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 Outcomes
- After 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.
Introduction
Welcome, 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 DSM
It’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 ADHD
I’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 CDS
Considering 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 Studies
Let’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 to meet their needs.
For instance, incorporating a movement break during transitions—like math to language arts—could help Sarah and Colby re-engage. A teacher might ring a bell and lead the class through a quick activity, such as raising their hands and performing “windshield wiper” motions. As the teacher provides instructions during the movement, she reinforces key points: “First, clean off your desks. What did I ask? Clean off your desks. Next, what folder are we taking out? The blue one—because it’s for language arts. And what homework do we need? The haiku.” This interactive approach reinforces the goal while engaging both Sarah and Colby.
Breaking the tasks into smaller, manageable parts is another effective strategy. For example, the teacher might set a countdown for desk clearing, saying, “I’m going to count backward from 20. By the time I finish, your desks should be clear.” She could then use a time timer for the next step: “Now that the desks are clear, I’m setting the timer for three minutes. By then, I expect the blue folder and haiku homework to be on your desk.” This kind of structured, step-by-step guidance accommodates both students.
Anticipatory support could also make a difference. The educational assistant could cue Colby ahead of time to pay attention instead of intervening after the directions. A visual list of the steps might help Sarah retrieve the necessary materials more efficiently. Both students benefit from point-of-performance coaching, but it’s tailored to their specific needs: Sarah needs support to focus her impulsive actions, while Colby needs help accessing directions and staying alert.
These strategies illustrate how understanding each child's unique needs allows us to design interventions that will set them up for academic and social success.
Both Diagnoses: Inability to Pay Attention
The overarching theme for both ADHD and Cognitive Disengagement Syndrome (CDS) is the difficulty in sustaining attention. While there is a significant overlap, with 25 to 40% of children with CDS also meeting the criteria for ADHD, CDS can exist as a standalone condition. This duality adds layers of complexity to the diagnostic process.
This complexity can be particularly challenging for those of us working in schools. Often, there’s limited time to delve deeply into the nuances of a diagnosis and truly understand its unique aspects. Yet, understanding these distinctions is essential for tailoring interventions and supports that address each child’s specific needs.
Pinpointing the Causes of this Condition
Researchers continue exploring the potential causes of Cognitive Disengagement Syndrome (CDS), and some fascinating possibilities are emerging. Environmental factors play a significant role, including a lack of stimulation during early development, exposure to chemicals or toxins, and the impact of chronic stress. Prolonged stress leads to constant cortisol release, which may contribute to the neurochemical imbalances seen in these children.
Another area of interest lies in the mechanisms of attention and arousal, which appear dysregulated in CDS. It strikes me that these children often seem lost in daydreams or appear sleepy, almost as if they lack the neurological "fuel" to propel themselves forward. It’s not simply about motivation or volition—it’s deeper than that. Neurologically, they cannot generate the drive to engage with their environment.
Genetics also likely play a role, particularly when there’s a family history of attention and focus difficulties. This familial link may provide additional clues as to why some children develop CDS. Additionally, comorbidities with ADHD, depression, and anxiety are frequently observed, further complicating the clinical picture.
What intrigued me most was the possibility of comorbidity between CDS and ADHD. At first glance, the two might seem oppositional, but a child could have both conditions. For instance, you might see the hyperactivity and impulsivity of ADHD paired with the daydreaming and foggy cognition of CDS. This combination creates a child who struggles with both outward hyperactivity and internal disengagement, which presents unique challenges for intervention and support. Understanding this overlap helps us refine our approach, ensuring we meet the needs of children with these complex presentations.
Other Differences
There are many differences between Cognitive Disengagement Syndrome (CDS) and ADHD, particularly in how children respond to interventions. For example, many children with CDS do not respond well to stimulant medications, which are often effective for managing ADHD symptoms. As a result, research is increasingly exploring the potential of non-stimulant treatments for CDS.
Social skills training is another area where differences emerge. While children with ADHD may benefit from such training, their needs and outcomes differ from those with CDS. Dr. Russell Barkley highlights that children with ADHD often require point-of-performance coaching—real-time accountability and immediate feedback to help them perform tasks effectively. This type of direct intervention helps them manage impulsivity and stay on track in the moment. However, even if they can practice and verbalize appropriate responses in a structured setting, such as co-therapy sessions with a speech and language pathologist or occupational therapist, they often struggle to apply those skills in real-life situations. They "talk the talk" but fail to "walk the walk" when emotions or impulses take over.
On the other hand, children with CDS respond differently. Their challenges often stem from issues with attention, alertness, and input processing, which means they benefit more substantially from social skills training. This training can help them build self-awareness—recognizing when they are not paying attention or when their anxiety is affecting their ability to engage. The goal is to develop strategies to address their alerting and input challenges, making it easier for them to focus and respond appropriately in social and academic contexts.
