Disruptive, Impulse-Control, and Conduct Disorders.pptx this teaching material useful for medicine and psychiatric professional students

1. Disruptive, Impulse-Control, and
Conduct Disorders
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2. Five conditions comprise this category
They include two that are associated with childhood:
 (1) oppositional defiant disorder and
 (2) conduct disorder
 both of which are will be discussed in the child
psychiatry course
The remaining three disorders are
 1-intermittent explosive disorder
 2-kleptomania, and
 3-pyromania

3. essential feature of Disruptive, Impulse-Control,
and Conduct Disorders
1) “The failure to resist an impulse, drive, or temptation to perform
an act that is harmful to the person or to others”
2) Increased tension or arousal before the act
3) Pleasure or gratification or relief at the time of the act
4) Sometimes with regret, self-reproach, or guilt feeling following
the act
5) and later a compulsive drive to reduce dysphoria.

4. Impulse
 Defined as- “a sudden spontaneous inclination or incitement to
some usually unpremeditated action.”
 Impulsivity and impulse-control disorders are by definition
highly interrelated, with both involving a pattern of behavior
in which the individual frequently acts on an impulse with at
least the potential for negative consequences.
 impulsivity implying acting without forethought and
compulsivity being acting after too much thought or an
obsession

5. Impulse and compulsion
 impulsivity implying acting without forethought and
 compulsivity being acting after too much thought or an obsession
 both impulsivity and compulsivity share an inability to inhibit a
potentially harmful behavior in response to a stimulus, whether
the stimulus is external or internal.

6. Intermittent Explosive Disorder
 Three key features of the diagnosis of (IED) include:
 (1) repeated aggressive acts that result in assault of destruction
of property,
 (2) the disproportionate response to the stimulus that preceded
the aggression, and
 (3) the fact that the aggressive acts are “not better accounted
for” by other psychiatric disorders or drugs or a documented
general medical condition. Disorder should be considered only
after all other disorders that are associated with aggressive
impulses or behavior have been ruled out.”

7. Cont...
 Completing the action brings immediate gratification and
relief.
Within a variable time afterward, the individual experiences
a conflation of remorse, guilt, self-reproach, and dread.
These feelings may stem from obscure unconscious conflicts
or awareness of the deed's impact on others (including the
possibility of serious legal consequences in syndromes such
as kleptomania).

8. ETIOLOGY
Psychodynamic, psychosocial, and biological factors
all play an important role in impulse-control disorders
however, the primary causal factor remains unknown.
Some impulse-control disorders may have common
underlying neurobiological mechanisms.
Fatigue, incessant stimulation, and psychic trauma can
lower a person's resistance to control impulses.

9. Psychodynamic Factors
 An impulse is a disposition to act to decrease heightened
tension caused by the buildup of instinctual drives or by
diminished ego defenses against the drives.
 The impulse disorders have in common an attempt to bypass
the experience of disabling symptoms or painful affects by
acting on the environment.
 August Aichhorn described impulsive behavior as related to a
weak superego and weak ego structures associated with
psychic trauma produced by childhood deprivation.

10. Otto Fenichel
 impulsive behavior to attempts to master anxiety, guilt,
depression, and other painful affects by means of action.
 He thought that such actions defend against internal danger
and that they produce a distorted aggressive or sexual
gratification.
 To observers, impulsive behaviors may appear irrational and
motivated by greed, but they may actually be endeavors to
find relief from pain.

11. Heinz Kohut
 considered many forms of impulse-control problems, including
gambling, kleptomania, and some paraphilic behaviors, to be
related to an incomplete sense of self.
 He observed that when patients do not receive the validating and
affirming responses that they seek from persons in significant
relationships with them, the self might fragment.
 As a way of dealing with this fragmentation and regaining a
sense of wholeness or cohesion in the self, persons may engage
in impulsive behaviors that to others appear self-destructive.

12. Heinz Kohut…
 Kohut's formulation has some similarities to Donald Winnicott's
view that impulsive or deviant behavior in children is a way for
them to try to recapture a primitive maternal relationship.
 Winnicott saw such behavior as hopeful in that the child searches
for affirmation and love from the mother rather than abandoning
any attempt to win her affection.
 Pts attempt to master anxiety, guilt, depression, and other painful
affects by means of actions, but such actions aimed at obtaining
relief seldom succeed even temporarily.

