Conduct Disorders

The American Psychiatric Association, through its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; 1994), defines conduct disorder (CD) as a [Page 1227]repetitive and persistent pattern of behavior that violates the basic rights of others or the key age-appropriate social norms and rules of conduct that operate within particular settings (home, school, community). Youth who are diagnosed with CD typically engage in a serious pattern of acting-out, aggressive, and disruptive behavior that is often called antisocial. Examples of such behavior include bullying, hostile verbal or physical assault, defiance of existing rules, resistance to adult influence, stealing, fire setting, and property destruction.

CD is part of a cluster of DSM-IV diagnoses that define disruptive behavior disorders across the developmental spectrum, including oppositional defiant disorder (ODD) in the early years, conduct disorder (CD) in the middle and adolescent years, and antisocial personality disorder (ASPD) in adulthood. Although these conditions are interrelated, only a relatively small number of individuals progress through all three of these conditions during their developmental age span from the preschool years to young adulthood. A substantial number of children and youth desist from these conditions as they mature; a much smaller number become chronic persisters and move from ODD to CD in middle adolescence to ASPD in young adulthood. The average age of onset for ODD is 6 years, approximately 9 years for CD, and young adulthood for ASPD.

CD and its behavioral expression through antisocial behavior patterns account for the highest rate of referral of children and youth for mental health services. The prevalence of CD among children and youth is substantial and varies widely, ranging from 1% to up to 20%, depending on the particular study cited. American Psychiatric Association estimates range from 6% to 16% for males under 18 years old and from 2% to 9% for females. Mental health experts indicate that up to 22% of school-age children and youth experience significant adjustment problems that warrant therapeutic attention; a majority of them involve ODD and CD problems.

Two major subtypes of CD include childhood onset (sometimes called early starters) and adolescent onset (sometimes called later starters). Childhood-onset CD typically begins early on in a child's life and is often preceded by higher than normal levels of aggression or a diagnosis of ODD. Physical aggression is a hallmark attribute of this disorder. Adolescent-onset CD is generally considered less serious and is not, as a rule, preceded by the presence of CD diagnostic criteria prior to the age of 10 years. Later onset CD in adolescence is usually not associated with physical aggression and is characterized by exposure to fewer risk factors.

CD is also assessed as to its severity as part of the diagnostic process (i.e., mild, moderate, severe). To receive a diagnosis of CD, an individual must be judged to have displayed at least 3 of 15 behavioral indicators over a 12-month period. These indicators are distributed across the domains of aggression to people and animals (1–7), destruction of property (8–9), deceitfulness or theft (10–12), and serious violation of rules (13–15). As a rule, the gender ratio of students with CD in the elementary school years is 4:1, favoring boys; by middle school, however, the ratio is approximately 1:1, with girls engaging in much higher levels of relational or indirect aggression (e.g., trashing reputations, excluding others from desirable social activities, socially discriminating against others).

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