Conduct disorder
Conduct Disorder
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 A1-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 harm (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 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).
Acts of deceitfulness or theft 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 A11); or stealing items of nontrivial value without confronting the victim (e.g., shoplifting, forgery) (Criterion A12).
There may also be 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.
- 312.81 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 puberty. Many children with this subtype also have concurrent Attention-Deficit/Hyperactivity Disorder. Individuals with Childhood-Onset Type are more likely to have persistent Conduct Disorder and to develop adult Antisocial Personality Disorder than are those with Adolescent-Onset Type.
- 312.82 Adolescent-Onset Type. This 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.
- 312.89 Unspecified Onset. This subtype is used if the age at onset of Conduct Disorder is unknown.
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 a 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 some of 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 may be low, despite a projected image of "toughness." For other individuals, measured self-esteem may be overly inflated. 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, particularly with regard to verbal IQ. 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 Learning 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, history of maternal smoking during pregnancy, peer rejection, association with a delinquent peer group, neighborhood exposure to violence, and certain kinds of familial psychopathology (e.g., Antisocial Personality Disorder, Substance Dependence or Abuse).
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 (which is predictive of a worse prognosis).
Conduct Disorder, especially the Childhood-Onset Type, is 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 nonconfrontational 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. General population studies report rates ranging from less than 1% to more than 10%. Prevalence rates are higher among males than females. 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 the preschool years, but the first significant symptoms usually emerge during the period from middle childhood through middle adolescence. Oppositional Defiant Disorder is a common precursor to the Childhood-Onset Type of Conduct Disorder. 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 Disorders, Anxiety Disorders, Somatoform Disorders, and Substance-Related Disorders.
Familial Pattern
Estimates from twin and adoption studies show that Conduct Disorder is influenced by both genetic and environmental factors. 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 to authority figures), it does not include the persistent pattern of the more serious forms of behavior in which either the 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 with a Mood Disorder. 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 the Mood Disorder. If criteria for both are met, diagnoses of both Conduct Disorder and the Mood 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 "Additional Conditions That May Be a Focus of Clinical Attention," p. 740). 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.
Diagnostic criteria for Conduct Disorder
- 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
- often bullies, threatens, or intimidates others
- often initiates physical fights
- has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
- has been physically cruel to people
- has been physically cruel to animals
- has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
- has forced someone into sexual activity
- Destruction of property
- has deliberately engaged in fire setting with the intention of causing serious damage
- has deliberately destroyed others' property (other than by fire setting)
- Deceitfulness or theft
- often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
- has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
- Serious violations of rules
- often stays out at night despite parental prohibitions, beginning before age 13 years
- 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)
- is often truant from school, beginning before age 13 years
- Aggression to people and animals
- The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
- If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
Code based on age at onset:
- 312.81 Conduct Disorder, Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years
- 312.82 Conduct Disorder, Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10 years
- 312.89 Conduct Disorder, Unspecified Onset: age at onset is not known
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
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.