13. Psychosocial Factors
Psychosocial factors implicated causally in impulse-
control disorders are related to early life events.
The growing child may have had improper models for
identification, such as parents who had difficulty
controlling impulses.
Other psychosocial factors associated with the
disorders include exposure to violence in the home,
alcohol abuse, promiscuity, and antisocial behavior.

14. Biological Factors
 Experiments have shown that this is associated with specific
brain regions, such as the limbic system, and that the inhibition
of such behaviors is associated with other brain regions.
 Relationship with low cerebrospinal fluid (CSF) levels of 5-
hydroxyindoleacetic acid (5-HIAA) and impulsive aggression
 testosterone, have also been associated with violent and
aggressive behavior.
 temporal lobe epilepsy and certain impulsive violent behaviors,
as well as an association of aggressive behavior in patients who
have histories of head trauma with increased numbers of
emergency room visits and other potential organic antecedents.

15. Biological Factors …
 A high incidence of mixed cerebral dominance may be found in
some violent populations.
 serotonin neurotransmitter system mediates symptoms evident in
impulse control disorders.
 The dopaminergic and noradrenergic systems have also been
implicated in impulsivity.
 childhood attention-deficit/hyperactivity disorder (ADHD).
 Lifelong or acquired mental deficiency, epilepsy, and even
reversible brain syndromes have long been implicated in lapses
in impulse control.

16. INTERMITTENT EXPLOSIVE DISORDER
 Intermittent explosive disorder manifests as discrete episodes of
losing control of aggressive impulses;
 these episodes can result in serious assault or the destruction of
property.
 The aggressiveness expressed is grossly out of proportion to any
stressors that may have helped elicit the episodes.
 The symptoms, which pts may describe as spells or attacks,
appear within minutes or hours and, regardless of duration, remit
spontaneously and quickly.

17. INTERMITTENT EXPLOSIVE DISORDER …
 After each episode, pts usually show genuine regret or self-reproach,
and signs of generalized impulsivity or aggressiveness are absent b/n
episodes.
 The diagnosis of this disorder should not be made if the loss of control
can be accounted for by schizophrenia, antisocial or borderline
personality disorder, ADHD, conduct disorder, or substance
intoxication.
 epileptoid personality has been used to convey the seizure-like quality
of the characteristic outbursts, which are not typical of the pt.'s usual
behavior, and to convey the suspicion of an organic disease process, for
e.g., damage to the CNS.

18. Epidemiology
Intermittent explosive disorder is underreported.
more common in men than in women.
Men found in correctional institutions and the women in
psychiatric facilities.
about 2 % of all persons admitted to a university hospital
psychiatric service had disorders that were diagnosed as
intermittent explosive disorder; 80 percent were men.

19. Comorbidity
 High rates of fire setting in patients with intermittent explosive disorder
have been reported.
 Other disorders of impulse control and substance use and mood, anxiety,
and eating disorders have also been associated with intermittent
explosive disorder.
Etiology
 Psychodynamic Factors. Psychoanalysts have suggested that explosive
outbursts occur as a defense against narcissistic injurious events.
 Rage outbursts serve as interpersonal distance and protect against any
further narcissistic injury.
 Psychosocial Factors

20. Intermittent Explosive Disorder DSM-5
Diagnostic criteria
A. Recurrent behavioral outbursts representing a failure to control
aggressive impulses as manifested by either of the following;
 1. Verbal aggression (e.g., temper tantrums, tirades, verbal
arguments or fights) or physical aggression toward property,
animals, or other individuals, occurring twice weekly, on
average, for a period of 3 months. The physical aggression does
not result in damage or destruction of property and does not
result in physical injury to animals or other individuals.
 2. Three behavioral outbursts involving damage or destruction of
property and/or physical assault involving physical injury
against animals or other individuals occurring within a 12-month
period.

21. DSM-5…
 B. The magnitude of aggressiveness expressed during the recurrent
outbursts is grossly out of proportion to the provocation or to any
precipitating psychosocial stressors.
 C. The recurrent aggressive outbursts are not premeditated (i.e.,
they are impulsive and/ or anger-based) and are not committed to
achieve some tangible objective (e.g., money, power, intimidation).
 D. The recurrent aggressive outbursts cause either marked distress
in the individual or impairment in occupational or interpersonal
functioning, or are associated with financial or legal consequences.

