PROTOCOL: Pre-graduation Transition Services for Persons with Autism Spectrum Disorders: Effects on Employment Outcomes

The Problem, Condition or Issue

The first paper identifying a condition called autism was published in 1943 (Kanner, 1943). Today, the condition is referred to as autism spectrum disorders (ASD) and refers to a range of mild to severe forms of neurological disorders marked by impairment in social functioning, communication, and repetitive and unusual patterns of behavior.

According to the Centers for Disease Control and Prevention (CDC), the rate of autism has increased over the past two decades to 1 in 88 children currently being identified with ASD (CDC, 2012). Additionally, functional limitations caused by ASD continue into adulthood and often create barriers to independent living and stable long-term employment (Autism Society of America, 2008).

As the number of individuals diagnosed with ASD rises, attention is increasingly focused on potential employment outcomes for individuals with ASD, especially for individuals exiting public school settings. Individuals without severe disabilities are eight times more likely to be employed than individuals with very severe disabilities (National Organization on Disability, 2000). Individuals with ASD are among those least likely to be employed (Cameto, Marder, Wagner, & Cardoso, 2003; Dew & Alan, 2007). In fact, Lawer, Brusilovskiy, Salzer, and Mandell (2009) found that persons with autism are more likely than persons with mental retardation (MR), specific learning disability (SLD) or other impairments to be denied employment services due to their disability being too severe to benefit from such services. Those who did receive services received a more expensive set of services than those with other impairments, except for those with MR. However, successful employment for individuals with ASD appeared to be dependent on direct job supports such as job coaching, follow up, and follow along supports (Lawer et al., 2009).

Although economic conditions and employer attitudes are important factors for employment opportunities for individuals with ASD, appropriately addressing specific behaviors common among individuals with ASD can greatly improve employment outcomes (Schaller & Yang, 2005). Several studies have indicated that people with ASD are more likely to lose their employment for behavioral and social interaction reasons rather than their inability to perform work tasks (Dew & Alan, 2007; Hurlbutt & Chalmers, 2004; Unger, 1999). Further, Belcher and Smith (1994) found that higher levels of social inclusion and acceptance were correlated with longer job retention. Social challenges faced by persons with ASD listed by Mahwood and Howlin (1999) include lack of social understanding, such as failure to respect others' personal space, talking too little or too much, over reliance on supervisors, and inappropriate dress or personal habits. Behavior management challenges affecting employment must be understood and addressed consistently by employment support service providers in order to effectively facilitate attaining and maintaining employment by individuals with ASD. Higgins, Koch, Boughfman, and Vierstra (2008) recommended that school-to-work transition programs include services such as job seeking skills, career exploration opportunities, supported employment, accommodations planning, and services to employers. Hasazi, Johnson, Hasazi, Gordon, and Hull (2001) found that 75% of individuals with disabilities who had received vocational classes while in school were employed 1 year post graduation, and 64% of students who had worked during high school were employed 2 years post graduation.

The Intervention

Of particular importance is a need to help school-age individuals with ASD transition to employment. According to the CDC, there are currently approximately 730,000 individuals with autism in the United States between the ages of 0 and 21. Many (if not most) of these individuals will presumably require transitional employment services. Interventions addressing barriers to employment have been shown to facilitate transition success. For example, workplace behavior problems are a common reason why people with ASD lose a job (McClannahan et al., 2002). Behavior problems for school-age individuals with ASD can manifest in various ways, including insistence on sameness and resistance to change, sustained odd play, expressing emotions for reasons not apparent to others, preference to be alone, tantrums, and executive function problems.

While research has been conducted and reported on behavioral management such as cognitive/behavioral training, self management strategies, and social skills development (Mahwood & Howlin, 1999; McClannahan et al., 2002), there is a need to examine the effects and aggregate findings of school-to-work-oriented programs designed to improve behavior management and social interaction and, as a result, improve employment outcomes for individuals with ASD.

Interventions included in this review produce an employment outcome. Intervention techniques would include those that (a) use social adjustment techniques to increase the social acceptability of an individual in a work place setting, (b) use behavioural adjustment techniques to decrease behaviors that are not acceptable in the workplace, (c) use a combination of social and behavioral adjustment interventions to increase workplace acceptance, (d) develop skills that may be needed in a specific work environment, (e) focus on developing skills to complete job applications, produce a vita/resume, or engage in person-to-person job interviews; and/or (f) focus on parental or third-party supports aimed at acquiring and maintaining a job.

How the Intervention Might Work

School-based transition programs often pursue a variety of pathways to achieve the desired outcome of the program – employment. Due to the fact that the characteristics of individuals differ markedly depending on where an individual falls on the autism spectrum, it is appropriate for schools to take divergent pathways to achieve employment outcomes for their students with autism spectrum disorders. As stated previously, interventions aimed at directly producing an employment outcome are included in this review. Interventions that would solely produce some level of “readiness” for employment are not included in this review's interventions.

Generally, school-to-work transition programs for students with autism spectrum disorders develop individualized plans and strategies to prepare and assist students' movement into employment positions for which they have interest. The intervention will provide assistance in preparing the student for the social and behavioural demands of the employment site and will also provide a level of support at the work site to deal with social and behavioural adjustment issues that may arise.

Interventions of interest included in the review are expected to vary widely. For example, in some cases an intervention might include assistance in helping to prepare materials such as résumé and deal with online application processes. In other cases, the intervention may focus on the demands of a job interview and socially appropriate responses and behaviors for various potential inquiries. In other cases, an intervention may prepare individuals by shaping the ability to perform appropriately in social interactions and to “read” emotions, humor, sarcasm, and other common dimensions in general interactions. Some interventions may focus on job skill development and its transference and maintenance on a work site. Other interventions may incorporate pieces of many of these interventions in their own transition to work strategy.

