The transition into adulthood is a critical period in the life course that shapes later outcomes. Many adults on the autism spectrum fare poorly across a wide range of quality of life indicators. Understanding the multilevel factors that influence transition outcomes is necessary to develop strategies that promote better outcomes. In this scoping review, we characterize the use of social-ecological factors in adult autism outcome studies, identify understudied areas of research, and provide recommendations for future research. We conducted a literature search for studies in which the relationship between social-ecological factors and transition outcomes among transition-age youth with autism was assessed. We organized variables used in studies across 5 levels of influence: family-, interpersonal-, institutional-, community-, and policy-level factors. Our findings reveal that both breadth and depth of social-ecological factors usage in autism outcomes studies is limited because of the narrow inclusion of variables across social-ecological levels, the overreliance on a limited number of national data sets, and the overall lack of variation in research design. We propose 9 recommendations to inform the development of multilevel studies.

Autism spectrum disorder (ASD) is a developmental disability characterized by social and communication impairments.1 Each year, nearly 50 000 adolescents with autism turn 18 in the United States.2 Many of these young adults will require continued supports as they transition out of special education and into community-based care; however, there are few evidence-based interventions, transition models, and adult services for them to transfer into.3,4 Developing innovative, effective practices requires a holistic understanding of the factors that impact transition outcomes.

Policy and practice recommendations often reveal a need for multilevel approaches to achieving positive transition outcomes.5,8 However, most transition interventions for youth on the autism spectrum focus primarily on altering individual-level behaviors and skills.3,9 Little research has been conducted to examine the social-ecological factors that may influence outcomes during and after the transition period.10 Social-ecological factors refer to a wide range of environmental influences, ranging from peer relationships and family structure to societal norms and policies, that can have a direct or distal impact on individual development.11 Some researchers have conceptualized the dynamic intersection between individual behaviors and social-ecological influences during the transition into adulthood.5,7,12,14 Consistent with the World Health Organization’s International Classification of Functioning, Disability and Health framework for understanding disability, in these models, it is recognized that outcomes are a function of the interrelationships among individual characteristics and their surrounding sociocultural environments.15 In this scoping review, we aimed to identify the ways in which researchers have used social-ecological factors in research about young adult outcomes.

We followed Cochrane and Arksey and O’Malley16 guidelines for conducting scoping reviews. Scoping reviews are preliminary assessments of the size and scope of available research. Their aim is to identify the nature and extent of a body of research to inform later reviews and research priorities. Unlike systematic reviews, scoping reviews typically do not have a process for assessing the quality of the included literature.

We searched studies published from January 1, 2005, to January 31, 2016. We considered a study to be correlational if its authors examined the relationship between 2 or more quantifiable variables.17 To be included in our review, the study had to be published in a peer-reviewed, English-speaking journal; be based on a US sample; have ASD as the primary focus or main comparison group; and have observed outcomes among transition-age youth (TAY) between the ages of 14 and 26 years. We excluded studies in which individual-level life skills (eg, vocational skills or independent living skills) or behaviors (eg, social communication and executive functioning) were the only dependent variables. All included studies had at least 1 social-ecological independent variable (defined below).

We organized social-ecological factors into 5 levels of influence: (1) family-level factors include characteristics of households or family systems (eg, household income, parental expectations, and involvement in transition planning), (2) interpersonal-level factors describe the relationships TAY have with nonfamily members (eg, peers, teachers, and service providers), (3) institutional-level factors refer to the nature of, participation in, and the characteristics of institutions or organizations that TAY interact with (eg, schools, health care and vocational services), (4) community-level factors describe sociodemographic features of a person’s locale (eg, economic indicators and the availability of services), and (5) policy-level factors refer to rules, regulations, and laws that influence the design, availability, and delivery of services, supports, and assistance.

Twenty articles met inclusion criteria for this review.18,37Table 1 describes sample characteristics and methodological attributes across studies. Table 2 describes the social-ecological correlates included in the reviewed research.

