Measuring Clinician–Client Relationships in Speech-Language Treatment for School-Age Children Purpose Clinician–client relationships may influence treatment success in speech-language pathology, but there are no established tools for measuring these relationships. This study describes the development and application of a set of scales for assessing clinician–client relationships in children's speech-language treatment. Method Twenty-two triads of participants completed a longitudinal ... Research Note
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Research Note  |   February 01, 2017
Measuring Clinician–Client Relationships in Speech-Language Treatment for School-Age Children
 
Author Affiliations & Notes
  • Kerry Danahy Ebert
    Rush University, Chicago, IL
  • Disclosure: The author has declared that no competing interests existed at the time of publication.
    Disclosure: The author has declared that no competing interests existed at the time of publication. ×
  • Correspondence to Kerry Danahy Ebert: Kerry_ebert@rush.edu
  • Editor: Krista Wilkinson
    Editor: Krista Wilkinson×
  • Associate Editor: Amanda Van Horne
    Associate Editor: Amanda Van Horne×
Article Information
Speech, Voice & Prosodic Disorders / Research Notes
Research Note   |   February 01, 2017
Measuring Clinician–Client Relationships in Speech-Language Treatment for School-Age Children
American Journal of Speech-Language Pathology, February 2017, Vol. 26, 146-152. doi:10.1044/2016_AJSLP-16-0018
History: Received January 28, 2016 , Revised June 24, 2016 , Accepted August 13, 2016
 
American Journal of Speech-Language Pathology, February 2017, Vol. 26, 146-152. doi:10.1044/2016_AJSLP-16-0018
History: Received January 28, 2016; Revised June 24, 2016; Accepted August 13, 2016

Purpose Clinician–client relationships may influence treatment success in speech-language pathology, but there are no established tools for measuring these relationships. This study describes the development and application of a set of scales for assessing clinician–client relationships in children's speech-language treatment.

Method Twenty-two triads of participants completed a longitudinal study. Each triad had 1 school-age child enrolled in speech-language treatment, 1 caregiver, and 1 speech-language pathologist (SLP). The clinician–client relationship scales were administered to all 3 types of participants at study onset and again 2 weeks later. Treatment progress measures were collected 4 months later. Analyses established the reliability and validity of the clinician–client relationship scales.

Results Adequate internal consistency reliability and test–retest reliability were established for all 3 versions of the scale (child, caregiver, and SLP). Convergent validity was moderate between SLPs and children but lower when caregivers were included. Predictive validity analyses established significant relationships between caregiver and SLP ratings of the clinician–client relationship and future treatment progress.

Conclusions This exploratory study established the viability of the clinician–client relationship scales for further development and application. The importance of establishing and utilizing measures of the clinician–client relationship in speech-language pathology is discussed.

