Health professionals’ implementation and related experiences of Brain Blocks : the role of intervention, implementer, organisation, and social context characteristics

Faculty of Social and Behavioural Sciences

Graduate School of Child Development and Education

Health professionals’ implementation and related experiences

of Brain Blocks: The role of intervention, implementer,

organisation, and social context characteristics

Research Master Child Development and Education Research Master Thesis

Supervisors: dr. Floor van Rooij (UvA), dr. Elena Syurina (VU) Second assessor: dr. Cristina Colonnesi (UvA)

Third assessor: dr. Henny Bos (UvA) Email: chantie.luijten@student.uva.nl 16 July, 2017

Acknowledgements

My thesis would not have been possible without the support, feedback, and explanation of my supervisors dr. Floor van Rooij and dr. Elena Syurina. I sincerely appreciate all their time and work, and feel like I have learned a lot about the work as a researcher. I have gained more knowledge about and experience in conducting mixed methods research and I was able to practise in my academic writing and presenting skills. Furthermore, I would like to express my sincere gratitude to Kees-Jan Kan for his help and clear explanations regarding the confirmatory factor analyses and structural equation modelling. I feel fortunate to have followed the first Brain Blocks workshop and I experienced Brain Blocks to be an interesting and valuable intervention for people with ASD and/or their family. Therefore, I would like to thank Stephan van de Ven, the developer of Brain Blocks, for giving me this opportunity.

Moreover, this research would not have been possible without the participants. I would like to thank all the health professionals that offered their time to fill in the questionnaire and to be interviewed. They were all very excited about this research. Every questionnaire and interview was interesting to analyse and together they have been really instructive and

enjoyable. I would like to express my gratitude for their time and energy. Finally, I would like to thank my family and friends who have supported me during the writing of my thesis.

Abstract

There are many interventions for people with autism spectrum disorder (ASD) that aim to improve core deficits in communication, social interactions, and/or restricted behaviours. These interventions often tend to adapt people with ASD to the “normal” environment, whereas ASD cannot be cured. Moreover, there is no global consensus regarding the effectiveness of ASD interventions. Brain Blocks is a psychoeducational intervention that offers a unique way to talk to people with ASD and/or those around them (e.g., family, teachers) about ASD. The present study aims to gain insight into the

implementation processes of health professionals who implement Brain Blocks in a more social context (e.g., at home, at school), their experiences hereof, and the role of intervention, implementer, organisation, and social context characteristics in these processes. A sequential mixed methods design was selected: the study consisted of (1) a quantitative (N = 164) and (2) a qualitative part (N = 14). Study 1 showed that Brain Blocks is most often implemented for psychoeducation and/or as a communication tool. Participants recognised different intervention characteristics to apply to Brain Blocks. Study 2 showed that Brain Blocks is often provided in a flexible and personalised manner, with certain adaptations made to the interventions. This was primarily to fit the client’s situation, unless health professionals felt not capable enough of doing so. Intervention, implementer, organisation, and social context characteristics seemed to play a role in the implementation process. Furthermore, the experiences of implementing Brain Blocks were positive. Recommendations for further research are provided.

Key words: Autism spectrum disorder, Psychoeducation, Implementation, Evaluation, Intervention, User perspective, Social context, Family, Mixed methods

Health professionals’ implementation and related experiences of Brain Blocks: The role of intervention, implementer, organisation, and social context characteristics

Every child is unique and comes with a personal set of developmental needs and requests to meet those individual needs (Schmidt, 2010). Whereas many children have a relatively similar set of developmental needs and requests, this set is different for children with, for example, Autism Spectrum Disorder (ASD). The brains of children with ASD work differently than the brains of children without ASD. Previous research has, for example, found qualitative differences between the brains of individuals with ASD and neuro-typically developed individuals without ASD (McAlonan et al., 2005). As a consequence, children with ASD have different developmental needs and different requests to meet them.

ASD is an umbrella term and includes five developmental disorders: autism, Asperger syndrome, Rett syndrome, pervasive developmental disorder (PDD-NOS), and childhood disintegrative disorder (Smith, 2010). As such, ASD is a heterogeneous condition; no two children or adults with ASD have exactly the same profile, but difficulties fall into core domains of social interactions, verbal and non-verbal communication, and stereotyped and repetitive interests and behaviours (Lord, Cook, Leventhal, & Amaral, 2000; Jansen et al., 2010). The symptoms can present with a range of severity and in a variety of combinations (Constantino & Todd, 2003; Marshall, Lionel, & Scherer, 2013).

There are several signs that may indicate whether a child should be evaluated for ASD diagnosis. For example, children may appear deaf, display a lack of eye contact, and abruptly stop talking. Children with ASD have difficulties with understanding social cues, including body language, facial expressions, and gestures. As a consequence, they may behave

aggressive toward or withdraw from others, demonstrate self-injurious behaviours, and/or lose control altogether. Moreover, children with ASD are fixated on a particular object or toy and participate in stereotypic behaviours, like hand flapping (Adams, Gouvousis, VanLue, &

Waldron, 2004). The symptoms are present before three years of age and, therefore, ASD is often diagnosed during childhood. However, ASD can be diagnosed among young people and adults too as ASD manifests during childhood, but runs throughout the whole life (Jansen et al., 2010). In the Netherlands, about 3% of the children aged 4-12 years have ASD according to their parents (NJI, 2015).

There are many interventions for people with ASD; including behavioural, educational, medical, and alternative medicine interventions to compensate for their

difficulties. Depending on the aim of the treatment, one or a combination of interventions is selected. Moreover, intervention selection depends on the child’s age, developmental status, and the severity of ASD symptoms (Warren et al., 2011). In general, interventions aim to improve core deficits in communication, social interactions, or restricted behaviours (Allen-Meares, MacDonald, & McGee, 2016; Warren et al., 2011). Such improvements aim to, then, improve the development of greater functional skills and independence (Warren et al., 2011). It appears that such interventions often tend to adapt people with ASD to the “normal” environment. Although they may lead to functional improvements or improved quality of life and independence of people with ASD, ASD cannot be cured (Scassellati, Admoni, &

Matarić, 2012).

Moreover, there is no global consensus on which intervention strategy is most

effective in improving ASD symptoms (Warren et al., 2011). Whereas some people improve a great deal from an intervention, others show moderate improvement, and yet others fail to improve. This indicates that different people with ASD may benefit from different approaches (Schreibman, 2000). As ASD is a heterogeneous condition and there are no two people with ASD who have the exact same profile, it becomes increasingly important to determine a priori which intervention or intervention components will be most beneficial for individuals. As a consequence, research indicates that the development of personalised interventions

should allow maximisation of intervention gains for all individuals with ASD. Personalised interventions address the critical issue of “what works for whom” instead of an “one-size-fits-all” approach favouring a single treatment (Schreibman, 2000). Empirical research indeed showed that ASD interventions need to be adapted to each individual personally (Bosa, 2006).

