Employers increasingly need to assess and address autism issues in the workplace without discrimination. Lucy Kenyon explains.
We live in a world where many organisations are struggling to understand and fulfil their legal obligations to people with disabilities. Fitness for work poses significant professional challenges for occupational physicians in a litigious society keen to point the finger when something goes wrong.
Equally challenging are the pressures felt by employers to implement advice at any cost or to let an employee go on the grounds that it is not reasonably practicable to make adjustments for them.
A consequence of a poorly managed case is reluctance to risk a similar situation in future, which can potentially lead to discriminatory practices.
Autism-spectrum conditions are among those that represent a particular challenge to employers that want to embrace the diversity and skills that autistic employees could bring to the workplace.
This article reflects on the author’s experience and aims to identify useful tools that employers can refer to when confronted by a challenging case.
Prevalence of autism
Approximately four boys and one girl in every 1,000 are likely to have an autism-spectrum condition (Taylor et al, 2013). Recognition and diagnosis of the condition have increased dramatically since the 1970s, when many cases were diagnosed as a learning difficulty.
In recent decades, workplace environments have increasingly become open-plan offices, with more distractions and the demand for emotional intelligence, flexibility and adaptability. New demands for flexibility have also affected employers with a shift from prescriptive legislation to framework regulations and guidance (Health and Safety at Work Act 1974).
This brings specific challenges for people with autism, including distraction, unpredictability and uncertainty. It is also likely that if you have employees born before 1990 that a significant number of them will not have received a diagnosis of autismspectrum disorder (ASD), but could display behaviours and emotions that affect their ability to cope with the work environment
The key argument in this article is that incorporating arrangements for people with ASD reduces the impact of stress at work and subsequent performance and absence problems. A range of services is available, the most common being OH, case management (CM) and vocational rehabilitation (VR).
OH nurses and case managers “collaborate with clients by assessing, facilitating, planning and advocating for health and social needs on an individual basis”, according to the Case Management Society UK. The objective of a professional case manager is to maximise a productive life for clients, while identifying disability support that represents value for money. Effective CM should improve the “social, ethical and financial health” of a business (Case Management Society, 2015).
VR emphasises individualised employment arrangements for those with severe disabilities. However, businesses with comprehensive and effective reasonable adjustment policies are usually well equipped to participate in the support process (Corey et al, 1996).
The following case studies are taken from the author’s caseload. Some details have been changed to protect anonymity.
Health and safety referral
Jill was a kitchen assistant. She was referred to OH for her absence following disciplinary action by management. At the assessment, she reported stress caused by conflict with her manager, particularly over how health and safety (H&S) notices were adhered to in practice. Managers considered her obstructive and confrontational, whereas she reported acute distress about what she perceived as “breaking the H&S rules”.
Jill was very angry and needed to express her frustrations. She had a strong sense of right and wrong and little insight into how the way she articulated her frustrations might affect her colleagues. She felt unable to return to work because she could not continue providing what she perceived as a sub-standard and illegal service.
OH proved to be a safe environment for Jill to articulate her difficulties and understand that her perceptions and understanding were different from most of those around her, resulting in her self referring to her GP. Her uncertainty reduced and she gained control of her stress response (Greco and Roger, 2003).
I recommended a case conference on neutral ground for all parties to meet and discuss the issues. This included providing copies of job descriptions, performance measures and work instructions. In this case, I felt that the symptoms that were related to distress were so deep seated, and that they were unlikely to resolve without a psychological intervention of some kind. HR provided a psychological assessment as a reasonable adjustment, followed by a short-term intervention. An outcome of the intervention was that all three parties engaged in the process to resolve the relationship breakdown.
The reasonable adjustment in this case took the form of counselling, to provide the staff member with strategies to overcome psychological barriers to addressing problems and support to improve the distress that they may feel.
The parties met with an HR adviser and trade union representative to discuss their concerns and clarify the job description. This created an opportunity to restructure the way in which the service was delivered.
An independent mediator was brought in to help the team agree to core behaviours and re-establish the position of the line manager. After the CM intervention, the performance management framework was reviewed to give clearer guidance to managers and staff.
Alana was a graduate trainee working as a data analyst for a large financial organisation. She was referred to OH as part of the disciplinary procedure, following an incident at work when she had shouted at a colleague.
She had reported her autism condition on application for the role, and it had been diagnosed while she was at university. The Government’s Access to Work scheme, which helps disabled people into employment, had supported her during this process, and she could not understand why she had been referred. In her view, she did not have a problem at work and wanted to be left alone to do her job.
To establish communication and trust, I used her job description to structure my assessment model (Roper et al, 2000). I requested a copy of her performance review, which showed that she excelled at analytical skills and the ability to deal with large volumes of numerical data.
