealth University Miami University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Sluggish cognitive tempo (SCT) and daytime sleepiness are both common in individuals with attention-
deficit/hyperactivity disorder (ADHD). There appears to be considerable overlap between the tired and
lethargic aspects of SCT and behaviors frequently exhibited by individuals with daytime sleepiness.
However, no studies have examined the degree to which these constructs overlap and whether or not they
are empirically distinct. In Study 1, a confirmatory factor analysis with the SCT subscale of the Barkley
Adult ADHD Rating Scale-IV (BAARS-IV) and the Epworth Sleepiness Scale (ESS) was conducted in
a sample of 768 college students. Results demonstrated that SCT and daytime sleepiness exhibit
considerable overlap but are empirically distinct. In Study 2, we examined the relation between SCT and
daytime sleepiness and also the impact of comorbid SCT and sleepiness on the functioning of 58 college
students rigorously diagnosed with ADHD. Regression analyses in both Study 1 and Study 2 showed that
SCT predicts daytime sleepiness above and beyond symptoms of ADHD, anxiety, and depression. The
2 constructs were significantly related (r .51), with the highest correlations occurring between the SCT
tired and lethargic items with daytime sleepiness. College students with ADHD SCT and daytime
sleepiness were significantly more impaired than college students diagnosed with ADHD without SCT
or daytime sleepiness. Together, these results fill an important gap in the literature by confirming SCT
to be overlapping but empirically distinct from daytime sleepiness and demonstrating that SCT and
daytime sleepiness are associated with functioning in college students with ADHD.

Keywords: ADHD, attention-deficit/hyperactivity disorder, sleep, sluggish cognitive tempo, college

students

Children and adolescents with attention-deficit/hyperactivity
disorder (ADHD) frequently experience sleep disturbances, with
prevalence rates for sleep problems in samples of youth with
ADHD between 25% and 50% (Sung, Hiscock, Sciberras, &
Efron, 2008; Yoon, Jain, & Shapiro, 2012). The relation between
sleep and ADHD is not limited to childhood, with as many as 50%
of adults with ADHD endorsing the presence of sleep disturbances
such as insomnia (Voinescu, Szentagotai, & David, 2012). Indi-
viduals with ADHD experience a wide range of sleep disturbances,
including higher rates of problems with sleep latency, bedtime
resistance, night awakenings, and difficulties with morning awak-
enings in comparison to their peers (Cortese, Faraone, Konofal, &
Joshua M. Langberg, Department of Psychology, Virginia Common-
wealth University; Stephen P. Becker, Department of Psychology, Miami
University; Melissa R. Dvorsky, Department of Psychology, Virginia
Commonwealth University; Aaron M. Luebbe, Department of Psychology,
Miami University.
Correspondence concerning this article should be addressed to Joshua
M. Langberg, Department of Psychology, Virginia Commonwealth Uni-
versity, 806 West Franklin Street, P.O. Box 842018, Richmond, VA
23284-2018. E-mail: jlangberg@vcu.edu
1
Lecendreux, 2009). Not surprisingly given these problems, indi-
viduals with ADHD often report feeling excessively sleepy during
the daytime hours (Cortese et al., 2009; Owens, 2009). Daytime
sleepiness is characterized by a lack of energy, persistent tiredness,
and feelings of drowsiness and sluggishness (Drake et al., 2003).
Daytime sleepiness is associated with increased risk for academic
and behavioral impairment in samples of youth with (Langberg,
Dvorsky, Marshall, & Evans, 2013) and without (Astill, Van der
Heijden, Van IJzendoorn, & Van Someren, 2012; Beebe, 2011;
Fallone, Acebo, Seifer, & Carskadon, 2005) ADHD.
In a largely separate literature, approximately 30%50% of
youth with ADHD have been shown to exhibit slow processing,
sluggishness, apathy, drowsiness, and inconsistent alertness, be-
haviors that have been labeled sluggish cognitive tempo (SCT).
Although some SCT items emerged in the literature in the 1960s
and 1970s (see Becker, Marshall, & McBurnett, 2014, for a his-
torical overview of the SCT construct), it was in the 1980s that
Lahey and colleagues (e.g., Lahey et al., 1988; Neeper & Lahey,
1986) first demonstrated SCT symptoms to be distinct from the
inattentive and hyperactive-impulsive symptoms characteristic of
ADHD. As research examining the SCT construct began to ad-
vance, it was initially posited that a significant minority of children
with ADHD, Predominantly Inattentive Type (ADHD-I) were best
characterized by the presence of SCT symptoms and relative
 2 LANGBERG, BECKER, DVORSKY, AND LUEBBE
absence of hyperactive/impulsive symptoms (Carlson & Mann,
2002; Lahey et al., 1988; McBurnett, Pfiffner, & Frick, 2001;
Milich, Balentine, & Lynam, 2001). Still, although SCT symptoms
are more strongly related to ADHD symptoms of inattention than
to symptoms of hyperactivity/impulsivity (Willcutt et al., 2012), a
sizable number of individuals with ADHD Combined Type also
display clinically significant levels of SCT symptoms (Barkley,
2012; Carlson & Mann, 2002; Willcutt et al., 2012). Similar to
sleep disturbances, the presence of SCT is not unique to samples
of children with ADHD, with approximately 50% of adults with
elevated ADHD symptoms exhibiting clinically significant SCT
(Barkley, 2012). Further, comorbid SCT symptoms are associated
with increased impairment in social, academic, and executive
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functioning in youth with ADHD (Barkley, 2013; Becker & Lang-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
berg, 2013, 2014; Carlson & Mann, 2002; Langberg, Becker, &
Dvorsky, 2014; Marshall et al., 2014; McBurnett et al., 2001), as
well as among adults displaying elevated ADHD symptoms (Bar-