For children with CDS, interventions should focus on helping them recognize and process the input they receive. This involves teaching the skill of "taking in" information and using it to navigate social and situational demands. Unlike ADHD, where children know what to do but cannot follow through due to impulsivity or emotional dysregulation, CDS involves a foundational problem with how input is received and understood. The therapeutic approach must account for this distinction, emphasizing accommodations, tools, and techniques to support their ability to effectively process and act on incoming information.
Attitude Magazine
I’ve found Attitude Magazine to be a fantastic resource for attention and focus-related articles, and I especially appreciate how they incorporate practical ideas and even offer continuing education opportunities. One resource I’ve found particularly useful is their free download on inattentive ADHD, which provides a more in-depth look at what we might now call Cognitive Disengagement Syndrome (CDS). This overlap in terminology exists because CDS hasn’t yet been included in the DSM, so there’s still some ambiguity in how it’s classified.
This article, though published nine years ago, remains relevant and insightful. It predates the naming of CDS but discusses three distinct presentations of ADHD that align with much of what we observe today. These include:
- ADHD Impulsive-Hyperactive Type: Marked by impulsivity and hyperactive behaviors.
- Inattentive Type: Characterized by a lack of focus and the absence of hyperactivity, which closely aligns with what we now think of as CDS.
- Combined Type: A mix of inattention and impulsivity.
What I particularly appreciated about the article was its practical focus. Regardless of the terminology, it offered numerous strategies for engaging students, scaffolding their tasks, and helping them navigate their challenges in accessing their curriculum and broader life activities. These ideas are invaluable for educators and therapists alike as we work to create supportive environments that allow these students to thrive.
How is CDS Diagnosed?
Diagnosing Cognitive Disengagement Syndrome (CDS) involves careful observation of a child’s developmental age and behaviors, similar to the process for other diagnoses. There are key indicators that help differentiate CDS from other attention-related conditions.
You’ll often notice a student struggling with poor attention to detail, frequently losing items, or being ill-prepared to gather the needed materials. This consistent difficulty impacts their ability to complete activities independently. For example, an effective IEP objective might state: The student will be able to name and gather all items necessary to start an activity, initiate the task, and finish it, returning all items to their original location. This measurable goal allows us to assess their progress within a structured timeframe, like a 40-minute lesson. Without such support, aides or teachers often end up stepping in to gather and organize materials for the student.
Other diagnostic clues include a tendency not to respond when spoken to, frequent careless mistakes, and challenges with sustaining cognitive focus. Even when they enjoy a project, they may leave it unfinished, highlighting the procrastination and daydreaming qualities characteristic of CDS. These students are not just externally distracted—they are also often internally preoccupied, which makes them unaware of their surroundings.
Initiating tasks is another significant hurdle. They may avoid activities requiring sustained mental effort, even if the tasks are well within their ability level. This avoidance stems not from a lack of interest but from the overwhelming cognitive effort such tasks demand.
When we step back and observe these patterns—difficulty gathering materials, inattentiveness, avoidance, and procrastination—it becomes clear that CDS presents unique challenges that require targeted strategies and supports. Addressing these needs through tailored goals, accommodations, and consistent scaffolding is critical for helping these students succeed.
Interventions
Based on the descriptions, signs, and symptoms of Cognitive Disengagement Syndrome (CDS), several quick and practical interventions can be implemented immediately to support these students. Let’s focus on the school day, where routine and ritual are fundamental expectations. One of the first questions I ask when intervening is, “Who in this classroom still hasn’t mastered the routine?” By January, most students have settled into the rhythm of the day, but a child with CDS may still struggle to perform basic routines like unpacking their backpack, gathering necessary materials, or following morning rituals. This indicates a gap between their skills and developmental expectations.
Checklists and Visual Cues
Checklists can help address forgetfulness, but they must be concise and relevant. For example, a quick, clear checklist like “Clean desk, blue folder, haiku” might have helped Sarah. Beyond specific tasks, consider the broader routines expected of a fourth-grader: unpacking, organizing materials, ordering lunch, completing a morning task, and joining group activities. If these routines remain challenging, the student needs targeted support to succeed.
Promoting Independence with Informational Signs
Strategically placed signs around the classroom can guide students who struggle with working memory. Something as simple as a visual sequence for hanging up backpacks or a letter and number line on their desk can reinforce independence. Some children may still benefit from these accommodations by third or fourth grade. Removing these supports prematurely can lead to frustration and failure. Providing these tools isn’t a step backward—it’s a step toward helping them access the curriculum effectively.
