The DSM-IV Outline for Cultural Formulation: A Critical Demonstration With American Indian Children

The publication of DSM-IV is notable for the improved coverage of cultural issues in the diagnosis of mental disorders. In particular, Appendix 1 of DSM-IV includes an “Outline for Cultural Formulation” (Outline) which assists the clinician in evaluating the impact of an individual's cultural context on diagnosis and treatment. However, the capacity of the Outline to facilitate the development of comprehensive cultural formulations for children and adolescents has not been established. In this article the use of the Outline with American Indian children is reviewed critically. Based on the Outline, cultural case formulations for four American Indian children were developed and their comprehensiveness was assessed. Applied to the case material, the Outline provided a clear template for the development of cultural formulations. Nonetheless, several gaps in the material required by the Outline were identified, particularly in the areas concerning cultural identity and cultural elements of the therapeutic relationship. Clinicians working with children should recognize the strengths as well as the limitations of the Outline and expand their cultural descriptions accordingly. Several additions to the text of the Outline that will facilitate the development of comprehensive cultural formulations specific to children and adolescents are proposed.