661855

research-article2016
AUT0010.1177/1362361316661855AutismHedley et al.

Review

Autism

Employment programmes and 1­–13

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DOI: 10.1177/1362361316661855

autism spectrum disorder: A systematic aut.sagepub.com

review of the literature

Darren Hedley1, Mirko Uljarević1,2, Lauren Cameron1,

Santoshi Halder3, Amanda Richdale1,2 and Cheryl Dissanayake1

Abstract
Individuals with autism spectrum disorder face significant challenges entering the workforce; yet research in this area is
limited and the issues are poorly understood. In this systematic review, empirical peer-reviewed studies on employment
programmes, interventions and employment-related outcomes in individuals with autism spectrum disorder over 18 years
with and without intellectual disability were identified and evaluated. The review was prefaced by a summary of previous
systematic reviews in the area. Web of Science, Medline, PsychINFO, ERIC and Scopus databases were systematically
searched through to October 2015. From 32,829 records identified in the initial search, 10 review and 50 empirical
articles, comprising N = 58,134 individuals with autism spectrum disorder, were included in the review. Selected articles
were organised into the following themes: employment experiences, employment as a primary outcome, development of
workplace skills, non-employment-related outcomes, assessment instruments, employer-focused and economic impact.
Empirical studies were limited by poor participant characterisation, small sample size and/or a lack of randomisation and
use of appropriate controls. Poor conceptualisation and measurement of outcomes significantly limited study quality
and interpretation. Future research will require a multidisciplinary and multifaceted approach to explore employment
outcomes on the individual, the family system, co-workers and the employer, along with the impact of individual
differences on outcome.

Keywords
autism spectrum disorder, competitive employment, outcome, supported employment, vocational rehabilitation,
vocational support, vocational training

Although typically diagnosed in childhood, autism spec-
trum disorder (ASD) (American Psychiatric Association
(APA), 2013) is a lifelong condition; adults with ASD con-
tinue to face significant challenges across the lifespan with
poor or, at best, highly variable long-term outcomes in
adulthood (Howlin, 2000). The lifetime cost of ASD in the
United States is estimated to range from US$1.4 million to
US$2.4 million depending on whether the individual has
co-occurring intellectual disability or not, with yearly
costs estimated at US$236 billion (Buescher at al., 2014).
The cost is similar in the United Kingdom, ranging from
£0.92 to £1.5 million (US$1.4–US$2.2 million) (Buescher
et al., 2014). This is a particularly pressing issue as ASD
evidenced by increased stress, anxiety, depression and
somatic health problems (Karst et al., 2012; McStay et al.,
2014; Uljarević et al., 2016).
Studies conducted in the United States (Holwerda et al.,
2012; Roux et al., 2015; Shattuck et al., 2012a), the United
Kingdom (Howlin et al., 2004), Australia (Baldwin et al.,
2014) and Canada (Eaves and Ho, 2008) indicate high
rates of unemployment in ASD compared to other
1OlgaTennison Autism Research Centre, La Trobe University, Australia
2Cooperative Research Centre for Living with Autism (Autism CRC),
Australia
3University of Calcutta, India

