A Systematic Review of Vocational Interventions for Young Adults With Autism Spectrum Disorders

Article (PDF Available)inPEDIATRICS 130(3):531-8 · August 2012with60 Reads
DOI: 10.1542/peds.2012-0682 · Source: PubMed
Abstract
Many individuals with autism spectrum disorders (ASDs) are approaching adolescence and young adulthood; interventions to assist these individuals with vocational skills are not well understood. This study systematically reviewed evidence regarding vocational interventions for individuals with ASD between the ages of 13 and 30 years. The Medline, PsycINFO, and ERIC databases (1980-December 2011) and reference lists of included articles were searched. Two reviewers independently assessed each study against predetermined inclusion/exclusion criteria. Two reviewers independently extracted data regarding participant and intervention characteristics, assessment techniques, and outcomes, and assigned overall quality and strength of evidence ratings based on predetermined criteria. Five studies were identified; all were of poor quality and all focused on on-the-job supports as the employment/vocational intervention. Short-term studies reported that supported employment was associated with improvements in quality of life (1 study), ASD symptoms (1 study), and cognitive functioning (1 study). Three studies reported that interventions increased rates of employment for young adults with ASD. Few studies have been conducted to assess vocational interventions for adolescents and young adults with ASD. As such, there is very little evidence available for specific vocational treatment approaches as individuals transition to adulthood. All studies of vocational approaches were of poor quality, which may reflect the recent emergence of this area of research. Individual studies suggest that vocational programs may increase employment success for some; however, our ability to understand the overall benefit of supported employment programs is limited given the existing research.
A Systematic Review of Vocational Interventions for
Young Adults With Autism Spectrum Disorders
abstract
BACKGROUND AND OBJECTIVE: Many individuals with autism spectrum
disorders (ASDs) are approaching adolescence and young adulthood;
interventions to assist these individuals with vocational skills are not
well understood. This study systematically reviewed evidence regard-
ing vocational interventions for individuals with ASD between the ages
of 13 and 30 years.
METHODS: The Medline, PsycINFO, and ERIC databases (1980Decem-
ber 2011) and reference lists of included articles were searched. Two
reviewers independently assessed each study against predetermined
inclusion/exclusion criteria. Two reviewers independently extracted
data regarding participant and intervention characteristics, assessment
techniques, and outcomes, and assigned overall quality and strength of
evidence ratings based on predetermined criteria.
RESULTS: Five studies were identied; all were of poor quality and all
focused on on-the-job supports as the employment/vocational intervention.
Short-term studies reported that supported employment was associated
with improvements in quality of life (1 study), ASD symptoms (1 study), and
cognitive functioning (1 study). Three studies reported that interventions
increased rates of employment for young adults with ASD.
CONCLUSIONS: Few studies have been conducted to assess vocational
interventions for adolescents and young adults with ASD. As such, there
is very little evidence available for specic vocational treatment
approaches as individuals transition to adulthood. All studies of voca-
tional approaches were of poor quality, which may reect the recent
emergence of this area of research. Individual studies suggest that
vocational programs may increase employment success for some;
however, our ability to understand the overall benet of supported em-
ployment programs is limited given the existing research. Pediatrics
2012;130:531538
AUTHORS: Julie Lounds Taylor, PhD,
a
Melissa L.
McPheeters, PhD, MPH,
b
,
c
Nila A. Sathe, MA, MLIS,
c
Dwayne Dove, MD , PhD,
a
Jeremy Veenstra- VanderW eele, MD,
d
and Zachary Warren, PhD
a
,
e
a
Department of Pediatrics, Vanderbilt Kennedy Center,
b
Department of Obstetrics and Gynecology, Vanderbilt Medical
Center,
c
Vanderbilt Evidence-based Practice Center, Institute for
Medicine and Public Health, Vanderbilt Medical Center,
d
Departments of Psychiatry, Pediatrics, and Pharmacology,
Center for Molecular Neuroscience, Vanderbilt Kennedy
Center/Treatment and Research Institute for Autism Spectrum
Disorders, and
e
Departments of Pediatrics and Psychiatry,
Vanderbilt Kennedy Center/Treatment and Research Institute for
Autism Spectrum Disorders, Vanderbilt University, Nashville,
Tennessee
KEY WORDS
autism spectrum disorders, supported employment, vocational
training
ABBREVIATION
ASDautism spectrum disorder
This project was funded under contract HHSA 290 2007 10065 I
from the Agency for Healthcare Research and Quality, US
Department of Health and Human Services. The authors of this
report are responsible for its content. Statements in the report
should not be construed as endorsement by the Agency for
Healthcare Research and Quality or the US Department of Health
and Human Services.
