Vocational Rehab & ASD

As a result of a growing population of adults with ASD who need support entering the workforce, there has been a substantial increase in efforts to offer vocational rehabilitation, job training, and opportunity (Autism Speaks, 2013b). Individuals with ASD can participate in the workforce through the same channels as those without disabilities including: self-employment, customized employment, and competitive employment (Autism Speaks, 2013). In addition, there are facilitated options (supported by individuals and/or employment support organizations) that are unique to individuals with disabilities such as supported employment or sheltered workshops (Dove, McPheeters, Sathe, Taylor, Veenstra-Vanderweele, & Warren, 2012). Supported employment typically occurs in community-based jobs with a job coach (Dove et al., 2012). Sheltered workshops are a setting in which only disabled coworkers perform tasks in a segregated and supported setting (Dove et al., 2012).

About 17% of young adults with ASD enter competitive employment directly out of high school (Taylor & Selzer, 2012). However, when facilitated employment options are included, the rate increases to 37% for young adults with ASD (Taylor & Selzer, 2012). Although this is still half the rate of young adults without disabilities (Newman, Wagner, Knokey, Marder, Nagle, & Shaver, 2011), the rate demonstrates that facilitated options can double employment opportunities for those with ASD.

As described earlier, the VR is comprised of state-operated centers offering competitive employment opportunities to people with disabilities. Brusilovskiy, Lawer, Mandell, and Salzer (2008) evaluated adults with ASD in the VR and found individuals with ASD are also the most likely population to be denied state vocational services due to the severity of their condition. However, of the clients accepted by the VR, 42% worked in competitive employment (Brusilovskiy, et al., 2008). Inclusion success was measured using factors such as higher functional skills, comparative conversational skills, high social capital and higher household income (Anderson et al., 2013). In addition, the use of services directly resulted in likelihood to achieve employment (Anderson et al., 2013).

When an individual uses the VR, the expense to the state to maintain an employee with ASD is an average of $2,380 per person, the highest average of all comparable disabilities (Brusilovskiy, et al., 2008). Similar to employees with comparable disabilities, 28% of the clients with ASD did not have any costs associated with them (Brusilovskiy, et al., 2008). This demonstrates that almost one out of three individuals with ASD employed through the VR have no additional cost to the company associated with their employment. However, of those that do have additional cost, it is approximately $2,300 USD. This indicates that determining a general representation of the potential efficiency and cost of an employee with ASD is difficult, because the nature of the diagnosis is dynamic and each individual calls for a unique set of accommodations (if any at all). Accommodations include job coaches, mentors, on-site training, simulation training, daily schedule prompts, visual prompts, transition warnings, work area with minimal distractions, headphones, routine breaks, PDA with communication software, sensitivity training for co-workers and self assessments (Standifer, 2009). In addition, assessment and evaluation tools are particularly useful for defining opportunities. Taylor and Selzer (2012) developed a Vocational Index for individuals with ASD on a scale of independence. The Vocational Index is a coding system with eleven categories coded on a 9-point scale to reliably evaluate the individual with ASD’s current employment experience. It is based on the inherent responsibilities of their education/job and the number of employment hours (Taylor & Selzer, 2012). This tool and similar tools measuring vocational experience are useful for analyzing vocational progress over time and/or for predicting vocational outcomes (Taylor & Selzer, 2012).

DSM-5 & The Autism Dx

         ASD was first included in the APA DSM-III in 1980 as “infantile autism” (APA, 2010). In today’s DSM-5, it is referred to as “Autism Spectrum Disorder” (APA, 2013). The most recent change from the DSM-IV to the DSM-5 was a significant diagnostic change because of reasons explained by the chair of the DMS-5 Task Force: “In suggesting these revisions, the work group has considered the many advances in the field of ASD and neurodevelopmental disorders, as well as concerns of advocacy groups, family members and the medical groups who treat those living with autism disorders” (APA, 2010).

