Annals of International Occupational Therapy

Review Open Access

Barriers and Facilitators to Employment for Adults With Autism: A Scoping Review

Erin Harmuth, BA, MOT; Emerald Silletta, BA, MOT; Anthony Bailey, BSc, MBBS, DCH, MRCPsych, FRCPC; Tracy Adams, BHK, MScOT; Charlotte Beck, MLS; Skye Pamela Barbic, BSc, BScOT, MSc, PhD

  • Annals of International Occupational Therapy. 2018;1(1):31-40
  • https://doi.org/10.3928/24761222-20180212-01
  • Posted April 9, 2018

Abstract

Background:

Employment is a significant factor contributing to identity and quality of life for adults with autism spectrum disorder (ASD). Currently, relatively little is known about the most efficient and effective ways to support adults with ASD to obtain and maintain employment. This scoping review was performed to: (a) summarize the barriers and facilitators to employment for adults with ASD; (b) synthesize key findings; and (c) highlight the gaps and limitations in the current body of literature.

Methods:

We searched seven databases: ABI/INFORM (ProQuest), the Cochrane Database of Systematic Reviews (Ovid), the Cumulative Index to Nursing and Allied Health Literature–CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), PsycINFO (EBSCO), and PubMed (searched 08/22/16 to 08/25/17).

Results:

The final review of 161 articles highlighted the complex personal, environmental, and work-specific needs of adults with ASD, including individual or personal factors, such as general level of functioning and possession of job-specific skills; environmental or context-specific facilitators, such as level of social support and customized job accommodations; and aspects of the work that facilitate employment for this population, such as comprehensive job training and on-site coaching.

Conclusion:

Our review suggests that focusing attention on customized, long-term supports and accommodations within encouraging and informed communities and workplaces contributes to successful employment for individuals with ASD. This scoping review of the literature indicates that there is a need for a coordinated and systematic approach to employment support and training for adults with ASD. [Annals of International Occupational Therapy. 2018;1(1):31–40.]

Abstract

Background:

Employment is a significant factor contributing to identity and quality of life for adults with autism spectrum disorder (ASD). Currently, relatively little is known about the most efficient and effective ways to support adults with ASD to obtain and maintain employment. This scoping review was performed to: (a) summarize the barriers and facilitators to employment for adults with ASD; (b) synthesize key findings; and (c) highlight the gaps and limitations in the current body of literature.

Methods:

We searched seven databases: ABI/INFORM (ProQuest), the Cochrane Database of Systematic Reviews (Ovid), the Cumulative Index to Nursing and Allied Health Literature–CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), PsycINFO (EBSCO), and PubMed (searched 08/22/16 to 08/25/17).

Results:

The final review of 161 articles highlighted the complex personal, environmental, and work-specific needs of adults with ASD, including individual or personal factors, such as general level of functioning and possession of job-specific skills; environmental or context-specific facilitators, such as level of social support and customized job accommodations; and aspects of the work that facilitate employment for this population, such as comprehensive job training and on-site coaching.

Conclusion:

Our review suggests that focusing attention on customized, long-term supports and accommodations within encouraging and informed communities and workplaces contributes to successful employment for individuals with ASD. This scoping review of the literature indicates that there is a need for a coordinated and systematic approach to employment support and training for adults with ASD. [Annals of International Occupational Therapy. 2018;1(1):31–40.]

Employment is a significant factor contributing to identity and quality of life (Blank & Hayward, 2009; J. Scott et al., 2013; Walsh & Tickle, 2013). Although many adults with autism spectrum disorder (ASD) wish to work (Hendricks, 2010), numerous studies have shown poor employment outcomes for this group (Bennett & Dukes, 2013; M. Scott, Falkmer, Girdler, & Falkmer, 2015; Taylor, Henninger, & Mailick, 2015; Taylor & Seltzer, 2011). For example, the unemployment rate for adults in developed countries is 4.4% to 6.5% (Australian Bureau of Statistics, 2017; Statistics Canada, 2017; U.S. Department of Labor, 2017), yet for adults with ASD, this rate is estimated to be 66% (M. Scott, Falkmer, Girdler, & Falkmer, 2015). Unemployment for those with ASD has significant individual and societal costs, with estimates from the United Kingdom and the United States suggesting costs ranging from $1.4 to $2.4 million U.S. dollars during an average life span (Buescher, Cidav, Knapp, & Mandell, 2014). There is very little research on the return on investment for supporting adults with ASD to work. With increased evidence of the personal and economic challenges associated with unemployment for adults with ASD (Barnhill, 2007; Hedley et al., 2016; Holwerda, van der Klink, de Boer, Groothoff, & Brouwer, 2013), it is important to understand how these adults can be supported to participate fully in meaningful activities, including work.

Autism spectrum disorder is defined as “persistent deficits in social communication and social interaction across multiple contexts” (American Psychiatric Association, 2013). It is a complex neurodevelopmental disorder that usually arises because of a complex genetic predisposition (French, Bertone, Hyde, & Fombonne, 2013). The detected prevalence has increased significantly during the past 20 years (French et al., 2013), and for children in developed countries, the rate varies between 0.8 and 23.6 in 1,000 individuals (Christensen et al., 2016; Taylor et al., 2015). Consequently, large numbers of affected teenagers are now approaching working age, which is especially significant because individuals with ASD experience symptoms that often can be perceived as barriers to employment, including persistent deficits in social communication and interactions; restricted, repetitive patterns of behaviors (Chen, Sung, & Pi, 2015); varying degrees of adaptive functioning; and co-occurring mental health and medical concerns (Roux et al., 2013).