All authors meet authorship criteria; have made substantial
contributions to conception and design, acquisition of data, or
analysis and interpretation of data; have participated in drafting
the article or revising it critically for important intellectual
content; and have given nal approval of the version to be
published.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-0682
doi:10.1542/peds.2012-0682
Accepted for publication May 14, 2012
Address correspondence to Julie Lounds Taylor, PhD, Vanderbilt
Kennedy Center, PMB 40230 Appleton Pl, Nashville, TN 37203.
E-mail: julie.l.taylor@vanderbilt.edu
(Continued on last page)
PEDIATRICS Volume 130, Number 3, September 2012 531
REVIEW ARTICLE
The number of children diagnosed with
an autism spectrum disorder (ASD)
began rising rapidly nearly 20 years
ago, in the early 1990s,
1,2
and it is
presently estimated that 1 in 88 chil-
dren in the United States has an ASD.
3
Many of these children are now tran-
sitioning to adulthood. Adults with ASD
incur substantial public costs
46
; thus,
there is an urgent public health and
scientic need to identify which ser-
vices and interventions are most ef-
fective in increasing the quality of life
of these individuals and their potential
for independent functioning.
While historically there has been a sci-
entic and clinical focus on early iden-
tication and intervention in the eld of
ASD research, core social communi-
cation and repetitive behavior symp-
toms typically last throughout the life
course for most individuals. Further-
more, the limited extant research on
outcomes for adolescents and young
adults with ASD documents difculties
in achieving markers of functional in-
dependence, including employment, for
the vast majority.
7
Specically, most
adults with ASD live dependent lives;
fewer than one-third have regular em-
ployment; most live with their parents
or in supported living; and those who
are employed are often in jobs that pay
below a living wage.
812
In part because
of these high levels of dependence, the
majority of individuals with ASD will
require some sor t of support or in-
tervention, often at intensive levels,
throughout adolescence and adult-
hood.
46,13,1 4
The transition out of high
school and into the adult service system
is a time of particular vulnerability
for individuals with ASD. Although few
studies have examined this stage of the
life span specically, 1 study suggests
that improvements in symptoms and
problem beha viors observed while youth
with ASD were in high school slowed
down or stopped after they left high
school.
15
Furthermore,astudyusingthe
National Longitudinal T ransition Study2
found that youth with ASD were at in-
creased risk for no employment or
educational activities in the rst 2
years after exiting high school.
16
Upon
high school exit, these individuals lose
all mandated special education ser-
vices, and they enter a world of adult
services that is plagued by long waiting
lists and which is unprepared to meet
their unique needs.
15,17,18
To date, the specic programs and in-
terventions that underlie more positive
functional, adaptive, social, and em-
ployment outcomes for individuals with
ASD during the transition to adulthood
and beyond are poorly understood.
Furthermore, it is unclear how such
outcomes are best assessed in the face
of the inherent heterogeneity and wide
scope of impairments associated with
ASD.
19,20
This lack of information po-
tently limits the ability of individuals,
families, practitioners, and service sys-
tems to provide the appropriate care to
optimize quality of life and minimize the
costs associated with ASD over an indi-
viduals life span.
The goal of this report was to review the
literature on the effectiveness of voca-
tional interventions for individuals with
ASD, with a particular focus on the
transitionto adulthood. This review was
conducted as part of a larger system-
atic review of therapies for adolescents
and young adults (ages 1330 years)
with ASD. Information on other thera-
pies (eg, behavioral, educational, allied
health, medical) addressed in the full
review can be found at http://www.
effectivehealthcare.ahrq.gov.
METHODS
Search Strategy
We searched Medline via the PubMed
interface, PsycINFO (psychology and
psychiatry literature), and ERIC (educa-
tional literature) from 1980 to December
2011 using relevant controlled vocabu-
lary terms and key terms related to
ASD (eg, autistic disorder) and therapy
(eg, therapeutics). The reference lists of
all included articles were also hand-
searched to identify additional studies
and of recent narrative and systematic
reviews related to therapies for ASD to
identify potentially relevant articles.