Movement Breaks and Prime-the-Pump Activities
Movement breaks are essential for alerting and preparing these students to engage. For example, teachers can incorporate a short, purposeful activity directly connecting to the task ahead. Instead of relying on a generic video, an embodied approach works better. A teacher could approach the child directly and say, “Let’s punch this out together. First, clean off your desk. Second, get out the blue folder. Third, grab your haiku.” This personal interaction is far more engaging than an abstract prompt.
Music can also be a powerful tool to rev up or alert students. For instance, play upbeat music for a few moments, then turn it off and say, “Your desk should now be clear. You should have your blue folder and haiku ready.” This structured rhythm helps the student transition while maintaining focus.
Flexible Seating Options
Providing varied seating can help children with CDS sustain focus. Movement-friendly options, like wobble stools, yoga balls, standing desks, or even allowing students to sit “cowboy-style” with their chest against the back of the chair, can make a significant difference. These accommodations give them the input they need to stay engaged longer. For example, a standing desk could be the “deal breaker” that keeps them productive during a 45-minute task.
Oral and Hydration Supports
Access to gum, mints, or even a lifesaver candy can help alert these students, as the oral stimulation provides a subtle yet effective focus boost. A water bottle on their desk supports hydration and can serve as a simple, functional alerting strategy.
These interventions are small adjustments that collectively address the core challenges of CDS. They help students access their learning environment more effectively while building independence and engagement. The key is to continue incorporating these supports as students grow older, recognizing their long-term importance in helping them thrive.
Continued Listening Challenges
When addressing the listening challenges of individuals with Cognitive Disengagement Syndrome (CDS), we can use creative and purposeful strategies to help them stay engaged without becoming overwhelmed or distracted.
One potential tool is doodling but with boundaries. While freeform doodling, like drawing a castle or an elaborate scene, might distract them, providing structured coloring tasks, such as filling in a mandala, can offer a calming and focusing activity. For example, the teacher might say, "You can color your mandala for one minute, then put your pencil down to listen to directions." This approach gives their brain a brief break while ensuring they’re prepared to re-engage. Although it might initially feel cumbersome, such strategies can effectively balance their need for mental respite with the classroom’s demands.
Interrupting and redirecting blurting behaviors is another common challenge. Daydreaming often leads to impulsive sharing of unrelated thoughts, so establishing clear, consistent signals for these moments is essential. For younger children, this could be a simple visual cue like a finger to the lips or the sign for "waiting." For older students, a verbal prompt like, “Hold that thought, and I’ll come back to you after directions,” can gently redirect without discouraging participation. Consistent feedback at the point of performance ensures they remain connected to the task.
Auditory tools can also be powerful. A whisper phone, for instance, allows students to hear themselves as they verbalize steps like, "First, I clean my desk; second, I take out my blue folder." This self-talk reinforces focus and task sequencing. Whisper phones work particularly well because they amplify sound in their ears, encouraging them to regulate their voice volume while staying engaged.
Timed and tactile cues can further enhance self-regulation. Tools like time timers provide visual countdowns while vibrating watches can discreetly alert students at irregular intervals, prompting them to self-check. Teach them to ask reflective questions like, “Am I on task? Am I paying attention? Am I here?” If the answer is no, they know to redirect themselves back to the task.
Finally, simple sequencing strategies like using fingers to count out steps—“First this, second that, third that”—can be straightforward yet effective ways to help students stay organized and focused on multi-step tasks.
By layering these strategies—visual, auditory, tactile, and verbal—students with CDS can develop greater self-awareness and gradually build the skills to manage their challenges. The key is to tailor these supports to the individual’s needs, ensuring they’re both practical and sustainable within the classroom environment.
Project Completion
Scaffolding project completion is a critical area where we can support students with Cognitive Disengagement Syndrome (CDS) and similar challenges, especially in inclusive school settings. Functional, meaningful interventions help students build skills that transfer directly to classroom experiences.
Incorporating their tasks into therapy sessions can be incredibly effective for students who struggle with completing multi-step assignments. When students work on long-term projects—introduced as early as second grade and continuing throughout their academic career—we can help them break the process into manageable steps. Reviewing the teacher’s rubric and co-creating a game plan for completion empowers the student. This approach offers the perfect opportunity for accountability and regular check-ins during one-on-one or small-group sessions.
For example, if a student resists working on their project during therapy, saying, "Let’s do something else today," this procrastination can be gently addressed: "We can’t put this off; there’s a deadline, and it’s important to stay on track." This structured yet supportive framework helps students learn how to prioritize and manage their workload.
In addition to academic tasks, craft projects are a wonderful way to assess and scaffold skills like attention to detail, recalling directions, and problem-solving. Crafts serve as a “laboratory” to observe how well students manage multi-step processes. I vividly recall a particular activity highlighting these dynamics—a glyph project with first—and second-graders.