Currently, relatively little is known about the most efficient and effective ways to support adults with ASD to obtain and maintain employment (Johnson & Joshi, 2016). The literature suggests that the low employment rates seen globally are potentially related to individual and environmental factors. At the individual level, poor social communication and interpersonal skills are commonly reported as challenges to gaining and maintaining employment (Brownlow, 2010; Gal, Landes, & Katz, 2015). At the environmental level, some have posited that the real barriers to employment for this group lie not in the socially atypical mannerisms of ASD but instead in society's labeling of the idiosyncrasies associated with ASD as “deficits” instead of positive attributes in the workplace (Lorenz, Frischling, Cuadros, & Heinitz, 2016). Much of the current research indicates significant gaps in understanding the daily challenges that prevent those with ASD from maintaining meaningful employment. Occupational therapists may play a key role in optimizing the delivery of services to optimize employment outcomes for this population. Consequently, to optimize the health and wellness of adults with ASD through engagement in employment, we conducted a scoping review of the literature to summarize the current state of evidence and the prevailing narratives.

Methods

Study Design

Given that knowledge about this topic is relatively recent, a scoping review was conducted in place of a systematic review. A scoping review is a rigorous and systematic method of determining the type of research that has been published in a particular field of interest. This method has been used frequently across health fields to create a structural foundation for an emerging topic (Arksey & O'Malley, 2005). A scoping review also allows investigators to map the current research without becoming overwhelmed by the depth and specifics of each study, as can occur with a systematic review (Arksey & O'Malley, 2005). For this review, we used the methods outlined by Arksey and O'Malley (2005), including determining the research question, identifying relevant studies, performing study selection, appraising the quality and extracting the data, and collating and summarizing the results in a report.

Arksey and O'Malley (2005) indicated that the review process should be iterative and reflexive; the research team adapted their methods as needed to develop a feasible approach to reviewing the existing literature. The purpose of this scoping review was to: (a) identify the current breadth of research on employment and ASD; (b) synthesize the key findings; (c) highlight gaps and limitations in the extant literature; and (d) propose recommendations for further study. Our research team posed the following research question: What is known in the existing literature about the barriers and facilitators to employment for adults with ASD?

A comprehensive search of the following electronic databases was conducted: ABI/INFORM (ProQuest), the Cochrane Database of Systematic Reviews (Ovid), the Cumulative Index to Nursing and Allied Health Literature–CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), PsycINFO (EBSCO), and PubMed. Significant terms derived from the research question were selected and expanded to create a comprehensive list of primary search terms and variants, including “autism spectrum disorder,” “autism,” “Asperger syndrome,” “Rett syndrome,” “pervasive developmental disorder not otherwise specified (PDD-NOS),” and “child pervasive developmental disorder,” as well as a combination of the following work-related terms: “employment,” “employment, supported,” “unemployment,” “workplace,” and “occupation.” Combinations of these terms were then tested across each of the selected databases in an iterative manner to allow for the identification of new combinations of terms or other related citations. Medical Subject Heading (MeSH) terms, MeSH tree, and related terms found in key words and article references were also searched, and truncation was used for maximum recall when applicable. All searches included at least one identifier for ASD (e.g., autism, Asperger) linked to at least one identifier for employment. The search was performed in August 2016 and yielded 2,083 articles. After duplicates were removed, two of the authors (E.H. and E.S.) individually reviewed the titles of each study to determine eligibility based on the predetermined inclusion and exclusion criteria. On completion of this initial review, the two lists were reconciled and then combined for further assessment based on study abstracts; finally, a full-text review was completed by two of the authors (E.H. and E.S.). Throughout this review period, the research team received RSS notifications from the aforementioned databases as new articles became available, until June 30, 2017. These articles were similarly reviewed for inclusion criteria and suitability within the research topic.

The following inclusion criteria were used to guide and further narrow the search: (a) published in English; (b) published between January 1, 2000, and June 30, 2017; (c) included human subjects, 18 years and older; (d) included research subjects with a diagnosis of ASD or a variant from previous versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM); and (e) referenced literature from peer-reviewed journals, edited books, or grey literature. Exclusion criteria were identified as follows: (a) journal articles outside of those defined in the inclusion list (e.g., opinion articles, commentaries, book reviews); (b) undergraduate dissertations; and (c) policy analyses.

Because our study range spanned across years and included the use of different editions of the DSM to diagnose ASD, our search did not separate study participants based on level of function or specific diagnosis (i.e., autism vs. Asperger syndrome). For the purposes of this study, we grouped each of these disorders under the umbrella of ASD in the same fashion as the current edition of the DSM, the DSM-V.

Charting the Data

Through careful and repeated review of the literature, we identified the key themes and issues discussed in the relevant studies—such as the process of ASD intervention or the content of the support program—to provide context and generalizability for readers. This information was recorded in a data extraction framework, along with key pieces of information on each study (e.g., author, publication year, location, type and duration of intervention, study population, outcome measures, and important results), where available. The information was synthesized and interpreted to map the scope and breadth of existing research.

Results

Our search strategy returned 2,083 citations for initial screening, and after duplicates were removed, 1,315 unique citations remained. Of these, 1,035 citations were excluded because their titles or abstracts did not address both employment and adults with ASD, which left 280 citations. Finally, the full text of the remaining articles was read and assessed for eligibility. The final number of eligible citations that met the inclusion criteria and were included in this review was 161. The Figure provides a summary of the search and retrieval process. The included studies were published between 2000 and 2017 in a variety of predominantly English-speaking countries, including the United States, England, Australia, and Canada.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. RCT = randomized controlled trial.