Across a diverse array of health-related fields, the working relationship between a clinician and a client 1   is considered a crucial contributor to treatment success (e.g., Innes & Cameron, 2013; Kim, Yates, Graham, & Brown, 2011; Rakel et al., 2011). Such relationships may be particularly central to treatments delivered via behavioral (rather than pharmaceutical) means: A positive collaborative relationship between clinician and client lays the foundation for successful treatment delivery. This concept is best developed in counseling psychology, a field in which some have argued that clinician–client relationships influence treatment outcomes more than treatment programs do (Flükiger, Del Re, Wampold, Symonds, & Horvath, 2011; Laska, Gurman, & Wampold, 2014). It is important to note that such relationships extend beyond a simple emotional connection between clinicians and clients; for example, in Bordin's (1979)  pantheoretical model, the working relationship comprises agreement on goals, collaboration on tasks, and the emotional bond.
In speech-language pathology, the role that clinician–client relationships play in treatment is not yet established. Consideration of this topic dates back at least to the late 1960s, when Manning and Cooper (1969)  investigated the feelings of adults receiving stuttering treatment toward their clinicians. Since that time, there is ample evidence that clinician–client relationships are considered a valuable component of speech-language treatment. Relationships have been highlighted in the literature on aphasia (Shill, 1979), cognitive–communication impairments (Kovarsky, Schiemer, & Murray, 2011), and stuttering (Manning, 2010). A survey study of clinicians (Ebert & Kohnert, 2010) indicated that the ability to build a clinician–client relationship was considered more important to successful treatment than other clinician qualities (e.g., patience or motivation). Last, several speech-language treatment studies with children have noted the possibility that factors common across treatments (e.g., clinicians) could have played a role in study results (e.g., de Sonneville-Koedoot, Stolk, Rietveld, & Franken, 2015; Gillam et al., 2008; for a complete discussion of common factors in treatment, see Wampold, 2001). However, these studies did not measure clinician–client relationships.
Two recent qualitative studies have provided important insight into the nature of clinician–client relationships in speech-language treatment (Fourie, Crowley, & Oliviera, 2011; Plexico, Manning, & DiLollo, 2010). Particularly relevant to the current study is Fourie et al.'s (2011)  interviews of six school-age children receiving speech-language treatment. Themes from these interviews indicated that children valued several characteristics of their speech-language clinicians—including the ability to make treatment fun, to create routines and rituals, and to provide choices—but that the children did not fully understand the clinicians' role. This type of in-depth qualitative work builds understanding of the determinants of clinician–client relationships. Nonetheless, quantitative investigations are needed to examine the extent to which clinician–client relationships influence treatment progress and outcome in speech-language pathology. In order to carry out quantitative investigations, the field of speech-language pathology needs an established tool for measuring clinician–client relationships. To date, such a tool has not been tested.
The purpose of this study was to develop and test a measure of clinician–client relationships in speech-language treatment for school-age children. A scale validated for children's counseling psychology was adapted to suit speech-language treatment and then piloted with a group of school-age children receiving speech-language treatment. Results of the pilot study, including preliminary psychometric properties of the scale, are presented here. The final section of this research note discusses the need to expand this line of work and the potential applications of a quantitative clinician–client relationship measure.
A set of rating scales—the Therapeutic Alliance Scales for Children (TASC-r), developed by Shirk and Saiz (1992)  and revised by Creed and Kendall (2005) —was adapted from counseling psychology to speech-language pathology. The TASC-r was designed as a 12-item rating scale for use in children's psychotherapy. Items assess all three of the components of Bordin's (1979)  model (i.e., goals, task, and bond). TASC-r versions appropriate for children, their caregivers, and their clinicians have been previously developed and validated (Creed & Kendall, 2005; DeVet, Kim, Charlot-Swilley, & Ireys, 2003; Shirk & Saiz, 1992). Caregivers play an integral role in children's treatment (DeVet et al., 2003), and thus their perspective is included. TASC-r ratings have been shown to predict both treatment participation and treatment progress in children's psychotherapy (Accurso, Hawley, & Garland, 2013; Hawley & Weisz, 2005).
The TASC-r was selected for adaptation to speech-language pathology because of its established validity and because its theoretical basis—Bordin's (1979)  model—applies to speech-language pathology as well as psychotherapy. For the current project, the TASC-r scales were adapted by (a) altering all versions to refer to speech-language goals and speech-language clinicians rather than counseling goals and therapists and (b) reducing the semantic and syntactic complexity of the children's version to increase its suitability for completion by children with language impairments.
The primary objective of this project was to establish psychometric properties of these adapted scales within a pilot group of school-age children enrolled in speech-language treatment. Properties of all three versions of the scales (i.e., child, caregiver, and clinician) were examined. The psychometric properties of interest included internal consistency reliability, test–retest reliability, convergent validity, and predictive validity (see Accurso et al., 2013). High internal consistency reliability ensures that the items in the scale measure a common construct, whereas high test–retest reliability ensures that responses are consistent over time. Convergent validity is an index of how closely the child, caregiver, and speech-language pathologist (SLP) measures align. It would be expected that the three perspectives on the relationship would overlap moderately but not completely, suggesting that the same construct is being measured from three viewpoints. Predictive validity is the extent to which the clinician–client relationship ratings can predict treatment progress; it was hypothesized that a valid assessment of the clinician–client relationship would relate to treatment progress.
Method
Participants