An example of such a personalised intervention is Brain Blocks. Brain Blocks, developed in 2009 by Stephan van de Ven, a Dutch psychomotor child therapist, is an ASD psychoeducational intervention. Compared to previous interventions that hope to cure people with ASD and aim to adapt them to the “normal” environment by focusing on the core deficits in communication, social interactions, or restricted behaviours, Brain Blocks is a visual

medium that helps people with ASD to better understand themselves, in relation to others. It is a toolbox that offers a unique way to talk to children of seven years and older, up to adolescents, and adults with ASD (and/or those around them, for example parents, siblings, friends, and teachers) about ASD. As such, Brain Blocks promotes interaction and allows someone with ASD to form his or her own words and images and test these among

professionals. This will aid ASD-related communication. In other words, Brain Blocks is a means of communication to achieve “one image and one language” (Brain Blocks, 2017).

By helping people with ASD to understand how their brain works in relation to the brain of people without ASD, Brain Blocks is expected to improve their overall functioning within society, improve their functional impairments, and reduce long-term health, social, and financial costs for society as a whole. Moreover, Brain Blocks was developed with the aim of being able to personalise the intervention. In total, there are three Brain Blocks workshops to train health professionals. These workshops and the manual of Brain Blocks, especially regarding workshop 2 and 3, stimulate participants to let go of the structure and the manual and focus on the client and his or her needs. In addition, Brain Blocks is supposed to be implemented using the client’s social environment. It is suggested to involve parents, for

example, regarding the considerations to start using Brain Blocks and which choices should be made, but also to create commitment. Furthermore, although Brain Blocks is originally developed for people with ASD, health professionals use it for other disorders, such as Attention Deficit Hyperactivity Disorder (ADHD), as well (Brain Blocks, 2017).

Health professionals seem to be very enthusiastic about Brain Blocks and receive positive experiences from people with ASD and their families (Verdegaal, 2017). However, as for many other ASD interventions, there is a need to evaluate the effectiveness of Brain Blocks, starting with its implementation processes. Prior research has shown that

interventions are often not implemented the way they were intended to be implemented (i.e., low fidelity), even though fidelity is considered to form a critical link between intervention effectiveness studies and actual practice (Stahmer, 2007; Caron, Bérubé, & Paquet, 2017). Fidelity needs to be taken into account in order to draw valid inferences about intervention effects, as the quality with which a program is designed and the underlying theoretical model it is based on matter little if the fidelity with which the intervention is implemented is low or even lacking (Gesundheit, 2016). If an intervention is not implemented in the correct way, and there are difficulties with drawing conclusions about its effectiveness from the results regarding the underlying theoretical model. Moreover, the degree of fidelity appears to be positive related to the degree of intervention outcomes (Durlak & Dupre, 2008).

The diffusion of innovation theory (DIOT; Rogers, 1962, 2003) can be used to increase our understanding of the implementation of ASD interventions. Diffusion refers to the process by which a new practice (e.g., an intervention) is communicated over time among members of a social system (Rogers, 1962, 2003). This process consists of four stages: dissemination, adoption, implementation and maintenance (Rohrbach, Graham, & Hansen, 1993), which are illustrated in Figure 1. During dissemination, administrators are made aware of the intervention and encouraged to adopt it. During adoption, administrators form attitudes

towards the intervention and commit to initiate it. During implementation, practitioners begin to use the intervention. Thus, adoption can be seen as a behavioural intention, whereas

implementation can be seen as the actual behaviour (the course of action). Finally, during maintenance, the innovation moves from implementation to institutionalisation (Dingfelder & Mandell, 2011).

The present study focuses on the implementation stage. There are several

characteristics that affect whether an intervention is implemented successfully or not. These are related to 1) the intervention itself, to 2) the user, to 3) the organisation of the user, and 4) the social(-political) context, as illustrated in Figure 2. These will be discussed in the

following.

The DIOT discusses five important intervention characteristics: relative advantage, compatibility, complexity, trialability, and observability. Relative advantage is the degree to which an intervention is perceived as better than ones it supersedes. Compatibility refers to the degree that an intervention is perceived as consistent with the existing values, beliefs, past history, and current needs of the implementers. In addition, the intervention needs to be compatible with organisational values and capacities. Complexity is the degree to which an intervention is perceived as difficult to understand and use. Generally speaking, innovations that are perceived as complex are less easily adopted. Trialability refers to the degree to which an intervention may be experimented with on a limited basis. Observability is the degree to which the results of an intervention are visible to others (Dingfelder & Mandell, 2011).

Stals (2012) added a sixth intervention characteristic to those mentioned above:

flexibility. This can be defined as the flexibility with which an intervention is implemented by the implementer. First of all, this is because change or modification of an intervention is very likely during the implementation phase. This is often referred to as “re-invention” (Dingfelder & Mandell, 2011; Stals, 2012). Implementers may simplify an intervention if it is too

complex or they may personalise the intervention to make it more their own. Secondly, implementers may re-invent an intervention to assure a good fit between the intervention and the client. Each client might have different needs. Consequently, it is important for

interventions to offer possibilities for flexible interpretation to some extent, without changing the underlying theoretical model, in order to respond to clients’ individual needs (Stals, 2012).

Knowledge and skills are important user or implementer characteristics. Implementers need them to implement an intervention, but they also affect the implementers’ feelings of self-efficacy. Health professionals who feel capable of working with a new intervention are more likely to do so (Fleuren, Wiefferink, & Paulussen, 2004; Fleuren et al., 2014). In addition, the organisational and social(-political) context are important as the implementer is part of an organisation, which in turn is part of a larger environment. The organisational context of the implementer refers to the context in which the intervention is being implemented. In line with the present study, it is important to take the organisational

characteristics into account as Brain Blocks may be provided to the client in different settings: either at home or in a school environment or within a practice. Also, the implementer may be restricted, because of certain regulations by the organisation, for example financially. Such restrictions may, then, affect their implementation processes.

The social(-political) context includes rules and legislation, but also client

characteristics and characteristics of the client’s social environment (e.g., family, school) (Fleuren et al., 2004; Fleuren et al., 2014). The client may be the most obvious source of intervention outcome variability (Schreibman, 2000). ASD, especially, is a heterogeneous disorder and every person with ASD has a different profile (Jansen et al., 2010). Important client characteristics that affect the adaptation of an intervention to provide it in a

personalised manner include age, degree of cognitive impairment, language level, social engagement as well as the specific behavioural profile. Important family characteristics

include parental stress and depression, marital adjustment, and perceived community support (Schreibman, 2000). Additionally, an important school characteristic is for example the client’s relationship with the teacher.

A conceptual model (Figure 3), based on the model as presented in Figure 2 and specified by the theory discussed above, was developed for this study. The present study will be a step towards the overall evaluation of Brain Blocks by investigating the implementation processes of health professionals who implement Brain Blocks in a more social context (e.g., at home, at school) than, for example, psychologists do. Examples of such health

professionals are ambulant care workers, coaches, and mentors. Consequently, regarding the social(-political) context, the focus will be on the social rather than political context

characteristics. Any important (political) regulations or legislations will be discussed in relation to the organisational context, which includes regulations or legislations as well.

