DSM diagnosis of conduct disorder (CD)*A review

MARTIN OLSSON

Olsson M. DSM diagnosis of conduct disorder (CD)*A review. Nord J Psychiatry 2009;63:102 112. Oslo. ISSN 0803-9488. Conduct disorder (CD) is a condition that describes an aggressive, antisocial and criminal individual with social maladjustment. A diagnostician must consider symptoms, time and function when making a diagnosis. The aim of the article is to provide a general outline of the CD diagnosis described in DSM, using three databases*Medline, PsycIFO and Social Sciences Citation. The diagnostic criteria give an impression that individuals with this condition constitute a homogeneous group, but empirical studies show that these individuals can only be seen as a heterogeneous group. Although the diagnosis describes a temporary condition, it seems to be a fairly stable condition when the CD symptoms start at an early age. More boys than girl seems to have this condition. CD is a condition that often appears with other conditions. During the assessment of psychiatric conditions, especially a heterogenic condition like CD, it would be most appropriate to also use dimensional approaches. If clinicians use dimensional approaches, they will also take under consideration the high comorbidity between CD and internalizing problems. Antisocial behaviour, CD symptoms, CD, Conduct disorder. Martin Olsson, The Danish National Institute of Social Research, Herluf Trolles Gade 11, DK1052 Kbenhavn K, Denmark, E-mail: mao@sfi.dk; Accepted 12 November 2006.

he origin of the word diagnose is Greek and means through knowledge: dia means through and gnosis means knowledge (1). A diagnosis is an identification, definition and description of a specific problematic condition. This condition can often come and go. In the best case, a caregiver provides a diagnosis by assessing information gathered from examining the individual. The psychiatric diagnosis conduct disorder (CD) is without any doubt the oldest described problem condition among children and adolescents (2). This article provides an extensive picture of CD described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) produced by the American Psychiatric Association (APA).

Aim
The aim of the article is to provide a general outline of the CD diagnosis described in the DSM. The CD diagnosis symptoms, stability, subgroups, epidemiology and comorbidity are taken into perspective from empirical research.

adjustment and criminality). The main components are in themselves often used and studied constructs. To acquire a general outline of the CD diagnosis, three databases*Medline, PsycIFO and Social Sciences Citation*were used. The words conduct disorder and CD were used to search the databases. From the references of the acquired studies, the general outline was extended. Many of the acquired studies gave suitable knowledge about CD or its main components, but a few studies clearly distinguish between the main components and CD. Moffitt et al. (3), for example, distinguish between CD and antisocial behaviour by concluding that an individual must have at least five antisocial symptoms before the individual can be identified with CD. In this present article, the components are all called CD symptoms if the referred study is about a main component. Studies about the main components are important in this present review because they provide specific knowledge about a certain context or perspective of the CD diagnosis.

The diagnostic criteria of CD

Until now, APA has today published six DSM-manuals from 1952 to 2000. The first child and adolescent psychiatric diagnoses were presented in DSM-II 1968, but the first time CD was used was in DSM-III1 (2, 47).
DOI: 10.1080/08039480802626939

Method
Several studies have examined CD or its main components (aggressiveness, antisocial behaviour, social mal# 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As)

DSM

DIAGNOSIS OF CONDUCT DISORDER

Today the DSM manual consists of a multiaxial system, a system that gathers a variety of information about an individual to uncover the foundation of the problems (8). This multiaxial system was first introduced in DSMIII and consists of five axes. Axes IIII are the diagnostic axes. Axis I is for clinical syndromes and disorders that could attract attention for a clinical assessment and treatment. CD belongs to Axis I. The diagnosis criteria of CD consist of several CD symptoms (Table 1). Since the first description of CD in DSM-III, the symptoms have been in some degree altered, but since DSM-IV, they have been the same. Today in studies made in the USA there is an ongoing discussion whether, for example, gun carrying should be included among the CD symptoms in DSM (9). Some of the symptoms describing physical aggression, theft, burglary, sexual harassment, lying, pyromania, running away and truancy could be seen as core symptoms in CD, because they have been symptom criteria in several DSMpublications and in other diagnostic manuals (4). Even if the diagnosis in Axis I is temporary, the stability of the diagnosis is of interest.
Table 1. DSM-IV-TR diagnostic criteria.

