Keith Conners

Obituaries

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j2253 (Published 06 July 2017)Cite this as: BMJ 2017;358:j2253

Last words on ADHD from the father of the diagnosis

Allen Frances professor emeritus former chair, Bernard J Carroll professor emeritus former chair Department of Psychiatry and Behavioral Science, Duke University, North Carolina, USA

Shortly before his death on 5 July 2017, Keith Conners helped us write this obituary. He didn’t want to talk himself up, but rather provide one last word of warning on attention deficit hyperactivity disorder—a condition that 50 years ago he helped identify and validate, but recently had done his best to restrain. Keith had collaborated with Leon Eisenberg in the early 1960s, when what we now call ADHD began to take shape, and probably knew more about what the disorder is, and is not, than anyone who has ever lived.

Psychopharmacology in children

As a young child psychologist at Johns Hopkins, Eisenberg asked Keith to analyse data from the very first randomised clinical trial of d-amphetamine (Dexedrine) in children with severe hyperactivity and impulsivity. Soon after, he conducted the first trial of a much newer drug, methylphenidate (Ritalin), and published papers announcing distinctly positive results. By the end of the 1960s, Conners had developed what became the standard rating scales that were used to assess children’s symptoms and measure the impact of treatment. His work provided the foundation for psychopharmacology in children, which at the time was controversial.

Although it went through several name changes—hyperkinetic reaction of childhood, minimal brain dysfunction, and, finally, attention deficit disorder in 1980—the condition became an official diagnosis that was included in the Diagnostic and Statistical Manual of Mental Disorders and was gradually accepted by the medical establishment and society. Throughout this evolution, Keith participated in the most important trials, the most important studies, and the most important conferences—always lending an erudition and wit that his colleagues admired greatly.

Landmark study

Keith was always the smartest person in any room he entered. A chess prodigy in his home state of Utah, he entered the University of Chicago at age 16 and became a Rhodes scholar at Oxford, gaining first class honours in philosophy, psychology, and physiology. He earned his PhD in clinical psychology at Harvard. He worked at Johns Hopkins, Harvard, and other universities before founding the ADHD clinical programme at Duke in 1989. He helped lead the landmark Multimodal Treatment Study of Children with ADHD—the “MTA study,” generally described as the most comprehensive and influential study in child psychiatry—and founded the Journal of Attention Disorders. Although he was a master of psychological theory, he remained an active clinician who treated countless patients and their families.

A serious man in a serious specialty, Keith Conners still managed never to fully grow up. In the most magical way, he was Peter Pan and a Renaissance man in equal parts. His mind and spirit retained their curiosity and delight in all aspects of the human comedy. He inhaled everything from Plato to modern novels. (This was a man who not only read Steinbeck but actually drank with him during a chance encounter in Spain.) He was a consultant during the planning stages of a new educational television show for children that became Sesame Street. He painted in oil and watercolour, and he lived and died with perhaps the only department at Duke that was more important than his own—its basketball team. He had an uncanny ability to switch easily from the particular to the general, from objective to subjective, from this moment to eternity.

Overdiagnosis?

Keith was justifiably proud of his work on ADHD, but in his final years he began to cringe at how the diagnosis—so useful

when correctly applied to the few—had become so badly misapplied. He considered the true prevalence of childhood ADHD to be around 2-3%; rates of diagnosis, meanwhile, have risen persistently, to the point where today about 11% of American children are already diagnosed with ADHD, and 15% will receive the diagnosis before they turn 18. Other countries, to various extents, have seen similar unjustified rises. Keith believed that the overdiagnosis and overmedication of millions of children resulted from aggressive marketing by pharmaceutical companies, careless doctoring, worried parents, and schoolroom chaos. Large studies in many countries have shown that the best predictor of whether a child is diagnosed with ADHD is his or her birth date—the youngest children in any elementary school class, who are naturally more immature than their peers, are diagnosed considerably more often than the older children. Keith knew that attention and hyperactivity problems occur on a spectrum, with only the severe end needing treatment with stimulants, first Ritalin (methylphenidate) and now mostly Adderall (amphetamine and dextroamphetamine), Concerta (methylphenidate), and Vyvanse (lisdexamfetamine). He was most recently alarmed by the widespread carelessness in diagnosing ADHD in adults and by the risk that the prescription of stimulants can worsen a missed psychiatric diagnosis. He called the overdiagnosis of ADHD in the US “a national disaster of dangerous proportions.”

Keith did not go quietly. Like his mentor, Leon Eisenberg, he discussed his horror in articles and at professional conferences; as he became too feeble to fly, he allowed a reporter from the New York Times to tell his story, warts and all, in a book called ADHD Nation. The book helped expose the distortion of the diagnosis by medical and corporate interests, and the epidemic of stimulant abuse on college campuses and now high schools. He courageously accepted his role, however unwitting, in ADHD’s veering so far off course—and, recognising his impending mortality, was eager to speak up before it was too late. He helped compose his obituary, hoping it might help improve practice and the lives of children who otherwise might be misdiagnosed. It takes a man of special integrity to criticise his own life’s work and to spend his last days wanting to protect people from its misuse.

Keith’s heart, so devoted to the welfare of children throughout his remarkable life, finally gave out soon after his 84th birthday. We worked with him at Duke over many years, and we both loved him. We will miss him terribly, as will medicine and psychology, and the many patients, families, and school systems that benefited from his work.