Recognizing Adult ADHD: What Donald Trump Can Teach Us About Attention Deficit Hyperactivity Disorder

RECOGNIZING ADULT ADHD

What Donald Trump Can Teach Us About Attention Deficit Hyperactivity Disorder

John Kruse M.D., Ph.D.

Copyright © 2019 by John Kruse M.D., Ph.D.

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An important note: This book is not intended as a substitute for the medical recommendation of physicians or other health-care providers. Rather, it is intended to offer information to help the reader cooperate with physicians and health professionals in a mutual quest for optimum well-being. The author has not directly treated Donald Trump. Some identities have been changed to protect patient confidentiality.

Recognizing Adult ADHD

What Donald Trump Can Teach Us About Attention Deficit Hyperactivity Disorder

By Dr. John Kruse

1. PSY022010 - Attention-Deficit Disorder (ADD-ADHD)

2. PSY000000– Psychology, General

3. PSY036000 – Psychology, Mental Health

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DEDICATION

Dedicated to the patients who have shared so much with me, and who have taught me so much over the years.

INTRODUCTION

The ADHD Problem

Attention Deficit Hyperactivity Disorder, or ADHD, derails careers, destroys relationships, damages self-esteem, and even kills people. It substantially increases the risk for incarceration, drug abuse, serious accidents, and suicide. Because ADHD symptoms often respond quickly and dramatically to medications and other treatments, we can avert tragedies by accurately identifying and treating adult ADHD.

You might be one of the almost ten million adults already receiving effective therapy for ADHD. Or perhaps you’re among the tens of millions of family members, friends, and co-workers overwhelmed by the chaos, inconsistencies, and contradictions produced by someone in your life with ADHD. You might not even be aware you have it or are affected by those who do, since millions of adults with ADHD remain undiagnosed and untreated. Even if none of these groups applies to you, we live in a society growing evermore ADHD-like, which pushes us to react in ways that more closely resemble ADHD-driven behaviors. This book aims to teach you to recognize and understand ADHD in yourself and others, and provides coping strategies for addressing ADHD-driven behaviors.

When I started my psychiatric practice a quarter century ago, very few people recognized that adults could have ADHD. Even now, understanding of the condition remains superficial despite the proliferation of books and blogs about adult ADHD. We often dismiss ADHD as merely indicating distractibility (There’s a squirrel!) or fidgetiness, leading to the incorrect conclusion that failing to identify the condition harms nobody. We all need to learn more about ADHD in order to cope with this condition at individual, relational, and societal levels.

A Presidential Problem?

A conversation with one of my adult patients with ADHD, in the midst of the 2016 presidential campaign, inspired me to write this book. We were sitting in my San Francisco office a few days after the second presidential debate between Hillary Clinton and Donald Trump. Fiercely intelligent, Cassandra devoted little time or energy to politics, but watching the split screen images contrasting Mrs. Clinton’s calm, methodical, and coherent presentation with Trump’s frequent interruptions, unfinished thoughts, rambling sentences, and incessant motion had jolted Cassandra into recognizing her own ADHD behaviors splashed across the television screen. Suddenly, she saw how her symptoms might appear to others.

At that point, I had been treating Cassandra for ADHD and associated depression and anxiety for fifteen years. (I have altered the names and occasional details of the individual patients discussed in this book in order to protect anonymity.) Blonde, slim, and six feet tall, with high cheekbones, she still turns heads on the streets of San Francisco at well past forty. Her ADHD, however, and the failure of those around her to grasp the impact of ADHD on her behaviors and relationships, had repeatedly damaged her career and her romantic life, despite her intelligence, charisma, and good looks. Careers in television, hotel management, and veterinary medicine had all eluded her. Several years ago, she was simultaneously embroiled in two marriages and one divorce. Even after combining awareness of her ADHD with hard work and helpful medications, she still struggled. She summed it up with, I don’t know how to put it all together and make a life.

Another comment by Cassandra towards the end of that session galvanized me to work on improving our collective recognition of what adult ADHD looks like, and how it harms individuals and society. The best thing Trump could do for me would be to come out as having ADHD! She perceived that by publicizing ADHD’s effect on a powerful, prominent person like Donald Trump, she could increase societal understanding of, and acceptance for, this brain condition, and that doing so might improve her own life.

