‘Sluggish cognitive tempo, ADHD and motivation’ In Conversation with Dr. Zoe Smith

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In this podcast, Dr. Zoe Smith, recent ACAMH awards 2020 Winner (Research) Trainee of the Year, talks about sluggish cognitive tempo, ADHD and academic motivation. Zoe tells us how she educates families about the failure cycle, and how they can find solutions for their children with ADHD.

Zoe also talks about school-based ADHD interventions, and the importance of culturally responsive interventions for youth with ADHD.

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Dr. Zoe Smith
Dr. Zoe Smith

Zoe received her B.A. with distinction in psychology from Kenyon College in 2015, beginning her graduate work that fall. Zoe’s program of research has focused on the validity, clinical utility, and underlying features of a construct known as Sluggish Cognitive Tempo (SCT) in youth with ADHD. Zoe is also interested in how motivation plays a role in deficits seen in both SCT and ADHD and how interventions may alleviate these deficits. In the future, she hopes to develop and pilot a brief, problem-focused intervention to alleviate the most impairing aspects of SCT. Clinically, Zoe has focused on evidence-based interventions with pediatric populations, including youth and young adults within the hematology/oncology and transplant division of the Children’s Hospital of Richmond. Follow Zoe on Twitter @DrZoeRSmith. (Bio from VCU)


Interviewer: This podcast is brought to you by the Association for Child and Adolescent Mental Health, ACAMH for short. You can find more podcasts and other resources on our website, www.acamh.org and follow us on social media by searching ACAMH.

Hello, welcome to the In-Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology.

Today I’m interviewing Zoe Smith, a Paediatric Psychology Post-doctoral Research Fellow at Loyola University Chicago. Zoe’s research focuses on ADHD and sluggish cognitive tempo, SCT. Zoe has just won the ACAMH 2020 Research Trainee of the Year award.

If you’re a fan of our in-conversation series please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues.

Zoe welcome. Thank you for joining me and congratulations on your ACAMH award. Can you start with a brief introduction of who you are and what you do?

Zoe Smith: Yes, of course. Thank you so much for having me. I’m currently a post-doctoral fellow at Loyola University Chicago under the mentorship of Grace and Hombach. So I earned my PhD in Clinical Psychology this year from Virginia Commonwealth University after completing my clinical internship at University of Chicago Medicine. As a postdoc I am currently working on writing papers, running data analysis, mentoring graduate students, seeing patients serving on committees. I’m also working on writing up a grant.

Interviewer: Zoe, how did you come to be interested in child and adolescent mental health?

Dr. Zoe Smith: So I’ve always been interested in working with children and adolescents and my dad helped me think through some of my values on what I want in a career and what’s important to me and how to work towards my strengths. So one thing that was always very important to me as a young person and continues to be important now was community service, particularly through high school and college. I was always drawn to working with young people, particularly from historically excluded backgrounds.

I noticed that working with people in schools or I work with people on Head Start, I noticed that there were many young people that were being, kind of, lost in our current school system and I wanted to receive training and how to advocate for those students. That, you know, our systems have failed or just kind of falling behind in some way. Particularly for students who the systems are purposely failing, like students of colour or who have disabilities status and are frim historically excluded backgrounds.

Interviewer: We’ll focus a bit more on that later. Your research focuses on academic motivation for youth with ADHD and impairment related to the construct of sluggish cognitive tempo, SCT. What is sluggish cognitive tempo?

Dr. Zoe Smith: A great question. It is a fairly new construct in our field. So I really love talking about it. So I learned about sluggish cognitive tempo or SCT while doing this research experience for undergraduate students or under-represented backgrounds at the University of Cincinnati. I think it was between my junior and senior year of college and I actually learned about it from one of the leading experts on SCT, Stephen Becker. I was able to learn a little bit about it as an undergrad, and I became interested when I was pursuing my PhD. SCT refers to a set of behavioural symptoms.

So that includes excessive day-dreaming, mental confusion and fogginess, being lost in one’s thoughts and slowed behaviour and thinking. Initially, it was theorised to be potentially a pure inattentive sub-type or presentation of ADHD, but research has consistently found it to be distinct from ADHD. So SCT is associated with ADHD symptoms, more particularly inattentive symptoms, but is negatively or not significantly associated with hyperactivity and impulsivity. One of the interesting things about SCT is that it is strongly associated with ADHD which we typically fall into what we call externalising disorders.

