A Developmental Conceptualization Of Clinical Problem Solving

ELSEVIER
A DEVELOPMENTAL
CONCEPTUALIZATION OF
CLINICAL PROBLEM SOLVING
NELSON MOSES
Long Island University, Brooklyn Campus, New York, New York
DAVID A. SHAPIRO
Western Carolina University, Cullowhee, North Carolina
A taxonomy for assessing clinician development in three areas of problem solving based
upon cognitive learning theory (Shapiro & Moses, 1989) was applied to the analysis
of videotaped clinical sessions involving three student clinicians. The purpose was to
evaluate, from a developmental perspective, the clinical performance of clinicians rated
by their supervisors as performing at different skill levels. Three developmental profiles
in three domains of problem solving (perspective taking, variables considered, and
solutions generated during clinical problem solving) were derived from these analyses.
The results supported the application of a developmental conceptualization to the
assessment and facilitation of problem-solving skills in the professional preparation of
speech-language pathologists.
INTRODUCTION
In 1985, ASHA's Committee on Supervision in Speech-Language Pathol-
ogy and Audiology identified and discussed 13 necessary tasks for effective
supervision. One competency specified as central to the first of these tasks
was the "Ability to facilitate independent thinking and problem solving
by the supervisee." (ASHA, 1985; see, also, Anderson, 1988; Casey, Smith,
& Ulrich, 1988; Farmer & Farmer, 1989; Moses & Shapiro, 1992; Roberts
& Smith, 1982; Shapiro & Anderson, 1989; Shapiro & Moses, 1989). The
facilitation of problem-solving skills in clinical settings presents significant
challenges to the supervisory profession when the complex nature of clini-
cal interactions in speech-language pathology is considered.
In the present study, clinical problem-solving behaviors of three student
Address correspondence to Nelson Moses, Ph.D., Associate Professor, Long Island University,
Department of Speech,Communication Sciences,and Theater, H409, 1UniversityPlaza, Brooklyn,
New York 11201.
J. COMMUN. DISORD. 29 (1996), 199-221
© 1996 by Elsevier Science Inc. 0021-9924/96/$15.00
655 Avenue of the Americas, New York, NY 10010 SSDI 0021-9924(95)00023-7

200 MOSES and SHAPIRO
clinicians, described by their supervisors as performing at different skill
levels, were evaluated from a developmental perspective. This study was
motivated by research in the area of cognitive psychology which suggests
that developmental factors are implicated in complex problem solving by
adults (e.g., Fosnot, 1990; Karmiloff-Smith, 1986; Moses, 1994). If so, de-
velopmental factors may be central to the expert management of clinical
interactions in speech-language pathology, which contain, arguably, among
the most complex problem-solving situations imaginable (Klein & Moses,
1994; see, also, Schultz, 1972, who modeled clinical decision making from
an information-processing orientation).
The Complex Nature of Clinical Problem Solving
There are numerous factors that complicate the assessment and remedia-
tion of speech-language disorders. Clinicians must cope with the unpredic-
tability inherent in trying to change another person's behavior. Clinicians
must manage a plethora of information. They must be cognizant of the
complex variables implicated in language-learning disabilities, including
language content, form, and use, as well as sensorimotor, cognitive, and
social-emotional factors that may be maintaining the disability. They must
adopt the perspective of their clients when planning and executing clinical
procedures, while at the same time remaining professional and goal-directed.
Clinicians must manage the ongoing stream of information that is gener-
ated in face to face contact with clients, and devise engaging, goal oriented,
effective activities in the process.
Clinicians are also required to infer and target in therapy such abstract
entities as content categories, phonological processes, syntactic parameters,
etc. Clinicians also need to consider how people learn language, and upon
reflection, may discover that much about language and language learning
conflicts with their personal beliefs (Michael, Klee, & Bransford, 1993). The
idea that children may control aspects of their own learning is often espe-
cially hard for clinicians to believe (Klein & Moses, 1994).
The Nature of Developmental Factors
Rather than viewing the clinical challenges cited above as requiring ag-
gregates of disparate skills, Shapiro and Moses (1989) have proposed that
a restricted set of developmentalfactors may play a role in the achievement
of clinical skills. With children, the term "developmental" signifies that in-
dividuals construct schemes and belief systems for organizing knowledge,
and that these schemas and beliefs influence how individuals manage in-
formation, the perspective they adopt for interpreting events and recogniz-
ing problems, and the possibilities they can envision for solving problems

CLINICAL PROBLEMSOLVING 201
(e.g., Duckworth, 1972; Nelson, 1986; Piaget, 1971; 1985; 1987; Wansart,
1990). Development also signifies that internal organization, personal be-
liefs, and perspectives can undergo transformations given time and appro-
priate problem-solving experiences (Inhelder, Sinclair, & Bovet, 1974;Moses,
1981; Piaget, 1985).
Researchers who have applied such a "constructivist" view of human be-
havior to adults have depicted the acquisition of problem-solving skills as
a developmental and cyclical process that occurs across one's lifespan (e.g.,
Fischer, 1980; Fosnot, 1991; Karmiloff-Smith, 1986; Moses, 1994). In such
a process, the development of problem-solving skills is not age related, as
are sequences in other domains (e.g., Piaget's 1954cognitive stages, or Bloom
and Lahey's 1978language phases). Rather, problem solving skills may un-
dergo a sequence of transformations whenever individuals address new prob-
lems, and as different aspects of a behavioral system develop (Fischer, 1980;
Karmiloff-Smith, 1986; Moses, 1994).
Clinician Development
Shapiro and Moses (1989) presented a model of creative problem solving
containing aspects of clinician development in four areas of problem solv-
ing: orientation of perspective, dimensions of behavior conceptualized, pos-
sible solutions generated, and causal concepts. Clinicians functioning at
early developmental levels, challenged by novel and complex problems en-
countered during clinical interactions, manifest the following characteris-
tics: (a) centration on a personal point of view about language learning
and clinical problems (e.g., viewing self in sole control of a client's learning
and the client as the source of problems); (b) consideration of relatively
few perceivable variables when thinking about causes of problems; and (c)
generation of single solutions to problems. At more advanced levels of de-
velopment, clinicians incorporate the client's perspective, consider the in-
teraction of multiple variables as contributing to clinical problems (includ-
ing variables such as linguistic organization that can be identified only
through inferential reasoning), and envision many potential solutions to
problems. Table 1 presents aspects of clinician development in problem
solving.
Methodological Considerations in the Investigation
of Clinician Development
If developmental factors influence clinical problem solving, then identify-
ing these factors is of major significance to supervisors whose responsibil-
ity is to facilitate professional growth. Understanding the components of
expert problem-solving would facilitate assessments of clinical interactions

