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Pundits have lambasted Donald Trump for his lying, nattered about his narcissism, and decried his sociopathy, while simultaneously describing his behavior as chaotic, inept, inconsistent, impulsive, unconventional, inattentive, ignorant, and devoid of planning or follow through. While making assertions about other mental health problems, they have been simultaneously cataloging symptoms of Mr. Trump’s Attention Deficit Hyperactivity Disorder (ADHD). We neglect his ADHD at our own peril, as highlighted by his handling of the COVID-19 pandemic.

We need to pay attention to Mr. Trump’s ADHD, because ADHD shapes his behavior in ways pervasive, pertinent, pernicious, and preventable. ADHD causes chaos not just for those with the condition, but also for those they interact with. ADHD can destroy relationships, derail careers, and even kill people. We all need to become better at recognizing ADHD because this disorder of disorder harms millions of Americans, yet once identified we can usually treat it quickly and substantively.

We make diagnoses in psychiatry, as in the rest of medicine, to understand health impairments, to predict the course of a condition if left untreated, and to suggest appropriate remedies. Diagnoses are tools for teaching, not weapons for wielding.

We require an awareness of ADHD to make sense of Mr. Trump. If narcissism were the primary driver of Mr. Trump’s behavior, we would not expect him to manifest, on a daily basis, so many actions and statements that undermine the image of a mature, measured, intelligent, and diligent mind at work.

The official definition of adult ADHD requires exhibiting at least five of eighteen observable behaviors, pervasively since at least age twelve, in a manner inappropriate for one’s age, in multiple settings, and in patterns that we can’t attribute to another mental illness. We have all seen ample instances in which Mr. Trump 1) makes careless mistakes due to inattention, 2) has trouble sustaining attention, 3) does not follow through on initial plans, 4) is distracted by extraneous stimuli, 5) has difficulty organizing tasks and activities, 6) interrupts others, 7) blurts out comments, 8) talks excessively, 9) walks around when others are seated, and 10) is generally restless and fidgety. By chronically displaying these ten symptoms, he more than fulfills the criteria for diagnosing adult ADHD.

A unique pairing of circumstances allows for this armchair diagnosis. We are dealing with a mental health condition, unlike virtually all others, that is defined by objective behaviors. We are also assessing an individual, currently one of very few on the planet, for whom we possess, in the public domain, a vast trove of relevant behavioral data. We don’t need to know Mr. Trump’s inner thoughts, feelings, or motivations for these behaviors. Because Mr. Trump’s ADHD diagnosis relies only on public information, no violation of confidentiality occurs by publicizing this assessment.

Whether Mr. Trump is aware of his symptoms, knows of his condition, or agrees with the observations of others, remains irrelevant to making the diagnosis. Extensive research shows that problems with inattention make individuals with ADHD rather unreliable historians. Since they don’t track their own inattentiveness very well when it occurs, they are unlikely to report it accurately later.

Furthermore, a vast body of literature indicates that we reduce, rather than increase, stigma, by talking openly, factually, and acceptingly, regarding the mental health disorders of public figures. The ethical arguments thus align for publicizing this particular diagnosis, of this particular man, at this particular time. The evidence that Mr. Trump’s ADHD contributes powerfully to his dangerousness to the country, as exemplified by the current COVID-19 crisis, further argues for publicly discussing his condition.

This neither means nor implies that Mr. Trump “only” has ADHD. Many people with ADHD have co-occurring conditions. And any specific behavior has multiple determinants. What I am arguing is that the pattern of poor planning, inappropriate prioritizing, and ongoing ignorance, that have characterized the administration’s approach to COVID-19, as well as the impulsive, untruthful, and contradictory commentary still spewing forth from the president, are most accurately and succinctly understood as manifestations of Mr. Trump’s ADHD.

More than 20,000 scientific studies undergird our understanding of ADHD as a neuro-developmental condition, with a strong genetic basis, that often persists through adulthood. Researchers find measurable neurochemical and neuroanatomical anomalies in the brains of people with ADHD, with perhaps the most notable findings being at the network level, where we see aberrant connectivity between the frontal cortex and other brain regions.

We currently conceptualize ADHD as a malfunctioning of the executive functions of the brain, with resulting problems in controlling attention, managing time, regulating impulses and movements, organizing thoughts, planning activities, prioritizing actions, and regulating emotion. Despite the name, the “deficit” in ADHD actually lies in the control of attention, not the ability to attend. Individuals with ADHD have difficulties with directing, sustaining, and switching attention. We have chosen a chief executive with an executive function disorder.