For those unfamiliar, a glyph is a rubric-based craft that adds personalized details based on specific criteria. In this case, it was an autumn-themed scarecrow. The steps included cutting out parts of the scarecrow, then coloring and assembling it based on personal attributes (e.g., coloring the hat red if you had brown hair or blue if you had blonde hair, adding striped or polka-dot pants based on favorite colors, etc.).
When I worked with a group of eight students—four of mine and four who were borderline for motor, attention, or visual-spatial skills—it was clear this activity could easily overwhelm them. To make it manageable, I broke it down into clear, sequential parts:
Cutting Out: I had them start by cutting out all the scarecrow parts, focusing only on this step while discarding the trash in a shared basket. This helped establish order and minimized distractions.
Introducing the Rubric: Once all the parts were ready, I distributed individual copies of the rubric and explained that we would focus on one step at a time. For each step, they would complete the task, raise their hand for me to check, and then move on to the next.
Working at Their Own Pace: This structure allowed each child to work at a pace that suited them. Some students gained momentum after completing the first task, while others benefited from consistent check-ins and encouragement.
Observing Problem-Solving: As they moved through steps like coloring the scarecrow’s hat or pants based on criteria like eye color or favorite color, I saw their engagement grow. They were making decisions, following directions, and staying organized.
Interestingly, my group finished the project ahead of the others, not because they were faster but because the task was broken into digestible parts. This method allowed each child to focus on what was before them, reducing overwhelm and improving their self-regulating ability. A structured activity like this would have been ideal for students like Sarah or Colby, especially with scaffolding from a therapist or teacher.
Breaking projects into smaller steps, offering regular feedback, and fostering independence through hands-on, guided tasks can make all the difference for students who struggle with attention, focus, and organization. It’s not just about completing the project—it’s about teaching them how to approach and manage complexity in a way that builds confidence and competence over time.
Tackling Disorganization
Tackling disorganization at any age requires us, as therapists, to first establish a baseline understanding of the student’s existing skill set and identify where they are lagging. The process they use and the product they create are equally important to assess.
How often have we watched students approach a task in a way we’d never expect to lead to success—yet they somehow complete it? When we dictate the process too rigidly, we unintentionally impose our thinking patterns on them, which might feel unnatural or counterproductive. Instead, asking open-ended, metacognitive questions that guide their thinking while honoring their individuality is more effective: “Where do you want to start? What’s your plan? How long do you think this will take?” These questions help us understand their thought process, validate their knowledge, and collaboratively tweak their approach when necessary.
This balance between guidance and autonomy is key. By doing this, we’re not just teaching them how to complete one task—we’re helping them build lifelong metacognitive skills for understanding how they think, plan, and organize.
It’s also important to recognize that a lack of follow-through is not laziness. Neurological challenges often prevent students from focusing or executing tasks at the same level as their peers, despite their chronological age. Our role isn’t to lower expectations but to supplement and scaffold in a way that enables success. For example, if a student struggles with breaking down a long-term project, we might collaborate to co-create a step-by-step plan that makes the task manageable.
This principle applies to older students as well. Middle schoolers, in particular, often struggle with transitioning to greater academic demands, and their organizational challenges can become more pronounced. Here’s where we must embrace modern tools that resonate with their world. Many of us still write in planners, a valid and personal organizational style, but it’s not always the most practical for today’s students. Instead, teaching students to use digital tools, like Google Calendar, can streamline their organizational process and foster independence.
For example, a student might use Google Calendar to input assignments, set reminders, and check off completed tasks. Some families even share calendars, creating a collaborative system for communicating homework, family activities, and upcoming responsibilities. This integration of technology meets students where they are and helps them develop habits that will serve them well into adulthood.
Ultimately, our goal is to focus on the student’s strengths while addressing their challenges in a way that feels intuitive and achievable for them. By respecting their unique approach to tasks and providing tools that fit their world, we create an environment where they can thrive, both academically and personally.
Self-Care
Another critical area of organization to address, beyond academics, is self-care and managing personal belongings. We’ve all experienced misplacing items, but for these students, it’s a frequent and often overwhelming occurrence. Whether it’s forgetting homework, tools for a task, items they need to bring to school, or things they need to retrieve for classwork, the pattern of forgetfulness can extend to almost every aspect of their daily lives.
This can also include essentials like lunch, lunch money, or even remembering to return something borrowed from a peer. These lapses, while unintentional, can create ripple effects socially. Forgetting to repay a favor or return a loaned item might lead to peer misunderstandings or resentment. Over time, the student may start to appear flighty, inattentive, or disconnected, which can make it harder for them to stay socially integrated. They may be perceived as inconsiderate or unreliable, even when their intentions are good. This social misalignment can lead to feelings of rejection or exclusion.