The following research questions have been formulated: 1) How do health

professionals implement and use Brain Blocks in practice? 2) What are their experiences hereof? 3) What role do the intervention, implementer, organisation, and social(-political) context characteristics play in these processes? These questions will be addressed using two study parts: 1) a quantitative study, followed by 2) a qualitative study. Part 1 will focus on the role of the intervention characteristics relative advantage, compatibility, complexity,

trialability, and observability. Part 2 will investigate the role of intervention characteristic flexibility, the implementer, organisation, and social context characteristics to gain more in-depth understanding of the implementation processes of health professionals.

Methods Design

The present study aims to gain insight into health professionals’ implementation processes of Brain Blocks, their experiences hereof and the role of different characteristics. A

sequential mixed methods design was selected and, thus, the study consisted of two parts. Part 1 was quantitative and an online questionnaire was conducted herein. This part provided insight into the intervention characteristics relative advantage, compatibility, complexity, trialability, and observability of Brain Blocks and provided ideas about the role of the

remaining characteristics in the implementation, as presented in the conceptual model (Figure 3). Based on the results of the questionnaire, an interview guide was developed. The interview was conducted in part 2 of this study to obtain in-depth knowledge about health professionals’ implementation processes of Brain Blocks and their experiences hereof. Thus, part 2 mainly focused on the sixth intervention characteristic, the flexibility with which Brain Blocks was implemented, and the implementer, organisation, and social context characteristics. This quantitative-qualitative order was particularly useful for explaining study findings as qualitative data are primarily used to augment quantitative data (Hanson et al., 2005).

Approval was received to conduct the present study from the ethical committee of the Faculty of Social and Behavioural Sciences, University of Amsterdam (Ethics Review Board FMG – UvA; project ID: 2017-CDE-7758).

Procedure

Part 1. Participants were recruited in two ways; during the second and third workshop of Brain Blocks and through email. The response rate was approximately 27.9% as multiple participants within one company were approached using one email and several emails gave errors or did no longer exist. The inclusion criteria were completion of at least the first Brain Blocks workshop in the past year and implementation of Brain Blocks according to the workshops they completed already. Participants received a letter of information, about the purpose of the study and confidentiality of all data, after which their active informed consent was obtained. Then, participants received a link to the online questionnaire. At the end of the

questionnaire, they were asked whether they would like to participate in an additional interview about their implementation processes and experiences.

Part 2. Participants for the interview were recruited based on the questionnaire. Health professionals who 1) participated in part 1, the questionnaire, who 2) worked in a more social context, contrary to for example psychologists, and who 3) answered “yes” to the question whether they would like to participate in an additional interview about their implementation processes and experiences were approached. The present study aims to gain insight into implementation processes of Brain Blocks outside a treatment room and within the clients’ social context. It was, therefore, important to recruit health professionals (e.g., ambulant care workers, autism coaches, and family therapists) who are sufficiently involved within the social context. Psychologists, on the other hand, mainly use Brain Blocks as psychoeducation and do not translate the intervention to a social context (e.g., school, home). Inclusion criteria were completion of at least the first Brain Blocks workshop in the past year and participants need to have implemented Brain Blocks according to the workshops they completed already. Participants were approached through email and asked whether they would like to participate in an interview. They received a letter of information, including the purpose of the interview and the guarantee of confidentiality of all data. Before start of the interview, active informed consent of the participants was obtained, including consent to record the interview. The response rate was 69.6%.

Participants

Part 1. Of the 195 participants who filled out the questionnaire, 31 were excluded because they did not implement Brain Blocks yet. Of the 164 participants, 26 (15.9%) participated in a workshop and 138 (84.1%) were approached by e-mail.

Part 2. In total 16 interviews were planned, of which 2 were cancelled. As such, 14 participants were interviewed in total.

Intervention

Brain Blocks is a psychoeducational toolbox to help people with ASD to better understand themselves, in relation to others. The Brain Blocks box includes two heads illustrated on boards: one illustrates the head of someone without ASD, whereas the other illustrates the head of someone with ASD. Both heads are used to increase understanding of the difference between how the brain of someone with ASD functions compared to someone without ASD. Overall, Brain Blocks is used to explain that ASD is an information processing and contact difference, which leads to different consequences in daily life functioning. These differences are made visual with the use of wooden blocks and cylinders, as presented in Figure 4. For example, the brain of someone without ASD functions like connected cylinders that can easily change and connect with other cylinders. The idea is, then, that such a brain is flexible and adaptive to new information, whereas the brain of someone with ASD is more rigid. The latter functions according to well-organised row of blocks that can become chaotic when too much information needs to be processed at once.

The manual of Brain Blocks starts with chapter 1. This chapter called “the basics” and explains four steps: “autism from the inside or outside?”, “information processing”, “how does the brain of a child without autism work?”, and “how does the brain of children with autism work?”. Then, there are 16 themes divided into a second and third chapter. Chapter 2 named “autism as information processing disorder” includes eight themes: “cleaning up time”, “eye for details”, “order of handling”, “transition time”, “changes and uncertainties”, “moving”, “specific interests”, and “what is important and what is not?”. The third chapter called “autism as contact disorder” includes 8 themes: “autism as contact disorder”, “round and square information”, “emotions”, “bridges”, “a different experience”, “Gilles de la Tourette”, “anxiety”, and “ADHD” (Van de Ven, 2011).

In total, there are three workshops to train health professionals. Generally, during the workshops, it emphasised that Brain Blocks can be implemented in a flexible manner to personalise the intervention. Workshop 1 introduces Brain Blocks as a psychoeducational tool and trains health professionals to use it like that. It introduces the basic structure of Brain Blocks. Moreover, the workshop emphasises the involvement of the social environment, such as parents. Health professionals can start applying the first steps of Brain Blocks after they completed workshop 1 already (Brain Blocks, 2017). In workshop 2, communication is the central theme and health professionals learn to use Brain Blocks in a more flexible manner compared to the first workshop. This workshop is about making contact between the health professional and the client and aims to clarify different communication steps. The health professional can apply this workshop to discuss situations the clients encounter (Van de Ven, 2016a). Workshop 3 focuses on therapeutic processes to help clients achieve their goals. These processes are related to consciousness in attitude, knowledge, skills, and experiences as well as to physical and mental boundaries (Van de Ven, 2016b). Workshop 2 and 3 are

deepening and train health professionals to be able to let go of the basic structure and implement Brain Blocks in a more flexible manner according to all its possibilities (Brain Blocks, 2017).

