Symptom Network Analysis of Attention-Deficit/Hyperactivity Disorder and Emotional Symptoms in Adults: Results From the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

Christophe Gauld, MD, PhD; Sarah Tebeka, MD, PhD; Diane Purper-Ouakil, MD, PhD; Pierre Fourneret, MD, PhD; Hugo Peyre, MD, PhD; Yann Le Strat, MD, PhD

J Clin Psychiatry 2025;86(4):24m15287

Abstract

Objective: The diagnosis of attention-deficit/hyperactivity disorder (ADHD) is based on a set of symptoms and 2 main dimensions (impulsive/hyperactive and attentional). While the relationships between ADHD symptoms and emotional dysregulation (ED) have been widely studied, the interactions between individual symptoms have rarely been examined. The purpose of this study was to assess which symptoms are most influential (central) and which symptoms connect (bridge) the 2 main dimensions of ADHD and ED.

Methods: Data from wave II (2004–2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-II) were utilized, which included a large, nationally representative sample of the US population (N=33,546). Eighteen ADHD symptoms were examined based on DSM-5-TR criteria, along with 4 variables related to ED. Symptom network analyses were conducted to explore the relationships between ADHD and ED symptoms.

Results: The prevalence of ADHD was found to be 10.12% (N=3,397). Among all ADHD and ED symptoms, ED symptoms had the lowest influence (centrality) values. In terms of bridging the 2 ADHD dimensions, 2 ED symptoms were among the 4 most influential.

Conclusions: The low centrality of ED symptoms supports the traditional focus on the 2 main dimensions of ADHD. However, the significant role of ED symptoms in connecting the impulsive/ hyperactive and attentional dimensions highlights their importance within the ADHD framework. These findings have potential implications for the epidemiology, public health, research, and clinical understanding of ADHD.

J Clin Psychiatry 2025;86(4):24m15287

Author affiliations are listed at the end of this article.

Members Only Content

This full article is available exclusively to Professional tier members. Subscribe now to unlock the HTML version and gain unlimited access to our entire library plus all PDFs. If you’re already a subscriber, please log in below to continue reading.

Subscribe Now

Already a member? Log in

References (60)

