Patterns of aberrant, dysfunctional behavior causing distress and dysfunction define mental disorders. Mr. Trump has a Disorder Disorder. His impulsive, inconsistent and emotionally-driven actions wreak havoc. In recent weeks he has swamped us with a veritable tsunami of chaos and discord: announcing and then reneging on a thirty day pullout of troops from Syria; fast-forwarding by two months the retirement of Secretary of Defense Mattis who quit in response to the Syria decision; visiting troops in Iraq without warning the host country; publicly boasting that he would accept credit for a government shut down but then trying to pin responsibility on others; staging a presidential address rife with misinformation about immigration, crime, and national security. Completely separate from whether one agrees with any of his underlying policies, his pattern of behavior undermines, alienates, and confuses his allies, while frightening and enraging opponents.
Mr. Trump’s Disorder Disorder has a name: ADHD or Attention Deficit Hyperactivity Disorder. Comprehending that his ADHD shapes all that he thinks and does helps make his actions more intelligible to us, prepares us for a future filled with more of the same types of behavior, and offers approaches for coping with his dysfunction.
Why does it matter to anyone other than mental health professionals that he has a psychiatric disorder? We make psychiatric diagnoses for the same reasons we identify diseases in the rest of medicine — to understand symptoms, to help predict the course of illness, and to indicate beneficial treatment options. Pointing out that Mr. Trump fulfills the definition of ADHD transcends mere name-calling to illustrate the antithesis: employing a label to comprehend, explain, and ameliorate a condition. Diagnosis underlies the healing arts but can not preclude whether others misuse and weaponize words.
Some have claimed that Mr. Trump’s socially sanctioned successes (wealth, reality show ratings, the highest elected office in the land) demonstrate that he couldn’t possibly have a mental health condition. But having mental health conditions doesn’t preclude achievement or excellence. Other presidents have been clinically depressed, and numbers of world-class athletes, artists, and entrepreneurs have spoken about their depression, bipolar disorder, panic attacks, ADHD and other mental health conditions. While psychiatric disorders may make the the path to the top more challenging or dictate an unconventional route to prominence, there is no inherent reason that having a mental illness would prevent notable accomplishments.
Unlike other common mental health conditions, psychiatry defines ADHD entirely by observable behaviors, rather than through an assessment of thoughts, feelings, or motives. The public domain contains abundant documentation that Mr. Trump objectively, completely and persistently fulfills the definition of ADHD. The wealth of behavioral data substantiating his ADHD surpasses what any clinician could glean through a personal evaluation. The trove of public information contains far more incidents, over a great span of time, in a far greater variety of contexts, corroborated by many more third parties, than any expert assembles in hours of individual, personal scrutiny. One may quibble with whether experts have written a perfect definition of ADHD, but Mr. Trump certainly embodies the term. He could be the poster boy for adult ADHD.
ADHD goes beyond troubles with distractibility and hyperactivity to encompass a broad range of executive function deficits. Mr. Trump has trouble directing, sustaining, and flexibly shifting attention, he has difficulties with prioritization and planning, he lacks impulse control and he has poor emotional regulation, all of which are common problems for those with ADHD. (Although not everyone with ADHD manifests every one of these traits.) Because ADHD profoundly affects all input entering and all emissions exiting his brain, as well as influencing his decision making, we have an ethical duty to be talking about what ADHD is and how it shapes this president. Our chief executive has an executive function disorder.
Although ADHD can be exhausting (to both the individual and those around them) it is never an exhaustive explanation for an individual’s actions. Life experiences, genetic propensities, family dynamics and other conditions all contribute to shaping each individual’s personality. A full psychiatric diagnosis of Mr. Trump would require a direct evaluation to establish, for example, whether his repeated narcissistic comments and actions genuinely reflect dismissive attitudes towards other people and an over-inflated valuation of himself. His ADHD appears to be more primal and pervasive than his narcissism, as indicated by the vast number of comments he utters on a daily basis that are patently false, self-contradictory, petty, or irrelevant. If his narcissism were pre-eminent he would suppress those utterances that undermine the image he strives to project of an intelligent, strong, impeccable, capable and dominant man.