kley, 2012).
Multiple authors have noted the considerable similarities and
potential overlap associated with measures of SCT and measures
of daytime sleepiness (Cortese et al., 2009; Fallone et al., 2005;
Mayes et al., 2009; Willoughby, Angold, & Egger, 2008). How-
ever, only one study published to date has examined the relation
between these two constructs, and no research has evaluated
whether or not these two constructs are empirically distinct. Spe-
cifically, Voinescu and colleagues (2012) examined the prevalence
of sleep disturbances in a sample of adults with symptoms of
ADHD. In this sample of 550 Romanian adults, participants were
classified into an ADHD-likely group, a non-ADHD group, and a
chronic insomnia group based on self-report on the Barkley Adult
ADHD Rating Scale (BAARS-IV; Barkley, 2011a), which in-
cludes an SCT subscale along with Diagnostic and Statistical
Manual of Mental Disorders, fourth edition (DSMIV; American
Psychiatric Association [APA], 2000) symptoms of ADHD.
Adults in the insomnia and ADHD-likely groups had significantly
higher scores on the SCT subscale in comparison to the non-
ADHD group. Further, in the ADHD-likely group, the correlation
between the insomnia and SCT measures was significant and large
(r .66). To our knowledge, this is the only study completed to
date in which the association between SCT and sleep has been
reported.
SCT is a multifaceted construct, and it is likely that certain
aspects of SCT are more highly related to daytime sleepiness than
others. Recent measure development studies suggest that SCT
consists of slow, sleepy, and daydreaming factors (Jacobson et al.,
2012; Penny et al., 2009). The slow aspect of SCT includes apathy,
motivation, being slow or delayed in completing tasks, and lacking
initiative. Sleepy SCT behaviors include drowsiness, appearing
sluggish or tired, and being underactive; daydreaming SCT behav-
iors include getting lost in ones own thoughts and seeming to be
in ones own world. Importantly, each of these SCT factors relates
differently to the ADHD symptom dimensions. The SCT behaviors
related to being apathetic and lacking motivation/initiative largely
load onto a single factor along with DSMIV inattention items
(Barkley, 2013; Lee, Burns, Snell, & McBurnett, 2014), whereas
the sleepy/daydreamy aspects of SCT appear to be empirically
distinct from DSMIV symptoms of inattention (Becker, Luebbe,
Fite, Stoppelbein, & Greening, 2014; Jacobson et al., 2012; Penny
et al., 2009; Willcutt et al., 2012). These findings have implica-
tions for studies examining the relation between sleep and SCT.
Specifically, the SCT behaviors found to be most distinct from the
ADHD inattention dimension are those that are most highly char-
acteristic of individuals with sleep disturbances (i.e., drowsy and
sluggish/tired). Accordingly, it is possible that SCT drowsy/tired
behaviors are actually manifestations of daytime sleepiness. Alter-
natively, it is possible that SCT and daytime sleepiness are distinct
but related and commonly comorbid, potentially due to a shared
genetic etiology.
The purpose of the present study was to examine the relation
between SCT and daytime sleepiness in samples of young adults
with and without ADHD. Given that symptoms of anxiety and
depression are frequently comorbid with ADHD and have been
shown to relate to both sleep (Accardo, Marcus, Leonard, Shults,
& Elia, 2012) and SCT (Becker & Langberg, 2013; Becker,
Luebbe, et al., 2014; Garner, Marceaux, Mrug, Patterson, & Hod-
gens, 2010), the relation between SCT and daytime sleepiness was
examined above and beyond symptoms of ADHD, anxiety, and
depression. In Study 1, using a large general college student
sample, confirmatory factor analysis (CFA) was used to determine
whether SCT and daytime sleepiness best fit together as a single
factor or as distinct constructs. Further, the relation between SCT
and sleep above and beyond ADHD, anxiety, and depression was
examined. Study 2 consisted of a comprehensively diagnosed
sample of college students with ADHD. In addition to examining
the relation between SCT and sleep in this clinical sample, group-
ing analyses were conducted to explore how comorbid SCT and
daytime sleepiness impact functioning. We hypothesized that SCT
and daytime sleepiness would be distinct but that significant over-
lap would exist, especially between the sluggish/sleepy aspects of
SCT and daytime sleepiness. We also predicted that SCT would be
associated with daytime sleepiness above and beyond symptoms of
ADHD, anxiety, and depression and that college students with
comorbid SCT and daytime sleepiness would exhibit significantly
more impairment than students with ADHD alone.
Study 1
Method
Participants. Participants were 768 undergraduate students
ages 1734 (M 18.76, SD 1.15) enrolled in an introductory
psychology course at a public midwestern university. Approxi-
mately two thirds of the participants were female (68%, n 521).
The majority of participants were Caucasian (91%); the remaining
participants were African American (3%), Hispanic (2%), Asian/
Asian American (2%), or other/multiracial (2%). Most participants
(n 500) were in their first year of college.
Procedure. This study was approved by the university Insti-
tutional Review Board (IRB). After providing informed consent,
participants completed the study measures as part of a larger
survey. Participants received course credit for their participation.
Measures.
SCT and ADHD symptoms. SCT and ADHD symptoms were
assessed using the BAARS-IV (Barkley, 2011a). The BAARS-IV
is a self-report measure that includes the 18 DSMIV symptoms of
ADHD (APA, 2000) and nine symptoms of SCT (e.g., easily
confused; slow moving). Each item was rated using a 4-point scale
(1 never or rarely, 4 very often). The four-factor structure of
 SCT AND SLEEP 3

