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Statistical Manual of Mental Disorders (DSM IV), 4th
edition, 1994
American Psychiatric Association
Conduct Disorder, 312.8
Diagnostic Features
The essential feature of Conduct Disorder is a repetitive and persistent pattern
of behavior in which the basic rights of others or major age-appropriate
societal norms or rules are violated (Criterion A).
These behaviors fall into
four main groupings: aggressive conduct that causes or threatens physical harm
to other people or animals (Criteria Al-A7), nonaggressive conduct that causes
property loss or damage (Criteria A8-A9), deceitfulness or theft (Criteria
A10-A12), and serious violations of rules (Criteria A13-A15).
Three (or more)
characteristic behaviors must have been present during the past 12 months, with
at least one behavior present in the past 6 months.
The disturbance in behavior
causes clinically significant impairment in social, academic, or occupational
functioning (Criterion B).
Conduct Disorder may be diagnosed in individuals who
are older than age 18 years, but only if the criteria for Antisocial Personality
Disorder are not met (Criterion C).
The behavior pattern is usually present in a
variety of settings such as home, school, or the community. Because individuals
with Conduct Disorder are likely to minimize their conduct problems, the
clinician often must rely on additional informants. However, the informant's
knowledge of the child's conduct problems may be limited by inadequate
supervision or by the child's not having revealed them.
Children or adolescents with this disorder often initiate aggressive behavior
and react aggressively to others.
- They may display bullying, threatening, or
intimidating behavior (Criterion A1);
- initiate frequent physical fights (Criterion
A2);
- use a weapon that can cause serious physical hurts (e.g., a bat, brick,
broken bottle, knife, or gun) (Criterion A3);
- be physically cruel to people (Criterion A4)
- or animals (Criterion A5);
- steal while confronting a victim (e.g., mugging, purse
snatching, extortion, or armed robbery) (Criterion A6);
- or force someone into
sexual activity (Criterion A7). Physical violence may take the form of rape,
assault, or in rare cases, homicide.
Deliberate destruction of others' property is a characteristic feature of this
disorder and may
- include deliberate fire setting with the intention of causing
serious damage (Criterion A8)
- or deliberately destroying other people's property
in other ways (e.g., smashing car windows, school vandalism) (Criterion A9).
Deceitfulness or theft is common and may include
- breaking into someone else's
house, building, or car (Criterion A10);
- frequently lying or breaking promises
to obtain goods or favors or to avoid debts or obligations (e.g., "conning"
other people) (Criterion Al l);
- or stealing items of nontrivial value without
confronting the victim (e.g., shoplifting, forgery) (Criterion A12).
Characteristically, there are also serious violations of rules (e.g., school,
parental) by individuals with this disorder.
Children with this disorder often
have a pattern, beginning before age 13 years, of staying out late at night
despite parental prohibitions (Criterion A13).
There may be a pattern of running away from home overnight (Criterion A14).
To be considered a symptom of Conduct
Disorder, the running away must have occurred at least twice (or only once if
the individual did not return for a lengthy period). Runaway episodes that occur
as a direct consequence of physical or sexual abuse do not typically qualify for
this criterion.
Children with this disorder may often be truant from school,
beginning prior to age 13 years (Criterion A15).
In older individuals, this
behavior is manifested by often being absent from work without good reason.
Subtypes
Two subtypes of Conduct Disorder are provided based on the age at onset of the
disorder (i.e., Childhood-Onset Type and Adolescent-Onset Type). The subtypes
differ in regard to the characteristic nature of the presenting conduct problems,
developmental course and prognosis, and gender ratio. Both subtypes can' occur
in a mild, moderate, or severe form. In assessing the age at onset, information
should preferably be obtained from the youth and from caregiver(s). Because many
of the behaviors may be concealed, caregivers may underreport symptoms and
overestimate the age at onset.
Childhood-Onset Type. This subtype is defined by the onset of at least one
criterion characteristic of Conduct Disorder prior to age 10 years. Individuals
with Childhood-Onset Type are usually male, frequently display physical
aggression toward others, have disturbed peer relationships, may have had
Oppositional Defiant Disorder during early childhood, and usually have symptoms
that meet full criteria for Conduct Disorder prior to puberry. These individuals
are more likely to have persistent Conduct Disorder and to develop adult
Antisocial Personality Disorder than are those with Adolescent-Onset Type.
Adolescent-OnsetType. T'his subtype is defined by the absence of any criteria
characteristic of Conduct Disorder prior to age 10 years. Compared with those
with the Childhood-Onset Type, these individuals are less likely to display
aggressive behaviors and tend to have more normative peer relationships (although
they often display conduct problems in the company of others). These individuals
are less likely to have persistent Conduct Disorder or to develop adult
Antisocial Personality Disorder. The ratio of males to females with Conduct
Disorder is lower for the Adolescent-Onset Type than for the Childhood-Onset
Type.
Severity Specifiers
Mild. Few if any conduct problems in excess of those required to make the
diagnosis are present, and conduct problems cause relatively minor harm to
others (e.g., lying, truancy, staying out after dark without permission).