            The DSM-IV had ASD divided into four separate disorders: autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified. Consistency in diagnosis was complicated, so the DSM-5 brought them together under the same umbrella to improve diagnostic accuracy (APA, 2013b). The reason for this was explained by a member of the DSM-5 Neurodevelopmental Disorders Work Group as, “The recommendation of a new category of autism spectrum disorders reflects recognition by the work group that the symptoms of these disorders represent a continuum from mild to severe, rather than being distinct disorders” (APA, 2010). All diagnoses from the DSM-IV are still applicable to the DSM-5 criteria for ASD, but instead of separately defined conditions, they are now on defined on a continuum. In addition to combining the diagnoses, the APA also added new components - overall development, course and language - all in an effort to create a more sensitive and accurate diagnostic standard (APA, 2010). A final change to the DSM-5 was to the diagnostic criteria: in DSM-IV the onset of ASD was not defined, but the DSM-5 indicates that ASD characteristics must be present from early childhood.

Defining ASD

Autism Spectrum Disorder (ASD) is a complex set of characteristics that continues to evolve as more research surfaces with new findings. It is recognized more frequently in males, with a male to female ratio of 4:1 (NIH, 2013; NIMH, 2013). Co-occurring conditions are common and typically include: Fragile X syndrome, tuberous sclerosis, epileptic seizures, Tourette syndrome, learning disabilities and attention deficit disorder (APA, 2013; NIMH, 2013). The most common co-occurring condition is epilepsy, developing in 2-3 out every 10 cases (NIMH, 2013). The cause of ASD remains unknown with research focusing on genetic, prenatal, neurological and environmental factors or a combination thereof. There are several different interpretations for defining ASD. The Center for Disease Control and Prevention (CDC) (2013) offers a sociological perspective stating:

Autism spectrum disorder is a developmental disability caused by differences in the brain… There is usually nothing about how people with ASD look that sets them apart from other people, but they may communicate, interact, behave, and learn in ways that are different from most other people.

This definition is expanded by the National Institute of Mental Health (2013), which states:

Autism is a group of developmental brain disorders, collectively called autism spectrum disorder. The term “spectrum” refers to the wide range of symptoms, skills, and levels of impairment, or disability that children with ASD can have. Some children are mildly impaired by their symptoms, but others a severely disabled.

The two previous definitions offer general insights to the impairments, but they are limited in specifying characteristics. In the DSM-5, the APA (2013) defines ASD in the following terms:

Autism spectrum disorder is characterized by persistent deficits in social communication and social interaction across multiple contexts, including deficits in social reciprocity, nonverbal communicative behaviors used for social interaction, and skills in developing, maintaining and understanding relationships. In addition to the social communication deficits, the diagnosis of autism spectrum disorder requires the presence of restricted, repetitive patterns of behavior, interests or activities. Because symptoms change with development and may be masked by compensatory mechanisms, the diagnostic criteria may be met based on historical information, although the current presentation must cause significant impairment.

For the purposes of this study, the American Psychiatric Association (APA) definition will be applied. It appears to be the most inclusive and is considered the standard for diagnosis and research

The History of ASD

         The history of cases of individuals with observed expressions analogous to ASD date back as far as 1806. At that time they were considered cases of insanity (Wolff, 2004). The evolution of ASD (aka autism) began in 1943 – 1944 when two different researchers, Leo Kanner in Baltimore, Maryland, U.S. and Hans Asperger in Vienna, Austria separately described cases of children who presented symptoms similar to those of schizophrenia (Barthélémy & Bonney-Brilhault, 2013). Both researchers identified the symptoms as “autism” because it was a term used to describe schizophrenic individuals who withdrew from reality (Barthélémy & Bonney-Brilhault, 2013). Kanner’s description of children with autism was that they, “have come into the world with innate inability to form the usual, biologically provided affective contact with people” (Wolff, 2004, p.203). Both Asperger and Kanner’s observations included stereotypic behaviors, poor emotional and social interactions, lack of empathy and poor body coordination (Wolff, 2004). At that time, Kanner postulated that autism and childhood schizophrenia were caused by distant parents (Kanner, 1949), which popularly became known as “Refrigerator Mothers”. It was not until two decades later that researchers focused on developing more sensitive diagnostics demonstrating that autism did not directly relate to schizophrenia or to poor parenting (Bailey, Phillips & Rutter, 1996; Folstein & Rutter, 1977; Rutter, 1968; Rutter, 1970). Since the early 1970’s, there have been academic journals reporting on expressions of autism. It has become commonly referred to as ASD, and to date there are four journals dedicated entirely to ASD. In the 1990s an increasing number of parents and advocates emerged and led cultural, political and attitudinal change toward ASD in the U.S.