this measure has been established in a nationally representative Results

sample of adults, and the scales demonstrate satisfactory internal
consistency and testretest reliability over a 2- to 3-week period CFA. In the initial CFA measurement model, the nine SCT
items and eight daytime sleepiness items were each predicted by
(Barkley, 2011a). Internal consistencies in the present study were
their respective latent constructs, and the two latent constructs
SCT .86, ADHD Inattention .85, ADHD Hyperactivity
were allowed to correlate. The initial model fit was poor,
.67, and ADHD Impulsivity .79.
2(118) 1134.43, p .001; CFI 0.76; TLI 0.72;
Anxious and depressive symptoms. Internalizing symptoms
RMSEA 0.101 (90% CI [0.100, 0.112]). Modification indices
were measured using the Depression and Anxiety subscales of the
were used to prune the model, with correlated residuals considered
Depression Anxiety Stress Scales-21 (DASS-21; Antony, Bieling,
when the items were conceptually very similar (e.g., SCT item
Cox, Enns, & Swinson, 1998). In reference to the past week,
lethargic, more tired than others with SCT item underactive or
participants rated each item using a 4-point scale (1 did not
have less energy than others; sleepiness item sitting and read-
apply to me at all, 4 applied to me very much or most of the
ing with sleepiness item watching TV). Eight within-factor
time). The DASS-21 demonstrates acceptable internal consistency
correlated residuals were added to the measurement model. This
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and concurrent validity with other measures of anxiety and depres- measurement model demonstrated acceptable fit, 2(110)
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sion (Antony et al., 1998) and has been used in studies examining 380.85, p .001; CFI 0.94; TLI 0.92; RMSEA 0.057
ADHD symptoms in college students (e.g., Gudjonsson, Sig- (90% CI [0.050, 0.063]). Factor loadings and the correlation be-
urdsson, Eyjolfsdottir, Smari, & Young, 2009). In the present tween the latent SCT and daytime sleepiness factors of this optimal
study, internal consistencies for the Anxiety and Depression sub- model are displayed in Figure 1.
scales were .78 and .87, respectively. Next, we examined whether a one-factor model constraining
Daytime sleepiness. The Epworth Sleepiness Scale (ESS; SCT and daytime sleepiness to be equal fit better than the two-
Johns, 1991) was used to measure participants daytime sleep- factor model. The one-factor model had mediocre model fit,
iness. Participants rated the likelihood of dozing or falling 2(111) 690.65, p .001; CFI 0.86; TLI 0.83; RMSEA
asleep across eight different situations commonly encountered 0.082 (90% CI [0.077, 0.088]) and was significantly inferior to the
in daily life (e.g., sitting and reading, watching TV, as a two-factor model that did not constrain SCT and daytime sleepi-
passenger in a car for an hour without a break). Each item is ness to be equal, 2(1) 309.91, p .001. These findings
rated on a 4-point scale (0 no chance of dozing, 1 slight
chance of dozing, 2 moderate chance of dozing, 3 high
chance of dozing), and a mean score of the items was calculated
as an overall index of daytime sleepiness. The ESS is a com-
monly used measure of daytime sleepiness (Moul, Hall, Pilko-
nis, & Buysee, 2004) and demonstrates adequate internal con-
sistency and testretest reliability in adults with and without
sleep disorders (Johns, 1992). The ESS has been previously
used with college students (e.g., Lund, Reider, Whiting, &
Prichard, 2010). In the present study, .71.
Data analyses. First, the latent structure of SCT and daytime
sleepiness was examined in a CFA model using Mplus Version 5.1
(Muthn & Muthn, 1998 2007). The initial two-factor CFA
model included the SCT and daytime sleepiness latent constructs
predicting their respective indicators and included correlations
among SCT and daytime sleepiness. Theory and modification
indices were then used to prune the model for optimal fit. Multiple
indices were used to test overall model fit, with the following
indicating acceptable fit: comparative fit index (CFI) .90,
Tucker-Lewis Index (TLI) .90, and root-mean-square error of
approximation (RMSEA) .08 (Kline, 1998). We then examined
in a subsequent model whether SCT was distinct from daytime
sleepiness. A chi-square difference test was used to determine
whether the hypothesized two-factor solution or an alternative
one-factor model was optimal, where a significant increase in
chi-square in the constrained one-factor model would indicate that
the two-factor model was superior.
Next, hierarchical regression analyses were conducted in order
Figure 1. Two-factor model of sluggish cognitive tempo (SCT) and
to examine whether SCT symptoms predicted daytime sleepiness
daytime sleepiness in college students (Study 1). Item numbers correspond
above and beyond ADHD and internalizing symptoms. Specifi- to the Barkley Adult ADHD Rating Scale-IV (Barkley, 2011a) for SCT
cally, ADHD and internalizing symptoms were entered on Step 1 items and the Epworth Sleepiness Scale (Johns, 1991) for daytime sleep-
in predicting daytime sleepiness, followed by SCT symptoms on iness items. All pathways shown are standardized estimates and significant
Step 2. (p .05).
 4 LANGBERG, BECKER, DVORSKY, AND LUEBBE
suggest that SCT and daytime sleepiness, although correlated, are
distinct constructs in the present sample.
Correlation analyses. Variable means, standard deviations,
and intercorrelations are displayed in Table 1. All of the psycho-
pathology dimensions (i.e., SCT, ADHD, anxiety, depression)
were significantly correlated with each other (rs .16 .67, ps
.001) and with daytime sleepiness (rs .22.40, ps .001). SCT
and ADHD inattention were the psychopathology dimensions most
strongly associated with daytime sleepiness (rs .40 and .36,
respectively).
SCT in relation to daytime sleepiness. Hierarchical regres-
sion analyses predicting daytime sleepiness were conducted, with
ADHD and internalizing dimensions entered on Step 1 followed
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by SCT symptoms on Step 2. Neither age nor sex was correlated
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with daytime sleepiness, and so these demographic variables were
not included in the regression model. All variance inflation factor
(VIF) values were below 2.1 (values 10 are typically considered
problematic), and all tolerance values were above .45 (values
.10 are typically considered problematic; Cohen et al., 2003),
indicating that our regression model did not suffer from problems
with multicollinearity. As shown in Table 2, ADHD inattentive
and anxious symptoms significantly predicted daytime sleepiness
in Step 1. When SCT was added to the model at Step 2, the
predictive value of ADHD inattention and anxiety was reduced
(though both remained significant), and SCT was the strongest
predictor of daytime sleepiness.
Study 2
Using a large sample of college students, results from Study 1
demonstrate that SCT and daytime sleepiness are correlated but
distinct factors. Further, SCT was found to be strongly associated
with daytime sleepiness above and beyond internalizing and
ADHD symptoms. The purpose of Study 2 was to test whether the
pattern of results obtained in Study 1 would be replicated in a
clinical sample of college students rigorously diagnosed with
ADHD. In addition, analyses in Study 2 were focused on exploring
how comorbid SCT and daytime sleepiness impact the functioning
of college students with ADHD.
Method
Participants. Participants were 68 undergraduate students en-
rolled in a public university in Virginia. However, the daytime
Table 1
Study 1: Means, Standard Deviations, and Bivariate Correlations
Variable 1 2
1. SCT .67 .44
2. ADHD Inattention .50
3. ADHD Hyperactivity
4. ADHD Impulsivity
5. Anxiety
6. Depression
7. Daytime sleepiness
M 1.91 1.74 1.73
SD 0.55 0.49 0.55
Note. SCT sluggish cognitive tempo; ADHD attention-deficit/hyperactivity disorder.
p .001.
sleepiness measure was only collected for 58 of the participants
because of a delay in obtaining IRB approval for the Pediatric
Daytime Sleepiness Scale (PDSS) measure (described below). In
comparing the demographic characteristics of those participants
for whom daytime sleepiness data were collected (n 58) with
those without daytime sleepiness data (n 10), no differences
were found for age, gender, ethnicity, year in school, parent
education level, family income, and ADHD medication status
(ps .05). Similarly, no differences were found for ADHD
subtype, symptoms of ADHD, SCT, anxiety, depression, grade-
point average (GPA), or functional impairment ratings (ps .05).
Participants ranged in age from 17 to 30 years (M 19.90,
SD 2.75), and slightly over half (n 32) were male. Forty-two
participants (72%) self-identified as Caucasian; the remaining par-
ticipants were either African American (n 5), Hispanic (n 6),
or multiracial (n 5). Approximately half the participants (n
27) were in their first year of college, with remaining participants
in their second (n 13), third (n 10), or fourth (n 8) year. On
the basis of procedures described below, 30 participants were
diagnosed with DSMIV ADHD-I, and 28 participants were diag-
nosed with ADHD-C. Thirty-five participants were taking medi-
cation for ADHD.
Procedure. The study was approved by the university IRB.
The inclusionary criteria were (a) attendance at the university
where the research was being conducted; (b) consent for research
staff to contact participants parent/guardian for a diagnostic in-
terview; (c) meeting full diagnostic criteria for ADHD-I or
ADHD-C; and (d) not meeting criteria for a pervasive develop-
mental disorder, bipolar disorder, or psychosis. Diagnosis was
determined through administration of both Part I and Part II of the
Conners Adult ADHD Diagnostic Interview for the DSM-IV
(CAADID; Epstein, Johnson, & Conners, 2000; Epstein & Kollins,
2006) separately to both the student and his or her parent/guardian.
The CAADID interview assesses both current and childhood
symptoms and impairment as well as age of onset and pervasive-
ness of symptoms across time. Part I of the interview provides a
detailed patient history designed to obtain information about past
mental health diagnoses, medication usage, psychiatric comorbid-
ity, and other potential risk factors. Part II is the ADHD portion of
the interview.
Strict diagnostic inclusion criteria were adhered to in this
study because of questions/debates in the field regarding the
validity of self-report in college students with ADHD and
3 4 5 6 7
.33 .43 .46 .40
.37 .34 .37 .36
.48 .39 .27 .26
.27 .16 .23
.63 .26
.22
1.60 1.51 1.52 1.96
0.60 0.48 0.55 0.45
 SCT AND SLEEP 5