Moderate. The number of conduct problems and the effect on others are
intermediate between "mild" and "severe" (e.g. stealing without confronting a
victim, vandalism).
Severe. Many conduct problems in excess of those required to make the diagnosis
are present, or conduct problems cause considerable harm to others (e.g. forced
sex, physical cruelty, use of â weapon, stealing while confronting a victim,
breaking and entering).
Associated Features and Disorders
Associated descriptive features and mental disorders.
Individuals with Conduct Disorder may have little empathy and little concern for
the feelings, wishes, and well-being of others. Especially in ambiguous
situations, aggressive individuals with this disorder frequently misperceive the
intentions of others as more hostile and threatening than is the case and
respond with aggression that they then feel is reasonable and justified. They
may be callous and lack appropriate feelings of guilt or remorse. It can be
difficult to evaluate whether displayed remorse is genuine because these
individuals learn that expressing guilt may reduce or prevent punishment.
Individuals with this disorder may readily inform on their companions and try to
blame others for their own misdeeds. Self-esteem is usually low, although the
person may project an image of "toughness." Poor frustration tolerance,
irritability, temper outbursts, and recklessness are frequent associated
features. Accident rates appear to be higher in individuals with Conduct
Disorder than in those without it.
Conduct Disorder is often associated with an early onset of sexual behavior,
drinking, smoking, use of illegal substances, and reckless and risk-taking acts.
Illegal drug use may increase the risk that Conduct Disorder will persist.
Conduct Disorder behaviors may lead to school suspension or expulsion, problems
in work adjustment, legal difficulties, sexually transmitted diseases, unplanned
pregnancy, and physical injury from accidents or fights. These problems may
preclude attendance in ordinary schools or living in a parental or foster home.
Suicidal ideation, suicide attempts, and completed suicide occur at a higher
than expected rate. Conduct Disorder may be associated with lower than average
intelligence.
Academic achievement, particularly in reading and other verbal
skills, is often below the level expected on the basis of age and intelligence
and may justify the additional diagnosis of a Leaming or Communication Disorder.
Attention-Deficit/Hyperactivity Disorder is common in children with Conduct
Disorder. Conduct Disorder may also be associated with one or more of the
following mental disorders: Learning Disorders, Anxiety Disorders, Mood
Disorders, and Substance-Related Disorders. The following factors may predispose
the individual to the development of Conduct Disorder: parental rejection and
neglect, difficult infant temperament, inconsistent child-rearing practices with
harsh discipline, physical or sexual abuse, lack of supervision, early
institutional living, frequent changes of caregivers, large family size,
association with a delinquent peer group, and certain kinds of familial
psychopathology.
Associated laboratory findings.
In some studies, lower heart rate and lower skin conductance have been noted in
individuals with Conduct Disorder compared with those without the disorder.
However, levels of physiological arousal are not diagnostic of the disorder.
Specific Culture, Age, and Gender Features
Concerns have been raised that the Conduct Disorder diagnosis may at times be
misapplied to individuals in settings where patterns of undesirable behavior are
sometimes viewed as protective (e. g., threatening, impoverished, high-crime).
Consistent with the DSM-IV definition of mental disorder, the Conduct Disorder
diagnosis should be applied only when the behavior in question is symptomatic of
an underlying dysfunction within the individual and not simply a reaction to the
immediate social context. Moreover, immigrant youth from war-ravaged countries
who have a history of aggressive behaviors that may have been necessary for
their survival in that context would not necessarily warrant a diagnosis of
Conduct Disorder. It may be helpful for the clinician to consider the social and
economic context in which the undesirable behaviors have occurred. ,
Symptoms of the disorder vary with age as the individual develops increased
physical strength, cognitive abilities, and sexual maturity. Less severe
behaviors (e.g., lying, shoplifting, physical fighting) tend to emerge first,
whereas others (e.g., burglary) tend to emerge later. Typically, the most severe
conduct problems (e.g., rape, theft while confronting a victim) tend to emerge
last. However, there are wide differences among individuals, with some engaging
in the more damaging behaviors at an early age.
Conduct Disorder, especially the Childhood-Onset Type, is much more common in
males. Gender differences are also found in specific types of conduct problems.
Males with a diagnosis of Conduct Disorder frequently exhibit fighting, stealing,
vandalism, and school discipline problems. Females with a diagnosis of Conduct
Disorder are more likely to exhibit lying, truancy, running away, substance use,
and prostitution. Whereas confrontational aggression is more often displayed by
males, females tend to use more non confrontational behaviors.
Prevalence
The prevalence of Conduct Disorder appears to have increased over the last
decades and may be higher in urban than in rural settings. Rates vary widely
depending on the nature of the population sampled and methods of ascertainment:
for males under age 18 years, rates range from 6% to 16%; for females, rates
range from 2% to 9%. Conduct Disorder is one of the most frequently diagnosed
conditions in outpatient and inpatient mental health facilities for children.
Course
The onset of Conduct Disorder may occur as early as age 5-6 years but is usually
in late childhood or early adolescence. Onset is rare after age 16 years. The
course of Conduct Disorder is variable. In a majority of individuals, the
disorder remits by adulthood. However, a substantial proportion continue to show
behaviors in adulthood that meet criteria for Antisocial Personality Disorder.
