70 Chapter 6
CD into ‘unsocialised’ and ‘socialised’ types according to whether peer
relationships are normal or not. DSM-IV has no comparable categories.
In clinical practice, the great majority of children and adolescents with
CD do have impaired peer relationships. Nevertheless, there is limited
evidence from cluster analytic studies for a relatively small group of
conduct-disordered individuals who do make enduring friendships, display
altruistic behaviour, feel guilt or remorse, refrain from blaming others and
show concern for others. These individuals with socialised CD tend to
be older and to engage in less aggressive antisocial acts such as stealing,
truanting and drinking alcohol. They could be considered ‘well-adjusted
criminals’ who are not regarded as deviant within their own subculture. In
contrast, there is increasing interest in a subgroup who displaypsychopathic
tendencies, most notably callous-unemotional traits (lack of feeling for
the distress of others despite being aware of it, typically associated with
insensitivity to punishment). Such individuals are more often bullies and
are prone to be cruel to animals.
Differential diagnosis
There is usually not much doubt about the diagnosis if detailed informa-
tion is obtained from more than one source. Multiple informants are vital,
since disruptive behaviour may only occur in one setting, for example, just
at home or just at school. Epidemiological studies have shown that there
is a fairly low correlation between teacher and parent ratings of disruptive
behaviour, often around 0.3.
Differential diagnoses include:
1 Adjustment disorder: this can be diagnosed when onset occurs soon after
exposure to an identifiable psychosocial stressor such as divorce, be-
reavement, adoption, trauma, and abuse (within one month according
to ICD-10 and within three months according to DSM-IV) and when
symptoms do not persist for more than six months after the cessation of
the stress or its consequences.
2 ADHD: disruptive behavioural disorders can be mistaken for ADHD and
vice versa. This is partly due to overlap in symptoms, as shown in
Box 6.3. Defiance, aggression and intentionally antisocial behaviour are
not part of pure ADHD. In clinically referred populations, disruptive
behavioural disorders and ADHD often co-exist, when there is a danger
of missing the ADHD.
3 Normality: the child or adolescent’s behaviour is within the normal
range, but parents or teachers have unrealistically high expectations.
4 Subcultural deviance: some children and adolescents are antisocial but not
particularly aggressive or defiant, and they are well adjusted within a
deviant peer culture that approves of drug use, shoplifting, etc. It might
be accurate to apply an ICD-10 diagnosis of socialised CD, but it is
arguably a mistake to pathologise what can be seen as a cultural variant.