From ADHD pioneer to assessment giant

Keith Conners, PhD, is a pioneer in ADHD research and is considered a giant in the field of ADHD assessment. In this interview, Conners talks about his education, his career path and how several turns of luck got him into the test publishing business. 

Tell us a bit about your childhood and your education

I was born during the Great Depression in a little canyon town called Bingham, in Utah, and later moved to Salt Lake City. In the fourth grade, I had rheumatic fever. In those days, the treatment was sulfa drugs and lying in bed. So I spent pretty much a whole year in bed and was told not to move because it would damage my heart. I had no television, of course, but I had a few books lying around from my older sister who was just starting college. I tried to read as much as I could of those books, and I also read our encyclopedias. By the time I finally recovered, I had missed a whole school year. It turns out that doing a lot of reading was a pretty unusual thing for the school kids of the day, so by the time I got to junior high school, a teacher suggested that I should skip high school. I went to the University of Utah where they had tryouts for early entry to the University of Chicago, where I was accepted. 

When I finally left Chicago to go to Oxford as a Rhodes Scholar, I chose philosophy as my main course of study. At that time, philosophy was integrated with psychology, so I also had my first exposure to psychology when I got to Oxford, in a program called Philosophy, Psychology and Physiology. In this program, I got a quick grounding in the early history of psychology, and that became my ticket when I graduated. After graduation, I didn’t have a lot of money, and I didn’t know how I was going to support myself in graduate school. But it turned out that I was qualified as a teaching assistant for Stanford’s clinical psychology program. It was that year that got me thinking of clinical psychology as a career. From there, I transferred to Harvard, where I studied clinical psychology and began working with patients in a clinical setting.

How did you first become interested in studying ADHD?

I really became interested during my first job at Johns Hopkins Hospital. Perhaps I can tell you a little bit about how I got there. During my postdoctoral year, I got a letter from John Money, one of the pioneers in sex research at Johns Hopkins. He invited me to come and work with him. I declined the offer, but he told Leon Eisenberg, the head of child psychiatry, about me. Eisenberg invited me to come and visit Johns Hopkins, where I interviewed for a job as his research assistant. He said to me, “You know, as a psychologist, working in a medical setting, you’re going to be at a disadvantage working with MDs, because the MDs rule pretty much everything that goes on. The only ticket you have is your research productivity. So if you want to work here, it’s going to be about how much you publish.”

I signed on with him just as he was finishing the very first randomized clinical trial of amphetamines in the treatment of hyperactive children. It was a study of delinquent boys in a house cottage setting. The study had just completed and he asked me to analyze the data. I was pretty stunned by the results, because the treatment they were using seemed to produce almost universal change in these kids. They stopped bedwetting, they stopped being aggressive, and for the first time, they seemed to be amenable to the program in the cottages they were living in. I was very impressed with the findings, and that got me involved in my lifetime career of studying hyperactive kids.

How did you end up authoring an ADHD rating scale?

The offshoot of that very first study was that they were using a checklist of symptoms, which allowed the researchers to measure the effect of the drug as seen by the cottage parents and teachers. They had a set of questions for the parents in the cottages and another set of questions for the teachers. It was a checklist that they got from the table of contents in Leo Kanner’s Child Psychiatry handbook. I started working with that checklist by using statistical methodology to look at the clusters of symptoms. I basically discovered a series of very distinct clusters, which later became the basis of the DSM criteria. 

Eventually, I interviewed several hundred patients with this checklist and I made it available for others to use. It turned out to be something that a lot of people wanted. The federal government decided to use the checklist as the primary measure in the new field of child psychopharmacology.

How did your checklist end up getting published?

For about 20 to 25 years, I simply copied the scale myself and I mailed it out by hand to hundreds and hundreds of people who proceeded to change it, copy it, and claim it.

I made one attempt to get the rating scale published by a leading test publisher, but they turned it down. That kind of discouraged me, although I wasn’t surprised. This was a homegrown, academic kind of thing and, apparently, it didn’t have that kind of marketable appeal. Then, one day, I was walking across the floor of the American Psychological Association meeting, and this fellow named Dr. Steven Stein came up to me and said, “You know, we have a publishing company starting up that would love to have your checklist.” I replied, “I’m not interested in commercializing my scale. Nobody would want it anyway; they get it for free now.”

He was very persuasive in telling me that I was underestimating what that scale meant to people in our field. We had a long debate about whether it was even worthy of doing such a thing. Then he said, “Let us take your scale. We have some good scientists, and we have a staff who can change it into a form that will help get it into more people’s hands. But more importantly, it will make sure that the scale is scientifically accepted and respected. Right now, there is no standardized version.” After that discussion, I agreed to license the scale. In the end, this was a load off my mind­ — I got to transfer all of the many details to someone else. Just to create a manual, for example, is a very big job.