To help students navigate these challenges, strategies for managing their belongings and commitments should be integrated into their support plan. Simple, consistent systems like checklists, labeled bins or cubbies, and reminders (both visual and digital) can go a long way. For instance, teaching them to use a tool like a daily checklist for personal items—lunch, school supplies, or borrowed items—can build a habit of checking and organizing before leaving home or class.
Additionally, fostering accountability in a supportive way is key. For example, if they forget to return a borrowed item, instead of focusing on the mistake, guide them toward problem-solving: “What could you do to ensure this doesn’t happen again? Let’s set a reminder together.”
Building awareness of these organizational lapses and offering tools to address them not only helps with practical self-care but also reduces the social fallout. By scaffolding these skills, we can help students feel more capable, included, and aligned with their peers, ultimately supporting their sense of belonging and self-confidence.
Accommodations Extending Beyond School Day
Accommodations for students with organizational challenges can and should extend beyond the school day to reinforce their skills and help them succeed in all environments. Collaboration with parents, peers, and educational staff is essential in building a consistent support system.
One effective strategy is for parents to share a digital calendar with their child, as mentioned earlier. This allows them to track assignments, events, and deadlines, fostering accountability and communication. Additionally, a daily checklist can help the student manage what to pack at the end of the school day and what to bring back in the morning. This checklist could be used in conjunction with a peer coach or an educational assistant who reviews the steps out loud with the student. Real-time verbal cues like, “Don’t forget your green science folder—we’ll need it to pick an experiment tomorrow,” can anchor the task and increase the likelihood of follow-through.
Interestingly, involving a peer in this process can often be more effective than guidance from an adult. A peer’s input may feel more relatable and engaging, making the student more receptive. In contrast, repetitive instructions from adults—what some might call the "Charlie Brown teacher effect" (wah, wah, wah)—can lose their impact over time. Peer collaboration not only supports organizational skills but can also strengthen social connections.
Outside of organizational strategies, it is crucial to educate students and their parents about the importance of exercise, sleep, and nutrition. These foundational elements play a significant role in improving attention, focus, and overall cognitive function. Pairing this with mindfulness techniques can enhance self-awareness, helping students recognize when they’re losing focus or becoming disorganized. Practices like short breathing exercises or body scans can be easily taught and implemented.
Audiobooks can be a game-changer for academic support, particularly for assignments requiring active reading. By pairing listening with parental or caregiver support for comprehension, students are less likely to become overwhelmed or lost in the auditory input. Caregivers can pause to ask questions or discuss key points, ensuring the student stays engaged and understands the material.
These accommodations, tailored to meet the student’s needs across home and school environments, provide a cohesive structure. By building these supports into their daily routines, we create a framework that addresses immediate challenges and fosters independence and confidence over time.
Social Emotional Challenges
Social-emotional challenges can peg students with attention difficulties as "space cadets." While we all have moments of distraction, for these students, it’s not occasional; it’s a daily occurrence. Their lack of attention is often misinterpreted as disinterest, negatively affecting relationships with peers and educators. Over time, they may be perceived as unreliable, unable, and unfocused, further isolating them socially and emotionally.
This misunderstanding creates significant barriers. Their consistent zoning out or inability to follow through on tasks leads others to assume they are uninterested or incapable rather than recognizing it as a neurological issue. The resulting social rejection or exclusion reinforces feelings of inadequacy, damaging their self-esteem and making it harder for them to engage meaningfully.
To address this, we must focus on education, empathy, and practical strategies to shift perceptions and effectively support these students. By reframing how their behaviors are interpreted, providing targeted social-emotional support, and fostering peer understanding, we can help prevent the long-term consequences of these harmful labels.
Let's Set the Scene: Case Studies
When setting the scene—whether on the playground, in the cafeteria, at an assembly, or even during a timed academic activity like a mad minute—it’s important to recognize that students with attention challenges often experience reduced cognitive processing speed. This trait impacts their academic performance and their ability to respond effectively in social situations.
In a mad minute, for example, the expectation for rapid output can overwhelm them, leaving them unable to keep up with their peers. Similarly, in social contexts, they may struggle to process and respond to conversations or interactions quickly enough to stay engaged. This delay can create a cascade of challenges: they may feel left out, frustrated, or unincluded. Over time, this exclusion can lead to one of two common responses—they may withdraw further into themselves or act out aggressively to express their frustration.
Understanding these dynamics allows us to tailor supports to meet their needs. Breaking tasks into smaller, manageable steps, creating opportunities for unpressured social interactions, and fostering a classroom or playground culture that values inclusion and patience are essential. Interventions like providing extra time, offering structured peer interactions, or using tools like visual or verbal prompts can help bridge the gap between their processing speed and the demands of their environment. Creating a supportive framework can help these students feel more included, capable, and confident in both academic and social settings.
