A robust brain network for sustained attention from adolescence to adulthood that predicts later substance use

Reviewer #1 (Public Review):

This study explored the relationship between sustained attention and substance use from ages 14 to 23 in a large longitudinal dataset. They found behaviour and brain connectivity associated with poorer sustained attention at age 14 predicted subsequent increase in cannabis and cigarette smoking from ages 14-23. They concluded that the brain network of sustained attention is a robust biomarker for vulnerability to substance use. The big strength of the study is a substantial sample size and validation of the generalization to an external dataset. In addition, various methods/models were used to prove the relationship between sustained attention and substance use over time.

Reviewer #2 (Public Review):

Weng and colleagues investigated the relationship between sustained attention and substance use in a large cohort across three longitudinal visits (ages 14, 19, and 23). They employed a stop signal task to assess sustained attention and utilized the Timeline Followback self-report questionnaire to measure substance use. They assessed the linear relationship between sustained attention-associated functional connections and substance use at an earlier visit (age 14 or 19). Subsequently, they utilized this relationship along with the functional connection profile at a later age (age 19 or 23) to predict substance use at those respective ages. The authors found that connections in association with reduced sustained attention predicted subsequent increases in substance use, a conclusion validated in an external dataset. Altogether, the authors suggest that sustained attention could serve as a robust biomarker for predicting future substance use.

This study by Weng and colleagues focused on an important topic of substance use prediction in adolescence/early adulthood. While the study largely achieves its aims, several points merit further clarification:

(1) Regarding connectome-based predictive modeling, an assumption is that connections associated with sustained attention remain consistent across age groups. However, this assumption might be challenged by observed differences in the sustained attention network profile (i.e., connections and related connection strength) across age groups (Figures 2 G-I, Fig. 3 G_I). It's unclear how such differences might impact the prediction results.

(2) Another assumption of the connectome-based predictive modeling is that the relationship between sustained attention network and substance use is linear, and remains linear over development. Such linear evidence from either the literature or their data would be of help.

(3) Heterogeneity in results suggests individual variability that is not fully captured by group-level analyses. For instance, Figure 1A shows decreasing ICV (better-sustained attention) with age on the group level, while there are both increasing and decreasing patterns on the individual level via visual inspection. Figure 7 demonstrates another example in which the group with a high level of sustained attention has a lower risk of substance use at a later age compared to that in the group with a low level of sustained attention. However, there are individuals in the high sustained attention group who have substance use scores as high as those in the low sustained attention group. This is important to take into consideration and could be a potential future direction for research.

The above-mentioned points might partly explain the significant but low correlations between the observed and predicted ICV as shown in Figure 4. Addressing these limitations would help enhance the study's conclusions and guide future research efforts.

Reviewer #3 (Public Review):

Summary:

Weng and colleagues investigated the association between attention-related connectivity and substance use. They conducted a study with a sizable sample of over 1,000 participants, collecting longitudinal data at ages 14, 19, and 23. Their findings indicate that behaviors and brain connectivity linked to sustained attention at age 14 forecasted subsequent increases in cigarette and cannabis use from ages 14 to 23. However, early substance use did not predict future attention levels or attention-related connectivity strength.

Strengths:

The study's primary strength lies in its large sample size and longitudinal design spanning three time-points. A robust predictive analysis was employed, demonstrating that diminished sustained attention behavior and connectivity strength predict substance use, while early substance use does not forecast future attention-related behavior or connectivity strength.

Weaknesses:

It's questionable whether the prediction approach (i.e., CPM), even when combined with longitudinal data, can establish causality. I recommend removing the term 'consequence' in the abstract and replacing it with 'predict'. Additionally, the paper could benefit from enhanced rigor through additional analyses, such as testing various thresholds and conducting lagged effect analyses with covariate regression.