A Review of Synthesis Studies Addressing Employment and Autism
H. Nelson & D.B. Nicholas
University of Calgary
Employment is an important part of adult life, but it has been reported that autistic adults have the lowest rates of employment across all populations with disabilities. Statistics on disability in Canada indicated that only 33% of the autistic adult population report being employed.1 Yet autistic individuals bring a wide and diverse range of strengths and skills that could be beneficial in the workplace. Some highlighted traits in the literature include attention to detail, a strong sense of morality, intellectual capacity, technological skills, trustworthiness, loyalty, kindness, proficiency in repeating tasks, high quality of work, artistic skills, creative talents, good memory, visual perception, prompt responses, low absenteeism, and a strong work ethic.2
In addition to addressing the economic risk of low employment rates of autistic individuals, increasing employment outcomes is also associated with increased cognitive functioning, social opportunities, positive peer relationships, and overall quality of life.3 Due to the growing awareness of the importance of employment opportunities and supports for autistic adults, this topic has been the subject of literature reviews that summarize existing research, which are also broadly known as synthesis or secondary reviews. To catalogue the recent trends in the literature and identify areas where more or updated research would be beneficial, the following review summarizes seventeen identified synthesis articles published on adult autism and employment within the last ten years. The purpose is to identify key learnings on employment supports and identify potential pathways forward. To provide a brief framework, the following will discuss the definition of employment, common challenges, employment supports, employment outcomes, intervention focuses, and then conclude with gaps and strengths of the literature.
Defining Employment Support
The concept of supported employment describes seven principles key to establishing equitable opportunities. Simply summarized, anyone with a desire to work, regardless of disability, should be able to choose and obtain work in comparably paid, competitive jobs that are integrated into one’s community rather than segregated employment. This requires system shifts, such as focusing on individual strengths rather than deficits, establishing necessary vocational supports, and removing any systemic barriers to employment for autistic individuals.4
The literature identifies common factors contributing to challenges in reaching successful employment for autistic individuals at individual and societal levels. Social difficulties (e.g., interpreting verbal and non-verbal communication, social cues, and understanding unspoken norms), varying presentations of reactive and phenotype behaviours (e.g., inflexible routines, task management, hyperactivity, ritualistic activities, etc.), co-occurring conditions, education levels, and family socioeconomic status were identified as common barriers acting on an individual level. However, it is recognized these become or are intensified as barriers due to impact of societal barriers, such as employer attitudes, inequitable access to adequate vocational services and supports, and impact of disability policies.5
Employment supports for autistic adults commonly fall into three general intervention areas, which each primarily focus on different stages in the process of acquiring and retaining employment. The common intervention types are skill development, workplace accommodations, and integrated supported employment programs. As applications of technology are developed and become more common, technological tools are increasingly being integrated into employment supports.
Fostering individual skill development to obtain employment, execute tasks, and retain employment6 is a common strategy to facilitate positive employment outcomes. Many review articles focus on identifying skill-based intervention strategies and evaluating their effectiveness.6,7 Studies have noted that most interventions have focused on skill development for job-specific tasks, with only a few studies focusing on skills to obtain and retain employment, or pre-employment and post-employment skills.6,8
In 2016, Anderson and colleagues noted that effective employment “interventions should lead to lasting and generalized behaviour changes and target behaviours that are truly adaptive and useful in the workplace” (p.35).7 In that early review, where articles evaluating behaviour skills training, video-based interventions, and self-management oriented interventions were identified, it was noted that only behaviour skills development has established a high enough effectiveness consistency across studies to be considered an evidence-based practice. This evaluation highlighted the need for ongoing research establishing the effectiveness of other strategies to meet the needs of autistic employees. Later review articles add to the dialogue. A recent and prevalent trend in the literature for skill development is the integration of technology-based interventions.
Synthesis-type reviews were published in 2017 and 2022. Despite a few small differences in an otherwise similar inclusion criteria, the number of articles included in each article, eighteen articles in 20173 versus forty-eight articles in 20228, speaks to an increased focus on technology-based interventions. The latest review notes a wide range of technology applications (e.g., phone/tablet, video, virtual reality, radio and headset, computer, robot, and use of multiple devices) being used for the development of job-specific skills, interview skills and general, transferable skills, such as time management or social skills. Strategies being applied include video modelling, video prompting, mock interviews, and cueing and feedback separately and in some combination.8 It should be noted that only seventeen of the included studies take place within a current or potential workplace, with the remainder being used as a pre-employment strategy in school, a transition setting or a research setting.