Table 2
Study 1: Multiple Regression Models Predicting Daytime Sleepiness From ADHD, Internalizing, and SCT Symptoms

Step 1: Model summary Step 2: Model summary

B SE t B SE t

Variable F(5, 759) 28.55 , R .16
2
F(1, 758) 29.44 , R .19
2

ADHD Inattention 1.86 .30 .25 6.25 .89 .23 .12 2.59
ADHD Hyperactivity .34 .28 .05 1.22 .21 .27 .03 .77
ADHD Impulsivity .46 .23 .08 1.96 .39 .23 .07 1.71
Anxiety .94 .33 .13 2.82 .73 .33 .10 2.22
Depression .10 .29 .02 .35 .19 .28 .03 .66
SCT 1.66 .31 .26 5.43
Note. Dashes indicate that the variable was not entered in the Step 1 model. ADHD attention-deficit/hyperactivity disorder; SCT sluggish cognitive
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tempo.

p .05. p .01. p .001.
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concerns about malingering (e.g., Sollman, Ranseen, & Berry,
2010). Specifically, parents/guardians had to endorse at least
six symptoms in an ADHD domain on the CAADID as present
and impairing during childhood for a student to be included.
Further, the student and his or her parents/guardians had to
endorse a total of six symptoms in a domain as currently present
and impairing on the CAADID. For documentation of current
ADHD symptoms, we did allow parent interview data to be
supplemented with student self-report, and vice versa. How-
ever, both the parent and student had to endorse a minimum of
four symptoms in a domain as currently present and impairing
for supplementing to occur. Once an ADHD diagnosis was
confirmed, student self-report on the CAADID interview was
prioritized in making ADHD subtype determinations.
Students were referred to the study in one of three ways.
First, flyers describing the study were included in the orienta-
tion packets of all incoming freshman. The flyers stated that
students with difficulties with attention and concentration
and/or students with a diagnosis of ADHD were eligible to
receive a free diagnostic evaluation. Students and their families
were informed that if an ADHD diagnosis was confirmed, the
evaluation report could be used as documentation at the Uni-
versity Disability Services Office and at Student Health Ser-
vices. In addition, students and their families were told they
would be compensated $75 for their time and effort in coming
to the University to complete the evaluation procedures. Sec-
ond, the University Disability Services Office e-mailed the flyer
to all students in their database currently receiving accommo-
dations for ADHD. The e-mail stated that students who were
interested in the study should call the study research coordina-
tor to complete a phone screen. Third, the flyer was posted in
the Disability Services Office, at Student Health, and in all
university dorms. Students who called research staff to express
interest in the study were read a phone script describing the
study in detail and administered a phone screen. On the phone
screen, the student had to endorse either a current diagnosis of
ADHD or at least four of nine DSMIV symptoms of inattention
in order to be scheduled for an inclusion/exclusion evaluation.
In total, 139 students called, expressed interest in the study, and
completed the phone screen. Of these, 94 were eligible based on
the phone screen and completed the inclusion/exclusion evalu-
ation, 68 met full study criteria and were enrolled, and 58
completed all the measures included in this study.
Measures.
Demographic/student characteristics. Students completed a
demographics questionnaire that provided information about their
age, gender, ethnicity, employment status, ADHD medication sta-
tus, and current living status (i.e., whether they lived with their
parents or on campus). In addition, parents/guardians completed a
demographics questionnaire that provided information about
household income and parents education level.
SCT and ADHD symptoms. As in Study 1, participants com-
pleted the BAARS-IV (Barkley, 2011a) described above. Consis-
tent with past work with the BAARS-IV (Barkley, 2012), partic-
ipants were considered to have clinically significant levels of SCT
symptoms if they endorsed five or more of the nine SCT items as
present often or very often (scores of 3 or 4). Internal consis-
tencies in the present study were SCT .79, Inattention
.81, Hyperactivity .77, and Impulsivity .78.
Daytime sleepiness. The PDSS (Drake et al., 2003) was spe-
cifically developed and validated as a self-report measure to ex-
amine the relationship between daytime sleepiness and academic
functioning. The PDSS is one of six sleep measures to meet criteria
as well established according to the American Psychological
Association Division 54 evidence-based assessment criteria (Le-
wandowski, Toliver-Sokol, & Palermo, 2011). The PDSS consists
of eight items loading onto a single factor. Participants were asked
to rate each item on a scale ranging from 4 (always) to 0 (never).
One item (Item 3) was reverse scored, and then a mean score was
created using all eight items. Although the PDSS was originally
designed to assess daytime sleepiness in middle-school age ado-
lescents (1115 years of age), the measure has been used in
multiple studies that included older adolescents (e.g., Maganti et
al., 2006; Tan, Healey, Gray, & Galland, 2012). To remain con-
sistent with our cutoff strategy for SCT on the BAARS-IV, in this
study we classified participants as exhibiting clinically significant
daytime sleepiness if four or more items were endorsed as occur-
ring often or very often (scores of 3 or 4). Using this cutoff
strategy resulted in a daytime sleepiness mean item score of 2.64
(SD 0.29) and a total sum score of M 21.12 (SD 2.37) for
the clinically significant group, which is consistent with past work
that used cutoffs to identify individuals with clinically significant
 6 LANGBERG, BECKER, DVORSKY, AND LUEBBE
daytime sleepiness on the PDSS (Drake et al., 2003; Maganti et al.,
2006). The PDSS total mean score was examined in the present
study ( .96).
Anxious/depressive symptoms and school maladjustment.
Participants completed the Behavior Assessment System for Chil-
dren, Second Edition, Self-Report of Personality College Version
(BASC-2: SRP-College Version; Reynolds & Kamphaus, 2004).
Items were rated on a 4-point rating scale (1 never; 2
sometimes; 3 often; 4 almost always). There are 12 clinical
subscales on the BASC-2: SRP-College Version, with higher
scores representing increased levels of maladaptive functioning.
On the clinical subscales, T-scores greater than 65 are considered
indicators of clinically significant levels of distress (Reynolds &
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Kamphaus, 2004). The BASC-2 demonstrates excellent psycho-
