Conduct
Disorder
Group Type
Solitary Aggressive Type
Undifferentiated Type
The essential feature of this disorder is
a persistent pattern of conduct in which the
basic rights of others and major
age-appropriate social norms or rules are
violated. The behavior pattern typically is
present in the home, at school, with peers,
and in the community. The conduct problems
are more serious than those seen in
Oppositional Defiant Disorder.
Physical aggression is common. Children or
adolescents with this disorder usually
initiate aggression, may be physically cruel
to other people or to animals, and frequently
deliberately destroy other people's property
(this may include fire-setting). They may
engage in stealing with confrontation of the
victim, as in mugging, purse-snatching,
extortion, or armed robbery. At later ages,
the physical violence may take the form of
rape, assault, or, in rare cases, homicide.
Covert stealing is common. This may range
from "borrowing" others possessions
to shoplifting, forgery, and breaking into
someone else's house, building, or car. Lying
and cheating in games or in schoolwork are
common. Often a youngster with this disorder
is truant from school, and may run away from
home.
Associated features. Regular
use of tobacco, liquor, or nonprescribed
drugs and sexual behavior that begins
unusually early for the child's peer group in
his or her milieu are common. The child may
have no concern for the feelings, wishes, and
wellbeing of others, as shown by callous
behavior, and may lack appropriate feelings
of guilt or remorse. Such a child may readily
inform on his or her companions and try to
place blame for misdeeds on them.
Self esteem is usually low, though the person
may project an image of
"tough-ness." Poor frustration
tolerance, irritability, temper outbursts,
and provocative recklessness are frequent
characteristics. Symptoms of anxiety and
depression are common, and may justify
additional diagnoses.
Academic achievement, particularly in reading
and other verbal skills, is often below the
level expected on the basis of intelligence
and age, and may justify the additional
diagnosis of a Specific Developmental
Disorder. Attentional difficulties,
impulsiveness, and hyperactivity are very
common, especially in childhood, and may
justify the additional diagnosis of
Attention-deficit Hyperactivity Disorder.
Age at onset. Onset is
usually prepubertal, particularly of the
Solitary Aggressive Type. Postpubertal onset
is more common among females than males.
Course. The course is
variable, mild forms frequently showing
improvement over time and severe forms
tending to be chronic. Early onset is
associated with greater risk of continuation
into adult life as Antisocial Personality
Disorder. In some cases there may be adequate
social functioning in adulthood, but
persistence of illegal activity, which may be
considered to be Adult Antisocial Behavior.
Finally, many people with Conduct Disorder in
childhood, particularly the Group Type,
achieve reasonable social and occupational
adjustment as adults.
Impairment. The degree of
impairment varies from mild to severe. It may
preclude attendance in an ordinary school
classroom or living at home or in a foster
home. When antisocial behavior is extreme,
institutionalization, with its temporary loss
of autonomy, may be necessary.
Complications. Complications
include school suspension, legal
difficulties, Psychoactive Substance Use
Disorders, venereal diseases, unwanted
pregnancy, high rates of physical injury from
accidents, fights (and retaliation by
victims), and suicidal behavior.
Predisposing factors. The
following conditions have been noted as
likely predisposing factors: antecedent
Attention-deficit Hyperactivity Disorder or
Oppositional Defiant Disorder, parental
rejection, inconsistent management with harsh
discipline, early institutional living,
frequent shifting of parent figures (foster
parents, relatives, or stepparents), absence
of a father or presence of a father with
Alcohol Dependence, large family size, and
association with a delinquent subgroup.
Prevalence and sex ratio. It
is estimated that approximately 9% of males
and 2% of females under the age of 18 have
the disorder.
Familial pattern. The
disorder is more common in children of adults
with Antisocial Personality Disorder and
Alcohol Dependence than in the general
population.
Differential diagnosis. Isolated
acts of antisocial behavior do not justify a
diagnosis of Conduct Disorder, and may be
coded as Childhood or Adolescent Antisocial
Behavior. The behavior qualifies for a
diagnosis of Conduct Disorder only if the
antisocial behavior continues over a period
of at least six months, and thus represents a
repetitive and persistent pattern. When such
a pattern exists, there will usually be
obvious impairment in social and school
functioning of a type not generally observed
when the antisocial behavior represents an
isolated act.
Though oppositional Defiant Disorder includes
some of the features observed in Conduct
Disorder, such as disobedience and opposition
to authority figures, the basic rights of
others and major age-appropriate societal
norms or rules are not violated as they are
in Conduct Disorder.
The irritability and antisocial behavior
often seen in Bi-polar Disorder in children
or adolescents can erroneously be considered
symptoms of Conduct Disorder. However, manic
episodes are usually brief whereas Conduct
Disorder tends to persist.
Attention-deficit Hyperactivity Disorder and
Specific Developmental Disorders are common
associated diagnoses, and should also be
noted when present.
Diagnostic Criteria for Conduct
Disorder
A. A disturbance of
conduct lasting at least six months, during
which at least three of the following have
been present:
- has stolen without confrontation of a
victim on more than one occasion
(including forgery)
- has run away from home overnight at
least twice while living in parental
or parental surrogate home (or once
without returning)
- often lies (other than to avoid
physical or sexual abuse)
- has deliberately engaged in
fire-setting
- is often truant from school (for
older person, absent from work)
- has broken into someone else's house,
building, or car
- has deliberately destroyed others'
property (other than by fire-setting)
- has been physically cruel to animals
- has forced someone into sexual
activity with him or her
- has used a weapon in more than one
fight
- often initiates physical fights
- has stolen with confrontation of a
victim (e.g, mugging,
purse-snatching, extortion, armed
robbery)
- has been physically cruel to people
B. If 18 or older, does
not meet criteria for Antisocial Personality
Disorder.
