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Support for Higher Education Students with Autism Spectrum Disorder

Young adults with autism spectrum disorder (ASD) are increasingly attending postsecondary education. However, the graduation rate and academic performance of tertiary-level students with ASD are significantly poorer than that of neurotypical students. In addition, postsecondary students with ASD struggle with loneliness, anxiety, high level of stress, depression, and suicidal behaviors. This review focuses on the current psychological support systems for students with ASD enrolled in higher education. A range of interventions are available, many of which are feasible and show high satisfaction rates among students with ASD. This review shows the need for institutions of higher education to provide psychological supports for students with ASD.


Introduction
Autism spectrum disorder (ASD) is characterized by significant impairment in social interaction, verbal and nonverbal communication deficits, and restricted and repetitive interests and behavior (APA, 2013). These symptoms range in severity from mild to severe and usually persist throughout the lifespan. While many individuals with ASD have intact or high intellectual ability, non-social neurocognitive impairment has been observed in domains such as aspects of working memory (Williams, 2006), planning (Hughes et al., 1994), and executive functioning (Ozonoff et al., 1994). This constellation of social and non-social deficits in information processing limits adaptation and success in adult life significantly, despite normal intellectual ability. Furthermore, people with ASD are vulnerable to numerous psychiatric and neurological disorders such as depression, epilepsy, sleep disorder, anxiety disorder, and obsessive-compulsive dis-

Search Results
The database search identified 466 papers, the abstracts of which were then manually reviewed to ensure that the studies investigated postsecondary students with ASD. Most of the excluded articles studied adolescents or children for intervention. 45 articles remained after titles and abstracts were screened to ensure that the study focused on university or college students with ASD. 24 articles were excluded because participants did not meet the eligibility criteria. One case report was also excluded. After examination of the full articles, 19 articles were judged to meet inclusion criteria ( Figure 1).

Overview of the Reviewed Studies
The 19 articles included in this study were published in peer-reviewed journals and described postsecondary support or interventions in college or university settings. The articles were published after 2013, when the definition of ASD was determined by the APA in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. The sample size in the 19 articles was 3 (Ashbaugh et al., 2017;Jackson et al., 2018) to 52 (Hiller et al., 2018. A total of 297 students with ASD were enrolled in the 19 studies and 81% of participants were male (n = 241). All the papers reported that participants were college or university students with ASD. The interventions were designed to help students develop skills that might enable them to cope with the demands of university life. Most of the interventions showed high effectiveness and rates of satisfaction in participants. The details of these interventions are described subsequently in the paper and Table 1. Ames et al. (2016) reviewed the ASD Mentorship Program intended to help students with ASD navigate the social and academic framework of postsecondary campus life. Twenty-three students participated. Majority of the students was successful in achieving personal goals and high levels of satisfaction. In addition, the students indicated that they enjoyed the individual meetings with their mentors. Ashbaugh et al. (2017) demonstrated an intervention that consisted of weekly meetings to plan social activities around the interests of three students with ASD, improve organizational skills, and target specific social skills. In addition, each participant had a peer mentor for support during the social activities. The results showed that, following intervention, all participants demonstrated increased participation in community-based social events, extracurricular activities, and peer interactions, and improved in their Grade Point Average (GPA). Furuhashi (2017) conducted a group therapy program consisting of CBT and recreational activities to enhance university-related behavior. Fifteen students participated in the program, and 11 students completed it. The results showed significant post-intervention improvements in depressive symptom, anxiety, and self-esteem, which indicated that the group therapy involving CBT was effective for students with ASD.

Details of Each Paper
Hiller et al. (2018) evaluated a support group program for university students with ASD designed to address common challenges including social life on campus, academic skills, managing group work, and time and stress management. They reported that participants showed significantly higher self-esteem, reduced loneliness, and lower anxiety at the end of the program compared to that at the beginning. However, subscales examining social anxiety, academic distress, and depression did not show significant differences. Jackson et al. (2018) developed the writing learning strategy training on the writing performance of three college students with ASD. One-hour sessions were Psychology held individually with each student approximately two times per week to deliver the intervention. The learning strategy was referred to as DATE; Developing the thesis statement, adding supporting details, tying it together, and Editing and revising. Ten scripted lessons were used during the intervention, and a multiple baseline across participants design was used to assess the effects of the learning strategy intervention. All three students improved in the quality of their writing. Lei et al. (2020) evaluated changes in social network structure and perceived social support among first-year students with the ASD (n = 21) and typically developed (n = 182) the first-year students in their transition to the university.
Both groups gained friends who provided better support during the first year of university over time. Social anxiety showed a long-term differential negative impact on both the groups.
Longtin (2014) examined the results of Interdisciplinary Collaborative Support Service Program on five students with ASD. Each participating student was each assigned to a graduate student mentor who met with their mentee individually on a weekly basis to provide guidance on college life, social pragmatics, executive function, study habits, relationship building, job search, and self-advocacy.
All the mentors agreed that the collaborative support services promoted the academic and social success of their mentees.