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metric properties (see Tan, 2007, for a review). The Anxiety,
Depression, and School Maladjustment subscales from the
BASC-2: SRP-College were examined in the present study, and
internal consistencies were Anxiety .88, Depression .86,
and School Maladjustment .79.
Overall functioning. Participants completed the Barkley
Functional Impairment Scale (BFIS; Barkley, 2011b), which as-
sesses psychosocial impairment in 15 domains of major life activ-
ities. The BFIS is a norm-referenced measure (N 1,200) with
high internal consistency (.97) and testretest reliability over a 1-
to 2-week period (.72) reported in the normative sample. Partici-
pants rated impairment in each major life activity on a 10-point
Likert scale ranging from 0 (not impaired) to 9 (severely im-
paired). A not applicable option is also available for each item
(e.g., most of our college participants indicated n/a for the item
assessing impairment in taking care of and raising your chil-
dren). An item mean score can be calculated (i.e., average item
score across all 15 domains of functioning; .96).
GPA. Participants GPA was used as an objective measure of
academic functioning and was coded on the basis of a system
developed and refined in past work with adolescents and young
adults (Molina et al., 2009). Importantly for a college sample,
students GPA was calculated taking into account the number of
credits attempted and when students withdrew from courses or
earned incomplete grades. Specifically, for each student, the sum
of their course grades was multiplied by the number of credit hours
earned and then divided by the total attempted credit hours. For all
students, A 4.0, B 3.0, C 2.0, D 1.0, and F 0. GPA
for the fall semester was used in the analyses as these grades
corresponded with the collection of ratings.
Analytic plan. Hierarchical regression analyses were con-
ducted in order to examine whether SCT symptoms predicted
daytime sleepiness above and beyond ADHD and internalizing
symptoms. As in Study 1, ADHD and internalizing symptoms
were entered on Step 1 in predicting daytime sleepiness, fol-
lowed by SCT symptoms on Step 2. As with Study 1, none of
the participant demographics/characteristics (i.e., age, sex, race,
home or school residence, ADHD medication status, current
employment status, parent education level, family income, year
in school) was significantly correlated with daytime sleepiness,
and so these variables were not included in the regression
model.
Initially, the 30 ADHD-I participants were compared with the
28 ADHD-C participants to determine whether any significant
differences were present on the variables of interest. ADHD-I
and ADHD-C participants did not differ on daytime sleepiness,
t(66) .61, p .54, or SCT, t(66) .86, p .40. Further,
the two groups did not differ on any of the demographic
variables or on internalizing symptoms, t(66) 1.66, p .11.
Accordingly, ADHD-I and ADHD-C participants were com-
bined and treated as a single group.
As described above, and following past research in this area
(Barkley, 2012, 2013), participants were grouped on the basis of
whether or not they exhibited clinically significant levels of SCT
or daytime sleepiness symptoms. Using the symptom cutoffs de-
scribed in the Measures section, four groups were created: (a)
ADHD present but neither SCT nor sleepiness present (n 15);
(b) ADHD and SCT present but not sleepiness (n 9); (c) ADHD
and sleepiness present but not SCT (n 12); and (d) ADHD, SCT,
and sleepiness all present (n 22). Given the small numbers of
participants in groups (b) and (c), these two groups were combined
for the grouping analyses to form an ADHD present and either
SCT or sleepiness present group (n 21). The three groups were
then compared on the ADHD symptom dimensions, symptoms of
anxiety and depression, and all demographic variables to deter-
mine what variables to consider as covariates in subsequent anal-
yses.
Three separate analyses of covariance (ANCOVAs) were then
run, comparing the three groups on overall impairment, school
maladjustment, and GPA. Significant ANCOVAs were followed
up with pairwise comparisons between groups. Cohens d effect
sizes were calculated to determine the magnitude of the difference
between the groups on the measures of impairment (Group 1 Mean
Group 2 Mean / pooled SD).
Results
Correlation analyses. Variable means, standard deviations,
and intercorrelations of study variables are presented in Table 3.
Symptoms of hyperactivity, anxiety, depression, and SCT were
significantly correlated with daytime sleepiness (rs ranging
from .23 to .51, ps .05). Table 4 presents bivariate correlations
between the individual SCT items and daytime sleepiness to ex-
amine the overlap between areas of SCT and sleepiness (rs ranging
from .04 to .51). Although overall SCT was moderately associ-
ated with daytime sleepiness in both studies, the SCT items
showed wide variability in their individual associations with day-
time sleepiness (see Table 4). In particular, the same two SCT
items had the highest correlations with the daytime sleepiness
scores in both studies, and both of these items are conceptually
similar to daytime sleepiness (i.e., have trouble staying alert or
awake in boring situations and lethargic, more tired than oth-
ers).
SCT in relation to daytime sleepiness. Next, hierarchical
regression analyses predicting daytime sleepiness were conducted
with ADHD and comorbid internalizing symptoms entered on Step
1, followed by SCT symptoms entered on Step 2. All VIF values
were below 1.88, and all tolerance values were above .53, indi-
cating that multicollinearity was not a problem in our regression
model. As shown in Table 5, ADHD hyperactive symptoms sig-
nificantly negatively predicted daytime sleepiness in Step 1. When
SCT was added to the model at Step 2, the predictive value of
 SCT AND SLEEP 7

Table 3
Study 2: Means, Standard Deviations, and Bivariate Correlations

Variable 1 2 3 4 5 6 7 8 9 10

1. SCT .56 .02 .23 .31 .41 .42 .51 .10 .51
2. ADHD Inattention .17 .37 .03 .13 .52 .24 .24 .09
3. ADHD Hyperactivity .51 .16 .02 .07 .11 .01 .23
4. ADHD Impulsivity .18 .04 .28 .06 .03 .06
5. Anxiety .59 .42 .29 .24 .31
6. Depression .29 .45 .04 .31
7. Overall impairment mean .29 .09 .28
8. School maladjustment .12 .45
9. Grade-point average .12
10. Daytime sleepiness
M 2.58 2.88 2.45 2.41 56.19 52.22 5.07 51.83 2.33 2.26
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SD 0.56 0.52 0.65 0.77 11.47 12.45 1.66 9.33 1.04 0.55
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Note. SCT sluggish cognitive tempo; ADHD attention-deficit/hyperactivity disorder.

p .05. p .01. p .001.

