Cognitive Dysfunction among U.S. High School Students and Its Association with Time Spent on Digital Devices: A Population-Based Study

Round 1

Reviewer 1 Report

I am reviewing “Cognitive Dysfunction Among US High School Students and Its Association with Time Spent on Digital Devices: A Population-Based Study” for Adolescents.  The paper seemed solid and accomplishes its goals.  I make grammar suggestions throughout the paper. 

Line 36 should say “participants with CD reported substance abuse, such as”.  Line 37 should say 9.0%) and they reported a higher prevalence”.  Line 38 should replace “&” with “and”.  Line 39 should say “reported a high prevalence of CD, whereas participants with adequate sleep reported low prevalence”.  Line 40 should say “In a regression”.  Line 41 should say” demonstrated higher odds of CD”.  Line 4 should say “high odds of cognitive”.

Line 50 should say “diagnosed illnesses in children.  In children aged”.   Line 51 should say “9.4% of them reported ADHD”.  Line 52 should say “3.2% of them experienced depression”.  Line 55 should say “Research has shown that ADHD is a prevalent”.   On line 57, what is MDD?  Spell out and put MDD in parentheses the first time it is mentioned.  Line 59 should say “media; 18% of them reported more than 10 hours of usage.  Of the total daily”.  Line 66 should say “Individuals with severe ADHD symptoms may be at great risk”.  Line 69 should say “lifestyle and high depression rates”.  Line 69 should say “shown that frequent daily cellphone and tablet use causes sleep”.  Line 90 should say “The YRBSS”.  Line 91 should say “The YRBSS”.  Line 93 should say “every 2 years”.  Line 94 should say “study was the”.  Line 98 should say “9 to 12”.  Line 99 should say “Variables, such as”.

Line 104 should say “study was to evaluate”.  Line 106 should say “study was to”.  Line 116 should say “helped us gather”.  Line 125 should say “can include a range”.  Line 130 should say “separate individuals who met the 8 hours of sleep criterion vs individuals who did not.”  Move lines 141-142 up to the previous paragraph.  Line 141 says “they”, but they who?  Line 141 says “Responses”, but why capitalize?   Line 146 should say “day for 2 weeks”.  The sentence on line 147 should be put with the previous paragraph. 

Line 153 should say “analyses were performed”.   Line 160 should say “2-tailed t-tests.”  Line 160 should also say “The alpha level was set at .05, which means that p-values had to be equal to or less than .05 to indicate significance.”  Line 165 should say “Of the total”.   Line 166 should say “of them reported cognitive dysfunction.”  Line 171 should say “individuals who had ever tried illicit”.  Line 172 should say “reported high frequencies”.  Line 173 should say “high frequencies”.  Lines 179 should say “reported high prevalence”.  Line 181 should say “individuals with”.  Line 182 should say “high frequencies”.  Line 186 should say “The multivariate….that the odds”.  Line 187 should say “was high in participants”.  Line 189 should say “were at high”. 

Line 195 should say “reported high frequencies”.  Line 201 should say “for four or more hours”.  Line 203 should say “being female, reporting concurrent”.  Line 204 should say “sad and hopeless were associated with high”.  Line 212 should say “4 of more hours”.  Line 214 should say “found that, along with pathological”.  Line 216 should say “sad and hopeless were associated with high”.  Line 219 should say “The argument”.  Line 221 should say “suicidality, but they reported”.  Line 223 should say “These results suggest”. 

Line 229 should say “ADHD  experience”.  Line 233 should say “behaviors, such as”.  Line 236 should say “high prevalence…high odds”.  Line 238 should say “shows a similar pattern”.  Line 239 should say “reported a high”.  Line 240 should say “hopeless and suicidal”.  Line 240-241 should say “Although gender-specific differences …functions were found, it is”.  Line 24 should say “4 hours”.  Line 251 should be connected to the previous paragraph.  Line 252 should say “activities were associated”.  Line 261 should say “First, the”.  Line 262 should say “tablets, but”.  Line 263 should say “Second, YRBSS”.  Line 265 should say “effects of each activity.  Third, it was”.  Line 267 should say “Finally,”.  The authors should add a summary paragraph at the end of the paper that concludes with a conclusion sentence.

Author Response

We have made all the grammatical changes that were suggested in the review. Thank you for your valuable time and effort reviewing our manuscript!

Reviewer 2 Report

I see some merit in the actual contents of the paper. However, before to consider its publication, I would like to suggest some improvements to the authors.

