CHAPTER 21

Conduct Disorder

DAVID 1. KOLKa

DESCRIPTION OF THE DISORDER

Clinical Significance
Child conduct disorder (CD) is composed of a diverse array of troublesome aggressive and
antisocial acts. The behaviors include fighting, stealing, lying, defiance, property destruc-
tion, temper outbursts, and other coercive or hostile acts (e.g., threats of violence, sexual
aggression). Individually, these behaviors are both common and problematic in their own
right. Official crime statistics indicate that more than 1.4 million juveniles in this country
were arrested for nonindex crimes (e.g., vandalism, running away) and nearly 900,000 for
index crimes (e.g., larceny/theft, robbery) in 1986 (Federal Bureau ofInvestigation, 1987).
Many of these behaviors are pervasive among patient and nonpatient populations (Kazdin,
1985, 1987a). Given their prevalence, antisocial behaviors are quite costly to society. For
example, the expected crime and correction costs for a repeated juvenile offender in one
report were between $225,000 and $350,000 on a lifetime basis that reflected 1.5 arrests per
year over a 13.3-year period of criminal activity (Greenwood, unpublished paper, cited in
Shamsie & Hluchy, 1991). The other costs involved are less tangible and include the
personal, family, and community impact of serious antisocial behavior.
Antisocial behaviors are of considerable durability. For example, chronicity of these
behaviors is reflected in their high frequency, occurrence in multiple settings, diversity,
and early onset (Loeber, 1982). Several behaviors, especially aggression and theft/stealing,
are quite stable across time in children and adolescents (Loeber, 1990). Even in very young
children, fighting is a stable form of disruptive behavior that tends to be associated with

This chapter was supported, in part, by grants from the National Institute of Mental Health (MH-39976) and
National Center on Child Abuse and Neglect (CDP2239).

DAVID J. KOLKO • Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine,
Pittsburgh, Pennsylvania 15213.
Handbook of Aggressive and Destructive Behavior in Psychiatric Patients, edited by Michel Hersen, Robert T.
Ammerman, and Lori A. Sisson. Plenum Press, New York, 1994.

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heightened ratings of antisocial behavior (Tremblay et al., 1991). Moreover, serious conduct
problems have shown consistency within families (Kazdin, 1987a).
Perhaps as a consequence of their stability, antisocial behaviors account for the
majority of clinical referrals. In a recent study by Weisz and Weiss (1991), 14 ofthe 20 most
"referable" problems represented individual behaviors associated with CD, with six of
the top seven behaviors being vandalism, poor school work, running away from home,
truancy, sexual problems, stealing outside the home, and attacking people. Interviews with
parents of clinically referred boys suggest that the rates of similar behaviors, such as
engaging in fistfights (45%), stealing (18%), or vandalism (17%), are of significant clinical
proportions (Loeber, Green, Lahey, & Stouthamer-Loeber, 1991). Epidemiological evidence
shows that CD children, specifically boys, are more likely than their non-CD peers to
receive mental health/social services and special education (Offord, Boyle, & Racine,
1991). Unfortunately, these individual behaviors are quite resistive to treatment and, thus,
all too often convey a poor long-term prognosis (Kazdin, 1987a). Indeed, several CD
symptoms (e.g., aggression, stealing, lying, truancy) are strong predictors of delinquency
(Loeber, 1990) and are often associated with subsequent problems such as school dropout,
poor work histories, substance abuse, marital problems, and adult criminality (see Caspi,
Elder, & Bem, 1987; Huesman, Eron, Lefkowitz, & Walder, 1984). That the adverse
consequences of antisocial behavior are more frequently experienced by others (e.g., child's
parents, teachers, peers) than by the CD children themselves may contribute to a lack of
desire for change and, ultimately, limited therapeutic outcomes. A closer examination of the
diagnostic criteria of CD may help to articulate the basis for this position.

Diagnosis
The diagnostic criteria for CD are based on the revised Diagnostic and Statistical
Manual of Mental Disorders (DSM-III-R) (American Psychiatric Association, 1987). The
diagnosis is assigned to children who exhibit chronic (i.e., for a period of at least 6 months)
violations of social norms and the rights of others. The diagnostic criteria require no spe-
cific set of core symptoms for rendering the diagnosis but, rather, simply the presence of
at least three individual symptoms. Repeated physical aggression directed toward peers and
adults is one of the principal features of CD. Other symptoms include offenses against
people (e.g., assault, rape) and property (e.g., stealing, destruction, firesetting), as well as
noncriminal status offenses (e.g., lying, running away, truancy). Clearly, the antisocial acts
that make up CD convey a heightened potential for physical injury and the use of coercive
forms of control.
Apart from the addition of some individual symptoms, the primary difference between
DSM-III-R and the prior DSM-III criteria is the absence in DSM-III-R of the aggressive-
nonaggressive and socialized-unsocialized dimensions that were used in DSM-III to
designate four diagnostic subtypes (see American Psychiatric Association, 1980). Instead,
there are three SUbtypes in DSM-III-R: solitary aggressive type, group type, and un-
differentiated type. The solitary aggressive type, which is similar to the undersocialized-
aggressive type included in DSM-III, is characterized by persistent physical aggression
exhibited by the individual alone. In contrast, the group type, which corresponds to the
socialized-nonaggressive type in DSM-III, involves the display of diverse conduct prob-
lems in a group context wherein there exists some loyalty to group members. Finally, the
undifferentiated type represents a category with diverse clinical features that do not
easily reflect those of the two prior SUbtypes. Recent empirical evidence suggests greater