It is also strongly associated with depression and anxiety, which kind of falls under internalising. So I think SCT is a great example of this movement and psychology towards trans- diagnostics and moving away from these strict categories because it’s associated with what people have historically considered quite different constructs. So a growing body of research has suggested that psychopathology should be understood in a more dimensional way, like a hierarchical approach.

So this would suggest like there might be this general psychopathology factor that contributes to externalising and internalising dimensions, that subdivide into what we right now consider, you know, disorders or constructs, like on the internalising side we have things like anxiety, depression, and on externalising we have ADHD and oppositionality and we have these constructs like SCT even internalising and externalising constructs that have this potentially shared etiology within these dimensions. So with SCT being associated with those, I think it just kind of shows this bigger picture.

Interviewer: Right. Is it in DSM-5 then?

Dr. Zoe Smith: No, it is not, and there’s not really right now a movement to get it in as a disorder. I know that it’s been considered, but right now there’s just not necessarily a purpose or a reason to get that into the DSM right now. We’re still studying if it is a disorder on its own or if it’s more trans-diagnostic construct, similar to emotion regulation that affects lots of different disorders, like emotion regulation affects people with ADHD and depression and anxiety.

So we’re still doing research on it and it is a relatively new construct. I think it started in the 80s and there was some research on that and then really in the past two decades has there been, kind of, this explosion of SCT work. So as an early career researcher it’s been a really wonderful time to start my career in this area because there are so many really interesting things we still need to learn about SCT.

Interviewer: Can you say more about your research on academic motivation? What did you explore and what did you find?

Dr. Zoe Smith: Yes, so I wrote a review on academic innovation in youth with ADHD. It’s in the Clinical Trial and Family Psychology Review. So one thing that I noticed, I was an ADHD specialty clinic at my graduate programme. So I worked with a lot of families, with youth with ADHD and I would always hear from families and sometimes adolescents or young people with ADHD this mantra of they are lazy or I’m lazy or I’m not a good student, which is totally not true.

I really dislike the term lazy or saying that they’re unmotivated. So I wanted to look into the research. So what I found through my review and also some subsequent papers I’ve written on ADHD and motivation, I did find that youth with ADHD suffer for lower levels of intrinsic, which is internal motivation and extrinsic or externally stimulated motivation, like getting a good grade as lower than their peers without ADHD.

I also found that youths with ADHD were more likely to have higher levels of what we call a motivation, which is kind of a construct where people are neither intrinsically or extrinsically motivated and don’t necessarily understand the reason behind executing certain behaviours, like why homework performance is important.

Kids with a motivation are detached from their work and don’t believe their effort will change the outcome, almost like the concept of learned helplessness. So this is particularly important to note for youth and even adults with ADHD is that often the school environment or the work environment is not really ADHD friendly.

So, for example, in middle school which in the US is typically 16th grade, that includes switching classes, less individualised time with teachers, increased homework demands, more didactic instruction which for many kids with ADHD who have trouble staying organised, switching tasks with time management this may start to feel really overwhelming. So my clients would start to say, I don’t care which, you know, to me as a therapist means that they have probably reached this a motivation stage through some sort of negative reinforcement. Whether it’s their parents or teachers telling them they’re not trying hard enough. Whether it is a failing grade or not doing well because they’re forgetting to turn in their homework even though they’ve completed it and actually do understand what they’re learning.

So using this information from my research and also following in some great footsteps, like, for example, Maggie Sibley [s.l. 09:55] who has been including motivational interviewing with her clinical interventions. I’ve started doing that in my own practice and my own, you know, future grant ideas. What I do is I help to try to educate families about this failure cycle that is often pretty common in youth with ADHD, where they might not do well. They get a lot of nagging or negative reinforcement about whatever that behaviour was that was frustrating for the parents or the teachers or for themselves.

So they started to say, I don’t care. I want to give up. So what I do, along with helping with accommodations and identifying strengths, I also try to increase motivation and help to kind of pare back effort with positive outcomes. So one way I do that or one way that I found to be helpful is asking adolescent what are their goals, which can sometimes take time, particularly with adolescents who don’t even want to be in therapy.

And, you know, sometimes our goal ends up being decreasing, nagging from their parents which is a fine place to start, and then I use whatever goal they created to help them see how effort or other organisation, time management planning or cognitive behavioural therapy skills may help move them towards whatever goal they’ve decided.

Interviewer: What about the parents? You mentioned that they also can be part of the intervention. What can they do then to help motivate their children?