may affect as many as 1 in 68 individuals (Centers for

Corresponding author:
Disease Control and Prevention (CDC), 2012) and, in Darren Hedley, School of Psychology and Public Health, La Trobe
addition to impacting the individuals themselves, ASD has University, Melbourne, VIC 3086, Australia.
considerable negative effects on family members as Email: d.hedley@latrobe.edu.au
2 Autism
disability groups. For example, the Australian Bureau of
Statistics reports the labour force participation rate for
people with ASD is 42%, lower than for people with other
disabilities (53%) and people without disabilities (83%)
(Australian Bureau of Statistics (ABS), 2014). In the
United States, only 58% of young adults with ASD
reported working for pay outside of the home, fewer than
for individuals with emotional, speech or learning disabili-
ties (90%) and also intellectual disability (74%) (Roux
et al., 2015). Even when individuals with ASD are
employed, the meaningfulness of their employment is
questionable as it tends to be in low paying jobs with lim-
ited working hours and in jobs that are most often well
below the individual’s level of education and expertise
(Holwerda et al., 2012; Roux et al., 2015; Shattuck et al.,
2012a). Current employment outcomes for people with
ASD are very concerning given the multifaceted effects
of employment (or lack of employment) on both the
individual and society.
Employment serves as one means of offsetting the eco-
nomic costs of ASD (Cowen, 2011). Individuals who tran-
sition from the welfare system to competitive employment
have the potential to increase national gross domestic
product (Deloitte Access Economics, 2011). Additionally,
meaningful employment has been associated with
increased sense of agency and better subjective well-being,
while unemployment can have negative effects on psycho-
logical and physical health and, furthermore, has been
associated with increased mortality and higher suicide
rates (Wanberg, 2012). Employment (or the lack thereof)
can have a significant impact on families as well with one
of the major concerns of parents of individuals with ASD
being their child’s ability to live independently once par-
ents are no longer able to support them (Van Bourgondien
et al., 2014). There is some evidence that employment may
improve independence, thus potentially helping to allevi-
ate this worry (Howlin et al., 2005).
Vocational options for adults with ASD range from seg-
regated day programmes to supported and competitive
employment (Gerhardt et al., 2014). For individuals with
ASD and an IQ >70, supported employment can lead to
better outcomes than non-specialist programmes, particu-
larly in transition to competitive employment (Mawhood
and Howlin, 1999). In individuals with and without an
intellectual disability, better outcomes have also been
reported for supported compared to segregated work set-
tings such as sheltered workshops (Cimera et al., 2012).
However, in the United States, it is estimated that up to
three times as many individuals with ASD are in segre-
gated settings compared to supported settings (Wehman
et al., 2007).
The number of adults with ASD who utilise employ-
ment services is steadily increasing (Burgess and Cimera,
2014). However, despite costs for employment services
being relatively higher than for most other disability
groups, employment outcomes remain poor for these
individuals (Burgess and Cimera, 2014; Cimera and
Cowan, 2009). In a recent review of US State services for
transition-aged adults with ASD, corresponding to the
period where individuals leave school and transition into
higher education or employment settings (i.e. leaving
high school to early 20s), Burgess and Cimera (2014)
found that over US$4 million had been invested in
vocational rehabilitation services designed to provide
pathways to supported employment. Nonetheless, this
investment resulted in successful employment of only
36% of transition-aged adults with ASD across all States
over a 10-year period; however, it was noted that
outcomes may improve when services are handled by
specialised ASD service providers.
It has been suggested that one potential factor contrib-
uting to the low expectations and poor work outcomes in
ASD is the emphasis on impairment and social deficits
instead of strengths and expertise (Holwerda et al., 2012).
Human resource policies that focus on social skills and
teamwork, even when those skills are not essential to the
particular workplace or job, create a barrier to entering the
workforce for individuals who are perceived as ‘socially
awkward’ (Richards, 2012). Furthermore, there is mount-
ing evidence that individuals with ASD, who may other-
wise be well suited for a position, may require assistance
to gain and maintain meaningful employment, with fam-
ily members often playing a critical role in securing this
employment (Howlin et al., 2004). In a recent Australian
study of employed persons with a self-reported clinical
diagnosis of ASD, over half (54%) indicated that they
needed some level of support to find employment and
two-thirds (66%) indicated they would like more support
at work for symptoms associated with their ASD (Baldwin
et al., 2014). Although individuals with ASD benefit from
services to both locate and maintain employment, a high
number report that they are not receiving the support ser-
vices they need (Roux et al., 2015). Despite poor employ-
ment outcomes and a clear need for support services, to
date there remains a marked lack of empirical research
regarding employment supports or related interventions
for adults with ASD (Baldwin et al., 2014; Nicholas et al.,
2015; Taylor and Seltzer, 2011).
There is a pressing need for the identification of appro-
priate work options and services that support and promote
better employment outcomes for adults with ASD. The
goal of this review is to provide a systematic overview of
the literature regarding employment programmes or inter-
ventions, and employment-related outcomes for individu-
als with ASD. We first summarise previously published
reviews on the topic as a way of providing a snapshot of
the current understanding in this area and background to
the empirical articles reviewed. We then provide a detailed
systematic review of published articles that describe or
report employment, vocational or support programmes
Hedley et al. 3
Table 1.  Search terms by domain.
Category Search termsa,b
Population autis*, asd, asperger*, pervasive development*
disorder*, spectrum disorder*
Intervention access, instruction, intervention, model,
program, service, supported employ*, training,
treatment, transition, support*
Domain adult, employ*, rehab*, vocation*, work*
aTermsfrom each domain were connected with ‘OR’ and between
domains with ‘AND’.
bDomains and terms were derived from Westbrook et al. (2012).
and employment-based outcomes, which target or include
individuals with ASD. As there is currently little consensus
as to what constitutes a successful support programme
