Image by Suju from Pixabay
John Kruse
Jul 9 · 4 min read

President Trump remained largely on script and spoke in complete sentences during his July 4th speech. He bobbed his head, gestured with his hands, and walked around only about a third as much as he usually does when speaking. And his pupils, almost obscured behind the rain splotched plexiglas screen and his hooded eyelids, were significantly dilated. He simultaneously displayed these same three signs of coherent speech, decreased hyperactivity, and pupillary dilation during his third debate with Hillary, in this year’s State of the Union speech, and during his January “Build the Border Wall” speech. This triad convincingly reveals when our president has consumed stimulant medication to control his ADHD.

People with hyperactive ADHD, like Mr. Trump, have great difficulties suppressing fidgeting, or in removing the rambling, non-sequiturs, and interruptions from their speech. Intentionally corralling both their actions and their vocalizations at the same time remains nearly impossible. Since humans can’t voluntarily control the diameter of their pupils, only medication exposure explains the synchronous changes in eyes, speech, and restlessness displayed by Mr. Trump on these occasions. And only stimulant medications would dilate pupils while reducing the rambling speech and physical restlessness of someone with ADHD.

Many medications only produce benefits after days or weeks of consumption. In contrast, stimulant medications used for ADHD have direct beneficial effects within minutes on sustaining attention, reducing distractibility, suppressing impulses, regulating emotion, and a host of other executive function deficits. The desired results of stimulants wane quickly as blood levels drop. For decades, experts debated whether children with ADHD should take their medication every day, or instead take “medication holidays” on weekends and vacations when there is ostensibly less need for sustained attention outside of the classroom. Those advocating vacations from drugs claimed that the days off medication would reduce the likelihood of tolerance, addiction, or other adverse responses to the pills.

Many of my adult patients with ADHD more strongly appreciate the benefits of their medications on Mondays, after a few days off their medications. Although this might suggest tolerance, it could also indicate a difference in perception: they experience a greater contrast between their Sunday off the meds and their Monday back on them, whereas consecutive weekdays all on the meds may feel relatively similar.

Those who favor intermittent or interrupted stimulant usage offer two additional arguments. Most individuals with ADHD have some fluctuations in the severity of their symptoms: some days one wakes up in a brain fog where everything is out of sync, attention drifts, items are forgotten, and fidgeting is irresistible, and some mornings one feels more like they are “firing on all cylinders”. Perhaps one needn’t take medications on those occasional good days. Also, with many jobs, different days with different tasks place very different demands on the brain. Stimulants may be essential for shuffling through a pile of onerous paperwork, but might be superfluous for an interesting and active day out in the field making calls on customers.

For adults with ADHD, clinical sentiment has tilted towards taking stimulant medications every day. People with severe ADHD can be so disorganized that if one encourages them to skip days of taking medication, they will end up forgetting to take it on days they need it. Extensive research and clinical evidence indicate that ADHD impairs not just classroom performance, but life performance. Weekends, not just workdays, require good time management, attentive communication, patience, and prioritization of tasks, so why would one jeopardize success in the rest of life by skipping meds on weekends?

Mr. Trump has chosen to take stimulant medications on occasions where he deems it advantageous to appear more focused, more professional, more presidential. In doing so he displays a cardinal ADHD trait of focusing on what is interesting to him rather than what is important. He wants to create a more favorable impression of himself when delivering high-profile speeches before a general audience. He knows that at campaign rallies his base largely accepts, and even relishes, him in his unmedicated state. However, we elected him to a full time job — we aren’t just paying him to give a few select speeches.

A few days ago reporters leaked commentary from the British Ambassador to the US, extensively critiquing Mr. Trump. The complaints focused not on policy issues, but on problematic behavioral characteristics that directly result from Mr. Trump’s severe, under-treated ADHD, including: having “no filter”, and being “simple”, “blunt”, “unpredictable”, “incompetent”, “incoherent”, “chaotic”, “clumsy and inept”. I for one, want Mr. Trump to take his medications every day, so that he demonstrates discernment, complexity, tact, consistency, skillfulness, coherence, organization, coordination, and eptness.

I want a president who is prepared to make thoughtful decisions rather than responding to impulses (calling a missile strike, cancelling it, telling us about it, then denying his own story). I want a president who plans and follows through on big decisions, whether he is negotiating with North Koreans, or tearing up treaties or trade agreements, or designing plans for comprehensive medical coverage or immigration reform. For someone with ADHD this severe, we are all at risk, and we all suffer on the days Mr. Trump does not take his stimulant medications.

Help me keep an eye on the president, because we know that when his sentences stay on track, when he stops fidgeting and when his pupils are dilated, he has shown up properly medicated and ready for duty.

John Kruse

Written by

John Kruse MD, PhD, San Francisco psychiatrist, father of twins, marathon runner.

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