Why Doesn’t Trump Take His ADHD Meds Every Day?
He’d be more stable and we’d be more safe
During a recent interview about neurodiversity, I was asked why President Trump doesn’t take his stimulant medications consistently. I had already described the behaviorally based definition of ADHD, how data from the public record amply and objectively confirms that Trump has the condition, and the evidence (hugely dilated pupils, drastically reduced hyperactivity, increased coherence of speech) that Trump takes stimulant medications when he wants to reduce his ADHD symptoms and appear presidential. I explained that while we could be certain of Trump’s ADHD, and his use of stimulant medications, we would be speculating if we discussed why he only consumes his medications sporadically. As the COVID-19 crisis has reminded us regarding medical professionals making public pronouncements, we must distinguish what we know, from what we think is likely to be true.
We know that Mr. Trump meets the full diagnostic criteria for ADHD. At most, we can say that, he is highly likely to have a Narcissistic Personality Disorder as well. We define ADHD based on objective behavioral criteria (excessive fidgeting, interrupting of others, distractibility, impulsive decisions) whereas to determine whether someone is a narcissist we need to know why they act in ways that appear to be self-centered, self-aggrandizing, or dismissive of the humanity of others. Yet we have heard volumes over the past four years regarding Trump’s putative narcissism and sociopathy and almost nothing about his unequivocal ADHD.
Failing to identify ADHD leads to false conclusions
The term diagnostic overshadowing explains how mental health professionals, and others, become so distracted by dramatically aberrant features of one condition that they are blinded to less flashy conditions that might also be present. Clinicians treat hundreds of thousands of adults with ADHD for depression, or anxiety, or substance abuse problems for years without awareness of their underlying ADHD. Similarly, Trump gets our attention when he compares himself favorably to Lincoln or to god, blithely orders children to be put in cages, or enthusiastically encourages Americans to battle each other. Even when we comment on his short attention span, constant interrupting, jumping from topic to topic, impulsively blurting out comments, trouble putting in sustained mental effort, non-stop fidgeting and gesturing, and displays of poor organization, planning, and prioritizing, our descriptions of these behaviors universally omit pointing out that these are all symptoms of his ADHD.
When we fail to identify mental health issues, we draw false conclusions about behavior. Numerous columnists have mentioned Trump’s dramatic improvement in performance from the first debate with Biden, to the second. All of these writers interpreted Trump’s decreased interrupting, better emotional control, and greater ability to speak three consecutive sentences on the same topic, to a conscious decision on the president’s part to act more maturely. They claimed that this demonstrated that Trump could simply have chosen to behave more like a normal adult throughout his presidency.
Every one of these commentaries missed the fact that the president’s second debate performance was enhanced by stimulant medication. His huge pupils (covering 40% of his iris, compared to about 8% for Biden) along with the huge reduction in hyperactivity (grimacing, gesturing, torso-twisting), and his enhanced ability to speak coherently (comments stayed on topic, thoughts followed each other logically) document that he took stimulant medications before the second debate. Stimulants have enabled the president on numerous important occasions, to appear somewhat more presidential. The “real” Trump, as described by numerous aides, associates, and family members, is the ADHD Trump of the first debate.
Trump could take his meds and still appeal to his base
We gave control of the country to a man who is manifestly not in control of his own behavior. He can’t turn his ADHD on or off at will. He hasn’t been acting — we’ve all seen him try to imitate others, and how exaggerated and unnatural those performances are. The extent of Trump’s choice lies in deciding whether or not to take his stimulant medications.
Stimulant medications reduce, but don’t eliminate, ADHD symptoms. In the second debate, Trump was still spontaneous enough, still politically incorrect enough, to provide entertainment value, to pique viewers’ interest, to lure people in with his hot authenticity while eschewing cool calculation. Trump was still Trump, and behaved far outside the norms we would expect for an ordinary human talking to another for 90 minutes. He still appealed to his base.
So why doesn’t Trump take his stimulants consistently? Why are many people inconsistent with their ADHD medications? I conjecture that there are multiple reasons.
So what’s the down side to Trump taking his meds?
Over several years of attending psychiatric conferences, I would hear one colleague raise the same questions at the end of every lecture on ADHD. Why did all of the kids he treated for ADHD hate to be on stimulant medications, while the adults with ADHD begged for these very same medications? Were the younger brains that different in their physiologic response to the medications?
The lecturers would invariably point out that the medications seem to be similarly effective across the age span, whether we are looking at laboratory studies of performance on executive function tasks, or assessments of ADHD symptom reduction in the real world. Sometimes they would indicate that side effects of stimulants do tend to be more prominent in kids (appetite suppression, headaches, stomach aches, emotional flattening, more rarely moodiness and irritability). Often the speakers would imply or directly assert that most of the differences in the desire to take the medications was psychological, a result of changes in attitudes as a consequence of aging.
For children with ADHD, medications deliver a clear message that the parents or teachers or coaches in your world think that there is something wrong with you, something defective in need of fixing. You are being marked as an outcast, a deviant. Furthermore, the benefits of stimulant medication may not appear very attractive. We are trying to get a child to study more, which can feel like an attempt to play less and have less fun. In contrast, adults have real life experiences showing that their ADHD symptoms had led to failed classes, disrupted relationships, speeding or parking tickets, and reprimands at work. Adults want to improve their performance, and they have the objectivity to see that the medications help them succeed in a neurotypical world.