Instruments

Part 1. Since no accessible questionnaire was found that fitted the present study, a questionnaire was developed based on previous research and instruments. Before distributing the questionnaire online, it was piloted among colleagues, who were familiar with Brain Blocks. The questionnaire started with general questions about the implementers of Brain Blocks. Regarding the demographic characteristics, a western background included being born in Europe, USA, Canada, Australia and New Zealand, whereas a Non-Western background included being born in an African, Middle Eastern, Asian or South-American

country. A low educational level included pre-vocational education and middle vocational education, whereas a high educational level included senior general education, pre-university education, higher vocational education and university education.

Then questions followed about the general implementation of Brain Blocks (e.g., target group, setting, and the aim with which Brain Blocks is used) after which questions and statements followed about the implementation processes and the experiences hereof. These items were derived from previous research and instruments focusing on the DIOT (Rogers, 1962, 2003), including six intervention characteristics (i.e., relative advantage, compatibility, complexity, observability, trialability, and flexibility) as well as implementer, organisation, and social context characteristics related to the implementation of interventions. Instruments were collected from Moore and Benbasat (1991) and Atkinson (2007), as they contained examples of how the DIOT (Rogers, 1962, 2003) could be operationalised, and from Fleuren, Paulussen, Van Dommelen, and Van Buuren (2014) and Widdershoven, Bongers, and Van Nieuwenhuizen (2013), as they contained examples of how the discussed characteristics affecting the implementation of interventions could be operationalised. The complete questionnaire consisted of 32 items, including multiple-choice questions, statements, and some open-ended questions. It was made sure of that the questionnaire included both positive and negative directed questions.

Of the 32 items, 13 items were developed as statements based on the theory to measure the first five intervention characteristics: four items regarding relative advantage (i.e., items 11, 12, 13, and 14), four items regarding compatibility (i.e., items 15, 16, 17, and 20), three items regarding complexity (i.e., items 18, 19, and 21), one item regarding

trialability (i.e., item 22), and one item regarding observability (i.e., item 23). Examples are “Brain Blocks has a clear additional value compared to previous (psychoeducational) interventions for people with ASD” to assess relative advantage, “Brain Blocks does not fit

the way I work in daily practice” to assess compatibility, and “Brain Blocks is too difficult for me to use” to assess complexity. Furthermore, “I have had enough opportunities to practice with Brain Blocks before actually applying Brain Blocks in practice” was used to assess trialability and “I have seen how others (e.g., colleagues) applied Brain Blocks in practice before I really did it myself” to assess observability. Participants rated the statements on a 5-point Likert scale ranging from 1 = “Strongly Disagree” to 5 = “Strongly Agree”. In addition, participants rated how they liked to use Brain Blocks on a similar 5-point Likert scale and participants were asked whether they were content with the way they used Brain Blocks in practice, ranging from 1 = “No, not at all” to 5 = “Yes, very much”. See Appendix 1 for the developed Brain Blocks questionnaire.

Part 2. The interview guide was developed based on the outcomes of the

questionnaire. The interview was piloted first among colleagues, who completed the first Brain Blocks workshop and were familiar with the content of the second and third workshop, including the 16 themes addressed in Brain Blocks (e.g., “autism from the inside or outside?”, “cleaning up time”, “autism as contact disorder”, “round and square information”, and

“bridges”). Hereafter, adaptions were made to finalise the interview guide. See Appendix 2 for the interview guide.

Analytical approach

Part 1. First, descriptive analyses were performed using the Statistical Package for the Social Sciences (SPSS, standard version 24, 2016). In addition, T-tests were used to compare the extent to which health professionals liked to use Brain Blocks and their content with the way they are using it between those who completed workshop 1 and those who completed workshop 2 (and workshop 3) as well.

Part 1 mainly focused on the first five intervention characteristics and the

compatibility, and complexity) and two single items (representing trialability and

observability). In the next step, confirmatory factor analysis, these were all included in the measurement model, along with trialability and observability. It was first investigated whether or not this measurement model fulfilled common fit criteria (see below). Adjustment was allowed for, if this would improve the fit, but only if the adjustments were theoretical defendable. The theoretical measurement model (further referred to as the hypothesised model) is illustrated in Figure 5: relative advantage, compatibility, and complexity are operationalised as latent common factors with multiple measures as (observed) indicators, while trialability, observability, the content with the way participants use Brain Blocks, and the like to use Brain Blocks are operationalised as latent factors with single indicators (and 0 measurement error variance). In the final model, a structural equation model, relative

advantage, compatibility, and complexity, trialability, and observability were regarded as predictors of trialability and observability.

Confirmatory factor analyses (CFA) and structural equation modelling (SEM) were performed in R (version 3.3.1; R Core Team, 2016) using package lavaan (Rosseel, 2012) to examine the reliability and validity of the hypothesised measurement model. Beforehand, the assumptions of multivariate normality were evaluated. As the intervention characteristics were not normally distributed, robust maximum likelihood estimation (MLR) was used in order to estimate model parameters and evaluate the goodness of fit of the model(s). This estimation method provides a test statistic that is asymptotically equivalent to the Yuan– Bentler T2 test statistic (Yuan & Bentler, 2000), and standard errors that are robust against violations of normality. Also, as MLR fits the model using all available information at the individual level, no deletion or imputation of missing data was needed.

Goodness of model fit was judged based on the χ2 test model of fit (p (χ2) > .05). The χ2 statistic indicates a significant discrepancy between the model and the data and that exact

fit of the model has to be rejected. As in large samples, the test is considered to be too strict and very small model misspecifications may already lead to rejection of the model, the following alternative measures of approximate fit and relative fit were also considered: the root mean square error of approximation (RMSEA; Steiger & Lind, 1980), Akaike

information criterion (AIC; Akaike, 1974), and Bayesian information criteria (BIC; Raftery, 1995; Schwartz, 1978). RMSEA values smaller than .05 indicate close fit and values smaller than .08 were considered satisfactory (Browne & Cudeck, 1992). AIC and BIC assess the fit by balancing model complexity (number of parameters) versus goodness of fit to the sample data. Lower values indicate more balanced models. Furthermore, modification indices (MIs) were used to investigate possible local misfit. Decisions to allow for additional parameters were made on empirical grounds, but only if these parameters were theoretically defendable grounds. The aim was always to minimise the number of additional parameters in order to prevent overfitting

As briefly mentioned above, the measurement model of choice, so possibly the hypothesised model, possible an adjusted model, was used for further analyses using structural equation modelling and served to investigate the influence of five intervention characteristics (i.e., relative advantage, compatibility, complexity, trialability, and

observability) on the implementation of Brain Blocks and experience hereof. All intervention characteristics that were small and generally not significant were constrained to 0, resulting in a final, relatively parsimonious prediction model. Relative fit was assessed using χ2 difference test. A p-value of ≤ 0.05 was considered to be statistically significant, hence indicating a significant worsening of fit.

