Moderate: The number of conduct problems and the effect on others are intermediate between those specified in “mild” and those in “severe" (e.g., stealing without confront- ing a victim, vandalism).
Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering).
Three subtypes of conduct disorder are provided based on the age at onset of the disorder.
Onset is most accurately estimated with information from both the youth and the care- giver; estimates are often 2 years later than actual onset. Both subtypes can occur in a mild, moderate, or severe form. An unspecified-onset subtype is designated when there is in- sufficient information to determine age at onset.
In childhood-onset conduct disorder, individuals are usually male, frequently display physical aggression toward others, have disturbed peer relationships, may have had op- positional defiant disorder during early childhood, and usually have symptoms that meet full criteria for conduct disorder prior to puberty. Many children with this subtype also opmental difficulties. Individuals with childhood-onset type are more likely to have per- sistent conduct disorder into adulthood than are those with adolescent-onset type. As compared with individuals with childhood-onset type, individuals with adolescent-onset conduct disorder are less likely to display aggressive behaviors and tend to have more normative peer relationships (although they often display conduct problems in the com- pany of others). These individuals are less likely to have conduct disorder that persists into adulthood. The ratio of males to females with conduct disorder is more balanced for the adolescent-onset type than for the childhood-onset type.
A minority of individuals with conduct disorder exhibit characteristics that qualify for the ”with limited prosocial emotions” specifier. The indicators of this specifier are those that have often been labeled as callous and unemotional traits in research. Other personality features, such as thrill seeking, fearlessness, and insensitivity to punishment, may also dis- tinguish those with characteristics described in the specifier. Individuals with character- istics described in this specifier may be more likely than other individuals with conduct disorder to engage in aggression that is planned for instrumental gain. Individuals with conduct disorder of any subtype or any level of severity can have characteristics that qual- ify for the specifier "with limited prosocial emotions," although individuals with the spec- ifier are more likely to have childhood-onset type and a severity specifier rating of severe.
472 Disruptive, Impulse-Control, and Conduct Disorders
Although the validity of self-report to assess the presence of the specifier has been sup- ported in some research contexts, individuals with conduct disorder with this specifier may not readily admit to the traits in a clinical interview. Thus, to assess the criteria for the specifier, multiple information sources are necessary. Also, because the indicators of the specifier are characteristics that reﬂect the individual’s typical pattern of interpersonal and emotional functioning, it is important to consider reports by others who have known the individual for extended periods of time and across relationships and settings (e.g., par- ents, teachers, co-workers, extended family members, peers).