Conduct Disorder
grouptype
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:
(1) has stolen without confrontation of a victim on more than one occasion
(including forgery)
(2) has run away from home overnight at least twice while living in parental
or parental surrogate home (or once without returning)
(3) often lies (other than to avoid physical or sexual abuse)
(4) has deliberately engaged in fire-setting
(5) is often truant from school (for older person, absent from work)
(6) has broken into someone else's house, building, or car
(7) has deliberately destroyed others' property (other than by
fire-setting)
(8) has been physically cruel to animals
(9) has forced someone into sexual activity with him or her
(10) has used a weapon in more than one fight
(11) often initiates physical fights
(12) has stolen with confrontation of a victim (e.g, mugging,
purse-snatching, extortion, armed robbery)
(13) 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.
grouptype
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.
Page 8
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Conduct Disorder
grouptype
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:
(1) has stolen without confrontation of a victim on more than one occasion (including forgery)
(2) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning)
(3) often lies (other than to avoid physical or sexual abuse)
(4) has deliberately engaged in fire-setting
(5) is often truant from school (for older person, absent from work)
(6) has broken into someone else's house, building, or car
(7) has deliberately destroyed others' property (other than by fire-setting)
(8) has been physically cruel to animals
(9) has forced someone into sexual activity with him or her
(10) has used a weapon in more than one fight
(11) often initiates physical fights
(12) has stolen with confrontation of a victim (e.g, mugging, purse-snatching, extortion, armed robbery)
(13) 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.
grouptype
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.