Pre-Graduation Transition Services for Improving Employment Outcomes among Persons with Autism Spectrum Disorders: A Systematic Review

Abstract

The objective of this Campbell systematic review was to determine the effectiveness of pre-graduation interventions aimed at persons with autism spectrum disorders (‘ASD’) to shape behaviors, social interactions, and/or skills that result in employment in mainstream competitive employment settings.

No studies were identified that met all the inclusion criteria specified for the review. This review was not able to identify definitive interventions that predictably and positively supported the development of transition programs designed to produce employment outcomes for individuals with ASD. Given the regulations and funding often surrounding transition programming for students with disabilities, it is remarkable that such limited research attention has been paid to the effectiveness of interventions that produce the intended result of such programs. Future research efforts are needed to develop studies that utilize a rigorous experimental design to determine the relative effectiveness of the various interventions being utilized in transition programming for students with ASD. It is also important for such studies to identify actual employment outcomes that result from presumed preparatory or facilitating interventions utilized in transition programs.

Executive Summary/Abstract

BACKGROUND

As the number of individuals diagnosed with autism spectrum disorders (ASD) rises, attention is increasingly focused on potential employment outcomes for individuals with ASD, especially for those individuals that are exiting public school settings. Individuals without disabilities are eight times more likely to be employed than individuals with 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).

OBJECTIVE

To determine the effectiveness of pre-graduation interventions aimed at persons with autism spectrum disorders to shape behaviors, social interactions, and/or skills that result in employment in mainstream competitive employment settings.

SEARCH STRATEGY

Studies were identified using electronic search techniques of 30 computerized databases. The keywords used in the computerized bibliography searches were divided into three categories: population, treatment, and domain and design characteristics. The searches covered the period from 1943 through 2011. Grey literature identified through electronic searches was submitted to the same inclusion criteria as other studies. The same time range (1943 - 2011) and inclusion criteria were applied to a search of the grey literature for unpublished studies. References from individual studies were searched for potential studies to consider for inclusion. In addition, unpublished dissertations and theses were identified through the search strategy for review and consideration.

SELECTION CRITERIA

A two-stage process was used to determine inclusion or exclusion of studies: (1) title and abstract stage and (2) full text stage. The participant sample of the study was secondary school-age individuals (ages 14-22), with a diagnosis of Autism Spectrum Disorder (ASD). Interventions for this review were included if they were designed as an approach to prepare and/or place transition-age individuals with ASD into gainful employment. Interventions that address the acquisition of job-related skills/behaviors or social employment-appropriate skills/behaviors without an employment outcome were excluded. Studies with a research design of randomized controlled trials, quasi-experimental, or single subject experimental were coded for inclusion.

DATA COLLECTION AND ANALYSIS

The combined electronic and hand searches produced a total of 5,665 citations at Stage 1 Title/Abstract. Of these studies a total of 85 citations were advanced for collection of a full text copy of the study (Full-Text Stage 2). The search results were examined independently by three of the review authors.

RESULTS

This review was not able to identify definitive interventions that predictably and positively supported the development of transition programs designed to produce employment outcomes for individuals with ASD. Upon review of the full-text for each of the 85 studies, no studies were identified that met all the inclusion criteria specified for the review. The following describes the reasons for exclusion of the studies identified through the Stage 2 review procedures: studies that did not describe or assess an intervention (n = 40), did not present outcomes related with gainful employment (n = 38), did not contain participants with ASD (n = 3), or did not provide quantitative data (case study) (n = 4).

AUTHORS' CONCLUSIONS

While no definitive conclusions can be drawn based upon the current review, the authors did identify qualitative research and other related studies that addressed elements of potential successful employment placements for transition-age individuals with ASD that are detailed in Appendix B.