Part 2. Data gathered from the semi-structured interviews were transcribed verbatim based on the audio recordings. The interviews were analysed using means of content analysis in which the concepts from the diffusion of innovation theory served as a basis for coding

(Pope, Ziebland, & Mays, 2000). First, data was analysed by starting with a familiarisation of the transcript by thorough reading. Next, the concepts based on intervention, implementer, and social context characteristics were used as guiding concepts to code the transcripts (i.e., deductive coding). However, if any relevant information was found during the analysis that did not fit any of the codes, this information was analysed using inductive coding. The interviews were transcribed and coded using ATLAS.ti.

Pronouns are used to determine quantity in the results (Sandelowski, 2001). Few and rarely refer to something that occurred in less than 20% (n ≤ 3) of the participants; several and minority indicate that something occurred in between 20 and 49% (3 < n < 7) of the interviews; often and majority between 50 and 80 % (7 ≤ n < 11), and many, most, and frequently refer to more than 80 % (n ≥ 11) of the interviews. Furthermore, quotations from the participants were used in order to illustrate the results, noting additional information about the profession of the respondent.

Results Part 1

Descriptive analyses.

Background variables. Table 1 presents the descriptive characteristics for background variables of the final analysis sample (N = 164). The participants were aged between 20 and 64 years, most of them were female (n = 146, 89.0%) and had a high educational background (n = 151, 92.1%). In addition, 39 participants (23.8%) completed the second workshop in addition to the first and 23 participants (14.0%) completed workshop 3 as well.

Implementation of Brain Blocks. Table 2 presents the descriptive characteristics of the implementation of Brain Blocks. The majority of the participants implemented Brain Blocks among children/young people with ASD with an average to high level of intelligence (n = 123, 75.0%) and during home visits (n = 92, 56.1%). Participants mostly implemented

Brain Blocks as a psychoeducational intervention (n = 160, 97.6%) and aimed to increase the client’s understanding of ASD (n = 153, 93.3%).

Furthermore, Brain Blocks was most often implemented with adaptations per situation. Participants adapted the materials of Brain Blocks (n = 30, 18.3%) and their

language during Brain Blocks sessions (n = 54, 32.9%). Additionally, they used the ability to build “bridges” (i.e., Brain Blocks materials that can be used to come up with solutions to problems faced by clients and reorganise the chaos within their heads) (n = 39, 23.8%), a time-out room (n = 11, 6.7%), or a conversation with the client’s mentor (n = 11, 6.7%). Other participants (n = 14, 8.5%) made different kinds of adaptations. One participant

answered to the open-ended question regarding the adaptations participants make: “It depends on the client and the situations, I look at what suits the person across me and what helps”. Another participant combined Brain Blocks with another intervention: “By combining it with POPtalk”.

Characteristics. Table 3 presents to which extent participants considered the specific intervention characteristics (i.e., relative advantage, compatibility, complexity, trialability, and observability) to apply to Brain Blocks. Although the questionnaire mainly focused on the intervention characteristics, it also included the implementer and social context

characteristics. Regarding the implementer characteristics, the majority of the participants reported to have enough knowledge and skills to use Brain Blocks in practice: 66.5% (n = 109) agreed. Furthermore, almost all participants took the opinion of the client (n = 151, 92.1%) and/or the family into consideration (n = 123, 75.1%). The majority of the participants included the client’s level of intelligence (n = 133, 81.1%), communication difficulties (n = 125, 76.2%), age (n = 114, 69.5%), social skills (n = 106, 64.6%), language skills (n = 103, 62.8%), personality characteristics (n = 102, 62.2%), behavioural problems (n = 90, 54.9%), and attention difficulties (n = 90, 54.9%) within their implementation processes of Brain

Blocks. Only 4.3% of the participants (n = 7) did not include client characteristics in their implementation.

Furthermore, most participants involved the social environment of the client in their implementation of Brain Blocks (n = 149, 90.9%). People from the social environment could, for example, attend sessions in which Brain Blocks was applied, either during the first session or multiple session. In addition to the closed question, participants were allowed to explain themselves. One participants said: “I do not implement Brain Blocks for the child alone, but involve the parents simultaneously”. Also, clients sometimes explain Brain Blocks to their social environment themselves: “The client explained it to parents/residential supervisors his/herself.” Other participants have separate sessions with people from the client’s social environment, like the parents or teachers. One participant said: “By explaining Brain Blocks individually, at school as psychoeducation and for brothers/sisters to discuss situations.” It should be noted that some participants mentioned in the open-ended part of the question that the inclusion of the social environment depends on the client. For example: “Not yet

applicable, the client is not ready for this. Brain Blocks should be made really small and explained step by step, and repeated. Additional stimulations are not yet possible”.

Finally, participants included the family situation (n = 113, 68.9%), social support of the client and/or family (n = 94, 57.3%), parental stress (n = 76, 46.3%), relationship with the teacher (n = 71, 43.3%), ethnicity of the client and/or family (n = 27, 16.5%), and parental depression (n = 27, 16.5%) in their implementation processes. However, 11.6% of the participants (n = 19) did not include any social context characteristics.

Experiences of implementing Brain Blocks. Participants seemed to like using Brain Blocks (M = 4.23, SD = 0.62). Also, participants appeared to be content with the way they are using Brain Blocks in daily practice (M = 4.24, SD = 0.69). The correlation between these two variables was moderate, r(161) = 0.385, p < .001. It appears that the more participants like to

use Brain Blocks, the more they are content with the way they are using it. In addition, most participants believed that Brain Blocks helped people with ASD (n = 160, 97.6%), whereas the remaining four participants (2.4%) answered with maybe. Additional descriptive characteristics of Brain Blocks implementation experiences are presented in Table 4.

There were no significant differences found between participants who completed workshop 1 alone compared to participants who completed workshop 1 and 2 (and 3) regarding the extent to which they liked to use Brain Blocks, t(162) = 0.36 and their content with the way they used Brain Blocks in practice, t(161) = -1.55 (ps > .05).

Confirmatory factor analyses. The hypothesised model regarding the different items related to the intervention characteristics (Figure 5) can be considered acceptable, but did not fit the data well: χ2(73) = 129.554, p < .001, RMSEA = .069, 90% CI [0.049; 0.088], AIC = 4806.748, BIC = 4998.560. Based on modification indices (MIs), it appeared that three items measured a different dimension than hypothesised. Item 11 measured compatibility rather than relative advantage, item 15 measured complexity rather than compatibility, and item 18 measured compatibility rather than complexity. The model was modified accordingly into a new model in which three items (i.e., question 12, 13, and 14) were treated as measuring the dimension relative advantage, five items (i.e., 11, 16, 17, 18, and 20) were treated as

measuring the dimension compatibility, and three items (i.e., question 15, 19, and 21) were treated as measuring complexity. This adjusted measurement is presented in Figure 6. This model did fit the data well: χ2(73) = 101.220, p = .016, RMSEA = .049, 90% CI [0.023; 0.070], AIC = 4780.932, BIC = 4972.744. Therefore, this adjusted model was used as the measurement model in subsequent steps. Standardised parameter estimates are provided in Figure 6 and Table 5.