Figure:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. RCT = randomized controlled trial.

Study type and quality of level of evidence varied greatly within the included literature (Table 1). The highest level of evidence included studies classified as systematic reviews, meta-analyses, and randomized controlled trials (n = 28). The second highest level of evidence included studies that were classified as nonrandomized but used two groups, such as cohort and case–control studies (n = 26). Most of the included literature, however, had lower levels of evidence, including nonrandomized, one-group studies (n = 35) and descriptive studies that included an analysis of outcomes (n = 72). Many of these articles were background studies (n = 36) that gave either broad overviews of ASD symptoms or specific accounts of adults' lived experiences navigating employment with this diagnosis.

Levels of Evidence of Studies Reviewed (n = 161)

Table 1:

Levels of Evidence of Studies Reviewed (n = 161)

Likewise, the use of outcome measures varied greatly. Of the 161 reviewed studies, 31 specified the use of a tool to measure outcomes in a standardized way and 13 used more informal self-, parent-, or employer-reported tools to measure outcomes and levels of satisfaction.

Conceptualization of Employment

Employment was described with a variety of parameters, ranging from type of work and tasks performed, to hours and compensation, to level of integration between employees; fewer than half of the studies specifically described the work performed (n = 70). Most commonly, the type of work was briefly discussed based primarily on title (n = 47), including examples such as clerical work (e.g., Baldwin, Costley, & Warren, 2014), employment as a grocery clerk (e.g., Briel & Getzel, 2014), and retail work (e.g., Lynas, 2014). Less frequently, compensation was specifically described (n = 19); more commonly, it was noted that employees with ASD received lower compensation than neurotypical employees (e.g., Seaman & Cannella-Malone, 2016). Number of hours worked was outlined most often in terms of full-time, part-time, and casual work (n = 20). Chiefly, the articles noted that, again, relative to neurotypical employees, adults with ASD tended to work fewer hours and rarely achieved full-time employment (e.g., Henry, 2013). Few articles described work in the context of sheltered employment (i.e., a factory-like environment with mundane tasks employing only those with developmental disabilities) versus supported, integrated, or competitive employment. Three articles described maintenance of employment after a particular intervention or program (e.g., Cimera & Burgess, 2011).

Facilitators to Employment

Aside from depicting the type of work that adults with ASD are and are not participating in, much of the literature described the internal and external factors that facilitate employment for this population. The review showed that this is a complex topic, with a wide variety of influences on the success of employment, including individual or personal facilitators, environmental or context-specific facilitators, and aspects of the work that facilitate employment for this population.

Individual or person-related facilitators. The reviewed literature reflected the diversity of person-related facilitators to employment, but focused primarily on the level of functioning of adults with ASD: being “high-functioning,” with lower levels of ASD-specific behaviors (n = 20), was a frequently cited facilitator (e.g., Rebholz, 2012). Related to functioning, possessing insight into one's strengths and weaknesses was also considered an important facilitator (n = 11) in adults who tended to be successful in finding and maintaining employment (e.g., Whetzel, 2014). More practically, possessing skills related to a specific job (e.g., Gal, Ben Meir, & Katz, 2013), whether through interest or through previous experience, was also described as a facilitator (n = 14). Few studies examined gender as a factor contributing to employment. Those that examined gender noted that being male may be perceived as a facilitator to employment (e.g. Migliore, Timmons, Butterworth, & Lugas, 2012). However, the authors of these studies noted that these results may be inconclusive because few female study participants were included.

Environmental or context-specific facilitators. The literature highlighted various physical, social, and cultural environments as major facilitators to employment for adults with ASD. The social environment, particularly the network of supportive and understanding people surrounding the adult with ASD, including coworkers (e.g., Hudson, 2004), specific support staff (e.g., Friedman, Warfield, & Parish, 2013), family (e.g., Cimera, Wehman, West, & Burgess, 2012), and friends (e.g., Brownlow, 2010), was highlighted as a strong facilitator to employment (n = 77). The literature also showed that diversity training specific to ASD increases the understanding and support of coworkers and supervisors of adults who have ASD (n = 22) (e.g., Lynas, 2014; Wehman et al., 2016). Specific to the physical work environment, access and provision of individualized accommodations was frequently reported (n = 66) as a major contributing factor to employment success (e.g., Feldman-Sparber, 2015). Customized work-place accommodations are most commonly facilitated by professionals working alongside the adult with ASD, both through the initial weeks of work and during the course of the job, to help in the maintenance of employment (e.g., McDonough & Revell, 2010; Westbrook et al., 2012). Provision of long- and short-term workplace supports was the most frequently referenced (n = 96) environmental facilitator to employment for adults with ASD. Workplace supports also included access to an on-site job coach (e.g., for monitoring of quality of task performance), supports for workplace participation (e.g., transportation to the work site), and assistance in the setup of workplace accommodations (e.g., McNaughton & Richardson, 2013).

Work-related facilitators. Related to the work and job tasks themselves, the literature highlighted a need for comprehensive, multiple-area training to best facilitate employment for this population (n = 61). The review suggested that training should include skill development in the areas of behavior and emotion management (e.g., Bennett & Dukes, 2013), communication and social interactions (e.g., Bonete, Calero, & Fernandez-Parra, 2015; Dipeolu, Storlie, & Johnson, 2015), self-advocacy (e.g., Chappel & Somers, 2010), and soft job skills (e.g., Seaman & Cannella-Malone, 2016). Job site training related to specialized work tasks was included within this area (e.g., Lattimore, Parsons, & Reid, 2006). Moreover, support and coaching for the job search process itself (e.g., Hillier et al., 2007) was outlined as a component that often contributes to employment success (n = 28). Interestingly, a large portion of the articles reviewed (n = 58) discussed the importance of a good job “fit” (e.g., Hurlbutt & Chalmers, 2004). A good job fit was conceptualized as consideration of an employee's interests, strengths, preferences, and abilities in directing job application, performance, and maintenance.