Given the regulations and funding often surrounding transition programming for students with disabilities, it is remarkable that such limited research attention has been paid to the effectiveness of interventions that produce the intended result of such programs. Future research efforts are needed to develop studies that utilize a rigorous experimental design to determine the relative effectiveness of the various interventions being utilized in transition programming for students with ASD. It is also important for such studies to identify actual employment outcomes that result from presumed preparatory or facilitating interventions utilized in transition programs.

1 Introduction

According to the Centers for Disease Control and Prevention (CDC, 2012), 1 in 88 children were on the autism spectrum in 2012. This number is a 23% increase in the prevalence rate since the last CDC report issued in 2009. Additionally, functional limitations caused by autism spectrum disorders (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 with ASD who are exiting public school settings. In the United States, vocational rehabilitation agencies are charged with providing service to support employment outcomes of individuals with disabilities, including those with ASD. Vocational rehabilitation agencies are seeing an increase in the number of transition-age people with ASD accessing their employment support services. In fact, the number of people with ASD accessing services increased from 1,908 in 2002 to 8,893 in 2010. This represents a 21% annual average increase (Butterworth et al., 2012). 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).

Educational systems in Australia, the United Kingdom, and the United States start preparing youth with ASD for life after statutory education in the last years of their education (Autism Spectrum Australia, 2011; National Autistic Society, n.d.). In the U.K. and U.S., this planning begins at age 14. In the U.S., for example, transitional planning is explicitly defined and regulated via the Individuals with Disabilities Education Act (IDEA), which governs how states and public agencies provide transitional services to children with disabilities (IDEA, 2004). Transitional services in the IDEA refers to a coordinated set of activities for a student with a disability that are: •

designed to facilitate the student's movement from school to post-school activities, including postsecondary education, vocational education, and integrated employment (including supported employment);

•

based on the individual student's strengths, preferences, and interests; and

•

comprised of instruction, related services, community experiences, the development of employment, and other post-school adult living objectives (IDEA, 2012).

In addition, the IDEA requires that transition services be included in all Individualized Education Program (IEP) plans for students with a disability, as defined by federal regulations, upon reaching 16 years of age. IEP's may be developed for younger students with disabilities if determined to be appropriate by the student's IEP team. Transition services addressed by the IEP are to be a coordinated set of activities that promote movement from school to post-school activities such as: postsecondary education, vocational training, employment, adult services, independent living, and/or community participation.

Although economic conditions and employer attitudes are important factors in acquiring 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 identified 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 for persons with ASD need to be better understood and addressed by employment support service providers, especially those that plan and implement school-to-work transition programs.

A need exists to better understand the factors that are related to effective and efficient transition to employment by transition-age young people with ASD. Rigorous examination in this area will promote more efficient and effective transition programming that more predictably produces employment outcomes for students with ASD exiting educational settings.

1.1 CONTRIBUTION OF THE REVIEW

This review intended to identify and describe the effectiveness of behavioral and social interventions that prepare school-age youth with autism spectrum disorders for employment after graduation. In addition, the review intended to serve as guidance for planners of transition programs and as an indicator of where further research would be beneficial.

More needs to be known about the effectiveness of strategies that are successful in supporting the transition of youth with ASD into employment settings. As the population of persons with ASD grows, more demands and expectations will center on schools and vocational support agencies to effectively facilitate their transition into appropriate work and community living settings.

A glossary to assist readers in understanding the differences in terminology related to the variety of employment outcomes and job support interventions is provided in Appendix 8.1: Glossary of Job Support and Intervention Terminology. This review highlights trends and gaps in the current relevant literature base.

2 Objective

The objective of this review was to determine the effectiveness of pre-graduation interventions aimed at persons with ASD to shape behaviors, social interactions, and/or skills that result in employment in mainstream competitive employment settings.

This review did not include interventions that were provided to solely develop employment readiness outcomes (e.g., increase in work-related skills that were not utilized in actual paid work) or behavior shaping that was not translated to an actual work setting. The review required studies to demonstrate an actual employment outcome as a result of a school-to-work transition program or related interventions that may be provided by other agencies, such as state departments of vocational rehabilitation, within the transition process for youth with autism spectrum disorders.

