Examining the effectiveness of the Cultural Formulation Interview with young children

Article

Examining the effectiveness of the Cultural Formulation Interview with young children: A clinical illustration

Martin J. La Roche1 and Jill Betz Bloom2

Abstract

After years of extensive research, the Cultural Formulation Interview (CFI) was released in the fifth edition of the

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Similar to its predecessor, the Outline of the Cultural

Formulation (OCF), the CFI aims to refine the psychiatric assessment process by systematically examining cultural factors.

However, in contrast to the OCF which employs open-ended questions, the CFI uses a semi-structured interview format.

Unfortunately, children and adolescents have only been included in a handful of OCF and CFI studies, which raises questions

about their applicability with youth, particularly young children (11 years or younger). In this article, we start examining the

usefulness of the CFI with young children and propose recommendations to enhance its benefits by suggesting the devel-

opment of a supplementary module specifically designed for young children. These ideas are illustrated with the assessment

of a 6-year-old boy of Somali descent.

Keywords

assessment, children, cultural diversity, Cultural Formulation Interview, refugees, Somali

The Cultural Formulation Interview (CFI) was first introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association (APA), 2013). The CFI is a more standardized version of the Outline of the Cultural Formulation (OCF), which was first described in the DSM-IV (APA, 1994). The CFI oper- ationalizes many of the OCF’s questions into a semi- structured interview composed of 16 questions with explicit instructions to assess an individual’s experience and social context. While the OCF was relegated to the ninth appendix of the DSM-IV (APA, 1994), the CFI is described in the more prominent section III of the DSM- 5 (APA, 2013), which seems to reflect its increased cred- ibility (La Roche, Fuentes, & Hinton, 2015).

The CFI was designed to identify cultural and con- textual factors relevant to the diagnosis and treatment of different problems; it aims to more accurately under- stand patients’ symptoms and world views by examin- ing them in relationship to their cultural context. The underlying assumption of the CFI is that culture shapes a patient’s perspective and approach to clinical care, influencing when, where, how and to whom patients narrate their experiences of illness and distress

(Kirmayer, 2006). In addition, the authors of the CFI (Lewis-Fernández, Aggarwal, Hinton, Hinton, & Kirmayer, 2016) underscore culture’s fluidity and con- ceptualize it as an open dynamic system that undergoes continuous change over time. Furthermore, the CFI authors explain that most individuals and groups are exposed to multiple cultures and socioeconomic con- texts (Lewis-Fernández et al., 2016).

In contrast to the DSM-5’s prevalent biomedical view of disorders as constellation of symptoms that are accurately examined independently of their cultural context, in the CFI mental health disorders are concep- tualized as embedded in cultural contexts (La Roche et al., 2015; Regier, Narrow, Kuhl, & Kupfer, 2011). The CFI explores symptoms as locally shaped by dif- ferent cultural contexts.

Transcultural Psychiatry

2020, Vol. 57(4) 515–524

! The Author(s) 2018

Article reuse guidelines:

sagepub.com/journals-permissions

DOI: 10.1177/1363461518780605

journals.sagepub.com/home/tps

1Boston Children’s Hospital and Harvard Medical School 2William James College

Corresponding author:

Martin J. La Roche, Boston Children’s Hospital/Harvard Medical School,

75 Bickford St, Jamaica Plain, MA 02130, USA.

Email: [email protected]

Directly assessing patients’ cultural characteristics and contextualizing their symptoms allows clinicians to design psychotherapeutic treatments based on these characteristics rather than cultural stereotypes (Lewis- Fernández et al., 2016). Furthermore, directly assessing patients’ cultural beliefs, idioms of distress or meanings helps practitioners avoid misdiagnosis, obtain clinically useful information, improve clinical rapport and thera- peutic efficacy, guide research and training, and clarify cultural epidemiology (Lewis-Fernández et al., 2016). In fact, there is a growing literature that demonstrates that complementing psychiatric assessments with the OCF or CFI significantly increases the accuracy and cultural validity of DSM’s diagnoses (Bäärnhielm, S., Åberg Wistedt, & Scarpinati Rosso, 2015; Kirmayer, Thomb, Jurcik, Jarvis, & Guzder, 2008; Lewis- Fernández et al., 2016). Nevertheless, employing the CFI by itself does not result in a diagnosis. The infor- mation obtained by the CFI must be integrated with other clinical material to produce a comprehensive clin- ical and contextual evaluation. In addition, it is import- ant to clarify that the CFI guidelines do not require clinicians to have a thorough knowledge of their patients’ cultural background. However, an enhanced knowledge of patients’ cultural background often increases CFI’s diagnostic accuracy (Lewis-Fernández et al., 2016).