Faraone SV, Asherson P, Banaschewski T, et al. Attention-deficit/hyperactivity disorder. Nat Rev Dis Primers. 2015;1:15020. PubMed CrossRef
Faraone SV, Sergeant J, Gillberg C, et al. The worldwide prevalence of ADHD: is it an American condition?. World Psychiatry. 2003;2(2):104–113. PubMed
Sayal K, Prasad V, Daley D, et al. ADHD in children and young people: prevalence, care pathways, and service provision. Lancet Psychiatry. 2018;5(2):175–186. PubMed CrossRef
Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry. 2007;190:402–409. PubMed CrossRef
Simon V, Czobor P, Bálint S, et al. Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Br J Psychiatry. 2009;194(3):204–211. PubMed CrossRef
Cortese S, Song M, Farhat LC, et al. Incidence, prevalence, and global burden of ADHD from 1990 to 2019 across 204 countries: data, with critical re-analysis, from the Global Burden of Disease study. Mol Psychiatry. 2023;28(11):4823–4830. PubMed CrossRef
Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716–723. PubMed CrossRef
Song P, Zha M, Yang Q, et al. The prevalence of adult attention-deficit hyperactivity disorder: a global systematic review and meta-analysis. J Glob Health. 2021;11:04009. PubMed CrossRef
Katzman MA, Bilkey TS, Chokka PR, et al. Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry. 2017;17(1):302. PubMed CrossRef
Retz W, Retz-Junginger P, Thome J, et al. Pharmacological treatment of adult ADHD in Europe. World J Biol Psychiatry. 2011;12(suppl 1):89–94. PubMed CrossRef
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed Revised. American Psychiatric Association; 2022.
Barkley RA. International consensus statement on ADHD. Clin Child Fam Psychol Rev. 2002;5(2):89–111. PubMed CrossRef
Bunford N, Evans SW, Wymbs F. ADHD and emotion dysregulation among children and adolescents. Clin Child Fam Psychol Rev. 2015;18(3):185–217. PubMed CrossRef
Faraone SV, Rostain AL, Blader J, et al. Practitioner Review: emotional dysregulation in attention-deficit/hyperactivity disorder - implications for clinical recognition and intervention. J Child Psychol Psychiatry. 2019;60(2):133–150. PubMed CrossRef
Martel MM. Research review: a new perspective on attention-deficit/ hyperactivity disorder: emotion dysregulation and trait models. J Child Psychol Psychiatry. 2009;50(9):1042–1051. PubMed CrossRef
Shaw P, Stringaris A, Nigg J, et al. Emotion dysregulation in attention deficit hyperactivity disorder. Am J Psychiatry. 2014;171(3):276–293. PubMed CrossRef
Able SL, Johnston JA, Adler LA, et al. Functional and psychosocial impairment in adults with undiagnosed ADHD. Psychol Med. 2007;37(1):97–107. PubMed CrossRef
Surman CBH, Biederman J, Spencer T, et al. Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: a controlled study. ADHD Atten Def Hyp Disord. 2013;5(3):273–281. PubMed CrossRef
Hirsch O, Chavanon M, Riechmann E, et al. Emotional dysregulation is a primary symptom in adult Attention-Deficit/Hyperactivity Disorder (ADHD). J Affect Disord. 2018;232:41–47. PubMed CrossRef
Thompson RA. Emotion regulation: a theme in search of definition. Monogr Soc Res Child Dev. 1994;59(2–3):25–52. PubMed CrossRef
Barkley RA. The important role of executive functioning and self-regulation in ADHD. J Child Neuropsy. 2011;113(21):41–56.
Martel MM, Levinson CA, Langer JK, et al. A network analysis of developmental change in ADHD symptom structure from preschool to adulthood. Clin Psychol Sci. 2016;4(6):988–1001. PubMed CrossRef
Barkley RA. Attention-Deficit Hyperactivity Disorder: A Clinical Workbook. 2nd ed. The Guilford Press; 1998.
Mitchell JT, Robertson CD, Anastopolous AD, et al. Emotion dysregulation and emotional impulsivity among adults with attention-deficit/hyperactivity disorder: results of a preliminary study. J Psychopathol Behav Assess. 2012;34(4):510–519. CrossRef
Boyd CJ, West B, McCabe SE. Does misuse lead to a disorder? The misuse of prescription tranquilizer and sedative medications and subsequent substance use disorders in a U.S. longitudinal sample. Addict Behav. 2018;79:17–23. PubMed CrossRef
Grant BF, Dawson DA, Stinson FS, et al. The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991–1992 and 2001–2002. Drug Alcohol Depend. 2004;74(3):223–234. PubMed CrossRef
Moss HB, Chen CM, Yi HY. Prospective follow-up of empirically derived Alcohol Dependence subtypes in wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC): recovery status, alcohol use disorders and diagnostic criteria, alcohol consumption behavior, health status, and treatment seeking. Alcohol Clin Exp Res. 2010;34(6):1073–1083. PubMed CrossRef
Cortese S, Faraone SV, Bernardi S, et al. Gender differences in adult attention-deficit/hyperactivity disorder: results from the national epidemiologic survey on alcohol and related conditions (NESARC). J Clin Psychiatry. 2016;77(4):e421–e428. PubMed CrossRef
De Alwis D, Lynskey MT, Reiersen AM, et al. Attention-deficit/hyperactivity disorder subtypes and substance use and use disorders in NESARC. Addict Behav. 2014;39(8):1278–1285. PubMed CrossRef
Peyre H, Hoertel N, Cortese S, et al. Long-term effects of ADHD medication on adult height: results from the NESARC. J Clin Psychiatry. 2013;74(11):1123–1124. PubMed CrossRef
Bernardi S, Faraone SV, Cortese S, et al. The lifetime impact of attention deficit hyperactivity disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Psychol Med. 2012;42(4):875–887. PubMed CrossRef