She had good organisational skills but had disagreed with her manager on workload priorities and struggled when making strategic recommendations and presenting findings. She was subject to a disciplinary procedure for taking what she had considered to be the “calculated risks” required by her job description.
Key misunderstandings had stemmed from the description of the required behaviours: “start with the customer and work backwards”; “collaborate effectively at all levels across organisation”; and “take calculated risks”.
Interventions included providing a work buddy for day-to-day debriefing and support and mediated meetings to redefine and re-establish relationships. Reasonable recommended adjustments included: rewriting her job description in unambiguous and direct terms with examples; and providing resources to assist and coach her on the areas she found difficult, such as making strategic recommendations.
The analyst positions were therefore restructured into specialist analyst and business-support roles. This enabled all the individuals within the organisation to work to their strengths.
The National Institute for Health and Care Excellence gives recommendations on therapies that should be prescribed for certain health conditions, but provision of NHS counselling services remains inconsistent. While individuals with ASDs can excel in attention to detail and systematic approaches at work, their challenging behaviour can be a major barrier for achieving equality in employment.
Traits of autism that can cause potential difficulties include:
- “executive function” (ie a person may be detail focused and less able to see the whole picture);
- difficulties in predicting the consequences of an action;
- difficulties in processing information (eg verbal, written, auditory or experience);
- reduced safety awareness (over-reliance on procedures);
- distraction due to sensory issues (noise, smells, proximity);
- understanding the concept of time; and
- literal understanding.
Case examples and recommendations exist for supporting individuals with ASDs at work (Hagner and Cooney, 2005; Schall, 2010). The following general approaches and their implications may also help employers of people with autism (Hagner and Cooney, 2003):
- using specialist employment agencies to assist employers and applicants;
- having clear unambiguous codes of conduct, job descriptions and competency frameworks;
- using direct and unambiguous communications; and
- creating documents including agendas containing standard and specific points for discussion, timescales.
Adjustments or adaptations that could be made for an employee with an ASD include:
- a consistent schedule/shift/manager(s);
- a defined set of job responsibilities;
- use of organisers to structure jobs;
- a reduction of idle or unstructured time;
- clear reminders;
- feedback and reassurances;
- assistance from a CM/VR specialist where appropriate;
- working arrangements and responsibilities of OH, line managers, HR; and
- positive behaviour support (Schall, 2010).
Resources available to employers to help resolve cases, and the referral to and cooperation with these services, should be incorporated into HR policies relating to the management of health limitations in the workplace. These include:
- Access to work
- Autism research
- Autism Speaks: Employment Tool Kit
- British Association for Supported Employment
- British Disability Forum
- Clearkit by The Clear Company
- Disability Action Alliance
- Do It Profiler
- GP or consultant reports
- Health and safety advice
- Hidden Impairment Toolkit
- Mental Health Foundation
- National Autistic Society
- Remploy employment services
- The big I.D.E.A.
Reasonable adjustments for autism in the workplace
Reasonable adjustments are a fair and robust way managing health-related performance and attendance issues in the workplace. Employers should consider any request on its individual case merits rather than worrying about setting a precedent.
An assessment should explore:
- social interaction deficits;
- cognitive inflexibility; and
- sensory abnormalities.
Adjustments should support individual needs and include the provision of:
- time off or flexi-time to attend a health improvement programme to improve performance performance or attendance, for example cognitive behavioural therapy; and
- temporary redeployment or alternative work activities to support VR or promote skills or rehabilitation after an acute episode.
Finally, the process must have clearly defined objectives and success criteria to ensure that employment decisions can be made in a timely and appropriate manner.
There is no need for employers to buy into costly health management schemes in order to fulfil their duties under the Equality Act 2010. Policies and procedures should accommodate regional variations in access to local primary care services and facilitate arrangements for employees to access these services.
Assessment of work functionality and fitness for work is becoming a commercial opportunity, with government funding available under the Fit for Work programme launched in 2015. Specialist providers such as the National Autistic Society also offer assessments of work functionality.
Employers need to have clear policies and be informed about how specialist these need to be. No matter how altruistic an organisation’s culture may be, the employer must ensure that they are getting the best from, and providing the most job satisfaction to, their employees.
Employers should monitor the health trends within their organisation and use OH professionals to advise them on proactive interventions such as flexible health benefits. These could involve partnerships with specialist disability services.
A robust health-risk management approach will help employers quantify the cost benefit of providing health interventions, for example fast-track diagnostics or targeted therapies where the NHS services have limited access or long waiting lists in the location. Managers and HR departments can easily estimate the likely duration of restricted or alternative duties by checking “time to treatment” data on NHS trust websites or with a consultancy such as Dr Foster Health Intelligence.
Employers that embrace the principles of VR and build these into health management policies may have a similarly positive impact for neuro-typical workers, and this will help promote them as employers of choice and support staff retention.
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