Fragmented employment inclusion and lifespan health outcomes for autistic adults: systemic barriers and implications in China.

Abstract

Background: Employment is a core social determinant of long-term health, well-being, and social inclusion across the autism lifespan, yet autistic adults face severe, globally pervasive employment inequities. Existing research has disproportionately focused on childhood diagnosis and intervention, with limited exploration of systemic barriers to substantive employment inclusion for autistic adults, particularly in non-Western family-led welfare contexts amid state welfare retrenchment. This study addresses this gap by examining how multi-stakeholder goal misalignment shapes fragmented employment inclusion for autistic adults and its implications for health equity.

Methods: This study integrates Job Fit Theory and Regulatory Focus Theory to conduct an exploratory qualitative analysis, using maximum variation sampling to recruit 37 key stakeholders (parents, parents-led organizations, pre-employment training institutions, and employers) across four Chinese cities (Beijing, Guangzhou, Xi'an, and Changchun). Data were collected through 48 semi-structured interviews and long-term participant observation of sheltered workshops and cross-sector negotiation meetings, with thematic analysis applied for data coding. Autistic adults were not directly interviewed in this study because we focused on key interest-holders who directly shape their employment trajectories and daily work experiences.

Results: Core findings reveal three critical forms of fragmented inclusion: parents' collective prevention orientations narrow skill-demand matching to behavioral compliance, isolating autistic adults from mainstream labor markets; employers' promotion-prevention conflicts result in symbolic hiring ("paid absence"-a practice where employers keep autistic adults on the payroll and pay them salaries but do not require them to attend work or perform meaningful tasks), maintaining formal employment status while undermining substantive inclusion; and these dynamics form a "proxy-driven fragmented inclusion paradox," trapping job fit in a low-equilibrium state where short-term employment stability perpetuates capability deprivation.

Conclusions: This study reveals how policies redistribute regulatory labor to families, exacerbating health inequities for autistic adults. These findings point toward a normative ethical framework that balances protection and autonomy and underscore that employment policies must empower autistic adults as active agents in their own employment trajectories. The findings offer critical insights for global autism employment policy and health equity practice for autistic adults.