ADHD, Inattention, and Inanity

Mr. Trump has a notoriously short attention span, with perhaps the most alarming demonstration being his oft reported boredom with daily security briefings, even after aides have substantially truncated the reports, and inserted snappy graphics in futile attempts to help him focus. He displayed his inattentiveness during a COVID-19 news briefing with Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, by uttering several comments immediately afterwards that contradicted Dr. Fauci and indicated that the president had not registered what his health expert had just said. Mr. Trump provided another example of this pattern of inattention when he claimed on February 28th, at a South Carolina rally, “Whoever thought of this? Two weeks ago who would’ve thought this would be going on?”. Actually, anyone paying attention had, by then, heard hordes of medical experts state that the coronavirus would not disappear overnight. Mr. Trump’s lack of awareness in the current crisis reprises his false claims that “nobody knew” that fixing health care, or that lowering drug prices, would be complicated.

Not only has Mr. Trump’s ADHD caused him to miss vital information, other ADHD traits, including procrastination, and avoiding tasks that require sustained mental effort, have contributed to his remaining ignorant about basic facts of the problem. His ADHD has contributed to his ignorance about the lethality of COVID-19, the threat it poses to America and the world, and the length of time needed to develop medications to treat it or vaccines to prevent it.

Because of problems with directing attention, people with ADHD tend to respond to what is immediately in front of them, and this unfortunately appears to have been a driving factor for Mr. Trump appointing Vice President Pence to be in charge of the administration’s COVID-19 response. Unnamed sources reported that the president chose Mr. Pence because he was standing around “not doing anything else”. In public, the president reinforced this rationale by repeatedly mentioning that he was using people “already on staff” to deal with the crisis. The additional explanation proffered, that he chose Mr. Pence for his “expertise in public health” was risible, given Mr. Pence’s history as Governor of Indiana. Because of his religious beliefs, Mr. Pence notoriously defied public health officials, and delayed approval of a clean needle exchange program that was known to delay the spread of infections, thereby prolonging an HIV outbreak. Both strategically and cosmetically, the choice of Mr. Pence appears to be an ADHD-driven blunder.

Inattention to details, particularly around communication regarding personnel changes, has plagued the administration, repeatedly fostering disorganization. In confronting the coronavirus, the administration failed to clearly inform Secretary of Health and Human Services Alex Azar that Mr. Pence was now in charge. This led to confusion about whether Vice President Pence, Secretary Azar, the medical scientists, or Mr. Trump himself, was making the important decisions. It remains unclear whether we will follow best public health practices, or opt for whatever the president feels like doing in the moment

ADHD, Planning, and Prioritization

Because of problems with controlling attention and prioritizing tasks, those with ADHD attend to what interests them, rather than what is important. You may know that Iran will retaliate against your economic and political escalations, but you play golf day after day, rather than studying contingency plans and learning (before you approve a launch) that your missile strikes might actually kill people. Or you focus on how fears of COVID-19 may be exploited by the Democrats, or adversely affect the stock market, because these topics interest you, while ignoring the more important underlying threat to lives and livelihoods.

Because of their executive function deficits, those with ADHD tend to overvalue rewards in the present and diminish the salience of future threats. Mr. Trump cut funding for global disease outbreaks at the CDC by 80%, and completely shut down the global health security unit of the National Security Council, despite medical and military leaders warning him strongly against doing so. Experts knew that growing populations, increased global trade, and climate change all dramatically increased the likelihood of pandemics, but for Mr. Trump, the immediate “reward” of cutting budget expenditures outweighed any potential risk of being less prepared and more vulnerable to future waves of infections.

Once COVID-19 arose as a problem, multiple aspects of ADHD confounded Mr. Trump’s ability to effectively deal with the crisis. In addition to minimizing looming problems until they arrive, ADHD also contributes to procrastination, to avoiding responses that take concentrated or sustained thought and effort, to viewing problems in concrete terms and imagery, and to opting for immediate responses rather than those that unspool gradually.

Public health experts have noted that China’s draconian quarantine measures gave us a full month to begin addressing the coronavirus problem before it arrived in our country, but that the US largely squandered that window of opportunity. Mr. Trump minimized the threat in his January 22 comments from Davos, when cases in China were increasing by hundreds each day, with, “We have it totally under control. It’s one person coming in from China. We have it under control, it’s going to be just fine.” When he did start acting, ADHD predisposed him to focus on travel restrictions, because closing borders was a concrete, immediate, and quickly accomplished goal. However, he neglected to set up reasonable protocols for quarantines, was slow to start developing and producing test kits, delayed in setting up public health infrastructure or insuring that adequate supplies were available for a major health crisis, and dallied with planning for the impact of coronavirus on health care workers, hospitals, businesses, or schools. As a result of inadequate quarantine measures and insufficient ability to test carriers of the coronavirus, COVID-19 has already resulted in numerous cases of avoidable infections, and deaths. We still do not know the scope of this disaster because of continued limitations on testing.

