Abstract
The aim of this study is to holistically synthesise the extent and range of literature relating to the employment of individuals with autism spectrum disorder. Database searches of Medline, CINAHL, PsychINFO, Scopus, ERIC, Web of Science and EMBASE were conducted. Studies describing adults with autism spectrum disorder employed in competitive, supported or sheltered employment were included. Content analysis was used to identify the strengths and abilities in the workplace of employees with autism spectrum disorder. Finally, meaningful concepts relating to employment interventions were extracted and linked to the International Classification of Functioning, Disability and Health Core Sets for autism spectrum disorder. The search identified 134 studies for inclusion with methodological quality ranging from limited to strong. Of these studies, only 36 evaluated employment interventions that were coded and linked to the International Classification of Functioning, Disability and Health, primarily focusing on modifying autism spectrum disorder characteristics for improved job performance, with little consideration of the impact of contextual factors on work participation. The International Classification of Functioning, Disability and Health Core Sets for autism spectrum disorder are a useful tool in holistically examining the employment literature for individuals with autism spectrum disorder. This review highlighted the key role that environmental factors play as barriers and facilitators in the employment of people with autism spectrum disorder and the critical need for interventions which target contextual factors if employment outcomes are to be improved.
Introduction
Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition with adult outcome studies revealing that few individuals with ASD live independently, have social relationships or are employed, experiencing poor mental health and overall quality of life (Hendricks and Wehman, 2009; Howlin et al., 2013; Kirby et al., 2016; Levy and Perry, 2011; Magiati et al., 2014; Seltzer et al., 2004). However, some adults with ASD successfully gain post-secondary qualifications, participate in long-term employment, live independently and engage in social and romantic relationships (Billstedt and Gillberg, 2005; Eaves and Ho, 2008; Farley et al., 2009). It is likely that this variability in outcomes is, at least in part, attributable to the heterogeneity of ASD and variability in personal factors, such as intelligence quotient, language abilities, comorbid conditions (Farley et al., 2009; Henninger and Taylor, 2013; Howlin et al., 2004; Kirby et al., 2016; Magiati et al., 2014), environmental factors including family support, access to interventions and the availability of support services (Holwerda et al., 2012; Levy and Perry, 2011). While research, to date, has largely focussed on impairment, ASD may also be associated with strengths with the potential to leverage improvements in functioning and quality of life (de Schipper et al., 2015; Mottron et al., 2009).
Individuals with ASD possess strengths and abilities, which can be harnessed in the work environment, often performing well in jobs requiring systematic information processing and a high degree of accuracy, precision and repetition (Baldwin et al., 2014; de Schipper et al., 2016; Walsh et al., 2014). Capitalising on these strengths (Clifton and Harter, 2003) and focusing on the person-job-environment fit (Lorenz and Heinitz, 2014) could support successful outcomes for people with ASD in a variety of employment contexts (Hendricks, 2010; Mawhood and Howlin, 1999). However, despite increasing recognition of the potential contribution that individuals with ASD can make in the workplace, they continue to experience many challenges securing and maintaining employment (Hendricks, 2010; Howlin and Moss, 2012; Hurlbutt and Chalmers, 2004). This is partly driven by models of service which continue to focus on remediating impairments, with little regard for the strengths of people with ASD, perpetuating low expectations and ultimately poor employment outcomes (Holwerda et al., 2012; Lorenz and Heinitz, 2014).
Australian adults with ASD participate in employment at a rate of 42%, in comparison to 53% of all individuals with disabilities, and 83% of individuals without disabilities (Australian Bureau of Statistics, 2009, 2010). In the United Kingdom, 15% of adults with ASD of working age are in full-time paid employment (Mavranezouli et al., 2013; Rosenblatt, 2008), and only 34% (aged 21–48 years) have ever participated in ‘some’ form of employment, inclusive of independent work, self-employed or sheltered employment (Howlin et al., 2004). Similarly, in the United States, 58% of young adults (aged 18–25 years) with ASD have worked for pay, and only 21% are in full-time employment (Bureau of Labor Statistics, 2013; Roux et al., 2015). While some individuals with ASD do find employment, many work in positions below their qualifications or skill level, working reduced hours and receiving lower rates of pay than their co-workers in comparative positions (Howlin et al., 2004; Roux et al., 2015; Shattuck et al., 2012). At the individual level, poor employment outcomes among adults with ASD negatively impact socioeconomic status, quality of life and mental health (Fleming et al., 2013; Gerhardt and Lainer, 2011; Wanberg, 2012), and at the societal level on lost productivity and increased reliance on government funding (Järbrink et al., 2007; Krieger et al., 2012; Roux et al., 2013).
Employment commonly occurs within environments that are potentially challenging for individuals with ASD (Leonard et al., 2010; Müller et al., 2003; Nord et al., 2016). In the life area of work and employment, the hallmark impairments of ASD manifest in difficulties mastering the job application process, remembering and following instructions, interacting and communicating effectively with co-workers and integrating into the workplace culture (Baldwin et al., 2014; Krieger et al., 2012; Müller et al., 2003). It is however likely that the low levels of participation in employment are influenced by environmental factors such as employers’ attitudes and concerns over real and perceived barriers to employing individuals with ASD including accommodation costs, additional supervision needs, sick leave, workforce heterogeneity and concern in relation to employee productivity (Hernandez and McDonald, 2010; Ju et al., 2013; Unger, 2002). Common employment processes and practices such as traditional approaches to job advertising and interviewing (Scott et al., 2015; Strickland et al., 2013) and job descriptions requiring generic skills such as teamwork and social-communication skills that are not always essential to the job role, are also likely barriers to securing employment for this group (Fraser et al., 2011; Richards, 2012).
Employment services assist individuals with ASD with recruitment, the interview process, job placement, workplace accommodations and ongoing support. While employment services aim at maximising employment outcomes for individuals with ASD, they remain less than optimal and do not provide sufficient and appropriate supports (Alverson and Yamamoto, 2016; Anderson et al., 2017; Lawer et al., 2009; Nicholas et al., 2014). Often, employment services overlook the social support needs and on-the-job training required by employees with ASD and have a tendency to treat their needs homogenously (Nicholas et al., 2014; Richards, 2012). Many employment service providers are not trained to comprehensively meet the unique and varying needs of ASD, nor do they have an understanding of the strengths of this population to assist with providing individualised ASD-specific support for employment success (Chen et al., 2015a; Müller et al., 2003). The costs associated with providing vocational supports for ASD may also be a barrier for employment services. The ASD group is considered one of the most costly populations to support in employment, receiving the highest varying and number of supports, remaining longer in the service system yet achieving comparatively poorer employment outcomes to other disabilities (Burgess and Cimera, 2014; Chen et al., 2015b; Cimera and Cowan, 2009; Seaman and Cannella-Malone, 2016). This is problematic, given the increasing number of individuals with ASD requiring and utilising vocational support services (Burgess and Cimera, 2014). It is essential that our understanding about the type and level of support required improves, along with the role that extrinsic social and environmental factors play in fostering employment success for individuals with ASD (Kirby et al., 2016; Nicholas et al., 2014).