3 Methods

3.1 CRITERIA FOR INCLUSION AND EXCLUSION OF STUDIES IN THE REVIEW

A two-stage process was used to determine inclusion or exclusion of studies: (1) title and abstract stage and (2) full text stage.

3.1.1 Title and Abstract Stage

Studies were assessed and selected for advancement to the next stage of inclusion if evaluation met at least one of the two following criteria:

3.1.1.1 Participants

The participant sample of study was transition-age individuals (14-22 years), with a diagnosis of Autism Spectrum Disorder (ASD). The review was designed to identify effective interventions that could be implemented by school-to-work programs or other pre-graduation vocational development programs; therefore, adult employment programs were excluded. For a review on the effectiveness of employment assistance for adults out of school, see Westbrook, Nye, Fong et al. (2012).

3.1.1.2 Intervention

Interventions for this review were included if they were designed as an approach to prepare and/or place transition-age individuals with ASD in a gainful competitive employment setting earning minimum wage or above. Due to the significant rates of unemployment among persons with ASD, this review sought to identify school-to-work transition services that were effective in producing employment outcomes for students with ASD. Interventions that addressed the acquisition of job-related skills/behaviors or social employment-appropriate skills/behaviors without an employment outcome were excluded. The types of employment targeted for inclusion were competitive, supported, or integrated employment. Studies in which the experimental groups assigned to sheltered work or non-integrated work interventions were excluded from the review due to not providing the integrated or mainstream format of employment.

If these criteria were not clear from the title or abstract, the study was advanced for retrieval of the full text to determine eligibility.

3.1.2 Full-Text Stage

Full-texts of studies from all citations/abstracts advanced from Stage 1 were retrieved for a final determination of inclusion in the review and analysis. All of the following criteria were required for each study in order to be included in the review and analysis.

3.1.2.1 Research Design

Included studies had to use an experimental or randomized controlled trial design (RCT), quasi-experimental design (QED), or single subject experimental design (SSED) to report the effects of the intervention.

3.1.2.2 Participants

The recipients of the intervention were individuals with an ASD, were of secondary school age (14-22 years), and were involved in transition from school-to-work activities. Study participants eligible for inclusion were individuals diagnosed with Asperger Syndrome, Autism, Rett Syndrome, Childhood Disintegrative Disorder, or Pervasive Developmental Disorder-Not Otherwise Specified, as defined in the DSM-IV-TR (American Psychiatric Association, 2000). Study participants with ASD and other secondary disabilities were included. However, study participants with primary disabilities such as intellectual disability, schizophrenia, attention deficits, or other non-autism related conditions were excluded.

Participants not employed at the time of the study intervention were the focus of this review. Reviewers did not exclude studies in which the participant pool included both participants who had an employment history and those who did not. Individuals who were employed prior to an intervention study were not excluded in this review.

3.1.2.3 Intervention

The intervention under investigation had to be directed towards addressing skills and/or behaviors needed by individuals with ASD for employment. Eligible interventions addressed social, behavioral, cognitive, or specific employment skills (e.g., operating a cash register) related to the acquisition and maintenance of employment among the study participants. Interventions of interest involved relatively specific and structured experiences in a school-to-work transition process designed to support employment placement, for example, providing guidance in completion of applications, résumés, and engaging in interviews; shaping of work skills and appropriate employment setting social skills; or teaching of appropriate work-related communication skills.

Interventions for inclusion were a part of school-based transition programming or could have been ancillary transition services that were provided by other agencies such as a state vocational rehabilitation agency. Interventions to be included in this review were to be divergent in their scope and area of focus: for example, the development of social skills rather than development of work-specific skills because of the particular needs of the subject group. This is appropriate due to the wide variation in personal characteristics that are displayed across the autism spectrum. To accommodate this need and appropriate variation in interventions, studies for inclusion focused across social, behavioral, and/or skill-oriented interventions. Interventions of any length duration were included provided adequate description was provided. Interventions for inclusion were required to demonstrate an employment outcome as a component of the transition process.