(Baldwin et al., 2014), our inclusion criteria were purpo-
sively broad – we include single-case studies as well as
controlled clinical outcome studies. Our particular focus
was to describe outcomes of the currently available sup-
port programmes and, where possible, the predictors of
successful outcomes for individuals with ASD.
Method
Our review methodology adhered to the steps described in
the Preferred Reporting Items for Systematic reviews and
Meta-Analyses (PRISMA) statement (Liberati et al.,
2009).
Search strategy
Web of Science, Medline, PsychINFO, ERIC and Scopus
databases were searched for published articles available
through to October 2015. No date limit in terms of the
beginning point of the searches was set. Search terms
were identified based on our specific aims and informed
by previous reviews on the topic. Combinations of terms
(truncated versions) across all fields (title, abstract, key-
words) were searched for across the categories ‘popula-
tion’, ‘intervention’ and ‘domain’ (Westbrook et al.,
2012). Search terms are provided in Table 1. Database
searches were supplemented by searches through refer-
ence sections of all identified empirical and review arti-
cles to locate any articles that may have been overlooked
in the database search.
Inclusion and exclusion criteria
Articles published in English were included if they were
(a) empirical studies (regardless of their design), (b) pub-
lished in peer-review journals (conference abstracts and
theses were excluded) and (c) reporting on an employment-
related intervention, vocational programmes or implemen-
tation of employment-related supports. Articles included
individuals with ASD (including autism, Asperger’s dis-
order or pervasive developmental disorder not otherwise
specified (PDD-NOS)) with and without an intellectual
disability who were 18 years of age or older – however,
studies that also included a subset of participants under
18 years of age were not excluded, as long as the sample
also included individuals aged 18+ years. Studies report-
ing on other populations (e.g. intellectual disability) in
addition to individuals with ASD were also included.
There were no restrictions on sample size. Systematic,
meta-analysis and narrative review articles were also
identified for inclusion.
Study selection and coding procedures
Following the initial database search, duplicates were
removed and study titles were reviewed to remove obvi-
ously irrelevant articles. Abstracts of candidate articles
were then reviewed for potential inclusion for full review.
Inclusion at this stage only required that the article
describes a study or review of employment and ASD.
Identified articles were divided between the first four
authors (D.H., M.U., L.C. and S.H.) who conducted a full
review of the article. The reviewers also scanned the refer-
ence sections to identify additional articles that might have
been missed. Articles were then coded, and those that did
not meet the inclusion criteria were flagged for removal.
Two reviewers independently evaluated each flagged
study and a decision to remove or include the study was
based on consensus. Differences were resolved through
discussion and agreement.
Studies were coded for the following ‘background’
information: (a) publication source, (b) geographical ori-
gin of the study, (c) design (single case, qualitative, quasi-
experimental/experimental, mixed method, review,
cross-sectional, longitudinal), (d) full description of both
ASD group and other control groups (i.e. other clinical
conditions), (e) chronological age (CA) and developmen-
tal level (IQ), (f) goal of the study, (g) type of programme,
(h) measures, (i) outcomes and (j) limitations.
Results
Figure 1 provides an overview of the search results at each
stage of the process. We identified 50 empirical and
10 review articles (including three systematic reviews)
that were subsequently included in our final review.
A detailed summary of all the aspects of these articles,
from methodology to results and limitations, is provided in
Supplementary Appendices 1 and 2. The majority of iden-
tified articles were from the United States (n = 46), with
other represented countries including the United Kingdom
(n = 4), Spain (n = 3), Israel (n = 2), Australia, Germany,
Hong Kong, Japan and the Netherlands (all n = 1). With the
exception of only a few of the empirical studies, study
4 Autism
Figure 1.  Search results at each stage of the process.
quality was affected by poor characterisation of partici-
pants, a failure to independently confirm diagnostic status
with standardised assessment instruments, limited use of
standardised outcome measures, non-random assignment
to treatment and control groups, generally small number of
participants, poor representation of females, non-blinded
assessment of outcomes and application of non-standard
or poorly described interventions (please refer to
Supplementary Appendix 2 for a detailed summary of
study limitations).
Previous systematic reviews
Ten review articles on various aspects of employment-
related research in ASD were identified. Only systematic
reviews that provided information on search strategy and
inclusion and exclusion criteria were considered. Four arti-
cles were not systematic and were excluded (Capo, 2001;
Chen et al., 2015; Vogeley et al., 2013; Wilczynski et al.,
2013), and one review was excluded as it did not provide
reasons why particular studies were included/excluded
(Hendricks, 2010).
Shattuck et al. (2012b) explored common themes and
methodological aspects of empirical studies (conducted in
United States, United Kingdom and Canada; published
between 2000 and 2010) on employment, education and
social participation in ASD. Of 23 studies identified, 16
studies focused on employment. Identified studies evalu-
ated individual behavioural vocational interventions
(N = 8) and group/agency-level vocational programmes
(N = 5) and indicated that both these types of programmes
were efficacious and feasible. However, Shattuck and col-
leagues noted significant methodological limitations, most
notably in terms of sample characterisation, which was
considered poor. Studies were particularly inconsistent in
characterisation and measurement of level of functioning
and impairment, and failing to provide information on
socioeconomic position, race and ethnicity of participants.
Furthermore, the majority of studies focused on individu-
als with ASD who were younger than 30 years of age.
Focus on exploring the self-determination, involvement in
decision-making and various aspects of quality of life for
adults with ASD were highlighted as key areas for future
research.
Storey (2003) focused on natural support strategies,
identifying 11 empirical studies involving people with an
intellectual disability that were published between 1988
and 2001. Natural support strategies including social
skills instruction, problem-solving, communication skills
instruction and co-worker supports were deemed as