Study Selection
Study inclusion and exclusion criteria
were developed in consultation with
an expert panel of clinicians and re-
searchers involved in ASD. We included
all study designs and required that
studies include at least 20 participants
with ASD between 13 and 30 years of
age. A cutoff sample size of 20 was
selected a priori to balance the need
to identify studies able to assess effec-
tiveness with our ability to identify
enough studies to review. In addition,
studies had to be published in the year
1980 or later, after the publication of
standardized diagnostic criteria for ASD
in the Diagnostic and Statistical Manual
of Mental Disorders, Third Edition.
Two investigators independently as-
sessed each study against these in-
clusion criteria, with disagreements
resolved by a senior investigator.
Data Extraction
Using standardized forms, 2 investi-
gators independently extracted data
regarding study design; descriptions of
the study populations, intervention, and
comparison groups; and baseline and
outcome data, as well as data about
harms or adverse effects. Data were
also captured on the conduct and
timing of assessments to inform the
assessment of quality. Principal out-
comes of interest included effects on
core symptoms of ASD and com orbid
symptoms and conditions, includ-
ing sleep, anxiety, hyperactivity, and
challenging behavior (eg, irritability/
agitation), as well as effects on voca-
tional, independence, and family-related
outcomes.
532 TAYLOR et al
Study Quality Assessment
Two investigators independently as-
sessed each study by using a quality
assessment form developed by the re-
view team with input from experts in
the eld. A number of elements were
evaluated with a series of yes/no ques-
tions in eachdomain (eg,Wereoutcomes
coded and assessed by individuals
blinded to the intervention status of
the participants?).These elements were:
study design; diagnostic approach;
participant ascertainment and char-
acterization; intervention description;
outcomes measurement; and statistical
analysis.
Disagreements between assessors
were resolved through discussion to
reach consensus. Overall assessment
of quality was determined by using
a prespecied algorithm that is avail-
able in the full report.
The strength of evidence of the current
research was assessed by using
methods established in the Agency for
Healthcare Research and Quality Ef-
fective Health Care Programs Methods
Guide for Effectiveness and Compara-
tive Effectiveness Reviews.
21
Assess-
ments were based on consideration of
4 domains: risk of bias, consistency in
direction of the effect, directness in
measuring intended outcomes, and
precision of effect (Table 1). We deter-
mined the strength of evidence sepa-
rately for major intervention-outcome
pairsbyusingaprespecied ap-
proach described in detail in the full
review.
Data Synthesis
Given the considerable heterogeneity
in the interventions and outcome
measures used in studies meeting
our inclusion criteria, we did not
conduct any meta-analyses. We sum-
marized characteristics of study pop-
ulations and interventions and used
descriptive statistics to report study
outcomes.
RESULTS
Figure 1 outlines the ow of papers
retrieved for the review. We identied
6 papers reporting on 5 unique study
populations and addressing the impact
of supported employment/vocational
interventions on outcomes for adoles-
cents and young adults with ASD. Studies
included 1 nonrandomized controlled
trial reported in 2 publications,
22,23
2
prospective cohort studies,
24,25
1 case
series,
17
and 1 cross-sectional study.
26
Interventions addressed in the studies
all involved nding and implementing
on-the-job supports for young adults
with ASD, and studies were conducted
in the United States,
26
United King-
dom,
17,25
Spain, and Germany.
2224
All
studies were considered to be poor
quality; Table 2 outlines quality con-
siderations and key outcomes for each
study.
Among studies targeting outcomes
related to core symptoms of ASD, 1 non-
randomized trial
22,23
examined the impact
of supported employment (community-
based jobs with a job coach) versus
sheltered workshops (dened as piece
work being performed in segregated
progr ams with only disabled coworkers)
on autism symptoms
23
and quality of
life.
22
Participants were 55 young
adults who had received a clinical di-
agnosis of autism (mean age: 21 years;
mean IQ: mid-50s). Investigators assig-
ned 26 participants to a sheltered
workshop group and 21 to a supported
work group. It is unclear why the sum
of number of participants in each group
does not match the total sample size. All
of the jobs for those in the supported
group were in the community with no
more than 2 individuals with ASD in the
same workplace. Youth in the supported
group worked between 15 and 30 hours
a week, were paid competitive wages,
and each had a job coach.
The average length of community em-
ployment at follow-up was 30 months.