McCoy et al. (2014) explored a biofeedback intervention in 10 students with
ASD and 37 typical college students. Exploratory data analysis was used to identify trends resulting from a 10-week study. They concluded that both the ASD and the typical groups showed a small improvement in heart rate variability.
However, the ASD group demonstrated greater improvement than the typical group.
Pearlman-Avion and Aloni (2016)  grams developed for college students with ASD. In this report, college students with ASD were each assigned to either of two new programs which were an intervention based on virtual reality, Brain-Computer Interface for ASD, and a psychosocial intervention, called College and Living Success. Preliminary evidence supports the feasibility and acceptability of both programs. Eight students with ASD participated in this study. Four of the students were assigned to each of the two experimental programs. Results indicated that expanded research on psychosocial and computer-assisted intervention approaches for this population was warranted, given the preliminary data obtained.

Discussion
In this paper, 19 empirical studies on interventions for postsecondary students with ASD are reported. A diverse range of interventions were evaluated, most of which showed high effectiveness and rates of satisfaction in participants. However, all papers have different intervention methodologies (i.e., randomly controlled trial, pre-experimental designs), durations, and evaluation scales (i.e., social skills, executive function, grade point average), making it difficult to identify the most effective one that can be universally implemented. The limited number of studies and paucity of empirical evidence limit the generalizability of the results. In spite of the limitations, several interesting interventions have been noted such as mentoring and group settings. In addition, university students with ASD preferred peer mentoring and support groups for nonacademic support according to recent surveys (Accardo et al., 2019;Anderson et al., 2020).
Papers published on group setting for high-functioning ASD investigated a cohort of patients at the beginning and end of the intervention program (Pugliese & White, 2014;Hiller et al., 2018;Furuhashi, 2017;Schindler et al., 2015;Weiss & Rohland, 2015) demonstrated the feasibility and acceptability of group settings. Most participants in those studies reported that they could talk about their symptoms with group members, and no problems in facilitating the groups were reported.
Several studies on mentoring have also reported on other types of support (Ames et al., 2016;Ashbaugh et al., 2017;Pearlman-Avnion & Aloni, 2016;Rando et al., 2016;Roberts & Birmingham, 2017;Schindler et al., 2015;Siew et al., 2017;Todd et al., 2019). The participants indicated that they were extremely satisfied with the mentoring programs, citing the following three reasons for their positive response: 1) Mentors and mentees experienced a natural progression in the relationship, in which they became more open and comfortable. They were able to develop enjoyable peer-like interactions within the relationship; 2) Mentors were supportive and flexible in appropriately assisting mentees with their various needs. In addition, being a familiar supportive connection involved the mentor as a guide and a friend to the mentee; and 3) Mentors and mentees were learning together. Mentors learned about how to mentor students with ASD, whereas mentees learned about the university experience and that many of their challenges were common with several students in postsecondary settings (Roberts & Birmingham, 2017).
An individual with ASD may feel like an outsider in a group of typically developing peers, which creates feelings of isolation in the individual with ASD.
The feelings of isolation may develop into anxiety and depression. Treatment delivered in a group context and mentoring may not only ease feelings of isolation but also provide a natural opportunity for growth in positive social interactions. Group settings including mentoring programs enable social interaction and the sharing of experiences with others, thereby reducing social isolation (Ames et al., 2016;Ashbaugh et al., 2017;Furuhashi, 2017;Hillier et al., 2018;Pearlman-Avnion & Aloni, 2016;Pugliese & White, 2014;Rando et al., 2016;Roberts & Birmingham, 2017;Schindler et al., 2015;Siew et al., 2017;Todd et al., 2019). Most participants also indicated that they found meetings to be the most helpful component of therapies. Furthermore, participants with ASD stated that it was helpful to meet other patients with ASD, have people in similar situations to talk to, see that many of the peers share the same problems, and learn how others with ASD solve their problems. The group setting may have helped nor-malize their problems. Group settings and mentorship provides the opportunity to feel accepted and understood by mentors or peers struggling with the same disorder and offers the chance to practice problem-solving skills in a relatively naturalistic, safe, and supportive environment. Thus, group settings and mentorship can provide a sense of being normal and being understood and provide a safe space to talk about an isolated experience. In other words, the group setting and mentorship may offer several advantages over individual therapy. The findings in the studies reviewed are promising, especially given the high rates of comorbidity between ASD and anxiety (Attwood, 2005).
Most of the studies are pre-experimental and generally had a small sample size. The limited number of previous studies and paucity of empirical evidence limit the generalizability of the results. Thus, larger-scale experimental research with longer intervention periods and better descriptions of student characteristics is indicated. In addition, students with ASD cannot ask for support according to a report by Anderson et al. (2020). Thus, it is crucial to develop the best methods of delivery. A more rigorous research design using methodologically strict randomized clinical trials that includes comparisons of treatments and independent evaluators will be required to evaluate treatment efficacy.

Conclusion
There were 19 studies found that demonstrated feasibility and social validity for interventions that included mentoring, CBT, social skill development, and small size group. Especially, small size group settings and peer mentoring are effective and provide the opportunity to feel accepted and understood by mentors or peers struggling with the same disorder and offer the chance to practice problem-solving skills in a relatively naturalistic, safe, and supportive environment.
However, comprehensive approaches designed to address the core neurocognitive and socio-cognitive impairments, and sensory sensitivities in young adults with ASD have yet to be developed. Thus, additional research is needed on effective methods of enhancing the college experiences and outcomes of students with ASD. The increase of students with ASD in higher education is no longer a new phenomenon. Many students with ASD have unique characteristics and need effective accommodation and support. Research is just beginning to identify methods that can be used to support post-secondary students with ASD.

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.