promising approaches for increasing workplace integra-
tion for individuals with an intellectual disability. Taylor
et al. (2012) identified five empirical studies on employ-
ment/vocational interventions for young adults with ASD
that met their specific inclusion criteria: age range of
13–30 years, sample size of ⩾20 and published between
1980 and 2011. All the identified studies evaluated the
efficacy of on-the-job supports for individuals with ASD.
Vocational interventions were associated with better
vocational outcomes and outcomes in terms of core ASD
traits, cognitive functioning, quality of life and ability to
function independently. However, Taylor et al. noted
little consistency between identified studies in terms
of reported/studied outcomes. Studies were of poor
methodological quality providing little to no evidence
base for any specific intervention or support. A particular
strength of the review was the fact that Taylor et al.
evaluated the quality of individual studies and defined
domains used to assess the strength of evidence for
particular interventions.
Examining studies published up to 2011, Holwerda
et al. (2012) explored the predictors of work participation
for adults with ASD in longitudinal studies. The only
Hedley et al. 5
factor found to consistently predict work outcomes across
studies was IQ, with an IQ <50 usually associated with
poor outcomes. However, although an IQ >70 was more
likely to be associated with a positive employment out-
come, this was not always the case, and outcomes in indi-
viduals without intellectual disability were variable and
less predictable, thereby limiting the practical value of IQ
in predicting individual work outcomes (Holwerda et al.,
2012). Similar to Taylor et al. (2012), a strength of the
review was the fact that an assessment of methodological
quality of identified studies was conducted.
In a systematic search of the literature on employ-
ment assistance interventions for adults with ASD,
Westbrook et al. (2012) identified only two studies that
met their stringent inclusion criteria (which necessarily
limited generalisability). One of the identified studies
(Mawhood and Howlin, 1999) reported that individuals
with ASD in supported employment programmes had
better employment outcomes than individuals who did
not receive support; however, a second identified study
(García-Villamisar et al., 2000) failed to find differences
between individuals who received supported employ-
ment versus the ones who received sheltered employ-
ment. Westbrook and colleagues noted that both studies
were of low methodological quality and concluded that
there was no strong support for the programmes
reviewed. Finally, Nicholas et al. (2015) conducted a
critical interpretive synthesis of empirical studies on
employment interventions in ASD published up to 2012.
In total, 10 studies divided into supported employment
(eight studies) and technology-based applications/tools
(two studies) were identified. Nicholas et al. noted
that identified studies suggested positive employment-
related outcomes including ability to obtain and retain a
job, higher wages and higher job satisfaction as well as
potential cognitive improvements. However, conclu-
sions were limited by methodological limitations of
identified studies including small sample size, inconsist-
ent conceptualisation and measurement of outcomes,
the lack of long-term outcome monitoring and lack of
replication.
In summary, the reviews undertaken to date covering
the period from 1988 to 2012 indicate that although natural
supports may be potentially useful for people with an ASD
and intellectual disability, the existing research is flawed
for a range of reasons and there is little empirical support
for the programmes or interventions reviewed. However,
despite the above noted strengths, systematic reviews con-
ducted thus far have been varied in their focus on ASD and
employment, which has ranged from restricted to broad,
and in the range of literature examined. It is thus difficult
to form a comprehensive picture in terms of the current
state of the literature on employment in ASD, and also in
terms of the evidence base for particular employment/
vocational programmes.
Empirical studies
In the section that follows, published articles on particu-
lar employment programmes or interventions, or
employment-related outcomes for adults with ASD
were examined. We first provide an overview of partici-
pant demographics in included studies. A review of
empirical studies follows, organised by the following
themes: employment experiences, employment as pri-
mary outcome, development of workplace skills, non-
employment-related outcomes, assessment instruments,
employer-focused and economic impact.
Participant demographics.  Table 2 provides an overview of
participant demographics from the reviewed studies,
organised into qualitative studies and studies with five or
fewer participants, quantitative or qualitative studies with
more than five participants, studies that used the US Reha-
bilitation Services Administration (RSA-911) database
and those that used mixed methods, incorporating both
quantitative and qualitative methodology. In total, studies
included 58,134 individuals with ASD; however, the
majority of cases were derived from the RSA-911 database
(215–34,501 individuals). The number of individuals with
ASD from other studies ranged from 1 to 130. Individuals
ranged in age from 15 to 65 years, with an average age of
approximately 25–28 years across study types, and were
predominantly male (74%–91% of the sample). Where
reported, IQ ranged from 30 to 164, with the average >70
across studies. Characterisation of participants across
studies was generally poor, particularly with regard to abil-
ity level (i.e. IQ) and details of the diagnostic process. Fur-
thermore, several studies failed to provide basic
demographic information on their participants, such as
gender and age (please refer to Supplementary Appendix 1
for specifics of data provided in individual studies).
Employment experiences
One Australian (Baldwin et al., 2014) and one US (Hillier
and Galizzi, 2014) study explored the employment experi-
ences of individuals with ASD and their families. Overall,
despite reporting a high participant education level com-
pared to the general population and employment across a
wide variety of occupations, respondents with ASD faced
disadvantage in the labour market resulting in underem-
ployment and overrepresentation in low-paid, casual and
entry-level positions. Participants reported a lack of sup-
port and understanding in the workplace, and a desire for,
but lack of workplace accommodations for symptoms
associated with their ASD. Hillier and Galizzi also identi-
fied the high costs to families to support their child in
employment including time (e.g. preparing for work,
transport to work, interview preparation, supervision and
emotional support) as well as loss of income, loss of career
opportunities and depreciation of work skills.
6 Autism

