Association Between Psychiatric Comorbidity and Employment in Adults with ASD

Background: In recent years, the amount of literature focused on outcomes in adults with autism spectrum disorder (ASD) has increased exponentially. However, we still have much to learn about why these adults have varying outcomes compared to adults without ASD, as well as adults with other disabilities. Employment is critical to independence, and employment rates among adults with ASD are low, even for adults with average and above average cognitive abilities. Prior studies report that about 50% of adults with ASD do not earn a wage. Psychiatric disorders may impact employment status and frequently occur in this population. Common psychiatric disorders identified in adults with ASD include anxiety, depression, and obsessive-compulsive disorder (OCD).  

Objectives: To evaluate the association between psychiatric comorbidity and employment status in a population-based cohort of adults with ASD. 

Methods: As part of a large adult outcomes study, individuals with ASD were originally ascertained during the 1980’s for a state-wide autism epidemiological study in Utah. Participants with an intellectual quotient (IQ) ≥50 were included for this component of the adult follow up study. Employment status (i.e., unemployed, day program, sheltered workshop, supported employment, part-time employment, full-time employment), psychiatric comorbidity (i.e., history of anxiety, depression, and obsessive-compulsive disorder (OCD) and IQ were queried during an in-person assessment which included a semi-structured interview, Mini PAS-ADD Clinical Interview, and Wechsler Adult Intelligence Scale, 4^th Edition or Stanford Binet, 5^thEdition. Employment status was condensed into three categories: unemployed (unemployed and day program), employment with support (sheltered workshop and supported employment), and independent employment (part-time employment, full-time employment). Demographics were calculated through descriptive statistics. Ordinal regression models were fit to look at the association between employment status and the presence of psychiatric comorbidity. Effect sizes were measured by odds ratios (OR) and 95% confidence intervals (95% CI). 

Results: The study sample consisted of 68 participants (78% male; mean age 35.4 years, SD=5.4).  Fifty-six percent of participants had mild intellectual disability (ID), while 44% had an IQ ≥70.  No statistically significant association was found between intellectual ability and employment status (Figure 1; OR=0.60; 95% CI=0.24-1.49). The odds of being independently employed were significantly heightened among individuals without comorbid OCD (OR=4.25; 95% CI=1.50-12.04) and anxiety (OR=3.15; 95% CI=1.22-9.08). No association was found between the presence of depression (OR=1.10; 95% CI=0.33-3.64) or experiencing one or more psychiatric comorbidities (OR=2.25; 95% CI=0.86-5.81) and employment status (Table 1). 

Conclusions: Although no significant association was found between ID and employment status, many of the adults in the current sample were unemployed or participated in employment with supports (sheltered workshop or supported employment). Frequencies of OCD and anxiety were higher among adults with ASD who are unemployed or in employment with support settings compared to those who work in settings without accommodations.  The absence of a statistically significant difference in employment status between those with mild ID and without ID suggests the importance of other aspects of impairment that impact the ability to obtain and maintain gainful employment.