Interventions for Work/Employment Participation for Autistic Adults (2013–2020)

Full Systematic Review Question

This systematic review addressed the question “What are the interventions within the scope of occupational therapy to address participation in activities of daily living, instrumental activities of daily living, rest and sleep, work, education, play, leisure, social participation, and health management among autistic people over the age of 18?”

Current Theme Reported

The main theme of the studies included in this systematic review brief is work/employment participation.

Clinical Scenario

Employment is a key indicator of quality of life for adults. The unemployment and underemployment of autistic adults is a major concern because of associated risks of decreased socioeconomic status (Butterworth et al., 2012; Hendricks, 2010), health (Hedley et al., 2019; Ipsen, 2006), daily living skills (Clarke et al., 2021), and overall quality of life (Kober & Eggleton, 2005; Scott et al., 2019). Historically, research indicates that autistic adults who receive specialized vocational instruction are more likely to be competitively employed (Bennett et al., 2013; Dotson et al., 2013; Kellems & Morningstar, 2012; Walsh et al., 2014; Wehman et al., 2015). Occupational therapy practitioners must understand which interventions are effective in supporting multiple facets of employment participation, from job acquisition and training, as well as work engagement and success.

Summary of Key Findings

Ten articles were reviewed that focused on employment participation (Table 1). These articles were further divided into themes based on whether the intervention outcomes focused on (a) competitive employment (i.e., getting a job, number of hours worked, and/or maintaining employment) or (b) development of employment skills or behaviors in the context of the job (i.e., social skills in the context of work and/or quality of job performance). The strength-of-evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018). We used the Oxford Centre for Evidence-Based Medicine (2009) levels of evidence for this review. For single-subject research design studies, the level of evidence and quality assessment were done using methodology from Romeiser Logan et al. (2008).

Bottom Line for Occupational Therapy Practice

The studies included in this review demonstrate that intensive manualized intervention approaches combining direct instruction with multimodal supports (visual supports, behavioral supports, employer job site training, and environmental modifications) in the context of customized supported employment and/or internship settings contribute to acquiring and maintaining competitive employment for autistic young adults. There is low strength of evidence from single-case designs with small samples, indicating that assistive and technology and behavioral approaches that are tailored to the individual for task performance within the context of specific jobs improve the development and performance of specific job skills.

Comprehensive, multimodal job training and support programs delivered at high intensity positively impact competitive employment outcomes for autistic young adults. Occupational therapy practitioners can refer youth and adults to community-based programs and contribute to programs as multidisciplinary team members. Occupational therapy practitioners can help identify an individual’s goals and priorities, analyze occupational performance within the context of desired job and work activities, and contribute to customized person, task- or environment-based interventions, modifications, or accommodations. Individualized assistive technology and behavioral supports as methods to teach targeted work behaviors and skills within the work environment yielded improvements in employment participation through the development of job skills and independent task performance. Though supported by a lower strength of evidence, individualized interventions delivered using assistive technology and behavioral supports in context and as a component of job coaching programs show promise, with the identification and implementation of such supports also falling into the scope of occupational therapy practice. Studies included in this systematic review were determined to have outcomes that measured employment participation, and studies that focused on skill acquisition outside of employment settings were excluded.

The studies in this review are limited by the lack of reporting and/or attention to the engagement of autistic adults as stakeholders in the research process and limited information about whether individual study goals and outcomes were stakeholder generated. Studies of occupational therapy interventions and outcome measures that more fully capture dimensions of meaningful work participation are needed to expand the evidence base for occupational therapy practices and outcomes.