Employment as primary outcome

DSM-IV (n = 3); CARS (n = 2); medical

DSM-III (n = 2); medical report (n = 3)

ADI-R (n = 1); medical report (n = 1)

ASD: autism spectrum disorder; FSIQ: Full Scale IQ; SD: standard deviation; DSM-III: Diagnostic and Statistical Manual of Mental Disorders (3rd ed.); DSM-IV: Diagnostic and Statistical Manual of Mental
report (n = 5); SRS (n = 2); ADI-R
US vocational rehabilitation services.  Vocational rehabilita-
tion services are administered by the US Department of
Education and provide support for individuals with ASD

(n = 1); self-report (n = 1)

to find and maintain employment. Services include coun-
selling, assessment and diagnosis, job search assistance,
assistive technology and on-the-job training (Lawer et al.,
Diagnostic process reported

2009; McDonough and Revell, 2010). There has been a

steady increase in the use of vocational rehabilitation ser-
Method

vices in the United States by individuals with ASD (Bur-

gess and Cimera, 2014; Cimera and Cowan, 2009; Lugas
et al., 2010).
Disorders (4th ed.); CARS: Childhood Autism Rating Scale; SRS: Social Responsiveness Scale; ADI-R: Autism Diagnostic Interview – Revised; NR: not reported.
# Studies

Studies using the associated RSA-911 database have

dVR: Vocational Rehabilitation; RSA-911: Case Service Report data set is collected by the Rehabilitation Services Administration (RSA) of the US government.
found a range of both positive and negative outcomes
NR
10

including the following: (a) improved employment out-

2
5

comes for service recipients with ASD (Burgess and

<70–126

Cimera, 2014; Lawer et al., 2009; Lugas et al., 2010;

66–131
30–164
Range

Wehman et al., 2014a); (b) supported employment results

in increased earning potential, reduced service cost and
higher likelihood of gaining competitive employment
74.29 (22.25)c

104.9 (8.63)g

compared to sheltered employment (Cimera et al., 2012;

80 (31.19)

Lawer et al., 2009); (c) transition-aged adults with ASD

M (SD)

aAt least four studies were based on identical study samples (García-Villamisar et al., 2000, 2002; Smith et al., 2014, 2015).

work fewer hours per week, earn less and cost more to
FSIQ

NR

service when compared to individuals without ASD

(Burgess and Cimera, 2014; Cimera and Cowan, 2009);
16–59

16–65
18–55
15–42
Range

(d) males and females with ASD benefit equally from on-
the-job supports, but counselling and guidance, job search
assistance and other services (e.g. job licences, tools and
24.24 (4.32)b

27.46 (7.73)e
27.93 (6.54)f
24.87 (5.93)

equipment, medical care) may be more beneficial for

Age (years)

males (Sung et al., 2015); (e) males with ASD and co-
M (SD)

occurring anxiety and/or depression experience a 50%

reduction in the odds of finding employment (Sung et al.,
2015) and (f) significant predictors of successful case clo-
Male

sure for individuals in competitive employment included

80
74
91

79
%

older age, more years of education, not having a secondary

215–34,501

disability and receiving job finding and job placement and

maintenance services (Lawer et al., 2009; Schaller and
8–100

9–130
Range

Yang, 2005). However, for individuals receiving supported

1–5

employment services, being Black/African-American was

negatively related to successful case closure (Schaller and
5717 (10,669)
28.68 (22.30)

46.50 (56.34)
Table 2.  Summary of participant demographics.

Yang, 2005). Moreover, adults with ASD were more likely

3.11 (1.20)
# Participants (ASD)

than other disability groups to be denied services due to

M (SD)

the severity of their disability, but were as likely as adults

with an intellectual disability or specific learning disabili-
ties to secure competitive employment. Being White,
57,172
Total

male, of older age, having more education and higher ser-

717a

186
59

bDerived from means for n = 16.

vice expenditure significantly predicted positive competi-

eDerived from means for n = 4.
cDerived from means for n = 4.

gDerived from means for n = 2.

fDerived from means for n = 4.

tive employment outcomes and employment was positively

Studies

associated with on-the-job supports (Lawer et al., 2009).