Participant recruitment was conducted by first enrolling SLPs, who then referred eligible children to the project. Children were eligible if they were 6 to 12 years old and receiving individual treatment for any speech-language disorder other than intellectual developmental disorder or autism spectrum disorder; these diagnoses were excluded because they may influence both the strength of the relationships a child forms and his or her ability to evaluate them (Kazdin & Durbin, 2012).
Recruitment yielded 22 triads of participants. Each triad consisted of one child (n = 22), his or her SLP (n = 14 because some SLPs treated more than one participating child), and a caregiver (n = 20 because two caregivers had multiple children participate). Participating children included 13 boys and nine girls ranging in age from 6;6 (years;months) to 11;11 (mean age = 8;11). The SLPs reported communication disorders for each participating child; these disorders included speech sound (n = 8), oral (n = 16) and written (n = 10) language, fluency (n = 2), auditory processing (n = 2), and voice (n = 1) disorders. The number of reported disorders per child ranged from one to three. The children had received an average of 29 previous treatment sessions from the participating SLP.
Caregiver participants included 19 mothers and one father. All parents reported some postsecondary education, ranging from an associate-level degree to a graduate degree. The 14 SLPs were all women and were employed in private clinic settings.
Measures
Clinician–Client Relationship Scales
Three versions of the clinician–client relationship scale—one for each type of participant—were developed. Each scale contained 12 statements, and the participant was asked to rate the truth of each statement using a Likert scale. Statements for all three versions appear in the Appendix. Adult participants used a 7-point Likert scale (ranging from not at all true to very much true), and child participants used a simpler 4-point scale with the same end points (Accurso et al., 2013; Creed & Kendall, 2005).
Progress and Process Measures
Three measures were gathered to capture treatment process and progress at the conclusion of the 4-month study period. Two of the measures were provided by the SLP. First, the SLP was asked to rate the child's progress in therapy on a 7-point Likert scale ranging from far less progress than I expected to far more progress than I expected. This general rating scale was used to capture progress across the range of communication disorders exhibited by the child participants. As a second measure, SLPs provided a record of the child's attendance at scheduled treatment sessions during the study time period. This measure was included because prior work (Accurso et al., 2013; Hawley & Weisz, 2005) has demonstrated a link between caregiver ratings and session attendance. The attendance data were transformed into percentages (i.e., percentage of treatment sessions attended from the study start date through study completion).
The final progress measure was the change in children's communication skills as reported by the caregiver. Caregivers completed the Children's Communication Checklist–Second Edition (CCC-2; Bishop, 2006) at the start of the study and at study completion approximately 4 months later. The measure was chosen because it indexes a range of communication skills. To complete the CCC-2, the caregiver rates the frequency of 70 communication behaviors; ratings are translated into scaled scores indexing 10 areas of pragmatic and nonpragmatic communication. Only the four scaled scores indexing nonpragmatic communication (i.e., the Speech, Syntax, Semantics, and Coherence indices) were used; these four scores were summed to obtain an index of the child's overall communication at each time point. The difference between these sums served as a caregiver-rated index of change in children's communication skills during the study. One caregiver did not return the final CCC-2, and the final value for this variable was 21.
Procedures
The study followed a longitudinal design with three distinct time points for each participating triad. At the first time point, caregivers provided background information about the child, completed the first CCC-2, and completed the first clinician–client relationship rating. Children completed their version of the clinician–client relationship rating with the assistance of research staff as needed (e.g., assistance with reading items or with comprehending scale instructions). Children were separated from both caregivers and SLPs while completing the scale, and all participants were assured that their ratings would not be seen by the other members of the triad. SLP activities at the initial time point were completed online; SLPs provided background information about child participants and completed their version of the clinician–client rating scale via web survey.
The second time point took place approximately 2 weeks later. The rating scales were repeated for all three groups (SLP, caregiver, and child) in order to calculate test–retest reliability. Last, the third time point occurred approximately 4 months after the first study time point. At this final time point, SLPs provided the progress rating, status rating, and attendance data online. Parents were asked to return the second CCC-2 via mail.
Analyses
Five of 12 items on each relationship scale were phrased negatively, and for these items the Likert response scale was inverted for analyses. A total score for the relationship scale was then obtained by summing the ratings across the 12 items. For analyses requiring comparisons between groups, children's summed scores were multiplied by a factor of 1.75 (i.e., 7/4) to place them on the same 84-point scale as the two adult groups.
Because of the small sample size and the varying levels of measurement of the therapy progress and process variables, each of the three variables was transformed into a 3-point ordinal scale for analyses. Values for each variable were coded as below average, average, or above average. For example, SLP ratings of far less progress, less progress, and somewhat less progress were coded as below average; SLP ratings of about the progress I expected were coded as average; and SLP ratings of somewhat more progress, more progress, and far more progress were coded as above average. Nonparametric independent-samples median tests were used to determine whether the initial clinician–client relationship ratings differed across the below-average, average, and above-average groups. Because of the exploratory nature of the study, the criterion for statistical significance was set at p ≤ .10.
Results
Figure 1 shows the distribution of total clinician–client relationship scale ratings for each of the three groups of respondents. In all three groups, the maximum score was 84; five caregivers, three children, and one SLP marked the highest possible rating on each of the 12 statements. Caregiver ratings were narrowly distributed at the top of the scale, whereas ratings from children and from SLPs were distributed more broadly across the scale.
Figure 1.

