REFLEXIVE NOT REFLECTIVE:

WHAT DONALD TRUMP CAN TEACH US ABOUT ADULT ADHD

Jul 6, 2018 · 9 min read

Carol joined the chorus last week. “That was a really impressive display of ADHD!” she said, referring to one of President Trump’s recent outbursts. For the past two years, many of my patients with Attention Deficit Hyperactivity Disorder (ADHD) have identified some of their own patterns and propensities replicated in the behavior of Mr. Trump, and concluded that he must have ADHD. More recently, even my patients with anxiety or depression, like Carol, have been commenting on Mr. Trump’s ADHD, and how his actions add stress to their own lives.

These observations led me to examine Mr. Trump’s behavior and realize how robustly he meets full diagnostic criteria for ADHD. Rather than seeing what he says and does as contradictory, chaotic, confusing and outrageous pieces of isolated and problematic behavior, ADHD provides a coherent, unifying, explanation. Our president exemplifies the essence of ADHD by behaving in ways that are reflexive, not reflective.

Given the prominence of Mr. Trump, and how frequently he inserts himself (largely because of his ADHD) into our collective awareness, he is a daily reminder of how severely and pervasively ADHD can affect people. He is a veritable Poster Boy for Adult ADHD. We need greater attention to, and understanding of, ADHD because there are still millions of Americans who have this treatable condition, but are either unaware of it, or believe it to be trivial and not worthy of medical attention.

In over two decades of working with adults with ADHD, I have seen ADHD cause serious damage and distress to the lives of individuals with ADHD and to the lives of their loved ones. I have witnessed people experience profound relief when their ADHD was finally recognized. And I have seen patients substantially improve their lives when their ADHD was addressed with medications or cognitive-behavioral therapies, or both.

So what type of behavior supports a diagnosis of ADHD? In June alone, Mr.Trump instituted a policy of separating children of apprehended immigrants from their parents, blamed the policy on the Democrats, said that only Congress could change the rules, rescinded the policy with an executive order after a vast public outcry, then verbally defended the child separation policy and continued to disparage immigrants from central America. The same month he boasted of his good relationships with other leaders of the western world, claimed he had successful meetings at the G7 summit, then exploded in a rash of insults and trade restrictions when he felt that he had been insulted by his Canadian host. (Still with me?) Also in June, he announced, renounced, then vowed to proceed with levying tariffs against China, Canada, Europe, Mexico and much of the rest of the planet. Before flying to Singapore for a summit with Kim Jong-un, he proclaimed that he did not need to prepare for the encounter because the event was about “attitude”, dismissing the importance of history, culture, strategy or international power and alliances. (There’s more…) He gleefully applauded his signing of an agreement that put fewer restrictions on the North Koreans than they had acceded to in previous accords with the U.S., and was far weaker than the Iran nuclear agreement that he had shredded the week before. He also argued that the North Korean deal had succeeded in part, because they could “trust” him to look out for their safety.

And although the topics change slightly, June resembled May, and April, and March and… every other month of this presidency. This litany runs on and on, but the point is to avoid cherry-picking isolated, cotton-pickin’ facts and to remind us how Mr. Trump’s ADHD is a pervasive pattern of aberrant behavior that adds to the anxiety of his audience. Mr. Trump has been consistently inconsistent, disorganized, self-contradictory, impulsive, emotional, superficial, and a disrupter of conventional norms.

Our current understanding of ADHD is that it is a problem of executive functions, not just an issue of distractibility. ADHD goes far beyond the “Oh, there’s a squirrel!” meme. Executive functions include directing, maintaining, and switching attention, inhibiting responses, regulating emotions, utilizing short-term memory, managing time, organizing, and planning. When we fail to understand the ADHD filter through which Mr. Trump perceives and addresses the world, we misconstrue much of what he says and does. ADHD affects what he attends to and therefore the flow of information into his brain. ADHD diminishes his ability to restrain his impulses and thus shapes what comes out of his mouth. And ADHD reduces his ability to control his own emotions, which magnifies the volatility, impulsivity, and superficiality of his actions. It is ironic that for chief executive we have chosen a man with an executive function disorder.