19

19

Thus, while there were ASD-specific issues identified that

#

8
4

affected employment outcomes for adults with ASD, this

VR/RSA-911d
Quantitative,

population, at least in the United States, was also affected

Qualitative,

by employment biases found in the general population,

method
Design

Mixed
N ⩽ 5

N > 5

including race, age, gender, mental health status and edu-

cation level.
Hedley et al. 7
ASD employment programmes.  The following three branded
employment support programmes were identified: the
TEACCH Supported-Employment Program (N = 1 study),
SEARCH (N = 5 studies) and National Autistic Society
(NAS) Prospects (N = 3 studies). The TEACCH Program
(Keel et al., 1997) provides a job coach who assists with job
placement and training. Individuals or small groups are sup-
ported in a business, or alternatively, the programme sup-
ports a group of individuals who provide services to the
community. Between 1986 and 1997, the programme served
around 100 persons (42% with intellectual disability), plac-
ing 96 of them in jobs with reported job retention of 89%.
Project SEARCH (Schall et al., 2015; Wehman et al.,
2012a, 2012b, 2014b) is a 9-month industry (e.g. banking
centre, hospital) internship for youth with developmental
disabilities in their final year of high school, modified to
accommodate youth with ASD. The programme led to
more individuals gaining competitive employment (87.5%
compared to 6.25% of individuals receiving services
according to their Individualized Education Plans (IEPs)
only, and 84% compared to 55% retention when compared
to individuals receiving supported employment services
at 18 months), higher wages (US$9.89/h compared to
US$8.82/h) and fewer intervention hours required to secure
employment (80.64 h compared to 184 h) compared to
standard supported employment programmes (Schall et al.,
2015; Wehman et al., 2014b). Furthermore, it is one of the
few programmes to be supported by a randomised trial
(Wehman et al., 2014b). The UK NAS Prospects–supported
employment service placed 68% of clients in 192 jobs
between 1995 and 2003. NAS provides some evidence that
involvement in the programme leads to an increase in inde-
pendent living (Howlin et al., 2005) and returns improved
employment outcomes compared to a non-randomly
assigned control group (Mawhood and Howlin, 1999).
In addition to the studies reviewed above, three studies
exploring non-branded support programmes were identi-
fied. Hillier et al. (2007) reported improved employment
rates and income for nine individuals with ASD following
1 year of participation in a non-specific, vocational support
programme providing pre- and post-placement services.
However, the study did not use a control group and was
affected by small sample size. Finally, two qualitative
studies described the involvement of occupational thera-
pists in Japan (Arikawa et al., 2013) and a 4-month work-
training programme in the United States (Burt et al., 1991)
that both led to successful employment outcomes for indi-
viduals with ASD with borderline to above average intel-
lectual ability.
Development of workplace skills
Ten studies used a pre- and post-intervention multiple
baseline design to assess interventions designed to teach
workplace skill acquisition or to effect behaviour change.
Intervention techniques included video modelling (Allen
et al., 2010; Burke et al., 2013), audio coaching (Bennett
et al., 2010, 2013), behaviour skills training plus perfor-
mance cue delivered via an iPhone application (Burke
et al., 2010), applied behaviour analysis (Lerman et al.,
2015), pre-work task assessment on task choice (Lattimore
et al., 2002, 2003) and job-site training plus simulation
training (Lattimore et al., 2006, 2008). One case study
(Wehman et al., 2007) described the use of a job coach,
applying situational assessments and on-the-job skills
training to support one individual in a department store.
However, formal outcome measures were absent. Overall,
these studies provide support for the use of behavioural
techniques to teach workplace skills and modify behaviour
in individuals with ASD who presented with varying
symptom severity and IQ.
Four studies involving randomised control trial meth-
odology assessed the use of technological aides to support
workers with ASD or to target specific skills, across a vari-
ety of workplace outcomes. Use of a personal digital assis-
tant (PDA) was associated with reduced number of hours
of job coaching and increased total hours worked in a sup-
ported environment (Gentry et al., 2015). A multimedia
program was found to improve interviewing skills (Smith
et al., 2014; Strickland et al., 2013) and was associated
with improved rates of attaining competitive employment
(Smith et al., 2015). One further case study (Hill et al.,
2013) reported that an iPad™ increased independence, con-
fidence, time management and organisation skills at work.
Overall, this wide range of studies supported the use of
both behavioural intervention techniques and technologi-
cal aides in improving workplace skills in adults with
ASD. Behavioural intervention techniques have long been
known to be helpful in teaching a wide variety of skills to
individuals with ASD (Jacobson and Holburn, 2004).
However, while these interventions were obviously bene-
ficial to the individuals involved, the large range of skills
taught in the above studies and small number of individu-
als involved limit the generalisability of the specific
interventions.
Non-employment-related outcomes
Three outcome studies examined the effect of supported
versus sheltered employment on core ASD symptoms
(García-Villamisar et al., 2000), quality of life (García-
Villamisar et al., 2002) and cognitive skills (García-
Villamisar and Hughes, 2007). Overall, these studies
reported improved outcomes, including quality of life, no
deterioration of ASD symptoms (symptoms increased in
the sheltered group) and improved cognitive functioning
for supported employment settings compared to sheltered
employment. Nonetheless, the results were affected by
methodological weakness such as non-random assignment
to treatment group and a lack of baseline data collection.
8 Autism
Liu et al. (2013) examined the effects of a workplace-
training programme on social, communication and emo-
tional behaviour at work in a pre-test, post-test group
design involving 14 participants with ASD and mild-to-
moderate intellectual disability. Intervention improve-