Distribution of total clinician–client relationship rating scores by participant group. Boxes display the distribution of the total score, summed from the ratings of 12 statements, on the clinician–client rating scale for each group. Children's ratings were originally made on a 4-point scale (for a maximum total score of 48). For this group, total scores were rescaled to match the caregiver and speech-language pathologist (SLP) scales (made on a 7-point scale for a maximum total score of 84). The maximum (upper whisker), 75th percentile, median, 25th percentile, and minimum (lower whisker) are displayed.

 Distribution of total clinician–client relationship rating scores by participant group. Boxes display the distribution of the total score, summed from the ratings of 12 statements, on the clinician–client rating scale for each group. Children's ratings were originally made on a 4-point scale (for a maximum total score of 48). For this group, total scores were rescaled to match the caregiver and speech-language pathologist (SLP) scales (made on a 7-point scale for a maximum total score of 84). The maximum (upper whisker), 75th percentile, median, 25th percentile, and minimum (lower whisker) are displayed.
Figure 1.

Distribution of total clinician–client relationship rating scores by participant group. Boxes display the distribution of the total score, summed from the ratings of 12 statements, on the clinician–client rating scale for each group. Children's ratings were originally made on a 4-point scale (for a maximum total score of 48). For this group, total scores were rescaled to match the caregiver and speech-language pathologist (SLP) scales (made on a 7-point scale for a maximum total score of 84). The maximum (upper whisker), 75th percentile, median, 25th percentile, and minimum (lower whisker) are displayed.

