Autism and neurodiversity in the workplace: A scoping review of key trends,employer roles,interventions and supports

3.1.1 Theoretical frameworks for the employer perspective

The Theory of Planned Behaviour (TPB) (Ajzen, 1991), identified in this scoping review is a useful framework for analysing employer perceptions towards hiring disabled persons (see Fig. 2). The TPB delineates the role of social influence variables in predicting intentions to engage in specific behaviours and has assisted in the understanding of why changes in employer awareness can lead to better change outcomes for employees. According to TPB, three theoretically independent categories are assessed to measure behavioural intention. These are behaviour beliefs (personal attitudes towards or evaluation of a behaviour and its perceived outcomes), normative beliefs (the beliefs of others and social pressures related to a behaviour), and control beliefs (beliefs about resources and skills required to undertake a behaviour). These three categories act as a function for behavioural intention. Action is more likely to occur if one approves of the behaviour, perceives it as socially acceptable, and has resources to enable the behaviour (Ajzen, 1991). A selective review of the demand-side employment literature and employers’ attitudes towards disability, showed that although behaviour and control beliefs were significant, normative influences of management were the most important predictor of behaviour (Burke et al., 2013). In contrast, all three (behaviour, normative and control beliefs) were identified more recently as evenly balanced in influencing hiring agents’ lack of extending job opportunities to autistic persons (Mai, 2019).

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Fig. 2

Theory of planned behavior (TPB): A cognitive decision-making model (Ajzen, 1991).

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Fig. 3

The international classification of functioning, disability and health core sets (World Health Organisation, 2001).

In essence, TPB outlines the role of social influences in predicting intentions to adopt specific behaviours and clarifies why changes in employer knowledge can lead to better outcomes for autistic employees. In a survey of 92 employers from a convenience sample of small, medium, and large companies in Seattle, USA, TPB successfully predicted employer intentions to engage in outreach activities. Subjective norms were of greatest importance, which implied that senior and mid-line management needed to be targeted to establish normative expectations supportive of hiring disabled persons (Fraser et al., 2011).

Several reviews have suggested the use of other theoretical frameworks to examine the role of the employer (Harmuth et al., 2018; Scott et al., 2019). The Person-Environment-Occupation Model notes that interventions may be more effective when they acknowledge the person holistically, with diversity training specific to autism as well as a coordinated and systematic approach (Harmuth et al., 2018). The ecosystem framework has been proposed to highlight the employment of autistic persons as inextricably linked to community resources such as family support, workplace capacity building (e.g., employers, co-workers) and policy (Nicholas et al., 2018a). Using a Leadership Theoretical Framework, a phone interview was conducted with 54 adult autistic employees derived from a national, internet-based, voluntary autism register in the USA (Parr & Hunter, 2014). Although authentic leadership had the highest correlation with satisfaction, organisational commitment and work engagement, each person on the spectrum is likely to have different needs and preferences for several important leadership behaviours (Parr & Hunter, 2014). Transformational leadership had the highest correlation with performance, and consideration had the highest correlation with intentions to turnover (Haskins, 2019). Employers who provide an authentic leadership style, direct communication, detailed tasks, and consistent workplace structures are more effective in improving work performance and interpersonal outcomes for autistic persons (Haskins, 2019). As employers often lacked control over many aspects of organisational life when enacting their responsibilities as managers, their capacities for thinking and action, and their actual knowledge of autism, are all powerful shapers of their responses in managing autistic persons (Cockayne, 2019).

There has been a gradual inclination towards the need to understand autistic persons in a broader perspective, extending beyond diagnostic criteria into various aspects of functioning and environmental domains (Mahdi et al., 2018). Many factors in the work environment can serve to either inhibit or facilitate the inclusion of autistic persons (Waisman-Nitzan et al., 2019). Support from employers and co-workers are important contributors to a positive work environment (Khalifa et al., 2019). Unfortunately, the ICD (International Classification of Diseases) 10 (WHO, 2001) and DSM (Diagnostic and Statistical Manual of Mental Disorders) V (American Psychiatric Association, 2013) classification systems used for the diagnosis of autism do not take environmental factors into account. A holistic perspective which integrates personal, social, and environmental aspects is required, particularly as the significance of environmental factors is often emphasised by autistic persons and their caregivers. Ultimately, a personalised rather than diagnosis-based method of resource allocation and reimbursement will mark a paradigm shift in the diagnostic assessment of autism (Bölte et al., 2018).