In the 20 studies reported in Table 1, 6 sources of data were used. Most were reliant on large secondary data sets. The authors of 15 studies drew from the National Longitudinal Transition Study–2,* the authors of 2 studies used the National Survey of Children with Special Health Care Needs,20,30 and the authors of 1 study used the Rehabilitation Services Administrative Case Services Report.23 The authors of the remaining 2 studies directly recruited families of adults with autism.34,35 Sample sizes ranged from 39 to 17 818 people. The age of participants with autism ranged from 12 to 26 years, and the mean proportion of sample members who were male was 85%. The percentage of each study’s participants who were white ranged from 56% to 90% (mean = 74%).

The vast majority of study authors used logistic regression to examine the association of independent variables on transition outcomes. The authors of only 2 studies examined moderating or mediating mechanisms.25,26 The authors of 2 studies used structural equation modeling,25,26 and the authors of 1 study employed sequence analysis.36 The authors of 2 studies observed individual transition outcomes across multiple time points.36,37 Although the authors of 6 studies referenced some theoretical orientation or conceptual framework,18,25,26,28,30,32 authors explicitly used that theory or framework to inform which factors to include in the analytical model in only 4 studies.25,26,28,30

#### Family Level

The authors of 19 studies assessed family level variables, which included household and/or parent income (n = 19),18,22,24,37 parent education (n = 6),20,22,25,26,37 parent expectations (n = 3),21,22,25 parent satisfaction with services (n = 2),20,21 parent involvement (n = 5),20,22,24,28 family composition (n = 3),20,26,30 and family support (n = 1).26 The relationship between family-level variables (such as household and/or parent income and parents’ education) and transition outcomes varied across studies.

Parent income was the most common social-ecological correlate. Higher parent income was positively linked to living independently18 and youth participation in transition planning.24 Some study authors found a positive relationship between parent income and postsecondary employment, educational attainment, and social engagement,19,21,22,25,27,31,33,36 whereas others found no significant association.19,27,29,34,36,37 Lower parent income was associated with decreased access to services.30,32

Parental educational attainment was significantly associated with youth postsecondary education attendance21,37 and employment22,25 but not with independent living or friendships.25

Parent expectations and involvement in transition planning were positively associated with postsecondary education attendance,21,25,26 employment,22,25,26 independent living,25 and friendships.25 The odds of receiving health care transition services were higher if parents were involved in decision-making and satisfied with their child’s health care.20

#### Interpersonal Level

Bullying was the only interpersonal factor assessed across studies. TAY who were bullied or teased in high school had higher odds of mental health service use28 and lower odds of postsecondary employment than their peers who were not bullied.26 None of the authors of studies included in this review examined the quality or nature of social interactions or social networks among TAY and nonfamily members.

#### Institutional Level

Institutional-level factors included high school urbanicity (n = 3),19,21,27 contact between the high school and postsecondary institution staff during transition planning (n = 2),21,22 and whether a student’s high school provided families with information about postsecondary services (n = 1).21 Postsecondary outcomes did not vary by high school urbanicity.19,21,27 TAY had higher odds of postsecondary employment if their high school contacted a vocational rehabilitation representative during transition planning.22 However, contact between high schools and postsecondary education institutions (eg, a 2- or 4-year college or vocational and/or technical school) was not a significant predictor of postsecondary education attendance.21

#### Community and Policy Levels

No study authors examined community-level factors. The authors of 1 study examined the impact of policy on transition outcomes and found that postsecondary employment was higher among residents of states that mandated transition planning by age 14, as opposed to age 16.23

In this study, we characterized the use of social-ecological factors in TAY autism outcome studies. Overall, the authors of few studies examined social-ecological factors and none examined community-level factors. The range of factors examined was limited, and the explicit use of theory or conceptual frameworks to inform study design and analyses was rare. Although most health and allied fields train researchers in social-ecological and systems theories of human development, few study authors actually employed ideas and measures that allowed us to understand the context for development and outcomes of TAY on the autism spectrum. As a result, most studies and recommendations focused on measuring and intervening on individual-level factors without regard to social-ecological context.