The more the media covered Trump’s actions and utterances, the more my patients with ADHD exclaimed some version of: He has ADHD, doesn’t he? As a psychiatrist specializing in adult ADHD, I had privately concurred that Trump’s behavior seemed to fit the diagnosis, but the sheer volume of comments on this topic led me to examine the issue in more detail. In addition to reviewing definitions of ADHD and standards for diagnosis¹, I watched numerous video appearances of Trump, some going back forty years, and read accounts by his friends, associates, and collaborators about how his mind works. My investigations, as described in this book, confirmed that Trump does indeed fulfill the criteria for an ADHD diagnosis. Moreover, I found myself agreeing with Cassandra about the importance of not squandering this teachable moment, but instead utilizing it to foster a greater understanding of ADHD, and of Trump himself.

Rather than seeing Trump as a jumble of unusual traits juxtaposed into a single and singular man, the lens of ADHD focuses our attention on how this condition provides a unifying explanation for so many of his aberrant and contradictory behaviors. While the ADHD label enshrines the symptoms of distractibility and hyperactivity, problems with attention and physical restlessness represent just two islands of impairment in the expanse of potential problems created by this condition. ADHD affects a broad range of what we call executive functions². Executive functions describe the command and control operations of the brain, including how we direct, alter, and maintain our attention; use working memory; manage time; prioritize; plan for the future; suppress impulses; and regulate emotions³. Impairments in executive functions explain why people with ADHD display so many different problems, and can present them so inconsistently.

The impaired executive functions of the brains of individuals with ADHD produce a wide range of real-world problems. ADHD contributes, in Trump and others, to a variety of dysfunctional behaviors that can include: directly contradicting comments made minutes earlier; uttering verifiably untrue statements; focusing on appearances rather than substance (judging women by how they look; showing enthusiasm for military parades but not military planning); obsessively returning to topics when others have moved on (inaugural crowd size, electoral victory); blurting out inappropriate comments (shit-hole countries; having a bigger button than Kim Jung-un); anger outbursts; and not preparing for important events (ignoring security briefings; not preparing for debates or negotiations). We simplify and clarify the task of trying to comprehend the behavior of someone with ADHD when we understand that ADHD manifests in all of these seemingly disparate ways. Furthermore, realizing that all of these ostensibly unrelated issues are part of a larger problem allows us to be less distracted by each individual action and less perturbed by each unconventional utterance, and also informs us regarding effective ways to address these problems.

On an almost daily basis for several years, Trump has amazed America and puzzled pundits with his unconventional, ill-informed, impulsive, childish, disorganized, rude, uncouth, untruthful, and self-centered behaviors. Comments from a single article in The New Yorker⁴ include how Trump lacks self-restraint, said things that were considered scandalous and disqualifying, made outlandish and often incompatible claims, exhibits crudeness and more than occasional intemperance. The near ubiquitous description in the media of his ADHD traits contrasts vividly with the stark absence of acknowledgment that these problems could all be manifestations of his ADHD. Transfixed by details, almost nobody is addressing the bigger picture. Hundreds of articles describe his lying, narcissism, sociopathy, pettiness, poor manners, and short temper. (There are too many to cite, but for a few vivid, articulate, and pertinent articles, see the bibliography⁵. Out of this vast cornucopia of commentary only a few authors mention that ADHD might be one of Trump’s mental health issues⁶.

A Solution?

The world remains unaware of, or dismisses as trivial, Trump’s ADHD, despite its contribution to substantive dysfunction. Similarly, millions of individuals impaired by ADHD don’t recognize their own condition, and therefore don’t seek treatment. I have tied these twin tragedies together in this book with the hope that we can 1) improve our recognition of adult ADHD whether it presents in presidents or the general population, 2) promote more effective treatment for ADHD, and 3) develop skilled coping strategies for dealing with individuals who have ADHD. The president, due to the prominence of his position and the severity of his ADHD, intrudes constantly into our consciousness. Because he reaches a far broader audience than any sports hero or entertainment celebrity, he has inadvertently cast himself as the poster boy for adult ADHD—an ideal agent to educate us about this condition.