Baek JH, Eisner LR, Nierenberg AA. Epidemiology and course of unipolar mania: results from the national epidemiologic survey on alcohol and related conditions (NESARC). Depress Anxiety. 2014;31(9):746–755. PubMed CrossRef
Grant BF, Dawson DA, Stinson FS, et al. The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample. Drug Alcohol Depend. 2003;71(1):7–16. PubMed CrossRef
Grant BF, Dawson DA. Introduction to the national epidemiologic survey on alcohol and related conditions. Alcohol Res Health. 2006;29(2):74–78.
Carragher N, Krueger RF, Eaton NR, et al. ADHD and the externalizing spectrum: direct comparison of categorical, continuous, and hybrid models of liability in a nationally representative sample. Soc Psychiatry Psychiatr Epidemiol. 2014;49(8):1307–1317. PubMed CrossRef
Ruan WJ, Goldstein RB, Chou SP, et al. The alcohol use disorder and associated disabilities interview schedule-IV (AUDADIS-IV): reliability of new psychiatric diagnostic modules and risk factors in a general population sample. Drug Alcohol Depend. 2008;92(1–3):27–36. PubMed CrossRef
Bringmann LF, Elmer T, Epskamp S, et al. What do centrality measures measure in psychological networks? J Abnorm Psychol. 2019;128(8):892–903. PubMed CrossRef
Epskamp S, Borsboom D, Fried EI. Estimating psychological networks and their accuracy: a tutorial paper. Behav Res. 2018;50(1):195–212. PubMed CrossRef
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Amer Psychiatric Pub Inc; 1980.
Biederman J, Faraone S, Milberger S, et al. Predictors of persistence and remission of ADHD into adolescence: results from a four-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry. 1996;35(3):343–351. PubMed CrossRef
Hart EL, Lahey BB, Loeber R, et al. Developmental change in attention-deficit hyperactivity disorder in boys: a four-year longitudinal study. J Abnorm Child Psychol. 1995;23(6):729–749. PubMed CrossRef
Wilens TE, Biederman J, Faraone SV, et al. Presenting ADHD symptoms, subtypes, and comorbid disorders in clinically Referred adults with ADHD. J Clin Psychiatry. 2009;70(11):1557–1562. PubMed CrossRef
Haslbeck JMB, Waldorp LJ. How well do network models predict observations? On the importance of predictability in network models. Behav Res. 2018;50(2):853–861. PubMed CrossRef
Stringaris A. Irritability in children and adolescents: a challenge for DSM-5. Eur Child Adolesc Psychiatry. 2011;20(2):61–66. PubMed CrossRef
Stringaris A, Goodman R, Ferdinando S, et al. The Affective Reactivity Index: a concise irritability scale for clinical and research settings. J Child Psychol Psychiatry. 2012;53(11):1109–1117. PubMed CrossRef
Nigg JT, Casey BJ. An integrative theory of attention-deficit/ hyperactivity disorder based on the cognitive and affective neurosciences. Dev Psychopathol. 2005;17(3):785–806. PubMed CrossRef
Castellanos FX, Proal E. Large-Scale Brain Systems in ADHD: beyond the Prefrontal-Striatal Model. Trends Cogn Sci. 2012;16(1):17–26. PubMed CrossRef
Posner J, Kass E, Hulvershorn L. Using Stimulants to Treat ADHD-Related Emotional Lability. Curr Psychiatry Rep. 2014;16(10):478. PubMed CrossRef
Lenzi F, Cortese S, Harris J, et al. Pharmacotherapy of emotional dysregulation in adults with ADHD: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2018;84:359–367. PubMed CrossRef
Surman CBH, Biederman J, Spencer T, et al. Deficient emotional self-regulation and adult attention deficit hyperactivity disorder: a family risk analysis. Am J Psychiatry. 2011;168(6):617–623. PubMed CrossRef
Biederman J, Spencer T, Lomedico A, et al. Deficient emotional self-regulation and pediatric attention deficit hyperactivity disorder: a family risk analysis. Psychol Med. 2012;42(3):639–646. PubMed CrossRef
Barkley R. Deficient emotional self-regulation: a core component of attention-deficit/hyperactivity disorder. J ADHD Relat Disord. 2010.
Seidman LJ, Valera EM, Makris N. Structural brain imaging of attention-deficit/ hyperactivity disorder. Biol Psychiatry. 2005;57(11):1263–1272. PubMed CrossRef
Cuthbert BN. Research Domain Criteria: toward future psychiatric nosologies. Dialogues Clin Neurosci. 2015;17(1):89–97. PubMed CrossRef
Morris SE, Cuthbert BN. Research Domain Criteria: cognitive systems, neural circuits, and dimensions of behavior. Dialogues Clin Neurosci. 2012;14(1):29–37. PubMed CrossRef
Thorell LB, Tilling H, Sjöwall D. Emotion dysregulation in adult ADHD: introducing the comprehensive emotion regulation inventory (CERI). J Clin Exp Neuropsychol. 2020;42(7):747–758. PubMed CrossRef
Borsboom D, Cramer AOJ, Kalis A. Brain disorders? Not really: why network structures block reductionism in psychopathology research. Behav Brain Sci. 2018;42:e2. PubMed CrossRef
Miller DJ, Derefinko KJ, Lynam DR, et al. Impulsivity and attention deficit-hyperactivity disorder: subtype classification using the UPPS impulsive behavior scale. J Psychopathol Behav Assess. 2010;32(3):323–332. PubMed CrossRef
Rosenthal EA, Broos HC, Timpano KR, et al. Does emotion-related impulsivity relate to Specific ADHD symptom dimensions, and do the Effects Generalize Across Comorbid Internalizing and Externalizing Syndromes? J Atten Disord. 2024;28(2):178–188. PubMed CrossRef
Carver CS, Johnson SL, Joormann J, et al. Serotonin Transporter Polymorphism Interacts with childhood Adversity to predict aspects of impulsivity. Psychol Sci. 2011;22(5):589–595. PubMed CrossRef