The CFI is described as ‘‘a work in progress’’ or a ‘‘living document that will be modified with new know- ledge’’ (Kirmayer, 2016, p. 268). The CFI (see Appendix 1 in the Supplemental Online Material) explores the following four areas: 1) Cultural definition of the problem; 2) Cultural perceptions or understand- ing of the cause(s) of the problem, which includes two subareas, stressors/supports and role of cultural iden- tity; 3) Cultural factors affecting self-coping and past help-seeking; and 4) Cultural factors affecting current help seeking. Two versions of the CFI are available, one for patients (which will simply be referred to as CFI) and a CFI-Informant Version. The CFI is directly administered to patients and gleans information from their own world view, while the CFI-Informant Version is completed by significant other(s) of patients or people who can provide relevant information about them or their context. The CFI-Informant Version aims to assist clinicians in conducting a cultural assess- ment of the presenting clinical problem from the per- spective of key informant(s) such as spouse, other family member(s), teacher(s) or other significant per- son(s) in their life who can offer clinically relevant information. When collateral information is possible, the CFI-Informant Version supplements what patients report or it may become the primary source of infor- mation when patients are unable to participate actively in their assessment, such as in the case of young

children, individuals with cognitive impairment or florid psychosis (Lewis-Fernández et al., 2016). Often, only the CFI-Informant Version is used with the par- ents and/or teachers of a child, while neither CFI ver- sion is directly used with children, particularly young children (Rousseau & Guzder, 2016). Both CFI ver- sions measure the same four areas but the CFI- Informant Version does so from the perspective of per- son(s) close to the patient and it includes the following question: ‘‘How would you describe your relationship to the patient?’’

Both CFI versions can be complemented by one or several of the 12 Supplementary Modules (e.g., cultural identity). Each of these 12 modules provides additional and more detailed questions to assess specific domains briefly explored in the CFI as well as questions that can be used during the cultural assessment of particular groups, such as children and adolescents, older adults, and caregivers. Evaluators can decide to use several or none of these 12 supplementary modules.

Over 150 published studies have employed the OCF. Given the CFI’s semi-structured format, it is likely that a greater number of research studies will soon start benefiting from its easier use (Lewis-Fernández et al., 2016). However, the vast majority of OCF studies have used adult samples. Only a handful of publications were identified that have used the OCF with children, particularly young children. In this paper, the term ‘‘young children’’ refers to youth who are 11 years of age or less, or youth who have not reached the formal operations stage. According to Piaget (1972) the formal operations stage is the last cognitive stage in an indi- vidual’s development and it entails an ability to think in abstract terms and think critically and comparatively about situations. The age at which the formal operation stage emerges varies from culture to culture but in industrialized and highly-educated countries it often starts developing around the time the child is 11 years of age (Cole, 1998).

The handful of researchers (i.e., Novins et al., 1997; Mian, Al-Mateen, & Cerda, 2010) who have employed the OCF with children have consistently noted its potential to assess cultural issues and suggested that the paucity of OCF research is explained by the fact that it was designed for adults. As a means to address OCF’s significant limitations in assessing children, the CFI incorporated two main additions (Rousseau & Guzder, 2016). First, it included the CFI-Informant Version that is administered to people who are signifi- cant in a child’s life, such as parent/guardian(s) and teachers, and second, it crafted a supplementary module 9 entitled ‘‘School-Age Children and Adolescents’’ (SACA) to be directly administered to the child (see Appendix 2 in the Supplemental Online Material).

516 Transcultural Psychiatry 57(4)

The first improvement underscores the importance of using the CFI-Informant Version with children’s parent(s) or guardian(s), which acknowledges that they are key to their children’s clinical presentation. In addition, the possibility of having several people complete supplemental forms reflects the complexity of cultural views and contexts. The child is exposed to multiple cultural influences at home, school, and in their communities. Even within the same family each parent or sibling may have distinct cultural views (e.g., different acculturation levels) that can be assessed through different informant versions.

