Conduct Disorder

   The medicalizing of persistent antisocial behavior on the part of children goes back to Cesare Lombroso and the degeneration theorists of the nineteenth century. (See Criminality and Psychiatry; Psychiatric Genetics: degeneration theory [1857].) Lombroso believed that criminals were born, and demonstrated from youth onward signs of "moral insanity" (he called them "pazzi morali"). Moreover, youthful antisocials were in many cases, he said, afflicted with epilepsy, and their outbursts could be seen as ictal in nature. In the second edition of 1878 of The Criminal Male (L’uomo delinquente), Lombroso pointed to "The complete identity and analogy between the morally insane man and the born-criminal." As Lombroso wrote in 1902 in the New Anthology of Sciences (Nuova Antologia di Scienze) of one youthful criminal who became a notorious brigand in adult life, "He was a born criminal, above all because . . . he was subject to epileptic episodes, an illness that is . . . at the bottom of born criminality. . . . It manifested itself acutely between ages of 12 and 15, at the time in which he became incorrigible and cruel toward his father." Even after the driven determinism of degeneration theory had passed from the scene, the concept of innate criminality remained in the literature of forensic and adolescent psychiatry. In the eighth edition of his textbook (1915), Emil Kraepelin raised "the question of the born criminal."

   From the 1920s onward, psychoanalysts saw conduct disorder, or juvenile delinquency, as a problem of individual character pathology. Here, a key contribution stemmed from Viennese educator and psychoanalyst August Aichhorn (1878–1949); namely, his 1925 classic work, Verwahrloste Jugend: Die Psychoanalyse in der Fürsorgeerziehung (translated into English in 1935 as Wayward Youth—the German subtitle meant "psychoanalysis in foster institutional care"). Freud wrote the preface. Aichhorn said, "It has been well established that much delinquent behavior arises on the basis of neurosis, meaning that neurotic changes in ego-structure occur in connection with delinquency" (p. 29).

   As well, Chicago psychoanalyst Franz Alexander (1891–1964) suggested the concept of "acting out" in a 1930 article on "the neurotic character" in the International Journal of Psychoanalysis: "The asocial tendencies, which the neurotic represses and confines to substitutive gratification . . . are all given free rein by the true criminal without the presence of inner conflict." Whereas some neurotics "acted out" their impulses in such forms as masturbation, others did so in life (pp. 296, 304). (Alexander was not writing expressly of adolescents with conduct disorder, yet the notion of "acting out" subsequently was applied not to adult murderers but wayward teenagers.)

   Simultaneously, a sociological perspective on delinquency flourished, initiated by sociologists Clifford Robe Shaw (1895–1957) and Henry Donald McKay (1899–1980), both at the Institute for Juvenile Research in Chicago. In 1929, President Herbert Hoover had created the National Commission on Law Observance and Enforcement, known popularly as the Wickersham Commission after its chairperson, New York lawyer George W. Wickersham, in response to public concern about gang wars in Chicago among other matters. In 1931, Shaw and McKay, in their Social Factors in Juvenile Delinquency (volume two of the Report on the Causes of Crime, published by the National Commission), noted that, "The community fails to function effectively as an agency of social control in these areas of high rates of delinquents" (p. 387). In 1942, Shaw and McKay brought out Juvenile Delinquency and Urban Areas, an opening gong in the sociology of delinquency.

   After the Second World War, conduct disorder and juvenile delinquency became widely considered as socially caused. In 1946, Lester Eugene Hewitt of the Child Guidance Institute of the University of Michigan and Richard L. Jenkins (1903–?), a Chicago child psychiatrist, argued in Fundamental Patterns of Maladjustment that youthful antisocial behavior was the result of "particular environmental situations" rather than either psychodynamics or biology. Psychiatrists took leading roles in the 1950s in the huge wave of concern about "juvenile delinquency," distinguishing bewtween "individual delinquency," for which there would be psychoanalytic explanations, and "sociologic delinquency," attributable to ethnic subcultural behavior.

   In 1966, sociologist Lee Nelken Robins (1922–) of Washington University in St. Louis reported a follow-up study of 500 children brought to child guidance clinics in St. Louis and then tracked down 30 years later: In her book Deviant Children Grown Up: A Sociological and Psychiatric Study of Sociopathic Personality, she found that conductdisordered children often became sociopathic adults.

   As for official postwar diagnosis in American psychiatry, DSM-II in 1968 had no particular label for the conduct-disturbed, noting only an "adjustment reaction of adolescence: irritability and depression associated with school failure and manifested by temper outbursts, brooding and discouragement" (p. 49).

   "Conduct disorder" as a diagnosis for willful and misbehaved adolescents, mainly boys, entered DSM in the third edition in 1980, having as its essential feature, "a repetitive and persistent pattern of conduct in which either the basic rights of others or major age-appropriate societal norms or rules are violated." The disorder was subdivided on the basis of how socialized and aggressive the children and adolescents were. "Conduct disorder" was, in the DSM typology, the childhood version of "antisocial behavior" in adults, and nestled alongside "oppositional disorder," the latter being "a pattern of disobedient, negativistic, and provocative opposition to authority figures." The Manual also struck a genetic note that became more accentuated in successive editions: "Familial pattern: the disorder is more common in children of adults with antisocial personality disorder and alcohol dependence than in the general population." DSM-III-R (1987) and DSM-IV (1994) made no essential changes to the overall concept.