1. There are some acronyms that need to be explained the first time they appear in the text

2. This section should be improved. The justification for the motivation of this study is relatively weak and not clearly explained. While the authors establish some links to some extant literature, authors need to establish a more coherent framework for the overall paper. That means, the introduction should clearly indicate the need for this paper in relation to extant research studies. There needs to be a clear link to the vast majority of studies investigating the field. There is no background in this introduction stating the urge and novelty of the study in which innovative ideas must be flown through the background along with the useful insights.

In addition, there should be clearly defined research questions.

Finally, there should be an overview of the rest of the research at the last paragraph of the introduction.

3. A literature review section is necessary. The literature review needs to be integrated with the claims that the author make in order to show the importance of its contribution.

4. Although there is some discussion now, I found it weak as there isn’t relation between the findings and the authors’ literature review. Authors need to show that results are relevant (as compared with the work of other authors that have been published before). Similarly, the paper would benefit from a discussion about observed findings which contradicted what was expected.

Overall, try to provide sufficient validation regarding the novelty of this research along with beneficial.

Finally, I would like that authors show better the consequences for academics and practitioners of the results.

5. Conclusion. Authors should write a true conclusion section. Begin with a brief summary of paper motivations, objectives and findings. Finally, include limitations and future research

Author Response

1. There are some acronyms that need to be explained the first time they appear in the text
Our response - We have made changes to our manuscript, explaining acronyms when they appear for the first time.

2. This section should be improved. The justification for the motivation of this study is relatively weak and not clearly explained. While the authors establish some links to some extant literature, authors need to establish a more coherent framework for the overall paper. That means, the introduction should clearly indicate the need for this paper in relation to extant research studies. There needs to be a clear link to the vast majority of studies investigating the field. There is no background in this introduction stating the urge and novelty of the study in which innovative ideas must be flown through the background along with the useful insights. In addition, there should be clearly defined research questions. Finally, there should be an overview of the rest of the research at the last paragraph of the introduction.
Our response - We have reorganized sections in the introduction to provide a clearer understanding of the background, motivation, and highlighted findings from previous research.

3. A literature review section is necessary. The literature review needs to be integrated with the claims that the author make in order to show the importance of its contribution.
Our response - We have once again performed a literature review and we have incorporated it into the discussion section in order to show the importance of our findings.

4. Although there is some discussion now, I found it weak as there isn’t relation between the findings and the authors’ literature review. Authors need to show that results are relevant (as compared with the work of other authors that have been published before). Similarly, the paper would benefit from a discussion about observed findings which contradicted what was expected. Overall, try to provide sufficient validation regarding the novelty of this research along with
beneficial. Finally, I would like that authors show better the consequences for academics and practitioners of the results.
Our response - We have made some changes in the discussion section to better reflect the association between our findings and findings of previously published research papers, further explaining the similarities as well as contradictory findings. We have added additional references.

5. Conclusion. Authors should write a true conclusion section. Begin with a brief summary of paper motivations, objectives and findings. Finally, include limitations and future research
Our response - We have added a conclusion section as requested.

Reviewer 3 Report

Major comments:

Based on the first two paragraphs it is unclear what is the focus of the manuscript. May I please strongly suggest to the authors that they reorganized the information in these two paragraphs and add necessary information to these two paragraphs to make it clear that the focus is on cognitive dysfunction as per the title of the manuscript? Thank you. 

Section 3.2 Cognitive dysfunction. On page 3, lines 121 - 123, the authors state that they believe the question Q93 "encompasses a broad spectrum of dysfunction". I am most concerned about this as the authors have made this judgement without any sort of confirmation from the data source regarding the connection between cognitive dysfunction and mental difficulties. This I believe is a major methodological and conceptual flaw.

Section 4.1 Demographic characteristics. Based on my statement above I do not believe that the students who participated in the YRBSS have reported cognitive dysfunction as asserted by the authors. Rather, they have given an indication of physical, mental and emotional problems that cause them to have difficulty concentrating, remembering or making decisions. I think this is a huge assumption on the part of the authors and it is a very misleading assumption. 

Page 8 lines 206-208. On what basis do the authors make the assertion that four or more hours of daily internet usage falls under pathological usage? What is the scale used to measure this as a pathology? Have the authors any past academic literature to support this assertion? 

In fact the entire paragraph on Page 3 lines 206-225 is making connections with past research on cognitive dysfunction based on the authors' assertions alone in lines 206-208 that the average use of the students of the internet constitutes a pathology. This is most misleading and severely lacking in scientific rigor. 

On Page 9 line 229 the authors again make mention of ADHD. Is the focus of the manuscript ADHD of cognitive dysfunction?