Barriers to Employment

The literature on barriers to employment for adults with ASD was extensive, describing a range of personal, environmental, and job- and task-specific factors that hinder employment success.

Person-related barriers. Studies focused on stereotypical characteristics of the ASD population in describing common barriers to participation and inclusion. For example, many studies identified communication and social difficulties as obstacles to finding and maintaining work (n = 65), particularly related to engaging in interactions with coworkers and supervisors (e.g., Briel & Getzel, 2014). In addition, exhibiting increased ASD symptoms on the job site was portrayed as a hindrance (n = 47). Most of these symptoms were described as atypical and/or disruptive behavioral characteristics, such as restrictive and repetitive behaviors (e.g., Giarelli, Ruttenberg, & Segal, 2013), self-harm (e.g., Hendricks, 2010), and abnormal sensitivity to sensory stimuli (e.g., Burkhardt & Cardillo, 2012). These symptoms also can manifest themselves in obsessive adherence to routine (e.g., Gal et al., 2015) or strong resistance to change (e.g., Hurlbutt & Chalmers, 2004), both of which act as barriers in the workplace. In addition, decreased executive functioning skills are presented as a hindrance (e.g., Hendricks, 2010). Finally, mental health issues and diagnosed mental health conditions (n = 30), particularly depression and anxiety (e.g., Hill, Belcher, Brigman, Renner, & Stephens, 2013), created roadblocks to employment for those with ASD.

Environment-related barriers. The literature also addressed barriers in the individual's environment. The most frequently cited obstacle was a lack of long-term workplace support programs or a lack of access to such programs (n = 32) because of underfunding for adults in this population (e.g., Gerhardt & Lainer, 2011), particularly in rural areas (e.g., Ridley & Hunter, 2006). Another frequently cited hindrance to successful employment in the work setting was the negative attitude of employers, managers, and coworkers (n = 18), which can heighten existing social anxiety (e.g., Briel & Getzel, 2014). The social environment of a workplace can also act as a barrier when the job requires a nonpreferred level of social interaction for the employee (n = 17), such as a customer service position for an individual who finds small talk challenging.

Work-related barriers. Many studies in this review referenced employment barriers related to the job itself and the required tasks. For instance, occupations that offered low wages, poor conditions, shortened hours, and/or no opportunities for growth (n = 37) were unlikely to facilitate long-term, stable employment for those with ASD (e.g., Ohl et al., 2017). Likewise, a poor job fit for the individual was an obstacle to workplace success (n = 34), particularly within jobs that do not align with the employee's specific skills (e.g., Rausa, Moore, & Anderson, 2016), experiences (e.g., Hurlbutt & Chalmers, 2004), and/or education (e.g., Taylor et al., 2015). Finally, a lack of individualized workplace training was frequently listed as a barrier to employment (n = 28) because tailored programs are most effective for this population (e.g., Gerhardt, Cicero, & Mayville, 2014) and can teach specific “soft skills” commonly lacking in those with ASD (e.g., social skills training, self-advocacy training, time management training) (e.g., Henry, 2013).

Discussion

Several key themes emerged through the data charting process (Table 2). Each theme describes a factor that led to successful employment experiences. For example, the literature suggests that adults with ASD who possess one or a combination of the following attributes may have more success in seeking and maintaining employment: having work-related experience or skills, having insight into one's strengths and weaknesses, and being “high-functioning” (e.g., presenting with fewer ASD symptoms). Likewise, the fit of the job with the individual, in terms of abilities, preferences, sensory needs, task demands, and social requirements, with corresponding employment, is an important factor to consider when seeking work opportunities. It is suggested that the better the job fit, the more likely the individual will be to succeed.

Key Themes Summarized in the Scoping Review (N = 161 Studies)

Table 2:

Key Themes Summarized in the Scoping Review (N = 161 Studies)

The literature also suggests that the social surroundings highly affect a person's ability to succeed in occupational pursuits along the employment continuum (i.e., high school and university job preparation, the job search process, and maintenance of employment). Specifically, when individuals with ASD are surrounded by supportive communities that encompass coworkers, managers, family, and friends, they are more likely to have a positive employment experience. Likewise, professionals who support those with ASD within the employment process, such as job coaches, teachers, mentors, and vocational support staff, result in more success for the individual when they themselves have received comprehensive training. The support provided by these highly trained professionals is most effective when it is specifically customized to the individual and provided over the long term. In addition, individuals with ASD who receive workplace training in multiple areas, ranging from job-specific to social to stress management skills, are more likely to be better prepared for the work environment.

As highlighted by the recurring themes in this review, interventions may be more effective when they acknowledge the individual in a holistic manner that considers personal preferences and abilities, the work environment, work activities, and the interplay among these components. To address each of these areas effectively, it is helpful to use a guiding conceptual framework. One such framework, found in the field of occupational therapy, fits well with this holistic approach: the Person-Environment-Occupation model (Law et al., 1996). In this model, the component of the Person includes intrinsic factors: physiological, cognitive, spiritual, neurobehavioral, and psychological. The Environment includes extrinsic factors: social support, social and economic systems, culture and values, built environment and technology, and the natural environment. The Occupation component includes clusters of tasks and activities that make up the variety of ways in which individuals spend their time, including productive activities, such as employment. Viewing all of these components together and not as separate entities allows consideration of the plethora of unique factors that affect an individual's success, increasing the effectiveness of employment support.