Steve was really good on his word. We were at the beginning of a boom in psychopharmacology, where the scale had already been used for over 20 years. We were at the beginning of a phase where the computer was making a big difference in the exposure and use of these kinds of scales, and Steve had already started a business of computerizing technical products. With both of those things going, in the first year, as he promised, it was selling more than I was making as a professor.

I think it’s one of those many chances of luck that have checkered my career. You know, it was luck for me to have turned my rheumatic fever into an advantage in my own development. It was luck for me to have a schoolteacher who said I belonged at a higher level. It was luck to get chosen as a Rhodes Scholar, which opened a lot of doors, including Stanford and Harvard. It was entirely chance that John Money handed my letter to Leon Eisenberg. My career, I guess like a lot of careers, is subject to chance. There are turning points and changes in direction that come about because of chance events, and I had plenty of those. The saying by Louis Pasteur, “Chance favors the prepared mind,” comes to the fore here. It wasn’t that my prepared mind got me anywhere, but I had a lot of chances that allowed me to use what I did know.

What advice do you have for people who are thinking of publishing a test or rating scale?

If you have an idea for some tool that could be published in the field that we work in, ADHD, or any other mental disorder, find a publisher that does a few things. First, make sure they have an expert scientific staff to publish it with the best science available. Second, try to find a publisher that has, as its leader, someone who is a leader in psychology, not just someone who is there to manage a businesses to make money. Finally, find a publisher that will treat you well as an author.

Your scales are used as part of the ADHD assessment process. What do you think is the responsible way to assess for ADHD?

A responsible assessment happens in phases. It begins with an interview or observation of the child, followed by information gathering on the perceptions of the parents and outside information from other sources. This has to be gathered over a series of observations in which you are looking at the total life story, beginning in early childhood. A clinical history includes a screening phase where, for example, a rating scale can be used to get a list of the symptoms or problematic behaviors that are showing up, and to get a list or look into where there are areas of impairment. The assessment should also go through a family history, because that will give you some clues as to the genetic background of this child. And then there is the early perinatal and birth history, and the history of early schooling. But unless there are strong symptoms with impairment before the age of 7 to 12, then it’s not ADHD. It’s a process that may take as many as three to four visits in order to establish a reasonable certainty. 

My rating scales are very useful as information gathering tools. But these ratings scales are an aid to the diagnostic process; they are not in and of themselves the diagnosis. Unfortunately, they’re often used as the last stop on the information gathering. But the assessment itself should be a comprehensive assessment of multiple observers and a thorough history of the psychiatric background. (Author’s Note: You can view a video of Conners’ full response to this question.)

What would you tell someone who is just learning how to use one of your tests?

This is what is really important for people to know: No matter how well written they are, people don’t like to read manuals. But one of the things I learned very early in my training is that any tool you plan to use for another human being, do it exactly as prescribed. And that’s why you read the manual. Read it to find out exactly how to use that tool. So if you are using one of the Conners rating scales or one of my continuous performance tests, it’s important that you remember that the results of that come from a certain way of administering, scoring and interpreting it. We try to put all of that information in the manual. 

Also, the best way to learn is under the supervision of someone who is already an expert at it. If you have a mentor or a teacher who is already administering complex tests, get them to instruct you, and watch them administer the tests. 

When you think about your legacy, what do you want it to be?

First of all, I don’t want to leave the scene — I love being here. I enjoy talking to my colleagues by email, phone or conferences. I enjoy being asked by experts in other fields to help with issues surrounding ADHD in their fields. I guess all of us have to have a choice of legacy at some point. I just wrote an obituary for a longtime colleague of mine, and writing about him, I thought well, you know, he was really a guy who gave a lot to his colleagues. He gave a lot of himself to his students. He really cared about his patients and enjoyed that a great deal. He was very kind and he was not stuffy at all. He affected a lot of people in a positive way in his life. I’d like to have something like that said about me.

What advice do you have for practitioners beginning their careers?

One piece of advice is something I really regret that I didn’t do at the beginning. I wish I had taken the advice of one of the great novelists of all time to write in your journal every day. No matter what you write about: your thoughts, what’s happening where you live, what’s going on — anything in the world you live in. It can be a few sentences or 100 paragraphs; it really doesn’t matter. If I had done that from the beginning, writing in my journal every day, I would have written about the people I can now barely remember, the places I’ve been, what was my experience at that time in my life. If I had done that every day since I began, I wouldn’t now have to write a great memoir or a fundamental text on ADHD. All I’d have to do is go to my journal and arrange the pages in order to fit the story I was trying to tell. So I wish I had done that. And you guys out there should be doing that now. Once you get to my age, there will be all of that information from your life that only you had access to. As you get to my age, you’ll wish you had access to that information, for your own joy and satisfaction and for that of others.