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DSM-III

Disorders

  1. Conduct Disorder, Undersocialized, Aggressive
  2. Conduct Disorder, Undersocialized, Nonaggressive
  3. Conduct Disorder, Socialized, Aggressive
  4. Conduct Disorder, Socialized, Nonaggressive
  5. Atypical Conduct Disorder

Differential Diagnosis

Isolated acts of antisocial behavior

Isolated acts of antisocial behavior do not justify a diagnosis of Conduct Disorder and may be recorded as Childhood or Adolescent Antisocial Behavior. The behavior qualifies for a diagnosis of Conduct Disorder only if the antisocial behavior represents a repetitive and persistent pattern. When such a pattern exists there will usually be obvious impairment in social and school functioning that frequently will not be present when the antisocial behavior represents an isolated act.

Oppositional Disorder

In Oppositional Disorder there are some of the features that are present in Conduct Disorder, such as disobedience and opposition to authority figures. However, the basic rights of others and major age-appropriate societal norms or rules are not violated as they are in Conduct Disorder.

Attention Deficit Disorder and Specific Developmental Disorder

Attention Deficit Disorder and Specific Developmental Disorder are common associated diagnoses, and should also be noted when present.

DSM-IV

Diagnostic Criteria

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 to others (e.g., a bat, brick, broken bottle, knife, gun)
  4. has been physically cruel to people
  5. has been physically cruel to animals
  6. has stolen while confronting a victim (e.g., mugging, purse 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 is 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-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10 years

Specify severity:

  • Mild: few if any confuct 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 th diagnosis or conduct problems cause considerable harm to others

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 puberty. 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-Onset Type

This subtype is defined by the absence of any criteria characteristic of Conduct Disorder prior to age 10 years. Compares 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 or 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 a weapon, stealing while confronting a victim, breaking and entering).

Differential Diagnosis

Oppositional Defiant Disorder

Although Oppositional Defiant Disorder includes some of the features observed in Conduct Disorder (e.g., disobedience and opposition to authority), 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.

Attention-Deficit/Hyperactivity Disorder

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.

Manic Episode

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 episodis 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.

Adjustment Disorder

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.

Child or Adolescent Antisocial Behavior

Isolated conduct problems that do not meet criteria for Conduct Disorder or Adjustment Disorder may be recorded as Child or Adolescent Antisocial Behavior. 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.

Antisocial Personality Disorder

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.

DSM-5

Diagnostic Criteria

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 at least three of the following 15 criteria in the past 12 months from any of the categories below, 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 causes serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
  4. Has been physically cruel to people.
  5. Has been physically cruel to animals.
  6. Has stolen while confronting a victim (e.g., mugging, purse 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 Violation 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 the 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 whether:

  • Childhood-onset type: Individuals show at least one symptom characteristic of conduce disorder prior to age 10 years.
  • Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years.
  • Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years.

Specify if:

  • With limited prosocial emotions: To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings. These characteristics reflect the individual's typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to asses the criteria for the specifier, multiple information sources are necessary. In addition to the individual's self-report, it is necessary to consider reports by others who have known the individual for extended periods of time (e.g., parents, teachers, co-workers, extended family members, peers).
    • Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules.
    • Callous - lack of empathy: Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others, even when they result in substantial harm to others.
    • Unconcerned about performance: Does not show concern about poor/problematic performance at school, at work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance.
    • Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions "on" or "off" quickly) or when emotional expressions are used for gain (e.g., emotions displayed to manipulate or intimidate others).

Specify current severity:

  • 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, other rule breaking).
  • Moderate: The number of conduct problems and the effect on others are intermediate between those specified in "mild" and those in "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).

Subtypes

Three subtypes of conduct disorder are provided based on the age at onset of the disorder. Onset is most accurately estimated with information from both the youth and the caregiver; estimates are often 2 years later than actual onset. Both subtypes can occur in a mild, moderate, or severe form. An unspecified-onset subtype is designated when there is insufficient information to determine age at onset.