THE

STABILITY OF THE

CD

SYMPTOMS

In several studies, CD symptoms have shown tangible stability from childhood to adolescence and into adulthood (1013). CD is considered the most stable form of all psychosocial disorders during childhood and adolescence (4, 14). In clinical populations, up to 88% could be re-diagnosed with CD within 3 years and up to 45% within 4 years (15). In normal populations, up to 43% could be associated with CD within 2.5 years (16). The stability for aggression and externalizing behaviour have shown to be more stable for girls than boys over a 4-year period (17); however, the individual stability for boys CD symptoms over a longer period is more stable than for girls CD symptoms (18). Among adolescents with CD symptoms in Stockholm, 76% of the boys and 30% of the girls had been registered in official records for criminality or psychiatric disorder 16 years later. High stability seems to be associated with early onset of CD symptoms (19). For DSM CD diagnosis, the stability of the CD symptoms have been taken into account (Table 1: Code based on age at onset) although studies have found that several different typologies of a subgroup can

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. (4) has been physically cruel to people. (5) has been physically cruel to animals. (6) has stolen while confronting a victim. (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. Deceitfulness or theft (10) has broken into someone elses house, building or car. (11) often lies to obtain goods or favours or to avoid obligations. (12) has stolen items of nontrivial value without confronting a victim. 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. (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. Code 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. Unspecified Onset: age at onset is not known. 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.

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help separate individuals with persistent CD symptoms from those individuals with more transient CD symptoms (20).

Subgroups of CD
DSM-IV-TR identifies two subgroups or specifications of CD (Table 1). One is based on the individuals age when the CD symptom began and the one is a specification on the CD symptoms severity. The specification based on age has its origin in DSM-IV and have only been marginally altered in DSM-IV-TR. The CD symptoms severity specifications have its origin in DSM-III-R and have basically been unchanged since then. When the diagnosis of CD was formed in DSMIII, other specifications were excluded or complemented (Table 2). The specifications in DSM have not been obvious. For example, the specifications in DSM-III were about different social adjustments. Since DSM-IV, social adjustment is an obvious part in the CD diagnosis because the function aspect was formed as a part of the diagnosis (Table 1, item B). The formation of subgroup of CD taken into the DSM manual could be done from prognosis of the condition. At least five different subgroups could be discussed.

CHILDHOOD-ONSET TYPE RESPECTIVE ADOLESCENT-ONSET TYPE

This subgroup is part of the DSM-IV-TR diagnosis of CD (Table 1) and has strong support from research showing that age onset has significant sense of the CD symptoms stability (3, 2131). Moffitts theory about life-course persistent (LCP, early onset) versus adolescent-limited (AL, late onset) antisocial behaviour is a well-known theory of age onset (3, 2628, 32). LCP seems to be associated with both neurological factors (e.g. severe temperament) and exposure of environmental risk factors (e.g. poor parenting and antisocial parents). There are several studies in support of Moffitts theory (2224, 29). Moffitt makes no gender differences in theory, but there seems to be empirical support that
Table 2. List of conduct disorder (CD) specications in different DSM-editions.
Diagnostic manual DSM-III, year 1980 Specification Undersocialized aggressive Socialized aggressive Undersocialized nonaggressive Socialized nonaggressive Atypical Group type Solitary aggressive type Undifferentiated type Childhood-onset type Adolescent-onset type

significantly more boys than girls seem to have an early onset (LCP) (26, 33, 34). This gender difference does not exist in late onset (AL). Evidence that the onset age for CD symptoms is lower for boys than girls is not obvious in all studies (21). The onset-age is not completely conclusive for the stability; there is only one marker that clarifies whether the individual had or did not have CD symptoms before a certain age (35). Furthermore, it could be difficult to determine when the CD symptom arose, which also renders more difficulties to the specification (36). There differentiation age in DSM-IV-TR is age 10 (below childhood-onset and above adolescent-onset), if the age at onset in unknown there is also an unspecified onset. Moffitt (37) argues that AL starts alongside puberty at age 1315 for boys and a bit earlier for girls. There is also data supporting this age as a differentiation age using prediction models (28). Most certainly many children and adolescents have differentiated biopsychosocial maturity. In the coming DSM manual, the code based on age at onset could most probably be better in clinical assessments if it took consideration to these arguments. One way of dealing with this could be a change in two of the codes. If the adolescent-onset type instead is: absence of any criteria characteristic of Conduct Disorder prior to age 13 years, considerations is taken to empirical data. If the unspecified onset is changed to unspecified onset type and complemented with the phrase: or onset of at least one criterion characteristic of Conduct Disorder at age 1013 an easier differentiation in clinical assessment could be done and the subgroup could still give prognostic value.