Dr. Zoe Smith: Lots of things and I think ADHD interventions have done a really great job of providing the psycho education to parents on how they can help their teens or their young people with ADHD, and I think that stemmed from behaviour therapy which we typically do with younger kids, which is really parent focused and parents learning these skills that will help modify behaviour or kind of increase positive reinforcement. I specialise with adolescents. Sometimes they come to me. Parents are really frustrated and the teen is really frustrated.

It’s really hard to have open communication together. So I provide some information about ADHD and how it’s probably affected whatever they’re coming to talk to me about. Whether it’s their relationship, whether it’s academics, whether it’s peers and then I try to work with the parents on understanding what the goals are. So what the kid’s goals are? What they’ve decided, and trying to also shape parents behaviour too. So let’s go back to my example of nagging.

So that seems to be very motivating for your teen is to decrease that. So what if you just asked once about homework and if they do it or not that’s up to the teen. That’s their responsibility. So trying to get them to, kind of, come on board and help within the intervention. Parents are so helpful and also they can be so creative. What I tell families, their parents and the teens themselves, they are the experts. I’m the expert on treatment.

I’m the expert on these interventions, but they’re the experts on themselves. So I often find that parents are coming up with these really wonderful creative solutions on how to help their teen or come up with things that their teen really enjoys. So I really like to be very collaborative with the whole family, and you know sometimes teens don’t want that, but most of the time, you know, they do want their parents’ positive attention and they’ve had a lot of negativity. So when we start to kind of help to rebuild that relationship we often see a lot of positive effects.

Interviewer: Great. Sluggish cognitive tempo, as you’ve already said, is associated with depression, sleep and academic difficulties over and above ADHD symptoms. I understand you’re working to create a community based intervention for adolescents with ADHD and high levels of SCT. Can you tell us more about this?

Dr. Zoe Smith: Yes, I’m very excited about this project. It is still in the early stages and I’m working with a really wonderful team of mentors to write a grant proposal for NIMH using their K23 mechanism. So the first aim that we’ve been thinking about for this grant is intervention development.

So we know that youth with ADHD and high levels of SCT have higher rates of depression, rumination, peer withdrawal and suicidal ideation. So I’m focused on creating an intervention that will incorporate multiple strategies to help decrease these comorbidities or this impairment.

So the first aim is intervention development, and I’m writing about and then hoping to use a mixed methods approach, which means I want to conduct focus groups with community providers who typically see these kids, the adolescents and parents themselves to help with intervention development and what they feel like would be a feasible intervention, either if it’s the adolescents and parents for themselves or for the providers. Does it make sense in their clinic or would they be able to do something like this?

I’ll also be incorporating, hopefully, some text-based technology to help kind of increase participation and help with the goals that they create in the intervention each week, kind of similar to what I talked about earlier with what I do in individual therapy, is to kind of help them work towards whatever goals they’ve made that week to try to practice.

Interviewer: What’s the timescale on that?

Dr. Zoe Smith: So I’m a postdoctoral fellow and usually the case when I hear mechanism is for early career faculty. So hopefully the timing is soon when I am able to get a faculty position.

Interviewer: Zoe, last year in the Journal of Child Psychology and Psychiatry, the JCPP, you co-authored a paper looking at whether sluggish cognitive tempo symptoms improve with school based ADHD interventions. What did you find and what other interventions are shown to help young people with SCT?

Zoe Smith: So this was my dissertation work. It’s one of only two studies I know of right now that have examined how psychosocial interventions affect SCT symptoms. So I used multi-level modelling to look at how two school based interventions affected SCT symptoms and whether executive functioning and inattention predicted change in SCT symptoms. So one intervention is called the HOPS Intervention, which stands for the Homework Organisation and Planning Skills Intervention for Adolescents with ADHD, which my graduate school mentor Josh Langberg created.

The other was a behavioural intervention focused on rewarding adolescents for being on task. So they would have a goal and they would get points for having on task behaviour and creating goals for their homework. So I looked at these two interventions and what I found is there were no differences between this more organisation and time management and planning skills intervention and a more behavioural intervention and how they affected SCT symptoms, which was that they decreased SCT symptoms.

I then looked at whether executive functioning, which is a big part of the HOPS intervention, as well as inattention, which is part of both interventions, predicted that change in SCT symptoms and what we found that higher levels of change in executive functioning and inattentive symptoms predicted more change in SCT symptoms suggesting that these might be good targets for future interventions.