22,23
Differences between the supported
work and sheltered workshop groups
in autism symptoms or quality of life
were not signicant before interven-
tion. At follow-up, young adults who had
participated in the supported work
program had reduced (ie, improved)
autism symptom scores and higher
quality of life scores relative to those
who were in a sheltered workshop.
Furthermore, the autism symptom dif-
ferences were due to deterioration in
the sheltered group over time; the
supported group had no difference in
autism symptoms scores from before
to after intervention. In contrast, the
sheltered workshop group had no dif-
ference in quality of life over time; the
supported work group had quality of
life scores that improved from before
to after intervention.
A related prospective cohort study from
the same research group
24
examined
the impact of supported employment
in the community (supported work
group) versus vocational activities in
a sheltered setting (no supported work
group) on the cognitive development of
44 young adults with autism. Partic-
ipants were randomly selected from
the Spanish Program of Employment
for Autistic People; however, individu-
als were selected for the supported
TABLE 1 Domains Used to Assess Strength of Evidence
Domain Description
Risk of bias Reects issues in study design and conduct that could
result in biased estimates of effect
Consistency Reects similarity of effect sizes seen across studies.
Consistencycannotbe assessed whenonly1 studyis available
Directness Reects the relationship between the intervention and the
ultimate health outcome of interest
Precision Reects the level of certainty around the effect observed
REVIEW ARTICLE
PEDIATRICS Volume 130, Number 3, September 2012 533
work group based on enrollment in
previous sheltered workshops, no pre-
vious participation in other supported
work pr ograms, lack of severe behavior al
problems, and acceptable vocational
abilities. Thus, treatment assignment
seems to have been nonrandom.
The mean age of participants was 25.52 6
3.35 years for the supported work
group and 24.32 6 4.34 years for the no
supported work group.
24
Similar to the
aforementioned studies, all of the jobs
for those in the supported work group
were in the community, with no more
than 2 individuals with autism in the
same work place. Youth in the sup-
ported work group averaged 20 hours
of work per week, were paid competi-
tive wages, and each had a job coach.
The average length of community em-
ployment at follow-up was 30 months.
In contrast, the no supported work
group was on a waiting list for sup-
ported work and participated in non-
competitive vocational activities during
the study period.
24
It is unclear how
many participants were in each group.
At the start of the study, there were no
signicant differences between the
supported work and no supported
work groups in vocabulary, IQ, or au-
tism symptoms. There were also no
differences between groups at this
time on any of the 12 cognitive perfor-
mance tasks; these tasks are used to
measure constructs such as psycho-
motor speed, spatial recognition mem-
ory, and executive functioning. Results
suggested that, relative to the control
group, the supported employment pro-
gram was associated with improve-
ments over time in 8 of the 12 measures
of cognitive functioning.
24
Two cohort studies
17,25
and 1 cross-
sectional study
26
examined the impact
of employment/vocational interventions
on outcomes related to independent
functioning. One study examined the
outcome of a 2-year supported em-
ployment scheme for high-functioning
adults with autism or Asperger syn-
drome in the United Kingdom.
25
The 30
participants in the supported employ-
ment scheme had a formal diagnosis of
autism or Asperger syndrome, a per-
formance or verbal IQ score . 70, were
actively seeking work and able to travel
independently, were capable of eventu-
ally maintaining employment with min-
imal support, and had no psychiatric or
physical problems that would adversely
affect employment. An additional 20
individuals who met the study criteria
were contacted and enrolled into a no-
treatment comparison group. The sup-
ported employment scheme included
job nding and work preparation, edu-
cating potential and existing employers
and colleagues about ASD, and on-the-
job supports. On-the-job supports in-
cluded assistance from a support worker
with dealing with the social and occupa-
tional requirements of a job and educa-
tion about ASD for employers and work
colleagues. The frequency of supports
decreased over the study period.
Over the 2-year evaluation period, young
adults in the supported employment
group were signicantly more likely to
nd paid employment than those in
the comparison group (63.3% vs 25%),
and they spent a greater amount of
the study time employed (27.09% vs
12.35%).
25
For those who were em-
ployed, the number of hours worked per
week did not differ between the sup-
ported work versus the comparison
group; however, the supported work
group had higher wages per hour on
average. There were no signicant dif-
ferences in IQ, vocabulary, social un-
derstanding, or age between those who
were and were not able to nd work.
The investigators noted that the most
important aspect of their supported
work program, as well as the most ex-
pensive, was the job nding aspect,
which included many hours of making
presentations to, meeting with, and ne-
gotiating with potential employers.