Objections to the Solution

Over the years, I’ve detected three different rationales for why people avoid evaluation and treatment for ADHD. Because all of these people are aching, I categorize them as the not-awake group, the mistake group and the forsake group. Those not-awake remain unaware that they display ADHD symptoms or that ADHD is a serious and potentially treatable condition. Members of the mistake group, including their families, therapists, and doctors, confuse ADHD with other mental health problems and neglect to address the ADHD behaviors. Individuals of the forsake group know that they have ADHD but shun treatment out of fear of either stimulant medications or stigmatization for seeking mental health treatment.

Difficulties in directing and sustaining attention can render those with ADHD less aware of their own performances, and of how their inattentiveness, impulsiveness, or additional ADHD traits affect others. As one example, I’ve met many individuals with ADHD who consider themselves punctual, but then chronically arrive ten to twenty minutes late for appointments. Those oblivious to a problem remain unlikely to seek treatment for it. In addition to ADHD fostering reduced awareness regarding one’s own behavior, an incomplete understanding of ADHD blocks many from entering treatment. In dozens of evaluations I’ve heard people proclaim that their friends had labeled them spacey, not really present, or had even suggested they had ADHD, But I dismissed it because I thought it wasn’t really a thing. Those in the not-awake group often need repetitive, descriptive, non-condemning feedback about their ADHD in order to grasp that their problematic behaviors have a common origin and are potentially treatable.

Symptoms of anxiety, depression, bipolar disorder, substance abuse, and personality disorders often obscure underlying ADHD and create a barrier to effective diagnosis and treatment. Family members, therapists, and even psychiatrists can become so distracted by these other problems that they miss the underlying ADHD. In addition to these situations of co-occurring or co-morbid conditions where an individual simultaneously displays symptoms of both ADHD and another mental health condition, another problem exists: Observers sometimes misattribute symptoms as stemming from other causes in people who actually only have ADHD. For example, in some individuals we misidentify the restlessness and the rapid, ricocheting repartee produced by ADHD, falsely labeling these behaviors as a product of anxiety. Inaccurate diagnoses stymie our ability to provide targeted help to individuals with mistake group ADHD. Educating the public about what ADHD does and does not entail will help more people seek appropriate treatment.

Trump highlights how other conditions often overshadow or obscure ADHD. The media and mental health community emphasize his malignant narcissism, while perpetuating silence about his ADHD. However, his ADHD explains why someone so concerned with projecting power and competence acts so consistently to undermine this image with blatantly untrue statements, inconsistencies, temper tantrums, and lack of planning. When I have pointed out Trump’s ADHD to many of my astute, seasoned, and thoughtful psychiatrist friends, so often I hear a version of, Oh my god, you’re right! I was so distracted by all of his personality issues, I never saw the ADHD!

Beyond ignorance and confusion, fear fashions the third set of social barriers to discourage those with ADHD from seeking an evaluation. Worries about stigmatization or the adverse effects of treatment encourage avoidance of the mental health care system. Public discussions about ADHD—and in particular, addressing ADHD’s origins in the brain, reminding people about how frequently it persists into adulthood, and identifying specific individuals who display the condition—all help to reduce stigma. Education also works to lessen fears regarding treatment. Some of those with forsake group ADHD might opt for treatment if they learned that the serious adverse effects of stimulants are rarer than imagined, or that numerous non-stimulant medications and non-medication approaches can significantly reduce ADHD symptoms and improve functioning and life satisfaction.

Given that Trump robustly displays ADHD behavior—he walks like a duck, talks like a duck, and even tweets like a duck—why do we duck the issue and avoid talking about his ADHD? Although ignorance about adult ADHD contributes mightily to this silence, Trump’s powerfully polarizing personality presents other obstacles to a free and open discussion about his ADHD. The ADHD community fears that the diagnosis will be further stigmatized if people identify it too closely with the president. The president’s allies feel that any psychiatric label must be derogatory. His political enemies voice concern that a diagnosis might humanize him when they feel he should be demonized. And organized psychiatry proclaims that ethical reasons forbid discussions about Trump’s mental health.

