The Relationship of Attention Deficit Hyperactivity Disorder and Conduct Disorder to Juvenile Delinquency: Legal Implications

Home , Conduct disorder

Heather A. Foley, BA, Christopher 0.Carlton, MA, and Robert J. Howell, PhD

Attention deficitlhyperactivity disorder (ADHD) and conduct disorder (CD) are both disorders of childhood and adolescence that all too frequently extend into adulthood. But just what is the relationship between these two disorders? This study explores the overlap between these two disorders as they relate to juvenile delinquency; both are significant risk factors for the development of antisocial behavior. But there is more significance to the presence or absence of ADHD or CD in later antisocial behavior. Higher levels of defiant and/or aggressive behavior lead to antisocial acts as compared with lower levels of defiance and antisocial acts. Boys diagnosed with ADHD have higher felony rates than normal control boys, yet ADHD is not nearly as strong a predictor of offending behavior as is CD in study subjects. The presence of both CD and ADHD contributes to illegal behavior, and it is likely that early intervention in both disorders will reduce the prevalence of antisocial behavior.

Fifty-five percent of all crimes are con- cia1 concern. Attempts to remediate this mitted by juvenile de1inq~ents.j.~The concern include efforts that work toward 1987 statistics from the Federal Bureau of an understanding of the factors that pre- Investigation reported juvenile arrests dispose children to commit crime.', " made up 15 percent of all violent crimes Conduct disorder (CD) and attention def- and 33 percent of all property crimes.? icit hyperactivity disorder (ADHD) are Juvenile delinquency is an important so- two childhood disorders that are commonly associated with juvenile delin- Heather A. Foley and Christopher 0. Cat-lton ax doctoral students in clinical psychology at Brigham Young quent behavior.' For example. in a sam- University. Dl-. Howell is a professor of psychology at ple of incarcerated juvenile offenders Brigham Young University assigned full time to the clinical psychology doctoral pl-ogram. Address corre- ages l l to 17 years, 87 percent met the spondence to: Robert J. Howell, PhD, 284 TLRB, De- criteria for CD.4 Another study, by Zagar paltment of Psychology, Brigham Young University. Provo. UT 84602. et al.,' involved 1,056 delinquents and

Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 333 Foley, Carlton, and Howell found that 55 percent of them had either between ADHD and CD is found in the attention deficit disorder (ADD, an older type of behavior exhibited. While the be- term for ADHD) or ADHD, which is a havior of ADHD children may be disrup- much higher prevalence than is found in tive, it does not "violate age appropriate the nondelinquent population. Ultimately societal norms." Children with CD, by the question becomes, what are the fac- definition, do break societal norms. (See tors that are predisposing children to de- Appendix I and I1 for the DSM-IV criteria velop these disorders that seem to lead to of ADHD and CD). offending behavior? As will be discussed later in the article. there seem to be several predisposing factors that contribute Basic Studies About CD and to the development of CD. ADHD, and ADHD Predicting Juvenile delinquency in children; these include fa- Delinquency milial. social, environmental, and biolog- Several studies have linked CD and ical/genetic factors as well as the interac- ADHD to juvenile delinquency. Conduct tions among them.' disorder is the most common DSM diagnosis associated with delinquency, partic- Brief History of ADHD and CD ularly with more serious and persistent ADHD and CD are not solely disorders delinq~ency.~Approximately 90 percent of childhood. Barkley et ~1.~reported re- of juvenile offenders fulfill the criteria for sults from an eight-year follow-up study CD.4.9 Male adolescents with ADHD indicating that over 80 percent of the sub- have higher numbers of later arrests (36- jects still had ADHD symptoms in ado- 58%) for delinquent behavior than male lescence. Gittelman et a].' followed adolescents without ADHD.Io Barkley et ADHD children for 10 years into adult- aL6 reported that those diagnosed with hood and found that 31 percent still had ADHD and CD in adolescence had con- ADHD symptoms. However, there exists siderably higher rates of antisocial acts a sparsity of scientific studies investigat- than healthy control subjects. with the ing such continuity of ADHD into adult- most common antisocial acts being steal- hood. When CD-type symptoms are seen ing, theft outside the home, and fire set- in adults, the symptoms are commonly ting. diagnosed as antisocial personality disor- Children with ADHD and CD in child- der, although diagnostically these adults hood are also more likely to go on to must have had a conduct disorder as chil- commit crimes as adults. For example, a dren in addition to the adult symptoms. 14-year follow-up longitudinal study found that ADHD and antisocial behavior Criteria for ADHD and CD (i.e., behavior meriting criminal convic- Often ADHD and CD co-occur, mak- tion) in childhood were among the most ing it sometimes difficult to distinguish important predictors of later offending between the two psychopathologies. The behavior at age 32." A study of adult DSM-IV states that the key difference inmates by Eyestone and HowellI2 con-