SPECIFICATION

OF SEVERITY

DSM-III-R, year 1987

DSM-IV, year 1994

In DSM-IV-TR, the following specification of severity can be made: mild, moderate and severe (Table 1). The specification is not all about the number of CD symptoms. In DSM-III-R, the mild form of CD implied a low number of CD symptoms and the symptoms cause relatively little harm towards others. DSM-IV mentioned examples of mild CD symptom: lies, truancy and stays out at night. The moderate form of CD, according to DSM-III-R, should be in between mild and severe. In DSM-IV, examples of moderate CD symptoms were described as stolen items without confronting a victim and vandalism. If it is a severe form of CD, several CD symptoms need to be manifested. Furthermore, these symptoms can cause considerable harm to others. DSM-III-R noted severe CD symptoms that cause severe physical injury to others, extensive vandalism or theft, and long-time running away from home. DSM-IV provided even more examples: non-consensual sexual activity, physical cruelty, use of weapons, and breaking and entering.
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Although few studies examine the 15 CD symptoms that predict persistent problem, there are studies that examine CD symptoms in relation to CD. One study showed that typical symptoms among children with CD were cruelty, running away from home, and breaking and entering (38). Some gender differences were also noted. For girls, CD symptoms that predicted persistent problems were fights and cruelty; for boys, predicting CD symptoms were stay out at night and running away. Another study showed that different CD symptoms seem to appear at different ages (34). CD symptoms appearing in age 811 years were usually lies, fights, bulling, pyromania, use of weapons and cruelty to animals. In the age 1113 years, CD symptoms include cruelty to people, theft, running away, truancy, mugging, breaking and entering, and forced sex (34). The coming DSM manual could take a stand in the question whether subjects differ qualitatively (sort of CD symptom) or quantitatively (number of CD symptoms) in CD. Robins & Price have consistently argued that it is the number of CD symptoms that predicts adult disorders, rather than any specific CD symptom (39). Existing specification of severity depends largely on clinical judgement, not empirically based research.

coming DSM manual could not take consideration to aggression in subtypes of CD.

CD

WITH OR WITHOUT ATTENTION-DEFICIT/

HYPERACTIVE DISORDER

OVERT AND

COVERT AGGRESSION

Aggression has shown to be stable over time and generations (40, 41). Although aggression is a vital part in the diagnostic classification of CD, no specifications of aggression are made in DSM-IV-TR. Research has shown that it could be fruitful to make a distinction between overt aggression (confrontational* makes threats, participates in fights and physical cruelty) and covert aggression (concealing*deceive, lie and truancy) (42, 43). Several studies have shown an association between physical aggression (overt) and the development of CD (35, 44, 45). In longitudinal studies of physical aggression in boys, the occurrence seems to decline with age (4648). A comparison between extreme physical aggressive girls and boys indicates that girls more often were aggressive to family members or friends and boys were more often extremely physical aggressive toward strangers (49). Covert aggression and relational aggression have many similarities. Relational aggression is about behaviour that deliberately destroys other peoples friendships or including/excluding peers in friend groups (5052). This aggressive behaviour seems to be typical for aggressive girls. There are several suggested dichotomous classifications of aggression (45). Empirical data show that several specifications of CD could be made with a starting-point from aggression (53). To make it work and be comprehensive, it would need a more complex and multidimensional classification system. DSM is not this type of classification system, which means that the
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In DSM-III-R 1987, a new construct*disruptive behavioural disorder (DBD)*was presented. DBD consisted of three disorders: CD, oppositional defiant disorder (ODD) and attention-deficit/hyperactive disorder (ADHD). DSM-IV excluded ADHD from DBD perhaps because ADHD in itself does not include aggressive behaviour. DSM-IV-TR makes today no specifications whether the CD diagnosis included ADHD or not, but the combination of CD and ADHD is frequent (see under Comorbidity). Several studies have shown how the combination of CD symptoms and ADHD worsen the effects for the individual*more violent behaviour, more psychiatric problems and more criminality (5459). Furthermore, the presence of ADHD seems to bring forward the onset of CD symptoms (23, 57, 60, 61). It seems that combining CD and ADHD gives severer and more stable problems for the individual. If the coming DSM manual still consists of a multiaxial system, there is no need for a subgroup on whether the subject with CD has a co-existing ADHD condition or not. Axis III in the DSM system is intended to encourage the clinician to notice conditions that could be overlooked. If the relation of CD and ADHD is properly explicit in the manual, the Axis III should cover the comorbidity problem of these two disorders.