Employment for adults with ASD can be holistically conceptualised using the International Classification of Functioning, Disability and Health (ICF) framework. The ICF takes a biopsychosocial perspective of health, providing a scientific basis and standardised language for coding and classifying health and health-related states (World Health Organization (WHO), 2001). The classification of health and health-related states are described in two parts, each consisting of two components. Part 1 ‘Functioning and Disability’ includes the components of, Body Functions and Structures (i.e. physiological functioning and anatomical parts of the body) and Activities and Participation (i.e. execution of a task and involvement in a life situation, respectively). Part 2 ‘Contextual Factors’ includes the components of, Environmental factors (i.e. physical, social and attitudinal environment) and Personal Factors (i.e. social and cultural factors intrinsic to the individual) (WHO, 2001). Using taxonomic principles and a hierarchical structure, the ICF organises three of the distinct components described above (i.e. Body Functions and Structures, Activities and Participation and Environmental Factors) into four levels of increasing detail (WHO, 2001). The first level of categorisation refers to the relevant chapters within the ICF, with each chapter providing a general overview of the areas of functioning. Each chapter comprises of second-, third- and fourth-level categories. For example, an ASD-relevant classification from the Activities and Participation component shows the hierarchical structure of the ICF:
Level 1 chapter: d7 – Interpersonal interactions and relationships.
Level 2 category: d710 – Basic interpersonal interactions.
Level 3 category: d7104 – Social cues in relationships.
Level 4 category: d71040 – Initiating social interactions.
The ICF perceives an individual’s functioning and disability as a dynamic process resulting from interactions between the health condition and contextual factors, that is, the outcome of work participation and employment is a result of the interaction of an individual with ASD and the environmental factors (McDougall et al., 2010; Schneidert et al., 2003; WHO, 2001). Given the many factors influencing work participation and employment of individuals with ASD, the ICF framework is useful in capturing this complex group of intertwined variables and organising this information in a meaningful, interrelated and easily accessible way (WHO, 2001). However, with more than 1650 categories to describe an individual’s functioning, using the ICF in its entirety remains too generic and unfeasible (Finger et al., 2012; Stuckl et al., 2002). In an attempt to address this limitation, ‘ICF Core Sets, or a condensed list of categories or domains of the ICF relevant to a specific health condition (e.g. ASD) or setting (e.g. the workplace)’ (Finger et al., 2012: 430), have been defined. The development of the ICF Core Sets for ASD enables consideration of functioning across the lifespan and understanding of participation in major life areas, including employment (Bölte et al., 2014, 2017; De Schipper et al., 2015, 2016). The implementation of the ICF Core Sets for ASD will be particularly useful in organising the ASD employment literature according to the target of interventions in relation to Body functions and Activities and Participation, and the modality of the interventions in relation to Environmental factors. The organisation of the ASD employment literature will highlight the gaps in current employment interventions, while re-inforcing successful interventions and their associated outcomes.
Although the number studies examining the employment interventions and outcomes has almost doubled in recent years, much remains unknown. This scoping review examines the extent and range of literature relating to the employment of individuals with ASD, employing the ICF as a framework to summarise and synthesise findings with the goal of informing future research and policy, and advancing evidence-based practice. As such, the primary objectives of this review were to: (1) holistically and comprehensively review the employment literature and employ the ICF framework (WHO, 2001); (2) explore measures used in evaluating employment outcomes; (3) identify the skills and abilities of individuals with ASD that contribute to successful employment; (4) describe, classify and link to the ICF current employment programmes and interventions in ASD (Cieza et al., 2005); and (5) summarise the overall outcomes of interventions and support programmes.
Methods
A scoping review examined the employment of individuals with ASD, supporting the mapping of key concepts underpinning the research, synthesising the literature and identifying gaps in the evidence, ultimately supporting the dissemination of findings to consumers, researchers and policy makers (Arksey and O’Malley, 2005). The review adopted the methodology for scoping reviews articulated by Arksey and O’Malley’s (2005) and refined by Daudt et al. (2013) and Levac et al. (2010), in: (1) identifying the research aims and objectives; (2) searching for relevant studies; (3) systematically selecting studies; (4) charting data; (5) collating, summarising and reporting the results including a methodological assessment of quality; and (6) consulting with stakeholders to inform or validate study findings (Arksey and O’Malley, 2005).
Search strategy
Scoping search strategies promote a comprehensive and broad search of the literature, employing multiple sources (Levac et al., 2010). The literature was searched using electronic databases Medline (1966), CINAHL (1982), PsychINFO (1920), Scopus (1960), ERIC (1992), Web of Science (1972) and EMBASE (1947) for publications from their earliest records to their most recent publication (June 2018). A further computer search of reference lists of all relevant retrieved articles identified additional significant papers, and employment policies, reports and proceedings retrieved from relevant government websites, networks and organisations. Search terms used were grouped in relation to: (1) diagnosis; (2) age; (3) intervention and (4) outcome (Table 1). Combinations of search terms were identified, truncated, exploded and adjusted to achieve optimal results with the assistance of a librarian to comply with each of the databases.
Search terms a .
Terms were connected with ‘OR’ and between terms with ‘AND’.
Search terms truncated and exploded.
Study selection
The scoping review process is iterative, involving a multidisciplinary team to ensure a transparent, replicable and rigorous process (Levac et al., 2010). Authors defined and refined the inclusion criteria based on increasing familiarity with the literature (Arksey and O’Malley, 2005). Following the inventorying and study of abstracts, the research question was revised. Studies were included if, (1) participants were individuals with ASD (including autism, Asperger’s disorder or pervasive developmental disorder not-otherwise specified (PDD-NOS), with or without an intellectual disability, and 18 years or older. Although the inclusion criteria stipulated participants should be 18 years and older, studies were included if a subset of the participants were under the age of 18, but the mean age of participants was ⩾18 years; (2) described the process of finding, gaining and maintaining employment (including the terms competitive, supported, sheltered employment, vocational activities, work experience or internships); (3) reported the use of any employment programmes, interventions or vocational supports and (4) published or translated in English. Studies were excluded if the documents were a book or book chapter, editorial or opinion piece, and if they focussed on transition planning. Four reviewers independently assessed the relevance of the selected articles.