Table 1. Aspects of Development in Problem Solving
Aspect From To
Perspective Identifies problems in the Identifies problems as
clinical interaction that seen from the perspective
affect self (i.e., that of others and self (client
cause personal discomfort- is major focus).
clinician is major focus).
Tends to think of problem Views problem resolution
resolution as caused by as being the result of
self or other authority active and shared client-
figure clinician interaction (i.e.,
goal establishment and
attainment).
Evaluates the efficacy of Evaluates problem-solving
problem-solving procedure procedure from multiple
from self-centered perspectives.
perspective.
Dimensions of Conceives of behavior as Conceives of behavior as
behavior unidimensional. Views multidimensional. Views
conceptualized problem as affecting and problem as affected by
affected by only one many dimensions of
dimension of behavior, behavior.
Possible Thinks of one problem- Generates and reflects upon
solutions solving procedure, multiple problem-solving
generated strategies.
Causal concepts Implements problem-solving Implements strategy and
strategy, but fails to reflects upon and modifies,
reflect upon or modify if appropriate, causal
causal theories, theories.
by both supervisees and supervisors, and the derivation of goals and proce-
dures both in supervision and in clinical intervention planning.
Investigating clinician development in context of clinical interactions is
a complex and long-range task, involving:
1. Derivation of tools for enhancing supervisors' insight into the develop-
mental status of individual clinicians in real life clinical and supervi-
sory interactions; such tools must be theoretically principled, and em-
pirically grounded;
2. Examination of developmental changes in individual clinicians over
time;
3. Description of individual differences among clinicians;
4. Exploration of characteristics of clinician development across disor-
der types (e.g., language, fluency, voice, etc.);
5. Delineation of characteristics of supervisory interactions that facili-
tate or impede clinician development.

CLINICALPROBLEMSOLVING 203
Purpose
The present study represents a preliminary phase of a work in progress.
Its general purpose is to introduce a developmental paradigm to supervi-
sion in speech-language pathology, and to encourage developmental studies
of the performance of speech-language pathologists in diverse clinical set-
tings. The specific purposes of this study were to (a) present a taxonomy
(Shapiro & Moses, 1989)for assessing clinician development in three areas
of problem solving; (b) apply the taxonomy to an analysis of videotaped
clinical interactions involvingthree student clinicians; and (c) illustrate how
developmental profiles of clinicians' problem-solving skills may be derived.
METHOD
Subjects
Subjects were three student clinicians (two graduate and one undergradu-
ate) in good academic standing (grade point average greater than 3.0) en-
rolled in clinical practicum in speech-language pathology. These clinicians
were selected from three groups of students rated as novice undergraduate,
novice graduate, and advanced graduate by their respective clinic supervi-
sors based on clinic performance.
Clinician A was a 20 year old undergraduate student who had completed
25 hours of supervised clinical practicum. Clinician B was a 23 year old
graduate student with 65 hours of supervised practicum. Clinician C was
a 25 year old graduate student who had 250 hours of supervised clinical
experience. None of the clinicians had any training in the supervisory pro-
cess. Their respective supervisors had earned the Certificate of Clinical Com-
petence from ASHA in speech-language pathology and were employed full-
time at the universities in which they supervised. These supervisors were
unfamiliarwith the taxonomyutilizedto analyzethe clinicians' performance
in the present study.
Materials
Based upon a model presented by Shapiro and Moses (1989) and Moses
and Shapiro (1992), a taxonomyfor assessing clinician development in three
areas of problem solving (Table 2) was designed for use in this investiga-
tion. The taxonomycontainsindices of speech-language pathologists'profes-
sional development in three domains of clinical problem solving:
1.0 Clinician's perspective reflected in clinical and supervisory interac-
tions;
2.0 Dimensions of behavior addressed in clinical and supervisory inter-
actions;
3.0 Problem solutions generated in sessions.

The Taxonomy for Assessing Clinician Development (Table 2) addressed
the first three domains of clinical problem solving in Table 1. The taxonomy
and its use assume that clinician development evolves along continua and
is reflected in observable changes in specifiable aspects of clinicianbehavior
in clinical and supervisory interactions. The first domain assumes that fa-
cility at problem solving requires clinicians to shift perspective-perhaps
the hallmark of communication (Shapiro & Moses, 1989). The second do-
main assumes that conceptualization of a problem proceeds from a focus
on unidimensionalto multidimensionalcauses. The third domain assumes
that solutions shift from single to multiple possible problem-solving
strategies.
The student clinicians conducted and videotaped their individual weekly
30-minute treatment sessions with children in the area of language inter-
vention. Clinician A's client was 4.5 years old, Clinician B's was 11, and
Clinician C's was 6. One randomly selected treatment session for each cli-
nician was analyzed.
Data Analysis
Problem episodes containing each clinician's recognition of a problem and
subsequent reaction were identified from the videotape and described by
one of the authors and a student research assistant. For this investigation,
a problem is defined by the clinician's behavior indicating that a client's
actions need modification (e.g., the clinician's correction of a misarticula-
tion), or by the client's indication that s/he is having difficultywith session
goals or procedures (e.g., a client's refusal to continue a scheduled treat-
ment activity).
One of the authors and a student assistant served as raters for analyzing
the clinical problem episodes. A training period of twenty-fourhours over
one month was provided to the student assistant and addressed identificat-
ion of clinical problem episodes and classification procedures utilizing the
taxonomy. Analysis of the three treatment sessions followed achievement
of 85% agreement between the two raters on classification of pilot data
utilizing the taxonomy.
Both raters analyzed independently 97 clinical problem episodes from
the three videotaped treatment sessions. ClinicianA's treatment session con-
tained 44 problem episodes, Clinician B's contained 39, and Clinician C's
contained 14. The student assistant was not informed of the subjects' clini-
cal or academic standing. As such, the assistant rated subjects in a blind
fashion. Each episode was evaluated with respect to the three domains of
problem solving in the taxonomy. Tables 3, 4, and 5 present excerpts from
the three clinician's treatment sessions including descriptions of goals,
materials, and procedures from the clinicians' lesson plans; problem epi-
sodes; and the clinician's subsequent reactions. Tables 6, 7, and 8 present

