Psychiatric disorders are very complicated due to their genetic, biological, and psychological nature, and cause problems in the behaviour, feelings, and cognition of the patient in a particular culture [1]. Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most common childhood psychiatric disorders characterized by persistent symptoms of inattention, impulsivity, and hyperactivity [2]. According to the fifth edition of the American Psychiatric Association Diagnostic and Statistical Manual (DSM-5), that there should be at least 6 symptoms of ADHD for at least 6 months and be inappropriate for the developmental level [3]. The dimensional approach used in the DSM to classify ADHD subgroups has been questioned. Studies have shown that these subgroups are not homogeneous [5, 6], and the diagnostic signs of this disorder are developmental that change over time. For example, the AD subgroup may include children who previously met the criteria for hyperactivity/impulsivity but now have no symptoms of hyperactivity/impulsivity [7]. For this reason, the studies comparing neuropsychological functions in different ADHD subgroups often have conflicting results in identifying significant differences between these subgroups [8, 9].
Recent studies has shown that a group of children with AD have symptoms of Sluggish Cognitive Tempo (SCT) which is often characterized by excessive daydreaming, mental fogginess and confusion, slow thinking, lethargy, apathy, and daytime sleepiness [10]. In the last decade, researchers have shown great interest in the construct of SCT [11]. The debate over whether SCT is a component of ADHD or an independent disorder continues among researchers. However, recent studies have supported the hypothesis that the SCT construct has a strong internal and external validity [12]. Although some studies have been conducted on ADHD and SCT, more studies are needed to differentiate between the two disorders. It seems that genetics, personality traits and executive functions are three important factors in distinguishing these two disorders. ADHD is associated with personality (e.g. behavioral activation system or reward sensitivity) and executive functions, whereas the relationship of SCT with executive functions is contradictory and its relationship with personality traits is tangible [13-17]. Therefore, due to the limited studies and contradictory results, this study aimed to compare the sensitivity to reward and punishment, response inhibition and sustained attention between school boys with ADHD and SCT.

This is a casual-comparative study. Participants were 100 elementary school male students (50 with ADHD and 50 with SCT) in Tabriz in the academic year 2019-20, who were selected through a screening method based on the
Swanson, Nolan, and Pelham-IV (SNAP-IV) Questionnaire and the SCT scale. Inclusion criteria were age 7-12 years, no learning disabilities, no mental retardation, no visual/auditory/motor impairments, and no diseases such as diabetes, epilepsy or heart disease which disrupted the study process. After selecting the subjects, the Balloon Analogue Risk Task was used to measure the sensitivity to reward and punishment, while the continuous performance test was used to measure response inhibition and sustained attention. For data analysis, Multivariate Analysis of Variance (MANOVA) and one-way ANOVA were performed in SPSS v. 20 software.

The mean age of boys was 9.8 years in the ADHD group and 10.1 years in the SCT group. Descriptive statistics of the study variables for the two groups are presented in Table 1.



The results of MANOVA showed that the sensitivity to reward and punishment, response inhibition and sustained attention were significantly different between the two groups (Wilks’ Lambda= 0.50, P <0.001), indicating that at least one of the dependent variables had a significant change in the two groups. One-way ANOVA was used to find which of the dependent variables were significantly different in the two groups, whose results are presented in Table 2. The results indicated that the boys with ADHD had higher scores in sensitivity to reward while the boys with SCT had higher scores in sensitivity to punishment. Moreover, those with ADHD had deficits in response inhibition while those with SCT had deficits in sustained attention.

The results of the present study showed that the sensitivity to reward was associated with ADHD and externalizing problems, while the sensitivity to punishment was associated with SCT and internalizing problems. To explain this finding, it can be said that impulsivity and reward seeking (reward sensitivity) are the most important predictors of ADHD. Fear, shyness, and anxiety are the most important symptoms of internalizing disorders [62]. People who are highly sensitive to reward neglect the environment and ignore environmental stimuli. Therefore, the task should not be a uniform task so that they can be able to concentrate on the tasks longer, otherwise they are easily distracted by irrelevant environmental stimuli, including those associated with pleasure. SCT is associated with symptoms of internalizing problems and is phenotypically similar to depression and anxiety [47]. Children who are highly sensitive to punishment are sensitive to conditional punishment and elimination of rewards; their main goal is to stop behaviours that are expected to lead to unpleasant consequences. In explaining the differences observed in response inhibition and sustained attention between the two groups, it can be said that, according to Barkley’s [10], ADHD is a developmental disorder that begins with hyperactivity, followed by attentional problems. Studies have shown that children with SCT have more problems with emotional self-regulation, arousal, vigilance, and mind wandering than children with ADHD [14-21], and these factors are negatively correlated with sustained attention. So, it seems reasonable that SCT children have problems with sustained attention.

Ethical considerations like gaining the informed consent of the participants and the confidentiality of responses were considered in this research. This study was approved by the Department of Psychology of the University of Tabriz and in coordination with the Education & Training Administration of East Azerbaijan with the letter number 1803/61781/132.

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Conceptualization, methodology, research and drafting: All authors; Resources, Editing and Finalization By: Elnaz Mohammadi; Data adjustment and analysis: Mohammad Shadbafi.

The authors declare no conflict of interest.

The authors would like to thank the head of the Department of Psychology at Tabriz University and the head of Education organization in Tabriz city, and all participants for their cooperation.
 

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