The use and success of technological interventions vary in application based on intended outcome, but generally have been found to be effective. Technological applications are still developing their foundation as an evidence-based practice, and were assessed in 2017 as having probable effectiveness as a strategy.3,7 The evidence base for technological interventions is likely to continue to grow due to the many noted benefits including cost-effectiveness, repeatability and, with the ongoing integration of technology into the workplace, supports can be discrete to avoid singling out and/or isolating autistic employees.3,6
Employment is valued by autistic individuals9, and not surprisingly, many synthesis reviews have spoken to the importance of workplace accommodations to foster that desire for employment success.9,10 One review highlighted four key concepts present in the literature where focused change can facilitate the creation of conditions for success rather than perpetuating barriers.9
Successful implementation of technological tools, as described above, such as personal digital assistants, covert audio coaching, and video modelling, in workplace environments have been found to improve workplace outcomes by facilitating employee capacity and confidence. Technology is noted as being an adaptive tool for individuals that is easy to use and reduces the need for more intensive one-to-one support in the workplace.9
Interventions focused on altering the physical environment by modifying light and sound sensory inputs to make workspaces easier to navigate and more productive are present in the literature but are less common than other strategies. More common are environmental interventions focused on employers adapting work procedures to include visual formats, cues, or other organizational methods to facilitate task management or by granting exceptions, such as flexible hours or reduced customer interaction. It is noteworthy that an employers’ perspective reported that these types of modifications do not require much effort to implement.9
Interpersonal relationships within the workplace are highlighted as being important to support individuals, which is reflected by its prominence in the literature. Employers, often working in partnership with external job coaches or specialists, have the capacity to tailor workplace training and supervision style to optimize communication on areas such as workplace culture, expectations, task assignment and follow up. Employer and co-worker flexibility and tolerance, in addition to working with employee strengths, are also identified to facilitate respectful and positive workplaces.9
Facilitating the relationships that foster a positive working environment for autistic adults require support for employers, including both supervisors and co-workers, to support positive attitudes and autism awareness. The literature is currently limited on developed and tested strategies to successfully shift workplace attitudes10, but some employer perspectives indicate a need for external support to understand and navigate aligning work environments with autistic employee needs.9
Integrated Supported Employment
Recognizing the holistic and interconnected components of employment, many reviews have noted the benefit of integrated supports for many autistic adults.9-12 Integrated supported employment refers to direct support integrated across the employment process on an ongoing basis and is usually delivered through developed program models. While the specifics and delivery models differ between each of these programs,12 a general overview identifies some key concepts.
In integrated supported employment, job coaches or employment specialists provide a range of services. In addition to skill development and supporting the application process, they can also assess workplace environment, compatibility, and, when necessary, can provide follow-up support through check-ins, additional training or acting as an advocate with the employer.9,11 In addition to workplace specifics, an integrated supported employment approach tends to take a holistic strategy to also support the development of skills such as “housing, transportation and financial management (p. 1327).”9 A recent study (2020) identified eight articles reviewing existing integrated supported employment programs and addressed the need for long-term and integrated success.9 One study indicated that while integrated supported employment programmes are more expensive in upfront costs, their effectiveness in increased employment and quality of life makes it an overall cost-effective strategy.10
Increasingly prominent in the literature are articles seeking to link intervention impacts with employment outcomes. Employment outcomes are measured inconsistently across articles; indicators range from most commonly noting details on employment contracts to least commonly evaluating impact on quality of life. In response to the wide variety of measurements used in studies, a recent review categorized the literature into three broad outcome areas of changes in employment status, vocational skills, and executive functioning skills.2 While interventions indicate improvement due to the intervention, the literature also points to the need for further research due to “continuing high rates of unemployment of participants following these interventions” (p. 893).2
Changing the Dialogue
A key contributor to continuing rates of high unemployment among autistic adults, despite intervention success, is that most employment interventions are individually focused, which requires the individual to adapt to existing systems. There has been a consistent call across reviews for a shift to a more systemic, or community, focus.4,13,14
There are substantial societal, familial, and individual financial costs10,15 associated with persistent under-employment for autistic individuals. This is viewed to result from a lack of employment opportunities for autistic individuals, further reflecting a lack of equitable accommodations.11 The thread connecting environment, relationships and attitudes is a need to shift societal attitudes that support equitable employment opportunities for autistic adults. To that end, a persisting gap and area for growth includes interventions designed to facilitate that shift.
Generally, there is a need to continue and deepen high-quality research to strengthen available evidence-based practice.16,17 There are a few key areas identified for further research. Research is needed on employer needs and supports, as well as the role of peer relationships.11 The current research has not sufficiently addressed the impact of other co-existing barriers such as race, gender, age, education levels and co-occurring conditions, and their potential link to employment outcomes.10 Similarly, the research and interventions supporting employment for autistic individuals remain predominately focused on those who do not also have cognition challenges.3,11 Accounting for individuals across the autistic spectrum needs to be prioritized, and there is needs to flexibly address needs over time and life changes.4,11 Finally, assessment of interventions should be expanded to include more quality of life measurements, and investigate the impact on personal identity development.11
As the literature on supporting employment for autistic individuals continues to grow, one article highlighted a key concept that we believe is incredibly important. Following their review of the literature, Scott and colleagues hosted focus groups with autistic adults to assess whether the results aligned with their experiences.2 Continuing to integrally include autistic voices and perspectives into this dialogue is important.18 This priority is important in ensuring future research aligns with, and is driven by, the needs of autistic people.