Criteria for severity of Conduct
Disorder:
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, e.g., serious
physical injury to victims, extensive
vandalism or theft, prolonged absence from
home.
Types
The predominant clinical features of the
three types presented here largely correspond
to categories derived from empirical studies.
These types refer to the conduct problems
alone, not to any coexisting mental disorder
which should also be diagnosed when present.
Each of the types can occur in mild,
moderate, or severe form.
The Solitary Aggressive Type corresponds,
roughly, to the concept of Undersocialized
Aggressive Type. Children with this type of
Conduct Disorder often make little attempt to
conceal their antisocial behavior; they are
often socially isolated. The Group Type is
more common and corresponds, roughly, to the
concept of Socialized Nonaggressive Type.
Usually these children claim loyalty to the
members of their group. Note that although
the Undifferentiated Type is defined here as
a residual group, it may be far more common
than either of the other two types.
Group Type
The essential feature is the predominance of
conduct problems occurring mainly as a group
activity with peers. Aggressive physical
behavior may or may not be present.
Solitary Aggressive Type
The essential feature is the predominance of
aggressive physical behavior, usually toward
both adults and peers, initiated by the
person (not as a group activity).
Undifferentiated Type
This a subtype for children or adolescents
with Conduct Disorder with a mixture of
clinical features that cannot be classified
as either Solitary Aggressive Type or Group
Type.
Oppositional
Defiant Disorder
The essential feature of this disorder is
a pattern of negativistic, hostile, and
defiant behavior without the more serious
violations of the basic rights of others that
are seen in Conduct Disorder. The diagnosis
is made only if the oppositional and defiant
behavior is much more common than that seen
in other people of the same mental age.
Children with this disorder commonly are
argumentative with adults, frequently lose
their temper, swear, and are often angry,
resentful, and easily annoyed by others. They
frequently actively defy adult requests or
rules and deliberately annoy other people.
They tend to blame others for their own
mistakes or difficulties.
Manifestations of the disorder are almost
invariably present in the home, but may not
be present at school or with other adults or
peers. In some cases, features of the
disorder, from the beginning of the
disturbance, are displayed in areas outside
the home; in other cases, they start in the
home, but later develop in areas outside the
home. Typically, symptoms of the disorder are
more evident in interactions with adults or
peers whom the child knows well. Thus,
children with the disorder are likely to show
little or no signs of the disorder when
examined clinically.
Usually the person does not regard himself or
herself as oppositional or defiant, but
justifies his or her behavior as a response
to unreasonable circumstances.
Associated features. Associated
features vary as a function of age, and
include low self-esteem, mood lability, low
frustration tolerance, and temper outbursts.
There may be heavy use of illegal
psychoactive substances, such as cannabis and
alcohol (before the legal age). Use of
tobacco is common. Often Attention-deficit
Hyperactivity Disorder is also present.
Age at onset. Although
precursors may appear in early childhood, the
disorder, as defined, typically begins by
eight years, and usually not later than early
adolescence.
Course. The course is
unknown. In many cases the disturbance
evolves into Conduct Disorder or a Mood
Disorder.
Impairment. Impairment is
usually greatest within the home.
Complications. Conduct
Disorder is a common complication.
Predisposing factors and prevalence.
No information.
Sex ratio. Before puberty,
the disorder is more common in males than in
females; in postpubertal children the sex
ratio is probably equal.
Familial pattern. No
information.
Differential diagnosis. In
Conduct Disorder all of the features of
Oppositional Defiant Disorder are likely to
be present; for that reason, Conduct Disorder
preempts the diagnosis of Oppositional
Defiant Disorder. In a psychotic disorder,
such as Schizophrenia, the features of
Oppositional Defiant Disorder may be seen,
particularly during the prodromal phase; and
a psychotic disorder therefore preempts the
diagnosis of Oppositional Defiant Disorder.
Features of Oppositional Defiant Disorder may
be seen during the course of Dysthymia, or a
Manic, Hypomanic, or Major Depressive
Episode, but in such cases the additional
diagnosis of Oppositional Defiant Disorder is
not made.
Diagnostic Criteria for
Oppositional Defiant Disorder
Note: Consider a criterion
met only if the behavior is considerably more
frequent than that of most people of the same
mental age.
A. A disturbance of at least
six months during which at least five of the
following are present;
- often loses temper
- often argues with adults
- often actively defies or refuses
adult requests or rules, e.g.,
refuses to do chores at home
- often deliberately does things that
annoy other people, e.g., grabs other
children's hats
- often blames others for his or her
own mistakes
- is often touchy or easily annoyed by
others
- is often angry and resentful
- is often spiteful or vindictive
- often swears or uses obscene language
B. Does not meet the
criteria for Conduct Disorder, and does not
occur exclusively during the course of a
psychotic disorder, Dysthymia, or a Major
Depressive, Hypomanic, or Manic Episode.
Criteria for severity of
Oppositional Defiant Disorder
Mild: Few, if any, symptoms
in excess of those required to make the
diagnosis and only minimal or no impairment
in school and social functioning.
Moderate: Symptoms or
functional impairment intermediate between
"mild" and "severe."
Severe: Many symptoms in
excess of those required to make the
diagnosis and significant and pervasive
impairment in functioning at home and school
and with other adults and peers.
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