Charting the data
Data were extracted from the selected articles according to the pre-determined framework (Arksey and O’Malley, 2005). Descriptive study characteristics were charted and organised by unique reference number, author, year of publication, country, design, participants, outcome measures, nature and stage of employment and quality and level of evidence.
Assessment of methodological quality
Methodological quality was independently assessed by two reviewers according to the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields (Kmet et al., 2004), comprising a checklist of 10 items for qualitative studies and 14 items for quantitative studies, underpinning calculation of an overall score of study quality. Scores were represented as percentages with the strength of the evidence categorised as strong (>80%), good (70%–80%), adequate (50%–70%) or limited (<50%) (Lee et al., 2008). Any inconsistencies between reviewers were resolved by discussion. The same two reviewers also determined the level of evidence of each study based on the guidelines developed by the Joanna Briggs Institute (The Joanna Briggs Institute, 2014).
Collating, summarising and reporting the results
Search results were analysed using a combination of techniques. Descriptive analysis characterised included studies, mapping the data, revealing the distribution of studies across employment type, focus of employment programmes or interventions and overall employment outcomes (direct and indirect). Assessment of the methodological quality of included studies provided an understanding of the strength of the evidence in relation to the study design (Kmet et al., 2004). Content analysis was used to analyse the content of the literature according to the pre-established categories of ‘ASD-related abilities’ as described by de Schipper et al. (2016), quantitatively investigating the frequency of the terms relating to ASD-related skills and abilities, and qualitatively focusing on the meaning and interpretation of the strengths that individuals with ASD contribute to the workplace (Joffe and Yardley, 2004).
Identifying and linking meaningful concepts to the ICF
Meaningful concepts were identified and extracted in relation to the target and modality of the intervention and then linked to the Body functions, Activities and Participation and Environmental factors components according to the linking rules and procedures described by Cieza et al. (2002, 2005). In cases where concepts were too broad and ICF categories could not be identified, specific codes were assigned, including; (1) ‘not definable (nd)’, when information provided by a meaningful concept was not sufficient to assign to an ICF category; (2) ‘personal factor (pf)’, when a concept was not contained in the ICF but was clearly a personal factor as defined by the ICF; (3) ‘not covered (nc)’, when a concept was not contained within the ICF and was clearly not a personal factor; and (4) ‘health condition (hc)’, when a concept referred to diagnosis or condition (Cieza et al., 2005). Identification and linkage of meaningful concepts to ICF categories were conducted independently by four researchers with linking experience, ensuring the quality and consistency of the results. Linking results of each of the researchers were compared, with any variance discussed to verify concepts and categories until consensus was reached.
Application of the ICF Core Sets for ASD
The linking process was informed by the ICF Core Sets for ASD (Bölte et al., 2018), which have been developed in response to the need for a standardised tool describing functioning in ASD across the lifespan (Bölte et al., 2014; Selb et al., 2015), with this review employing the brief ICF Core Sets for ASD inclusive of those categories essential in describing ASD (Cieza et al., 2004; Finger et al., 2012). The application of the brief ICF Core Sets for ASD was useful in identifying the targets of employment programmes and highlighting the potential targets of future interventions. The targets, modality and outcomes of employment programmes and interventions were linked to the brief ICF Core Sets for ASD at the second-level. Further linkage to the third and fourth-level was undertaken using the ICF Children and Youth version (ICF-CY) (WHO, 2007), as a supplement to the core sets. The frequency of each category was counted in accordance with the rule that if the same category was assigned more than once to the same employment programme or intervention, it was counted only once in the analysis (Selb et al., 2015).
Consulting with stakeholders
While considered an optional step in the review process (Arksey and O’Malley, 2005), consultation with consumers and the community was deemed an important and useful step in guiding all aspects of the review. Consultation with a community reference group occurred throughout the analysis, reporting this review to validate findings and inform further stages of the research project.
Results
A total of 4114 references were identified, and it was reduced to 2434 after the removal of duplicates and inappropriate reference types. Article titles and abstracts were reviewed according to the inclusion criteria, and when information for inclusion was lacking, full-text copies of the articles were retrieved and reviewed, with a final K = 134 articles meeting the inclusion criteria (Figure 1). The majority of identified articles were from the United States (k = 87), followed by the United Kingdom (k = 12), Australia (k = 8) and Sweden (k = 4). A total of 84 studies were quantitative, of which 22 studies extracted information from national databases rather than directly from participants, 44 were qualitative in design and five were reports and one used a mixed-methodology design. Given the high number of articles included in this review, the analysis of the 134 articles were divided into two categories: (1) general articles relating to employment outcomes (k = 98) and (2) articles evaluating employment programmes and interventions (k = 36).
Flow chart of study selection process.
General articles relating to employment outcomes (k = 98)
Quality assessment of studies and levels of evidence
A broad range of evidence was identified. The majority of research articles were rated from level II (quasi-experimental designs) through level V (expert opinion and bench research), with only four articles rated as level I evidence, according to the Joanna Briggs Institute hierarchy of scientific evidence for meaningfulness.
Overall, the methodological quality of the included articles ranged from limited (k = 18), to adequate (k = 16), to good (k = 12) to strong (k = 52) (Kmet et al., 2004). Shortcomings of quantitative studies (k = 59) included the absence of control groups, a lack of random allocation, small sample sizes, implementation of poorly described or non-standard interventions, along with non-blinded assessments and imprecise measurements of outcomes. Qualitative studies (k = 33) were limited by failures to adequately report methodological design and procedures including the absence of discussion in relation to if findings achieved a saturation, participants self-selecting as having ASD rather than confirmation of diagnosis, collectively impacting on the transferability and credibility of findings. Table 2 summarises the descriptive characteristics of the employment outcome studies only (k = 98).
Descriptive characteristics of general articles relating to employment outcomes (k = 98).
W/I/VT: work experience or internship or vocational training; S: sheltered employment; SE: supported employment; C: competitive employment; P: preparing for employment; S: seeking or securing employment; M: maintaining employment; X: indicates the type of employment explored, analyzed or discussed within the article; •: indicates the stage of employment explored, analyzed or discussed within the article; ASD: autism spectrum disorder; AS: Asperger’s syndrome; HFASD: high functioning ASD; PDD-NOS: pervasive developmental disorder not-otherwise specified, according to the DSM-IV (American Psychiatric Association, 2000); ID: intellectual disability; M: mean; Mdn: median; Qual: qualitative; Quant: quantitative; ADL: activities of daily living; NHS: National Health Services; VR: vocational rehabilitation; VR-JIT: virtual reality job interview training; TERA: Test of Early Reading Ability; AWSQ: Autism Work Skills Questionnaire; QOL-Q: Quality of Life Questionnaire; PWI: Personal Wellbeing Index; QLS: Quality of Life Survey; CANTAB: Cambridge Neuropsychological Tests Automated Battery; ADI-R: Autism Diagnostic Interview-Revised; WAIS-R: Wechsler Adult Intelligence Scale-Revised; WPE: Work Performance Evaluation; QALY: quality adjusted life year; JRAT: job readiness assessment tool; BLERT: Bell-Lysaker Emotion Recognition Test; SRS: Social Responsiveness Scale; SIB-R: Scales of Independent Behaviour-Revised; W-ADL: Waisman Activities of Daily Living Scale.