A friend of mine, a mental health practitioner with ADHD himself, captured the fear that associating Trump with ADHD would stigmatize the whole diagnosis when he insisted that I should subtitle this book …And Not Everyone with ADHD Is an Idiot or an Asshole. I believe I can advance that message more effectively without stooping to name-calling. As I discuss in Chapter 12, we reduce stigma by talking openly about conditions and categories. We lessen the potential harm that might arise from associating ADHD with this president by educating people that ADHD informs us about how Trump absorbs, processes, and utilizes information, but does not dictate his policies or the content of his utterances.

Furthermore, ADHD, important and influential as it can be, is always only one aspect of any individual, not the whole picture. Factors including age, intelligence, other character traits, childhood experiences, socioeconomic status, and family attitudes all have profound impacts on how any particular adult manifests symptoms of ADHD ⁷. A white, privileged, 20th century, New York City household, run by a multi-millionaire father who was both demanding and not particularly supportive⁸ produced Trump, and these forces that shaped him continue to influence the content of his ADHD-driven behaviors. We cannot attribute his apparently racist, sexist, xenophobic, authoritarian comments to his ADHD, even if they explain part of why he blurts them out rather than keeping them to himself.

People with ADHD, even though they share important traits, do not all appear or act identically⁹. We don’t expect all blondes, all blind people, or all those from blended families to be similar in other aspects of their lives. As noted above, although we require an understanding of ADHD to decipher how Trump’s mind works, we cannot blame ADHD for the content of his verbalizations or the policies he proclaims. Thus, while knowing that someone has ADHD helps us predict they will speak in a rambling, non-linear, emotionally driven manner, it does not dictate what items or topics that individual will fixate on, nor the direction of the next pivot.

Trump also helps with destigmatization because he demonstrates that even severe ADHD does not preclude societal success, and indeed much of his appeal—his spontaneity, unconventionality, and energetic presentations—are all attributes of his ADHD. Furthermore, his prominence could even encourage a healthy discussion about psychiatry’s role in society, the significance of a mental health diagnosis, and evolving stances towards privacy and which aspects of our leaders’ lives are pertinent in a democracy.

To those who worry that I am using ADHD as a cudgel to attack Trump, I aver that this diagnostic label describes his behavior far more accurately and empathetically than the phrases millions of others have already employed, including calling him a f***ing moron, a child, crazy, a pathological liar, and deranged¹⁰.

To those who object that ADHD excuses Trump’s behavior, I remind them that an explanation differs from an excuse. Possessing a framework for how he takes in information, processes it, and responds to it helps in understanding his decision-making process but does not exonerate him of responsibility for his actions. Furthermore, an accurate assessment of how his brain functions aids those who wish to craft an effective resistance to his statements and actions.

To organized psychiatry, as I discuss further in Chapter 3, the official definition of ADHD, uniquely among our common mental health conditions, depends entirely on observable behaviors. Thus, the trove of behavioral information in the public record pertaining to Trump provides a superior data set, compared to an in-person evaluation, in order to reliably determine that he fulfills diagnostic criteria for ADHD. No violations of confidentiality occur by describing Trump’s ADHD. Remaining silent about Trump’s ADHD causes more harm than does an informed discussion of how we can identify and respond to his condition.

Outline of the Book

I have organized Recognizing Adult ADHD into three sections, each challenging a certain dogma. The first section addresses the old, and largely refuted dogma that ADHD is not real, and in particular, that ADHD doesn’t exist in adults. I review evidence for the brain’s involvement in ADHD, address treatment issues, and discuss diagnostic criteria and co-morbidity confusion, using the example of Trump to clarify many of these topics. In the second section of the book I employ the concept of executive functions to help refute the dogma that ADHD is a trivial condition that doesn’t warrant attention or treatment. The third section tackles social aspects of discussing ADHD, including directly rebutting the dogma that psychiatrists must avoid speaking about the mental health problems of important public figures. ADHD’s interference with Trump’s abilities demands that we discuss this topic openly, substantively, and transparently regarding the basis of our assertions. I hope that my attempts to teach old dogmas new tricks are successful.

Disclaimers

This disclosure of Trump’s ADHD contains several additional disclaimers:

I am not attempting a full psychiatric diagnosis of Trump, which would have to include a comprehensive account of all his other mental health problems. This book focuses on his ADHD because of its primary role in explaining his actions and utterances. Only an in-person evaluation could determine whether he actually manifests the attitudes, feelings, thoughts, and behaviors required to diagnose almost all other psychiatric illnesses.