×
Reliability
Two types of reliability were investigated: internal consistency reliability and test–retest reliability. Internal consistency reliability was investigated with Cronbach's alpha (Cronbach, 1951) for the child, caregiver, and SLP relationship scales. Only data from the first administration of the scale were included in the analysis. Cronbach's α values were .79 for children, .76 for caregivers, and .91 for SLPs. All three values are considered to demonstrate acceptable internal consistency reliability (Tavakol & Dennick, 2011). For the caregivers, the Cronbach analysis indicated that one specific item, “I feel like my child's SLP spends too much time working on improving my child's speech or language skills,” reduced reliability; feedback from caregivers also indicated that they found this item confusing. Cronbach's α increased to .91 for the caregivers with this item removed. Further analyses utilized the adjusted caregiver scale with the problematic item removed. For the other two groups (children and SLPs), neither the Cronbach's analysis nor participant feedback identified any items for removal.
Test–retest reliability was investigated by calculating correlations between the first and second administration of the relationship scale for each group. Spearman's rho correlations were conducted due to the small sample size and ordinal level of measurement. The correlations were significant for all three groups: children, r s (21) = .82, p < .001; caregivers, r s (21) = .71, p < .001; SLPs, r = .91, p < .001.
Validity
Convergent validity was measured using Krippendorff's alpha. This flexible metric of agreement can be used with any number of raters and is appropriate for ordinal-level data (Krippendorff, 2004). Krippendorff's alpha was computed between each of the three pairs of raters and between all three members of a triad using the total scores from the first time point.
The Krippendorff's α value for convergence among all three members of the triad was .21, indicating positive but low agreement. Pairwise calculations indicated moderate agreement between SLPs and children (Krippendorff's α = .36), lower agreement between children and caregivers (Krippendorff's α = .18), and near-zero agreement between SLPs and caregivers (Krippendorff's α = .06).
The second type of validity was predictive validity. Table 1 shows the results of the nonparametric median tests that compared relationship ratings for the below-average, average, and above-average groups. Four tests reached statistical significance using the exploratory criterion of p < .10. When participants were grouped according to the SLP rating of treatment progress, the initial relationship ratings by both SLPs and caregivers differed among the groups (χ2 = 4.96, p = .084 for both tests). In other words, there was a predictive relationship between SLP and caregiver ratings of the clinician–client relationship at the first time point and the child's treatment progress 4 months later.
Table 1. Predictive validity by progress measure and rater.
Predictive validity by progress measure and rater.×
Progress measure Rater Median rating by progress group
Results of median test
Below average Average Above average χ2 p
Change in caregiver-rated skills Child 75.75 75.25 82.25 2.29 .318
Caregiver 73.00 77.00 75.00 5.71 .058
SLP 58.00 66.00 78.00 2.78 .249
SLP progress rating Child 71.75 73.50 80.50 3.65 .162
Caregiver 74.00 76.00 75.00 4.96 .084
SLP 57.00 77.00 62.00 4.96 .084
Attendance record Child 71.75 75.25 78.75 3.73 .155
Caregiver 75.00 75.00 76.00 6.34 .042
SLP 58.00 78.00 67.00 2.90 .234
Note. The median clinician–client relationship rating (below average, average, and above average) from the first time point is displayed by rater for each group on each of the three treatment progress and process measures. SLP = speech-language pathologist.
Note. The median clinician–client relationship rating (below average, average, and above average) from the first time point is displayed by rater for each group on each of the three treatment progress and process measures. SLP = speech-language pathologist.×
Table 1. Predictive validity by progress measure and rater.
Predictive validity by progress measure and rater.×
Progress measure Rater Median rating by progress group
Results of median test
Below average Average Above average χ2 p
Change in caregiver-rated skills Child 75.75 75.25 82.25 2.29 .318
Caregiver 73.00 77.00 75.00 5.71 .058
SLP 58.00 66.00 78.00 2.78 .249
SLP progress rating Child 71.75 73.50 80.50 3.65 .162
Caregiver 74.00 76.00 75.00 4.96 .084
SLP 57.00 77.00 62.00 4.96 .084
Attendance record Child 71.75 75.25 78.75 3.73 .155
Caregiver 75.00 75.00 76.00 6.34 .042
SLP 58.00 78.00 67.00 2.90 .234
Note. The median clinician–client relationship rating (below average, average, and above average) from the first time point is displayed by rater for each group on each of the three treatment progress and process measures. SLP = speech-language pathologist.
Note. The median clinician–client relationship rating (below average, average, and above average) from the first time point is displayed by rater for each group on each of the three treatment progress and process measures. SLP = speech-language pathologist.×
×
When progress groups were formed on the basis of the change in CCC-2 score, the caregiver's rating of clinician–client relationship differed significantly across the three groups (χ2 = 5.71, p = .058). In other words, children with greater change in communication skills over the 4-month period were more likely to have better clinician–client relationships according to the caregiver's perspective. Last, when progress groups were formed on the basis of treatment attendance, the initial caregiver relationship ratings differed among the groups (χ2 = 6.34, p = .042).
Discussion
This study explored the psychometric properties of a clinician–client relationship rating scale for children's speech-language treatment in a pilot group of school-age children. The first property of interest was internal consistency reliability; adequate values were established for all three groups of raters, supporting the claim that each version of the scale assesses a consistent construct. Test–retest reliability was also explored to examine the consistency of ratings across two time points for each group. Correlations were significant and large for all three groups. The establishment of adequate reliability is crucial to support future applications of the scales. Reliability is particularly notable for the child raters; this group had known communication impairments that could have affected their ability to comprehend the scale, but the results here suggest that their comprehension was sufficient to complete the scale reliably.
In addition to reliability, two types of validity were explored. Convergent validity results differed across groups. Convergence between children and SLPs was moderate and similar to the reported convergent validity values for children in psychotherapy (Accurso et al., 2013). In fact, moderate convergence was considered ideal because it suggests that the two raters are assessing the same construct from different viewpoints. However, convergence between all three members of the trio and between SLPs and caregivers was lower, signifying greater differences between viewpoints when caregivers were included. Last, convergence between SLPs and caregivers was near zero. One possible explanation for the lower convergence between caregivers and other groups is the lower variability in caregiver ratings. Caregivers in this pilot sample demonstrated consistently high relationship ratings, perhaps because they had more choice in the continuation of treatment than the children or SLPs. Future work should explore a wider range of caregiver perspectives, perhaps by exploring settings in which clients have less choice regarding their SLP (e.g., school-based settings).
Last, predictive validity was explored using three different measures of treatment process and progress. Despite the small, exploratory nature of the study, results were promising. The caregivers' views of the clinician–client relationship related significantly (p < .10) to all three measures of treatment progress and process. This may again relate to the caregivers' control over the treatment process. In counseling psychology for children, the caregivers' perspective on the clinician–client relationship better predicts treatment attendance than others' perspectives on the relationship, presumably because caregivers control this outcome most directly (Accurso et al., 2013). However, it must also be noted that SLP ratings predicted progress on only one of three measures and that children's ratings did not predict progress on any measure, even using a liberal criterion for statistical significance.
Overall, the preliminary psychometric properties established here support further investigation and use of the clinician–client relationship scales. Additional work clearly is needed to consider the scales' performance in larger groups and in new populations, such as adolescents or children receiving treatment in groups or in a classroom. Adaptation of the scales for adults with acquired communication disorders is needed as well, and research ultimately must consider the limits of who is able to complete such scales in terms of age, cognition, and degree of communication impairment.
Valid and reliable measures of clinician–client relationships have a number of clinical and research applications. Without these measures, the field cannot prove or refute the hypothesis that clinician–client relationships influence treatment progress and outcomes. If relationships do indeed have a significant effect on treatment (e.g., Flükiger et al., 2011), it becomes important to account for them statistically when studying the effects of new treatments (Norcross & Wampold, 2011). Without a valid measure of the relationship, its effects cannot be separated from the treatment effects of interest. Moreover, establishing measures of the clinician–client relationship paves the way toward investigating methods for improving such relationships. For example, qualitative work such as interviews (e.g., Fourie et al., 2011) could suggest techniques for improving clinician–client relationships, and then an established quantitative measure of the relationship (e.g., the one explored here) would be needed to determine the effects of the techniques.
Clinical applications of a valid clinician–client relationship measure also exist. SLPs could monitor client and family perceptions of the emotional bond and the collaboration toward common goals. Such feedback allows the clinician to identify problems and adjust approach or goals (Manning, 2010). Incorporating feedback may result in tangible improvements such as increased attendance at sessions, increased compliance with recommendations, and faster treatment progress. It is also consistent with the movement toward patient-centered care.
In summary, this exploratory study established the viability of a set of clinician–client relationship scales for speech-language pathology. Future work in this area may illuminate the mechanisms of successful speech-language treatment.
Acknowledgments
This work was funded by an American Speech-Language-Hearing Foundation New Investigators Grant. The author thanks Kahla Graham and Jeni Gillenwater for assistance with data collection, the Red Cap Project for data management, and all participating speech-language pathologists and families.
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Appendix
Clinician–Client Relationship Rating Scale Items
Adapted from Therapeutic Alliance Scales for Children (Accurso et al., 2013); original Therapeutic Alliance Scales for Children developed by Shirk and Saiz (1992) .
Child Version:
  1. I like spending time with my speech teacher.