A consideration of the themes in the literature showed several gaps. First, although some studies mentioned mental health conditions in the ASD population (Hayakawa, 2015; Hurlbutt & Chalmers, 2004), the implications of these comorbid conditions for employment are rarely discussed or incorporated into job recommendations. In addition, although the literature acknowledged negative attitudes of coworkers and employers, stigma specifically related to mental health was not addressed. Understanding the origins of the stigma may allow tailored education about ASD to be provided to an individual's surrounding community. Second, in the literature, the description of employment programs is either extremely specific, for example, job support with individualized Apple iPod applications (Gentry, Lau, Molinelli, Fallen, & Kriner, 2012), or very broad, for example, miscellaneous employment training (Migliore et al., 2012). This spectrum of detail led to a lack of evidence on which to base employment-related programming for both the employee and the surrounding staff. Future research to address these gaps can help occupational therapists to be better informed in their support of adults with ASD in finding and maintaining employment.

Limitations

During this review, several limitations arose concerning the quality of the research. First, the studies ranged in quality. The review included a small number of more rigorous studies, including randomized controlled trials and systematic reviews. Less rigorous research, such as descriptive studies, background reports, and first-person narratives, constituted nearly half of the reviewed articles. Although first-person narratives provide information that adds to the depth of understanding of individual experience, the overall lack of rigorous research within this field presents several concerns. For instance, few studies chronicled specific interventions or outlined the exact content and mechanism of employment support programs, but instead gave a summary of generic supports. We did not identify any studies that described interventions that were delivered specifically by an occupational therapist. Of the studies that described specific interventions, most were pilot projects that did not provide adequate details on the structure of interventions and did not use control groups or sufficient sample sizes. Studies also rarely differentiated between levels of ASD functioning within study participants. The terms “high-functioning” and “low-functioning” were not concretely defined across the literature. This lack of specification can make studies challenging to replicate and generalize. Additionally, because the average age range of study participants was 19 to 35 years, the experience of older individuals and those who received a late diagnosis is notably missing from the literature. Finally, although this study reviewed English language articles only, the worldwide community could benefit from the addition of international perspectives to this important and timely discussion.

Recommendations

When considering how to apply the findings of this review, it is helpful to note the persistent emphasis on providing support at a level and type of intervention to match the needs of the individual with ASD. To ensure holistic consideration of all areas that affect employment success, use of the Person-Environment-Occupation model or a similar holistic framework can help clinicians to create comprehensive and effective support and training programs. Including each piece of this model helps to ensure a good fit between an individual and a job, and the use of a coordinated and systematic approach to employment support and training for adults with ASD is recommended.