Mr. Trump’s ADHD has not only shaped how his administration structured its response to COVID-19, but also created for the world an image of inefficiency, cluelessness, and chaos. Even Republicans, like Ari Fleischer, George W. Bush’s Press Secretary, have tweeted that the administration’s handling of the pandemic press conferences was “Bizarre”. The ADHD-driven, piecemeal, inconsistent, self-contradictory commentary coming from the White House fails to convey an organized, serious, competent, or caring commitment to facing this challenge.

ADHD, Impatience, and Impulsivity

ADHD-driven impulsive blurting and tweeting constitute a hallmark of Mr. Trump’s candidacy and presidency. His base views the president’s unscripted words as a sign of authenticity. They view his inability to think before he speaks, as an asset, an unwillingness to yield to political correctness. Unfortunately, they often conflate Mr. Trump’s candor, with honesty.

Mr. Trump’s opponents often mirror an equally inaccurate interpretation of his speech, viewing all of his utterances as lies. With over 17,000 clearly documented untruths to date, Mr. Trump is truly an outlier among out and out liars. However, the vast majority of his untruths occur when he utters whatever is on his mind, without any attempt to make his words correspond to any worldly reality. His followers know how to decode his commentary, by mentally placing “At this moment, I feel that…” in front of every statement he makes. We can learn from this, because it will help everyone to be less bothered by his inconsistencies and blatant untruths.

We should reserve “lies” for statements that one knows to be false, and that are uttered with the intent to deceive. I believe that Mr. Trump makes both strategic lies (many of his statements regarding the Mueller investigation, and impeachment hearings) and what I call reflexive lies. Children with ADHD break rules, make numerous mistakes, and often get caught. Particularly in critical, rejecting environments, a subset of these children develop patterns of covering up or denying any infraction they are accused of. I have often seen this pattern of reflexive lying be more destructive to marriages, or other relationships, than the rule breaking itself. Thus, a husband, late for his wife’s birthday dinner, rather than admit he left work late, blames his tardiness on traffic, and not just on traffic (because that was predictable and hence, inexcusable), but on an elaborate story about a terrible accident on the freeway. The wife often becomes more upset at the suspected (or blatant) lie, rather than at the lateness itself. We have heard Mr. Trump make this reflexive type of lie numerous times, including recent claims that his coronavirus response has been “perfect” but that the media, or Democrats, or Europeans, or the Obama administration are really to blame for any problems.

When Mr. Trump repeatedly says untrue things, people learn to not believe him. When he makes divisive comments, viciously and repeatedly condemning people of color, immigrants, Muslims, or Democrats, large swaths of society don’t feel that their president has their interests at heart. (In contrast, although private tapes captured Nixon saying many racist, sexist, and bigoted comments, he had enough self control to not spew those views in public, and consequently he retained some plausibility when attempting to express concern about all Americans.) Mr. Trump’s divisiveness, and his lack of truthfulness, render him untrustworthy. This erosion of trust becomes particularly critical because research indicates that trust in one’s government is one of the most important variables for increasing public compliance with health recommendations in a pandemic.

The president issued statements that undermined his credibility from the onset of the coronavirus crisis. On January 22, he claimed the situation was “totally under control” as cases in China burgeoned, and that there was no reason to worry about a pandemic because “It’s going to be just fine.” Then two days later, he praised China for “their efforts and transparency” in fighting the coronavirus. This was after weeks of the Chinese prohibiting World Health Organization researchers from entering the country. The Chinese didn’t share vital epidemiological information about the outbreak, including important information such as the length of the incubation period before symptoms develop, or the duration of time that an individual remains infectious to others. This withholding hampered our ability to develop useful quarantine and public health responses. We should have all seen through Trump’s claim of Chinese “transparency”.

A month later, the president’s statements continued to contradict reality, when he said on February 26th, that “we’re working very well with the state” at the same time that California Governor Newsom was begging for more test kits. Mr. Trump then went on to proclaim “We’re testing everyone we need to test.” which was patently untrue then, and we’re still lagging in testing more than two weeks later. In contrast, South Korea, Singapore, Iceland and Germany all have much more extensive viral testing systems functioning.

Related to impulsivity, many individuals with ADHD demonstrate difficulty with regulation of emotions. Feelings come up more powerfully and quickly, and the individual becomes so immersed in the conflict that they have trouble pulling back and providing context for their interaction. Trump’s tenure in office is punctuated by firing people during rages, and breaking off negotiations in snits. This trait surfaced in the coronavirus when he became “livid” with Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, for saying coronavirus outbreaks in the US were a matter of when, not if. He has also launched angry tirades against his perception that the media has unfairly described his response to the coronavirus. While these outbursts may convey strongly felt beliefs, they also demonstrate that we have a leader unable to control himself, further undermining his authority.