According to the National Longitudinal Transition Study-2 (2011), of the young adults with autism interviewed eight years after leaving high school, 37.2% were employed at the time of the interview and 63.2% indicated that they had been employed at some point since leaving high school. In addition, youth with autism on average have held 3.1 jobs since leaving high school with an average duration of 24.7 months. Youth with autism reported the least average number of hours worked per week (24.1 hours) when compared to all other disability groups in the NLTS-2 study (2011). These data indicate that a large segment of youth with ASD are not progressing into and maintaining competitive employment placements. Interventions of focus in this review, however, are examples of strategies intended to support the transition of youth with ASD into employment placements.

Shattuck et al. (2012) analysed results of the NLTS-2 collected in 2007-2008 of subjects within two years of having left high school. Comparing youth in three other reported categories with those in the autism category, they found that those with ASD demonstrated significantly lower rates of employment and the highest ever rates of no participation in any postsecondary employment or school.

Interventions of interest in this review focus on strategies to bridge gaps identified in NLTS-2 for those with ASD that are successfully transitioning to employment placements through support from school-to-work transition programming.

Why it is Important to do the Review

Research has been conducted in the area of autism and school-to-work transition services (e.g., Rigsby-Eldridge, 1992), but such research has not been integrated in a comprehensive review format before. Thus, a systematic review on the effectiveness of behavioral and social interventions for transition-age individuals with ASD would not only provide resources for practitioners towards obtaining or maintaining employment, but also show evidence that can inform implementation of further research.

More needs to be known about strategies that are successful in securing and maintaining employment outcomes for individuals with ASD. Enhanced awareness of effective approaches is likely to increase the availability of more effective transitional school-to-work services for individuals with ASD, such as behavioral/social management, vocational rehabilitation, or communication facilitation interventions. A review of studies on transitional assistance would not only synthesize the effects and techniques of successful or unsuccessful interventions, but also call to attention the gaps in experimental research in this area.

Criteria for Inclusion and Exclusion of Studies in the Review

A two-stage process will be used to determine inclusion or exclusion of studies: (a) title and abstract stage and (b) full text stage.

Search Strategy for Identification of Relevant Studies

The search strategy for identification of relevant studies is highlighted below.

Databases searched will include the following databases (and others may be added):

a.

PubMed

In addition, a search of Google Scholar, Google Advanced, Yahoo Advanced, and Bing search engines will be conducted. Search strategies will be modified to optimize the search capabilities of each search engine.

Coding Procedures and Categories

Studies will be coded for inclusion/exclusion decisions at two stages, Stage 1: citation and abstract and Stage 2: full-text. Three coders will serve as independent reviewers at both stages. A fourth party will be used in the case that the reviewers disagree and cannot resolve a final coding value.

Full-Text Level

At the Full-Text Stage 2 level, a full text of all citations advanced from Stage 1 will be obtained and coded for an inclusion/exclusion decision. The decision for advancing the retrieved full-text studies to an inclusion status will be made by three reviewers for each study, independently evaluating each study. An inclusion decision for advancement to the coding stage of the process will require that a study meet all the criteria presented earlier. Inter-rater reliability will be established prior to initiating coding activities, thus minimizing coding disagreements. Any disagreements in the determination of the presence of these criteria will be resolved by discussion of the three reviewers. In the event reviewer differences cannot be resolved via consensus building, a fourth reviewer will be asked to render a final decision. An inter-rater reliability of 95% will be established.

At the Full-Text Stage 2 level, three reviewers will record all excluded studies and the reasons for exclusion independently.

Multiple studies that use the same sample or data will not be included. The most rigorous study focusing on our desired intervention outcome will be selected for inclusion.

Calculating Effect Sizes

The magnitude of the intervention effect will be calculated using the commonly accepted statistical formulae and dedicated programs available. While the outcome data may be available in different formats, we believe that most of the data will be presented in such a way as to require one of the following statistical approaches.

Synthesis of Effect Sizes

Studies using a two group experimental or quasi-experimental design will be included in the data synthesis for group design studies. Studies reporting either a pre-experimental single group pre- posttest or single subject experimental design will be analyzed separately and not combined with other design types. Studies that utilize PND and PZD will be included in the synthesis efforts.

Sensitivity Analysis

A sensitivity analysis will be conducted to assess the impact of a single study on the magnitude of an overall observed effect size. The sensitivity analysis will be conducted for overall study effect size and as appropriate, the impact of moderating variables (e.g., attrition, type of treatment, missing data, sample size, study design).

Publication Bias

Publication bias will be assessed for published vs. unpublished included studies through the visual inspection of a funnel plot and/or a moderator analysis.

Incomplete Reporting of Study Data

For studies reporting incomplete outcome data, we will first contact the senior author of the study and request the missing information to include in the analysis. If we are unable to obtain the needed information, we will attempt to use a method of imputation in which we will set the effect for the missing data to zero and then calculate the outcome effect size. Reported results will be presented both with and without the imputed data in order to assess the magnitude of the impact of the imputation process.

Subgroup Analyses

In order to assess the methodological quality of included studies, a subgroup analysis will be conducted for the design type (RCT vs QED). That is, the mean effect sizes will be calculated for each design type separately across all outcome variables.

Moderator Analyses

Moderator analyses will be conducted for a limited number of independent variables. The approach to the moderator analyses will be dependent on the available data. Meta-regression will be used if a sufficient number of studies are present to reasonably regress multiple factors on to the treatment effect size. At a minimum, the following categorical variables will be considered for moderator analyses if appropriate:

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Type of Intervention

Treatment of Qualitative Research

Qualitative research will not be used in the analysis of the intervention research.