334 Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 ADHD and CD Related to Juvenile Delinquency cluded that 25.5 percent of them had offending behavior, not the portion of the ADHD symptoms as children and still population that suffers from ADHD had them as adults. One study, in which alone. Another extensive review of lon- the findings were in contrast to those gitudinal studies15 found consistent evi- above,5 was done with formerly hospital- dence that ADHD leads to subsequent ized child psychiatric patients. It did not antisocial behavior. However, those stud- find that a prior diagnosis of CD was ies that controlled for the effects of co- conelated to adult criminality, since 57 morbid CD found that it was actually the percent of the children diagnosed with CD that was related to later antisocial CD had no prison record. The authors fail behavior. not ADHD. In other words. to mention, however, that apparently 43 when childhood ADHD is not accompa- percent did have a prison record. nied by conduct problems or aggression, In addition to being associated with it is not strongly related to adult antisocial externalizing problems such as delinquent behavior. Fergusson et a1.I6 also found behavior, childhood problems of CD and that ADHD was not correlated to offend- ADHD are also significantly associated ing behavior when comorbid CD effects with internalizing problems, which may were controlled. lead to depression.I3 For example, male Another study. by Satterfield et al.,I7 adolescents with diagnosed ADHD have demonstrated the heterogeneity of been found to have higher rates of insti- ADHD. They studied two different tutionalization than male adolescents groups of ADHD individuals and found without ADHD.I0 that those subjects with high aggression In general. the above evidence supports and defiance ratings had higher offending the hypothesis that CD and ADHD are rates than those ADHD individuals with both significant risk factors for the devel- lower aggression and defiance ratings. opment of adult antisocial behavior. However, this study also found that even However, several carefully done studies the ADHD boys with lower aggression have questioned the idea that ADHD and defiance ratings still had higher fel- alone is a strong predictor of juvenile ony rates than normal control boys. Bar- delinquency. Klein and Mannuzza14 re- kley et al.(j also reported that those diag- viewed several longitudinal studies that nosed with ADHD alone tend to have Sound that the link between childhood more antisocial acts than healthy control hyperactivity and criminality was not subjects. However, the important conclu- straightforward. They concluded that sion is that ADHD does not seem to be only a portion of those children diagnosed nearly as strong a predictor of offending with ADHD actually go on to develop behavior as CD. when the studies are antisocial behavior. This conclusion was controlled for comorbidity. based on their finding that some ADHD individuals also develop antisocial per- Differential Diagnosis sonality disorder; it is members of this Many people have questioned whether small group that have an increased risk of CD and ADHD are truly different disor-

Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 335 Foley, Carlton, and Howell ders. It is true that the two disorders do dating criteria. course, and family history commonly co-occur. Conduct disorder all strongly suggest that ADHD and CD has been reported to be present in as are two etiologically different disorders.15 many as 50 percent of people diagnosed with ADHD.8 Despite this high comor- Comorbidity of CD and ADHD bidity rate, there is much research evi- As mentioned above, about 50 percent dence supporting the belief that these are of those diagnosed with ADHD also have indeed two separate disorders. CD and antisocial behavior." Forehand One study demonstrated some ways in et report that the comorbidity of CD which the disorders differ in terms of the and ADHD is associated with more ar- long-term behavior outcome. Fergusson rests and more antisocial behavior, which et a1.I6 found that early conduct problems start at a younger age than in individuals at ages 6, 8. and 10 years were highly diagnosed with CD alone. Perhaps this continuous with offending behavior at occurs because those with ADHD as well age 13 but were unrelated to academic as CD are more likely to get caught or achievement when accounting for comor- because their impulsivity somehow leads bid ADHD effects. Similarly, this study to more arrests. The comorbidity group also found that ADHD was correlated to reportedly also were found to have lower academic difficulties but not to offending levels of intellectual and academic skills." behavior when CD effects were con- Barkley's6 report of the higher than nor- trolled. Another study18 also found differ- mal rate of antisocial acts among people ences of an academic type between the with ADHD is especially prevalent when two disorders. ADHD children more of- CD also is present. The comorbidity of ten have cognitive and achievement def- the two disorders seems to combine the icits than CD children. They are also worst features of both disorders.I8 more often "off' task" in classroom and It has been hypothesized that those play situations, but they were not found to whose ADHD continues into adulthood be at significant risk for behavioral devi- are at increased risk of developing CD, ance in adolescence. Conduct disordered which also commonly leads to substance children, on the other hand, are on task abuse and antisocial personality disorder. and have better volitional control and so- This may be one reason that ADHD is cial skills. but their behavioral and social noted as a significant risk factor for the outcomes are far worse. Furthermore, development of adult antisocial behav- school expulsion rate was found by one i~r.~ study to be "considerably higher" in boys with diagnosed CD than in those with Predisposing Factors for either ADHD only or normal controk7 Developing CD, ADHD, andlor All of the above is evidence of the differ- Delinquency entiation of CD and ADHD. An extensive As previously mentioned, there appear review of the literature similarly con- to be several predisposing factors that not cluded that differences in terms of vali- only contribute to the development of CD

336 Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 ADHD and CD Related to Juvenile Delinquency and ADHD, but also often exist comor- a significantly greater prevalence of bidly with these disorders in the manifes- ADHD and CD.2Vinally, Brown et ~1.'~ tation of delinquency. Generally, these classified many of these negative parent- include familial. social, environmental, ing qualities under general family disor- and biologicallgenetic factors; this article ganization, which often precedes and will address specific variables such as likely contributes to the onset of delin- parenting. peer relations. socioeconomic quency. status (SES), personal characteristics, and The influence of parental qualities. heredity. Each of these factors can exert meaning the personality characteristics of its influence individually or in the form of the caretakers, has drawn nearly the same multiple interactions. research attention as methods of parent- There are a number of studies that fo- ing. Additionally, these personality traits cus on parenting, which seems to be the are fsequently associated with the argu- most researched of the factors that may ment for the influence of heredity on de- lead to delinquency problems. Simons et linquent behaviors. Barkley er re- a1.I9 emphasized the important contribu- ported on risk factors that are associated tion of poor parenting to early delin- with ADHD in particular, although he did quency, echoing the views of Nagin and not control for the possible cornorbidity Farrington,") who pointed out a similar of CD. He found that the children diag- positive association with early onset, but nosed with ADHD as compared with a not late onset. delinquency. Similarly. normal population had parents with three conduct problems. as defined by Far- times more divorce, four times more rington et nl.," were also found to be changes of residence, and twice the num- related to poor parenting as well as inad- ber of fathers who had repeatedly conl- equate parental supervision. Stouthamer- mitted antisocial acts; also 11 percent of Loeber and LoeberD added poor marital the fathers had an antisocial personality relations to the list, while Loeber et nl.," disorder. Similarly, another study con- pointed out the contributions of negative cluded that children with CD had parents parent-child interactions and lack of pa- with relatively greater rates of psychopa- rental involvement. in addition to poor th~logy.'~They had both mothers and supervision. as correlates of delinquency. fathers who were diagnosed with APD. Primary trauma of physical andlor sexual and fathers who abused substances. In abuse results in girls, in particular, devel- contrast, however. ADHD was not asso- oping symptoms of delinquency and pa- ciated with any parental disorder in this th~logy.'~The behavior of these girls is study. In relation to the evidence of co- hypothesized to be a modeling of what n~orbidity,those diagnosed with CD and had been done to them by continuing to ADHD had fathers with greater levels of violate the rights of others. Furthermore. aggression, arrests. and imprisonment another study found that children who than those with CD alone. In addition, were abused severely enough to have Nagin and Farrington,"' and Stouthamer- been removed from their parents showed Loeber and Loeber2' concluded that the

Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 337 Foley, Carlton, and Howell parents' criminality is significantly corre- istics, interpersonal variables also have lated with late onset delinquency in their been shown to influence the manifesta- children, while Farrington et aL2' related tion of delinquency, particularly in the this characteristic to the development of a form of peer relations. La~rence'~ana- child's hyperactive-impulsive-attention lyzed this factor along with school per- problems. In combination, these results formance and found that association with suggest that CD, ADHD, and/or delin- delinquent peers weighed more heavily quency may have a family etiology that than school attachment in predicting de- could be the result of heredity, social linquent behavior. This leads to the ques- learning. or some other mode of familial tion of whether delinquent behavior at- transmission. C~ffey,~~however, empha- tracts similar peers, or do delinquent peer sized the former: "heredity and genetics relations cause the individual behavior? contribute significantly to the develop- Thornberry et ~71.~~attempted to answer ment of antisocial or criminal behavior" this question and concluded that the two (p 378). factors have an interactional effect. each Another area of predisposing factors influencing the other in important ways, includes the child's personal characteris- without one necessarily preceding the tics, among which the development of a other. learning disability appears paramount. Finally, environmental predisposing Crawfordm recalled the findings of two factors have received some attention. studies, each reporting a strong relation- with SES at the forefront, inviting con- ship between learning-disabled children flicting and controversial explanations. and delinquency. In these studies, the On the one hand, Williams and McGee30 probability of delinquency for adoles- attribute the source of delinquency to cents with learning disabilities was twice early antisocial behavior and "back- as great as for their peers without learning ground disadvantage." specifying that disabilities. prompting Crawford to call "later disadvantage is predictive of learning disabilities "one of the important delinquency" (p 455). Alternatively, causes of delinquency" (p 23). More re- Stouthamer-Loeber and L~eber~~found cently. Williams and McGee30 focused SES to be "only weakly related to delin- specifically on reading disabilities, and quency" (p 344), and Simons et al.I9 saw they found a significant association with only an "indirect" relationship between the later n~anifestationof CD in boys and SES and delinquency (p 270). Further- increased police contact among both boys more, "competent mothers seem to insu- and girls. Other personality traits related late a child against criminogenic factors to delinquency include negative emotions even in deteriorated neighborhoods" (p and weak constraint. Caspi et ~7l.~'ex- 41 l), according to McCord." Conse- plained that "in low constsaint individu- quently, it appears that the power of SES als, negative emotions may be translated has yet to be determined in the manifes- more readily into action" (p 187). tation of juvenile delinquency. In addition to intrapersonal character- Loeber and Dishi~n~~reviewed predic-

338 Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 ADHD and CD Related to Juvenile Delinquency tion studies on delinquency and rank or- response to the wide range of applications dered the principle predictors as follows: for which the Americans with Disabilities parental family management techniques, Act has begun to be uscd, including as a child's problem behavior, reports of defense for persons with ADHD. Conroy child's stealing, lying or truancy, family specifies "reasonable accomn~odations members' criminality or antisocial behav- for, ADHD's in the workplace" (p 465), ior, child's poor educational achievement, which includes a long list of possible SES, and separation from parents. Al- alternatives to assist such employees in though each of these factors has been completing their tasks. However, Conroy repeatedly linked to the development of points out that, according to the Ameri- CD. ADHD. and/or delinquency, Huiz- cans with Disabilities Act, "the employer inga et caution against pointing to a is neither required to change the 'essential single path to delinquency, emphasizing functions' of the job nor to provide an instead the heterogeneity of this group of accommodation that would be an undue individuals. With respect to ADHD, the burden" on the employer (p 466). This DSM-IV" affirms this position by pro- appears to open the door to further ambi- viding criteria for three distinct subtypes: guity, as terms such as "essential func- Combined Type. Predominantly Inatten- tions" and "undue burden" seem poten- tive Type. and Predominantly Hyperac- tially troublesome. tive-Impulsive Type. However, research In Ventura County, CA alone. three seems to be lacking regarding the differ- defendants have recently attempted to use ential developmental patterns of each of ADHD as a defense.39 While none of these subtypes. these cases resulted in an acquittal. trial and appeal courts have offered little for- Legal Implications Beyond mal opposition to defense attorneys use of Delinquency ADHD in this manner. I11 fact, inane of While juvenile delinquency tends to be the California cases, it is believed that the the usual medium through which adoles- sentence was diminished to a degree as a cents with ADHD and CD clash with the result of the ADHD defense, although the law. in recent years the court system has judge in the case did not explicitly state been faced with other complications of this. C~ffey~~warns that with the growing these disorders. specifically ADHD. literature on the genetic association to Cases have arisen in connection with the criminal behavior, the judicial system Americans with Disabilities Act in the must decide to what extent each possible workplace as well as the use of ADHD in factor will be assigned causal precedence. court defense. Overall, most experts in the field believe Conr~y~~recently called for an im- that "ADHD's best courtroom use is as a proved system for the determination of minimizing factor in sentencing or during disabilities under the Americans with the punishment phase of a death penalty Disabilities Act. This plea has come in case" (p 2).39

Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 339 Foley, Carlton, and Howell

Treatment and Outcome ability to concentrate and their parents Both ADHD and CD are correlated reported significant positive change in be- with an adult diagnosis of antisocial per- havi~r.~~Based on the above discussion sonality disorder especially if onset oc- of predisposing factors. biological and curs before age six. In terms of early family environmental influences seem to identification, those who commit a be possible targets for intervention. greater number of crimes and more seri- Conduct Disorder and ADHD in ous crimes are the ones who are more Females likely to go on to commit crimes in adult- CD is the second most common psy- hood.1° Because early onset is such a chiatric disorder found in adolescent strong predictor of long-term criminal of- girkw However, there are very few out- fending behavior, it is important to be come studies that include females in their able to identify which children will com- sample population. The few that do in- mit crimes as adults by looking for pre- clude females do not examine them sep- dictors and starting interventions while arately from the male population. Zocco- they are young.40.4i Similarly. the comor- lillo and Rogers44propose that the criteria bidity of CD with ADHD should alert the for CD in girls should be different from therapist to intensify treatment or to begin the current criteria, which apply to both the treatment as soon as pos~ible.~ boys and girls. They propose that for fe- Early onset ADHD and CD are partic- males, the criteria should be less ularly resistant to treatment.8 There does weighted to violence and criminality and not seem to be any significant advantage that the current criteria underdiagnose CD of one system over another when thera- in females. A new set of criteria to be peutic and correctional treatment strate- used for females was validated by their gies for these disorders are compared; all study finding that by using the new cri- of them seem to have similar out- teria they were able to predict poor outcome~.~.~~Satterfield et al.I7 found that come. It also found that female CD was intensive psychological and medication associated with a high comorbidity of de- treatment did not change offender rates in pression and anxiety. These results are the highly aggressive defiant ADHD chil- similar to those in studies that have found dren compared with the same type of a high comorbidity of antisocial person- group that was treated with only medica- ality disorder in women with depression tion and brief counseling. and anxiety. In general, it seems as Some treatment success has been found though girls need to exhibit very few by teaching boys with ADHD to relax by symptoms in order to be at increased risk using relaxation tapes and electromyo- for a poor outcome. a point of which graphic biofeedback or a combination of clinicians should be a~are.~ the two. After this training, the boys with In terms of ADHD in women, Klein ADHD showed significant improvement and Mannuzzai4could not find a longitu- on psychological tests that required the dinal study on ADHD females: however.