3.1.2.4 Outcome Measures

Eligible outcomes included attainment of an employment placement and specific data about the duration and/or retention of that placement. Eligible gainful employment consisted of competitive, integrated, or supported employment. Employment at sheltered work or non-integrated work settings was not considered as an outcome measure for this review. Employment encompassed full or part-time placements. Employment assistance interventions of any length duration were included. Although school-based transition services may focus on producing a variety of outcomes (e.g., community participation and independent living, among others), this review focuses only on those services that produced employment outcomes due to the key function employment can play in many quality of life areas of persons with ASD.

3.1.2.5 Publication Status

Published and unpublished studies were included in the evidence pool.

3.1.2.6 Country of Origin and Language of Publication

Studies that were conducted in any country were eligible. We did not exclude studies reported in languages other than English, but we did not specifically search for non-English literature; however, we did search five international databases. Non-English language studies that were retrieved or reviewed required the reviewers to obtain translation assistance from native speakers (e.g., Higuchi & Noutomi, 2010).

3.2 SEARCH STRATEGY FOR IDENTIFICATION OF RELEVANT STUDIES

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

3.2.1 Electronic Searches

Studies were identified using electronic search techniques of 30 computerized databases. We consulted database thesauri where they were available to ensure that the universe of appropriate synonyms had been included in the intervention and outcome search term categories. Search terms and search strategies were modified to fit individual databases.

Databases searched included: 1.

ABI Inform Global

Academic One File

Academic Search Complete

Australia Education Index

ARD (Autism Research Database)

Bing

British Education Index

Canadian Research Index

CBCA Education

10.

CINAHL Plus with Full Text

11.

CIRRIE (Center for International Rehabilitation Research Information and Exchange Database)

12.

Cochrane Central Registry of Controlled Trials

13.

Dissertation Abstracts International

14.

Educational Full Text

15.

Ed Line and Electronic Texts in Education

16.

ERIC

17.

FRANCIS

18.

Google (advanced)

19.

Google Scholar

20.

NARIC REHABDATA

21.

Professional Development Collection

22.

Psychology and Behavioral Sciences Collection

23.

PsycINFO

24.

PubMed/MEDLINE

25.

Sage Family Studies Abstracts

26.

Science and Technology Collection

27.

Sociological Abstracts

28.

Web of Science

29.

WorldCat [for monographs]

30.

Yahoo! (advanced)

3.2.2 Search Terms

The keywords used in the computerized bibliography searches were divided into three categories: population, treatment, and domain and design characteristics. The searches covered the period from 1943 through 2011. The first paper identifying a condition called autism was published in 1943 (Kanner, 1943); therefore, the start date for the search was 1943 (similar to a previous review: see Westbrook, Nye, Fong et al., 2012). All search terms were truncated using the appropriate conventions in order to include variations in endings of words and in spelling. Terms from the three categories were connected with “or” within each category and connected with “and” between categories.

Population

autis*

childhood disintegrative disorder*

pervasive developmental disorder*

spectrum disorder*

ASD

Asperger*

Rett*

Age

adolescen*

school age*

high school*

teen*

secondary*

young*

youth*

student*

Treatment

intervention*

model*

program*

practice*

instruction*

training*

service*

transition*

education*

school to work*

Domain

employ*

behavior*

rehab*

vocation*

work*

occupation*

trade*

career*

skill*

job*

Design

experiment*

control group*

single*

effect*

random*

For more information on the search strategy, see Appendix 8.2: Documentation of Search Strategies for the Systematic Review.