Many individuals with Conduct Disorder, particularly those with Adolescent-Onset
Type and those with few and milder symptoms, achieve adequate social and
occupational adjustment as adults. Early onset predicts a worse prognosis and an
increased risk in adult life for Antisocial Personality Disorder and
Substance-Related Disorders. Individuals with Conduct Disorder are at risk for
later Mood or Anxiety Disorders, Somatoform Disorders, and Substance-Related
Disorders.
Familial Pattern
Estimates from twin and adoption studies show that Conduct Disorder has both
genetic and environmental components. The risk for Conduct Disorder is increased
in children with a biological or adoptive parent with Antisocial Personality
Disorder or a sibling with Conduct Disorder. The disorder also appears to be
more common in children of biological parents with Alcohol Dependence, Mood
Disorders, or Schizophrenia or biological parents who have a history of
Attention-Deficit/Hyperactivity Disorder or Conduct Disorder.
Differential Diagnosis
Although Oppositional Defiant Disorder includes some of the features observed in
Conduct Disorder (e.g., disobedience and opposition te, authority figures), it
does not include the persistent pattern of the more serious forms of behavior in
which either thé basic rights of others or age-appropriate societal norms or
rules are violated. When the individual's pattern of behavior meets the criteria
for both Conduct Disorder and Oppositional Defiant Disorder, the diagnosis of
Conduct Disorder takes precedence and Oppositional Defiant Disorder is not
diagnosed.
Although children with Attention-Deficit/Hyperactivity Disorder often exhibit
hyperactive and impulsive behavior that may be disruptive, this behavior does
not by itself violate age-appropriate societal norms and therefore does not
usually meet criteria for Conduct Disorder.
When criteria are met for both
Attention-Deficit/Hyperactivity Disorder and Conduct Disorder, both diagnoses
should be given.
Irritability and conduct problems often occur in children or adolescents having
a Manic Episode. These can usually be distinguished from the pattern of conduct
problems seen in Conduct Disorder based on the episodic course and accompanying
symptoms characteristic of a Manic Episode. If criteria for both are met,
diagnoses of both Conduct Disorder and Bipolar I Disorder can be given.
The diagnosis of Adjustment Disorder (With Disturbance of Conduct or With Mixed
Disturbance of Emotions and Conduct) should be considered if clinically
significant conduct problems that do not meet the criteria for another specific
disorder develop in clear association with the onset of a psychosocial stressor.
Isolated conduct problems that do not meet criteria for Conduct Disorder or
Adjustment Disorder may be coded as Child or Adolescent Antisocial Behavior (see
"Other Conditions That May Be a Focus of Clinical Attention," p. 684). Conduct
Disorder is diagnosed only if the conduct problems represent a repetitive and
persistent pattern that is associated with impairment in social, academic, or
occupational functioning.
For individuals over age 18 years, a diagnosis of Conduct Disorder can be given
only if the criteria are not also met for Antisocial Personality Disorder. The
diagnosis of Antisocial Personality Disorder cannot be given to individuals
under age 18 years.
Diagnostic criteria for Conduct Disorder, 312.8
A. A repetitive and persistent pattern of behavior in which the basic
rights of others or major age-appropriate societal norms or rules are violated,
as manifested by the presence of three (or more) of the following criteria in
the past 12 months, with at least one criterion present in the past 6 months:
Aggression to people and animals
(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm te, others (e.g., a
bat, brick, broken bottle, knife, gun)
(4) has been physically cruel to people
(5)has been physically cruel with animals `
(6) has stolen while confronting a victim (e.g., mugging, pursuing, snatching,
extortion, armed robbery)
(7) has forced someone into sexual activity
Destruction of property
(8) has deliberately engaged in fire setting with the intention of causing
serious damage
(9) has deliberately destroyed others' property (other than by
fire setting)
Deceitfulness or theft
(10) has broken into someone else's house, building, or car
(11) often lies to obtain goods or favors or to avoid obligations (i.e., "cons"
others)
(12) has stolen items of nontrivial value without confronting a victim (e.g.,
shoplifting, but without breaking and entering; forgery)
Serious violations of rules
(13) often stays out at night despite parental prohibitions, beginning before
age 13 years
(14) has run away from home overnight at least twice while living in parental or
parental surrogate home (or once without returning for a lengthy period)
(15) is often truant from school, beginning before age 13 years
B. The disturbance in behavior causes clinically significant impairment
in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for
Antisocial Personality Disorder.
Specify type based on age at onset:
Childhood-Onset Type: onset of at least one criterion characteristic of Conduct
Disorder prior to age 10 years
Adolescent-OnsetType: absence of any criteria characteristic of Conduct Disorder
prior to age 10 years
Specify severity:
Mild: few if any conduct problems in excess of those required to make the
diagnosis and conduct problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between "mild"
and "severe"
Severe: many conduct problems in excess of those required to make the diagnosis
or conduct problems cause considerable harm to others
American Psychiatric Association
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