Although I provide the recipe by which we currently diagnose ADHD, my intention is to increase awareness about ADHD, not to encourage home-cooking enthusiasts towards self-diagnosis. If you remain hungry after reading this book, additional excellent sources of information about ADHD exist at libraries, bookstores, and online. My favorite references for digging more deeply into learning about and coping with adult ADHD include Gina Pera’s book Is It You, Me or Adult ADHD?¹¹, Russel Barkley’s book Taking Charge of Adult ADHD¹², and Jessica McCabe’s YouTube channel How to ADHD¹³. Just as we inform the public about signs of heart attacks and strokes—not for the purpose of self-diagnosis, but so that people will seek professional help in a timely manner if they display symptoms of these serious medical problems—we hope ADHD sufferers will seek professional help. If you have concerns that ADHD affects you or a loved one, find a mental health professional experienced with ADHD to confirm or rule out the diagnosis and, if needed, map out treatment strategies.

While pharmaceutical companies have occasionally provided me with meals, potentially influencing my opinions on certain topics, I have attempted to find objective information to substantiate all factual statements in this book. I also strive to identify those claims that are my own conjectures and not established facts.

This book does not contain any insider gossip about the president. I direct commentary to the ADHD-driven behaviors that shape his policy-making decisions, rather than focus on the politics and policies themselves.

I use the term ADHD (Attention Deficit Hyperactivity Disorder) throughout this book, rather than ADD. Colloquially many people use the two terms interchangeably, although some use ADD to indicate inattentive ADHD and ADHD to mean hyperactive ADHD. Officially the ADHD label encompasses inattentive ADHD, hyperactive ADHD, and a combined-type ADHD.

I consider adult ADHD to be a real, pervasive, misunderstood, and under-treated condition that harms people, their loved ones, and our whole society.¹⁴ Improving our understanding about ADHD will reduce barriers to treatment, and thereby lessen the direct and indirect havoc that ADHD wreaks¹⁵. We should talk about Trump’s ADHD because, in and of itself, it harms him, harms the presidency, harms the US, and harms the world. We should talk about ADHD because millions of American adults suffer and are less productive because of undiagnosed and untreated ADHD¹⁶. We should talk about adult ADHD because recognizing and treating this condition will reduce human misery¹⁷ and help millions achieve more in their lives¹⁸.

SECTION I

DONALD TRUMP: ADULT ADHD POSTER BOY

CHAPTER 1

ADULT ADHD ISN’T FAKE NEWS

The Reality of Adult ADHD

You may already feel that articles in print and online oversaturate us with information about ADHD. However, much of the past decade’s coverage centers around the increasing use, misuse, and abuse of stimulant medications, including how these substances destroy lives, and can even be lethal¹⁹,²⁰. Stimulant addiction and amphetamine-induced psychosis are uncommon but very serious potential adverse effects of treatment of ADHD, and that is why I always discuss these risks with my patients, and offer treatment options that include non-stimulant medications and other modalities.

However, we have been neglecting the other half of the ADHD story. Millions of American adults with ADHD have never received an accurate diagnosis, and thus remain unaware of their own condition. Only a portion of those diagnosed with ADHD have received treatment. And only a fraction of those who have been treated are receiving sustained and adequate treatment²¹, ²². Because ADHD can cause great suffering and dysfunction²³, and because in many cases treatment quickly and significantly improves aspects of the condition²⁴, ²⁵, the ongoing under-recognition and under-treatment of ADHD in adults contributes to serious societal and individual distress, functional impairment, and financial loss²⁶.

I first learned about adult ADHD almost a quarter century ago from one of my patients. Frank was in his mid-forties and had just finished six years of therapy with an experienced psychoanalyst. That therapy had led to no improvements in Frank’s depression or anxiety, and had failed to help Frank make any lasting changes in his life. Despite being intelligent, friendly, and willing to work, Frank had briefly held more than a hundred different jobs, and was on permanent disability for mental health reasons. He had even been fired from a job as a grocery store cashier. While making change for customers, Frank would start chatting about the interesting cowboy jacket or colorful shoes the customer was wearing, and would then have no recollection as to whether the customer had handed him some singles, or whether he had been handing them back to the customer as change. Consequently, Frank’s checkout lane was always far slower than the others, and at the end of the day, Frank’s till was always short several dollars. Even though employers liked how amiable he was and admired his ability to interact with customers, his inability to follow directions—to stay on track and complete a task—repeatedly led to his being fired.