CLINICAL PROBLEM SOLVING 205
Table 2. A Taxonomy for Assessing Clinician Development in Three Domains of
Problem Solving
1.0 Clinician's perspective reflected in clinical interactions
1.1 Factors contributing to the clinical problem:
1.l.1 Client's response to clinician's command or request is unacceptable to
clinician
I. 1.2a Mismatch between clinician's goal (specified in a session plan) and client's
behavior
I. 1.2b Mismatch between an unspecified goal and client's behavior
I. 1.3a Clinician does not address client's intent
I.l.3b Clinician's behavior is pragmatically non-communicative (e.g., does not
establish eye contact with client, lack of vocal inflection, etc.)
1.1.4 Unintelligible or extraordinary client behavior
1.1.5 Developmentally/culturally inappropriate goals
1.1.6 Developmentally inappropriate procedures
l.l.7 Developmentally/culturally inappropriate materials
1.2 Approach to problem resolution:
1.2.1 Indicates to the client that the behavior is unacceptable (e.g., asks or
commands child to revise behavior, states "no" in response to a behavior)
1.2.2 Blames the client (e.g., tells client that s/he is not trying hard enough)
1.2.3 Utilizes developmentally inappropriate procedures
1.2.4 Requests clarification
1.2.5 Incorporates client's spontaneous behaviors into goal-directed procedures
1.2.6 Evokes client's point of view about goals and procedures
1.2.7 Focuses on developmentally/culturally appropriate goals
1.2.8 Utilizes developmentally appropriate procedures
1.2.9 Utilizes developmentally/culturally appropriate materials
2.0 Dimensions of behavior addressed in clinical interactions
2.1 Approach to problem resolution:
2.1.1 Repeats failed effort to get client to modify behavior
2.1.2 Shifts focus by:
2.1.2a Modifying cognitive challenge of the task
2.1.2b Modifying verbal information presented to client
2.1.2c Modifying a sensorimotor challenge of the task
2.1.2d Modifying materials
2.1.2e Modifying pragmatic aspect of communication (e.g., eye contact,
tone of voice, reasons for talking)
3.0 Problem solutions generated in session
3.0.1 Repeats previous procedure
3.0.2 Shifts procedure by:
3.0.2a Modifying reward system
3.0.2b Modeling a target response as an expansion upon the client's behavior
3.0.2c Asking a question
3.0.2d Directing client
3.0.2e Encouraging client's effort at self-directed problem solving
3.0.2f Modifying cognitive challenge of the task
3.0.2g Modifying a sensorimotor challenge of the task
3.0.2h Modifying materials
3.0.2i Modifying pragmatic aspect of communication

Table 3. Excerpts from Novice-Clinician A's Session with a 4.5 Year-Old
Session goals: B will identify the color of objects upon request. B will
select appropriate object according to its color when directed by
the clinician
The problem-episode
(problem description)
Episode Beginning of episode Clinician's response
# and word problem to problem
2 Clinician touches child, shows him "What color is this? Names
cup, and asks: child responds, the correct color
"green" (wrong color) "yellow."
3 Child spontaneously described all "Are those all white?" I
cups as "white" (they are each a don't think they are all
different color), white. Child says, "They
are all yellow."
10 Child does not respond to clinician's "Can you pick up the red
query, "Is it under the red cup?" cup?"
16 Child begins to embed cups as "You're putting them away,
clinician asks, "What color is this?" enough with this game"
Child continues to
embed. She takes the
cups away from the
child.
30 Child says "I am bad." (dialectic "No, you are good. Tell
idiom for "cool") me I am good." Child
continues to repeat "I
am bad" and then "I am
cool."
34 Comment is unintelligible to clinician. "Speak more slowly"
41 "Cat. . . . I can't hear the last part
of the word" (withholds
crayon), "and I want to
hear the last part."
ratings of these episodes according to the problem-solving domains and
indices in the taxonomy.
Reliability
A procedure was implemented to ensure that the domains and component
categories in the taxonomy were acceptably reliable and that the two raters
classified the clinical problem episodes in approximately the same way. To
do so, percentages of agreement were computed for the independent rat-
ings of the 97 episodes (i.e., 100°70 of the data from the three treatment
sessions). These episodes required a total of 3,589 classification decisions
(i.e., 1,628 for the treatment session of Clinician A, 1,443 for B, and 518

Table 4. Excerpts from Intermediate-Clinician B's Session with an 11 Year-Old
Session goals: C will name animals, vegetables, body parts, and numbers depict-
ed on cards. C will recall names of animals, vegetables, body parts, and numbers
depicted on cards after the cards have been displaced, C will produce the pho-
neme in the initial position in words (t/0 substitution) when naming animals,
vegetables, body parts, and numbers. C will request names of objects using a
question form (such as, "Do you have "C will take turns in context of
a card game.
Problem description
# and problem to problem
1 Client points to card and "You think that a cockroach? That's
states "cockroach." a crab."
2 Child labels a snail, "snake." "That's a snail. If you want to call
it a snake that's OK."
14 Client says "tree" States "three."
18 Client should say, "Katie, do "You need to ask me for
you have a..." No something ....
response from client.
for C). A level of 80070agreement was set as an interrater reliability criterion
(Anderson, 1980). Agreement was determined through point-by-point com-
parisons of items identified by the two raters as manifested or not manifested
in the behavior of the clinician being evaluated. The agreement between
the two raters for each session was as follows: .96 (1,568/1,628), .96 (1,391/
1,443), and .97 (500/518), respectively. The two raters discussed and
reclassified all discrepancies. Only classifications for which there was agree-
ment were included in the results. These data indicate that the domains
and categories within the taxonomy are reliable, and that reliability between
the raters was acceptable.
RESULTS
Ninety seven problem-solving episodes were evaluated across the three treat-
ment sessions. Table 9 presents ratings of clinician perspective reflected in
clinical interactions.
Table 9 indicates that for Clinician A the most frequent factors contribut-
ing to a clinical problem were: the client's unacceptable responses to the
clinician's commands or requests (.99), mismatches between unspecified
goals and the client's behavior (.68), and developmentally and culturally
inappropriate goals and procedures (.99). Problem-solving procedures most
frequently involved indicating to the client that a behavior was unaccepta-