Employment settings
Articles were categorised according to employment type, including vocational skills training, such as work experience or an internship, and sheltered, supported or competitive employment. The majority of articles (k = 98) focussed on participants with ASD finding and securing roles in paid, supported or competitive employment, while 16 studies investigated work experience or vocational skills training with the goal of individuals eventually obtaining supported or competitive employment (Allen et al., 2010a, 2010b; Anderson et al., 2017; Arikawa et al., 2013; Baker-Ericzen et al., 2018; Briel and Getzel, 2014; Burgess and Cimera, 2014; Burke et al., 2010, 2013; Dotson et al., 2013; Gal et al., 2015b; Gilson and Carter, 2016; Hayes et al., 2015; Rosen et al., 2017; Seaman and Cannella-Malone, 2016; Walsh et al., 2018). One study explored whether participating in sheltered workshops prior to engaging in supported open-employment improved vocational outcomes for individuals with ASD (Table 2) (Cimera et al., 2012). A cluster of 20 articles explored and compared vocational outcomes across a variety of employment settings in relation to factors predicting outcomes (Bush and Tassé, 2017; Holwerda et al., 2012; Howlin et al., 2004) including, supports and services required (Autism Europe, 2014; Gladh and Sjölund, 2014; Hendricks, 2010; McDonough and Revell, 2010; Morgan and Schultz, 2012; Nicholas et al., 2014, 2017a; Rashid et al., 2017; Roux et al., 2015; Smith et al., 2017; Taylor and Seltzer, 2011, 2012; Walsh and Hall, 2012), the associated costs of ongoing support employment services (Cimera and Cowan, 2009; Järbrink et al., 2007; Migliore et al., 2014), and quality of life outcomes (Garcia-Villamisar et al., 2002). Articles were reviewed for the stage of employment, including job preparation, job acquirement and job retention. While job termination is an important aspect of the employment process, it did not feature in the published research, other than a few papers addressing it as a discussion point. Articles predominantly focussed on securing and maintaining a job, with less consideration for job preparation, an aspect more likely to be addressed in the transition literature, which was outside the scope of this review.
Outcome measures
Overall, measures utilised in the employment outcomes studies were primarily characterised as descriptive and observational, with several studies developing their own outcome tools (Howlin and Moss, 2012; Lorenz et al., 2016; Müller and Vangilder, 2014; Ohl et al., 2017). Outcomes were reported according to job type, hours worked, wages earned, and support services required and were supplemented by employee self-reports and anecdotal employer accounts of job performance. The few studies employing standardised measures (k = 16) utilised published measures to corroborate and standardise ASD diagnosis (e.g. Autism Diagnostic Interview-Revised), general intellectual abilities (e.g. Wechsler Adult Intelligence Scales), autistic trait severity (Social Responsiveness Scale, version 2) and adaptive behaviour (Scales of Independent Behaviour-Revised). Four articles utilised standardised employment-related measures, including the Autism Work Skills Questionnaire (AWSQ) (Gal et al., 2015a), the Vocational Index (Taylor and Seltzer, 2012), the Work Performance Evaluation (WPE) (Katz et al., 2015) and one study examining perceived effort–reward balance at work using the short Effort–Reward Imbalance (ERI) Questionnaire (Ohl et al., 2017). Only three studies explored the impact of employment on quality of life (Gal et al., 2015b; Garcia-Villamisar et al., 2002; Katz et al., 2015).
Content analysis of ASD-related abilities contributing to employment
A sub-group of articles relating to employment outcomes were identified as recognising the skills and abilities that individuals with ASD bring to the workplace. According to the ICF, these specific ASD-related skills and abilities are considered personal factors. While personal factors are not classified within the ICF due to their unique and varying characteristics, their contribution to an individual’s disability and functioning may impact on the outcomes of an intervention (WHO, 2001). Given ASD-related skills and abilities could not be linked to the ICF, content analysis was employed to identify the skills and abilities of individuals with ASD contributing to successful employment by examining and coding the results sections only of articles according to the ASD-related ability categories, as described by de Schipper et al. (2016). In total, 14 studies described results which aligned either with the previously described strengths of participants with ASD (de Schipper et al., 2016), or with additional skills and abilities in relation to punctuality, low absenteeism, high quality of work, prompt task commencement and strong work ethic, included in the category of ‘other’ (Table 3).
Article contribution to ASD-related skills and abilities in employment.
•: indicates all the ASD-related skills and abilities observed, recored, explored and/or discussed within the article.
ASD-related skills and abilities list taken from de Schipper et al. (2016).
Articles evaluating employment programmes and interventions (k = 36)
A total of 36 articles describing and evaluating employment programmes and interventions for individuals with ASD were included in the linking process. Articles comprised of a total of 556 participants, with a mean age of 23.6 (standard deviation (SD): 6.4) years, of which 84% were male. Table 4 summarises the descriptive characteristics of the selected employment programme and intervention studies (k = 36).
Descriptive characteristics of employment programme and intervention studies (k = 36) linked to the ICF.
W/I/VT: work experience or internship or vocational training; S: sheltered employment; SE: supported employment; C: competitive employment; P: preparing for employment; S: seeking or securing employment; M: maintaining employment; ASD: autism spectrum disorder; AS: Asperger’s syndrome; HFASD: high functioning ASD; PDD-NOS: pervasive developmental disorder not-otherwise specified, according to the DSM-IV (American Psychiatric Association, 2000); ID: intellectual disability; M: mean; RCT: randomised controlled trial; VM: video modelling; FT/PT: full-time/part-time; PDA: personal digital assistant; JOBS: Job Observation Behaviour Scale; ESCI: Evaluación de Solución de Conflictos Interpersonales; O-AFP: Osnabrück Ability to Work Profile; VABS-II: Vineland Adaptive Behaviour Scales – Second Edition; UDPMP: Universal Design Performance Measure for Productivity; SIB-R: Scales of Independent Behaviour-Revised; CHART: Craig Handicap Assessment and Rating Technique; SIS-EPS: Supports Intensity Scale-Employment Subscale; EPER: Employee Performance Evaluation Report; WPP: Work Personality Profile; OEI-R: Observational Emotional Inventory-Revised; PHQ-9: Patient Health Questionanire-9; SRS-2: Social Responsiveness Scale – Second edition; RBANS: repeatable battery for the assessment of neuropsychological status; BLERT: Bell-Lysaker Emotion Recognition Task.