340 Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 ADHD and CD Related to Juvenile Delinquency they were able to conclude that ADHD ated in a society regardless of who com- girls seem to be as vulnerable to devel- mits it. Prevention is the obvious oping CD as boys. deterrent. These findings suggest the importance Conclusion of early diagnosis and treatment of Researchers are working toward im- ADHD. If more than 25 percent of adult proving our ability to predict delin- criminals have ADHD, as Eyestone and quency, hoping to serve two goals. On the Howell1*found (and practically none of one hand. it would help parents, teachers, the inmates in their study had ever been court officials, and therapists to be aware treated as children), that suggests that of the warning signs of delinquency so early treatment of ADHD may be an ef- they could take action as soon as possible. fective deterrent. To accomplish this. Increasing our predictive powers would more education of teachers. physicians, also help increase our understanding of and parents is needed. the origins of delinquency. It would be Similarly with CD, early detection, di- useful to know the earliest age at which agnosis, and treatment may well reduce problems become predictors so that pre- resulting crime, although studies are lack- ventive efforts could be made before the ing to support this theory. Unfortunately, problem behaviors become entrenched. too many teenagers and other people are Loeber and Dishion3%uggest that future having children when they are ill- studies should use intercorrelations be- equipped to properly rear these children. tween different factors to try to improve Once again early detection, education, predictability as well as to establish vari- and help offered to potential parents may ables that are predictive of the absence of reduce the high incidence of pregnancies delinquency despite certain environmen- and of children who are likely to have tal risk factors. problems as they grow and develop. Accurate prediction would allow a fo- cus on the group with the highest risk, Appendix I and then interventions could be focused on that group. If it were possible to pre- DSM-IV Diagnostic Criteria for Attention Deficit/ dict with a 70 percent accuracy rate, and Hyperactivity Disorder (p 83-8513' if intervention was successful with 25 A. Either (I) or (2): percent of that group, then the interven- (I) Six (or more) of the following symptoms tion would be cost effective." of inattention have persisted for at least 6 There is ample evidence, as garnered months to a degree that is maladaptive and inconsistent with devcloprnental level: from the cited articles, that both CD and ADHD contribute to illegal behavior. Irzcrttentior? With 55 percent of all crimes being com- (a) Often fails to give close attention to mitted by juveniles, the legal implications details or makes careless mistakes in schoolwork, work, or other activities; of ADHD and CD become more appar- (b) Often has difficulty sustaining atten- ent. Certainly, crime should not be toler- tion in tasks or play activities;

Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 341 Foley, Carlton, and Howell

(c) Often does not seem to listen when Some impairment from the symptoms is spoken to directly; present in two or more settings (e.g., at school (d) Often does not follow through on in- [or work] and at home). structions and fails to finish school- There must be clear evidence of clinically sig- work, chores, or duties in the work- nificant impairment in social, academic, or occu- place (not due to oppositional behavior pational functioning. or failure to understand instructions); (e) Often has difficulty organizing tasks The symptoms do not occur exclusively during and activities; the course of a Pervasive Developmental Dis- (0 Often avoids, dislikes, or is reluctant to order, Schizophrenia, or other Psychotic Dis- engage in tasks that require sustained order and are not better accounted for by an- mental effort (such as schoolwork or other mental disorder (e.g., Mood Disorder, homework); Anxiety Disorder, Dissociative Disorder, or a (g) Often loses things necessary for tasks Personality Disorder). or activities (e.g., toys, school assign- ments, pencils, books, or tools); Type: (h) Is often easily distracted by extraneous Attention Deficit/Hyperactivity Disorder, Com- stimuli; bined Type: if both criteria for A1 and A2 are met (i) Is often forgetful in daily activities. for the past 6 months. (2) Six (or more) of the following symptoms Attention Deficit/Hyperactivity Disorder, Predom- of hyperactivity-impulsivity have per- inantly Inattentive Type: if criterion A1 is met but sisted for at least 6 months to a degree that criterion A2 is not met for the past 6 months. is maladaptive and inconsistent with de- Attention Deficit/Hyperactivity Disorder, Predonz- velopmental level: inantly Hyperactive-Impulsive Type: if criterion A2 is met but criterion A1 is not met for the past Hyperactivity 6 months. (a) Often fidgets with hands or feet or squirms in seat; Coding note: For individuals (especially adoles- (b) Often leaves seat in classroom or in cents and adults) who currently have symptoms other situations in which remaining that no longer meet full criteria, "In Partial Remis- seated is expected; sion" should be specified. (c) Often runs about or climbs excessively in situations in which it is inappropri- Appendix II ate (in adolescents or adults, may be limited to subjective feelings of rest- DSM-IV Diagnostic Criteria for Conduct Disorder lessness); (p 90-91) (d) Often has difficulty playing or engag- ing in leisure activities quietly; A. A repetitive and persistent pattern of behavior (e) Is often "on the go" or often acts as if in which the basic rights of others or major "driven by a motor;" age-appropriate societal norms or rules are vi- (0 Often talks excessively. olated, as manifested by the presence of three (or more) of the following criteria in the past Inzpulsivitv 12 months, with at least one criterion present (g) Often blurts out answers before ques- in the past 6 months: tions have been completed; Aggression to people and animals (h) Often has difficulty awaiting turn; (1) Often bullies, threatens, or intimidates (i) Often interrupts or intrudes on others others; (e.g.. butts into conversations or (2) Often initiates physical fights; games). (3) Has used a weapon that can cause serious B. Some hyperactive-impulsive or inilttentive physical harm to others (e.g., a bat, brick, symptoms that caused impairment were broken bottle, knife, gun); present before age 7 years. (4) Has been physically cruel to people;