Table 5. Excerpts from Advanced-Clinician C's Session with a 6 Year-Old
Session Goals: M will initiate and extend topics in context of a conversation
about play. M will label objects in a play house. M will coordinate the use of ad-
jectives and the noun to code attribution in context of play.
Problem description
# and problem to problem
2 Child comments, "Red stuff for the "Red stuff. What red
bed." stuff?."
Child: "Red and yellow."
Clinician: "What do you
need red and yellow
for?"
Child proceeds to describe
furniture placement in
the house.
Clinician. "That's a good
idea."
3 Child states, "A gun in the house." Clinician: "Do you have a
gun? This is for babies.
Won't that be danger-
ous?"
Child: "No."
Clinician: "No?"
4 Child holding a table. Trying to put Clinician: "It doesn't fit?
something into the drawer space. Maybe you need a bigger
Clinician: "What is that?" one."
Child: "Something aint's closing."
(Camera person asks is there a name
for it-interfering interaction).
Child: "fits."
5 Child: "That one's the Daddy. (In Clinician: "Daddy's in here?
response to Clinician's query, Mommy's in here. These
"What's that?" pointing to a room are two bedrooms."
in the doll house. Child: "for the children."
Clinician: "The children's
room."
7 Clinician: "You're going upstairs?" Clinician: "into the ceiling."
Child: Up in a wall (meaning behind Child: "Uh huh."
the roof or ceiling). Clinician: "What's in there?"
Child: "A mirror."
Clinician: "A mirror. That's
good in the morning."
14 Child: "She's dead." Clinician: "She's dead?
What happened to her?"
Child explains "Pushed her
and cut her."
Clinician repeats the child's
statements, and then
exclaims, "We have to
save her. She's all
better now."

Table 6. Ratings for Excerpts from Clinician A's Session
Perspective
Dimensions of
Problem Cause of behavior addressed, Solutions generated,
# problem Response clinical response clinical response
2 1.1.1 1.2.1 2.1.2b 3.0.1
1.1.2a 3.0.2b
1.1.5
1.1.6
3 1.1.1 1.2.1 2.1.1 3.0.1
1.1.4 1.2.3 3.0.2c
10 1.1.1 1.2.3 2.1.2b 3.0.1
1.1.2a 3.0.2d
1.1.5
1.1.6
16 1.1.1 1.2.1 2.1.1 3.0.1
1.1.2a 1.2.2 3.0.2d
1.1.3a 1.2.3 3.0.2h (C)
1.1.5
1.1.6
30 1.1.4 1.2.1 2.1.1 3.0.1
l.l.3a 1.2.3 2.1.2b 3.0.2d
3.0.2b
34 1.1.1 1.2.1 2.1.1 3.0.1
l.l.2b 1.2.3 2.1.2b
41 1.1.1 1.2.1 2.1.1 3.0.1
1.1.2b 2.1.2b
Table 7. Ratings for Excerpts from Clinician B's Session
Perspective
Dimensions of
1 1.1.1 1.2.1 2.1.2b 3.0.2b
1.1.2a 1.2.8
1.1.5
2 1.1.2a 1.2.8 2.1.2b 3.0.2b
1.1.5 1.2.5
14 1.1.1 1.2.8 2.1.2b 3.0.2b
1.1.2a
18 1.1.1 1.2.8 2.1.2b 3.0.2d
l.l.2a

Table 8. Ratings for Excerpts from Clinician C's Session
Perspective
Dimensions of
2 1.1.2a 1.2.4 2.1.2e 3.0.2a
1.2.5 3.0.2c
1.2.8 3.0.2i
3 1.1.4 1.2.1 2.1.2b 3.0.2c
1.2.4 2.1.2e 3.0.2d
1.2.8 3.0.2i
4 1.1.2a 1.2.5 2.1.2a 3.0.2b
1.2.4 2.1.2b 3.0.2c
1.2.8 2.1.2e 3.0.2e
3.0.2f
3.0.2i
5 1.1.2a 1.2.5 2.1.2b 3.0.2b
1.2.8
7 1.1.2a 1.2.5 2.1.2b 3.0.2b
1.2.8 2.1.2e 3.0.2c
14 1.1.4 1.2.4 2.1.2b 3.0.2b
l.l.2b 1.2.5 2.1.2ea 3.0.2c
1.2.8 3.0.2ia
aEmotionalcontent.
ble (.95). In addition, the clinician infrequently incorporated the client's
spontaneous behavior into goal-directed procedures (.10). These results are
indicative of a self-oriented perspective.
For Clinician B, the two most frequent factors contributing to clinical
problems were mismatches between specified goals and the client's behavior
(.77) and developmentally inappropriate goals (.99). Problem-solving proce-
dures, however, were developmentally appropriate (.99). These data indi-
cate both self-orientation resulting in developmentally inappropriate goals,
and client-orientation as seen in developmentally appropriate, goal directed
problem-solving procedures. This apparent contradiction is suggestive of
a transition in skill development. Clinician B also manifested a slightly higher
proportion of goal-directed procedures incorporating the client's sponta-
neous behavior (.14) than did Clinician A (.10).
For Clinician C, the most frequent factor contributing to a problem was
the mismatch between the clinician's specified goals and the client's behavior
(.46). The clinician frequently incorporated the client's spontaneous behavior
into goal-directed procedures (.85). Goals and procedures were develop-