ICF categories within the table can be found in ICF-CY version as developed by the World Health Organization (WHO, 2007).
ICF category codes defined according to the ICF Core Sets for ASD (Bölte et al., 2018) and linked according to the ICF linking rules (Cieza et al., 2005).
Quality assessment of studies and levels of evidence
The level of evidence of research evaluating employment programmes and interventions was rated according to the Joanna Briggs Institute hierarchy of scientific evidence for meaningfulness, from level I (experimental designs) to level V (expert opinion and bench research), with the majority of articles rated as level II evidence (quasi-experimental designs; k = 21) (The Joanna Briggs Institute, 2014). Many articles either described or evaluated the effectiveness of an employment programme or intervention with common study designs including multiple-baseline (k = 12), case studies (k = 8), randomised controlled trials (RCTs; k = 7), cohorts (k = 3), pretest–posttests (k = 4) and case–control (k = 2) (Table 4).
The methodological quality of programme and intervention studies ranged from limited (k = 8); adequate (k = 12); good (k = 3) and strong (k = 13) (Kmet et al., 2004; Lee et al., 2008). Limitations included small sample sizes, a lack of employment outcome measures resulting in a reliance on employee self-report and anecdotal employer accounts on job performance in the workplace, costly implementation of technology-based interventions, and poor translation of interventions and programmes into actual employment contexts.
Employment programmes and interventions
Studies included in this review targeted the various stages of the employment process including preparing, finding and securing and maintaining employment (Table 4). Of the included studies, 13 focussed on employment preparation using video modelling, role-playing or group training in teaching the necessary social, communication and vocational skills commonly utilised in acquiring a job. One study primarily focussed on gaining employment through individual placement support (McLaren et al., 2017), and eight studies focussed on maintaining a job, primarily employing behavioural and task management strategies delivered through technology, simulation training or job coaches. The remaining 14 studies addressed two or more stages of the employment process, with programmes and interventions initially targeting one stage and their respective outcomes targeting another, such as role-play used in teaching the appropriate social-communication skills in preparing for a job interview, that when implemented resulted in successfully securing a job (Smith et al., 2014; Strickland et al., 2013). Comparison groups varied. A pre–post study evaluated a manual-based workplace intervention compared to a no-treatment group of typically developing adults (Bonete et al., 2015). The personal digital assistant (PDA) intervention used a delayed RCT, with the control group receiving PDAs 12 weeks after beginning job placement (Gentry et al., 2015). An interview skills group RCT used waitlist control (Morgan et al., 2014). The remaining five RCTs included were all compared to no-treatment groups (Hayes et al., 2015; Smith et al., 2014; Strickland et al., 2013; Wehman et al., 2014, 2016b).
Intervention outcomes
Three broad outcomes; employment status, vocational skills and executive functioning skills were evaluated (Table 4).
Employment status
Changes in employment status were examined in 12 of the 36 included studies (Baker-Ericzen et al., 2018; Burt et al., 1991; Ham et al., 2014; Hill et al., 2013; Hillier et al., 2007; Lynas, 2014; McLaren et al., 2017; Mawhood and Howlin, 1999; Wehman et al., 2012, 2013, 2014, 2016b); measures utilised were descriptive in nature, such as employment level, wages earned, hours worked and job retention, only two standardised measures were used, including the Work Personality Profile and the Support Intensity Scale (SIS). The two RCTs by Wehman et al. (2014, 2016b) evaluated the effectiveness of the ‘Project SEARCH plus Autism’ intervention, a transition-to-work support programme in comparison to high-school special-education services as usual. The RCTs found a statistically significant increase in the number of participants in the experimental group employed following the programme compared to controls (p = 0.0001), with an 87% job retention rate at the 12-month follow-up compared to the control group’s 12% job retention rate. A study by Mawhood and Howlin (1999) evaluated an autism-specific employment support programme, with the experimental group attaining significantly higher rates of full-time or casual employment (p = 0.01), higher wages (p = 0.02) and requiring less support over a 2-year period (p = 0.001) compared to the control group. The remaining studies reported increased job placement and retention for individuals with ASD following intensive work-training programmes and job coaching. Overall, jobs were retained from between 6 and 30 months, wages earned ranged between US$5.01 and US$18 and an average of 25.45 h/week were worked (Baker-Ericzen et al., 2018; Burt et al., 1991; Ham et al., 2014; Hillier et al., 2007; McLaren et al., 2017; Wehman et al., 2012, 2013, 2014, 2016b).
Vocational skills
A total of 23 studies evaluated the change in vocational skills used in completing work-related tasks, socialising in the workplace and communicating, as shown in Table 4. A variety of standardised measures were used including the Job Observation and Behaviour Scale (Bennett et al., 2010), Evaluation for the Solutions to Interpersonal Conflicts and Osnabrück Ability to Work Profile (Bonete et al., 2015), the Scales of Independent Behaviour-Revised (Dotson et al., 2013; Liu et al., 2013), Supports Intensity Scale (SIS) (Gentry et al., 2015; Wehman et al., 2014, 2016b), Employee Performance Evaluation Report (Gentry et al., 2015), Social Responsiveness Scale-2 (Smith et al., 2014; Strickland et al., 2013), Social Skills Improvement Rating Scales (Walsh et al., 2018), repeatable battery for the assessment of neuropsychological status and Bell-Lysaker Emotion Recognition Task (Smith et al., 2014). A usability study of a video-modelling intervention found that individuals with ASD had greater difficulty selecting adaptive social responses during workplace scenarios compared to typically developing controls (p = 0.02). Although reporting that the video-modelling intervention provided less choice than controls (p = 0.01), they reported that it was more enjoyable (p = 0.02) and personally relevant (p < 0.05), indicating its potential in improving social skills in vocational contexts (Rosen et al., 2017). An RCT by Bonete et al. (2015) found that the experimental group reported significantly higher social problem-solving skills (p < 0.001) and socialisation in the workplace (p < 0.001) compared to the control group. In an RCT by Gentry et al. (2015), PDAs improved the experimental group’s task organisation skills resulting in significantly less hours of job-coaching support (p = 0.013) compared to the control group. Another RCT evaluating interview performances using video modelling (Hayes et al., 2015) revealed significant improvements in interview performances (p < 0.001) and associated grooming and hygiene (p = 0.02) compared to the control group. A pre–post study (Liu et al., 2013) found their workplace training programme to significantly improve the experimental group’s social-communication skills in the workplace (p = 0.02) compared to the control group and found improvements in their social workplace behaviours (p = 0.08). The RCT examining the effectiveness of interview skills training (Smith et al., 2014) revealed significantly greater skills in role-play performance for interviews (p = 0.04) and improvements in self-confidence (p = 0.06) compared to controls. Strickland’s RCT (Strickland et al., 2013) evaluated the effectiveness of teaching interview skills reporting the experimental group (p < 0.001) demonstrated significantly more effective verbal skills during an interview than controls. A pilot study of the SUCCESS intervention, targeting cognitive and social skills, used an adapted version of the Social Skills Performance Assessment to provide a measure of social skills within a vocational context. Following the intervention, individuals with ASD showed improvements in both communicating with co-workers and requesting time off (p < 0.05). While not reaching statistical significance, parents also reported improved hygiene in areas such as dressing professionally (Baker-Ericzen et al., 2018). The remaining studies primarily evaluated the effectiveness of vocational skills training via observation and self-report measures (Allen et al., 2010a, 2010b; Bennett et al., 2010; Burke et al., 2010, 2013; Dotson et al., 2013; Gilson and Carter, 2016; Kellems and Morningstar, 2012; Lattimore et al., 2006, 2008; Lynas, 2014; Morgan et al., 2014; Rausa et al., 2016) reporting an increase in workplace social interaction skills and the completion of targeted vocational tasks.