The World Health Organisation (WHO) International Classification of Functioning, Disability and Health (ICF) Core Sets (WHO, 2001) has not only been identified as a useful tool to examine the employment literature but can also be used to highlight the important role that environmental factors such as employer knowledge and awareness can play as a challenge to, or enabler of, employment for autistic persons. This includes how demand-side factors and employer practices interact with personal factors (Burke et al., 2013; Scott et al., 2015; Scott et al., 2019). In a study which examined the satisfaction of 114 employers in a program to support job success in young autistic adults, a demand-side approach, which treated employers as valued clients, appeared to result in higher levels of employer satisfaction (Müller et al., 2018). The ICF is a meaningful framework in which the effects of the complex interaction between personal and environmental factors can be contextualised. Furthermore, it broadens thinking beyond “fixing” a disability to one that places equal merit on enhancing functional capacity and promoting participation in all areas of life (WHO, 2001). As the functional differences seen in autism are heterogeneous with respect to disability and ability or exceptionality, the ICF has added value as a framework that can capture a person’s functioning across all dimensions of life. Interventions which target contextual factors are critically needed to improve employment outcomes in autism (Bölte et al., 2018; Scott et al., 2019).

As the Information Technology (IT) industry is a sector that has employed relatively more autistic persons, a theoretical framework to study IT workplace readiness to equitably include autistic persons in the workplace is very relevant (Annabi & Locke, 2019). As organisational and environmental factors are a result of neurotypicals’ knowledge and attitudes, when they are knowledgeable about autism, autistic employees will experience fewer barriers (Annabi & Locke, 2019).

The focus of initial research has been on supports for the employee. Studies have since emerged exploring the needs of employers and both employers and employees simultaneously (Vogeley et al., 2013). Both groups are committed to employment processes, but their understanding of the required support, expectations and productivity requirements differ (Scott et al., 2015). Unfortunately, the data is less than encouraging. Autism has been rated as the second-highest disability after acquired brain injury to generate the least interest in employment amongst employers. There may be a general interest amongst employers to hire disabled persons, but this interest diminishes when it involves hiring for their own company (Andersson et al., 2015). Autism in the workplace is not on the radar for most companies (Westover et al., 2018). Nearly half of employers indicated that the nature of work at their business was too difficult (Riesen & Oertle, 2019). Employers lacked knowledge regarding autism (Waisman-Nitzan et al., 2019). Although they may be knowledgeable about autism characteristics, they lacked understanding of autism in an employment setting. They also overwhelmingly believed that business managers did not have a good understanding of autism (Adams, 2018). This lack of appropriate understanding from employers and co-workers is one of the biggest barriers to successful employment (Chen et al., 2015).

While employers showed positive general attitudes, they had reservations towards hiring workers with certain types of disabilities (Ju et al., 2013). Attitudes and actions do not necessarily go hand in hand and the role of social desirability makes the precise reasons for this unclear (Andersson et al., 2015). Even while generally positive attitudes are reported, hiring practices may still be discriminatory. What employers know about autism is inaccurate and frequently based upon guesswork (Cockayne, 2019). Managing autistic persons or knowing autistic persons outside work is for many managers their main source of knowledge about autism (Cockayne, 2019). The pivotal nature of the managers’ role is clear, with recurrent themes emerging that it is ignorance of socio-cultural forces and the invisible nature of the condition that frustrates managers (Cockayne, 2019). Addressing the misconceptions of autism and how stigma can be a contributing factor to the low labour participation rate can provide opportunities for recognition of how autistic persons can provide benefits to the organisation (Vaughan, 2019). Employers may perceive the problem to be the employees, thus blinding them to their own contributions to the problem (Patton, 2019). However, positive past experiences with disabled persons are associated with more willingness to hire and retain disabled employees (Ju et al., 2013). Previous experience is linked to greater interest in hiring and employers had greater interest in hiring than they thought other employers had (Andersson et al., 2015). Post-hiring attitudes further demonstrated a shift from pre-hiring attitudes, via experiential learning in hiring and managing autistic persons (Vaughan, 2019).

The influence of employer size on employee attitudes has also been studied. For example, a general pattern of openness to hiring disabled persons the larger the employer size is noted (Jasper & Waldhart, 2013). There was a general trend of greater concern among small to medium-sized employers (Scott et al., 2017). Smaller employers perceived challenges at significantly greater levels than larger employers (Scott et al., 2017). Employers of autistic adults from larger organisations, which received external support and had previous experience with disabled persons, were more likely to have favourable attitudes (Scott et al., 2017).

