Should the DSM-IV diagnostic criteria for conduct disorder consider social context?

Objective: The text of the DSM-IV states that a diagnosis of conduct disorder should be made only if symptoms are caused by an internal psychological dysfunction and not if symptoms are a reaction to a negative environment. However, the DSM-IV diagnostic criteria are purely behavioral and ignore this exclusion. This study empirically evaluated which approach - the text's negative-environment exclusion or the purely behavioral criteria - is more consistent with clinicians' intuitive judgments about whether a disorder is present, whether professional help is needed, and whether the problem is likely to continue. Method: Clinically experienced psychology and social work graduate students were presented with three variations of vignettes describing youths whose behavior satisfied the DSM-IV criteria for conduct disorder. The three variations presented symptoms only, symptoms caused by internal dysfunction, and symptoms caused by reactions to a negative environment. The clinicians rated their level of agreement that the youth described in the vignette had a disorder, needed professional mental health help, and had a problem that was likely to continue into adulthood. Results: Youths with symptoms caused by internal dysfunction were judged to have a disorder, and those with a reaction to a negative environment not to have a disorder. The difference was not explained by the clinicians' judgments of the youths' need for professional help or the expected duration of symptoms. Conclusions: The clinicians' judgments supported the validity of the DSM-IV's textual claim that a diagnosis of conduct disorder is valid only when symptoms are due to an internal dysfunction.