The important part is, is that these interventions were created for adolescents with ADHD and this was an ADHD sample, and although SCT is highly related to ADHD, it will be important to not only look at interventions with individual ADHD, but also with potentially SCT only, and this didn’t really focus on the internalising symptoms of kids with SCT. So although we saw a decrease in SCT symptoms, there wasn’t as large of an effect as we would want in an intervention.

Which is why with the grant that I’m writing right now is we are focused on including more cognitive behavioural therapy that helps with kind of that depression. The only other study right now that I can think of that has examined this as well is a 2007 study by Doctor Phifer and colleagues who created an intervention for youth, specifically with ADHD inattentive presentation. I believe it was elementary age students. I think probably around second to fifth graders and included behavioural parent training, teacher consultations and a child’s skills group and they actually, I think, found a bigger effect size that we did. That their intervention decrease symptoms of SCT as well, which makes sense since it was created for youth with predominantly inattentive presentation who are more likely to have higher rates of SCT.

Interviewer: How much focus there is on SCT outside of the US, given that the research focusing on it seems to be relatively scant?

Dr. Zoe Smith: Yes. So I think because there isn’t as much research on it in general, it hasn’t been happening internationally, except I think in the past decade. I know that there’s been some research groups in Seine. There’s been research groups in Australia. I believe in China, I’ve seen some work and that’s largely been due to just more papers on it. More acknowledgement of it as a construct and the focus of. We finally have gotten better measurement of SCT and so we have been able to… A recent beta-analysis or a systematic review, I think actually came out about how to measure SCT.

So I think more people are starting to learn about it. So I expect that there will be more international examination of SCT. The other thing is it’s mostly in clinical child samples. We haven’t done as much research on adults. So I think that that is also starting to increase as well. I know Steven Becker did a talk at the Society for Paediatric Psychology last year and reminded people that the CBCL, which is a commonly used measure in research and also different interventions has some SCT items.

So I think that I’ve been seeing more work now in paediatric psychology in different areas just because someone spoke about it and it sounded interesting. So I’ve been seeing an increase. I think there’s a lot of really great ways to go and that’s why I’m really excited to be working on this new intervention and just learning more about the construct.

Interviewer: I’m just wondering about prevalence then and presumably as assessment measures improve, it presumably will go up with it. I mean, what’s the prevalence of SCT?

Dr. Zoe Smith: That’s a great question. Very few people have looked at that. I’m honestly not sure in the general population. I know that within people with ADHD, it’s been between 30% to 60% of people with ADHD have high rates of SCT, but since ADHD is the most common childhood disorder, which is about 3% to 5% of the general population, I would assume it might mean a little bit, maybe 1%. I don’t know. I don’t think there actually has been a lot of work on that, and that would be a great thing for us to do and to learn more about.

Interviewer: I think I interrupted you before, but you were going to talk about the other interventions that are shown to help young people with SCT.

Dr. Zoe Smith: Well there are just the two. Basically what I was thinking is that. So there’s my study that looked at the two school based interventions and Doctor Phifer’s study that looked at a more comprehensive intervention that included a lot of different skills, a lot of different areas. So there’s still a lot of work to be done on how to alleviate SCT symptoms and associated impairment. So I’m really looking forward to working on this new intervention and to thinking through what makes the most sense for people that have high levels of SCT.

Interviewer: Zoe, what other research projects are coming up for you?

Dr. Zoe Smith: Right now I’m focused on this intervention grant and also writing papers with my lab, which is called the CHATS Lab. I’ve also been lucky to be given some data on ADHD negative emotionality, which is helping to inform migrant development. This is kind of in my more motivational domain. I’m also working on a project looking at motivation longitudinally in youth with and without ADHD to see if ADHD status moderates the growth trajectories.

I’m also working on multiple papers with my current lab on youth with spina bifida, and as a postdoc I’m also, you know, on the job market looking for tenure track positions in clinical psychology. I have another year of postdoc after this one but I’ve started looking around a little bit.

Interviewer: Okay, you’re pretty busy. I mentioned earlier you recently became ACAMHS 2020 trainee of the year for research. What does recognition mean to you?

Dr. Zoe Smith: To be recognised alongside so many others who have been doing such wonderful work in promoting treatments that work for children and adolescents was a huge honour. It felt very validating as well. I think as an early career researcher and recent graduate, being recognised for your work makes you feel like I’m in the right place. I’m doing the right thing. I also truly appreciate the hard work that ACAMH put into making me and the other nominees and winners feel special.

