Adult Employment Assistance Services for Persons with Autism Spectrum Disorders: Effects on Employment Outcomes

Adults with Autism Spectrum Disorders (ASD) may face challenges in employment settings due to difficulties in social functioning. Bespoke employment interventions aim to make it easier for adults with ASD to secure and maintain jobs. This Campbell systematic review finds that there is not yet enough high quality research to draw a conclusion on their effectiveness. This review focused on employment interventions for adults 18 years or older with a diagnosis of ASD, and who were no longer enrolled in a school‐to‐work or secondary‐level education programs. The review considered interventions that centered on competitive, supported or integrated employment but did not include those where the treatment groups were not in an integrated or mainstream format of employment. The review focused on one outcome, attainment of a job placement, based on specific information about the duration and/or retention of that placement. One of the two included studies looked at a program where support workers gave guidance on job searching, work preparation and employer communication. The second study looked at supported employment involving jobs located in the local community and guidance from job coaches. Executive summary/Abstract BACKGROUND The incidence of Autism Spectrum Disorders (ASD) has been increasing over the last two decades. Currently, 1 in 110 children are identified with ASD in the United States (CDC, 2009). ASD refers to a range of neurological disorders that involve some degree of difficulty with communication and interpersonal relationships. The range of the spectrum for autism disorders is wide with those at the higher functioning end often able to lead relatively independent lives and complete academic programs even while demonstrating social awkwardness. Those at the lower functioning end of the autism spectrum often demonstrate physical limitations, may lack speech, and have the inability to relate socially with others. As persons with ASD age, options such as employment become increasingly important as a consideration for long‐term personal planning and quality of life. While many challenges exist for persons with ASD in obtaining and maintaining employment, some research is showing that, with effective behavioral and social interventions, employment can occur (Schaller & Yang, 2005). In fact, about 37% of individuals with ASD report having been employed for 12 months or more, four years after exiting high school (Newman, Wagner, Cameto, & Knokey, 2009). However, several studies show that individuals with ASD are more likely to lose their employment for behavioral and social interaction problems rather than their inability to perform assigned work tasks (Dew & Alan, 2007; Hurlbutt & Chalmers, 2004; Unger, 1999). Research has been conducted in the area of autism and employment, but such research has not been reported in a comprehensive evidence review format before. Thus, a systematic review on the effectiveness of adult employment assistance interventions for individuals with ASD would not only demonstrate the extent and magnitude of the interventions' effects, but also provide ideas for further research that can inform implementation and refinement of related employment‐focused programs. OBJECTIVE The objective of this review is to determine the effectiveness of adult employment interventions in securing and maintaining employment for adults with ASD. SEARCH STRATEGY The comprehensive search strategy used to identify relevant studies included the review of 28 relevant electronic databases. Search terminology for each of the electronic databases was developed from available database thesauri. Appropriate synonyms were used to maximize the database search output. Several international databases were included among the 28 databases searched. In addition, the authors identified and reviewed grey literature through analysis of reference lists of relevant studies. Unpublished dissertations and theses were also identified through database searches. The programs of conferences held by associations and organizations relevant to ASD and employment were also searched. SELECTION CRITERIA A two‐stage process was used to determine inclusion or exclusion of studies: (1) two reviewers independently reviewed the title and abstract of each identified study, and (2) for studies advanced from the first stage, two independent reviewers reviewed the full text of each study for final determination of inclusion or exclusion. Inclusion criteria allowed the following research designs: randomized controlled, quasi‐experimental, and single subject experimental designs. DATA COLLECTION AND ANALYSIS The electronic searches of databases yielded 8,528 citations for the first stage of review. Of these, a total of 77 citations were selected for second stage full‐text review of each study. Upon review of the full‐text for each of the 77 studies, two studies were retained, having met the inclusion criteria. Of the two included studies, both were quasi‐experimental research designs. The studies generally described the effects of a supported employment intervention for adults with ASD on either employment outcomes or aspects of cognitive functioning. The nature of the data provided did not lend itself to a traditional meta‐analysis. Given the number of studies, study designs, and the diversity of outcomes across the two studies, it was not possible to aggregate results across studies. RESULTS This review was not able to identify definitive interventions that predictably and positively supported the development of employment outcomes for individuals with ASD. There were two included studies. One, Mawhood and Howlin (1999), described outcomes directly related to employment by comparing an experimental group (n = 30) who received guidance from a support worker in the form of job finding, work preparation, and communication with the employers with a control group (n = 20) that did not receive any support. At the end of the two‐year study period, the authors found that the experimental group demonstrated significantly higher rates of having found paid employment (d = 1.067, 95% CI = 0.123 to 2.010), significantly longer periods of working time (d = 0.684, 95% CI = 0.111 to 1.257), and significantly higher wages (d = 1.177, 95% CI = 0.169 to 0.819). The experimental group also worked more hours per work week (d = 0.328, 95% CI = ‐0.628 to 1.284), but this effect was not significant. The second included study, Garcia‐Villamisar, Ross, and Wehman (2000), described differential effects of supported employment and sheltered employment for persons with autism. The experimental group received supported employment, i.e., jobs working between 15 and 30 hours per week in their communities and received job coach support services. The control group received sheltered employment, i.e., jobs that were not in their communities and with no job coaching services. Using measures of the Childhood Autism Rating Scale (CARS), the supported employment group was not significantly different from the sheltered employment group after treatment (d = ‐0.229, 95% CI = ‐0.764 to 0.306). The study did not report any differences in employment acquisition or maintenance between the two groups. In an analysis of risk bias of the included studies, it was found that there was a high level of substantial potential for bias across three of the five sources of bias analyzed including unit of assignment, unit of analysis, attrition, fidelity of implementation, and blinding. The methodological quality of both included studies was low. Therefore, these review results should not be interpreted as indicating definitive results related to the development of employment outcomes for persons with ASD. AUTHORS' CONCLUSIONS Qualitative and other relevant research studies connected to the employment of persons with ASD were also reviewed and suggest that the following may be elements of successful employment placement for persons with ASD: (1) identification of the most appropriate work settings and placements, (2) provision of effective supports on the job, (3) need for long‐term support services for the employer and the consumer, (4) costs for support, and (5) positive effects of employment on persons with ASD. While qualitative studies point to a number of promising issues for future research, they do not provide a definitive statement about what works. In addition, the authors noted that costs for community‐based employment interventions such as those included in this review are more expensive than other employment alternatives such as sheltered non‐integrated workshops. However, Howlin, Alcock & Burkin (2005) and others (e.g., Cimera & Cowan, 2009) show that supported employment service interventions, such as those identified in our included studies, are becoming less expensive to deliver. It seems important to note that community‐based integrated employment interventions, while expensive, do expand options for mainstream social integration, competitive wages, and community involvement.