FIGURE 1
Study ow diagram.
a
Numbers do not tally because studies could be excluded for multiple reasons.
b
One study
22,23
was reported in 2 separate publications.
534 TAYLOR et al
TABLE 2 Key Outcomes of Studies Assessing Medical Interventions in Adolescents and Young Adults With ASD
Study (Author, Year, Country, Groups,
N Enrollment/N Final Study, Quality)
Age (y) and IQ
a
Key Outcomes
Garcia-Villamisar et al,
22
,
23
2000;
Spain and Germany
G1: 21.07 6 4.18; G2: 21.64 6 3.75 Adults with ASD participating in a community work program
had lower autism symptoms and higher quality of life
scores relative to those who participated in a sheltered workshop.
G1, sheltered work, 26/26 IQ (Leiter): G1: 55.52 6 14.43;
G2: 57.41 6 15.01
Follow-up assessment was 30 months after the start
of the intervention.
G2, supported work, 25/21 Quality considerations: nonrandom assignment to groups;
inclusion/exclusion criteria not clearly stated; intervention
not fully described; measure of treatment delity not
reported; differences in concomitant interventions
not reported; outcomes not coded by masked assessors.
Quality: poor
Garcia-Villamisar and Hughes,
24
2007; Spain
G1: 25.52 6 3.35; G2: 24.32 6 4.34 Adults with ASD participating in a community work program versus
a wait-listed group who participated in noncompetitive
(ie, sheltered) vocational activities.
G1, supported employment IQ (Raven): G1: 41.14 6 4.45;
G2: 42.23 6 5.43
Follow-up assessment was 30 months after the start
of the intervention.
G2, Wait list; Overall N: 44/44 Relative to the wait-listed group, the supported employment group
experienced improvements over time in 8 of the 12 measures
of cognitive functioning.
Quality: poor Quality considerations: nonrandom assignment to groups; attrition
not reported; intervention not fully described; measure of treatment
delity not reported; differences in concomitant interventions
not reported; outcomes not coded by masked assessors.
Mawhood and Howlin,
25
1999;
United Kingdom
G1: 31.1 6 9.1; G2: 28.0 6 6.1 Two-year supported employment scheme for high-functioning
adults with autism or Asperger syndrome.
G1, supported employment
program, 30/30
IQ (WAIS full scale): G1: 98.8 6 16.3;
G2: 97.7 6 20.4
Adults in the supported work group were more likely to nd paid
employment (63% vs 25%) and had higher wages per hour on
average than a control group.
G2, control, 20/20 No differences between groups in number of hours worked per
week for those who worked.
Quality: poor Quality considerations: nonrandom assignment to groups;
systematic diagnostic approach not repor ted within study;
differences in concomitant interventions not reported;
outcomes not coded by masked assessors.
Howlin et al,
17
2005; United Kingdom G1a: 31.1 6 9.1; G1b: 31.4 6 9.3 For adults in the 8-year follow-up (19951996 sample), 13 of 19
(68%) who had been previously employed remained employed.
G1a, pilot-supported employment
program participants (19951996), 30/30
IQ (Raven nonverbal): G1a:
110.2 6 17.6; G1b:110.7 vs 19.5
For adults in the additional sample (20032005), employment
ranged from 70.5% to 54.3%, depending on regional site.
G1b, supported employment program
participants (20032005), 117/89
Quality considerations: no comparison group; attrition not
reported; differences in concomitant interventions not
reported; outcomes not coded by masked assessors.
Quality: Poor
Lawer et al,
26
2009; United States Age: 1825 y, 73.4%; 2534 y, 15.5%;
3544 y, 8.1%; 4554 y, 2.5%;
5565 y, 0.5%
Presence of on-the job supports was related to a higher
likelihood of employment in the community (competitive or
supported) for adults with ASD.
G1, vocational rehabilitation service
users, 1707/1707
On-the job supports were as effective in promoting employment
for adults with ASD as for adults with other developmental disabilities.
Quality: poor IQ: NR Quality considerations: no comparison group; systematic
diagnostic approach note reported within study; participants
not clearly characterized (no cognitive or developmental measures);
intervention not fully described; measure of treatment
delity not reported; differences in concomitant interventions
not reported; outcomes not coded by masked assessors.
G, group; NR, not reported; WAIS, Wechsler Adult Intelligence Scale.
a
Data are presented as the mean 6 SD.