Executive functioning skills
Changes in executive functioning skills were examined in 11 of 36 included studies (Arikawa et al., 2013; Baker-Ericzen et al., 2018; Gentry et al., 2012; Ham et al., 2014; Schall, 2010; Smith and Coleman, 1986), with five reporting positive changes in vocational skills, particularly in relation to employees’ self-management of their workplace behaviours (Burke et al., 2010; Hayes et al., 2015; Liu et al., 2013; Morgan et al., 2014; Wehman et al., 2013). Outcome measures included observation (Arikawa et al., 2013; Burke et al., 2010; Ham et al., 2014; Smith and Coleman, 1986), self-report (Gentry et al., 2012; Hayes et al., 2015; Wehman et al., 2013) and functional behaviour assessments (Schall, 2010). Standardised measures were used in only two studies. Liu et al. (2013) used the Observational Emotional Inventory-Revised, reporting that their workplace training programme improved the experimental group’s emotional response to socialisation resulting in improved concept of self (p = 0.04) compared to controls. The Delis–Kaplan Executive Functioning System (D-KEFS) and the Behaviour Rating Inventory of Executive Functioning – Adult (BRIEF-A) was used to provide a measure of executive functioning in a pilot study of the SUCCESS intervention, with improvements in both assessments observed (p < 0.05) post intervention (Baker-Ericzen et al., 2018). The RCT conducted by Hayes et al. (2015) demonstrated significant improvements in the experimental group in presenting ideas logically and succinctly during an interview (p = 0.009). Overall, studies examining executive functioning skills found that job coaches who implemented support strategies and the use of technology, such as iPods, assisted in participants’ task management, problem-solving and organisational skills, improved participants’ ability to self-regulate their workplace behaviours, subsequently increasing their productivity.
Linking employment programme and intervention results
In total, 2372 meaningful concepts were extracted from the 36 selected articles describing the evaluation of employment programmes and interventions for individuals with ASD, as described in the previous section. These concepts were linked according to the target of the intervention, in relation to Body functions and Activities and Participation, and the modality of the intervention in relation to Environmental factors (Supplementary Material). For example, an intervention targeting adults with ASD (Body functions) to improve their communication, professional behaviour and self-confidence skills in participating in a job interview (Activities and Participation), was delivered via a virtual reality software programme (Environmental factor) (Smith et al., 2014). According to this linking process, concepts were linked to a total of 131 unique ICF categories from the first to the fourth level of classification. The target of interventions accounted for 87% of linked categories, with the modality of the intervention only accounting for 13% of categories. In this review, the absolute and relative frequency for the 38 second-level ICF categories, with only the categories identified in at least 5% of the linked articles are reported. Three of the ICF components are represented by these categories, with 22 from Activities and Participation, eight from Environmental factors and eight from Body functions (Table 4). No categories were reported that related to Body structures.
Activities and participation
The greatest contribution of meaningful concepts were second-level categories within the Activity and Participation component of the ICF (Table 5). Six of the nine chapters are represented, with Chapter 3 – Communication denoting the main target of employment programmes and interventions, with the categories, d310 – Communicating with-receiving-spoken messages, d315 – Communicating with-receiving-non-verbal messages, d330 – Speaking, d350 – Conversation and comprising the focus of interventions in more than half the studies (k = 20). Subsequently, Chapter 8 – Major life areas, included the most frequently identified second-level category, d845 – Acquiring, keeping and terminating a job, which was both the target of programmes or interventions and the measured outcome in the majority of studies (k = 27). The chapters of (d1) learning and applying knowledge, (d2) general tasks and demands, (d5) self-care and (d7) interpersonal interactions and relationships, spanned the remaining categories associated with the intervention targets of the studies, which were overall aligned with well-recognised work-related needs of individuals with ASD (Chen et al., 2015a).
Absolute and relative frequencies of ICF categories from the Activity and Participation component of employment programmes and intervention studies (k = 36).
Environmental factors
Linking of meaningful concepts associated with Environmental factors component revealed that three of the five chapters were represented (Table 6). The most frequently linked category was e360 Other professionals, which described job coaches, employment coordinators and vocational rehabilitation counsellors, followed by e130 Products and technology for education representing products such as iPads, tablets and specifically designed software targeting vocational skills. Concepts relating to (e5) services, systems and polices described vocational rehabilitation and disability support services assisting individuals with ASD to find and secure employment. It is important to note the linking process aimed to identify those environmental categories associated with employment interventions and processes and did not describe the work environment itself. For example, the code e125 – Products and technology for communication may refer to the use of an iPad by individuals with ASD for communication purposes, but in this context, the iPad was used as a tool to deliver an intervention targeting job interview skills (Gentry et al., 2015; Smith et al., 2014). The work environment itself was not modified or influenced to improve employment outcomes.
Absolute and relative frequencies of ICF categories from the Environmental Factors component of employment programme and intervention studies (k = 36).
Body functions
Two of the eight chapters of the Body functions component were represented in the included studies (Table 7). The majority of categories were linked to Chapter 1 – Mental functions. The most prevalent categories included b122 – Global psychosocial functions, b177 – Intellectual functions, b140 – Attention functions and b164 – Higher-level cognitive functions, all of which included ASD characteristics that are regularly targeted in interventions. This component demonstrated that interventions and programmes targeted traits associated with ASD and varying difficulties in the process of preparing, finding and maintaining employment. The most frequently identified category was from the Body functions component, b122 – Global psychosocial functions, indicative of the focus on interventions on impairment-related factors.