The development of a supplementary module for SACA is a second significant improvement included in the CFI to assess children. The SACA module is designed to help clinicians explore age-related cultural dimensions. The questions are purposefully indirect to allow children or adolescents to express their feelings of being special or different or from a specific culture. The questions are written to yield the child’s representations of normality at home or challenges growing up at school, with friends or their community, which acknowledges that a child’s normal development is defined in cultural terms. The module includes 20 ques- tions in four main areas.

However, even this module specifically designed for children and adolescents contains the following caveats, ‘‘this supplement is directed to adolescents and mature school-age children. . . Some children may not be able to answer all questions; clinicians should select and adapt questions to ensure they are developmentally appropriate for the individual’’ (Lewis-Fernández et al., 2016, p. 309), which raises questions about its utility with young children. It is likely that the devel- opers of this module were concerned that its questions required formal operations thinking and that it relied too heavily on language. For example, question 14 (i.e., What do other children/youth your age expect from child/youth your age?) may not glean very different information from question 13 (e.g., What do your par- ents or grandparents expect from you?). The difference between questions entails contrasting contexts, which is a formal operation skill.

Kirmayer (2016) explains that the CFI has much potential as an assessment tool, yet it is still unclear how it is used in the clinical process. This is particularly important as assessment and treatment processes are not independent from each other. Furthermore, Kirmayer (2016) argues that the CFI stopped short of creating a more structured template that could link and organize the assessment data to clinical issues. In the assessment of young children, we outline several ideas to connect the information yielded by the CFI to the psychiatric assessment, which could be very useful for mental health providers working with young children

who need to glean and organize information from mul- tiple sources (e.g., school, family). Having an outline to organize this information may not only clarify the information but also save time. Not considering cul- tural information can lead to significant assessment and clinical errors (Kirmayer, 2016). As a result, clin- icians and researchers may start viewing the CFI as an invaluable tool to organize information in a more cul- turally valid manner instead of viewing it as another cumbersome scale to administer. However, to outline this process we need to start by briefly describing the psychiatric assessment and its main components.

The psychiatric assessment is the process of gather- ing information by a mental health provider (e.g., psychiatrist, social worker) about a patient within a psychiatric or mental health service with the purpose of making an accurate diagnosis (Angold et al., 1995; Maxmen & Ward, 1994). The psychiatric assessment is the first stage of any mental health treatment. Many outlines to conduct psychiatric assessments have been developed. Nevertheless, most include the following six components (Maxmen & Ward, 1994): 1) ‘‘Chief Complaint(s)’’ in which the main reason(s) patients are seeking mental health services are described; 2) ‘‘History of Problems’’ or how patients’ problems have evolved through time; 3) ‘‘Mental Status’’ or the symptoms patients are presenting; 4) ‘‘Diagnosis’’ which is a category(s) that reflects the constellation of symptoms patients are presenting; 5) ‘‘Biopsychosocial Formulation’’ or an explanation of why patients are experiencing certain symptoms and; 6) ‘‘Treatment Plan’’ or a systematic set of strategies designed to ameliorate patients’ symptoms. Additional components have also been used in the psychiatric assessment (Maxmen & Ward, 1994) (e.g., prognosis, physical examination), which are not herein included because they are not significantly influenced by the information yielded through the CFI. The way in which each of these six psychiatric assessment components is informed by the four areas of the CFI are outlined and illustrated through a psychiatric assessment of a 6-year-old boy of Somali descent conducted by the first author of this article, who is a Latino, male psych- ologist in his mid-50s. The goal of this paper is to start examining the utility of the CFI with young children and to suggest strategies to refine its use with young children. To ensure confidentiality identifiable data has been disguised or modified.

Case example

Jamaal came to the clinic located in their neighbour- hood with his mother and interpreter. The clinic is the oldest standing community health center in the United States and has a long tradition of serving and

La Roche and Bloom 517

welcoming diverse communities. The same interpreter was present for both assessment sessions. Before the session, all releases, consents, and confidentiality agree- ments were explained and signed. Jamaal was a well- groomed boy, with a shy smile and bright eyes, and appropriately dressed for the fall weather. He was born in Boston six years ago to Somalian parents. Jamaal speaks English fluently but his parents have a very limited understanding of English and are unable to express themselves in English. His parents recently separated for unspecified reasons. Although his father now lives in a different town he still visits Jamaal and his four siblings every day. Jamaal is the youngest; his two brothers are 22 and 17 years of age and his sisters are 15 and 8. Jamaal reported having a good relation- ship with his parents and each of his siblings.