ADHD is not Mr. Trump’s only mental health issue. ADHD is not responsible for the content of his specific policies, or for his racist, sexist, authoritarian-loving, and xenophobic thoughts and comments. As with everyone, whether or not they have ADHD, factors including culture, race, social status, parental behaviors and attitudes, intelligence, and temperament contribute to shaping our behavior. Mr. Trump has been strongly influenced by growing up rich and white in New York City, and by entering the profession of his father, who was forceful and not particularly nurturing, and valued the accumulation of power and possessions even if that involved breaking rules or hurting people. These factors, combined with his ADHD, have made Mr. Trump the man he is today. All that he shares with others who have ADHD are those patterns and problems of behavior related to poor impulse control, distractibility, inattentiveness and limited emotional control.

The presence of ADHD makes it harder to sort out what other conditions Mr. Trump might have. Due to his ADHD-driven lack of restraint, he blurts out whatever he is feeling at the moment, which may or may not represent his true thoughts or feelings on a given topic. Particularly since he makes so many contradictory statements, often within seconds of each other, it is not possible to determine which ideas he truly endorses.

If ADHD is the clear explanation for Mr. Trump’s impulsive, emotional, and inconsistent behavior, why aren’t we already immersed in a public discussion about this? Detailed written accounts of interactions with Mr. Trump, by both his supporters and adversaries, pile up pages and pages of descriptions that could be torn from the covers of manuals about ADHD-driven behavior. Videos of his rallies, his comments to the press, or his meetings with world leaders display more of this ADHD-driven behavior on a daily basis — the short attention span, the refusal to address important issues that don’t interest him, the poor preparation, the following his “gut” rather than taking time to think about issues. Yet almost nobody brings up his ADHD when discussing his problematic behavior.

Mr. Trump’s partisan enablers, his adamant enemies, and the mental health establishment, form a wall of denial around his ADHD. His defenders don’t want to hear anything that might diminish his glory. His opponents regard him as so toxic that he besmirches ADHD if it is applied to him. Organized psychiatry forbids discussing the president’s mental state.

To his defenders: ADHD provides a far more kind and comprehensive understanding of his behavior than does calling him “immature”, “crazy”, “temperamental”, “stupid”, “child-like”, or “a f***ing moron”. All of those labels have already been used by members of his own administration to describe the elements of his behavior driven by ADHD.

To his opponents: ADHD affects how he processes information, but it does not determine the content of his utterances. We can and must separate the divisive, bilious, degrading opinions from his ADHD-related troubles with impulsivity, distractibility, and poor self-regulation. ADHD, while crucially important to understanding the president’s mental make-up, is only a part of who he is. Moreover, ADHD is an explanation, not an excuse, for his behavior. Finally, we know that we reduce stigma about conditions (e.g. homosexuality, being a rape victim) by talking about the issues, not by attempting to hide their existence.

To the psychiatric establishment: if Mr. Trump walks like a duck, talks like a duck, and tweets like a duck, why are we ducking the issue and not addressing that he has ADHD? He meets full diagnostic criteria for ADHD based solely on observable behaviors documented in the public record. Nothing that he could say in a private evaluation would negate, erase, or explain away the evidence of his ADHD. To diagnose additional mental health conditions that Mr. Trump might have requires knowing his thoughts, feelings and motivations; these are not needed for an ADHD diagnosis. Furthermore, there is no violation of confidentiality, since all information is obtained from publicly available sources.

We should be talking about Mr. Trump’s ADHD because it is a major contributor to his aberrant behavior.

We should be talking about Mr. Trump’s ADHD because it contributes to destabilizing our social and political processes.

We should be talking about Mr. Trump’s ADHD because it is undermining America’s image and strength.

