Mark Twain meets DSM-III-R: Conduct disorder, development, and the concept of harmful dysfunction

Abstract The Diagnostic and Statistical Manual (3rd ed., rev.) (DSM-III-R) diagnosis of conduct disorder assumes that all children who engage in three or more criterion antisocial behaviors for 6 months or more suffer from a mental disorder. It resists all contextual information about a child's developmental history, capacities, strengths and circumstances, and assumes that the antisocial behavior necessarily stems from an underlying disorder. In this review, we use Mark Twain's narrative of the lives of Tom Sawyer and Huckleberry Finn as a point of departure for questioning the reasonableness of this assumption, and for examining normal as well as pathological pathways to antisocial behavior. We begin by reviewing the status of earlier controversies about the mental disorder concept in the service of documenting the impressive progress of the field in conceptualizing disorder. Next, we examine Wakefield's (1992a, 1992b) recently introduced “harmful dysfunction” concept of mental disorder and employ its criteria to evaluate the hypothesis that chronic antisocial behavior in childhood as defined by DSM-III-R is caused by an underlying mental disorder. We also examine some of the difficulties in discriminating between disorder- and nondisorder-based antisocial behavior, and consider issues that warrant attention in future theoretical and empirical work. Finally, we explore the pragmatic rather than scientific basis for DSM-III-R's mental disorder claim and argue that regardless of its status as a mental disorder, this most troubling and harmful behavior syndrome of childhood deserves the intensive interest, concern, and resources of the scientific and public health communities.