- Statistics Canada (2017). Canadian survey on disability. https://www23.statcan.gc.ca/imdb/p3Instr.pl?Function=assembleInstr&lang=en&Item_Id=348023
- Scott, M., Milbourn, B., , M., Black, M., , S., Halladay, A., Lerner, M., Taylor, J. L., & Girdler, S. (2019). Factors impacting employment for people with autism spectrum disorder: A scoping review. Autism: The International Journal of Research and Practice, 23(4), 869–901. https://doi.org/10.1177/1362361318787789
- Walsh, E., Holloway, J., McCoy, A., & Lydon, H. (2016). Technology-aided interventions for employment skills in adults with autism spectrum disorder: A systematic review. Review Journal of Autism and Developmental Disorders, 4(1), 12–25. https://doi.org/10.1007/s40489-016-0093-x
- Schall, C., Wehman, P., , L., & Taylor, J. P. (2020). Competitive integrated employment for youth and adults with autism: Findings from a scoping review. Child and Adolescent Psychiatric Clinics of North America, 29(2), 373–397. https://doi.org/10.1016/j.chc.2019.12.001
- Chen, J. L., Leader, G., Sung, C., & Leahy, M. (2014). Trends in employment for individuals with autism spectrum disorder: A review of the research literature. Review Journal of Autism and Developmental Disorders, 2(2), 115–127. https://doi.org/10.1007/s40489-014-0041-6
- Seaman, R.L., & Cannella-Malone, H. I. (2016). Vocational skills interventions for adults with autism spectrum disorder: A review of the literature. Journal of Developmental and Physical Disabilities, 28(3), 479–494. https://doi.org/10.1007/s10882-016-9479-z
- Anderson, A., Moore, D. W., Rausa, V. C., Finkelstein, S., Pearl, S., & Stevenson, M. (2016). A systematic review of interventions for adults with autism spectrum disorder to promote employment. Review Journal of Autism and Developmental Disorders, 4(1), 26–38. https://doi.org/10.1007/s40489-016-0094-9
- Kim, S.Y., Crowley, S., & Lee, Y. (2022). A scoping review of technology-based vocational interventions for individuals with autism. Career Development and Transition for Exceptional Individuals, 45(1), 44–56. https://doi.org/10.1177/21651434211041608
- Khalifa, G., Sharif, Z., Sultan, M., & Di , B. (2020). Workplace accommodations for adults with autism spectrum disorder: A scoping review. Disability and Rehabilitation, 42(9), 1316–1331. https://doi.org/10.1080/09638288.2018.1527952
- Hedley, D., , M., Cameron, L., Halder, S., Richdale, A., & Dissanayake, C. (2017). Employment programmes and interventions targeting adults with autism spectrum disorder: A systematic review of the literature. Autism, 21(8), 929–941. https://doi.org/10.1177/1362361316661855
- Nicholas, D.B., Attridge, M., Zwaigenbaum, L., & Clarke, M. (2015). Vocational support approaches in autism spectrum disorder: A synthesis review of the literature. Autism: The International Journal of Research and Practice, 19(2), 235–245. https://doi.org/10.1177/1362361313516548
- Baker-, M.J., ElShamy, R., & Kammes, R. R. (2022). Current status of evidence-based practices to enhance employment outcomes for transition age youth and adults on the autism spectrum. Current Psychiatry Reports, 24(3), 161–170. https://doi.org/10.1007/s11920-022-01327-2
- Westbrook, J.D., Nye, C., Fong, C. J., Wan, J. T., Cortopassi, T., & Martin, F. H. (2012). Adult employment assistance services for persons with autism spectrum disorders: Effects on employment outcomes. Campbell Systematic Review, 8(1), 1–68. https://doi.org/10.4073/csr.2012.5
- Shattuck, P.T., Garfield, T., Roux, A. M., Rast, J. E., Anderson, K., , E. M., & Kuo, A. (2020). Services for adults with autism spectrum disorder: A systems perspective. Current Psychiatry Reports, 22(3), 13–13. https://doi.org/10.1007/s11920-020-1136-7
- Jacob, D., Scott, M., , M., & , T. (2015). The costs and benefits of employing an adult with autism spectrum disorder: A systematic review. One, 10(10), e0139896–e0139896. https://doi.org/10.1371/journal.pone.0139896
- Fong, T. J., , A., McClelland, A. M., Murphy, K. M., & Westbrook, J. D. (2021). Interventions for improving employment outcomes for persons with autism spectrum disorders: A systematic review update. Campbell Systematic Review, 17(3). https://doi.org/10.1002/cl2.1185
- Weld-Blundell, I., Shields, M., Devine, A., Dickinson, H., Kavanagh, A., & Marck, C. (2021). Vocational interventions to improve employment participation of people with psychosocial disability, autism and/or intellectual disability: A systematic review. International Journal of Environmental Research and Public Health, 18(22), 12083–. https://doi.org/10.3390/ijerph182212083
- Taylor, L. J., Mcpheeters, M. L., Sathe, N. A., Dove, D., Veenstra-, J., & Warren, Z. (2012). A Systematic review of vocational interventions for young adults with autism spectrum disorders. Pediatrics (Evanston), 130(3), 531–538. https://doi.org/10.1542/peds.2012-0682