DSM Criteria for Conduct Disorder, Childhood-Onset Type
Conduct Disorder, childhood-onset type, is diagnosed when at least three characteristic behaviors from the DSM criteria are present within the past 12 months (with at least one in the past 6 months) AND at least one criterion was present prior to age 10 years.
Core Diagnostic Criteria
Conduct Disorder is characterized by 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, with at least one criterion present in the past 6 months:
Aggression to People and Animals
- Bullies, threatens, or intimidates others
- Initiates physical fights
- Has used a weapon that can cause serious physical harm to others
- Has been physically cruel to people
- Has been physically cruel to animals
- Has stolen while confronting a victim
- 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
- Has stolen items of nontrivial value without confronting a victim
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
- Is often truant from school, beginning before age 13 years
Childhood-Onset Type Specification
For the childhood-onset type, at least one characteristic of Conduct Disorder must be present prior to 10 years of age 1. This early onset is associated with:
- More persistent and severe antisocial behavior
- Higher risk of developing antisocial personality disorder in adulthood
- Approximately 75% of those with childhood-onset Conduct Disorder may progress to antisocial personality disorder 2
Severity Specification
The severity of Conduct Disorder is specified as:
- Mild: Few conduct problems beyond those required for diagnosis and problems cause relatively minor harm to others
- Moderate: Number of conduct problems and effect on others are intermediate between mild and severe
- Severe: Many conduct problems in excess of those required for diagnosis or conduct problems cause considerable harm to others
Clinical Considerations
Differential Diagnosis
- Oppositional Defiant Disorder (ODD) involves less severe violations of rules and norms, without aggression toward people/animals, destruction of property, or theft 3
- ADHD may co-occur but is distinguished by primary symptoms of inattention, hyperactivity, and impulsivity rather than rule violations 1
- Intermittent Explosive Disorder involves episodic aggressive outbursts rather than persistent patterns of rule-breaking 3
Gender Differences
- Boys typically show more overt confrontational behaviors and physical aggression
- Girls may display less physical aggression but more covert behaviors (lying, truancy) and relational aggression 4
- Current diagnostic criteria may be less sensitive to identifying conduct problems in girls 4
Prognostic Factors
Factors associated with poorer outcomes include:
- Earlier age of onset (childhood vs. adolescent)
- Greater initial severity of symptoms
- Comorbid ADHD
- Lower verbal intelligence
- Family socioeconomic disadvantage
- Having antisocial biological parents 5
Common Pitfalls in Diagnosis
- Failing to distinguish between normative rule-breaking and clinically significant conduct problems
- Not considering developmental stage when assessing behaviors
- Missing comorbid conditions that may influence presentation
- Overlooking contextual factors that may contribute to behavioral issues
- Not recognizing that some behaviors may be used to manage anxiety or other emotional states 3
The childhood-onset subtype is particularly important to identify early as it represents a more severe developmental trajectory and requires more intensive intervention to prevent progression to antisocial personality disorder in adulthood 6.