Subscales intervention characteristics. Based on the adjusted model, participants seemed to recognise the relative advantage of Brain Blocks (M = 4.00, SD = 0.53), as well as

it being compatible (M = 3.52, SD = 0.38), and it not being complex to use (M = 4.14, SD = 0.57). Furthermore, participants were often not able to practise with Brain Blocks before they actually implemented it (i.e., trialability) (M = 2.96, SD = 0.96), and most participants did not have the ability to observe others implementing Brain Blocks before they did so themselves (M = 2.62, SD = 1.11).

Internal consistency reliability for the first three intervention characteristics based on the adjusted model was tested using Cronbach’s alpha coefficient. The reliability of the subscales in the present study were as follows: α = .47 for relative advantage, α = .73 for compatibility, and α = .69 for complexity. The low reliability score for relative advantage may be explained by its low correlation with item 12, as presented in Figure 6. However, the item was expected to measure relative advantage based on the theory and exclusion of it did not really affect the model fit. As such, the item remained in the model. The other two reliability scores were satisfactory.

Predicting implementation experiences. As presented in Table 7 and Table 8, relative advantage, complexity, trialability, and observability were insignificant predictors of the extent to which participants liked to use Brain Blocks (ps > .05) and relative advantage, compatibility, and observability were insignificant predictors of the extent to which they were content with the way they used Brain Blocks practice (ps > .05). Their regression coefficients were constrained to 0, such that the final model included only compatibility as a predictor of the extent to which participants liked using Brain Blocks and complexity and trialability as predictors of the extent to which they were content with their use of Brain Blocks practice. Exclusion of trialability (p = .052) decreased the model fit and, therefore, trialability remained included in the model. The fit of both models as well as the difference between them are presented in Table 6. The structural equation model is illustrated in Figure 7.

A one-unit increase in compatibility was associated with a significant (b = 1.21 units on average) increase in participants’ like to use Brain Blocks. The standardised slope

indicated that each 1-SD increase in compatibility was associated with a β = .77 SD increase in the like to use Brain Blocks, which was a large effect. When complexity increased one unit, the participants’ extent to which they were content with the way they were using Brain Blocks in practise increased by b = 0.65 on average, holding trialability constant. When complexity increased one SD, participants’ content increased by β = 0.52 SDs on average. The effect was moderate. When trialability increased one unit, the participants’ extent to which they were content with the way they were using Brain Blocks in practise increased by b = 0.19 on average, holding complexity constant. When trialiability increased one SD, participants’ content increased by β = 0.16 SDs on average. The effect was small.

Part 2

Descriptive characteristics. Table 9 presents the descriptive characteristics for background variables of the interviewees (N = 14) of part 2. All interviewees were female except for one. The participants included (ASD) coaches (n = 3), ambulant care workers (n = 3), (school) mentors (n = 3), family therapists (n = 2), a social psychiatric nurse (n = 1), a care coordinator (n = 1), and a consultant regarding parental education (n =1). Some participants used Brain Blocks since a few months, whereas others used Brain Blocks for a couple of years (M = 11.00, SD = 10.56). Table 10 presents the duration of implementing Brain Blocks for each participant separately.

Different patterns emerged from the interviews. Two major themes were health

professionals’ experiences of implementing Brain Blocks and their way of implementing it. In addition, the major themes intervention, implementer, organisation, and social context

characteristics emerged, as presented in the conceptual model applied to this study (Figure 3). Moreover, different subthemes were coded in the interviews. The major themes and related

subthemes are presented in Table 11. Health professionals’ experiences of implementing Brain Blocks will be discussed first.

Experiences of implementing Brain Blocks. All participants were very enthusiastic about Brain Blocks and the way it could be implemented. They appeared to be appreciative of different characteristics of the intervention, including its ability to visualise ASD, the

flexibility with which it could be implemented, and the opportunity it created to communicate and understand one another. Participants actually experienced how Brain Blocks increased the insight into and understanding of ASD among clients and parents as well as among teachers and health professionals. Moreover, participants explained how the understanding and

appreciation among clients and the social environment towards each other improved by using Brain Blocks. Furthermore, they acknowledged Brain Blocks to be easy to combine with other methods and how you can keep using it when clients face new difficult situations. One respondent said, for example: “I believe that the strength of Brain Blocks comes from using it [whenever necessary].” (respondent 6, educational supervisor).

A few participants mentioned Brain Blocks being too expensive and, therefore, a barrier for schools or other health professionals to use it. Furthermore, only a few participants had a (single) negative experience with Brain Blocks, because clients did not or did not want to recognise themselves in the head with blocks, representing someone with ASD. Another client had an anxiety disorder and felt frightened by the idea of having blocks in your head. However, the participants had only one such a negative experience and so many more positive ones that they were still very enthusiastic about Brain Blocks and kept implementing it.

Implementation of Brain Blocks. The majority of participants just started implementing Brain Blocks and using it in practice (i.e., for six months or less). Most participants discussed how they practised with Brain Blocks before actually implementing it almost immediately after they followed a workshop. As such, participants in general appeared

to feel capable enough to use Brain Blocks. However, the limited experience with implementing the intervention seemed to affect their self-esteem and, consequently, the flexibility with which they implemented Brain Blocks. One respondent mentioned, for example: “[I implement it] as it is in the manual, because I believe I am still very ignorant, I really stick to the manual until I think I am comfortable enough to get rid of it all. However, I do not think so yet.” (respondent 1, ASD coach).

Most participants discussed how they started using Brain Blocks as was explained during the workshop and described in the manual. Participants appeared to agree that the first psychoeducational part of Brain Blocks could be implemented as it was:

When I consider the use of part 1, regarding the “full” head, I really follow the manual. Not entirely verbal, but that part just works and it can actually always be applied. When it comes to a specific situation, then yes, there is some creativity necessary sometimes. (respondent 3, coach/mentor)

As this quotation indicates, participants also discussed how, over time, they became more experienced and were able to let go of this particular structure. In other words, they described how they created their own way of using Brain Blocks, which was also

recommended by the developer of Brain Blocks.

Completion of additional workshops. This transition from following the workshop and the manual to, then, starting to let go of the structure appeared to not only be caused by participants’ own increasing experience with implementing Brain Blocks, but also by the additional workshops they completed. More specifically, many participants discussed how the completion of workshop 2 in addition to the first affected their implementation of Brain Blocks. For example, one respondent said:

After the first workshop, I tried to be good and stick to the manual, which actually was according to the workshop as well. Due to the second workshop, you more or less have all the freedom. That is also how the workshop started of course, like throw your manual away, because now we are going to do it differently. (respondent 2, individual supervisor)

This quotation also shows how the additional workshops stimulate participants to implemented Brain Blocks in a flexible manner.