His parents arrived in Boston 25 years ago fleeing escalating violence in Somalia. Civil war broke out in Somalia in 1988 leading to a massive population dis- placement that continues to this date. Currently, the Somali and Somali Bantu populations are the largest African groups living in the United States (Johnson, Ali, & Shipp, 2009) and constitute 45% of the African refugee population (Carroll et al., 2007). As a result of the civil war and the immigration journey to the US, many families have experienced severe violence. These traumatic experiences are often compounded in the US by resettlement stressors, acculturative stres- sors, poverty, and discrimination (Betancourt, Abdi, Ito, Lilienthal, & Agalab, 2015). Research indicates that among relocated Somalis, mental health diagnoses such as depression, post-traumatic stress disorder (PTSD), and anxiety range from 14% to 31.5% of the population (Boynton, Bentley, Jackson, & Gibbs, 2010) with 50% prevalence rate in some studies (Guerin, Guerin, Diiriye, & Yates, 2004).

Despite Somalis’ extensive need for mental health ser- vices, they rarely seek help. Furthermore, children utilize services even less often than adults (Ellis et al., 2010). Multiple barriers (e.g., language differences, difficulty accessing health services) often deter Somalis from seek- ing mental health services. However, researchers (e.g., Bettmann, Penney, Clarkson-Freeman, & Lecy, 2015; Ellis et al., 2010) explain that underutilization is also a result of Somalian cultural beliefs that often clash with Western mental health assumptions. For example, many Somalis believe that having PTSD or depression is a sign of weakness that is best dealt with by staying at home. Rather than seeking outside services families encourage their ill family members to stay home as a means to protect them from being publicly humiliated or insulted (Bettmann et al., 2015).

I first met with Jamaal’s mother, Mrs. S. while Jamaal played quietly in the waiting area. Mrs. S was a tall, slim woman in her late-30 s wearing a colorful

and highly ornamented hijab or veil. In an effort to establish rapport with her I inquired about transporta- tion issues. Once I felt that rapport had been estab- lished I asked ‘‘what brings you here?’’ which is the first question of the CFI informant version. This is also the first question of many psychiatric assessments and addresses patients’ chief complaint. She said ‘‘my son’s pediatrician Dr. O. recommended that Jamaal receive counseling.’’ Following CFI’s outline, I added. ‘‘People sometimes understand their problems in their own way, which may be different from the way in which doctors describe the problem.’’ Jamaal’s mother pro- ceeded to explain that her eldest son Mohamad, 22 years of age, was shot in front of their home and that he is still recovering from numerous gun wounds. The ‘‘criminal was never caught by the police.’’ According to traditional Somali culture, an assault to a family member is an affront to the entire family, which reflects the close-knit kinship relationships emphasized in Somalia (Wolf et al., 2014). Frequently after an assault mental health assistance is not sought; instead the assailant is required to pay damages to the family (Scuglik, Alarcón, Lapeyre, Williams, & Logan, 2007). Overall, this information about Somalian culture was used as hypotheses that could clarify Jamaal and his family’s experience. Nevertheless, these hypotheses had to be confirmed by their narratives (Kleinman, 1988; La Roche, 2013), which seemed to be the case as Jamaal’s mother said, ‘‘I don’t think the police care about Africans because they never caught the criminal.’’ The mother’s focus was on capturing the shooter so that he would have to compensate the family for the assault. She added that ‘‘they [police] don’t care about us or they would have caught the criminal. . . shootings are very frequent where we live. Our next-door neighbor was also shot a few months ago. We live in a very dangerous neighborhood. . .’’

Mrs. S. explained that the frequent neighborhood shootings were making Jamaal very nervous; he was having nightmares and he was not eating at school. Even his pediatrician was worried because he had lost weight. Mrs. S. continued, ‘‘after Mohamad [eldest son] was shot, Jamaal has not been the same. Before the shooting Jamaal was a happy child but now, he doesn’t go outside by himself. He doesn’t eat breakfast at school and he doesn’t play with his friends.’’ I asked how he played with his friends before and after the shooting. His mother responded, ‘‘before he never seemed afraid of going out but now he seems afraid of walking alone on the street.’’ She identified his night- mares, poor appetite and fear of walking alone as the most troubling aspects of his behavior, which were a response to question 3 of the CFI, which is also a good question to start exploring patients’ mental status. I asked many additional questions examining his mental

518 Transcultural Psychiatry 57(4)

status. As his symptoms were identified a history of problems was also completed. It was found that before his brother was shot he did not present anymajor mental health symptoms (e.g., nightmares, lack of appetite).