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(5) Has been physically cruel to animals; Severe: many conduct problems in excess of those (6) Has stolen while confronting a victim required to make the diagnosis or conduct prob- (e.g., mugging, purse snatching, extor- lems cause considerable harm to others. tion, armed robbery); (7) Has forced someone into sexual activity; '. Destruction of property References (8) Has deliberately e+gaged in fire setting Zagar R, At-bit J, Hughes JR, Busell RE, with the intention-,@ causing serious Busch K: Developmental and disruptive be- damage; havior disorders among delinquents. J Am (9) Has deliberately destroyed others' prop- Acad Child Adolesc Psychiatry 28:437-40, erty (other than by fire setting); 1989 Wolfgang R, Figlio M, Sellin T: Delinquency Deceitfulness or- theft in a Birth Cohort. Chicago: University of Chi- (10) Has broken into someone else's house, cago Press, 1971 building, or car; Forehand R, Wierson M, Frame C, Kempton (1 1) Often lies to obtain goods or favors or to T, Armisted L: Juvenile delinquency entry avoid obligations (i.e., "cons" others); and persistence: do attention problems con- (12) Has stolen items of nontrivial value with- tribute to conduct problems? J Behav Ther out confronting a victim (e.g., shoplift- Exp Psychiatry 22:261-4, 1991 ing, but without breaking and entering, Eppright TD, Kashani JH, Robinson BD, Reid forgery); JC: Comorbidity of conduct disorder and personality disorders in an incarcerated juvenile Serious violations qf rules population. Am J Psychiatry 150:1233-6, (13) Often stays out at night despite parental 1993 prohibitions, beginning before age 13 Lundy MS, Pfohl BM, Kuperman S: Adult years; criminality among formerly hospitalized child (14) Has run away from home overnight at psychiatric patients. J Am Acad Child Ado- least twice while living in parental or lesc Psychiatry 32568-76, 1993 parental surrogate home (or once without Barkley RA, Fischer M, Edelbrock CS, Small- ish L: The adolescent outcome of hyperactive returning for a lengthy period); children diagnosed by research criteria. I: An (15) Is often truant from school, beginning &year prospective follow-up study. J An1 before age 13 years. Acad Child Adolesc Psychiatry 29546-57, B. The disturbance in behavior causes clinically 1990 Gittelman R, Mannuzza S, Shenker R, Bon- significant impairment in social, academic, or agure N: Hyperactive boys almost grown up. occupational functioning. Arch Gen Psychiatry 42:937-47, 1985 C. If the individual is age 18 or older, criteria are O'Shaughnessy RJ: Clinical aspects of foren- not met for Antisocial Personality Disorder. sic assessment of juvenile offenders. Psychiatr Clin North Am 15:721-35, 1992 Type based on age of onset: Milin R, Halikas JA, Meller JE, Morse C: Childhood-Onset Type: onset of at least one crite- Psychopathology among substance abusing rion characteristic of Conduct Disorder prior. juvenile offenders. J Am Acad Child Adolesc Adolrscerzt-Oilset Type: absence of any criteria Psychiatry 30569-74, 1991 characteristic of Conduct Disorder prior to age 10 Satterfield JH, Hoppe CM, Schell AM: A years. prospective study of delinquency in 110 adolescent boys with attention deficit disorder Severity: and 88 normal adolescent boys. Am J Psychi- atry 139:795-8, I982 Mild: few if any conduct problems in excess of F.mlngton : DP: Implications of criminal ca- those required to make the diagnosis and conduct reer research for the prevention of offending. problems cause only minor harm to others. J Adolesc 13:93-113, 1990 Moderate: number of conduct problems and effect Eyestone LL, Howell RJ: An epidemiological on others intermediate between "mild" and "se- study of attention-deficit hyperactivity disor- vere." der and major depression in a male prison

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