3.2.3 International Contacts

Our efforts to find studies from outside the United States included searching in five non-United States and international databases, including Australia Educational Index, British Education Index, Canadian Research Index, CBCA Education, and FRANCIS. These databases did yield studies that were reviewed in Stage 1 of the title/abstract review procedures.

3.2.4 Grey Literature

Grey literature—such as unpublished manuscripts, dissertations and theses, or government reports—identified through electronic searches was submitted to the same inclusion criteria as other studies. The time range (1943 - 2011) and inclusion criteria for grey literature were the same as specified for the published studies.

3.2.5 Cross-Referencing of Bibliographies

The references in relevant journal articles and other reports of research results were scanned for additional studies for inclusion in the review.

3.2.6 Conference Programs

Recent conference programs and conference syntheses (2010-2011) from relevant associations and conferences were used to identify unpublished studies eligible for review inclusion.

Professional organizations/events that were examined included:

Autism Society of America

National Association of Rehabilitation Research and Training Centers International

Society for Autism Research

National Alliance for Autism Research

Autism Research Institute

National Autistic Society (UK)

Autism Research Centre (Cambridge)

Conference proceedings that were reviewed included:

Asia Pacific Autism Conference 2011

Penn Autism Network 2011 Conference.

Council for Exceptional Children (CEC) Annual Conference 2011

3.3 CODING PROCEDURES AND CATEGORIES

Studies were screened for inclusion/exclusion decisions at two stages, Stage 1: title and abstract and Stage 2: full-text. The same three coders served as independent reviewers at both stages. Inter-rater reliability was tested at both stages. A fourth party was not needed to resolve a coding value difference.

3.3.1 Title and Abstract Stage

At Stage 1, the decision for advancing the retrieved titles and abstracts to the full text stage retrieval was made independently by all reviewers. Inter-rater reliability was established with a random sample of 25 titles and abstracts. Reviewers demonstrated a 96% rate of agreement. When differences did arise, resolution occurred through discussion and agreement of the three reviewers. Titles and abstracts were advanced to full-text stage based on meeting two criteria from the following questions (items a, b, and c) or a designation by a reviewer of ‘unsure’ (item d): a.

Are the participants identified, described, and defined under the Autism Spectrum Disorder category?

Are the participants of secondary school age (ages 14-22)? Are the participants enrolled in a school-to-work transition program or secondary-level education/program?

Is this abstract/citation about employment?

Unsure of meeting inclusion criteria?

3.3.2 Full-Text Level

At the Stage 2 level, full texts of all citations advanced from Stage 1 were obtained and coded for an inclusion/exclusion decision. The decision for advancing the retrieved full-text studies to an inclusion status was made by three reviewers for each study, independently evaluating each study. An inclusion decision for advancement to the coding stage of the process required that a study met all the criteria presented earlier. Inter-rater reliability was established prior to initiating coding activities, minimizing coding disagreements. Coders demonstrated agreement in ranking a random sample of 20 studies at a 100% rate of agreement.

At the Stage 2 level, the three reviewers recorded all excluded studies and the reason for exclusion independently. For more information, see Appendix 8.4: Reasons Stage 2 Studies were Excluded from the Systematic Review.

When multiple studies used the same sample or outcome data, the study providing the most complete information focusing on our desired intervention outcome was selected for inclusion.

3.4 ASSESSMENT OF METHODOLOGICAL QUALITY

Included studies were coded by three independent reviewers for methodological quality on dimensions that included: •

Design type ◦

RCT Individual Randomized Design

◦

RCT Group Randomized Design

◦

Quasi-Experiment: Equivalent Comparison Design (individuals)

◦

Quasi-Experiment: Equivalent Comparison Design (groups)

◦

Quasi-Experiment: Non-Equivalent Comparison Design (individuals)

◦

Quasi-Experiment: Non-Equivalent Comparison Design (groups)

