Classification

The ICD-10 classification has a category for conduct disorders (F91). According to the ICD-10 Clinical Descriptions and Guidelines.^)

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.

An enduring pattern of behaviour should be present, but no time-frame is given and there is no impairment or impact criterion stated.

The ICD-10 Diagnostic Criteria for Research(4) differ, requiring symptoms to have been present for at least 6 months, and the introductory rubric indicates that impact upon others (in terms of violation of their basic rights), but not impairment of the child, can contribute to the diagnosis. The research criteria take a 'menu-driven' approach, whereby a certain number of symptoms have to be present. It lists 15 behaviours to consider for the diagnosis of conduct disorder, which usually, but not exclusively, apply to older children and teenagers. They can be grouped into four classes.

1. Aggression to people and animals:

• frequently initiates physical fights (this does not include fights with siblings)

• has used a weapon that can cause serious physical harm to others (e.g. bat, brick, broken bottle, knife, gun)

• often stays out after dark despite parenting prohibition (beginning before 13 years of age)

• exhibits physical cruelty to other people (e.g. ties up, cuts or burns a victim)

• exhibits physical cruelty to animals.

2. Destruction of property:

• deliberately destroys the property of others (other than by fire-setting)

• deliberately sets fires with a risk or intention of causing serious damage.

3. Deceitfulness or theft:

• often lies or breaks promises to obtain goods or favours or to avoid obligations

• steals objects of non-trivial value without confronting the victim, either within the home or outside (e.g. shoplifting, burglary, forgery).

4. Serious violations of rules:

• is frequently truant from school, beginning before 13 years of age

• has run away from the parental or parental surrogate home at least twice or has run away once for more than a single night (this does not include leaving to avoid physical or sexual abuse)

• commits a crime involving confrontation with the victim (including purse-snatching, extortion, mugging)

• forces another person into sexual activity

• frequently bullies others (e.g. deliberate infliction of pain or hurt, including persistent intimidation, tormenting, or molestation)

• breaks into someone else's house, building, or car.

To make a diagnosis, three symptoms from this list have to be present, one for at least 6 months. There is no impairment criterion. There are three subtypes: conduct disorder confined to the family context (F91.0), unsocialized conduct disorder (F91.1), where the young person has no friends and is rejected by peers, and socialized conduct disorder (F91.2), where peer relationships are normal. It is recommended that the age of onset be specified, with childhood-onset type manifesting before age 10, and adolescent-onset type after. Severity should be categorized as mild, moderate, or severe according to the number of symptoms or impact on others (e.g. causing severe physical injury, vandalism, theft).

For younger children, say up to 9- or 10-years-old, there is a list of eight symptoms for the subtype known as oppositional-defiant disorder (F91.3):

1. has unusually frequent or severe temper tantrums for his or her developmental level;

2. often argues with adults;

3. often actively refuses adults' requests or defies rules;

4. often, apparently deliberately, does things that annoy other people;

5. often blames others for his or her own mistakes or misbehaviour;

6. is often 'touchy' or easily annoyed by others;

7. is often angry or resentful;

8. is often spiteful or vindictive.

To make a diagnosis of the oppositional-defiant type of conduct disorder, four symptoms from either this list or the 'main' conduct disorder 15-symptom list have to be present, but no more than two from the latter. Unlike the 'main' variant, there is an impairment criterion: the symptoms must be 'maladaptive and inconsistent with the developmental level'.(4)

Where there are sufficient symptoms of a comorbid disorder to meet diagnostic criteria, the ICD-10 system discourages the application of a second diagnosis, and instead offers a single combined category. There are two major kinds: mixed disorders of conduct and emotions, of which depressive conduct disorder (F92.0) is the best researched, and hyperkinetic conduct disorder (F90.1). There is modest evidence to suggest these combined conditions may differ somewhat from their constituent elements.

The DSM-IV system(5) follows the ICD-10 research criteria very closely and does not have separate clinical guidelines. The same 15 behaviours are given for the diagnosis of conduct disorder 312.8, with almost identical wording. As for ICD-10, three symptoms need to be present for diagnosis. Severity, and childhood or adolescent onset are specified in the same way. However, unlike ICD-10, there is no division into socialized/unsocialized, or family-context-only types, and there is a requirement for the behaviour 'to cause a clinically significant impairment in social, academic, or social functioning'. Comorbidity in DSM-IV is handled by giving as many separate diagnoses as necessary, rather than by having single combined categories.

In DSM-IV, oppositional-defiant disorder is classified as a separate disorder on its own, and not as a subtype of conduct disorder. Diagnosis requires four symptoms from a list of eight behaviours, which are the same as for ICD-10; but unlike ICD-10, all four have to be from the oppositional list, and none may come from the 'main' conduct disorder list. It is doubtful whether oppositional-defiant disorder differs substantially from conduct disorder in older children in any associated characteristics, and the value of designating it as a separate disorder is arguable. (2) In this chapter, the term conduct disorder will henceforth be used as it is in ICD-10, to refer to all variants; oppositional-defiant disorder is included in this as a specific subtype.

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