REVIEW ARTICLE
PEDIATRICS Volume 130, Number 3, September 2012 535
This same research group conducted
a longer-term follow-up of their sup-
ported employment scheme, now titled
Prospects.
17
The study examined whether
the gains in employment made during
the rst 2 years of the project
25
per-
sisted for up to 8 years in a larger co-
hort (recruited from 3 regional sites in
the United Kingdom). In addition to the 30
young adults with ASD reported on in the
earlier study , an additional 117 young
adults with autism or Asperger syn-
drome who began receiving services
between 2002 and 2003 were added to
the cohort. Thirteen of the 19 young
adults in the original sample who found
employment remained employed 7 to 8
years later. For the young adults who
were added since the original cohort, the
rate of employment remained high,
ranging from 70.5% to 54.3% (depend-
ing on regional site). The majority of
employed young adults with ASD (84.7%)
were generally happy with their job.
A nal cross-sectional study
26
examined
the effectiveness of vocational rehabil-
itative services for adults with ASD
compared with adults with other devel-
opmental disabilities. The investigators
identied 1707 adults with ASD from
national data obtained from the US De-
partment of EducationsOfce of Special
Education and Rehabilitative Services.
The study reported that the presence of
on-the-job supports (which could in-
clude counseling, on-the-job training,
job search assistance, assessment and
diagnosis, and assistive technology)
was associated with a higher likelihood
of employment in the community (with
or without supports), and that on-the-
job supports were just as effective in
promoting employment for adults with
ASD as they were for adults with other
developmental disabilities.
DISCUSSION
Assessment of the Literature
We identied 5 studies reported in 6
publications and focused on supported
employment/vocational interventions.
17,2226
All of the studies focused on on-the-job
supports as the employment/vocational
intervention; no other vocational inter-
ventions were reported in the literature
meeting our study criteria. Our ability to
assess the benet of supported em-
ployment programs is limited, and no
study used random assignment, making
it difcult to draw conclusions about the
effectiveness of the programs. The ma-
jority of the studies were small, and all
were of poor quality. Thus, the strength
of the evidence for positive benets of
vocational interventions on employment,
core symptoms of ASD, and cognitive
development is insufcientatthistime,
meaning that we cannot estimate the
likely effect without further resear ch.
Supported employment interventions
are particularly understudied. Only 1
study examined rates of employment
for programs that lasted $3 years.
17
Furthermore, this longer-term study
did not include a control group, making
it impossible to determine the rates of
employment over time for young adults
with ASD who were not participating in
the supported employment interven-
tion. Finally, none of the studies exam-
ined whether increased employment
rates or improvements in other out-
comes were sustained after the ter-
mination of the supported employment
intervention.
Future Directions
The transition from adolescence to early
adulthood presents numerous chal-
lenges for individuals with and without
neurodevelopmental challenges. During
this interval, individuals with ASD are
presented with additional complexities
that require efforts to maximize the
achievement of individual goals for in-
dependence.Nonetheless,little research
addresses vocational and employment
needs in this population.
It is unlikely that large-scale implemen-
tation of interventions will be consid-
ered until a stronger evidence base is
developed, despite growing numbers of
individuals with need and some small
studies demonstrating initial promise. A
promising area for future study may be
identifying programs/interventions that
are appropriate candidates for devel-
oping treatment manuals to encourage
standardized replication of promising
approaches. Interventions with demon-
strated effectiveness in other popula-
tions withsimilardisabilitiesmay inform
the development of approaches for in-
dividuals with ASD.
Studies are also needed that illuminate
which aspects of multifaceted sup-
ported employment programs have the
greatest impact. Studies that do show
evidence of effectiveness in this area
should collect longer-term data to de-
scribe the degree to which ndings,
including the duration of employment,
continue after the intervention itself is
removed. These studies should also
broaden the outcomes measured, to
include other functional outcomes such
as quality of life, educational attain-
ment, residential outcomes, and social
outcomes. Furthermore, it will be im-
portant for such studies to demon-
strate and study the nancial impact of
specic programs over time on an in-
dividual, family, and systems level.
Research is also necessary to under-
stand how individual differences such
as the severity of ASD symptoms, soci-
odemographic factors, and physical and
mental health comorbidities may affect
the transition to adulthood as well as
treatment over an individualslifespan.