◦

Quasi-Experiment: Regression Discontinuity

◦

Single Group Quasi-Experiment: Interrupted Time Series Design

◦

Single Group Pre-test/Post-test design

◦

Withdrawal Single Subject Experimental Design (ABAB)

◦

Multiple Baseline Single Subject Experimental Design (MBL)

◦

Survey: Cross Sectional

◦

Survey: Longitudinal

•

Unit of assignment (e.g., individual vs. group/class)

•

Unit of analysis (e.g., Intention to Treat, Test only, Treated)

•

Attrition from pre-test to post-test

•

Fidelity of implementation (e.g., following replicable program of intervention)

•

Blinding of assessors/interventionists

Other data were to be extracted and coded from the primary studies included: publication source, subject characteristics, sample source, employment setting, intervention characteristics, type of employment, and outcome measurement. See Appendix 8.3 for the coding form.

3.5 CALCULATING EFFECT SIZES

The magnitude of the intervention effect was to be calculated using the commonly accepted statistical formulae and dedicated programs available. The protocol of this systematic review (Westbrook, Nye, Wendt et al., 2012) describes these statistical formulae in depth.

However, due to the lack of studies that met inclusion criteria, effect size calculations and syntheses were not possible.

3.6 TREATMENT OF QUALITATIVE RESEARCH

Qualitative research was not included in the analysis of the intervention research. However, a significant body of relevant qualitative and descriptive literature was identified by the authors in the Stage 1 and Stage 2 reviews. Reviewers summarized the trends from these related qualitative and descriptive studies in Appendix 8.2.

4 Results

4.1 INFORMATION RETRIEVAL

The combined electronic and hand searches produced a total of 5,665 citations at Stage 1 Title/Abstract. Of these studies a total of 85 citations were advanced for collection of a full text copy of the study (Stage 2 Full-Text). The search results were examined independently by three of the review authors.

Upon review of the full-text for each of the 85 studies, no randomized controlled, quasi-experimental, nor single-subject experimental studies were retained for having met all inclusion criteria described earlier. Should such studies be identified for updates of this review, the methods outlined previously will be employed. A list of the excluded studies and the reasons for exclusion are presented in Appendix 8.4. Studies did not describe or assess an intervention (n = 40), did not present outcomes related with gainful employment (n = 38), did not contain participants with ASD (n = 3), or did not provide quantitative data (case study) (n = 4). None of the 85 studies were included into a pool for further analysis.

4.2 RISK OF BIAS

The review team included three individuals at both stages of this review. Inter-rater reliability was tested using a random sample of 25 studies at Stage 1 Title/Abstract. The resulting inter-rater reliability from the 25–study sample was found to be 96%. Reviewers established consensus regarding advancement to Stage 2 of these titles and abstracts through discussion.

Reviewers at Stage 2 coded individual full-text studies for research design, participant characteristics, intervention, and outcome characteristics. Inter-rater reliability was established at this stage with a random sample of 20 studies. The resulting rate of reliability was 100%. Any coding differences at Stage 2 were resolved through discussion between the three reviewers resulting in a consensus decision regarding the inclusion or exclusion.

The assessment of individual study bias was not possible, as no studies met inclusion criteria for a full review.

4.3 EFFECTS OF INTERVENTIONS

No eligible studies were found; that is, none of the 85 full-text studies met the inclusion criteria; thus, effect size calculations and syntheses were not possible.

5 Discussion

This systematic review endeavored to determine the effectiveness of pre-graduation transition-oriented interventions aimed at persons with autism spectrum disorders to shape behaviors, social interactions, and/or skills that result in employment in mainstream competitive settings. The relevant studies identified through this review did not provide a clear linkage between interventions that shaped behaviors, modified social behaviors, or produced competitive skills with an employment outcome for persons with ASD. While transition services can appropriately focus on a variety of outcomes—such as vocational training, postsecondary education, adult support services, community participation, and independent living, among others—this review focused on the outcome of employment. Due to the very low rate of employment of persons with ASD after exiting the educational system, the authors wanted to identify interventions that were most successful in supporting employment attainment and maintenance. Without an employment outcome associated with a program evaluation, the authors were unable to determine if any change in behaviors, social skills, and/or work-related skills produced through study interventions was sufficient to support successful entry into a competitive employment setting.