ADHD hyperactivity was reduced to nonsignificance, and SCT
was the sole significant predictor of daytime sleepiness.
Group comparisons on ADHD, SCT, and daytime
sleepiness. Thirty-seven participants met the cutoff for clinically
significant levels of SCT, of which 27 (73%) also met the cutoff
for significant daytime sleepiness. Considering the reverse over-
lap, among the 34 participants who met the cutoff for sleepiness,
27 (79%) also met for SCT. As expected from the selection
criteria, the three SCT/sleepiness groups significantly differed in
total SCT symptoms, F(2, 56) 58.34, p .001, and total
daytime sleepiness symptoms, F(2, 56) 38.04, p .001. Spe-
cifically, the group with ADHD SCT and Sleep had the highest
levels of both SCT and daytime sleepiness, followed by the group
ADHD SCT or Sleep, followed by the group with ADHD alone;
all planned pairwise comparisons between these groups were sig-
nificant (p .01).
There were no significant ADHD subtype differences across the
three groups (p .05). Similarly, there were no significant dif-
ferences in anxiety (p .15) or depression (p .08) across the
three groups. There was a significant difference in gender propor-
tion, 2(2) 3.70, p .03, such that a significantly higher
proportion of females was found in the ADHD SCT or Sleep
group (76% female) than in the other two groups (ADHD alone
33% female, ADHD SCT and Sleep 50% female). Therefore,
gender was included as a covariate in subsequent group analyses.
Ethnicity, living status, employment status, parent education level,
family income, year in school, and ADHD medication status did
not differ across the three groups (ps .05).
Group differences in functional impairment across the three
groups were examined with ANCOVAs, followed up with pair-
wise comparisons (see Table 6). For overall functional impair-
ment, significant differences were found in the mean impairment
rating scores for the three SCT/sleepiness groups, F(2, 54) 5.37,
p .007, after controlling for the effect of gender. Pairwise
comparisons/planned contrasts revealed that participants in the
ADHD SCT and Sleep group had significantly greater overall
functional impairment compared with those in the ADHD-alone
group (p .005) and those in the ADHD SCT or Sleep group
(p .015). Those in the ADHD-alone group and those in the
ADHD SCT or Sleep group did not significantly differ in ratings
of overall functional impairment (p .59).

Table 4
Correlations of SCT Items With Daytime Sleepiness

Study 1: Daytime Study 2: Daytime

Variable sleepiness sleepiness

SCT Item 1: Prone to daydreaming when I should be

concentrating on something or working. .24 .28
SCT Item 2: Have trouble staying alert or awake in
boring situations. .35 .51
SCT Item 3: Easily confused. .30 .18
SCT Item 4: Easily bored. .26 .31
SCT Item 5: Spacey or in a fog. .26 .22
SCT Item 6: Lethargic, more tired than others. .34 .57
SCT Item 7: Underactive or have less energy than others. .25 .43
SCT Item 8: Slow moving. .24 .34
SCT Item 9: I dont seem to process information as
quickly or as accurately as others. .27 .04
SCT Total Score .40 .51
Note. SCT sluggish cognitive tempo.

p .05. p .01. p .001.
 8 LANGBERG, BECKER, DVORSKY, AND LUEBBE

Table 5
Study 2: Multiple Regression Models Predicting Daytime Sleepiness From ADHD, Internalizing, and SCT Symptoms

Step 1: Model summary Step 2: Model summary

B SE t B SE t

Variable F(5, 53) 2.67 , R .202
F(6, 52) 14.25 , R .38
2

ADHD Inattention .10 .13 .11 .17 .18 .14 .19 1.31
ADHD Hyperactivity .41 .20 .29 2.03 .26 .18 .18 1.40
ADHD Impulsivity .01 .22 .01 .03 .09 .20 .06 .45
Anxiety .11 .06 .28 1.75 .07 .06 .19 1.31
Depression .05 .06 .13 .85 .01 .05 .01 .09
SCT .50 .13 .57 3.77
Note. Dashes indicate that the variable was not entered in the Step 1 model. ADHD attention-deficit/hyperactivity disorder; SCT sluggish cognitive
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tempo.

p .05. p .001.
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Significant differences were also found for the school malad-
justment T-scores on the BASC-2 across the three SCT/sleepiness
groups, F(2, 54) 5.73, p .006, after controlling for gender.
Pairwise comparisons revealed that participants in the ADHD
SCT and Sleep group had significantly higher school maladjust-
ment problems compared with those in the ADHD-alone group
(p .001; d 1.14). Further, those in the ADHD SCT or Sleep
group had greater school maladjustment problems compared with
those in the ADHD-alone group, with results approaching signif-
icance (p .09; d .53).
Significant differences were not found in GPA across the three
SCT/sleepiness groups, F(2, 54) 1.52, p .23, after controlling
for the effect of gender. However, there was a moderate effect size
difference between participants in the ADHD-alone group and
participants with either ADHD and SCT or Sleep (d .68) and
between participants with ADHD alone and those in the ADHD
SCT and Sleep group (d .52).
General Discussion
In this study, we evaluated the relation between symptoms of
ADHD, SCT, and daytime sleepiness in samples of college stu-
dents with and without ADHD. This was the first study to evaluate
the degree to which SCT and daytime sleepiness are distinct or
overlapping constructs and how comorbid SCT and daytime sleep-
iness relate to functional impairment. Ratings of SCT and daytime
sleepiness demonstrated significant, moderate associations in sam-
ples of college students with (.51) and without (.40) ADHD. Factor
analysis conducted in a large general college sample demonstrated
that although highly related, SCT and daytime sleepiness are
empirically distinct. In both the clinical and nonclinical samples,
SCT predicted daytime sleepiness above and beyond symptoms of
ADHD, anxiety, and depression. Further, in the clinical sample,
college students with ADHD SCT and daytime sleepiness
endorsed significantly greater functional impairment in compari-
son to students without SCT and daytime sleepiness.
Multiple authors have noted the apparent overlap between
aspects of SCT and daytime sleepiness (e.g., Cortese et al.,
2009; Fallone et al., 2005; Mayes et al., 2009; Willoughby et
al., 2008). In particular, the sleepy, tired, and drowsy aspects of
SCT would seem to have considerable overlap with behaviors
often witnessed in individuals with daytime sleepiness, at least
from a face validity perspective. Correlation analyses in this
study demonstrate that substantial overlap indeed exists, with
the SCT items related to feeling lethargic and having trouble
staying awake having the strongest associations with daytime
sleepiness (see Table 4). There were some differences across
the two studies in terms of the degree to which SCT items were
correlated with sleepiness. Overall, correlations were larger in
the ADHD clinical sample. However, in the general sample, all
SCT items were correlated with daytime sleepiness, whereas in
the clinical sample, SCT items related to being confused, in a
fog, and slow to process information were not correlated with
sleepiness. These differences may be due to the nature of the
samples (i.e., general vs. clinical), differences in sample size, or
to differences in how daytime sleepiness was measured across
the two studies.