Absolute and relative frequencies of ICF categories from the Body Functions component of employment programme and intervention studies (k = 36).
Consultation with stakeholders
Focus groups were conducted with stakeholders comprising of adults with ASD, parents of individuals with ASD, employers, disability employment coordinators, practitioners and expert researchers. Stakeholders were presented with an opportunity to share their perceived concerns in relation to factors influencing the process of finding and securing a job for adults with ASD. Parents of adults with ASD stated Success is achieved in the workplace when people have an understanding of ASD and positive experiences with previous employees with ASD.
Stakeholders also provided feedback regarding the results of the scoping review. The stakeholders’ perceived employment concerns were validated by the findings from the scoping review and confirmed that the work environment plays a critical role in influencing employment opportunities and outcomes for people with ASD. While consultation with stakeholders improved the richness of the research process, further exploration of individual perspectives would likely refine feedback and enhance the translation process, given the diversity of the group. Such considerations may be beneficial when conducting future scoping review practices.
Discussion
Given that employment commonly occurs within complex environments, this scoping review used the ICF to enable a structured understanding of the factors contributing to finding and securing employment beyond the diagnosis and functioning levels of individuals with ASD (WHO, 2001). This review found RCT and quasi-experimental evidence to support the effectiveness of employment interventions in adults with ASD in improving vocational skills, executive functioning in relation to job performance and employment status outcomes. Statistically significant improvements were reported for intervention participants compared to control participants across outcomes. While the research is limited, it points to the need for further interventions to be developed and evaluated.
To date, ASD research has largely focussed on diagnosis and early intervention services for children, and as confirmed by the findings of the current review, a paucity of literature has focussed on examining the relative effectiveness of interventions in adulthood (Hedley et al., 2016; Howlin et al., 2015; Schall et al., 2015). Of the 134 employment studies identified for inclusion in this review, only 36 were intervention based. While these interventions studies had the stated collective purpose of improving employment outcomes, they were primarily impairment-focussed, targeting their interventions at intrinsic individual ASD characteristics, with little consideration of contextual influences. Interventions targeted ASD traits commonly associated with difficulties in finding and obtaining a job, such as executive functioning skills in relation to problem-solving, organisation, task management and behaviour regulation and social-communication skills required in interviews and workplace interactions (American Psychiatric Association, 2013; Hendricks, 2010; Müller et al., 2003). While many of these interventions were effective in increasing measured vocational and executive functioning skills, many participants continued to remain unemployed. The continuing high rates of unemployment among participants following these interventions suggest that impairment-focussed interventions alone are not sufficient in achieving and maintaining successful work-related outcomes for individuals with ASD (Ellenkamp et al., 2016).
One possible explanation to impairment-focussed interventions could be the entrenched use of the medical model in underpinning interventions in adulthood. The medical model views ASD as a problem of the individual, requiring them to take responsibility for their disability and make the necessary personal adjustments to be eligible for employment (Dempsey and Nankervis, 2006). While the employment interventions examined in this study did not require the individual with ASD to take responsibility for their disability, many targeted the associated traits of ASD and subsequently developed interventions targeted at personal change to assist in eligibility in finding and keeping a job (Bonete et al., 2015; Gilson and Carter, 2016; Liu et al., 2013; Morgan et al., 2014). This was evident when linking employment interventions to the ICF Core Sets for ASD. The greatest number of categories were derived from the Activities and Participation component, with interventions targeting core ASD traits such as, communication (d3); learning and applying knowledge (d1) and general tasks and demands (d2), with the outcome of acquiring, keeping and terminating a job (d8). Communication had the greatest number of categories, with more than 50% of interventions targeting the communication skills of individuals with ASD as the focus in improving employment outcomes. The use of impairment-focussed interventions was further supported by the Body functions component, indicating the most frequently targeted mental functions (b1) included intellect (b117); global psychosocial functions (b122) and higher level cognition (b164) of individuals with ASD. In an attempt to move away from the traditional medical model, many interventions have incorporated environmental factors such as, products and technology (e130) and job coaches (e360) in their approach (Allen et al., 2010a, 2010b; Arikawa et al., 2013; Smith et al., 2014). However, these environmental factors have merely been used as a means of delivering impairment-focussed interventions, rather than being the intervention itself, that is, an electronic device (environmental factor) is used to assist individuals with ASD in time and task management (body function-executive functioning) to improve work performance (activities and participation) (Gentry et al., 2015). The categories identified within the Environmental factors component indicated that support from allied health professionals, co-workers and employers (e3), organised support from government-funded services (d5) and products and technology (e1) interact with the employee with ASD and assist in determining their level of functioning in the workplace.
These findings highlight the usefulness of the biopsychosocial model of the ICF, yet no employment interventions examined in this study have purposefully incorporated the dynamic interaction between the person and the environment into their design. Conceptualising employment interventions is hampered by the paucity of research addressing intervention design in adults with ASD (Hedley et al., 2016; Holwerda et al., 2012). However, advances such as the publication of the ICF Core Sets for ASD (Bölte et al., 2018) provide an opportunity to not only holistically synthesise the literature relating to employment of individuals with ASD but develop interventions which consider functioning and disability and contextual factors.
Viewing individuals with ASD through an impairment-focussed lens results in an imbalanced view of ASD and fails to recognise the many strengths and abilities of this group (Armstrong, 2010). It is recognised that ASD is associated with many strengths and abilities which could be utilised in work environments (de Schipper et al., 2016). In contrast to the medical model, a strengths-based approach views the positive aspects that an individual brings to the workplace such as their talents, skills and abilities and highlights areas of competence (Steiner, 2011). This perspective promotes opportunity, performance and productivity by harnessing and developing an individual’s strengths rather than counteracting their weakness (Lorenz and Heinitz, 2014; Russo, 1999). In this review, only 14 articles considered the skills and abilities of employees with ASD and the subsequent benefits that these strengths bring to the workplace (Table 3) (Scott et al., 2017). While the skills and abilities of employees with ASD were identified, not a single study utilised a strengths-based approach in improving employment outcomes. Only two of the 14 studies incorporated the skills and abilities of individuals with ASD as part of the job matching process (Hagner and Cooney, 2005; Hillier et al., 2007). If adult-based interventions are to be more effective across the employment process, interventions should be conceptualised based on an integration of these dichotomous models. Given its biopsychosocial underpinnings, the ICF is an approach which is likely to have particular utility in this endeavour (WHO, 2007). Such an integrative approach to intervention development would focus on profiling an individual’s barriers and facilitators in acquiring a job and mitigating their weaknesses by promoting and supporting their strengths.