Conclusion

This review attempted to identify the breadth of existing literature on employment and adults with ASD. The themes that emerged were classified as either facilitators or barriers in the categories of person, environment, and work. The review process identified specific gaps that highlighted the need for more rigorous, high-quality studies in this field to create a foundation for evidence-based practice, with attention paid to the effects of mental health, coworker and employer sensitivity training, and the content of support programs on employment success. Although most of the literature was primarily produced in North America, the United Kingdom, Europe, and Australia, it may be hypothesized that the themes also would be applicable in less developed countries because they appear to be universal. Clearly, however, it would be helpful to have original research completed outside of the aforementioned locations to enhance the existing body of evidence. Based on the findings of this scoping review, focusing attention on customized, long-term supports and accommodations within encouraging and informed communities and workplaces contributes to successful employment for individuals with ASD.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
  • Arksey, H. & O'Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. doi:10.1080/1364557032000119616 [CrossRef]
  • Australian Bureau of Statistics. (2017). 6202.0-Labour Force, Australia, Nov 2017. Retrieved from http://www.abs.gov.au/ausstats/abs@.nsf/mf/6202.0
  • Baldwin, S., Costley, D. & Warren, A. (2014). Employment activities and experiences of adults with high functioning autism and Asperger's disorder. Journal of Autism and Developmental Disorders, 44(10), 2440–2449. doi:10.1007/s10803-014-2112-z [CrossRef]
  • Barnhill, G. P. (2007). Outcomes in adults with Asperger syndrome. Focus on Autism and Other Developmental Disabilities, 22(2), 116–126. doi:10.1177/10883576070220020301 [CrossRef]
  • Bennett, K. D. & Dukes, C. (2013). Employment instruction for secondary students with autism spectrum disorder: A systematic review of the literature. Education and Training in Autism and Developmental Disabilities, 48(1), 67–75.
  • Blank, A. & Hayward, M. (2009). The role of work in recovery. British Journal of Occupational Therapy, 72(7), 324–326. doi:10.1177/030802260907200709 [CrossRef]
  • Bonete, S., Calero, M. D. & Fernández-Parra, A. (2015). Group training in interpersonal problem-solving skills for workplace adaptation of adolescents and adults with Asperger syndrome: A preliminary study. Autism, 19(4), 409–420. doi:10.1177/1362361314522354 [CrossRef]
  • Briel, L. W. & Getzel, E. E. (2014). In their own words: The career planning experiences of college students with ASD. Journal of Vocational Rehabilitation, 40(3), 195–202. doi:10.3233/JVR-140684 [CrossRef]
  • Brownlow, C. (2010). Presenting the self: Negotiating a label of autism. Journal of Intellectual & Developmental Disability, 35(1), 14–21. doi:10.3109/13668250903496336 [CrossRef]
  • Buescher, A. V., Cidav, Z., Knapp, M. & Mandell, D. S. (2014). Costs of autism spectrum disorders in the United Kingdom and the United States. Journal of the American Medical Association Pediatrics, 168(8), 721–728. doi:10.1001/jamapediatrics.2014.210 [CrossRef]
  • Burkhardt, S. & Cardillo, S. (2012). ASD workforce: Workplace access for persons with autism spectrum disorders. In Deisinger, J. A., Burkhardt, S., Wahlberg, T. J., Rotatori, A. F. & Obiakor, F. E. (Eds.), Autism spectrum disorders: Inclusive community for the twenty-first century (pp. 27–45). Charlotte, NC: IAP Information Age Publishing.
  • Chappel, S. L. & Somers, B. C. (2010). Employing persons with autism spectrum disorders: A collaborative effort. Journal of Vocational Rehabilitation, 32(2), 117–124. doi:10.3233/JVR-2010-0501 [CrossRef]
  • Chen, J. L., Sung, C. & Pi, S. (2015). Vocational rehabilitation service patterns and outcomes for individuals with autism of different ages. Journal of Autism and Developmental Disorders, 45(9), 3015–3029. doi:10.1007/s10803-015-2465-y [CrossRef]
  • Christensen, D. L., Baio, J., Van Naarden Braun, K., Bilder, D., Charles, J., Constantino, J. N. & Yeargin-Allsopp, M. (2016). Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2012. Morbidity and Mortality Weekly Report Surveillance Summaries, 65(3), 1–23. doi:10.15585/mmwr.ss6503a1 [CrossRef]
  • Cimera, R. E. & Burgess, S. (2011). Do adults with autism benefit monetarily from working in their communities?Journal of Vocational Rehabilitation, 34(3), 173–180. doi:10.3233/JVR-2011-0545 [CrossRef]
  • Cimera, R. E., Wehman, P., West, M. & Burgess, S. (2012). Do sheltered workshops enhance employment outcomes for adults with autism spectrum disorder?Autism, 16(1), 87–94. doi:10.1177/1362361311408129 [CrossRef]
  • Dipeolu, A. O., Storlie, C. & Johnson, C. (2015). College students with high-functioning autism spectrum disorder: Best practices for successful transition to the world of work. Journal of College Counseling, 18(2), 175–190. doi:10.1002/jocc.12013 [CrossRef]
  • Feldman-Sparber, C. (2015). Analysis of evidence-based course of study predictors for improving the post-school outcomes of post-secondary education and employment for students with autism (Doctoral dissertation). Retrieved from ProQuest Dissertations & Theses Global (Order No. 3710160).
  • French, L. R., Bertone, A., Hyde, K. L. & Fombonne, E. (2013). Epidemiology of autism spectrum disorders. In Buxbaum, J. D. & Hof, P. R. (Eds.), The neuroscience of autism spectrum disorders (1st ed., pp. 3–24). New York, NY: Academic Press. doi:10.1016/B978-0-12-391924-3.00001-6 [CrossRef]
  • Friedman, N. D. B., Warfield, M. E. & Parish, S. L. (2013). Transition into adulthood for individuals with autism spectrum disorder: Current issues and future perspectives. Neuropsychiatry, 3(2), 181–192. doi:10.2217/npy.13.13 [CrossRef]
  • Gal, E., Ben Meir, A. & Katz, N. (2013). Development and reliability of the Autism Work Skills Questionnaire (AWSQ). American Journal of Occupational Therapy, 67(1), e1–e5. doi:10.5014/ajot.2013.005066 [CrossRef]
  • Gal, E., Landes, E. & Katz, N. (2015). Work performance skills in adults with and without high functioning autism spectrum disorders (HFASD). Research in Autism Spectrum Disorders, 10, 71–77. doi:10.1016/j.rasd.2014.10.011 [CrossRef]
  • Gentry, T., Lau, S., Molinelli, A., Fallen, A. & Kriner, R. (2012). The Apple iPod Touch as a vocational support aid for adults with autism: Three case studies. Journal of Vocational Rehabilitation, 37(2), 75–85. doi:10.3233/JVR-2012-0601 [CrossRef]
  • Gerhardt, P. F., Cicero, F. & Mayville, E. (2014). Employment and related services for adults with ASD. In Volkmar, F. R., Rogers, S. J., Paul, R. & Pelphrey, K. A. (Eds.), Handbook of autism and pervasive developmental disorders: Assessment, interventions, and policy (Vol. 2, 4th ed., pp. 907–917). Hoboken, NJ: John Wiley & Sons Inc.
  • Gerhardt, P. F. & Lainer, I. (2011). Addressing the needs of adolescents and adults with autism: A crisis on the horizon. Journal of Contemporary Psychotherapy, 41(1), 37–45. doi:10.1007/s10879-010-9160-2 [CrossRef]
  • Giarelli, E., Ruttenberg, J. & Segal, A. (2013). Bridges and barriers to successful transitioning as perceived by adolescents and young adults with Asperger syndrome. Journal of Pediatric Nursing, 28(6), 563–574. doi:10.1016/j.pedn.2012.12.010 [CrossRef]