22. DSM-5..
• E. Chronological age is at least 6 years (or equivalent
developmental level).
• F. The recurrent aggressive outbursts are not better explained
by another mental disorder (e.g., major depressive disorder,
bipolar disorder, disruptive mood dysregulation disorder, a
psychotic disorder, antisocial personality disorder, borderline
personality disorder) and are not attributable to another
medical condition (e.g., head trauma, Alzheimer’s disease) or
to the physiological effects of a substance (e.g., a drug of
abuse, a medication).
• For children ages 6-18 years, aggressive behavior that occurs
as part of an adjustment disorder should not be considered for
this diagnosis.

23. Physical Findings And Laboratory
Examination
• have a high incidence of soft neurological signs (e.g., reflex
asymmetries), nonspecific EEG findings, abnormal
neuropsychological testing results (e.g., letter reversal difficulties),
and accident susceptibility.
• Blood chemistry (liver and thyroid function tests, fasting blood
glucose, electrolytes), urinalysis (including drug toxicology), and
syphilis serology may help rule out other causes of aggression.
• Magnetic resonance imaging (MRI) may reveal changes in the
prefrontal cortex, which is associated with loss of impulse control.

24. Differential Diagnosis
• include psychotic disorders, personality change because of a
general medical condition, antisocial or borderline personality
disorder, and substance intoxication (e.g., alcohol, barbiturates,
hallucinogens, and amphetamines), epilepsy, brain tumors,
degenerative diseases, and endocrine disorders
• Conduct disorder
• antisocial and borderline personality disorders

25. Course and Prognosis
Intermittent explosive disorder may begin at any stage of
life, but usually appears between late adolescence and
early adulthood.
The onset can be sudden or insidious, and the course can
be episodic or chronic.
In most cases, the disorder decreases in severity with the
onset of middle age, but heightened organic impairment
can lead to frequent and severe episodes.

26. Treatment
A combined pharmacological and psychotherapeutic
approach has the best chance of success.
Group psychotherapy may be helpful, and family therapy
is useful, particularly when the explosive patient is an
adolescent or a young adult.
A goal of therapy is to have the patient recognize and
verbalize the thoughts or feelings that precede the
explosive outbursts instead of acting them out.

27. pharmacological
 Anticonvulsants have long been used, with mixed results, in
treating explosive patients.
 Lithium ,carbamazepine, gabapentin or divalproex and
phenytoin have been reported helpful.
 Benzodiazepines
 Antipsychotics
 Tricyclic
 Propranolol
 calcium channel inhibitors

28. KLEPTOMANIA
 Its is a recurrent failure to resist impulses to steal objects not
needed for personal use or for monetary value
 is characterized by mounting tension before the act, followed by
gratification and lessening of tension with or without guilt, remorse,
or depression after the act.
 The objects taken are often given away, returned surreptitiously, or
kept and hidden.
 Persons usually have the money to pay for the objects they
impulsively steal.
 The stealing is not planned and does not involve others.

29. KLEPTOMANIA…
Thefts do not occur when immediate arrest is probable
They do not always consider their chances of being
apprehended, although repeated arrests lead to pain and
humiliation.
These persons may feel guilt and anxiety after the theft, but
they do not feel anger or vengeance.
 Furthermore, when the object stolen is the goal, the
diagnosis is not kleptomania; in kleptomania, the act of
stealing is itself the goal.

30. Epidemiology
Its is not known, but it is estimated to be about 0.6 %.
The range varies from 3.8 to 24 5 of those arrested for
shoplifting.
There are reports that it occurs in fewer than 5 % of
identified shoplifters.
The male-to female ratio is 1:3 in clinical samples.

31. Comorbidity
Patients with kleptomania are said to have a high LT
comorbidity of MDD (usually, but not exclusively, depressive)
and various anxiety disorders.
Associated conditions also include other disorders such as
pathological gambling and compulsive shopping, eating
disorders, and substance use disorders, alcoholism in
particular.