Social: Play, Engagement, Social Connections
When considering these students' social challenges, it is important to recognize their play and peer interaction difficulties. For example, a child invited to play a game like Chutes and Ladders or Don’t Break the Ice might struggle to respond, often due to word retrieval challenges or difficulty processing the social moment. This hesitation can cause the peer to move on quickly, saying something like, “Oh, I’ll find someone else to play with then. See ya.” Similarly, for older students, a simple question like, “Do you want to go to the game tonight?” might leave them unable to produce a timely response, again missing a chance to connect.
Their difficulty with nonverbal communication cues further complicates these lively, fast-paced exchanges. One-on-one interactions can be challenging, but situations involving small groups or larger settings, such as cooperative work or after-school activities, often become overwhelming. This can inhibit participation, making these interactions feel invasive or unmanageable. As a result, their communication difficulties may significantly impact their ability to collaborate and engage socially, leading to feelings of exclusion and frustration.
To better understand and address these challenges, tools such as a 24-hour schedule, a typical day log, and an executive function checklist can be helpful. I use these tools diagnostically, working collaboratively with the student rather than simply asking them to complete forms independently. For example, when using a typical day log, I might ask questions like, “When is it hardest to pay attention?” or “Is there a specific subject or time of day when focusing is more difficult?” This approach allows me to identify patterns in attention and energy levels and provides valuable context for targeted interventions.
The 24-hour schedule offers a broader perspective, revealing the student’s routines and where support may be needed. Through questions like, “What happens when you wake up?” or “Do you need help getting your backpack ready?” I can identify areas of difficulty in their daily routines, such as morning disorganization or after-school challenges. This information helps me understand how their struggles may extend beyond the classroom.
The executive function checklist is particularly valuable for older students or teachers. For younger students, I may collaborate with the teacher to identify key areas where the child is lagging. With older students, I often involve them directly, asking them to identify their own challenges and then comparing these with my observations. This shared process fosters self-awareness and opens a dialogue about their strengths and areas for improvement.
These tools, used in a diagnostic and collaborative way, provide essential insights into the students' experiences. They guide practical interventions rooted in the students' real-life context, helping to address their social and organizational challenges while building their confidence and independence. By tailoring supports to meet their unique needs, we can foster more meaningful connections and empower them to thrive socially and academically.
Mindfulness
Mindfulness is essential, especially for students who lack self-awareness and alertness. It provides a pathway to help them reconnect with their bodies and the present moment. Here’s an example of how we can introduce mindfulness simply and engagingly.
Let’s start with a quick exercise. Shake one arm—just one. Shake it as much as you can: shake, shake, shake. Keep going. Now, stop and place your arm on your lap. Close your eyes or avert them, and focus on the sensations in that arm. You might feel warmth, coolness, tingling, or something else entirely. It could be in your fingertips, your elbow, or your forearm. There’s no right or wrong—just your body saying, “I’m here, I’m awake, I’m alert.”
Now, repeat this with the other arm. Shake it, shake it, shake it. Then rest it and close your eyes. Does this arm feel the same or different? Again, there’s no right or wrong. The goal is to notice simply. Finally, bring your attention to both arms. How do they feel now? This simple exercise can be a grounding moment, naturally bringing awareness to the body and signaling readiness to focus. For a child, even these small, intentional movements—like a stretch, shoulder roll, or wiggle—can help prepare them to pay attention.
Building on this, we introduce the concept of mindful presence through an “anchor.” Anchors are ways of staying in the moment, which can vary based on preference. They might focus on background sounds, their breath, or the tactile sensation of a hand resting on their thigh, chest, or belly. I particularly like the position of one hand on the heart and the other on the belly. As their mind starts to wander, they can return to the anchor, repeating a simple phrase like, “I am breathing,” or focusing on the feeling of their hand against their body.
Another technique is Daniel Siegel’s Yes Brain exercise, which encourages positivity and openness. Ask students to avert their eyes or close them, and simply listen as you repeat the word “yes” in different tones and rhythms. For example:
“Yes. Mmhmm. Yep. Yes. Yes. Yes. Uh-huh. Yes, indeed.”
They might notice sensations as they listen—lightness in their chest, a smile forming, or tingling. This simple repetition of positive affirmations helps them experience the flow of being present and engaged.
While these are brief demonstrations, extending the exercises to 30 or 60 seconds can help students build their mindfulness skills. These practices create a foundation for alertness, focus, and presence, helping them in the classroom and navigate the flow of their day-to-day lives. Mindfulness isn’t just a tool for focus—it’s a way of being in the moment, fostering calm and self-regulation in meaningful ways.