Attempts have been made to reassure employers that they would not incur additional costs when employing autistic persons over and above those associated with any new employee. Although this may be related to lower wages earned by those with autism and part-time working positions, this challenges pre-existing attitudes that hiring autistic adults results in increased costs and lower productivity (Scott et al., 2017). Openness about disability was the most important factor in hiring processes, followed by education and knowledge, extra resources, and guidance. Financial compensation was ranked as the least important (Andersson et al., 2015). Therefore, hiring autistic persons is potentially a good business decision. Additional benefits on workplace culture, diversity and inclusivity have also been identified (Scott et al., 2017). Employers reported high satisfaction rates in a range of key performance areas, and company benefits from participation of other staff, company image and customer relations (Beyer et al., 2016). The motivation to hire autistic persons includes a mixture of practical factors, social values and the fulfilment of a moralistic purpose. At the very least, employing autistic persons conveys an indirect societal benefit (Waisman-Nitzan et al., 2019).

A synthesis review of grey literature, which focused on services, supports and strategies that can foster employer capacity to support employment of adults with developmental disabilities, including autism, identified accommodation in the workplace as a vital factor, in addition to employment support, job coaching, education, awareness training and recruitment (Rashid et al., 2018). Employers reported a high willingness to make common accommodations for autistic employees (Adams, 2018). However, the process of requesting accommodations is not simple and requires disclosure by the employee. Furthermore, autistic persons may have different workplace accommodation needs than those with other types of disabilities, in particular support for social and communication skills (Lindsay et al., 2019). Employers are aware that they should make protective accommodations such as the provision of extra time and modifications to the physical working environment (Cockayne, 2019), supports of a non-physical nature (Pierce, 2018), and on-site training services through demand-side employment services (Stuckey, 2016). Accommodations are critical because they can help to enhance quality of life and work productivity (Lindsay et al., 2019). However, adjustments can also mark autistic persons as in need of special attention and treatment. The invisibility of autism is a major reason why accommodations are either not asked for, not offered, or provided imperfectly (Cockayne, 2019). Visibly disabled persons find it easier to maintain employment compared with invisibly disabled persons. Employers may be more uncertain or critical of invisibly disabled persons (Rashid et al., 2017b). There was a division of opinion between managers as to which autistic interns should be given special treatment, with a tendency to underestimate abilities and overestimate challenges pre- and post-internship (Remington & Pellicano, 2019). To allocate fair accommodations and promote distributive justice within the workplace, supervisors require knowledge and understanding of the employees’ strengths and needs related to their disability (Waisman-Nitzan et al., 2019). Arguably, accommodations should then apply to all employees, including those in management or supervisory ranks (Pierce, 2018).

Despite the recognition that autistic persons can excel in certain workplaces such as IT, these technology workers still experience isolation and workplace challenges. This may be due to a limited understanding of their talents and sub-optimal environmental accommodations (Annabi & Locke, 2019). Once again, despite the good intentions of many employers, there is a troublesome lack of understanding and a vantage point of disability for autistic persons, rather than the view that they are good workers who can bring important contributions to the workplace (Rashid et al., 2020). Moreover, many programs are still pan-disability or generic in their approach (Nicholas et al., 2018b). This means that more specific, personalised and autism-friendly employer programs need to be developed.

Studies that have highlighted changes in the social environment rather than seeking change in developmentally disabled persons, acceptance of diversity among employers and co-workers and the business sense of hiring developmentally disabled persons, previously identified as gaps in the literature, have now been published (Haskins, 2019; Jacob et al., 2015; Scott et al., 2017). More recently, organisational and personal factors facilitating successful employment of autistic adults were explored qualitatively using semi-structured interviews (Dreaver et al., 2019). Three themes were identified as key to supporting success, namely knowledge and understanding of autism, work environment and job match. Employer knowledge and understanding appeared to underpin the ability to facilitate employment. Knowledge of autism underpinned relationships between autistic employees and their co-workers and was a crucial factor in boosting their confidence. Autism education and awareness training was described as the most effective approach to developing positive relationships. The authors concluded that interventions and supports which targeted attitudes, and the workplace social environment, were essential for successful employment outcomes (Dreaver et al., 2019).