CD

WITH OR WITHOUT EARLY ANTISOCIAL

PERSONALITY DISORDER

(ASPD)

SYMPTOMS

According to DSM-IV-TR, an individual above age 18 can be diagnosed with CD if the criteria of ASPD not are fulfilled (Table 2, item C). In the multiaxial system of DSM, CD is Axis I and ASPD is Axis II. Disorders on the Axis II tend to be lifelong and pervasive and are usually used to diagnose adults. Even if ASPD is not diagnosed in an individual under age 18, the CD symptom that overlaps with the ASPD symptoms could form a specification. One of the most severe disorders in adulthood could be ASPD (62). There is a well-founded reason to associate ODD, CD and ASPD because these DSMdiagnoses can be described in a hierarchical developmental model (60, 63). In younger years, ODD could be seen as an earlier development stage to CD, which could be seen as an earlier developmental stage to ASPD. This does not mean that all children with ODD also will be diagnosed with CD followed by ASPD, but the risks increase if there are risk factors that function over time (60, 63). Several studies have shown the relationship between early ASPD symptoms and psychopathy

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symptoms and more psychosocial problems in present and later in life (19, 60, 6467). Psychopathy, according to Hare et al. (68), has two parts: egocentricity, callousness and manipulative behaviour; and encompassing impulsivity, irresponsibility and antisocial behaviour. Both these parts can incorporate some of the 15 CD symptoms. The core of CD could have one part of callousness and one part of the difficultness of learning by experience (69). If the relation of CD and ASPD symptoms is properly explicit in the coming manual, the Axis III should cover the problem of co-existing ASPD symptoms in subjects with CD.

PREVALENCE
POPULATIONS

IN DIFFERENT NORMAL

Epidemiology
Knowledge about prevalence in the population from gender, age, context and time is of importance both to understanding and for planning and administrating social welfare and healthcare (20). There is no uniform standardized way to measure and put together prevalence. Research has shown that prevalence can be influenced by different ways of measuring and the diagnosis procedure (70). To fulfil the diagnostic criteria in a prevalence study is not the same as providing care. Less than a fourth of the adolescents fulfilling criteria in a prevalence study seem to be providing care (71, 72). Table 3 shows examples on prevalence from different studies. The prevalence is specified on gender, age, geographic context, number, DSM-edition, and assessment Studies that are unclear on how they made the assessment have been excluded, e.g. Lewinsohn et al.s study (73).

The frequency of CD does differ in different prevalence studies (Table 3) (7479). In teenagers, up to 16% of the boys and up to 9% of the girls could be diagnosed with CD. A conservative assumption is that every teenage boy and every teenage girl shows the problems at a certain point. The differences in frequency in the different studies could partly be explained by gender and socioeconomic status (SES), but not by age (see below). Furthermore, the different DSM-editions could also be a part of the explanation, but probably the variation of CD frequency is related to methodological problems, different assessment and respondent. It is also reasonable to assume that attrition could influence the prevalence. Few of the studies described in Table 3 accounts for the attrition. The attrition fluctuates between 2% and 28% (74, 75, 79). Although some of these studies offered economical compensation, there was attrition. Quite likely, all the studies in Table 3 have similar attrition, but there is no attrition analysis showing how attrition influences the prevalence estimation. The diagnosis of CD could be viewed as the extreme end of aggressiveness, antisocial behaviour, social maladjustment and criminality, with the point of differentiation between CD and normal behaviour reflecting a convention rather than a dichotomy in nature (80, 81). The key problem is where to set to differentiation between normal and pathological. The differentiation is set to low, if prevalence studies in normal population show to many subjects with CD. Diagnosis reflexes

Table 3. Prevalence of conduct disorder (CD) in different normal populations (%).

