Psychological Disorders: Conduct Disorder
American
Description
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
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
has broken into someone else's house, building, or car
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
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-Onset
Type: 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
European
Description
Conduct disorders are characterized by a repetitive and persistent
pattern of dissocial, aggressive, or defiant conduct. Such behaviour,
when at its most extreme for the individual, should amount to major
violations of age-appropriate social expectations, and is therefore
more severe than ordinary childish mischief or adolescent rebelliousness.
Isolated dissocial or criminal acts are not in themselves grounds
for the diagnosis, which implies an enduring pattern of behaviour.
Features
of conduct disorder can also be symptomatic of other psychiatric conditions,
in which case the underlying diagnosis should be coded.
Disorders
of conduct may in some cases proceed to dissocial personality disorder
(F60.2). Conduct disorder is frequently associated with adverse psychosocial
environments, including unsatisfactory family relationships and failure
at school, and is more commonly noted in boys. Its distinction from
emotional disorder is well validated; its separation from hyperactivity
is less clear and there is often overlap.
Diagnostic
Guidelines
Judgements concerning the presence of conduct disorder should take
into account the child's developmental level. Temper tantrums, for
example, are a normal part of a 3-year-old's development and their
mere presence would not be grounds for diagnosis. Equally, the violation
of other people's civic rights (as by violent crime) is not within
the capacity of most 7-year-olds and so is not a necessary diagnostic
criterion for that age group.
Examples
of the behaviours on which the diagnosis is based include the following:
excessive levels of fighting or bullying; cruelty to animals or other
people; severe destructiveness to property; firesetting; stealing;
repeated lying; truancy from school and running away from home; unusually
frequent and severe temper tantrums; defiant provocative behaviour;
and persistent severe disobedience. Any one of these categories, if
marked, is sufficient for the diagnosis, but isolated dissocial acts
are not.
Exclusion
criteria include uncommon but serious underlying conditions such as
schizophrenia, mania, pervasive developmental disorder, hyperkinetic
disorder, and depression.
This
diagnosis is not recommended unless the duration of the behaviour
described above has been 6 months or longer.
Differential
diagnosis. Conduct disorder overlaps with other conditions. The coexistence
of emotional disorders of childhood (F93.-) should lead to a diagnosis
of mixed disorder of conduct and emotions (F92.-). If a case also
meets the criteria for hyperkinetic disorder (F90.-), that condition
should be diagnosed instead. However, milder or more situation-specific
levels of overactivity and inattentiveness are common in children
with conduct disorder, as are low self-esteem and minor emotional
upsets; neither excludes the diagnosis.
Excludes:
* conduct disorders associated with emotional disorders (F92.-) or
hyperkinetic disorders (F90.-)
* mood [affective] disorders (F30-F39)
* pervasive developmental disorders (F84.-)
* schizophrenia (F20.-)
F91.0 Conduct Disorder Confined To The Family Context
This category comprises conduct disorders involving dissocial or aggressive
behaviour (and not merely oppositional, defiant, disruptive behaviour)
in which the abnormal behaviour is entirely, or almost entirely, confined
to the home and/or to interactions with members of the nuclear family
or immediate household. The disorder requires that the overall criteria
for F91 be met; even severely disturbed parent - child relationships
are not of themselves sufficient for diagnosis. There may be stealing
from the home, often specifically focused on the money or possessions
of one or two particular individuals. This may be accompanied by deliberately
destructive behaviour, again often focused on specific family memberssuch
as breaking of toys or ornaments, tearing of clothes, carving on furniture,
or destruction of prized possessions. Violence against family members
(but not others) and deliberate fire-setting confined to the home
are also grounds for the diagnosis.
Diagnostic
Guidelines
Diagnosis requires that there be no significant conduct disturbance
outside the family setting and that the child's social relationships
outside the family be within the normal range.
In
most cases these family-specific conduct disorders will have arisen
in the context of some form of marked disturbance in the child's relationship
with one or more members of the nuclear family. In some cases, for
example, the disorder may have arisen in relation to conflict with
a newly arrived step-parent. The nosological validity of this category
remains uncertain, but it is possible that these highly situation-specific
conduct disorders do not carry the generally poor prognosis associated
with pervasive conduct disturbances.
F91.1 Unsocialized Conduct Disorder
This type of conduct disorder is characterized by the combination
of persistent dissocial or aggressive behaviour (meeting the overall
criteria for F91 and not merely comprising oppositional, defiant,
disruptive behaviour), with a significant pervasive abnormality in
the individual's relationships with other children.
Diagnostic
Guidelines
The lack of effective integration into a peer group constitutes the
key distinction from "socialized" conduct disorders and
this has precedence over all other differentiations. Disturbed peer
relationships are evidenced chiefly by isolation from and/or rejection
by or unpopularity with other children, and by a lack of close friends
or of lasting empathic, reciprocal relationships with others in the
same age group. Relationships with adults tend to be marked by discord,
hostility, and resentment. Good relationships with adults can occur
(although usually they lack a close, confiding quality) and, if present,
do not rule out the diagnosis. Frequently, but not always, there is
some associated emotional disturbance (but, if this is of a degree
sufficient to meet the criteria of a mixed disorder, the code F92.-
should be used).
Offending
is characteristically (but not necessarily) solitary. Typical behaviours
comprise: bullying, excessive fighting, and (in older children) extortion
or violent assault; excessive levels of disobedience, rudeness, uncooperativeness,
and resistance to authority; severe temper tantrums and uncontrolled
rages; destructiveness to property, fire-setting, and cruelty to animals
and other children. Some isolated children, however, become involved
in group offending. The nature of the offence is therefore less important
in making the diagnosis than the quality of personal relationships.
The
disorder is usually pervasive across situations but it may be most
evident at school; specificity to situations other than the home is
compatible with the diagnosis.
Includes:
* conduct disorder, solitary aggressive type
* unsocialized aggressive disorder
F91.2 Socialized Conduct Disorder
This category applies to conduct disorders involving persistent dissocial
or aggressive behaviour (meeting the overall criteria for F91 and
not merely comprising oppositional, defiant, disruptive behaviour)
occurring in individuals who are generally well integrated into their
peer group.
Diagnostic
Guidelines
The key differentiating feature is the presence of adequate, lasting
friendships with others of roughly the same age. Often, but not always,
the peer group will consist of other youngsters involved in delinquent
or dissocial activities (in which case the child's socially unacceptable
conduct may well be approved by the peer group and regulated by the
subculture to which it belongs). However, this is not a necessary
requirement for the diagnosis: the child may form part of a nondelinquent
peer group with his or her dissocial behaviour taking place outside
this context. If the dissocial behaviour involves bullying in particular,
there may be disturbed relationships with victims or some other children.
Again, this does not invalidate the diagnosis provided that the child
has some peer group to which he or she is loyal and which involves
lasting friendships.
Relationships
with adults in authority tend to be poor but there may be good relationships
with others. Emotional disturbances are usually minimal. The conduct
disturbance may or may not include the family setting but if it is
confined to the home the diagnosis is excluded. Often the disorder
is most evident outside the family context and specificity to the
school (or other extrafamilial setting) is compatible with the diagnosis.
Includes:
* conduct disorder, group type
* group delinquency
* offences in the context of gang membership
* stealing in company with others
* truancy from school
Excludes:
* gang activity without manifest psychiatric disorder (Z03.2)