  • Hayakawa, N., Okada, T., Nomura, K., Tsukada, T. & Nakamura, M. (2015). Is high job control a risk factor for poor quality of life in workers with high autism spectrum tendencies? A cross-sectional survey at a factory in Japan. Journal of Occupational Health, 57(5), 419–426. doi:10.1539/joh.14-0231-OA [CrossRef]
  • Hedley, D., Uljarevic, M., Cameron, L., Halder, S., Richdale, A. & Dissanayake, C. (2016). Employment programmes and interventions targeting adults with autism spectrum disorder: A systematic review of the literature. Autism, 21(8), 929–941. doi:10.1177/1362361316661855 [CrossRef]
  • Hendricks, D. (2010). Employment and adults with autism spectrum disorders: Challenges and strategies for success. Journal of Vocational Rehabilitation, 32(2), 125–134. doi:10.3233/JVR-2010-0502 [CrossRef]
  • Henry, A. R. (2013). Barriers to accessing support services in employment and health care for adults with autism spectrum disorders: A qualitative study (Doctoral dissertation). Retrieved from ProQuest Dissertations & Theses Global (Order No. 3609895).
  • Hill, D. A., Belcher, L., Brigman, H. E., Renner, S. & Stephens, B. (2013). The Apple iPad as an innovative employment support for young adults with autism spectrum disorder and other developmental disabilities. Journal of Applied Rehabilitation Counseling, 44(1), 28–37.
  • Hillier, A., Campbell, H., Mastriani, K., Izzo, M. V., Kool-Tucker, A. K., Cherry, L. & Beversdorf, D. Q. (2007). Two-year evaluation of a vocational support program for adults on the autism spectrum. Career Development for Exceptional Individuals, 30(1), 35–47. doi:10.1177/08857288070300010501 [CrossRef]
  • Holwerda, A., van der Klink, J. J., de Boer, M. R., Groothoff, J. W. & Brouwer, S. (2013). Predictors of sustainable work participation of young adults with developmental disorders. Research in Developmental Disabilities, 34(9), 2753–2763. doi:10.1016/j.ridd.2013.05.032 [CrossRef]
  • Hudson, R. (2004). The effect of brief training on attitudes and interactions of co-workers of individuals with autism (Doctoral dissertation). Retrieved from ProQuest Dissertations & Theses Global (Order No. 3164641).
  • Hurlbutt, K. & Chalmers, L. (2004). Employment and adults with Asperger syndrome. Focus on Autism and Other Developmental Disabilities, 19(4), 215–222. doi:10.1177/10883576040190040301 [CrossRef]
  • Johnson, T. D. & Joshi, A. (2016). Dark clouds or silver linings? A stigma threat perspective on the implications of an autism diagnosis for workplace well-being. Journal of Applied Psychology, 101(3), 430–449. doi:10.1037/apl0000058 [CrossRef]
  • Lattimore, L. P., Parsons, M. B. & Reid, D. H. (2006). Enhancing job-site training of supported workers with autism: A reemphasis on simulation. Journal of Applied Behavior Analysis, 39(1), 91–102. doi:10.1901/jaba.2006.154-04 [CrossRef]
  • Law, M., Cooper, B., Strong, N., Stewart, D., Rigby, P. & Letts, L. (1996). The Person-Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9–23. doi:10.1177/000841749606300103 [CrossRef]
  • Lorenz, T., Frischling, C., Cuadros, R. & Heinitz, K. (2016). Autism and overcoming job barriers: Comparing job-related barriers and possible solutions in and outside of autism-specific employment. PLoS One, 11(1), e0147040. doi:10.1371/journal.pone.0147040 [CrossRef]
  • Lynas, L. (2014). Project ABLE (Autism: Building Links to Employment): A specialist employment service for young people and adults with an autism spectrum condition. Journal of Vocational Rehabilitation, 41(1), 13–21.
  • McDonough, J. T. & Revell, G. (2010). Accessing employment supports in the adult system for transitioning youth with autism spectrum disorders. Journal of Vocational Rehabilitation, 32(2), 89–100. doi:10.3233/JVR-2010-0498 [CrossRef]
  • McNaughton, D. & Richardson, L. (2013). Supporting positive employment outcomes for individuals with autism who use AAC. SIG 12 Perspectives on Augmentative & Alternative Communication, 22(3), 164–172. doi:10.1044/aac22.3.164 [CrossRef]
  • Migliore, A., Timmons, J., Butterworth, J. & Lugas, J. (2012). Predictors of employment and postsecondary education of youth with autism. Rehabilitation Counseling Bulletin, 55(3), 176–184. doi:10.1177/0034355212438943 [CrossRef]
  • Ohl, A., Grice Sheff, M., Small, S., Nguyen, J., Paskor, K. & Zanjirian, A. (2017). Predictors of employment status among adults with autism spectrum disorder. Work, 56(2), 345–355. doi:10.3233/WOR-172492 [CrossRef]
  • Rausa, V. C., Moore, D. W. & Anderson, A. (2016). Use of video modelling to teach complex and meaningful job skills to an adult with autism spectrum disorder. Developmental Neurorehabilitation, 19(4), 267–274. doi:10.3109/17518423.2015.1008150 [CrossRef]
  • Rebholz, C. H. (2012). Life in the uncanny valley: Workplace issues for knowledge workers on the autism spectrum (Doctoral dissertation). Retrieved from ProQuest Dissertations & Theses Global (Order No. 3680488).
  • Ridley, J. & Hunter, S. (2006). The development of supported employment in Scotland. Journal of Vocational Rehabilitation, 25(1), 57–68.
  • Roux, A. M., Shattuck, P. T., Cooper, B. P., Anderson, K. A., Wagner, M. & Narendorf, S. C. (2013). Postsecondary employment experiences among young adults with an autism spectrum disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 931–939. doi:10.1016/j.jaac.2013.05.019 [CrossRef]
  • Scott, J., Fowler, D., McGorry, P., Birchwood, M., Killackey, E., Christensen, H. & Hickie, I. (2013). Adolescents and young adults who are not in employment, education, or training. BMJ, 347, 5270. doi:10.1136/bmj.f5270 [CrossRef]
  • Scott, M., Falkmer, M., Girdler, S. & Falkmer, T. (2015). Correction: Viewpoints on factors for successful employment for adults with autism spectrum disorder. PLoS One, 10(11), e0143674. doi:10.1371/journal.pone.0143674 [CrossRef]
  • 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. doi:10.1007/s10882-016-9479-z [CrossRef]
  • Statistics Canada. (2017). Labour force characteristics, seasonally adjusted, by province (monthly). Retrieved from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/lfss01a-eng.htm
  • Taylor, J. L., Henninger, N. A. & Mailick, M. R. (2015). Longitudinal patterns of employment and postsecondary education for adults with autism and average-range IQ. Autism, 19(7), 785–793. doi:10.1177/1362361315585643 [CrossRef]
  • Taylor, J. L. & Seltzer, M. M. (2011). Employment and post-secondary educational activities for young adults with autism spectrum disorders during the transition to adulthood. Journal of Autism and Developmental Disorders, 41(5), 566–574. doi:10.1007/s10803-010-1070-3 [CrossRef]
  • U.S. Department of Labor. (2017). The employment situation—November 2017. Retrieved from https://www.bls.gov/news.release/pdf/empsit.pdf
  • Walsh, F. P. & Tickle, A. C. (2013). Working towards recovery: The role of employment in recovery from serious mental health problems. A qualitative meta-synthesis. International Journal of Psychosocial Rehabilitation, 17(2), 35–49.
  • Wehman, P., Brooke, V., Brooke, A. M., Ham, W., Schall, C., McDonough, J. & Avellone, L. (2016). Employment for adults with autism spectrum disorders: A retrospective review of a customized employment approach. Research in Developmental Disabilities, 53–54, 61–72. doi:10.1016/j.ridd.2016.01.015 [CrossRef]
  • 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. Retrieved from http://ezproxy.library.ubc.ca/login?url=https://search-proquest-com.ezproxy.library.ubc.ca/docview/1698798025?accountid=14656 doi:10.4073/csr.2012.5 [CrossRef]
  • Whetzel, M. (2014). Interviewing tips for applicants with autism spectrum disorder (ASD). Journal of Vocational Rehabilitation, 40(2), 155–159. doi:10.3233/JVR-140668 [CrossRef]