Because employment is the major intended outcome of school-to-work pre-graduation transition programs for students with disabilities, it was surprising that the literature generally did not establish the effect of behavior shaping, social skill development, and vocational skill development on the actual employment outcome of the participants. In most cases, the studies that focused on transition programming could have tracked students for a longer period to identify those that were successful in moving into a competitive employment placement following the study intervention. No studies were identified that developed a design utilizing an experimental control group format. However, single subject experimental designs that were utilized and documented change in behaviors/skills did not facilitate understanding in terms of the adequacy of the change to support competitive employment placement.

This review intended to identify elements of a school-to-work transition program that implemented interventions designed to meet the specific transition needs of individuals with ASD. The available data for drawing a ‘what works’ conclusion did not serve as a foundation for the authors to determine the effectiveness of interventions in approaching job searching, job placement, or on-the-job supports such as job coaching to achieve successful employment outcomes for transition program participants with ASD. The scientific quality of the available studies is weak and generally do not utilize comparison group study designs. In addition, as stated earlier, studies do not link transition interventions to successful employment outcomes for subjects.

5.1 LIMITATIONS OF STUDIES

The primary limitation of this review is the lack of rigorously designed studies that allow for a causal interpretation of the measured outcomes related to persons with ASD (14-22 years of age) achieving employment outcomes through participation in tailored and specific interventions of a pre-graduation transition program. Studies identified in this review did not link transition interventions with the intended transition outcome of entry into the competitive employment workforce. Given the absence of a scientifically rigorous literature base addressing the effectiveness of school-to-work transition programs, there is clearly a need to establish an evidence base in order to assess and guide the implementation of programs that best prepare students with ASD to transition into adult integrated work experiences.

5.2 IMPLICATIONS FOR RESEARCH

This systematic review demonstrates the lack of available research that focuses on the employment outcomes produced by pre-graduation transition programs/services for school-age (14–22 years) persons with ASD. Given the federal regulations and supporting funding surrounding transition programming for students with disabilities, it is remarkable that such limited research attention has been paid to the effectiveness of interventions that produce the intended result of such programs. Future research efforts are needed to develop experimental studies that would utilize a randomized controlled design to determine the relative effectiveness of the variety of interventions being utilized in transition programming for students with ASD. It is also important for such studies to identify actual employment outcomes that result from presumed preparatory or facilitating interventions utilized in transition programs.

Although the currently available studies focusing on effective transition programming for students with ASD are limited, the basis for designing such studies appears to be both practical and feasible. Extending transition studies to include results in the form of employment outcomes for the participants are readily understood and quite possible in the field. While individual studies of transition programming for students with ASD may lack statistical power due to the low incidence in the population, it is quite feasible to link studies across the transition programming being carried out in most secondary settings involving students with disabilities. Linking studies and creating larger sample sizes will greatly facilitate the production of meaningful results for students with ASD as they attempt transition into mainstream employment settings. In other words, future research needs to focus on the implementation of studies with small “N” group samples that can, over time, provide a synthetic larger “N” that could support a meta-analysis producing higher quality results that would be useful in both school-based planning and implementation of transition programming for students with ASD.

5.3 PLANS FOR UPDATING THE REVIEW

The authors will examine the review every three years after publication for update as per C2 policy.

6 Acknowledgements

The production of this systematic review was supported through a grant (H133A08007) from the National Institute on Disability and Rehabilitation Research in the Office of Special Education and Rehabilitative Services of the U.S. Department of Education.

Footnotes

8 Appendices

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