32. Etiology
Psychosocial Factors.
Biological Factors.
Family and Genetic Factors.

33. Kleptomania –DSM-5 Diagnostic Criteria
• A. Recurrent failure to resist impulses to steal objects that are not
needed for personal use or for their monetary value.
• B. Increasing sense of tension immediately before committing the
theft.
• C. Pleasure, gratification, or relief at the time of committing the
theft.
• D. The stealing is not committed to express anger or vengeance and
is not in response to a delusion or a hallucination. E. The stealing is
not better explained by conduct disorder, a manic episode, or
antisocial personality disorder.

34. Differential Diagnosis
 Episodes of theft occasionally occur during psychotic illness, for
example, acute mania, major depression with psychotic features,
or schizophrenia.
 antisocial personality disorder

35. Course and Prognosis
 may begin in childhood, although most children and
adolescents who steal do not become kleptomaniac adults
 The onset -generally is late adolescence.
 Women are more likely than men to present for psychiatric
evaluation or treatment.
 Men are more likely to be sent to prison.
 Men tend to present with the disorder at about 50 years of age;
 women present at about 35 years of age.
 In quiescent cases, new bouts of the disorder may be
precipitated by loss or disappointment
 The course of the disorder waxes and wanes, but tends to be
chronic.

36. Treatment
 Insight-oriented psychotherapy and psychoanalysis have been
successful, but depend on patients’ motivations.
 Behavior therapy, including systematic desensitization, aversive
conditioning, and a combination of aversive conditioning and
altered social contingencies, has been reported successful, even
when motivation was lacking. The reports cite follow-up studies
of up to 2 years
 SSRIs, such as fluoxetine (Prozac) and fluvoxamine (Luvox),
appear to be effective in some patients with kleptomania. Case
reports indicated successful treatment with tricyclic drugs,
trazodone, lithium, valproate, naltrexone, and electroconvulsive
therapy.

37. PYROMANIA
• is the recurrent, deliberate, and purposeful setting of fires.
• Associated features include tension or affective arousal before
setting the fires; fascination with, interest in, curiosity about,
or attraction to fire and the activities and equipment associated
with firefighting; and pleasure, gratification, or relief when
setting fires or when witnessing or participating in their
aftermath.
• Pts. may make considerable advance preparations before
starting a fire.
• Pyromania differs from arson in that the latter is done for
financial gain, revenge, or other reasons and is planned
beforehand.

38. Epidemiology
 No information is available on the prevalence of pyromania, but
only a small percentage of adults who set fires can be classified as
having pyromania.
 The disorder is found far more often in men than in women, with a
male-to-female ratio of approximately 8:1.
 More than 40 % of arrested arsonists are younger than 18 years of
age.

39. Comorbidity
 substance abuse disorder (especially alcoholism); mood disorders
other impulse control disorders, such as kleptomania in female fire
setters; and various personality disturbances, such as inadequate
and borderline personality disorders.

40. Etiology
Psychosocial-Freud saw fire as a symbol of sexuality.
He believed the warmth radiated by fire evokes the same sensation
that accompanies a state of sexual excitation, and a flame's shape
and movements suggest a phallus in activity.
Biological Factors

41. DSM-5 Diagnosis Diagnostic
 A. Deliberate and purposeful fire setting on more than one occasion.
 B. Tension or affective arousal before the act.
 C. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts
(e.g., paraphernalia, uses, consequences).
 D. Pleasure, gratification, or relief when setting fires or when witnessing or participating in
their aftermath.
 E. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology,
to conceal criminal activity, to express anger or vengeance, to improve one’s living
circumstances, in response to a delusion or hallucination, or as a result of impaired judgment
(e.g., in major neurocognitive disorder, intellectual disability [intellectual developmental
disorder], substance intoxication).
 F. The fire setting is not better explained by conduct disorder, a manic episode, or antisocial
personality disorder.

42. Differential Diagnosis
 conduct disorder and antisocial personality disorder
schizophrenia or mania
brain dysfunction (e.g., dementia), mental retardation, or
substance intoxication

43. Course and Prognosis.
 often begins in childhood, the typical age of onset of pyromania is
unknown.
 When the onset is in adolescence or adulthood, the fire setting tends to
be deliberately destructive.
 Fire setting in pyromania is episodic and may wax and wane in
frequency.
 The prognosis for treated children is good, and complete remission is a
realistic goal.
 The prognosis for adults is guarded, because they frequently deny
their actions, refuse to take responsibility, are dependent on alcohol,
and lack insight.