For example, recent research not ad-
dressed in the full AHRQ systematic re-
view suggests that youth with ASD who
do not have an intellectual disability
may be more negatively affected by the
transition out of high school relative to
those with a comorbid intellectual dis-
ability.
12,27,28
Furthermore, relative to
families with higher socioeconomic sta-
tus,youthwithASDfromfamilieswith
fewer socioeconomic resources ar e less
536 TAYLOR et al
likely to receive formal services after
exiting high school.
29
Determining the
characteristics of individuals with ASD
who receive and benet from treatment
may help to understand who is un-
derserved, as well as allow for the tar-
geting of specic treatments to those
individuals for whom they are maximally
effective. Finally, foundational research
is necessary to understand the goals
of individuals with autism and their
families as future research studies are
planned.
CONCLUSIONS
Given shifts in our understanding of the
increased prevalence of ASD, the in-
creasing population of adolescents
and young adults with ASD is a chal-
lenging public health issue.
13
There is a
dramatic disparity between the estimated
costs associated with ASD, including
unemployment, underemployment, im-
pact on families, and health care utili-
zation costs, and the evidence base
for understanding what interventions
can optimize employment and other
important functional outcomes for
individuals with ASD. In the current
review, individual studies of different
on-the job supports reported increased
rates of employment in the community
relative to those without on-the-job
supports; however, given the meth-
odologic limits of such studies, the
strength of evidence (condence that
future research will not change our
understanding of the effect) for the
effect seen is insufcient. Similarly,
despite positive results related to
other outcomes (ie, quality of life, au-
tism symptoms, cognitive development)
reported in individual studies, the poor
quality of the studies, assessment of
unique outcomes in each stud y, and
lack of replication lead to insufcie nt
strength of evidence until further
studies are conducted t hat may con-
rm the observed effects. Research to
quantify the degree to which these
interventions are effective, under
what speciccircumstances,andfor
which individuals with ASD is critical
for the growing number of adoles-
cents and young adults with ASD who
are approaching the transition to
adulthood.
ACKNOWLEDGMENTS
We are grateful for the contributions of
our team members and our technical
expert panel members and key inform-
ants. We also appreciate the input of the
parents who participated as we formu-
lated our approach.
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PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Taylor has received research support from the National Institute of Mental Health, the Eunice Kennedy Shriver National Institute of
Child Health and Human Development, Autism Speaks, and the Marino Autism Research Institute. Dr Dove has received training support from the National Institute
of General Medical Sciences, National Heart, Lung, and Blood Institute, National Institute of Child Health and Human Development, Maternal Child Health Bureau,
the American Heart Association, and the Autism Speaks Autism Treatment Network. Dr Veenstra-VanderWeele has received research support from the National
Institute of Mental Health, the National Institute of Child Health and Human Development, the Agency for Healthcare Research and Quality, Autism Speaks, the
American Academy of Child and Adolescent Psychiatry, NARSAD, Seaside Therapeutics, Roche Pharmaceuticals, and Novartis. He has consulted for Novartis.
Dr Warren has received research support from the National Institute of Mental Health, the Eunice Kennedy Shriver National Institute of Child Health and Human
Development, the National Science Foundation, the Agency for Healthcare Research and Quality, Autism Speaks, the Marino Autism Research Institute , and the
Simons Foundation. Dr McPheeters and Ms Sathe have indicated they have no nancial relationships relevant to this article to disclose.
FUNDING: The full review project was supported by the Agency for Healthcare Research and Quality (contract HHSA 290 2007 10065 I). The primary author was
supported by the National Institute of Mental Health through a K01 award (K01 MH092598) during participation on the project and preparation of the manuscript.
538 TAYLOR et al
    • "These discouraging statistics suggest additional ramifications. There is a substantial discrepancy between the estimated costs associated with ASD, the evidence base for understanding what interventions can optimize employment, and the costs incurred (Taylor et al. 2012). For example, the costs related to the services for adults with autism are notably higher than their peers with other disabilities. "
    [Show abstract] [Hide abstract] ABSTRACT: With a disproportionately high unemployment rate, obtaining and maintaining employment is exceptionally difficult for individuals with autism spectrum disorders (ASD). Further, few individuals with ASD have been trained in the vocational skills needed to obtain gainful employment. The need to evaluate not only our current knowledge about the employment needs of individuals with ASD, but also to inquire about interventions, strategies, and supports in the workplace is pressing. The harsh reality of high unemployment rates for adults with ASD, and the consequently high cost of services, can be aided by examining the best practices for supporting employment. This review of the literature focuses on vocational training interventions targeted specifically to adolescents and adults with ASD. Twenty studies evaluating pre-employment, specific vocational skill training, and job retention interventions are discussed, trends in intervention characteristics are highlighted, and recommendations for future research are suggested.