Table 9. Proportional Frequencies for Subjects' Performance on Indices
of Clinical Perspective in Clinical Interactions
Clinician
lndiee A B C
Factors contributing to a clinical problem
l.l.l Client's repsonse to clinician's
command or request is unacceptable
to the clinician * .40 04/35) .00
I. 1.2a Mismatch between clinician's
specified goal and the client's behavior .21 (9/43) .77 (27/35) .46 (6/13)
1.1.2b Mismatch between an unspecified
goal and client's behavior .68 (29/43) .17 (6/35) .15 (2/13)
1.1.3a Clinician does not address
client's intent .17 (7/43) .00 .00
1.1.4 Unintelligible or extraordinary
client behavior .09 (4/43) .14 (5/35) .46 (6/13)
1.1.5 Developmentally/culturally
inappropriate goal ** ** .00
l.l.6 Developmentally inappropriate
procedures *** .00 .00
Approach to problem resolution
1.2.1 Indicates to the client that the
behavior is unacceptable .95 (38/40) .43 (15/35) .08 (1/13)
1.2.4 Request for clarification .05 (2/40) .00 (0/35) .54 (7/13)
1.2.5 Incorporates the client's
spontaneous behaviors into
goal-directed procedures .10 (4/40) .14 (5/35) .85 (ll/13)
1.2.6 Evoke client's point of view about
goals and procedures .00 .03 (1/35) .08 0/13)
1.2.8 Utilizes developmentally
appropriate procedures .00 **** ****
• The clinicianindicatedto the clientthat his behaviorwas unacceptablein all problemepisodes.
•*The goalsof all problemepisodeswerejudgeddevelopmentallyinappropriate.
•**The proceduresin all problemepisodeswerejudgedto be developmentallyinappropriate.
•***The proceduresin all problemepisodeswerejudgedto be developmentallyappropriate.
mentally appropriate. These results indicate that the clinician assumed the
client's perspective while remaining goal oriented.
Table 10 presents dimensions of the clients' behavior addressed by the
clinicians in clinical interactions. These data illustrate a decrease in the repe-
tition of failed efforts to get clients to modify behavior across clinicians
(Clinician A, .83; Clinician B, .09; Clinician C, .00). These data also illus-
trate an increase in the frequency of observed shifts in focus across clini-
cians (Clinician A, .57; Clinician B, 1.31; Clinician C, 1.58). These results

of Dimensions of Behavior Addressed in Clinical Interactions
Subject
Indice Clinician A Clinician B Clinician C
2.1.1 Repeats failed effort to
get client to modify
behavior .83 (36/43) .09 (3/35) .00
2.1.2 Shifts focus (collapsed
across indices a-e) .57 (24/43) 1.31 (46/35) 1.58 (19/12)
indicate increased ability to address multiple dimensions of behavior in clin-
ical problem solving across clinicians.
Table 11 presents the frequency of problem solutions generated by the
clinicians. These data illustrate a decrease in the repetition of previous proce-
dures (Clinician A, .95; Clinician B, .06; Clinician C, .00) and a correspond-
ing increase in the modification of problem solutions (Clinician A, .95; Cli-
nician B, 1.45; Clinician C, 2.00). These results are indicative of an increased
ability to generate multiple problem solutions across clinicians.
The limited number of subjects and preliminary nature of the investiga-
tion required that caution be exercised when comparing frequencies of be-
havior observed across clinicians. To further explore the implications of
these data, Spearman Correlation Coefficients were derived from an analy-
sis of relations among rankings of frequencies of the clinicians' problem-
solving behaviors collapsed across domains of problem solving. A nega-
tive correlation would be indicative of a differencein subjects' developmental
status, since with development, behavioral indices of an advanced level of
development would be greater in frequency (Tables 9, 10, 11, items 1.1.2a,
1.2.4, 1.2.5, 1.2.6, 1.2.8, 2.1.2, 3.0.2), whereas indices of less advanced de-
velopmental status would be lower (items 1.1.1, 1.1.2b, 1.1.3a, 1.1.5, 1.1.6,
1.2.1, 2.1.1., 3.0.1). Table 12 presents Spearman Correlation Coefficients,
z statistics, and one-tailed significance levels for comparisons of the rela-
tion between rankings of frequencies of behavioral indices of development
for subject pairs.
A comparison of rankings of proportional data from Clinicians A and
C revealed a significant negative correlation (rs(16) = --.51; z = -1.94; p <
.05). There was a negligible correlation between rankings of proportional
data from Clinicians A & B (rs (16) = .13; z = .45; p = .32). There was
a positive correlation between rankings of proportional data from Clini-
cians B & C (rs(16) = .55; z = 2.16; p < .05). Although these statistics
must be interpreted with caution, they support the finding that Clinicians

of Dimensions of Problem Solutions Generated in Session
Subject
lndice Clinician A Clinician B Clinician C
3.0.1 Repeats previous
procedure .95 (37/39) .06 (2/33) .00
3.0.2 Shifts procedure
(collapsed across indices
a-i) .95 (36/39) 1.45 (48/33) 2.00 (24/12)
A & C manifested the greatest difference in developmental status. The ab-
sence of correlation in the rankings of data from Clinicians A & B in light
of the positive correlation between Clinician B & C's data supports the
finding the Clinician B was functioning at an intermediate or transitional
developmental level. The positive correlation between the data from Clini-
cians B and C suggests correspondences in quality of performance; this
finding allows the possibility that the behavior of these clinicians represents
variation within a single developmental level.
DISCUSSION: THREE DEVELOPMENTAL PROFILES
The proportional data presented in Tables 9-11 and the correlational anal-
ysis of this data (Table 12) are suggestive of three different developmental
profiles of clinician performance in three domains of problem solving. We
Table 12. Spearman Correlation Coefficients, z Statistics, and One-Tailed
Significance Levels for Comparisons of Relations Between Rankings of
Frequencies of Behavioral Indices of Development for Subject Pairs
Collapsed Across Domains of Problem Solving
Subject Pair
AB BC AC
Spearman correlation
coefficient rs (16) 0.13 0.55 - 0.51
z Statistic 0.45 2.16 - 1.94
One-sided
significance level NS p < .05 p < .05
Proportional frequencies of 16 developmental indices (presented in Tables 9, 10, and 11) were ranked.
All starred data in Table 9 were treated as manifesting a 1.130frequency of occurrence for statistical anal-
ysis. NS = not significant.