In exploring the cultural perceptions (CFI’s questions 4–7) of the causes of Jamaal’s problems his mother explained that the shootings were the main reason for his problems. She indicated that Jamaal’s father and extended family also believed this was the case. One of the advantages of the information gleaned through the CFI questions is that it can add cultural specificity, not typically obtained, using standard psychiatric assess- ments. For example, as I continued to explore what vio- lence and Jamaal’s symptoms meant for them, Mrs. S. angrily said,

Americans do not care about Africans or Muslims.

Whites have dumped us in a bloody neighborhood so

that we kill each other. This is what Donald Trump

wants, isn’t he saying that he wants to get rid of all

Muslims?

Having experienced much discrimination from white people, Jamaal’s family found it difficult to trust them. I understood this could become a significant treatment barrier and that it should be addressed as soon as possible. Nevertheless, she quickly moved on to talk about housing issues.

Mrs. S. then described her repeated efforts to move out of the neighborhood and her frustration in com- pleting subsidized housing applications. Her English was not good enough to complete these forms, which would allowed me to further explore her self-coping and past help-seeking behavior when facing significant challenges (CFI question 11–13). Jamaal’s mother iden- tified that two crucial barriers for the well-being of her family were poverty and living in a violent neighbor- hood. She said that ‘‘it is very frustrating to seek help. When I phone people, they hang up on me. They do not understand my English but I keep trying for my family.’’ I offered to refer her to a case manager, to which she responded that in the past case managers had been useless. She explained that her previous case manager was ‘‘a very busy woman who did not seem to have time for my family. She did not answer my ques- tions just like most Whites don’t. Whites don’t care for Muslims. . .’’

In inquiring about her preferred types of help (CFI questions 13–15) I asked her what I should do to ensure that I did not make the same mistakes since I am not Muslim nor African. She answered that, ‘‘I should really try to care.’’ I asked her to explain what she meant by caring as it means different things for differ- ent people. Smiling, she said that we would have to work together to find that out. I asked further what a

good relationship would look like and she said that she would surely tell me if I was not caring enough.

Some of the CFI identity questions (questions 8–10) were not addressed in order or even during the same assessment session but much information was provided about their identity from the onset and throughout the assessment. For example, I realized that Mrs. S. used the plural form of words frequently, using the word ‘‘we’’ to refer to herself, Jamaal, or the family. Although, most people would agree that it is impossible to work with a child without the family, I soon realized that her identity and family were intricately interwoven. Her identity was more a reflection of family relation- ships than an individualistic, isolated construal of the self. Reflecting this view, in the treatment plan I under- scored the importance of including the family in the psychotherapeutic process. Moreover, her identity as a Muslim and African was central and often construed in opposition to American traditions and assumptions. She believed that because of her family’s religion, skin color, and place of birth they were discriminated against and marginalized in Boston.

Consistent with CFI guidelines (question 16) I fur- ther explored the meaning of cultural differences. I encouraged her to discuss any concerns that she might have had because I am Latino and not Muslim. Nevertheless, it is important to note that many add- itional cultural differences are also present, such as gender and educational level, that needed to be dis- cussed (La Roche, 2013). However, many patients choose not to address cultural differences during the first few sessions. Most patients have many and more pressing issues to discuss. Nevertheless, by asking the CFI questions the message was conveyed that it was appropriate to discuss cultural differences within the psychotherapeutic session. Some patients choose to take advantage of this possibility in later sessions (La Roche, 2013).

After Jamaal came to the office I asked a few rap- port-building questions before I asked the first question of the CFI to which he did not seem to know how to respond. Even after I clarified the question he just looked to the floor. I then proceeded to administer the SACA supplementary module (see Appendix 2 in the Supplemental Online Material) and I asked, ‘‘I would now like to know more about your feelings about being 6 years of age?’’ He limited himself to say, ‘‘it’s ok.’’ I then asked ‘‘do you feel like other chil- dren/youth your age?’’ to which he did not seem to know how to respond. The interviewer has repeatedly experienced the same situation where young children of different ethnic backgrounds do not know how to respond to any of the CFI’s questions including the SACA module. More often than not the answer is ‘‘I don’t know’’ or ‘‘my mother brought me here.’’