  2. I think it is hard to work with my speech teacher on my speech goals.

  3. I feel like my speech teacher tries to help me.

  4. I work with my speech teacher on my speech goals.

  5. When I'm with my speech teacher, I want our time to end quickly.

  6. I look forward to meeting with my speech teacher.

  7. I feel like my speech teacher spends too much time working on my speech goals.

  8. I'd rather do other things than meet with my speech teacher.

  9. I use my time with my speech teacher to make my speech or listening better.

  10. I like my speech teacher.

  11. I would rather not work on my speech goals with my speech teacher.

  12. I think my speech teacher and I work well together on making my speech or my listening better.

Caregiver Version:
  1. I like spending time with my child's SLP.

  2. I find it hard to work with my child's SLP on improving my child's speech or language skills.

  3. I feel like my child's SLP is on my side and tries to help me.

  4. I work with my child's SLP on improving my child's speech-language skills.

  5. When I'm talking with my child's SLP, I want the time to end quickly.

  6. I look forward to talking with my child's SLP.

  7. I feel like my child's SLP spends too much time working on improving my child's speech or language skills.

  8. I'd rather do other things than talk with my child's SLP.

  9. I use my time with my child's SLP to make changes that help my child.

  10. I like my child's SLP.

  11. I would rather not work on my child's speech-language goals with my child's SLP.

  12. I think my child's SLP and I work well together on improving my child's speech or language skills.

SLP Version:
  1. The child likes spending time with you, the SLP.