Frank’s psychoanalyst referred him to a respected academic center to find a new therapist and for an evaluation to see if ADHD explained why he never carried out his intended goals. The university psychologists tested Frank for several long days, only to conclude, as they referred him to me, It looks like maybe he has ADHD, but that doesn’t exist in adults. So I started working with Frank without any clear diagnosis. Although Frank was enthusiastic during our sessions and appeared to enjoy the interaction, he often showed up late. He would amble down the hallway, loudly berating himself for his tardiness, and for having stopped to chat with strangers even though he knew he was running late. Often he would spend the first few minutes pacing around the room, shouting further imprecations at himself for his inability to keep track of time. The later he was, the more upset at himself he became, and consequently he would consume even more of the remaining session with this self-directed venom.

Once seated, he was capable of talking almost non-stop during the sessions. His attention was like a honeybee, nuzzling against one blossom, vibrating with excitement, then buzzing over to a distant, more attractive bloom, humming intently there for a few seconds and then moving on, but never methodically plodding from one adjacent flower to another. Occasionally Frank would interject that he knew he wasn’t giving me time to respond. And despite how animated and energetic he was while talking, one of his foremost complaints was how tired he was and how low energy he perceived himself to be, and how, as soon as he got home, he would collapse into a chair; simple tasks like washing dishes or taking out the garbage would remain undone for weeks. Had Frank been eight years old, nobody would have questioned whether he had ADHD²⁷,²⁸.

The prevailing view that I heard throughout the clinical mental health world in the early 1990s was that anyone who had ADHD as a child outgrew it by the end of adolescence. In my four years of psychiatric residency training during that era, there was not a single mention in any lecture or presentation that adults could have ADHD, although childhood ADHD was presented as a standard and common diagnosis. However, even back then, a few clinicians and researchers recognized and were promoting adult ADHD as a valid diagnosis²⁹,³⁰. Published reports from decades before that era described adults with ADHD but used a variety of older names and diagnostic titles, such as minimal brain dysfunction³¹, a label that had also been used to describe children with ADHD ³². However, at the time, those reports drew little attention and had almost no impact on how the mental health world evaluated and treated adult patients.

We now know that childhood ADHD can have three different trajectories, with roughly a third showing no improvement in ADHD symptoms into adulthood, the middle third showing some improvement, and the remaining third no longer displaying symptoms of ADHD. The respective sizes of these three groups are approximations, in part because different studies have looked at somewhat different populations, and even more crucially, have used different cut-off criteria for how many symptoms must persist for ADHD to be considered completely in remission, partially remitted, or not at all in remission³³. While awareness of ADHD in adults has become more widespread clinically³⁴ and in popular culture³⁵, comprehension of what adult ADHD actually entails remains incomplete and is a topic of ongoing research³⁶, with still much to be done in the area of ADHD in adulthood³⁷.

Under-Diagnosis and Under-Treatment of ADHD

The lack of awareness of adult ADHD twenty-five years ago that led to confusion about what my patient, Frank, was dealing with, seems eerily replicated today by the lack of public discussion of Mr. Trump’s ADHD. While many of my patients bring up the possibility of Mr. Trump having ADHD, and some individuals with ADHD have offered such observations online, there has been a dearth of high profile op-eds, articles or other commentary about Mr. Trump’s ADHD (for several, see³⁸). I continue to be amazed and disappointed in the lack of discussion of Mr. Trump’s ADHD, because it so powerfully and pervasively influences his behavior. The few times I have heard mention of the possibility, commentators offer dismissive comments such as, Who really knows what he has? or It’s so obvious that he has ADHD, but without any acknowledgment regarding how profoundly ADHD drives a broad range of the president’s behaviors.

Judging from my clinical practice, there are two major reasons why ADHD in adults remains under-diagnosed, and both may be pertinent to the lack of public recognition of Mr. Trump’s ADHD. Virtually every month for the past two decades I have seen people in my San Francisco psychiatry office who are negatively affected by ADHD but who were not previously diagnosed with it. The first group includes those whose