Education is vital in hiring autistic persons (Rashid et al., 2020). This includes instruction for colleagues and supervisors about the strengths and weaknesses of autism (Vogeley et al., 2013), education about autism for individuals in hiring positions (Stuckey, 2016), training staff to build a supportive workplace (Hedley et al., 2017), intensive training before the onboarding of autistic employees (Haskins, 2019), disability diversity training of both “soft” and “hard” workplace skills (Albright et al., 2020), holistically designed policies and a whole-of-government approach (Khayatzadeh-Mahani et al., 2020). When employers and employees have greater awareness of autism, they will be more welcoming, accommodating, and supportive of autistic persons (Johnson et al., 2020). However, there has been minimal emphasis on strategies for better communication amongst employers, co-workers, and employees. The lack of emphasis on communication skills and lack of focus on developing communication strategies is a significant gap in the literature (Rashid et al., 2018).

The results of a multi-informant international survey of autistic persons, their families, employers (n = 35), service providers, and researchers indicated that the key barriers to employment included stigma, a lack of understanding of autism and communication difficulties (Black et al., 2019). All stakeholders endorsed a holistic approach to employment aimed at fostering communication between key stakeholders, addressing attitudes, using strength-based approaches, and providing early work experience. These findings conflicted with previous research that identified the provision of employer training and implementation of environmental supports as important for success (Black et al., 2019).

3.1.3 Employer specific interventions

Interventions which directly target employers are notably very limited in number and quality despite the suggestion that interventions are needed to address both knowledge and understanding of autism in the workplace and the skills required to modify the work environment appropriately (Scott et al., 2018). In the first study to experimentally examine a controlled intervention that led directly to competitive employment, an employer-based nine-month intervention programme was developed and implemented for autistic high school youth to learn job skills and acquire employment. The intervention was notably intensive and involved 720 field hours of supported employment using a highly trained autism employment specialist. At three months post-graduation, 90%in the treatment group had acquired competitive part-time employment compared with 6%in the control group. The majority (87.1%) had maintained employment after 12 months, which suggested that autistic youth can gain and maintain competitive employment with the right supports in place (Wehman et al., 2017).

Using a mixed-methods convergent parallel design, employers who participated in a 12-week employment preparedness program for autistic youth and young adults reported pro-inclusion attitudinal shifts and intentions to hire autistic persons, based on relationship formation and knowledge gain. Unfortunately, continued reticence to employ was noted as an ongoing barrier (Nicholas et al., 2019). The use of innovative technologies to empower managers to increase accessibility within their organisations has recently been explored. VR (virtual reality) allowed managers to educate themselves about the sensory environment and its impact on autistic persons. VR solutions can also provide information on immediate practical strategies that require minimal implementation costs (O’Sullivan et al., 2018).

The first Randomised Controlled Trial of an autism-specific workplace intervention involved 84 employers throughout Australia who employed at least one adult with self-identified autism, high functioning autism and Asperger’s syndrome, who participated in a 12-week intervention (Scott et al., 2018). The autism specific workplace tool was known as the Integrated Employment Success Tool (IESTtrademark) and comprised an employer self-administered paper-based practical manual with eight modules. The purpose of the IESTtrademark was to increase awareness of autism in the workplace, promote the strengths of autistic employees, recognise potential workplace difficulties for autistic employees and provide employers with strategies for workplace modification and adaptation. The IESTtrademark was developed from an environmental rather than personal perspective (Scott et al., 2018). Outcome measures were administered at baseline and 12 weeks, using a 20-item Employer Self-Efficacy Scale (ESES) and the Scale of Attitudes Towards Workers with Disabilities (SATWD). Self-efficacy beliefs are the perceptions that individuals have regarding their skills and abilities (Bandura, 1982; Sheeran et al., 2016). A significant improvement in self-efficacy was reported in the treatment group but, disappointingly, there was no significant difference in self-efficacy in implementing autism-specific workplace modifications and employer attitudes towards disability in the workplace (Scott et al., 2018). A subsequent evaluation of these outcomes revealed the importance of improving current and prospective employer knowledge and understanding of autism, despite the impracticalities associated with the use of a paper-based manual (Scott et al., 2020). Further evaluation of the effectiveness of the IESTtrademark in larger groups of employers with little to no previous experience and an online web-based application of the IESTtrademark to the employer population was recommended (Scott et al., 2020).