BMJ 2017;358:j2253 doi: 10.1136/bmj.j2253 (Published 2017 July 06)
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Obituaries
OBITUARIES
Keith Conners
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
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
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.
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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
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BMJ 2017;358:j2253 doi: 10.1136/bmj.j2253 (Published 2017 July 06)
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OBITUARIES
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
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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.
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