  2. The child finds it hard to work with you on speech-language goals.

  3. The child considers you to be an ally.

  4. The child works with you on improving speech-language skills.

  5. The child appears eager to have sessions end.

  6. The child looks forward to sessions with you.

  7. The child feels that you spend too much time working on his/her speech-language skills.

  8. The child is resistant to coming to speech.

  9. The child uses his/her time with you to work on speech-language goals.

  10. The child expresses positive emotion toward you, the SLP.

  11. The child would rather not work on speech-language goals.

  12. The child is able to work well with you.

Footnote
1 The term clinician–client relationship is used here to capture the construct of interest. In psychology, this construct is often called the therapeutic alliance.
The term clinician–client relationship is used here to capture the construct of interest. In psychology, this construct is often called the therapeutic alliance.×
Figure 1.

Distribution of total clinician–client relationship rating scores by participant group. Boxes display the distribution of the total score, summed from the ratings of 12 statements, on the clinician–client rating scale for each group. Children's ratings were originally made on a 4-point scale (for a maximum total score of 48). For this group, total scores were rescaled to match the caregiver and speech-language pathologist (SLP) scales (made on a 7-point scale for a maximum total score of 84). The maximum (upper whisker), 75th percentile, median, 25th percentile, and minimum (lower whisker) are displayed.

 Distribution of total clinician–client relationship rating scores by participant group. Boxes display the distribution of the total score, summed from the ratings of 12 statements, on the clinician–client rating scale for each group. Children's ratings were originally made on a 4-point scale (for a maximum total score of 48). For this group, total scores were rescaled to match the caregiver and speech-language pathologist (SLP) scales (made on a 7-point scale for a maximum total score of 84). The maximum (upper whisker), 75th percentile, median, 25th percentile, and minimum (lower whisker) are displayed.
Figure 1.

Distribution of total clinician–client relationship rating scores by participant group. Boxes display the distribution of the total score, summed from the ratings of 12 statements, on the clinician–client rating scale for each group. Children's ratings were originally made on a 4-point scale (for a maximum total score of 48). For this group, total scores were rescaled to match the caregiver and speech-language pathologist (SLP) scales (made on a 7-point scale for a maximum total score of 84). The maximum (upper whisker), 75th percentile, median, 25th percentile, and minimum (lower whisker) are displayed.

×
Table 1. Predictive validity by progress measure and rater.
Predictive validity by progress measure and rater.×
Progress measure Rater Median rating by progress group
Results of median test
Below average Average Above average χ2 p
Change in caregiver-rated skills Child 75.75 75.25 82.25 2.29 .318
Caregiver 73.00 77.00 75.00 5.71 .058
SLP 58.00 66.00 78.00 2.78 .249
SLP progress rating Child 71.75 73.50 80.50 3.65 .162
Caregiver 74.00 76.00 75.00 4.96 .084
SLP 57.00 77.00 62.00 4.96 .084
Attendance record Child 71.75 75.25 78.75 3.73 .155
Caregiver 75.00 75.00 76.00 6.34 .042
SLP 58.00 78.00 67.00 2.90 .234
Note. The median clinician–client relationship rating (below average, average, and above average) from the first time point is displayed by rater for each group on each of the three treatment progress and process measures. SLP = speech-language pathologist.
Note. The median clinician–client relationship rating (below average, average, and above average) from the first time point is displayed by rater for each group on each of the three treatment progress and process measures. SLP = speech-language pathologist.×
Table 1. Predictive validity by progress measure and rater.
Predictive validity by progress measure and rater.×
Progress measure Rater Median rating by progress group
Results of median test
Below average Average Above average χ2 p
Change in caregiver-rated skills Child 75.75 75.25 82.25 2.29 .318
Caregiver 73.00 77.00 75.00 5.71 .058
SLP 58.00 66.00 78.00 2.78 .249
SLP progress rating Child 71.75 73.50 80.50 3.65 .162
Caregiver 74.00 76.00 75.00 4.96 .084
SLP 57.00 77.00 62.00 4.96 .084
Attendance record Child 71.75 75.25 78.75 3.73 .155
Caregiver 75.00 75.00 76.00 6.34 .042
SLP 58.00 78.00 67.00 2.90 .234
Note. The median clinician–client relationship rating (below average, average, and above average) from the first time point is displayed by rater for each group on each of the three treatment progress and process measures. SLP = speech-language pathologist.
Note. The median clinician–client relationship rating (below average, average, and above average) from the first time point is displayed by rater for each group on each of the three treatment progress and process measures. SLP = speech-language pathologist.×
×