La Roche and Bloom 519

I asked Jamaal if he would like to draw or build something and he took some paper and crayons and started drawing four thick walls that looked like a ‘‘fort’’ and he drew himself inside. He stated that ‘‘he was in his home playing ball.’’ I asked how it is to be home and he responded, ‘‘it’s good inside the house, but outside it’s bad.’’ He did not respond when I asked him to draw the outside. I then asked him what is good about being inside and bad outside and he said,

Inside I have my family and we are happy together, but

outside there are many shootings. . . One time my

brother was shot. Many policemen and ambulances

came. There were lots of people. . . Another time I

was looking outside the window and there was another

shooting. I am very scared. I am scared that I will get

shot. I am scared that my mom will get shot. . . I am

scared of going outside so I stay inside. I play with my

tablet, watch TV and play with my sisters.

Following the SACA module questions I inquired about stressors and supports. His family was identified as a source of support while his neighborhood was viewed as a dangerous and stressful place.

In addition, he reported having frequent nightmares in which he was shot by streets thugs or kidnapped, ‘‘they are very scary’’ he explained. Furthermore, Jamaal reported often feeling dizzy and that his heart beat very quickly. Jamaal also had difficulty breathing and even feeling some ‘‘belly ache.’’ This was particu- larly true if he heard a

USEFUL NOTES FOR:

Examining the effectiveness of the Cultural Formulation Interview with young children: A clinical illustration

Introduction

The Cultural Formulation Interview (CFI) is a structured interview designed to gather information about the cultural context of a young child’s clinical presentation. It can be helpful for clinicians who work with diverse populations, such as those of diverse racial or ethnic backgrounds, or patients whose first language is not English. In this article, I will discuss the CFI from a clinical perspective and provide an example of how it was used in my practice.

Introduction

The Cultural Formulation Interview is a useful tool for assessing young children. It can be used to capture the cultural context of a child’s clinical presentation and care, as well as provide an opportunity to explore issues related to culture and language. The CFI has been shown to be an effective means of gaining rich information about the child’s family environment, social networks, beliefs and practices.

The Cultural Formulation Interview

The Cultural Formulation Interview (CFI) is used to assess the cultural formulation of children and young people who are experiencing high risk or trauma. It differs from other assessment tools in that it specifically aims to determine the way in which a person’s experiences have shaped their worldview, identity and sense of self.

The CFI was developed by Dr Richard Ekins and colleagues at the University of Salford, UK, as an alternative method when other assessment tools have failed to provide appropriate information about how people think about themselves or others due to their use being limited within specific contexts such as schools or hospitals; where there is little time available for questioning them properly due

to limited resources available; where there may be issues around confidentiality or privacy concerns etc…

Clinical Illustration

The clinical illustration is an important tool for clinicians who work with young children. It can be used to examine the effectiveness of a particular method or technique, as well as its applicability in different cultural contexts.

In this case study, we will examine how one can use the CFI interview to help understand a child’s culture and how it might shape their experience of play therapy.

Discussion

The Cultural Formulation Interview is a valuable tool for assessing young children to capture the cultural context of their clinical presentation. In this way, it can help us understand not only how children experience their illness in different parts of the world but also how they understand that experience. Resourceful clinicians will use CFI as an opportunity to explore with patients how they think about their illness and its treatment.

The interview is intended to be conducted by licensed mental health professionals who have received extensive training on cultural sensitivity in psychosocial assessment and intervention. Patients should be able to speak openly about any concerns or questions without fear of judgment or criticism from the interviewer (the researcher).

The CFI is a valuable tool for assessing young children to capture the cultural context of their clinical presentation.

The CFI is a valuable tool for assessing young children to capture the cultural context of their clinical presentation. The CFI can help clinicians understand how culture influences the presentation of symptoms, thereby facilitating more effective treatment and prevention efforts in healthcare settings.

The CFI is also useful for clinicians who work with multiple ethnic groups or different cultures within one organization, as it helps them understand what might be unique about each patient’s experience or situation (e.g., where they live).

Conclusion

I hope that this article has provided some insight into how to use the CFI interview with young children. It is a valuable tool for understanding the cultural context of their clinical presentation and for capturing a broad picture of the family’s social and emotional environment.