#### Family Level

Because of our findings, we suggest that TAY from high-income households have better transition outcomes and access to services. Families with more disposable income may be more likely to be able to pay for educational enrichment activities, services, and college,39 without needing public funding.40 Alternatively, more affluent families may also have more developed and effective social networks and greater social capital, which can be associated with improved outcomes. Little work has examined the role of family advocacy or preparedness for transition may have on later outcomes. Our first research recommendation is to expand the range of modifiable family-level factors examined as possible predictors of outcomes and understand programs and policies that might strengthen family capacity, regardless of household income (a variable that is relatively immutable).

Parental involvement in transition planning had a positive effect on postsecondary outcomes. However, this relationship was only examined in high school settings. This is a critical gap in the literature considering that transition extends well into the post–high school years. Moreover, none of the study authors examined sources of support for families and caregivers. A review of qualitative research studies revealed that parents, TAY, and professionals had discrepant views regarding the role of parental involvement after high school.41 In recent decades, it has become more common for TAY (with and without disabilities) to rely on their parents for support in early adulthood. Indeed, continued parental support can increase one’s chances for success.39 However, overreliance on parents could also prevent TAY from attaining the skills that are necessary for independence in adulthood. Our second research recommendation is to examine the role of parents in the continued transition to adulthood period and identify the family supports needed to ensure a successful transition.

No study authors examined how interpersonal relationships within families affected transition outcomes. This is a noticeable gap in the literature, considering that parent criticism has been found to increase maladaptive behaviors among adults with autism.42,43 Moreover, study authors have also shown that the quality of parent-child relationships can change during the transition into adulthood.38,44 Our third research recommendation is to examine the interrelationships among family context, family-systems, and adult outcomes.

#### Interpersonal Level

The studies included in this review were focused on the direct effects of peer rejection and social impairment on postsecondary outcomes. Little is known of the social support networks of TAY with autism or how those networks may contribute to positive transition outcomes. Nonfamily members (such as peers, service providers, and employers) offer support and resources that are critical during the transition into adulthood. Through these relationships, TAY receive emotional support, develop new skills, and build social capital.45 Our fourth research recommendation is to examine the influence of peer relationships and social networks on postsecondary outcomes.

#### Institutional Level

Most study authors did not include institutional-level factors. Interagency communication and collaboration are often considered paramount to effective service delivery and transition planning.46 None of the authors of the reviewed research examined how adult service systems interact with one another after high school exit. This is a critical gap in the literature, considering that parents often describe the adult service system as fragmented and inconsistent.41 Our fifth research recommendation is to characterize the quality of service delivery systems and their supports to identify modifiable targets for policy intervention.

No study authors examined the climate of relevant settings like colleges, the workplace, and high school. TAY with autism have described several aspects of the college and working environment as important to transition success,41 including awareness and acceptance of disability, flexible scheduling, and the knowledgeability of employers and faculty.47,48 Our sixth research recommendation is to examine how the organizational climate and related characteristics are associated with outcomes and how implementation research and delivery science can be used to modify these features of organizations.

#### Community Level

The authors of studies on neighborhood effects have established that the area in which an individual lives, works, and plays shapes individual outcomes.49 Researchers in child and adolescent development consistently show that neighborhood disadvantage negatively affects school readiness and achievement.50 Parents of TAY with autism have also reported that many services were not provided in a geographic area or were not convenient or accessible.35 Other factors (like the number of job openings and community views of disability) may also contribute to the experiences and outcomes of TAY. Including descriptive variables, such as those drawn from census tracts or through geocoding, or TAY’s subjective appraisals of neighborhood quality may help to identify which neighborhood factors are important to transition success. Our seventh research recommendation is to adapt established methods from public health to examine the influence of neighborhood and community factors on TAY outcomes.