There is no Conclusion section in this study at all. How is this possible in a manuscript submitted for peer-review?

 

Minor comments include:

Page 2 line 50: Please change to "most commonly diagnosed in children". Thank you.

Page 2 line 57: Please give the full meaning of MDD. 

Page 2 line 62: Please change to "excessive video game playing". Thank you.

page 3 line 116: Please do not use the word "conclusively". It may be misconstrued and be misleading.

I wish the authors the best in their academic endeavors. At present, I feel that the manuscript needs to be clearly conceptualized, and needs to be reworked from the very beginning. Perhaps the authors may think about narrowing down their focus, i.e. one type of digital device, they may be able to have a paper that is more sharp. At present, the paper comes across as trying to "cram" the evidence to suit a pre-determined outcome and I believe that the authors can do better than this. Thank you. 

Author Response

Based on the first two paragraphs it is unclear what is the focus of the manuscript. May I please strongly suggest to the authors that they reorganized the information in these two paragraphs and add necessary information to these two paragraphs to make it clear that the focus is on cognitive dysfunction as per the title of the manuscript? Thank you.

Our response - We have reorganized these paragraphs to make it clear that the primary focus of this manuscript is cognitive dysfunction.

 

Section 3.2 Cognitive dysfunction. On page 3, lines 121 - 123, the authors state that they believe the question Q93 "encompasses a broad spectrum of dysfunction". I am most concerned about this as the authors have made this judgement without any sort of confirmation from the data source regarding the
connection between cognitive dysfunction and mental difficulties. This I believe is a major methodological and conceptual flaw.

Our response - we have modified our language to better reflect the purpose of the question asked in YRBSS in accordance with the documentation found in CDC’s YRBSS data and analysis guidelines.

 

Section 4.1 Demographic characteristics. Based on my statement above I do not believe that the students who participated in the YRBSS have reported cognitive dysfunction as asserted by the authors. Rather, they have given an indication of physical, mental, and emotional problems that cause them to have difficulty concentrating, remembering, or making decisions. I think this is a huge assumption on the part of the authors and it is a very misleading assumption.

Our response - By including physical, mental, and emotional problems (as in physical and mental health) YRBSS aims to assess for cognitive dysfunction as a manifestation of those conditions. Since these questions are asked to children, YRBSS has adopted to language that is easier to understand for these children. As such, cognitive dysfunction is almost always a manifestation of primary illness (secondary to depression, dementia, substance abuse, etc). Additionally, since YRBSS is administered to children in school grades 9 to 12, those children with severe intellectual or functional impairment won’t make up the YRBSS population universe. We have further elaborated on it in the discussion and introduction, and that is the reason we have adjusted for underlying mood disorders, insomnia, and substance use as potential confounders. However, as per regression results, time spent on video games/the internet remains to be a
significant predictor after adjusting for confounders.

 

Page 8 lines 206-208. On what basis do the authors make the assertion that four or more hours of daily internet usage falls under pathological usage? What is the scale used to measure this as a pathology? Have the authors any past academic literature to support this assertion?

Our response - We have made changes to our language and we have further elaborated on our reasoning to address this.

 

In fact the entire paragraph on Page 3 lines 206-225 is making connections with past research on cognitive dysfunction based on the authors' assertions alone in lines 206-208 that the average use of the students of the internet constitutes a pathology. This is most misleading and severely lacking in scientific rigor.

Our response - We have made changes to the discussion to support or refute our claims.

 

On-Page 9 line 229 the authors again make mention of ADHD. Is the focus of the manuscript ADHD of cognitive dysfunction?

Our response - Children with ADHD have executive dysfunction and problems with response inhibition that is extensively studied, as such these children may be the one to spend more than 4 hours per day on video games/the internet. We have tried to explain our findings keeping potential confounders in mind.
Since YRBSS doesn’t ask for specific questions assessing presence of ADHD, the question we used to assess ADHD might be an indication of underlying ADHD along with other mental and physical conditions.

 

There is no Conclusion section in this study at all. How is this possible in a manuscript submitted for peer-review?

Our response - We have added a conclusion section to our manuscript.
Additionally, we have addressed the minor comments.

Thank you so much for your valuable time and effort reviewing our manuscript. 

Round 2

Reviewer 2 Report

The authors have modified some items of the paper according to the reviewers’ comments. For this reason, I think this last version of the manuscript is ready to be published by the Adolescents 

Reviewer 3 Report

Thank you for addressing my concerns. I wish you all the best in your academic endeavors.