Levels of Evidence of Studies Reviewed (n = 161)

Level of evidence Study design Number of articles selected
I Systematic reviews, meta-analyses, randomized controlled trials 28
II Two groups, nonrandomized studies (e.g., cohort, case–control) 26
III One group, nonrandomized studies (e.g., before and after, pretest and posttest) 35
IV Descriptive studies that include analysis of outcomes 72
Total: 161

Key Themes Summarized in the Scoping Review (N = 161 Studies)

Themes Facilitators Barriers
Person-related
  Physiological Not discussed Poor personal hygiene
Physical health issues
  Cognitive Skills specific to certain jobs Decreased executive function skills
Difficulty following instructions
  Self-identity Positive self-identity Low self-esteem
  Neurobehavioral Higher functioning More severe communication/social difficulties
Fewer symptoms More symptoms
  Psychological Insight Mental health challenges
Self-advocacy Resistance to change
Environment-related
  Social support Trained coaches, teachers, mentors, support staff Nonpreferred level of social interaction
Positive employer/coworker attitudes Negative employer/coworker attitudes
  Social and economic systems Long- and short-term workplace supports/programs Lack of long-term workplace supports/programs
Individualized accommodations Lack of information/access to programs
  Culture and values General value of diversity Social stigma
Understanding disclosure rights, positive disclosure experiences Negative disclosure experiences
  Built environment and technology Preferred level of sensory stimuli Poor person–environment fit
Technological aids
Natural environment Not discussed Not discussed
Work-related
  Training and support Training in multiple areas Lack of individualized workplace training
Support for job search, interview, job preparation Lack of support for job search, interview, job preparation
  Job fit and preferences Good job fit Poor job fit
Fair compensation, working conditions, opportunities to grow Unfair compensation, poor conditions
  Feedback and expectations Clear expectations, boundaries, schedule Unclear expectations, boundaries, schedule
Feedback, self-monitoring, goal setting
Authors

Ms. Harmuth is Occupational Therapist and a recent graduate of the Master's of Occupational Therapy Program, Ms. Silletta is Occupational Therapist and a recent graduate of the Master's of Occupational Therapy Program, Dr. Barbic is Assistant Professor, Department of Occupational Science and Occupational Therapy, Dr. Bailey is Professor and Chair of Child and Adolescent Psychiatry, and Ms. Beck is Liaison Librarian, Woodward Library, University of British Columbia, Vancouver, British Columbia, Canada. Mrs. Adams is Occupational Therapy Practice Coordinator for Vancouver Mental Health and Substance Use, Vancouver Coastal Health, Vancouver, British Columbia, Canada.

Ms. Harmuth and Ms. Silletta contributed equally to this work and should be considered as equal first authors.

The authors have no relevant financial relationships to disclose.

The authors thank Dr. Letitia Henville, Department of Occupational Science and Occupational Therapy, University of British Columbia, for ongoing editorial support throughout the proposal and manuscript preparation.

Address correspondence to Skye Pamela Barbic, BSc, BScOT, MSc, PhD, Assistant Professor, Department of Occupational Science and Occupational Therapy, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, Canada V6T 2A1; e-mail: skye.barbic@ubc.ca.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (https://creativecommons.org/licenses/by-nc/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.
Received: August 31, 2017
Accepted: November 30, 2017

10.3928/24761222-20180212-01

Sign up to receive

Journal E-contents