ments were noted for social behaviour and social
communication, with a reduction in the confusion sub-
scale of the Observational Emotional Inventory Revised
(McCarron and Dial, 1986). However, the study lacked a
control group, random assignment and blinded assess-
ment. One qualitative case study (Foley and Staples,
2003) targeted communication and literacy outcomes fol-
lowing an augmentative and alternative communication
and literacy intervention. However, outcomes were non-
systematic and varied across participants. Two studies
(Schall, 2010; Smith and Coleman, 1986) used single-
subject designs to assess the impact of positive reinforce-
ment on reducing challenging behaviour in the workplace
with some degree of success.
The few studies identified that investigated outcomes
unrelated to employment were generally of poor quality.
To date, evidence, in terms of outcomes beyond obtaining
employment, such as cognitive, mental health and well-
being, symptom severity, adaptive functioning and qual-
ity-of-life factors, is lacking.
Assessment instruments
Two work-related instruments that may benefit individu-
als with ASD at work to (a) identify their challenges and
abilities and (b) assess work performance were identi-
fied. The Autism Work Skills Questionnaire (AWSQ) is a
78-item, semi-structured, work-based assessment instru-
ment designed to create an employment profile for peo-
ple with ASD on domains such as work habits, level of
independence and sensory needs (Gal et al., 2013).
Significant differences between individuals with and
without ASD have been demonstrated for four of the five
main AWSQ domains, with a suggestion that the instru-
ment may be useful in matching individuals with ASD to
jobs (Gal et al., 2015). However, more research is
required to determine whether an employment profile has
a positive effect on employment outcomes. The Work
Performance Evaluation (WPE) was developed to assess
work performance in individuals with ASD (Katz et al.,
2015), but is currently limited by restricted score vari-
ance. The instrument is currently under review (E. Gal,
personal communication, 29 May 2016); however, fur-
ther research is needed to determine its potential useful-
ness as an outcome measure.
Employer focused
Three studies were identified that focused on employers
or organisations that support individuals with ASD. One
study asked employers to identify supports provided to
individuals with ‘severe disabilities’, including ASD
(Unger et al., 1998). Identified supports included assist-
ing individuals to find a job, job training and support for
work-related issues. Nesbitt (2000) developed a ques-
tionnaire to investigate organisational issues that might
affect workplace success associated with the NAS
Prospects–supported employment programme, described
earlier. The main finding was that organisations not
already employing an individual with ASD tended to
focus on the individual’s ability level, whereas organisa-
tions involved in NAS Prospects were more likely to rec-
ognise the contribution of a supportive environment to
the individual’s success. Palmen et al. (2010) evaluated
the effectiveness of a behaviour skills training pro-
gramme on the performance of four staff members who
provided job training to individuals with ASD. Following
the intervention, staff skills, particularly ‘error correc-
tion’, improved. However, there were no significant
changes in the targeted behaviour of the individuals with
ASD and as a result of the intervention.
There are currently very few studies on employers and
their perspectives and needs in relation to the employment
of adults with ASD. There is limited evidence that pro-
grammes such as NAS Prospects can be successful in
changing employers’ perceptions about the employment of
individuals with ASD and the role of environmental
accommodations to support workplace success.
Economic impact
An important aspect of examining employment for adults
with ASD is the economic impact from the perspective of
the individual with ASD, the employer and the commu-
nity. However, other than research reporting the broad
lifetime costs of ASD to the community identified earlier,
only one article has examined the cost-effectiveness of an
employment programme. Mavranezouli et al. (2014)
compared the cost-effectiveness of the NAS Prospects
programme with standard care. Although more expen-
sive, supported employment resulted in an increased
number of weeks employed and quality-of-life years
when compared to standard care, suggesting supported
employment for adults with autism is cost-effective for
both individuals and communities.
General discussion
Although until recently the main focus of research on ASD
in general, and intervention research in particular, has been
on the early years, there is a clear need to address chal-
lenges faced by adults with ASD (Howlin et al., 2015;
Taylor et al., 2012). Low employment rates of individuals
with ASD have been reported across different countries
and continents (ABS, 2014; Baldwin et al., 2014; Eaves
Hedley et al. 9
and Ho, 2008; Holwerda et al., 2012; Howlin et al., 2004),
with unemployment having a known negative impact on
an individual’s psychological and physical well-being, and
on family systems, as well as negative societal and eco-
nomic implications. Therefore, enabling individuals with
ASD to find and retain meaningful employment is an area
of particular need.
Research into employment in ASD: current
findings
Studies exploring the employment experiences of individ-
uals with ASD indicate that individuals with ASD face
considerable challenges in finding and retaining jobs, and
there is both a need and desire for better support and
accommodations at work (Baldwin et al., 2014; Hillier and
Galizzi, 2014).
Employment as a primary outcome has been considered
for a variety of comprehensive employment support pro-
grammes. Overall, it appears that enrolment in these pro-
grammes leads to improved employment outcomes, both
in terms of securing a job and in increased working hours
and wages (Burgess and Cimera, 2014; Cimera and Cowan,
2009; Hillier et al., 2007; Howlin et al., 2005; Keel et al.,
1997; Lawer et al., 2009; Lugas et al., 2010; Mawhood and
Howlin, 1999; Schall et al., 2015; Wehman et al., 2014a,
2014b). Some evidence for increased job retention has also
been reported (Schall et al., 2015). Factors found to be
associated with better employment outcomes were (not