The impairment of impulse control in ADHD helps explain why Mr. Trump displays reflexive, not reflective, behavior. His tweets and blurted comments represent what he feels in the moment, rather than a thoughtful exposition of any ideas in his head. Many of his erroneous statements aren’t so much attempts to deceive (although yes, he does make bona fide lies at times) but rather are expressions of what his gut perceives at that point. This aspect of his ADHD — appearing fresh, unscripted, and defiant of political correctness or conventional norms — appeals strongly to his base. Although at times his followers seem to confuse candor (saying what he feels) with honesty (being truthful), often they appear more aware than his critics that many of Mr. Trump’s statements are just verbalizations of what his gut tells him right at that instant.
Our understanding of Mr. Trump expands when we comprehend that ADHD brains tend to be interest-driven, not importance-driven. Even though Mr. Trump may appreciate that basic preparation and knowledge would enhance his performance and increase his likelihood of success, such homework bores his ADHD brain, so he refuses to prepare for campaign debates, for negotiations with North Koreans over nuclear arms or with Democrats over immigration or government shutdowns, or for lobbying congressional allies to pass tax bills or defeat Obamacare. He doesn’t even read security briefings that have been repeatedly condensed, simplified and embellished with pictures to try to capture his interest.
Too much emphasis on Mr. Trump’s narcissism and ignoring his ADHD also leads to misinterpreting his actions. When reporters viewed his visit to the troops in Germany and Iraq through the lens of self-aggrandizement, they jumped to the conclusion that the president had staged the large number of soldiers wearing MAGA hats. The media was then embarrassed when subsequent research failed to find evidence that these Trump supporters were plants. The president didn’t even bother to tell his Iraqi hosts that he was visiting, having the foresight to bring extra hats along appears unlikely. Awareness of Mr. Trump’s ADHD helped reveal the trip to be a hodgepodge of poorly planned proceedings. Our president’s genius lies not in planning self-celebratory events, but rather in exploiting almost any situation presented by the world or created by his own ADHD-driven disorder to glorify himself.
Altogether, ADHD offers a more accurate, comprehensive, and empathetic framework for considering Mr. Trump’s actions rather than calling him lazy, a liar, a moron, or a baby.
Throughout the campaigns and early months of his presidency, pundits who ignored Mr. Trump’s lifelong condition of ADHD persisted in telling us that he would soon “start acting presidential” — those aware of his ADHD knew better. Knowledge of his ADHD also allowed an accurate forecast that, despite his claims to being a grand deal-maker, he would be an abysmal negotiator. ADHD impairs Mr. Trump’s negotiating skills by rendering him: ill prepared; unable to embrace complexity or nuance; inept at keeping multiple objectives in mind; reliant on emotional volatility, threats and intransigence to coerce rather than persuade; willing to accept vacuous platitudes as victory; and prone to misrepresenting whatever he “won” in his negotiations.
Numerous pundits who focus on Mr. Trump’s narcissism and grandiosity have made two big predictions that fail to account for his ADHD. One is that the pressure of the Mueller investigation or House Democratic inquiries will create such stress that the president will unravel and become radically more reckless and impulsive. This fails to take account of the observation that many people with ADHD actually perform well at times of crisis, because extreme conditions can help to direct and focus their mental energies. Just looking at the record of “unforced errors” and 3:00 am tweets (the initial immigration ban on Muslims; restricting transgendered individual from the military; numerous surprise hirings and firings) demonstrates that many of Mr. Trump’s abrupt decisions and declarations came at moments of relative calm, and seem to reflect a response to boredom, not to stress. Moreover, Mr. Trump’s ADHD informs us that his unexpected pronouncements are manifestations of his personality, not primarily strategic attempts to put us all off balance.
Those ignoring Mr. Trump’s ADHD also predict that he is so narcissistic that he will never resign from office. However, walking away from a task out of boredom or frustration is classic ADHD-driven behavior. Furthermore, Mr. Trump has shown an ability to maintain his sense of greatness even after walking away from other failures (the “brilliant businessman” with multiple bankruptcies, god’s gift to women with two divorces and numerous unhappy mistresses). He frequently shares his view that he already considers himself one of the most accomplished presidents ever; it only burnishes his magnificence if he achieves this in less than a full term.