Prevention of Problems Caused by ADHD

ADHD persistently affects Mr. Trump’s performance as president by influencing everything that enters his brain (or doesn’t) and every output as well. ADHD remains pertinent to his planning, organizing, and prioritizing, and to how he presents to the world his response to COVID-19. ADHD perniciously affects his decision-making, consistency, truthfulness, and trustworthiness, impairing the fight against the coronavirus. While narcissism and other traits may influence some of the content of Mr. Trump’s responses, ADHD pervasively shapes how he interacts with this world, and has profoundly influenced his handling of the coronavirus crisis. An understanding of ADHD not only helps us comprehend and predict the president’s behavior, but also offers suggestions that may assist the president in addressing the current situation, and aid the public in dealing with this president.

Optimal amounts of structure and support can help those with ADHD to function effectively. Mr. Trump has used aides and accessories to carry out the executive functions that he would otherwise perform ineptly on his own. He has outsourced the rearing of his children, the stacking of the judiciary, and the drafting of deals designed to reward him even when his businesses fail. The chances of his election victory were enhanced by aides who took away his ability to Tweet two weeks before the election, thereby decreasing the likelihood that his on-line outbursts would give reluctant voters second thoughts about installing such a man as president. However, Mr. Trump’s recent appointment of North Carolina Representative Mark Meadows as his fourth Chief of Staff, signals that the president does not welcome anyone limiting his impulsivity and distractibility. Because Mr. Trump has shunned the human support that might curtail his ADHD-driven behaviors, we will continue to see rampant inattention, inconsistency, restlessness, and impulsivity on display in the White House.

Vigorous exercise, regular and sufficient sleep, meditation, and healthy diets can all help mitigate the dysfunction caused by ADHD. However, numerous physicians and personal aides have attested to Mr. Trump’s resistance to engage in any of these approaches that might improve brain functioning.

In contrast to his rejection of other assistance, Mr. Trump employs pharmacology to treat his ADHD symptoms. Mr. Trump takes stimulants medications prior to important speeches, when he deems it vital to appear presidential (e.g. the State of the Union, the Build the Wall speech, his third debate with Hillary, the announcement of the assassination of Al-Bagdadi). I base this assertion on three sets of observable, objective changes in the president. Compared to his public performance and presentation in other venues the same week as these important events, the president’s gesturing with his hands, head and torso drops to a third of its background rate. The coherence of his speech increases markedly. (He finishes sentences, and one sentence logically follows the next.) And his usually pinpoint pupils dilate to cover almost half of his iris. Only exposure to stimulant medications, like the Adderall used to treat ADHD, will produce these synchronous, reversible, measurable changes in hyperactivity, verbal coherence, and pupillary size, that we see in the president.

Stimulants enable those with ADHD to focus, and thereby examine thoughts or objects in a leisurely fashion, without being pulled off track by internal or external distractors. Consequently they no longer frenetically hop (physically or verbally) from one shiny object to another. Stimulants help those with ADHD appear calmer, more regulated, and more reasonable — in essence, more presidential. Interestingly, Speaker of the House Nancy Pelosi astutely made note of these medication-induced changes in Mr. Trump’s functioning. At this years’ National Prayer Breakfast, she commented that Mr. Trump had appeared “a little sedated” at both the State of the Union this year, as well as in 2019.

We should encourage Mr. Trump to take his medication every day, in order to improve his attention, decrease his impulsivity and enable him to think more effectively about the future. We should not settle for cosmetic pharmacology, allowing him to consume powerful medications only when he feels he needs them. We need him to be prepared for challenges at all times, whether they come in the form of drone strikes, cyber attacks, or viral invaders. We should monitor his hyperactivity, speech patterns, and pupils to let him know that we can tell when he is off his medications, and thus not prepared to fulfill the duties of the presidency.

For the future, we need more thorough vetting of presidential candidates, including their finances, physical wellbeing, and mental health. The public would have been well served by understanding that Mr. Trump’s ADHD was an essential feature of who he is, and that he would not suddenly “start acting presidential” once he took office. I am not advocating that ADHD, or depression, or other mental health conditions be a litmus test for candidacy. However, when present, the public has a right to know about the severity of such conditions, and any treatments the candidate uses to mitigate their impact. Even recruits to the lowest rank of our military are screened for a number of health issues, including ADHD, yet we allow others to be commander-in-chief with no such scrutiny. (Somewhat perversely, while ADHD itself is not a cause for rejecting military applicants, having received treatment for it is.)

All of us need to become more familiar with ADHD so that we recognize it in our family members, co-workers, and candidates. Millions of American adults with ADHD remain undiagnosed and untreated. Appropriate professional help can salvage careers, repair relationships, and even save lives.