    Full-text · Article · Mar 2016
    • "They can also identify discrepancies between vocational demands and the individual's knowledge, resources and skills (King et al., 2005). While several studies have looked at interventions to assist young adults with disability in school to plan their transition out of school (Nicholas, Attridge, Zwaigenbaum, & Clarke, 2014; Taylor et al., 2012;al., [ 2 6 7 _ T D $ D I F F ] 2013, 2012), at present no review has examined the available tools to assist with career planning for young adults with ASD. An important consideration in evaluating career planning tools is the psychometric properties of the tool. "
    [Show abstract] [Hide abstract] ABSTRACT: This systematic review aimed to identify tools published in peer reviewed journals that could be utilised in career planning for individuals with autism spectrum disorder (ASD), and to describe their clinical utility and psychometric properties. Due to limited results for ASD-specific tools, the search was broadened to career planning tools for individuals with a cognitive or developmental disability, which could be used by individuals with ASD. Six databases were electronically searched. Main search terms used were ‘disability’, ‘young adult’, ‘assessment’ and ‘employment’. Boolean operators expanded the search strategy. Two independent reviewers undertook data extraction and quality assessment. Electronic searches located 2348 literature items; 14 articles met inclusion criteria covering 10 career planning tools. Identified tools were of a predictive nature; however, none of the studies assessed all the psychometric properties necessary for evaluating a sound predictive tool. Only one addressed all three components of clinical utility. None of the identified tools had strong reliability or validity and their clinical utility remains unexplored.
    Article · Mar 2016
    • "Studies provided insights into what theme areas in developmental transitions are being examined in youth with mental health disorders, how these interventions are being conducted and the characteristics and quality of the current research on this understudied topic. Taylor et al. 2012 Hillier et al. 2007 Hagner et al. 2012 Burke-Miller et al. 2012 Killackey et al. 2008 Styron et al. 2006 Karpur Certo et al. 2003 Haber et al. 2008 SkillsTable 2. Key transition domains in mental health identified from interventions within the studies selected Domain Sub-domain Study Taylor et al. 2012 Hillier et al. 2007 Hagner et al. 2012 Burke-Miller et al. 2012 Killackey et al. 2008 Styron et al. 2006 Karpur et al Certo et al. 2003 Haber The evaluated interventions in this study consist of one or more domains of developmental transitions (e.g. employment only versus employment with independent living and social relationships). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Youth with mental health disorders often experience challenges when transitioning into adult roles (e.g. independent living, work and community engagement). Health interventions that address the needs of youth with mental health disorders during these challenges in their development (i.e. developmental transitions) have not been reviewed in the literature. This scoping review examines the peer-reviewed research that describes evaluated interventions addressing developmental transitions for youth with mental health disorders. Methods: A search of four prominent health literature databases (CINAHL, Embase, MEDLINE and PsycINFO) was conducted to identify evaluated developmental transition interventions for adolescents and youth (12-25 years) with mental health disorders. Study selection and analysis were guided by a methodological framework for conducting scoping reviews. Selected studies were described, assessed for quality and collated based on ten dimensions from two notable conceptual frameworks in developmental transitions and disability. Results: Nine studies met the inclusion criteria. The interventions within these studies demonstrated five specialized and four multi-faceted programmes (i.e. multiple domains). All domains from the two conceptual frameworks were represented differently across studies. The sub-domains from these studies were most frequently related to vocational-focused interventions, least frequently related to social activities and living situation and did not explicitly map onto the sexuality sub-domain. Three multi-faceted interventions incorporated all domains and utilized each intervention approach. Study quality was rated for seven of the nine studies. Quantitative methodology for five of the seven studies was rated as higher quality. Conclusions: Evaluated interventions described in the transitions literature for youth with mental health disorders predominantly focus on vocational needs. The least studied areas were the personal and interpersonal domains. These domains were only incorporated within interventions addressing multiple domains of developmental transitions. These insights can be helpful in guiding evidence-based practice and policy development, as well as informing gaps for future research programmes.
    Full-text · Article · Dec 2015
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