We should be talking about Mr. Trump’s ADHD because it is more accurate and less pejorative than seeing him as an “idiot” or a “brat” or a “bully”.

We should be talking about Mr. Trump’s ADHD because it suggests ways to respond to his behavior and to protect ourselves from it.

We should be talking about Mr. Trump’s ADHD because it serves as a reminder that adult ADHD is widely under-recognized and under-treated, even when it is causing serious problems.

The framework of ADHD as an executive function disorder allows us to understand why people with ADHD are “interest driven, not importance driven”. Mr. Trump repeatedly dismisses the need for daily security briefings because they don’t interest him. He doesn’t even bother to learn basic information about important legislation (repealing Obamacare, revising the Patriot Act, writing new tax codes, passing new immigration policy) when lobbying congressmen from his own party. Yet he comments obsessively about worn-out topics that stimulate him — the tallies of his electoral victory or his hatred for “Crooked Hillary”.

People with ADHD have strong tendencies to focus on visual appearances and surface impressions. Hence Mr. Trump’s pre-occupation with women’s bodies rather than their intelligence, character or experience; with military pageantry and parades rather than with actual strength or strategy; and with the size of his crowds, hands, or (nuclear) button. This is a man who thinks in terms of pictures, not philosophies.

Although much of the conventional thinking about ADHD focuses on difficulties in controlling attention, problems controlling emotions are also frequently present, particularly in individuals with prominent hyperactivity as well as inattentiveness. Mr. Trump made so many unusual sniffing, lip-pursing, grimacing, head-tilting, and shrugging gestures during the campaign that many suggested he might be abusing cocaine or have a neurologic disorder, rather than seeing this as an aspect of his ADHD. We have repeatedly seen Mr. Trump overreact to situations and berate adversaries, allies, and underlings, displaying the poor emotional regulation that is an aspect of his ADHD.

ADHD also explains why his fans praise Mr. Trump for his “truth telling” while objectively he is an outlier among out-and-out liars, uttering falsehoods far more often even than fellow politicians. Candor, or saying whatever he feels in the moment, is being confused with honesty, which is being truthful. The sheer volume of utterances that makes him look inconsistent, uninformed, weak, or dishonest reveals that ADHD is the source of these comments, not narcissism or political calculation.

Mr. Trump’s strengths — his boldness and creativity — are also aspects of his ADHD. No other real estate magnate, purveyor of luxury goods, or reality TV entertainer has even dared to run for president. His unconventional and impromptu thinking increases the potential for diplomatic breakthroughs, but also simultaneously elevates the risk for catastrophic failure. The unpredictability fostered by Mr. Trump’s ADHD-driven behavior has measurably increased the anxiety of Americans, across the political spectrum.

We can use our understanding of ADHD to help us adapt to this administration. Foreign powers already know how to engage his interest-not-importance-driven brain with parades in his honor, and his posters on their walls, rather than with intellectual discussions about global warming or how international trade functions. Those who want to change his positions should attempt it with vivid visuals and evocative emotions, not didactic discussions.

Another adaptation to his ADHD style is to worry less about his every word. His utterances become (somewhat) less distressing if they are heard as “this is what I feel right now” rather than imagining that they are attempts at stating truths or formulations of well-reasoned policies. Furthermore, given how often he contradicts, countermands, and reverses statements he has made, because of his ADHD, it is fine to check in with the news just once a day, rather than receiving a running update, since the information content of any individual comment is close to zero.

Mr. Trump is not just a product of our increasingly ADHD-like world, he is also driving the world to be more like himself. His incessant intrusions into the public discourse foster superficiality, emotional reasoning, immediate and impulsive reactions and distractibility. Technology and social media are already fragmenting our attention and obscuring the important with the titillating; Mr. Trump is magnifying these trends. If we don’t gain a better understanding of ADHD, we will continue to create a planet in which leaders like Mr. Trump become commonplace. Or, with knowledge, awareness, and sustained effort, we can strive to fill each day with nuance, rather than new angst.

John Kruse

Written by

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

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