In childhood-onset conduct disorder, individuals 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 (ADHD) or other neurodevelopmental difficulties. Individuals with childhood-onset type are more likely to have persistent conduct disorder into adulthood than are those with adolescent-onset type. As compared with individuals with childhood-onset type, individuals with adolescent-onset type 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 conduct disorder that persists into adulthood. The ratio of males to females with conduct disorder is more balanced for the adolescent-onset type than for the childhood-onset type.

Specifiers

A minority of individuals with conduct disorder exhibit characteristics that qualify for the "with limited prosocial emotions" specifier. The indicators of this specifier are those that have often been labeled as callous and unemotional traits in research. Other personality features, such as thrill seeking, fearlessness, and insensitivity to punishment, may also distinguish those with characteristics described in the specifier. Individuals with characteristics described in this specifier may be more likely than other individuals with conduct disorder to engage in aggression that is planned for instrumental gain. Individuals with conduct disorder of any subtype or any level of severity can have characteristics that qualify for the specifier "with limited prosocial emotions," although individuals with the specifier are more likely to have childhood-onset type and a severity specifier rating of severe.

Although the validity of self-report to assess the presence of the specifier has been supported in some research contexts, individuals with conduct disorder with this specifier may not readily admit to the traits in a clinical interview. Thus, to assess the criteria for the specifier, multiple information sources are necessary. Also, because the indicators of the specifier are characteristics that reflect the individual's typical pattern of interpersonal and emotional functioning, it is important to consider reports by others who have known the individual for extended periods of time and across relationships and settings (e.g., parents, teachers, co-workers, extended family members, peers).

Differential Diagnosis

Oppositional defiant disorder

Conduct disorder and oppositional defiant disorder are both related to symptoms that bring the individual in confiuct with adults and other authority figures (e.g., parents, teachers, work supervisors). The behaviors of oppositional defiant disorder are typically of a less severe nature than those of individuals with conduct disorder and do not include aggression toward individuals or animals, destruction of property, or a pattern of theft or deceit. Furthermore, oppositional defiant disorder includes problems of emotional dysregulation (i.e., angry and irritable mood) that are not included in the definition of conduct disorder. When criteria are met for both oppositional defiant disorder and conduct disorder, both diagnoses can be given.

Attention-deficit/hyperactivity disorder

Although children with ADHD often exhibit hyperactive and impulsive behavior that may be disruptive, this behavior does not by itself violate societal norms or the rights of others and therefore does not usually meet criteria for conduct disorder. When criteria are met for both ADHD and conduct disorder, both diagnoses should be given.

Depressive and bipolar disorders

Irritability, aggression, and conduct problems can occur in children or adolescents with a major depressive disorder, a bipolar disorder, or disruptive mood dysregulation disorder. The behavioral problems associated with these mood disorders can usually be distinguished from the pattern of conduct problems seen in conduct disorder based on their course. Specifically, persons with conduct disorder will display substantial levels of aggressive or non-aggressive conduct problems during periods in which there is no mood disturbance, either historically (i.e., a history of conduct problems predating the onset of the mood disturbance) or concurrently (i.e., display of some conduct problems that are premeditated and do not occur during periods of intense emotional arousal). In those cases in which criteria for conduct disorder and a mood disorder are met, both diagnoses can be given.

Intermittent explosive disorder

Both conduct disorder and intermittent explosive disorder involve high rates of aggression. However, the aggression in individuals with intermittent explosive disorder is limited to impulsive aggression and is not premeditated, and it is not committed in order to achieve some tangible objective (e.g., money, power, intimidation). Also, the definition of intermittent explosive disorder does not include the nonaggressive symptoms of conduct disorder. If criteria for both disorders are met, the diagnosis of intermittent explosive disorder should be given only when the recurrent impulsive aggressive outbursts warrant independent clinical attention.

Adjustment disorders

The diagnosis of an 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 and do not resolve within 6 months of the termination of the stressor (or its consequences). Conduct disorder is diagnosed only when the conduct problems represent a repetitive and persistent pattern that is associated with impairment in social, academic, or occupational functioning.