will refer, metaphorically, to these profiles of clinician performance as "the
kitchen sink", "the map reader", and "the air traffic controller."
The Novice "Kitchen Sink" Profile
Overview. The "kitchen sink" refers to three characteristics of Clinician
A's performance: self-orientation (in the domain of perspective taking),
attention to few dimensions of behavior (in the domain of dimensions of
behavior considered in clinical problem solving), and generation of a limited
number of possible solutions to problems (in the domain of possible solu-
tions generated).
Self-Orientation. Clinician A continuously redirected the focus of her
corrective actions from behavior of the child that was relevant to the ses-
sion goal, to a range of extraneous behaviors (Table 2, item 1.1.2b). These
extraneous behaviors sometimes were related to the procedure. For exam-
pie, in a color identification lesson, much energy was spent correcting the
child for embedding cups (the child had been told to align them). Some-
times, the extraneous behaviors that the clinician corrected were speech er-
rors unrelated to the session objective, as when the clinician corrected the
child for the unclear pronunciation of the word "cat" during a color
identification lesson.
In shifting the focus of her corrective actions, the clinician appeared to
be referencing an implicit set of self-determined criteria to make on-the-
spot judgements about acceptable and unacceptable behavior. In the pro-
cess, the child was confronted with the overwhelming task of modifying
a broad range of goal-related and extraneous behaviors.
Additional indices of the clinician's self-orientation were developmen-
tally and culturally inappropriate goals (expecting a four year old to code
"attribute state [color]" in a clinician directed context; frequent messages
to the child that his behavior was unacceptable (e.g., "Did I ask for all of
these [blocks]? No"; "It would help if you speak slower"; "Are those all
white? I don't think they are all white"); and ill founded accusations directed
toward the child (e.g., "Are you trying to look tough... I know you are
not so tough"; Table 2, items 1.1.5, 1.2.1., & 1.2.2).
Attention to Few Dimensions of Behavior. The second feature of Clini-
cian A's performance that was suggestive of the kitchen-sink profile was
attention to few dimensions of behavior. This was reflected in Clinician
A's most frequent response to problems: repeating a previously failed effort
to get the client to modify behavior (e.g., consistently telling the child to
"repeat after me"; Table 2, item 2.1.1.). The clinician's tendency to correct
almost every type of error observed, discussed above, also was indicative
to attention to few dimensions of behavior. This tendency suggests that
the clinician could not keep session objectives in mind while attending to

the stream of behavior that comprised the session. The clinician also was
comparing the client's behavior to static criteria for what was right or wrong.
She was not considering the complex set of variables that contribute to
clinical problems.
Enactment of FewPossible Problem Solutions. The third feature of this
clinician's performance that was suggestive of the kitchen-sink profile was
the lack of variety in problem-solving procedures generated. This was
reflected in Clinician A's most frequent responses to clinical problems-
correcting the child with a directive (Table 2, items 3.0.1, 3.0.2d), and reiter-
ating a question (item 3.0.2c).
The Intermediate "Map Reader Profile"
Overview. Clinician B's clinical performance was suggestive of a develop-
mental profile that we term the "map reader." This profile reflects a mixed
developmental profile, characterized by an emerging abilityto take the client's
perspective, reference multiple dimensions of behavior, and generate mul-
tiple problem solutions.
Mixed Perspective. The term "map read.er" refers, especially, to one as-
pect of Clinician B's performance in the domain of perspective taking: the
tendency to remain strictly focused on goals specified in the session plan
(Table 2, item 1.1.2a). Goals were judged as not developmentallyappropri-
ate to the client (e.g., targeting the labelling of hand-drawn pictures of sea
animals-crab, dolphins, octopus-with an eleven-year old child with
significant developmental delays; Table 2, item 1.1.5). The tendency to re-
main goal-oriented suggests, on one hand, that the clinician kept the num-
ber of target behaviors to an appropriate level for the client. This appeared
to represent a developmental advance over the lack of a consistent focus
(a central feature of the "kitchen-sink"profile). On the other hand, target-
ing developmentallyinappropriate goals suggests that Clinician B did not
reference the child's perspective when goal planning. The child's perspec-
tive was referenced, however, in developmentally appropriate procedures
(Table 2, item 1.2.9.).
Failure to set developmentallyappropriate goals resulted in a large propor-
tion of behaviors in the child that did not meet the clinician's criteria for
acceptable behavior. Consequently, the clinician engaged in a great deal
of corrective behavior (Table 2, item 1.2.1.). It was this pattern of focusing
on the achievement of developmentally inappropriate session goals-i.e.,
a preplanned albeit not consistentlyappropriate destination- that gave the
impression of a "map reader."
Intermediate and Inconsistent Ability to Address Multiple Dimensions
of Behavior. Another characteristic of Clinician B's performance sugges-
tive of the intermediate "map reader" profile is an inconsistent ability to