surprisingly) older age, better education, receipt of support
and absence of co-morbidity (Lawer et al., 2009; Schaller
and Yang, 2005). Benefits in terms of improved social,
communication and behavioural outcomes as a result of
employment programmes have also been reported (Liu
et al., 2013; Schall, 2010; Smith and Coleman, 1986). A
subset of identified studies evaluated a variety of interven-
tion techniques spanning from video modelling and audio
coaching to more traditional applied behaviour analysis-
based procedures as a way of teaching targeted workplace
skills and behaviours with mostly positive outcomes
(Allen et al., 2010; Bennett et al., 2010, 2013; Burke et al.,
2010, 2013; Gentry et al., 2015; Hill et al., 2013; Lattimore
et al., 2002, 2003, 2006, 2008; Lerman et al., 2015; Smith
et al., 2014, 2015; Strickland et al., 2013).
Studies that have focused on employers have identified
the need for better training of staff members who work
with individuals with ASD. Findings suggest that one of
the organisational issues that might negatively impact
employment for individuals with ASD is a tendency of
employers to focus on perceived limitations without rec-
ognising the importance of building a supportive work-
place (Nesbitt, 2000). Finally, one study (Mavranezouli
et al., 2014) explored the economic impact of a supported
employment programme versus standard care and con-
cluded that although initially more expensive, supported
employment was cost-effective in the long-term as it led to
increased employment and quality of life.
Research into employment in ASD: current
limitations and future directions
Irrespective of the design, the majority of identified
studies were limited in terms of their characterisation of
participants, with a number of studies omitting to pro-
vide even the most basic demographic information, such
as gender and age. Characterisation of participants was
particularly poor with regard to ability level, and few
studies provided any detail of how participant diagnosis
was confirmed. With the exception of studies that
explored the US Vocation Rehabilitation Services data,
the majority of other studies were affected by small sam-
ple size, which may well be a reflection of the low
employment rates in ASD. Furthermore, with one excep-
tion (Wehman et al., 2014b), randomised controlled tri-
als are currently missing. In addition to these limitations
that hamper our ability to assess the overall effectiveness
of particular employment programmes, the way that out-
comes have been conceptualised and measured is also
problematic across the majority of studies.
The effectiveness of employment programmes can be
expressed using indicators pertaining to job status, varying
from simple dichotomous outcomes (i.e. in terms of
obtaining a job or not), to more detailed information
regarding average work hours per week, income and match
between expertise, educational level and the nature of the
job. Furthermore, as discussed above, obtaining a job can
have an impact on the individual in terms of enhancing
positive and reducing negative aspects of well-being,
resulting in increased sense of agency as well as increased
social networks. Employment can also impact the family
in terms of leading to a more positive outlook on their
child’s future and, more generally, in terms of a positive
effect on parental well-being. However, the majority of
studies have simply looked at whether an individual has
been given a job or not, with few studies collecting more
detailed information, and even fewer studies exploring
non-work-related outcomes. We failed to identify any
studies that explored effects of employment on the family
system. Therefore, future research will have to be multi-
disciplinary and multifaceted in approach and needs to
explore a range of employment programme outcomes
including job status and job retention, the effects on per-
sonal and family well-being as well as cost-effectiveness
and other economic impacts.
Although it is well established that rates of employment
for individuals with ASD are very low, some individuals
are able to find and retain jobs and even progress in their
career. Researchers need to examine the factors that lead to
success in the workplace for these individuals with ASD in
order to inform the development of work-related or
10 Autism
workplace programmes and supports. Furthermore, while
employment programmes tend to lead to positive outcomes
for adults with ASD, this is not the case for all individuals.
Individual differences in outcomes are not at all surprising
as significant heterogeneity is apparent across every facet
of ASD including the timing of onset and course of symp-
tom development, the specific manifestation of symptom
profile, developmental outcomes in terms of cognitive/lan-
guage impairment and comorbidities including behaviour
problems and mental health difficulties (Bryson et al.,
2007; Prior et al., 1998; Vivanti et al., 2013). The impact of
individual differences on employment success or failure is
thus an important avenue for future research.
Factors that are associated with work-related outcomes
for adults with ASD remain under-researched and poorly
understood. Although older age, better education and lack
of comorbidities have been identified as positively related
to employment, it is not clear whether these factors are
general or specific for particular employment scenarios.
Future research is needed to identify the specific factors
that relate to employment outcomes for adults with ASD,
as knowing what works, for whom, and when, is a neces-
sary first step in being able to better support these indi-
viduals to lead healthy and fulfilling lives.
Acknowledgements
D.H. and M.U. contributed equally to the article. D.H. and M.U.
conceived and designed the systematic review. D.H., M.U. and
L.C. conducted the review, analysis and interpretation of articles.
S.H. assisted with the article review. D.H., M.U. and L.C. drafted
the article. All authors contributed to the revision of the final
article.
Funding
This research was supported by Hewlett Packard Enterprise and
the Australian Government Department of Human Services.
M.U. is supported by an Autism CRC postdoctoral fellowship. At
the time of writing, S.H. was supported by an Endeavour
Australia India Education Council Research Fellowship. The
authors declare no conflicts of interest.
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