44. Oppositional Defiant Disorder
 oppositional patterns and aggressive behaviors, are among the most
frequent reasons for children and adolescents to be referred for
psychiatric evaluation in USA .
 DSM-5-has divided ODD into 3-types:
Angry/Irritable Mood
Argumentative/Defiant Behavior, and
Vindictiveness.
A child may meet diagnostic criteria for ODD with a 6-month
pattern of at least four symptoms from the three types above.

45. Angry/Irritable Mood type
 Angry/Irritable children with ODD often lose their tempers, are
easily annoyed, and feel irritable much of the time.
Argumentative/Defiant Behavior Type
 children display a pattern of arguing with authority figures, and
adults such as parents, teachers, and relatives.
 Children with ODD actively refuse to comply with requests,
deliberately break rules, and purposely annoy others.
 These children often do not take responsibility for their actions,
and often blame others for their misbehavior.

46. Vindictive-Type
 Children with the Vindictive type of ODD are spiteful, and have
shown vindictive or spiteful actions at least twice in 6 months to
meet diagnostic criteria.
 ODD is characterized by enduring patterns of negativistic,
disobedient, and hostile behavior toward authority figures, as
well as an inability to take responsibility for mistakes, leading to
placing blame on others.

47. Children with ODD
 They frequently argue with adults and become easily annoyed by
others, leading to a state of anger and resentment.
 They may have difficulty in the classroom and with peer
relationships, but generally do not resort to physical aggression or
significantly destructive behavior
 In ODD , a child’s temper outbursts, active refusal to comply with rules, and
annoying behaviors exceed expectations for these behaviors for children of
the same age.
 ODD is an enduring pattern of negativistic, hostile, and defiant behaviors in
the absence of serious violations of the rights of others.

48. EPIDEMIOLOGY
 Epidemiological studies of negativistic traits in nonclinical
populations found such behavior in 16 to 22 % of school-age
children
 ODD can begin as early as 3 years of age, it typically is noted by 8
years of age and usually not later than early adolescence.
 ODD has been reported to occur at rates ranging from 2 to 16 %
with increased rates reported in boys before puberty, and an equal
sex ratio reported after puberty.
 The prevalence of ODD in males and females diminishes in youth
older than 12 years of age.

49. ETIOLOGY
psychoanalytic theory
 Classic psychoanalytic theory implicates unresolved conflicts
as fueling defiant behaviors targeting authority figures
behavioral behavior
 Behaviorists have observed that in children, oppositionality
may be a reinforced, learned behavior through which a child
exerts control over authority figures; for example, if having a
temper tantrum when a request or demand is made of the child
coerces the parents to withdraw their request, then tantrum
behavior becomes strongly reinforced.
 In addition, increased parental attention during a tantrum can
reinforce the behavior.

50. DSM-5 Diagnostic criteria
A. A pattern of angry/irritable mood, argumentative/defiant
behavior, or vindictiveness lasting at least 6 months as
evidenced by at least 4 symptoms from any of the following
categories, and exhibited during interaction with at least one
individual who is not a sibling.
Angry/Irritable Mood
1. Often loses temper.
2. Is often touchy or easily annoyed.
 3. Is often angry and resentful.

51. DSM-5 Diagnostic criteria …
Argumentative/Defiant Behavior
 4. Often argues with authority figures or, for children and adolescents,
with adults.
 5. Often actively defies or refuses to comply with requests from authority
figures or with rules.
 6. Often deliberately annoys others.
 7. Often blames others for his or her mistakes or misbehavior.
Vindictiveness
 8. Has been spiteful or vindictive at least twice within the past 6 months.

52. DSM-5 Diagnostic criteria …
• Note: The persistence and frequency of these behaviors
should be used to distinguish a behavior that is within normal
limits from a behavior that is symptomatic.
• For children younger than 5 years, the behavior should occur
on most days for a period of at least 6 months unless
otherwise noted (Criterion A8).
• For individuals 5 years or older, the behavior should occur at
least once per week for at least 6 months, unless other wise
noted (Criterion AS).
• While these frequency criteria provide guidance on a
minimal level of frequency to define symptoms, other factors
should also be considered, such as whether the frequency and
intensity of the behaviors are outside a range that is
normative for the individual’s developmental level, gender,
and culture.