attend to multiple dimensions of behavior in clinical problem solving. The
primary evidence of this developmental characteristic was an intermediate
proportion of shifts in problem-solving procedures (Table 2, items
2.1.2.a-2.1.2e). Clinician B frequently modified verbal information (by
modelling, item 2.1.2b), and pragmatic aspects of communication(by shift-
ing from questioning to conversational formats, e.g., after the child did
not respond to the question "What did you get", the clinician responded,
"OK, you won't tell me what you got"; Table 2, item 2.1.2e).
Additional evidence of the clinician's mixed developmental profile in ad-
dressing multiple dimensions of behavior was the tendency to remain fo-
cused on session goals, discussed above. This was indicative of the capacity
to keep targeted goals in mind when faced with the intense flowof behavior
that typically constitutes clinical sessions (a developmental advance in in-
formation processing over the kitchen-sink profile). The constant focus on
planned goals, however, also may have served an information reduction
function. The clinician, when goal setting, did not appear to utilize feed-
back from the child's behavior or background information indicative of
the child's cognitive and linguistic capacities.
Intermediate Variability in Problem Solutions Generated. Evidence of
an intermediate developmental profile was also manifested in problem so-
lutions generated. Clinician B exhibited an intermediate proportion of pro-
cedural shifts (Table 2, items 3.0.2a-i). Her most frequent responses to prob-
lems were modellinga target response as an expansion of the client's behavior
(3.0.2b), and modifying pragmatic aspects of communication (3.0.2i).
The More Advanced "Air Traffic Controller" Profile
Overview. The "air traffic controller" refers to a more advanced develop-
mental profile suggested by Clinician C's clinical performance. Four char-
acteristics of Clinician C's behavior were indicativeof an advanced develop-
mental profile. The clinician minimized the number of problems, and
approached those that did arise from the perspectives of both the child
and herself as the clinician. She also addressed multiple dimensions of be-
havior and generated multiple problem solutions.
Ability to TakeMultiple Perspectives. Clinician C assumed multiple per-
spectives when addressing clinical problems. This was reflected, primarily,
in goals and procedures which were judged to be developmentallyand cul-
turally appropriate for the client (Table 2, items 1.1.5and 1.2.9). This ap-
peared to contribute to the low number of problem episodes by increasing
the possibility that the client would be successful. Problems that did arise
were frequently related to unanticipated events (Table 2, item 1.1.4) such
as the client's unexpected assumption that there should be guns in a doll
house.

The clinician's most frequent problem-solving strategy was to incorporate
the client's spontaneous behavior in goal-directed procedures (e.g., as the
child played with dolls in the house, the clinician named the rooms of the
house, then queried the child about the names of the rooms; Table 2, item
1.2.5). This strategy addressed the child's need to be successful and accept-
able, and provided direction for the child. Furthermore, the clinician's ten-
dency to keep the session focused on planned goals (Table 2, item 1.1.2a)
suggested sensitivity to the child's information processing capacities.
Dimensions of Behavior Addressed. Clinician C demonstrated compe-
tence in considering multiple dimensions of behavior when addressing clin-
ical problems (Table 2, items 2.1.2a-e). Clinician C, like Clinician B, ap-
peared to focus on linguistic dimensions of behavior (modifying verbal
informationthrough modelling, item 2.1.2b), and pragmatic aspects of com-
munication (item 2.1.2e). In addition, Clinician C addressed cognitive fac-
tors (item 2.1.2a) when responding to problems. This involved modifying
behavior in order to simplify the task requirements for the child until the
child could produce a target response. For example, in an effortto encourage
the child to name rooms, the clinician asked the child, "Do you want to
tell me about the other rooms." After a period of silence, the clinician
clarified that request and simplified the task by labelling several rooms
(kitchen, bathroom, bedroom), using the carrier phrase, "This is . "
She finallyproduced the open-phrase, "This is ," gesturing to another
bedroom and using an anticipatory tone of voice. The child began label-
ling, "the daddy's room, the mommy's room." The clinician then repeated
the child's responses, in acknowledgement of the child's responses.
Problem Solutions Generated. Clinician C demonstrated the highest
proportion of procedural shifts (Table 2, items 3.0.2a-i). This finding indi-
cates skill in generating a variety of goal-directed procedures in response
to clinical problems. Frequent procedural shifts involved modelling appro-
priate responses (item 3.0.2b) and modifying pragmatic aspects of com-
munication (item 3.0.2i). Interestingly, the most frequent procedural shift
for Clinician C involved asking a question (item 3.0.2c). This also was a
frequent shift for novice Clinician A. The difference was that Clinician C's
questions functioned as requests for clarification (item 1.2.4)within a con-
versational mode. Clinician A asked questions as a primary procedure to
elicit target behaviors, and posed alternate questions in response to problems.
CONCLUSION
In this paper, preliminary data suggestive of developmental components
in three student clinicians' problem-solving skills were derived from analy-
ses of videotaped clinical interactions. Results wereconsistent with develop-

mental patterns in perspective taking, variables considered, and solutions
generated during clinical problem solving (Table 1), proposed by the authors
(Moses & Shapiro, 1992; Shapiro & Moses, 1989). One unexpected finding
was the difference among clinicians in their tendency to direct their atten-
tion to perceived "misbehaviors" not relevant to stated goals. The main-
tenance of goal orientation may be an important indicator of developmen-
tal status in perspective taking and dimensions of behavior addressed. This
finding is consistent with Schultz's (1972) identification of the ability to
consistently signal patients to express targeted behaviors as evidence of ex-
pert clinical practice.
The results of this study suggest that developmental factors involving
organization and interpretation of information may impact upon a variety
of clinical problem-solving behaviors. As such, these findings have several
implications for professional preparation, and particularly for the supervi-
sory process in speech-language pathology and audiology: (a) targeting the
developmental competencies of shifting perspective, conceptualizing mul-
tiple causes, and generating problem solutions could facilitate clinician's
problem-solving behavior; and (b) the clinical setting provides an ideal context
for achieving these competencies. Since these competencies are develop-
mental in nature, consideration needs to be given to designing supervisor-
clinician interactions and clinical training opportunities that facilitate trans-
formations in the ways clinicians organize and interpret information relevant
to clinical interventions (Klein & Moses, 1994; Shapiro & Moses, 1989).
Consideration also needs to be given to the range of factors that may
influence a clinician's developmental status.
One of these factors may be the clinician's age. In the present study, sub-
jects' age as well as amount of clinical and academic experience increased
in proportion to level of performance. Thus age as well as experience may
have impacted upon developmental status.
A second factor that may influence clinician development is the infor-
mation offered by supervisors. It is relevant that supervisors approved of
clinicians' goals prior to the clinical sessions evaluated. Nevertheless, some
goals and procedures were judged in the present study as developmentally
or culturally inappropriate for the client. This finding suggests a need to
critically examine the basis of supervisory as well as clinician judgements.
The developmental analysis of clinicians' behavior revealed that seeds
of professional growth are observable and quantifiable in novice clinicians.
For example, although Clinician A's performance most frequently was in-
dicative of "self-orientation", this clinician infrequently adopted the client's
perspective. It is critical to recognize incipient clinical skills as they provide
a foundation for professional development. The taxonomy presented in this
paper serves as an instrument for identifying and facilitating professional
skills in the area of clinical problem solving.