Mental health professionals, and others, become so distracted by dramatically aberrant features of one condition that they are blinded to less flashy conditions that may also be present
However, even if a higher percentage of adults than children personally find medications acceptable, many adults with ADHD still remain inconsistent in taking their medications. Part of this is due to the nature of ADHD, which makes regular habits, following schedules, and preparing in advance for future situations, all more challenging. Attending doctors appointments, filling prescriptions on time, and remembering to take daily pills, all provide opportunities for getting off track. The more severe the ADHD, the harder it is to establish and maintain these patterns. ADHD itself makes it harder to consistently take ADHD medications.
My work with an individual severely impaired by ADHD illustrates this point. For more than two decades I worked with Frank for a weekly hour of talk therapy and medication management. Frank knew that the stimulants helped him to be more functional. He had no side effects. Each week he would report that he knew he had missed at least a few doses of medication. We employed dozens of cognitive behavioral therapy tools to help him to remember his medication. Yet for several years, he would refill his monthly supply only every 13–14 months! Which meant that he was only taking a pill once every two weeks. Which meant that at least half the times when we met, he had not taken any pills since the last session. ADHD makes staying on track challenging.
Mr. Trump displays severe ADHD, with severe executive function deficits. Could he simply be not remembering to take his medications? While possible, this seems unlikely, particularly because he is in an environment surrounded by aides and advisors attending to his daily needs. Could staff and family be so fearful of appearing disloyal to the president if they were to check whether he had remembered his medication? It’s plausible, but seems unlikely to be the full story.
Obliviousness probably provides part of the answer. By its nature, many people with ADHD remain unaware of the impact of their behavior on others, they often literally and figuratively don’t know whose toes they are stepping on. This leaves them unaware of the range of problems caused by their ADHD, which deprives them of the ability to appreciate the full benefits of what the medication may do for them. Mr. Trump often seems genuinely unaware of how his behavior effects others, as exemplified by his apparent belief in statements where he claims to be the least racist person in a room, or acts bewildered by why all suburban woman might not love him, or when he takes umbrage with the press pointing out consequences of some of his actions and inactions. He often appears truly surprised that others find his behavior unacceptable.
A further degree of obliviousness remains a distinct possibility: Trump may not even know that he has ADHD. Although a variety of lines of evidence support the claim that he has taken stimulants for decades, he may truly believe that he has taken them primarily for weight loss, or as an energy boost, or to be a little more focused. Particularly given his concern with his self image the fear that he could be perceived as “sleepy” or “low energy” could drive his stimulant use without any awareness that he has ADHD.
Obliviousness probably provides part of the answer. By its nature, many people with ADHD remain unaware of the impact of their behavior on others
Or Trump could be aware of his ADHD, and poor medication compliance could signal denial about the condition. Trump never likes to acknowledge any imperfections in his body or brain. He may be resisting medication for reasons similar to the children for whom taking medication represents acceptance of being less than superlative. Small hands? Not me! I’m a stable genius, how could I need medication?
ADHD encourages spontaneity. It can magnify desires to do what one wants to do, when one wants to do it, and to rebel against authority or perceived attempts of others to control those impulses. Particularly when oppositional or narcissistic traits are in the mix, this desire to be unfettered can transform into overt defiance of authority. If a doctor, or parent or spouse tells you to take your medication, that may then increase resistance to doing so.
Trump clearly detests being told what to do. He likes to be able to proclaim that his gut knew better than the experts’ brains even though, or maybe particularly because, a series of blunders demarcates his life. He has failed repeatedly, and others have bailed him out, preventing him from learning much from his losses. His father launched Donald’s career with millions of dollars and important positions in the family real estate business, and then shoveled in millions more each time Donald’s projects led to massive losses. Thousands of laborers, contractors, and business partners have been stiffed by Donalds’ bankruptcies (or just because he felt like not paying), yet his own finances have been rescued by the lawyers who wrote the contracts that protected Donald while others were left holding the empty bag. He ignored public health advice, contracted COVID-19, received first class medical treatment, and then continued to rebel against medical advice before he had even fully recovered. Why would he bother to do what the doctor’s say, when he keeps getting rewarded for doing things his way?
Mr. Trump often seems genuinely unaware of how his behavior effects others, as exemplified by his apparent belief in statements where he claims to be the least racist person in a room, or acts bewildered by why all suburban woman might not love him
We have seen stimulants help make Trump less emotionally volatile, more organized in his thoughts, less impulsive in his utterances, and less hyperactive. Maybe he wouldn’t have approved missile launches at Iran, and then called them back minutes later when he realized they might kill people, if he had been taking his stimulants more regularly, and had been less impulsive. Maybe, on stimulants, he would have sat down and studied health care reform, or immigration rules, or North Korea, instead of making pronouncements and rushing to action with almost no knowledge of the issues involved. Maybe he would have blurted fewer insults to our allies and fawning approval of enemy despots, had he taken stimulants routinely. We will never know.
We do know that individuals with ADHD who take stimulants show reductions in distractibility, improved motivation to tackle daunting tasks, and less emotional dysregulation. They are likely to do better on tests, be involved in fewer car crashes, have fewer serious accidents, are less likely to become drug addicts, and less likely to die of suicide or murder. There are compelling reasons for Mr. Trump, and for the country, for him to take his stimulants more consistently.
I know that Donald Trump has ADHD. I know that stimulants help his ADHD symptoms. I don’t know why he takes them so sporadically. But I do hope that he and his handlers find ways for him to be more consistent with taking them. Our lives may depend on it.
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