53. DSM-5 Diagnostic criteria …
 B. The disturbance in behavior is associated with distress in the
individual or others in his or her immediate social context (e.g.,
family, peer group, work colleagues), or it impacts negatively on
social, educational, occupational, or other important areas of
functioning.
 C. The behaviors do not occur exclusively during the course of a
psychotic, substance use, depressive, or bipolar disorder. Also, the
criteria are not met for disruptive mood dysregulation disorder.

54. Specify current severity:
 Mild: Symptoms are confined to only one setting (e.g., at home, at
school, at work, with peers).
 Moderate: Some symptoms are present in at least two settings.
 Severe: some symptoms are present in three or more settings.
Pathology and Laboratory Examination
 No specific laboratory tests or pathological findings help diagnose
ODD .

55. DIFFERENTIAL DIAGNOSIS
 Periods of normative negativism
 Disruptive Mood Dysregulation Disorder
 adjustment disorder-Stress relate transit ODD
 conduct disorder
 schizophrenia, or a mood disorders
 ADHD
 cognitive disorders, and mental retardation

56. COURSE AND PROGNOSIS
 The course of ODD depends on the severity of the symptoms
and the ability of the child to develop more adaptive responses
to authority.
 The stability of ODD varies over time, with approximately 25 %
of children with the disorder no longer meeting diagnostic
criteria.
 Persistence of ODD symptoms poses an increased risk of
additional disorders, such as mood disorders, CD and substance
use disorders.

57. TREATMENT
• family intervention is primary treatment
• The primary treatment of ODD is family intervention using both
direct training of the parents in child management skills and careful
assessment of family interactions.
Cognitive behavioral therapy
• Emphasize on teaching parents how to alter their behavior to
discourage the child’s oppositional behavior by diminishing
attention to it, and encourage appropriate therapy focuses on
selectively reinforcing and praising appropriate behavior and
ignoring or not reinforcing undesired behavior emphasize teaching
parents how to alter their behavior to discourage the child’s
oppositional behavior by diminishing attention to it, and encourage
appropriate therapy focuses on selectively reinforcing and praising
appropriate behavior and ignoring or not reinforcing undesired
behavior
• individual psychotherapy

58. Conduct Disorder
 CD is an enduring set of behaviors in a child or adolescent that
evolves over time, usually characterized by aggression and
violation of the rights of others.
 Youth with CD often demonstrate behaviors in the ff. 4 categories:
1) physical aggression or threats of harm to people
2) destruction of their own property or that of others
3) theft or acts of deceit, and
4) frequent violation of age appropriate rules.

59. Other associated psychiatric disorders
 ADHD
 Depression
 learning disorders
 childhood maltreatment, harsh or punitive parenting, family
discord, lack of appropriate parental supervision, lack of social
competence, and low socioeconomic level

60. DSM-5 Diagnostic Criteria
 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 at least three of the
following 15 criteria in the past 12 months from any of the
categories below, 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 (e.g., a bat, brick, broken bottle, knife, gun).

61. DSM-5 Diagnostic Criteria…
 4. Has been physically cruel to people.
 5. Has been physically cruel to animals.
 6. Has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery).
 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 (other than by fire setting).

62. DSM-5 Diagnostic Criteria…
Deceitful ness or Theft
10. Has broken into someone else’s house,
building, or car.
11. Often lies to obtain goods or favors or to avoid
obligations (i.e., “cons” others).
12. Has stolen items of nontrivial value without
confronting a victim (e.g., shoplifting, but without
breaking and entering: forgery).

63. DSM-5 Diagnostic Criteria…
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 the parental or parental surrogate home, or once
without returning for a lengthy period.
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.

64. Specify whether:
 Childhood-onset type: Individuals show at least one
symptom characteristic of conduct disorder prior to
age 10 years.
 Adolescent-onset type: Individuals show no
symptom characteristic of conduct disorder prior to
age 10 years.
Unspecified onset: Criteria for a diagnosis of
conduct disorder are met, but there is not enough
information available to determine whether the onset
of the first symptom was before or after age 10 years.