Management Approaches
Research highlights a variety of management approaches for Cognitive Disengagement Syndrome (CDS), emphasizing that it’s not just what happens in the school setting but a holistic consideration of the child’s overall environment and routines. Strategies include cognitive-behavioral therapy (CBT), mindfulness practices for building self-awareness, assessments of 24/7 routines, including sleep patterns, leisure activities, and exercise, and careful medication management by a psychiatrist to ensure proper titration. Central to all of this is creating and maintaining structured routines.
Dr. Russell Barkley uses the metaphor of an imaginary gas tank in our brains. Routines and rituals help preserve that gas, making daily activities automatic and reducing the mental energy required. For example, brushing your teeth, pouring coffee, and grabbing your bag in the morning might feel robotic, but that’s the benefit of routine—it doesn’t drain cognitive resources. For students with CDS, however, the absence of routine means they’re constantly depleting their mental energy. They might appear dazed or disconnected, struggling to remember basic tasks like catching the bus. By embedding routines and rituals into their lives, we free up their mental capacity to focus on the tasks and alertness required during the school day.
The support system at home and school is equally critical. One effective strategy involves scaffolding routines with the help of educational assistants. For example, in a fourth-grade classroom, an educational assistant might meet a group of designated students at a set time—like 2:30 PM—to go over what they need to pack and prepare before leaving for the day. For students with one-on-one aides, this process can occur more privately, such as in the hallway, to avoid embarrassment. This end-of-day check-in could include a quick review of their day, helping them process what went well and what they need to bring home.
Similarly, a supportive routine can start in the morning. Some schools designate a specific place for students to meet with an educational assistant upon arrival, while others have aides greet students directly in their classrooms. This structured start ensures that routines and rituals are completed, giving the student a fresh, organized beginning to the day.
Additional accommodations can also make a significant difference. Allowing students the flexibility to pace themselves, providing quiet environments with tools like noise-canceling headphones or earplugs, and offering point-of-performance coaching or interventions help create a more supportive atmosphere. Combined with the embedding of routines, these strategies build a framework that supports focus, alertness, and overall functioning, enabling students with CDS to thrive both in and outside the classroom.
Myriad Avenues of Cognitive Engagement
In the 21st century, as we better understand the myriad avenues of cognitive engagement, research increasingly supports the idea of a spectrum of attention. This concept helps us recognize that Cognitive Disengagement Syndrome (CDS) is not simply the opposite of ADHD. Instead, it represents a distinct point along this spectrum. For many individuals, moments of under-engagement—feeling spaced out or disconnected—are as common as overstimulation, where focus becomes difficult due to overwhelming input.
This spectrum perspective broadens our understanding of how attention and engagement fluctuate, not only for students but also for the staff and educators working with them. Whether in the classroom or clinic, it’s common to observe these variations throughout the day. Recognizing this natural ebb and flow underscores the importance of tailoring interventions to meet individuals where they are at any given moment.
Personally, I find the concept of a spectrum of attention particularly compelling. It reflects the complexity of human focus and engagement and offers a framework for understanding the diverse experiences of those we support. It reminds us to approach challenges with empathy and flexibility, appreciating the nuances that influence each person’s ability to engage.
Self-regulation and Levels of Alertness
In working with students, we often focus on fostering self-regulation and improving alertness. However, for some students, like those with Cognitive Disengagement Syndrome, the challenge is much deeper. Their alertness resembles Swiss cheese—full of gaps. It’s not an occasional struggle on an off day; it’s an everyday reality.
These students drift in and out of focus, frequently daydreaming, forgetting, and missing essential details. What’s particularly striking is their lack of awareness of their own mishaps. They don’t register their mistakes or oversights unless an adult or a peer explicitly points them out. This chronic disconnection makes it even more important to implement consistent and structured strategies to help them stay engaged and build awareness over time. By addressing these gaps with patience and understanding, we can guide them toward greater self-awareness and help them bridge the holes in their alertness.
Engagement Spectrum
The concept of an engagement spectrum makes a lot of sense, particularly when we think about supporting students with varying levels of attention and focus. Observing students' behavior at different times throughout the day is a valuable way to gather data on their attention patterns. By reviewing this information with the student, using tools like the schedules discussed earlier, you can identify the times and activities where they are most engaged or where their attention tends to wane.
Incorporating alerting accommodations can further support their ability to stay engaged. These might include providing movement breaks, integrating tactile or sensory tools, or using visual and auditory cues to refocus their attention. Collaborating with the student to explore what works best for them enhances their self-awareness and empowers them to take a more active role in managing their engagement. Through these strategies, we can support their unique needs along the attention spectrum, helping them build the skills necessary to navigate their daily routines successfully.