#### Policy Level

The authors of only 1 study examined the correlation between policy factors and transition outcomes.23 This is a critical gap in the autism literature, considering the United States spends roughly $130 billion annually on services for people with autism.51 In addition to the reviewed study about state-mandated transition policies,23 research on children with special health care needs52 has also revealed how we can learn policy-relevant lessons by comparing outcomes across states. Our eighth research recommendation is to examine how mutable policy factors are associated with variability in TAY outcomes. Changing trends in the labor market also have important implications for people with autism. For example, many of the job losses during the 2007–2009 recession were in occupational classifications in which people with autism are most frequently employed,31,53 such as transportation and utilities and clerical occupations.54 Over the past several decades, the labor market has also shifted from a production industry to a service-based industry. The greatest projected growth in job opportunities are either in occupations that require a college degree55 or are low-paid service jobs.55,56 However, study authors suggest that many TAY with autism work in low-skilled, low-paying jobs.31 Our ninth research recommendation is to examine how occupational structures and other economic factors influence transition outcomes. Most study authors in this review failed to fully capture the dynamic intersections between individuals and their social-ecological environment because of a limited inclusion of variables across levels, an overreliance on a limited number of national data sets, and an overall lack of variation in research design. The design of future national surveys should include variables that allow for a rich understanding of social-ecological factors. The use of social network analysis also has the potential to address several gaps in the research. Findings from other large data sets, such as the Adolescent Health Survey, include network questions in their survey instrument. Findings from these analyses were used to help characterize the size and quality of TAY social networks.57 Finally, future researchers should emphasize longitudinal data collection. The authors of long-term studies of adults with autism have provided valuable insights into the trajectories of adult development,58,59 but few population-level studies have conducted long-term follow-up on postsecondary outcomes. The transition into adulthood is marked by rapid changes in social roles and participation in institutions. Many TAY cycle in and out of jobs, return home after living independently, and take time off school. Therefore, study authors who rely on a single observation period to determine the prevalence of postsecondary outcomes may produce biased estimates. Additionally, some study authors used a dichotomous measure of having ever had a job, attended higher education, or lived independently since leaving high school. Although these measures can be used to help to capture the presence of outcomes across a longer period of time, they fall short when used to characterize issues like the fit among personal aspirations, abilities, and outcomes. A part-time job in the service industry might represent a winning outcome for 1 person but underemployment for someone with different abilities and aspirations. The goal of this article was to examine the breadth of available research on social-ecological correlates. Therefore, we did not base our inclusion criteria on the quality or rigor of the research study. It is also important to acknowledge that correlation studies are not used to explain causal relationships. Some relationships among constructs may be bidirectional. Overall, there is scant research about the social-ecological factors that affect transition outcomes for TAY with autism in correlation research. The majority of the social-ecological correlates included in this review operated at the family and institutional levels. Interpersonal, community, and policy factors were generally excluded in the research. Additionally, because of a limited range of analytic methods, the majority of studies focused on direct effects rather than intervening mechanisms, hindering the understanding of the interrelationships of factors across ecological levels. • ASD autism spectrum disorder • • TAY transition-age youth Ms Anderson conceptualized and designed the review, conducted the initial literature search, and drafted the initial manuscript; Ms Roux helped with the conceptualization and design of the review, established interrater reliability in the inclusion of the reviewed studies, and participated heavily in the interpretation and revision of the manuscript; Dr Shattuck participated in the conceptualization and interpretation of the manuscript and critically reviewed each iteration of the manuscript; Dr Kuo advised in the development of the manuscript’s research question and direction, and critically reviewed the manuscript in its final form; and all authors approved the final manuscript as submitted. * Refs 18, 19, 21 ,22, 24–29, 31–33, 36, and 37. FUNDING: Supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the grant UA6MC27364 and title Health Care Transitions Research Network for Youth and Young Adults with Autism Spectrum Disorders for the grant amount of$900 000. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government.

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## Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.