Reconsidering the Diagnosis of Conduct Disorder to Reduce Discrimination

Conduct disorder is a psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, Text Revision) (DSM-5-TR); it is typically diagnosed in adolescents, with diagnostic criteria focused on aggression and the violation of social norms1 (Table 1). Conduct disorder is a requisite diagnostic precursor to antisocial personality disorder (ASPD), which can only be diagnosed in adults.1 Both diagnoses are associated with antisocial behavior; however, their diagnostic considerations are distinct. ASPD considers the patient’s internal traits (eg, callousness, hostility) as they relate to behaviors of social deviance; conversely, conduct disorder is defined by specific behaviors without consideration for the internal states or traits that motivate such behaviors. But there are nonpathological reasons for a youth to engage in certain conduct disorder behaviors. Evidence suggests that many antisocial behaviors are tied to a youth’s structural determinants of health2,3 (ie, the political, social, and economic systems affecting health, which often reinforce hierarchical patterns of advantage4). Conceptualizing conduct disorder behaviors strictly as pathology removes the impetus for cultural and structural change. It blames the youth—or their unwell brains—for socially unacceptable behaviors, implying these behaviors can be addressed through individual therapies, such as medication and counseling. However, addressing conduct disorder behaviors likely requires change on a societal and policy level. Therefore, the utility of conduct disorder as a diagnosis requires careful consideration.To be diagnosed with conduct disorder, a youth needs to engage in at least 3 of 15 specific behaviors, but many of these behaviors do not necessarily indicate a pathological psychiatric state. For example, one conduct disorder diagnostic criterion is truancy from school starting before age 13 years. It is inappropriate to assume a child’s truancy from school represents pathology; recent studies on chronic absenteeism show that truancy in elementary and middle school is strongly tied to structural causes, such as housing instability and lack of transportation.5 Similar parallels can be drawn between structural determinants of health and other conduct disorder criteria. For example, the 2 conduct disorder criteria regarding theft—the stealing of nontrivial items, with or without confronting a victim—do not consider why a youth might resort to theft. Studies show that social, environmental, and familial factors—including low socioeconomic status and high community crime rates—significantly influence a youth’s propensity for delinquency, including theft.6,7Even the conduct disorder criteria specifying aggressive or violent behaviors should not be assumed to be pathologic without appropriate context. Take, for example, youth involved with gangs. It is well documented that youth recruitment into gangs is not solely the result of a youth’s individual temperament and decisions; there are significant external factors influencing youth gang involvement, including community arrest rates, neighborhood drug use, family poverty, identified learning disability, and delinquent peers.8 Nonetheless, youth involved in gangs are at much higher risk of meeting the criteria for conduct disorder9,10—breaking and entering, use of a weapon, initiation of physical fights, etc. But do all youth involved in these antisocial behaviors truly have a psychiatric illness?The author posits that simply engaging in 3 of the 15 behaviors specified by the conduct disorder diagnosis should not suffice to determine a pathologic psychiatric condition, even if those behaviors impair social functioning. It must be considered that, for some youth, choosing not to engage in those behaviors could be equally—if not more—impairing. For example, trying to attend school in the absence of safe transportation could endanger the child’s life, or a youth might perceive choosing to join a gang as their household’s only chance for stable income. This essay does not intend to excuse antisocial behavior but rather suggests, in certain contexts, a child’s antisocial decision-making might be adaptive rather than pathologic. Although the DSM-5-TR allows some consideration of context when applying this diagnosis—suggesting the exclusion of patients in settings where disruptive behaviors are “near-normative”—it provides only extreme examples, such as individuals living in war zones. A youth need not live in such a high-threat environment as a war zone to find adaptive benefit in antisocial behaviors.Critics might suggest the problem lies not with the diagnosis of conduct disorder itself but with its application. For example, consider the diagnosis of attention-deficit/hyperactive disorder (ADHD), which is a neurodevelopmental condition characterized by inattention, hyperactivity, and impulsivity that impairs daily function.1 Youth with ADHD are more likely to engage in impulsive behaviors, can be intrusive or inappropriate toward others, and have higher rates of truancy.11 Studies show that white children are more likely to receive an ADHD diagnosis,12,13 while children of other races are more likely to receive a conduct disorder diagnosis—even when exhibiting equal or fewer aggressive behaviors as compared with white children.14,15 Critics might therefore propose any racial, ethnic, or socioeconomic inequity in the conduct disorder diagnosis is attributable to unconscious bias in providers, rather than an inherent flaw in the conduct disorder diagnosis. The author agrees that such unconscious bias exists but argues it does not fully account for the diagnostic inequities. Regardless of individual clinician bias, youth with structural risk factors for delinquency and antisocial conduct are at higher risk of exhibiting conduct disorder behaviors. These youth are more vulnerable to breaking the norms of a society that does not seem built for them to succeed.Critics might also suggest that some conduct disorder behaviors—sexual assault, animal cruelty—speak more to a youth’s temperament rather than environmental influences. The author agrees, to an extent, and suggests this may be ameliorated by developing a diagnosis with criteria focused on characteristics instead of behaviors. For example, using a criterion like callousness—ie, the disregard for others’ rights—gives providers more leeway to contextualize the youth’s behaviors. Admittedly, such criteria have flaws of their own (arbitrariness, prone to bias). However, characteristic-based criteria are more likely to identify youth who enjoy the suffering of others but have not engaged (or been caught engaging) in any of the 15 specific conduct disorder behaviors.Although changing the diagnostic criteria of conduct disorder is a reasonable solution, the author recommends conduct disorder be removed from the DSM entirely. For one, if the criteria were changed to de-emphasize specific behaviors, conduct disorder would no longer be a disorder of “conduct.” For another, patients already stigmatized with a conduct disorder diagnosis are unlikely to benefit from a change in criteria; most likely, conduct disorder would not be removed from their records until it was no longer recognized as a legitimate, billable diagnosis. And while psychiatric diagnoses often grant patients access to care and social services, the conduct disorder diagnosis is associated with higher clinician pessimism toward patient outcomes when compared with other psychiatric diagnoses16,17—which might counter the benefits of accessing care. Ultimately, the existence of conduct disorder too easily allows for “troubled” youth to be conceptualized as mentally ill. These youth highlight the cracks in the foundations of our society, and clinicians have enormous power in how they are perceived. Until our society is free from structural inequity, there is little utility in a diagnosis that pathologizes behaviors rather than their root causes.Thank you to Dr Eric Drogin for his review of the manuscript.