In addition, according to participants, the second workshop created new possibilities to cope with difficulties. Whereas after the first workshops several participants would not know how to react to clients that do not really start or explain their situation themselves, after the second workshop they got new ideas. Examples were explaining their own head or

displaying their idea of the client’s head in order to provoke a reaction of the client. This provided them with more insight into the client’s situation and brought them a step further in the process. Also, participants discussed how they thought of new possibilities to implement Brain Blocks after the second workshop, for example among children diagnosed with ADHD rather than ASD and even children with other disorders. One participants said:

If I had not completed workshop 2 yet, I would be more stuck, like okay, this is really for children with ASD and I have to explain the head without ASD first, followed by the head with ASD, and then we can continue working with the head with ASD. That is not necessary. This allows the use of a broader target group. (respondent 2,

If participants, after increasing their experience with implementing Brain Blocks and/or completing addition workshops, used the flexibility with which Brain Blocks can be implemented and implemented it in a more personalised manner, they explained to make certain adaptations to the intervention Based on different characteristics related to the

implementer, organisation, and social context, participants adapted, for example, the duration of the Brain Blocks process, language and the pace with which they explained Brain Blocks-related topics, they sometimes changed the materials, or even combined Brain Blocks with other interventions and methods. These adaptations will be discussed later related to the client’s characteristics. However, it should be noted that to make the role of different characteristics as well as experiences with Brain Blocks in the implementation explicit was hard for participants. One respondent explained: “Yes, I actually do think that I take all the experiences into account within following families, but to explain this very concretely, I think that is a bit more difficult.” (respondent 11, family therapist).

Clients’ diagnoses. Furthermore, participants implemented Brain Blocks primarily among people diagnosed with ASD. Half of the participants implemented Brain Blocks among diagnosed people only, whereas the other half implemented Brain Blocks among people who were not (yet) diagnosed or were diagnosed with other disorders, such as ADHD, as well. Except for not mentioning the word “autism”, the use of Brain Blocks and adaptation they made (over time) were not particularly different from people who were diagnosed with ASD. However, a few participants considered this to be a point of improvement and discussed how open Brain Blocks can be used and, therefore, what a shame it was to see the word “autism” everywhere. Nevertheless, they implemented among people with no or different diagnoses and, for example, put a piece of paper over the word “autism”.

Implementer characteristics. To gain insight into the implementer characteristics that play a role in the implementation of Brain Blocks, participants were asked about their

personal and work-related factors. A pattern related to the previous knowledge and skills as well as previous experiences emerged from the data.

Knowledge, skills, and experiences. All participants were experienced with ASD. They knew a lot about it and already implemented different kind of interventions for their clients with ASD before Brain Blocks, such as “Ik ben speciaal”. Most participants were positive regarding their use of these experiences in the implementation of Brain Blocks. One respondent said, for example:

I have a lot of knowledge about autism and […] that is what I feed on. That is very nice, I also use it in contact with the client. For example, how do you look at someone, how is the body posture, how is my body posture, what does the office room look like. (respondent 7, social psychiatric nurse)

Another respondent talked about the previous acquired skills regarding people with ASD: “I have a lot of experience of course in adapting to the child's level. […] also having conversations, conversation techniques, I use the solution-oriented coaching very much. So, that is what I am educated in.” (respondent 4, ambulant care worker). Participants previous knowledge, skills, and experiences seemed to be something just there, within them, which they included in the whole implementation process.

Participants also discussed how their previous experiences with people with ASD allowed them to implement Brain Blocks and explain ASD well:

I just believe that with my experience with people with ASD, I really have enough ability to use Brain Blocks in total: to offer the basics what is autism, what does it

mean, what do you encounter, how does the brain work, that kind of thing. I can handle the manual well. (respondent 1, ASD coach)

In addition, participants talked about how such experiences allowed them to

differentiate between clients and made it easier to understand the origin or cause of certain behaviours. These previous knowledge, skills, and experiences could be, based on the data, considered a base, from which they started to implement Brain Blocks.

However, one respondent discussed that although it helps to have experience with ASD, it is not a requirement for implementing Brain Blocks. She said:

I think Brain Blocks can be applied easily without all the knowledge that I have gained during my education. […] For Brain Blocks, I do not know if it is always necessary or something. The moment you use the blocks and mention that you think it is like this and this in your head, yes, then you do not immediately need to have a lot of

knowledge. I do not believe that. (respondent 2, individual supervisor)

Moreover, another participant mentioned a negative side of having a lot of experience. It affected, for example, how she coped with difficulties faced while using Brain Blocks:

A negative experience is that I have always explained psychoeducation in a visual way. Then, if I get stuck […] or I feel like I do not know anymore, I fall back into my previous explanation of psychoeducation very soon. That is, of course, a disadvantage of having experience. (respondent 7, social psychiatric nurse).

Thus, when she gets stuck with Brain Blocks and does not know how to continue with the client, she went back to the previous methods she used to provide psychoeducation to clients instead of findings a solution with Brain Blocks to the problem.

Organisation. Different patterns emerged from the data regarding the role of the organisational context of participants on their implementation process. Participants were either their own boss or they were employed within different organisation. As such, the organisation affected their implementation process due to 1) the setting they implemented Brain Blocks in. Furthermore, there was a variety in the way the implementation processes of employed participants were influenced by the 2) the organisation’s regulations and

legislations versus the freedom provided by the employer, and 3) the stimulation given by the employer to the participants.

Setting. The organisation of the participants affected where they implemented Brain Blocks. This was either at home or, more often, at the location of their organisation, like a school or care institution. Most participants did not experience any differences in their

implementation of Brain Blocks between these settings: “As long as there is a table to display it [Brain Blocks] on. That is all.” (respondent 3, coach). However, participants experienced different benefits within their specific Brain Blocks setting. One respondent discussed the benefit of implementing Brain Blocks at school:

What I really like is that it can be at a school and that you have a very low-threshold care for parents as well. […] We can easily involve parents. […] That is what I consider to be an advantage within the school, that it is very low-threshold. You actually have the triangle student, teacher, and parent very close. (respondent 2, ambulant care worker)

Another respondent discussed the advantage of implementing Brain Blocks at home compared to at the organisation:

You notice that when you go to the home situation that it is also easier for children to generalise it and to really be themselves at home. It is often that they come here for an hour or so and then it is like, now we are going to do Brain Blocks here and afterwards we are gone again and then it is ready. […] You also see more in the home situation. More happens. They dare to be more themselves. (respondent 8, family therapist)

Furthermore, all participants believed it was important within the organisation to be in a separate room and have one-on-one sessions with the clients or one-on-more session when the social environment was involved as well. This was to create a trustworthy relationship and an open space for the client. Moreover, when a Brain Blocks session is organised for health professionals, such as the supervisors and mentors of clients, it was important to not have a very large group in order to create an interactive session.