Summary
I hope you’re leaving with a fresh perspective on this diagnosis as we wrap up this seminar. The research surrounding it continues to grow and deepen, becoming more robust each year. Perhaps as we’ve explored this topic, certain students you’ve worked with have come to mind—those whose challenges now seem to align with what we’ve discussed.
As therapists, we have the unique privilege of observing students across various domains. Our perspective allows us to contribute specific, valuable insights to the team that might otherwise go unnoticed. This holistic view is vital to supporting these students and helping them thrive.
I applaud your work out there—your commitment to making a difference for these students does not go unnoticed. Thank you for joining me today, and I hope you leave feeling inspired and equipped to continue your incredible work.
Exam Review
1) What is a primary distinction between ADHD and Cognitive Disengagement Syndrome (CDS)?
2)In the classroom scenario presented in the workshop, what was Colby’s primary challenge?
3)What environmental factor may contribute to the development of Cognitive Disengagement Syndrome?
4)Why might social skills training be more effective for individuals with CDS compared to those with ADHD?
5)Which intervention is NOT typically recommended for managing Cognitive Disengagement Syndrome?
Questions and Answers
Is there any information on traumatic birth injury (TBI) about this syndrome, and what about the cortisol connection?
While no specific studies have directly linked TBI to CDS, it wouldn’t be surprising if such connections were found. Research on cortisol and its effects on neurodevelopment in TBI might provide insights into potential overlaps with CDS. However, further exploration is necessary.
Is the reference to Attitude Magazine correct?
Yes, Attitude Magazine or its online counterpart is what’s being referred to. It’s a helpful resource for understanding ADHD and related conditions like CDS.
Can CDS affect teens and young adults?
Absolutely. Many teens and young adults with CDS were scaffolded well by their families during childhood. Symptoms can become more apparent as they transition to more independent settings, such as middle school.
What are some recommendations for a successful morning routine for children before school?
Establishing an efficient routine for children can significantly reduce morning stress and improve their readiness for school. Start by using visual checklists to outline daily tasks, providing a clear and tangible guide for what needs to be accomplished. Preparing backpacks the night before and placing them near the door ensures a smooth transition out the door in the morning. Designate dedicated spaces for homework and school preparation, minimizing distractions by incorporating tools like headphones. As a parent, simplifying routines and finding ways to work smarter, not harder, can create a more organized and supportive environment for your child’s success.
What evaluation tools do you use for referrals for suspected CDS?
The evaluation process for a child with suspected Cognitive Disengagement Syndrome (CDS) begins with thorough classroom observations and detailed interviews with teachers to understand the child's challenges in their learning environment. Reviewing existing psychological and academic testing provides additional insight into their cognitive and behavioral profile. Collaboration with key professionals, including the school psychologist, speech-language pathologist, and guidance counselor, helps create a comprehensive picture of the child's needs. It is also crucial to assess for sensory and avoidance issues that might mimic or amplify the symptoms of CDS, ensuring a well-rounded and accurate approach to diagnosis and intervention planning.
Are children with CDS medicated the same way as ADHD children?
Typically, ADHD medications are tried first, but they may not always work. Non-stimulant options are increasingly explored. Due to their specialized knowledge, a psychiatrist, rather than a pediatrician, should guide medication decisions.
How can timers and watches help children self-monitor?
To support a child's time management and engagement, tools like the Time Timer can effectively provide visual cues for time awareness, helping them stay on track with tasks. Gentle prompts, such as whispering, "How many minutes for this task?" can further encourage their active participation and foster a sense of responsibility. Vibrating watches offer another valuable tool for periodic reminders, but their use should be tailored to the child's individual needs and the specific demands of the task, ensuring that interventions are both supportive and unobtrusive.
How do you approach a child with a comorbid diagnosis (e.g., hyperactivity and daydreaming)?
When supporting a child with a comorbid diagnosis, the focus should be on fostering effective regulation strategies tailored to their unique needs. Incorporating mindfulness practices and sensory interventions can help create a foundation for better self-regulation and engagement. Collaborating directly with the child is essential to identify tools and techniques that resonate with them, such as movement breaks, grounding exercises, or other personalized approaches. This collaborative process allows for developing individualized plans to help the child maintain focus and remain “long and strong” during their work sessions, promoting both their productivity and overall well-being.
Is CDS the same as ADD?
Yes, CDS is being seen as an evolution of what was previously referred to as ADD (Attention Deficit Disorder) without hyperactivity. ADD is expected to phase out, with CDS potentially becoming a recognized diagnosis.
Feel free to email me with further questions and let me know where you heard me speak!
References
Please refer to the additional handout.
Citation
Bowen-Irish, T. (2025). Cognitive disengagement syndrome: The opposite Of ADHD? OccupationalTherapy.com, Article 5776 Available at www.occupationaltherapy.com