Table 6
Study 2: Group Comparisons on ADHD, SCT, Sleepiness Symptoms, and Functional Impairment

Group 1: ADHD Group 2: ADHD SCT or Group 3: ADHD SCT

(n 15) Sleep (n 21) Sleep (n 22)
Impairment outcome M SD M SD M SD F p 2 Contrasts

Overall impairment 4.40 1.65 4.66 1.55 5.92 1.48 5.37 .007 .17 1, 2 3
School maladjustment 46.40 9.03 51.24 9.06 56.09 7.94 5.73 .006 .18 13
Grade-point average 2.78 1.03 2.09 1.01 2.24 1.03 1.52 .23 .06
Note. Group differences are examined after controlling for the effects of gender as a covariate in each of the models. Where the F test was significant,
the results of the pairwise group contrasts are shown as well. ADHD attention-deficit/hyperactivity disorder only; SCT sluggish cognitive tempo;
Contrasts pairwise contrasts of groups.
 SCT AND SLEEP
In Study 1, the ESS was administered. This scale asks partici-
pants to rate how likely they are to doze off during specific
activities (e.g., reading or watching TV). In Study 2, the PDSS was
administered. Similar to the ESS, the PDSS includes items related
to how likely the respondent is to doze or sleep during daytime
activities. However, the PDSS also includes items asking for the
respondents subjective feelings of tiredness/alertness during the
day (e.g., Are you usually alert most of the day? and How often
are you tired or grumpy during the day?). These items are highly
similar to the SCT items on the BAARS-IV that ask respondents to
indicate how frequently they have trouble staying alert or awake
and feel lethargic, and more tired than others. Accordingly, it
may be that the proclivity to actually fall asleep/doze (i.e., focus of
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ESS measure) better distinguishes SCT from daytime sleepiness
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than items focused on feelings of being sluggish, tired, and lethar-
gic.
Despite the significant associations found in the correlation
analyses, the magnitude of the associations (highest r .57)
suggests that these SCT items are not redundant with daytime
sleepiness. Likewise, results of the factor analysis suggest that the
SCT and daytime sleepiness are best viewed as empirically distinct
constructs. In the general college sample, the SCT and daytime
sleepiness latent factors were significantly correlated with each
other (r .50). However, a one-factor model had only mediocre
model fit and was significantly inferior to the two-factor model
containing SCT and daytime sleepiness as separate constructs. It is
worth noting that the ESS was the measure collected in the general
college sample and used in the factor analysis. Given the item-
level differences between the ESS and PDSS described above, it is
interesting to consider whether results would be different in a
clinical sample with the PDSS. It is also important to note that
consistent with past research with adult samples (Barkley, 2012),
in this study, the SCT construct from the BAARS-IV was treated
as a single factor. This is in contrast to research with youth with
ADHD in which SCT measures have been shown to consist of two
or three separate factors, including a sleepy factor (Barkley, 2013;
Jacobson et al., 2012; Penny et al., 2009). Additional factor ana-
lytic research is needed to determine whether daytime sleepiness is
distinct from the sleepy aspect of SCT in samples of youth with
and without ADHD.
The overlap between SCT and daytime sleepiness was particu-
larly evident in the results of the grouping analyses with the
clinical sample. Consistent with past work (e.g., Barkley, 2012;
Drake et al., 2003; Maganti et al., 2006), we grouped participants
on the basis of whether or not they exhibited clinically significant
levels of SCT and/or daytime sleepiness. In our sample of college
students with ADHD, comorbid SCT and/or daytime sleepiness
was the norm rather than the exception, with only 26% of the
sample not exhibiting either clinically significant daytime sleepi-
ness or SCT symptoms. In terms of overlap between SCT and
daytime sleepiness, it was more common for college students with
ADHD to have both comorbid SCT and daytime sleepiness (38%)
than to have either SCT alone (15%) or daytime sleepiness alone
(21%). Overall, 74% of the sample had either clinically significant
levels of daytime sleepiness or SCT symptoms.
The results of the grouping analyses are also consistent with past
research with samples of young adolescents with ADHD, which
have revealed comorbid SCT (Langberg, Becker, & Dvorsky,
2013) and daytime sleepiness (Langberg, Dvorsky, et al., 2013) to
9
be associated with more severe functional impairment (see Table
6). SCT exhibited significant, moderate correlations with self-
reported overall impairment and school maladjustment (see Table
3). Daytime sleepiness exhibited a small significant correlation
with overall impairment and a moderate, significant correlation
with school maladjustment. Analyses revealed that college stu-
dents with ADHD SCT and Sleep were significantly more
impaired than students with ADHD alone and were also more
impaired than students with ADHD SCT or Sleep on ratings of
overall impairment and school maladjustment (see Table 6). Group
differences on GPA were not significant. However, this was likely
due to limited power to detect effects, as effect size differences on
GPA between the ADHD-alone group and ADHD SCT or Sleep
group were moderate (d .68), as were differences between the
ADHD-alone group and the ADHD SCT and Sleep group (d
.58).
Interestingly, students with ADHD SCT or Sleep (i.e., stu-
dents with one comorbid condition but not two) only exhibited
significantly greater impairment in comparison to students with
ADHD alone on school maladjustment (i.e., no differences on
GPA or ratings of overall functional impairment). One possible
explanation for this finding is that the overall impairment rating
scale used in this study includes items that assess a variety of
functional domains, including but not limited to educational activ-
ities, social interactions, occupational activities, dating relation-
ships, and money management. It may be that daytime sleepiness
alone and SCT alone both negatively impact school/educational
functioning, but have less of an impact on other domains of
functioning. However, when SCT and daytime sleepiness are both
present in college students with ADHD, this appears to lead to
impairment across multiple domains of functioning. For school
maladjustment, in comparison to students with ADHD alone,
effect sizes were moderate when one comorbid condition was
present (d .53) and quite large when both SCT and daytime
sleepiness were present (d 1.14). This suggests that in terms of
school impairment, SCT and daytime sleepiness exert a powerful
additive effect.
Results of the regression analyses were similar across Study 1
and Study 2. Specifically, in both samples, SCT predicted daytime
sleepiness above and beyond symptoms of ADHD, anxiety, and
depression. Consistent with past research, ADHD symptoms of
inattention, anxiety, and depression were significantly correlated