The present study was restricted in scope and preliminary in nature. Clin-
ical interactions during single sessions were analyzed involving only chil-
dren with developmental language disorders. Additional research is needed
to substantiate claims that performance characteristics were indeed repre-
sentative of developmental factors. In addition, future studies must address
developmental changes in individual clinicians over time, individual differ-
ences among clinicians, characteristics of clinician development across dis-
order types, and characteristics of supervisory interactions that facilitate
or impede clinician development.
This study is suggestive of specific developmental components of clini-
cal problem solving behavior and invites continued inquiry into the nature
of development in diverse clinical settings across the professional lifespan
of the speech-language pathologist. Only when the critical elements of clin-
ical expertise are understood can the process of professional preparation
reach its full potential.
REFERENCES
American Speech-Language-Hearing Association. Committee on Super-
vision in Speech-Language Pathology and Audiology(1985). Clinical su-
pervision in speech-language pathology and audiology (Position state-
ment). Asha, 27, 57-60.
Anderson, J.L. (Ed.). (1980). Proceedings-Conference on Training in the
Supervisory Process in Speech-Language Pathology and Audiology.
Bloomington, IN: Indiana University.
Anderson, J.L. (1988). The supervisory process in speech-language pathol-
ogy and audiology. Boston: Little Brown/College Hill.
Bloom, L., & Lahey, M. (1978). Language development and language dis-
orders. New York: Wiley.
Casey, P.L., Smith, K.J., & Ulrich, S.R. (1988). Self-supervision." A career
toolfor audiologists and speech-language pathologists. Rockville, MD:
National Student Speech-Language-Hearing Association.
Cogan, M.L. (1973). Clinical supervision. Boston: Houghton-Mifflin.
Duckworth, E. (1972).The having of wonderful ideas. Harvard Educational
Review, 42, 217-231.
Farmer, S.S., & Farmer, J.L. (1989). Supervision in communication dis-
orders. Columbus, OH: Merrill.
Fischer, K.W. (1980). A theory of cognitive development: The control and
construction of hierarchies of skills. Psychological Review, 87, 477-531.

Fosnot, K. (1991). Enquiring teachers and enquiring learners. New York:
Teachers College Press.
Gentner, D., & Stevens, A.L. (Eds.) (1983). Mental models. Hillsdale, NJ:
Lawrence Erlbaum.
Goldhammer, R., Anderson, R.H., & Krajewski, R.J. (1980). Clinical su-
pervision" Special methodsfor thesupervision of teachers(2nd ed.). New
York: Holt, Rinehart, & Winston.
Granott, N.I. (1993). Patterns of interaction in the co-construction of knowl-
edge: Separate minds, joint efforts, and weird creatures. In R.W. Woz-
niak & K.W. Fischer (Eds.). Development in context: Acting and think-
ing in specific environments (pp 183-210). Hillsdale, NJ: Lawrence
Erlbaum.
Inhelder, B., Sinclair, H., & Bovet, M. (1974). Learning and the develop-
ment of cognition. Cambridge, MA: Harvard University Press.
Karmiloff-Smith, A. (1986). Stage/structure versus phase/process in model-
ing linguistic and cognitive development. In I. Levin (Ed). Stageandstruc-
ture (pp 77-105). Norwood, NJ: Ablex.
Klein, H.B., & Moses, N. (1994). Intervention planning for children with
communication disorders:A guide to clinicalpracticum andprofessional
practice. Englewood, NJ: Prentice-Hall.
Metz, K. (1985). The development of children's problem-solving in a gears
task: A problem space perspective. Cognitive Science, 12, 431-471.
Michael, A., Klee, T., Bransford, J.D., & Warren, S.F.G. (1993). The transi-
tion from theory to therapy: Test of two instructional methods. Applied
Cognitive Psychology, 7, 139-154.
Moses, N. (1994). The development of procedural knowledge in adults en-
gaged in tractor-trailer task. Cognitive Development, 9, 103-130.
Moses, N., & Shapiro, D.A. (1992). Assessing and facilitating clinical prob-
lem solving in the supervisory process. In S. Dowling (Ed). Totalquality
supervision: Effecting optimal performance. Proceedings. 1992National
Conference on Supervision (pp. 70-77). Houston, TX: University of
Houston.
Perry, W.G. (1970). Forms of intellectual and ethical development in the
college years. New York: Holt, Rinehart, & Winston.
Piaget, J. (1954). The construction of reality in the child. New York: Basic
Books.

CLINICAL PROBLEMSOLVING 221
Piaget, J. (1971). Biology and knowledge. Chicago: University of Chicago
Press.
Piaget, J. (1985). The equilibration of cognitive structures. Chicago: Univer-
sity of Chicago Press.
Roberts, J.E., & Smith, K.J. (1982). Supervisor-supervisee role differences
and consistency of behavior in supervisory conferences. Journal of Speech
and Hearing Research, 25, 428-434.
Schultz, M.C. (1972). An analysis of clinical behavior in speech and hear-
ing. Englewood Cliffs, NJ: Prentice-Hall.
Shapiro, D.A., & Anderson, J.L. (1988). An analysis of commitments made
by student clinicians in speech-language pathology and audiology. Journal
of Speech and Hearing Disorders, 53, 202-210.
Shapiro, D.A., & Anderson, J.L. (1989). One measure of supervisory effec-
tiveness in speech-language pathology and audiology. Journal of Speech
and Hearing Disorders, 54, 549-557.
Shapiro, D.A., & Moses, N. (1989). Creative problem-solving in public school
supervision. Language, Speech, and Hearing Services in Schools, 20,
320-332.
Wansart, W. (1990). Learning in solve a problem: A microanalysis of the
solution strategies of children with learning disabilities. Journal of Learn-
ing Disabilities, 23, 164-170.

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