Boys 6 10 9 16 16 9 5 4 4 11 4 4 10 13 14 7 14 10 4 Girls 2 4 8 4 9 7 1 1 1 7 1 2 3 5 8 4 3 3 1 Age 411 1216 1416 1013 1416 1721 915 915 916 35 512 1218 11 13 15 18 18 4.55 4.55 City or State Ontario, Canada Columbia, USA Upper New York State, USA n 2674 150 541 508 446 4500 4500 6674 413 1520 1073 921 843 972 930 934 2232 DSM III III III-R III-R III-R III-R IV IV IV IV IV IV IV IV III-R IV IV IV DICA DICA DISC Assessment/respondent Reference (71) (74) (75)

Smoky Mountains, USA

CAPA

(20) (76) (77)

USA

ESI-4, Teacher CSI-4/ASI-4, Teacher DISC-C SDI SDI DISC SDI Parent, Teacher Specified severity: Moderate-Severe

Dunedin, New Zealand

(3)

(78) (79)

England & Wales

DICA, Diagnostic Interview for Children and Adolescents; DISC, Diagnostic Interview Schedule for Children; CAPA, Child and Adolescent Psychiatric Assessment; ECI-4, Early Childhood Inventory-4; CSI-4, Child Symptom Inventory-4; ASI-4, Adolescent Symptom Inventory-4; DISC-C, Diagnostic Interview Schedule for Children-Child version; SDI,Self-reported Delinquency Interview.

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contemporaries social and cultural codes, values, norms, and views, including class and gender identification (82) and that is the way a convention works (likable or not). In DSM-IV-TR, the differentiation is set to three manifest CD symptoms (Table 1).

PREVALENCE

FROM AGE

PREVALENCE

IN CLINICAL POPULATIONS

The frequency of CD is higher in studies with clinical populations. A clinical population here reflects that the population is in some kind of treatment or assessment intervention because of individual problems. The combination of a clinical population reflects the context. This means that the prevalence of CD in a clinical context depends on care providers, politicians, treatment facilities, treatment trends and the diagnostic manual view CD. One study has shown that the transition from DSM-III to DSM-III-R was followed by a decreased prevalence (83). In teenagers in child and youth psychiatric care, Nordic studies have reported up to 75% of the boys and up to 55% of the girls are diagnosed with CD (8486). Ramklint et al. (85) also reported a high attrition (54%), which can have influenced the prevalence. Internationally, CD is considered one of the main reasons for clinical assessment of children and adolescents (69, 8790). Among subjects referred to child and adolescent care or social services agencies, it is possible that CD symptoms could be core problems. Clinicians could always take the CD diagnosis into consideration, at least among adolescents.

There is a separate meaning if CD is more frequent in some ages compared with other ages. This question remains: does CD have a relation to age? Some studies report a relation to age (9496); some do not (73, 75, 77). The difficulty of establishing whether CD relates to age is related to methodological problems and to the fact that CD is a heterogenic condition (20). It could be that in some age interval, like 515 years of age, the CD symptoms have a relation to age (95). Still, even if there are no age differences in prevalence, there seems to be empirical support that significantly more boys than girls seem to have an early onset (LCP) (26, 33, 34).

PREVALENCE

FROM

SES

PREVALENCE

FROM GENDER

In most populations, the frequency of boys is higher than the frequency of girls (Table 3). Studies have shown that CD symptoms have more similarities than dissimilarities among boys and girls up to age 7 (91, 92). As mentioned above, ODD could be seen as an earlier developmental stage of CD (60). ODD prevalence during late childhood and early adolescence shows slightly higher frequency among boys or no gender differences (20). To understand fully the development of CD, it is crucial to further explore whether gender differences change with age, context or informants, a relatively unexplored research area. However, it is important to keep in mind that most females CD might show their onset at older ages, which makes most females with CD late starters (AL) (3, 26, 33, 34). This does not mean that there are no gender differences. Certain trends and patterns in female criminality as compared with males have long been observed: women commit a small share of all crimes; their crimes are fewer, less serious, more rarely professional and less likely to be repeated; and in consequence, women are less frequently in penal establishments (93). The same could be said about CD behaviour.
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There are several studies that implicate higher frequency of CD in a context of low SES (22, 9799). One longitudinal study with a Danish sample showed a relation between criminality and IQ rather than the relation between criminality and SES (100). In one study, ethnicity rather than SES showed relation to CD symptoms in school environment (101). This study used different respondents, teachers and mothers in home environment. The relation between ethnicity and SES was not found in the home environment. The result was confusing for the authors and there is no real explanation (101). Even if the frequency of CD symptoms is higher in contexts of low SES, there are probably more variables in the context explaining CD further. It is important to keep in mind that there are contexts that could be considered markers rather than causal. A major problem of risk factors is to determine which risk factors are causes, and which are simply markers or correlated with causes (102). A casual risk factor is established from three criterions. First, the risk factor must be associated with the outcome (e.g. CD). Secondly, the risk factor precedes the outcome. Finally, the risk factor predicts the outcome after controlling for all other variables. The third criterion is best established in a randomized controlled trial (102). Nevertheless, Axis IV in DSM-IV-TR gives the clinician an opportunity to list clinically relevant psychosocial and environmental problems like poverty and low SES.