with SCT (see Tables 1 and 2; Becker, Luebbe, et al., 2014; Garner
et al., 2010). Also consistent with past research, symptoms of
anxiety and depression were significantly correlated with daytime
sleepiness in both samples (Accardo et al., 2012). Interestingly,
although all ADHD symptom dimensions were correlated with
daytime sleepiness in the general sample (rs .23.36), only
symptoms of hyperactivity were correlated with daytime sleepi-
ness in the clinical sample (r .23; see Table 2). The lack of a
significant correlation between inattention and daytime sleepiness
in the clinical sample may be due to restriction of range as
participants had to meet criteria for ADHD-I or ADHD-C to be
included, and therefore all had six or more symptoms of inatten-
tion. Likewise, the negative association between hyperactivity and
daytime sleepiness in the clinical sample likely reflects the clinical
nature of the sample, which includes some participants with
ADHD-C, who by definition experience clinically impairing
hyperactive-impulsive symptoms that one would expect to be
 10 LANGBERG, BECKER, DVORSKY, AND LUEBBE
behaviorally the opposite of daytime sleepiness. In the final model
in the general sample, SCT, anxiety, and inattention all predicted
daytime sleepiness, with SCT accounting for the greatest portion
of the variance. In the clinical sample, only SCT was a significant
predictor of daytime sleepiness.
Limitations
As noted above, this study focused on samples of young adults
with and without ADHD, and consistent with previous research
examining SCT in adults, SCT was considered a unitary construct.
It cannot be determined from these analyses whether the results of
the factor analysis would be similar in a sample of children with
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ADHD, particularly if a multifactored SCT measure was used
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(e.g., Barkley, 2013; Penny et al., 2009). Another important lim-
itation is the modest sample size (N 58) for the ADHD clinical
sample. The sample size may have limited our ability to detect
differences in the grouping analyses, especially between the
ADHD-only group and the ADHD plus SCT or daytime sleepiness
group. Further, the general college student sample examined in
Study 1 was limited in terms of diversity (9% ethnic minority). As
such, until these findings are replicated, it cannot be assumed that
these results will generalize to college students attending other
universities. Additional research with larger and more diverse
samples is needed before firm conclusions can be drawn regarding
the overlap between SCT and daytime sleepiness and the relation
of these constructs to functional impairment. In addition, only
daytime sleepiness was assessed in these two samples, and mea-
sures of sleep disturbance were not collected. Accordingly, it is
unknown whether the associations reported in this study would
generalize to specific sleep disturbances (e.g., sleep latency and
sleep-disordered breathing). Finally, although GPA is an ecologi-
cally valid measure of academic functioning, it is important to
acknowledge that school grades are a multidimensional construct
that may be influenced by many different factors, including class-
room behavior, homework completion, effort, motivation, and
attendance. As such, it is important to acknowledge that there is a
subjective aspect to GPA and that grades do not solely measure
academic knowledge.
Future Research
There are a number of interesting mediation pathways/relation-
ships that could be tested in future research. In a general sample of
508 children, Calhoun et al. (2012) found that processing speed
and working memory mediated the relationship between daytime
sleepiness and learning and attention problems. Given that one
aspect of SCT relates to slow processing, it is possible that SCT (or
the slow aspect of SCT) would mediate the relationship between
daytime sleepiness and functional impairment. Similarly, deficits
in executive function (EF) are common in individuals with ADHD,
and symptoms of inattention and SCT have been shown to relate to
the metacognitive aspects of EF (i.e., working memory and initia-
tive; Barkley, 2012, 2013; Becker & Langberg, 2014). Interest-
ingly, there is considerable evidence to support the assertion that
daytime sleepiness negatively impacts school functioning through
EF (Astill et al., 2012; Beebe, 2011). Accordingly, it could be that
SCT and daytime sleepiness both lead to functional impairment
through EF and that comorbid SCT and daytime sleepiness leads to
an additive negative effect on EF, and therefore, more severe
impairment. The present study suggests that comorbid SCT and
daytime sleepiness exert an additive impact on functioning, but
this study does not answer questions about the mechanisms
through which such impairment occurs.
Conclusions
Results from the present study suggest that although SCT and
daytime sleepiness are empirically distinct, they are also somewhat
overlapping constructs. Importantly from a clinical perspective,
our data suggest that individuals with clinically significant levels
of SCT symptoms are also likely to exhibit significant daytime
sleepiness, and vice versa, and that the combination of these two
conditions results in significant functional impairment. For exam-
ple, for ratings of overall impairment, the effect size difference
between college students with ADHD SCT and Sleep in com-
parison to those students with ADHD alone was large (d .97).
Given the interrelatedness and overlap between attention prob-
lems, SCT, and daytime sleepiness, it seems imperative that com-
prehensive ADHD evaluations include at least screening measures
for all three of these constructs. Current evidence-based assess-
ment recommendations support the assertion that comorbidities
should be assessed as part of ADHD evaluations (American Acad-
emy of Pediatrics, 2011); however, these recommendations focus
primarily on the need for assessment of oppositional defiant dis-
order, anxiety, depression, and learning problems (Becker, Lang-
berg, Vaughn, & Epstein, 2012; Langberg et al., 2010). Given that
(a) both SCT and daytime sleepiness frequently co-occur with
ADHD, (b) daytime sleepiness and SCT symptoms in many ways
mimic ADHD symptoms and could be mistaken for ADHD symp-
toms, and (c) comorbid SCT and daytime sleepiness significantly
increase the likelihood of more severe functional impairment, it
seems reasonable to suggest that these constructs be routinely
assessed in a similar manner to other common comorbidities. For
youth for whom ratings indicate the presence of significant levels
of inattention, SCT, and sleepiness, it will be particularly impor-
tant to establish a timeline in order to document age of symptom
onset. In cases in which sleep problems and SCT symptoms
precede the development of symptoms of inattention, the clinician
should work with the family to address sleep prior to making a
diagnosis of ADHD.
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Received March 20, 2013
Revision received January 30, 2014
Accepted February 10, 2014