This review also highlighted the lack of intervention studies considering environmental factors and the key role that they play in facilitating or hindering work participation. Environmental factors are integral in understanding the interaction between individuals with ASD and the work context in which they are employed (Schneidert et al., 2003). While many studies incorporated environmental factors into their interventions, such as employer and co-worker support, the use of job coaches and technology, these factors were simply used as a means in delivering or implementing the intervention targeting ASD characteristics. Of the 36 intervention-based studies, not one addressed the environmental factors as the primary target of their intervention. This finding is concerning, given the argument that disability can be viewed as a social construct influenced by the environment (Shakespeare, 2013). The social model approach challenges the concept of disability as solely the responsibility of the individual and instead advocates for societal action in removing the barriers and modifying the environment to promote full participation in all major life areas (Dempsey and Nankervis, 2006; Shakespeare, 2013). Employers are considered an environmental factor in the employment process, many of which are often in influential positions to hire prospective employees, implement workplace modifications, foster inclusive workplace cultures and employ organisational policies and practices that remove barriers to work participation (Erickson et al., 2014). In addition, the use of natural supports in the work environment encourages co-workers in providing assistance, training and feedback to employees with ASD (Storey, 2003). Natural supports are recognised for their consistency and reliability in the workplace and often result in opportunities for social interaction and inclusion (Mank et al., 1997). Despite their capacity to foster a tailored work environment for employees with ASD, employers and co-workers are an overlooked and underutilised resource.
Clinical implications
Previous medicalisation of the characteristics associated with ASD has resulted in the development of adult-based interventions focusing on impairment, leading to policies and practices targeting individuals rather than the environment and social organisations (Schneidert et al., 2003). This review provides a comprehensive overview of the contextual factors that may be required for improving employment outcomes for individuals with ASD. One such contextual factor are employers, who have previously demonstrated their capacity to provide workplace accommodations (Hartnett et al., 2011; Hernandez et al., 2009). Many employers unknowingly implement a generic approach to disability in the workplace, with a limited knowledge of ASD and the unique needs and accommodations required by this population (Richards, 2012). Employer interventions are needed to address both knowledge and understanding of ASD in the workplace and the skills required in modifying the work environment accordingly. Similarly, disability employment service providers may also benefit from such education-based interventions, as education is critical in empowering behaviour change and management (Daniali et al., 2016). Further consideration of contextual factors may include the use of natural support such as supervisors and co-workers to assist employees with ASD in completing work-related tasks, providing feedback and socialising by facilitating their job performance in the workplace (Storey, 2003). This may be achieved by providing ASD-specific education training and peer-mentoring programmes to upskill supervisors and co-workers, increasing their awareness and understanding of ASD. Training programmes are most likely to be cost-effective, time-efficient and easily implemented. Given the many benefits of peer-support in school-based environments for children and adolescents, such as positive behaviour change, increased cognitive, affective and social-communication skills, inclusion and a sense of well-being (Locke et al., 2012; McCurdy and Cole, 2014; Schlieder et al., 2014), this approach is likely to be equally beneficial when effectively translated into the work environment.
Research gaps and future directions
This scoping review reveals several gaps in the literature. The majority of included studies did not use standardised outcome measures when evaluating employment outcomes, many of which were descriptive and observational in nature or designed specifically for a particular study without further validation. The findings from this review revealed a significant lack of reliable and valid measures assessing employment intervention outcomes for adults with ASD (Howlin et al., 2015). In order to address this issue, there is a need to explore and define what constitutes as a successful employment outcome for adults with ASD (Taylor, 2017). While the heterogeneity associated with ASD will make the process of defining employment success challenging, there will most likely be consensus in relation to the broader definitions of certain outcomes including employment status, job satisfaction and engagement, financial gain and career growth and development. A better understanding of an individual’s perceived quality of life as a result of employment may be a more effective way of capturing and unpacking success.
Limitations
There were several limitations associated with this review. First, the inclusion criteria defined that only English text studies were to be included in this review, of which the majority represented a US-based perspective on employment outcomes for individuals with ASD. The lack of inclusion of non-English studies and an unequal representation across countries may present a biased view on the factors impacting employment outcomes. Next, given that adulthood and employment in ASD is an emerging area of research, much of the ASD employment literature that exists is either at a national level under the broader umbrella of disability, with many resources, services and programmes lacking scientific rigour and an evidence-based approach in their development and implementation. Finally, while a meta-analyses of the included studies would have increased the statistical power and enhanced estimates of the effect size of employment interventions, given the variability in outcomes and diffuse nature of the literature, this was not possible (Fagard, 1996).
Conclusion
This scoping review demonstrated the utility of the ICF as a comprehensive framework in reviewing and synthesising the employment literature in relation to the outcome measures used, the identified skills and abilities that individuals with ASD bring to the workplace and the overall outcomes of employment interventions and programmes. This review also promoted a more balanced approach in working with adults with ASD, encouraging the consideration of contextual factors, both environmental and personal, and their potential to influence work participation. It is imperative that future research acknowledges the defined gaps in this review, amending future practices and research designs.
Supplemental Material
AUT787789_supplementary_material – Supplemental material for Factors impacting employment for people with autism spectrum disorder: A scoping review
Supplemental material, AUT787789_supplementary_material for Factors impacting employment for people with autism spectrum disorder: A scoping review by Melissa Scott, Ben Milbourn, Marita Falkmer, Melissa Black, Sven Bӧlte, Alycia Halladay, Matthew Lerner, Julie Lounds Taylor and Sonya Girdler in Autism
Supplemental Material
AUT787789_Lay_Abstract – Supplemental material for Factors impacting employment for people with autism spectrum disorder: A scoping review
Supplemental material, AUT787789_Lay_Abstract for Factors impacting employment for people with autism spectrum disorder: A scoping review by Melissa Scott, Ben Milbourn, Marita Falkmer, Melissa Black, Sven Bӧlte, Alycia Halladay, Matthew Lerner, Julie Lounds Taylor and Sonya Girdler in Autism
Footnotes
Acknowledgements
The authors thank Emeritus Professor Sylvia Rodger AM, whose passion and commitment to creating a more inclusive community guided the continuous pursuit for improved employment outcomes for people on the autism spectrum. They thank Christopher Esposito and Alan Gerber for their time, feedback and guidance in this scoping review. They would also like to thank the community reference group for their valuable input and direction in the review.
Declaration of conflicting interests
S.B. and J.L.T. are both co-authors on the manuscript for submission, as well as sub-editors for Autism. The remaining authors have no conflicts to declare.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work was supported by the International Society for Autism Research (INSAR). The authors also wish to acknowledge the financial support from the Cooperative Research Centre for Living with Autism (Autism CRC), established and supported under the Australian Government’s Cooperative Research Centres Programme. The authors acknowledge the financial support of Curtin University to Melissa Scott through the Australian Postgraduate Award Scholarship. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.
References
Supplementary Material
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