Regulations and legislations versus freedom. Regulations and legislations could lead to restrictions in using Brain Blocks, according to participants. A few participants were, for example, limited in the number of sessions they could use for Brain Blocks with a client, as one respondent explained:

I think that is a shame, how it works. We are an organisation attached to many rules and agreements with contracts with municipalities, so what we can and cannot do. So, we have strict standards for certain parts. For psychoeducation of Brain Blocks, I always schedule five appointments. After that it has to be done, it is not entirely, but

after that it should not be called psychoeducation Brain Blocks. (respondent 13, ambulant care worker)

As such, participants were able to implement Brain Blocks for psychoeducation, but they were limited in the ability to use it for further purposes as well, including the discussion of different difficult situations and findings solutions to them or the transition from Brain Blocks to daily practice.

On the other hand, many participants discussed not to experience restrictions from their organisation and felt free to decide what to implement and how to implement it. The organisations’ main focus was on the clients and it appeared that participants were free to help the clients in the way they thought was best. Moreover, a respondent explained how she received hours specially to implement Brain Blocks:

I have received hours especially for Brain Blocks. So, I have four hours a week to spend on Brain Blocks. That is very helpful of course, because then I also have the time and space to really see clients for Brain Blocks and to implement within in the organisation. (respondent 8, family therapist)

Stimulation. Furthermore, often the organisations even encouraged the implementation of Brain Blocks. They organised Brain Blocks workshops or allowed participants to do a workshop if they wanted to. Only one participants mentioned that they were allowed to do workshop 1, but had to pay themselves for the second and third workshop. Furthermore, participants felt stimulated by exchanging experiences with colleagues. This could either be in organised “ASD group” or done themselves, as one participant, for

around who also use Brain Blocks. So, you can exchange experiences and ideas with each other.” (respondent 7, social psychiatric nurse). They used such opportunities to discuss difficulties faced with clients and to come up with solutions for upcoming sessions.

Social context characteristics. To gain insight into the social context characteristics that have a role in the implementation of Brain Blocks, participants were asked about the role of the 1) client and social environment characteristics. Regarding the social environment, participants mentioned the involvement of 2) family and school and the involvement of 3) health professionals, such as mentors and supervisors of the clients.

Client. The client characteristics played the most prominent role in the implementation of Brain Blocks. All participants included client characteristics in their decision-making processes: “Because in my opinion, I do it for the client and with the client. That is what I think. Otherwise if I keep following the manual, I will soon lose the motivation from the client.” (respondent 10, care coordinator). Different subthemes emerged from data, including the role of 1) general client characteristics, including clients’ age, problems, and ability to reflect and recognise, and of 2) the clients’ specific situation at each time (of the session). General characteristics. Participants implemented Brain Blocks among children, adolescents, and adults as well as among parents and, sometimes, among supervisors and mentors of clients and colleagues. As such, participants were asked whether there were any client characteristics and differences among them that affected their implementation process. Participants acknowledged the role of general characteristics, such as age, intelligence, and linguistic difficulties, in their implementation of Brain Blocks, as one respondent explained, for example, regarding clients’ age:

How I will use Brain Blocks depends very much on the age [of the client]. Will I use it more like I am really educating someone, really to transfer knowledge, or like I am

really in conservation with someone who can already tell me a lot about his own life? (respondent 1, ASD coach).

A few participants even adapted the materials to fit the age groups of the clients: “Especially among adolescents in puberty […]. I have two phones, an iPhone and a Samsung, and thinking in terms of blocks, blocks and cylinders, then I use a Samsung for the cylinders and the iPhone for blocks.” (respondent 7, social psychiatric nurse).

Furthermore, participants implemented Brain Blocks among people with high as well as low levels of intelligence. Accordingly, participants often adapted the language and pace with which they implemented Brain Blocks. Whereas this worked for most participants, one participant considered Brain Blocks to be too abstract for people with lower levels of intelligence and complemented it with another method:

I can also imagine that, if you have people with ASD who have much higher levels of intelligence, you can only use Brain Blocks. Then you can display the heads, gain insight and, then, it is done. However, regarding the target group that I work with, yes, they need much more visual material around it, in my opinion. I think that a head like that is very abstract. There is a set of blocks. I can tell them about that, but I can only show it if I have POPtalk. (respondent 5, coordinating supervisor).

The difficulties faced by the client, especially regarding their communication abilities, were often considered by participants as well. One respondent explained, for example, a situation of a client with communication difficulties: “She really has a problem with communication, because she reads it wrong and thinks she is being bullied. […] After the psychoeducation, I mainly looked at what she is getting stuck on and I picked those chapters.”

(respondent 6, educational supervisor). Thus, based on the difficulties experienced by clients, either in general or during the last (few) weeks, participants selected the relevant chapters of Brain Blocks or treated all chapter, but changed the order to fit the difficulties discussed during each session.

Furthermore, many participants also discussed a client’s ability to reflect. For

example, one respondent said: “Look, one client can hear a situation and immediately apply it to another situation, but I have also had students who could not really reflect on themselves and could not apply it. That step was way too big.” (respondent 4, ambulant care worker). These difficulties could be related to the clients’ age or their specific type of ASD, but

participants explained that it is hard for people with ASD in general to express emotions or to be compassionate. However, they discuss it to be a very important ability in order to

implement Brain Blocks successfully. They still believe Brain Blocks is a very valuable tool and, as such, participants sometimes repeat sessions or discussed topics, they help the client by giving suggestions instead of waiting for initiatives, or they use the materials (e.g., blocks, heads) in a different way. Additionally, many participants check with the client how it is going and whether they are still able to follow the session. Participants asked for example: “During the session, I often ask the client do you recognise this, how does this work for you, can you tell something about it, do you have an example.” (respondent 8, family therapist). Based hereon, participants select relevant chapters of Brain Blocks or adapt the order of the chapters.

Specific client’s situation. Although the role of these general characteristics of clients in the implementation of Brain Blocks was well explained by participants, the current

situation of the client, being able to take information in or not during each session, appeared to be the most important factor of all. According to many participants, it was extremely important that the client was open to Brain Blocks, how they were feeling and “how their

head was”. This appeared to be true for each session separately. Participants tended to look at how full the head of their client was during the moment of the session. One respondent said:

I think it still needs to fit into what the client is doing and that it is currently in his living situation, at the moment in his level of knowledge, about the experiences he is currently experiencing. I think you should really see Brain Blocks in a broader whole there for a while, now I am wondering what autism is. (respondent 12, consultant parental education).

If the client’s head would, for example, be too full, participants discussed to do something else than Brain Blocks and reschedule the session or they tried to connect with the clients first, before they started to use Brain Blocks. However, a few participants mentioned how you might actually use Brain Blocks when the client has a full head, as one respondent said:

You can [use Brain Blocks] when there is a full head. Well, yes, it depends on how full the head is, there must be room to be able to sit down [and do Brain Blocks], but it can also be used properly with a [full] head of course. Then you can ask, at that

moment, I see that you were angry just now, what is in your head, what do you think about, and then display it [with the blocks] together. […] The client may also get an understanding like oh, if I have such a full head, this is what happens, so I am angry, because it is so full that it is like it actually explodes, displaying blocks outside of the head, like nothing can be added anymore. (respondent 5, coordinating supervisor)