Moving on from how ADHD helps us understand and make predictions about Mr. Trump, the diagnosis also suggests a treatment plan. Hundreds of studies and millions of more functional patients patients establish stimulant medications as the most extensively tested and effective treatment for ADHD. A flurry of recent reports allege that Mr. Trump snorts Adderall, but if true we should be applauding, rather than mocking this behavior, as it would reflect an awareness of his condition and that he is taking steps that are actually likely to reduce, not magnify, his ADHD behaviors.
In addition to the option of medication treatment, knowledge of Mr. Trump’s ADHD informs us of the importance of compensatory strategies for addressing his deficits: creating enough structure so that he can thrive, and to help him get back on track when he derails. For the rich and powerful, the most common compensatory strategy for dealing with ADHD involves delegating executive function tasks to others. Mr. Trump has already had tax lawyers structure his businesses to ensure that even in bankruptcies he profits while creditors are stiffed, has had conservative legal societies select and vet his choices for federal judges, and out-sourced virtually all child-rearing to wives and nannies. The need for structure is also why so many of us are concerned that Mr. Trump employs an effective Chief of Staff, particularly now that so many other “grown-ups in the room” have left. Those advocating for “letting Trump be Trump” seem unaware that the likely result would be more chaos and discord, and less effective action to enact any policies or programs.
Awareness of Mr. Trump’s ADHD can guide us in taking better care of ourselves. Knowing that his comments are reflections of temporary feelings, rather than presentations of established facts, gives us permission to not listen to each and every pronouncement. The current media circus encourages us to attend to Mr. Trump as if we are watching a basketball game — whipping us into a frenzy of agitation and anticipation with every drive toward the basket and each trip up and down the court. If you work as a media pundit, scrutinizing every move may be important. For most of us, the final score and maybe a few game highlights suffice. Paying attention to every back and forth, reversal, denial and untruth uttered by this president is unnecessary because almost none of this verbiage affects the final score. Checking your newsfeed once a day or even just a few times a week suffices in keeping you apprised of actions that matter. Mr. Trump’s ADHD-driven chaos inspires confusion and chaotic anger in response; by appreciating his ADHD we can step back, separate the antics from the issues, and re-engage with the substance, not the shadows.
Ignorance of Mr. Trump’s ADHD undermines efficacy in trying to influence him. The last person to speak to him and grasp his attention plays an oversized role in his decision making. However, unless the situation resolves completely, which is often hard to determine because of his ADHD, someone else may then speak to the president, becoming the new pre-eminent influence and undermining the last-person strategy. Those who determine access to Mr. Trump wield more power in affecting decision making than was the case with previous presidents, reflecting again the disproportionate clout of his Chief of Staff.
Any successful strategy for working with Mr. Trump’s ADHD involves catering to what interests him rather than on what is important. He attends to concrete objects, particularly those redolent of wealth or power, rather than to conceptual goals. He focuses far more intently on actions that lead to personal aggrandizement than to those that improve the country or world, or that strive for higher principles like equality, or reciprocity. World leaders who have stressed the importance of global warming, denuclearization, or strengthening democracy abjectly failed to motivate Mr. Trump. Rather, hosting parades in his honor, erecting wall murals of his face, or dangling the prospect of a Nobel Peace Prize in front of him garner rapt attention. Those who have already effectively manipulated him know that a bright shiny object wields more influence than a cogent argument.
Finally, the consequences of missing Mr. Trump’s childhood ADHD highlight the importance of identifying this condition. Mr. Trump’s ADHD made him more restless, inattentive and impulsive than his peers, and to repeated reprimands for these aberrant behaviors. This negative attention certainly was an important contributor to his feelings of self doubt and insecurity, and his gargantuan efforts to compensate for these feelings. A more aware and more empathetic family and society would not have helped create such an individual.
Understanding that Mr. Trump’s ADHD impairs him on a daily basis makes much of his behavior more comprehensible, teaches us to anticipate that these patterns will continue, and suggest some strategies to make his behavior more tolerable. Learning how to ignore much of what he says helps insulate us from aspects of his behavior. Realizing that, particularly because of his ADHD, “this too shall pass”, helps us to endure. ADHD occurs across a spectrum of severity, but with cases as extreme as Mr. Trump’s, ignorance has certainly not led to bliss.
John Kruse MD, PhD, San Francisco psychiatrist, father of twins, marathon runner.