PREVALENCE

OVER TIME

Has the frequency of CD in society changed over time? Is there a time trend? Research shows that psychosocial problems among adolescences are more common today compared with earlier generations (103105). The CD symptom seems to increase. There is most certainly a difference in different countries related to culturespecific trends (105). Comparisons over time involve some problems because of changes in the diagnostic manual, variation of how the official statistic is

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collected, and variation in how different measurements are used (106). Collishaw et al. (106) conducted the most well-made study focusing on time trends in problematic conditions so far. Their result shows evidence of significant increase of CD symptoms over the last 25 years among teenagers in all social groups and family constellations. No other problematic conditions they focused on had an increase (106). Among studies focusing on CD symptoms, one shows no increase of CD symptoms over the last 20 years among children (107). This can be seen as an increase of CD symptoms in some age cohorts, but not in others.

Comorbidity
Comorbidity means that an individual has more than one problematic condition*an individual with more than one diagnosis. Because several reviews have pointed out the importance of specific disorders in the context of other comorbid conditions (20, 108, 109), I will focus on DSM-disorders or criteria comorbid with CD (ADHD, anxiety, mood disorders and somatoform disorders). In adolescents diagnosed with CD, it has been shown that 46% of the boys and 39% of the girls also have another DSM-diagnosis (95).

CD AND ADHD
There is no aggressive, hostile or criminal behaviour in the pure form of ADHD. Earlier it was stated that the combination of CD and ADHD worsens the effects for the individual and influence onset of CD symptoms. Beyond this it is often stated that these conditions have a high comorbidity (20, 95), but few studies show measurement on the comorbidity. About 50% of all children and adolescents with ADHD also have ODD/CD (58). Many adolescents probably have CD as well as ADHD, but there is no study to account for this in numbers.

The interaction between CD and anxiety and mood disorders is important and complex. Anxiety could be a symptom of psychiatric disorder and it could be bound to specific contexts or phobias (intensive irrational fear of certain occurrences). Anxiety can also contain panic attacks. In adolescents with CD, up to 48% also have some form of anxiety disorder (110, 111) and the variance among others seemed to depend on gender. Maughan et al. (95) showed that 10% of the boys and 16% of the girls with CD also had anxiety syndrome. Another study showed that up to 30% of children and adolescents with anxiety syndrome also had ODD/CD (112). Maughan et al. (95) showed that 14% of the boys and 12% of the girls with CD also had depression. De ry et al. (113) found that 98% of those with anxiety or depression syndrome also showed CD symptoms. It seems like children with emotional problems (fears and anxiety) without any traces of CD symptoms have decreased risk of future CD symptom. Even shyness seems to decrease the risk (114, 115). Fear and anxiety combined with CD symptoms seems instead to enhance the risk of CD (110, 112, 114, 115). Furthermore, it seems to be important to separate inhibited behaviour like anxiety and shyness from social withdraw, especially for boys (116). These behaviours are strikingly similar, but social withdraw seems not to protect against future CD symptoms. Furthermore, in a Finnish long-term follow-up, it was showed that boys at age 8 with a combination of conduct and internalizing problems had the worst outcome and highest risk of subsequent psychiatric disorders, committing criminal offences, or both at follow-up in young adulthood compared with those boys with pure problems (117).

CD AND

SOMATOFORM DISORDER

CD AND ANXIETY AND

MOOD DISORDERS

Poor psychiatric health among children and adolescents can be categorized (8). One category usually describes individuals that are a cause of a disturbance, noise and aggression. The term for this category is extrovert or externalizing problem. The problems express themselves as truancy, bulling, pilfering and thieving. CD and CD symptoms belong to this category. Another category usually describes individuals that turn problems and worries towards themselves. The term for this category is introvert or internalizing problem. The problems are expressed as nervousness, worries, anxiety and depression. Anxiety and mood disorders belong to this category (8). Although different diagnosis belongs to different categories that seem to be separated, there is high comorbidity. Studies with comorbidity measurement are showing wide variations.