They did a virtual ceremony and they created these YouTube links with people’s information. My family emailed the YouTube link around and so did my current mentor at Loyola. So even though it was virtual, it felt very special and it was really nice to be able to share it with others. Sometimes my family doesn’t really know what I’m doing. So it was nice to show, even if they didn’t really understand what the publications and everything meant, that I was being recognised. So it was really nice. It was truly a huge honour.

Interviewer: That’s great. Zoe, as you mentioned in your intro, in your clinical work you were focused on working with young people of different ethnicities, using what you describe as a cultural responsiveness and trauma focused lens. Can you say a bit more about this approach and why it’s important for young people with ADHD?

Dr. Zoe Smith: Absolutely. So youth of colour, particularly black and brown youth in America face systemic racism daily. As a clinician it’s vital to acknowledge and face our own biases and beliefs and educate ourselves on how systemic racism affects our clients. Racism occurs in all context. So that includes schools, hospitals, clinics that we work in and we as clinicians should understand that historical context of each place we see families. I believe Doctor Boyd discussed this and most of our interventions have not been culturally adapted or have historically excluded or not included people of colour.

So not only is it important for clinicians, for us and researchers and teachers to educate ourselves on cultural responsiveness and anti-racism, it’s also important for funding agencies to start prioritizing culturally responsive interventions. So although there’s been a lot of really great research and interventions for youth with ADHD, there’s been limited understanding of how health disparities and racism affects youth with ADHD. Since ADHD symptoms often affect the school environment. It’s very important for clinicians to help be advocates or help teach students and families to be advocates for themselves.

Like I said, I hate the word lazy. I hate when kids are labelled as problematic or trouble. It’s not effective and can be racist and often leads to a motivation in school or building relationships and becomes the self-fulfilling prophecy. So clinicians and interventionists need to work to understand how racism affects behaviours they are seeing. Understand these behaviours through a trauma focused lens, which means understanding the context and the toll racism takes.

Also as a clinician with everybody, focus on the strengths of families and how to use these strengths and formulating our treatment plan in our assessment.

Interviewer: It sounds like really important work. Zoe, what else is in the pipeline that you’d like to mention?

Dr. Zoe Smith: So I’m working on multiple papers. As I mentioned earlier, the grant submission on the intervention for youth of ADHD and SCT. Speaking of the grant, if there are any clinicians or providers in the Chicago area that may be interested in this work they should feel pleased to reach out. I would love to collaborate or hear other people’s ideas. I’m also running a clinical group through Loyola’s Wellness Centre for College Students next semester. That’s focused on organisation, time management and planning skills, as well as thought challenging that are often helpful for college students with ADHD, depression and or anxiety.

I’d also love to give a shout out to my current lab at Loyola, the CHATS lab with whom I’m working on multiple papers on youth with spina bifida. Helping to run some longitudinal SCM models and I’m looking at SCT in attention in youth with Spina bifida. Also, I’m always looking for new Twitter followers. I tweet about mental health. So if you’re interested in what I’ve been having to say you can always connect with me on Twitter, doctorzoersmith.

Interviewer: Finally, Zoe what is your takeaway message for those listening to our conversation?

Dr. Zoe Smith: Youth with ADHD and really all people, all youth are individuals that are coping with many different things in their lives. I would like to stress the importance of psychosocial interventions for youth and young people with ADHD who are often overlooked in the school system and do not always have access to mental health treatment because there’s misinformation or there’s lack of access about psychosocial treatments not working for youth with ADHD. Individuals and even some types of group therapy can be immensely helpful, particularly since youth with ADHD often have comorbidities such as anxiety, depression, emotion dysregulation or high levels of SCT.

Finally, it’s imperative that clinicians assess for trauma in youth with ADHD and educate themselves on how racism and adverse effects on mental and physical health of people of colour, and thank you ACAMH and Jo for having me on this podcast. .

Interviewer: Zoe, brilliant. Thank you ever so much. For more details on Zoe Smith please visit the ACAMH website www.acamh.org and Twitter at ACAMH. ACAMH is spelt ACAMH and don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.

This podcast was brought to you by the Association for Child and Adolescent Mental Health, ACAMH for short.


Hi Dr. Smith,
Enjoyed your interview. I see you went to Loyola in Chicago. I was wondering if you know of any psychologists or psychiatrists in the area who might have a specialty with SCT. Not sure if you see patients or still live in Chicago area. We live about 1 hour NW of Chicago so even the Rockford area is OK. Any help or information you could pass along would be greatly appreciated.
Thank you,
Bob Heinke

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