Somatoform disorder is a condition characterized by pain, stomach problems, sexual problems and psychoneurological symptoms. In DSM-IV, it is stated that somatoform disorder is related to CD symptoms. CD is described as a risk for somatoform disorders. Knowledge of this relationship, however, is limited and the diagnostic criteria for somatoform disorder have been radically altered over time (20). Nevertheless, Achenbach et al. (118) showed that somatic problems enhance the probability of CD symptoms among girls. Bardone et al. (119) found strong relations between adolescent girls with CD and poor physical health in adulthood. In addition, there are relations between somatoform syndrome and ASPD (3, 120).

Discussion
A first sight, the CD diagnosis, as it is described by the diagnostic criteria (Table 1), gives an impression that individuals with this condition constitute a homogeneous group. The diagnosis criteria describe a juvenile
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DIAGNOSIS OF CONDUCT DISORDER

with a history of noticeable aggressive, antisocial and criminal behaviour that leads to maladjustment. Individuals with this behaviour can only be seen as a heterogeneous group. A CD diagnosis should be a temporary condition according to DSM, but CD seems a fairly stable condition, especially if the CD symptoms appeared in early age. More boys than girl seems to have this condition. Many juveniles with this condition will have contact with a social worker, a treatment assistant or a school counsellor through social welfare or child and youth psychiatric care. CD is a condition that often appears with other conditions.

cially a heterogenic condition like CD, it would be most appropriate also to use dimensional approaches. If clinicians use dimensional approaches, they will also take under consideration the high comorbidity between CD and internalizing problem.

Considerations about the current DSM-system and future suggestions

The DSM system run-through is a rigorous constant survey and a new edition is published about every 10 years. DSM diagnosis is based on relevant research about the understanding of psychiatric problems and societal expressions. The coming DSM-V could have some alteration when it comes to the CD diagnosis. First, two of the codes based on age at onset could be altered. The age specification in the adolescent-onset type could be altered to age 13. The unspecified onset type could be renamed to unspecified onset type and an intermediate onset type could be added as suggested above. Secondly, the specification of severity in the coming DSM manual could take a stand that it is the number of CD symptoms rather than the sort of CD symptoms that differentiate specification of severity.

Clinical implications for the DSM diagnosis of CD

Children and adolescents with CD problems is not specifically a problem for psychiatric care, likely these children and adolescents are found in several contexts and among several professions. A universal nomenclature could likely facilitate co-ordination between different professions such as social welfare, psychiatric care and education. However, a universal nomenclature could also raise the question about who showed competence in making diagnosis. Many professionals in social welfare and education who daily handle children with CD problems simply do not have the basic training in making a diagnosis. High reliability of the diagnosis is best provided with a highly structured procedure when making a diagnosis (121). The DSM classification of psychopathology results in high comorbidity. Some criteria symptoms could be found in more than one diagnostic criteria list (109). Prevalence studies have shown that if an individual fits the criteria for one diagnosis, up to 51% of these individuals fit the criteria for another (72, 78, 108). If comorbidity exists, it is important to control the effects of the multiple diagnoses before controlling for the single diagnosis (122). Comorbidity can possible be explained by genetics (109). If the same symptom exists in two different diagnoses, it could be the result of one genetic syndrome. Comorbidity might also be blamed for the lack of success of general psychopharmacology treatment of CD. Even if different pharmacological interventions have shown promising options, no medication has yet received formal approval (123). The high comorbidity in DSM has also raised consideration about the appropriateness in classifying psychopathology as it is done in DSM (109, 124128). Several studies have questioned the dualism of biomedicine and it has been suggested that the high comorbidity in DSM is because of underlying dimensions or profiles (109, 127129). There are suggestions that these dimensional models could be done (124, 125, 127), but there are also promoters of parallel systems using both category diagnosis and dimensional diagnosis (130, 131). During the assessment of psychiatric conditions, espeNORD J PSYCHIATRY VOL 63 NO 2 2009

Note
1. DSM is not the rst diagnostic system that used the name CD in its nomenclature. The rst ofcial denition of CD is found in the ICD-8 (International Classication of Diseases) from1974 produced by the WHO (World Health Organization) (4). However, today DSM is the most used diagnostic manual (5).

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