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. 2025 Mar 29;190(9-10):e2065–e2071. doi: 10.1093/milmed/usaf099

Launching! To Adulthood, A Culturally Adapted Treatment Program for Military-Dependent Autistic Young Adults and Their Military Parents: A Pilot Study

Antonio F Pagán 1,✉,b, Jordan Kenemore 2,b, Maj Mark Ahlenius 3,b, Linda Hernandez 4,b, Stephen Armstrong 5,b, Katherine A Loveland 6,b, Ron Acierno 7,b
PMCID: PMC12459862  PMID: 40156911

ABSTRACT

Introduction

Military-dependent young adults (17-25 years old) with autism spectrum disorder (ASD) face significant barriers to accessing services during their transition to adulthood. Frequent relocations, disrupted care, and limited ASD-tailored interventions exacerbate the challenges for these families, with many young adults experiencing a “service cliff” as they age out of pediatric care and school-based services. Addressing these gaps is critical, particularly given the rising mental health challenges and executive dysfunction in this population. This study evaluates the preliminary efficacy of an adapted telehealth intervention, the Military-Launching! program, designed to support young adults with ASD and their military families.

Materials and Methods

A repeated measures design was used to evaluate changes in functioning, self-efficacy, and quality of life among 20 military-dependent young adults with ASD and 34 of their parents. Participants completed measures at baseline, mid-treatment, and post-treatment. Young adults met ASD diagnostic criteria and exclusion criteria included intellectual disability (IQ < 75) or severe mental health conditions. Recruitment was facilitated through military programs at bases in Texas.

Results

Significant improvements were observed in young adults’ social cognition (η = 0.52, P = .016) and executive functioning (BRIEF-A GEC, η = 0.26, P = .016). Parents reported significant reductions in stress (BRIEF-A BRI, η = 0.28, P = .004) and enhanced quality of life in social relationships (WHOQOL-BREF, P = .047). While adaptive functioning improvements were limited to specific subscales, parent-perceived transition readiness showed a large effect size (η = 0.36).

Conclusions

Preliminary findings suggest that the Military-Launching! program improves social cognition, executive functioning, and family outcomes for military-dependent young adults with ASD. Tailored, evidence-based interventions addressing co-occurring mental health and military-specific stressors are essential for fostering successful transitions to adulthood.

INTRODUCTION

Each year, over 100,000 adolescents with autism spectrum disorder (ASD) transition into adulthood, joining the 8 million adults with ASD in the United States.1,2 These figures likely underestimate the true number of adults with ASD, as many individuals remain undiagnosed—approximately 2 for every 3 diagnosed cases.3 ASD is often associated with challenges in social functioning, self-regulation, attention, and managing stress, all of which are critical for a successful transition to adulthood.4,5 Consequently, young adults with ASD frequently face difficulties across various aspects of daily life, such as education and employment, during this transitional period.6,7 Additionally, ASD is linked to an increased risk of mental health challenges, including suicide, among U.S. military service members.8 Please note the present paper chose to utilize person first and identity first language interchangeably throughout, which aligns with recent discussions on language preferences in the autism community.9,10 We also use preferred terminology by the autism community with respect to intellectual ability.11

The transition to adulthood is particularly challenging for military-dependent young adults with ASD, who often experience a significant “service cliff” when aging out of pediatric care and school-based services.2,12,13 This issue is especially pronounced for more than 35,000 military-dependent family members who currently receive ASD-related services.14,15 Unique stressors associated with military life, such as frequent relocations, prolonged separations from family members, limited access to specialized care, financial strain, and disrupted continuity of care, further complicate the transition process.16–18 Additionally, military families often lack the support systems available to civilian families, contributing to feelings of isolation.16–18

Currently, no comprehensive interventions exist to address co-occurring mental health challenges for military-dependent young adults with ASD or provide support for their military parents.19 Military families often lack sufficient education on ASD and struggle to set realistic goals for their children, particularly if their young adult was diagnosed later in life. Without interventions that consider the unique cultural and logistical contexts of military life, these young adults risk falling further behind in their development. To address these gaps, researchers must develop evidence-based interventions tailored to military-dependent young adults with ASD and their families.15,20

Group interventions for young adults with ASD have been tested21 but rarely address co-occurring mental health, executive dysfunction, nor are adapted for military families. Ensuring military families have access to tailored mental health interventions was the driving force behind our team’s previous work22 to adapt the 12-week, evidence-based, telehealth, Launching! to Adulthood23,24 program for young adults with ASD. For a detailed description of the adaptation process, see Pagán et al.22 Overall, the military adaptation of the Launching! program incorporated feedback from military ASD community members through focus groups and individual meetings. The adaptation focused on aligning the intervention with military cultural values, including mission readiness, resilience, and the challenges posed by frequent relocations (permanent change of station). Adjustments were made across the eight Ecological Validity Framework (EVF) dimensions (e.g., Language, Content, Context), ensuring relevance for military families. Key modifications included integrating peer co-leaders, adding an autistic advocate to parent sessions, incorporating psychoeducation on ASD to address military-specific expectations, and structuring family therapy sessions to bridge parent-young adult expectations. Telehealth was utilized to improve accessibility, and WhatsApp groups facilitated communication between sessions. Additionally, webinars covered essential transition topics, such as self-advocacy, legal rights, and financial planning, ensuring military families received tailored, practical support. The adapted program uses the Pediatric Self-Management model,25 which targets self-management behaviors in three key areas26: co-occurring mental health, executive functioning, and social cognition. The intervention integrates group and individual therapy sessions tailored to the needs of military families. Parent group therapy focuses on psychoeducation regarding ASD, along with skills to manage family communication, and skills to manage parental stress.

This pilot study used a repeated measures design to detect preliminary efficacy signals of this adapted intervention for both autistic young adults from military families and their parents. We aimed to evaluate if the military-adapted Launching! program was associated with significant improvements in social functioning, adaptive functioning, executive functioning, self-efficacy, and the quality-of-life military-dependent young adults with ASD. Additionally, we sought to evaluate if the program was associated with significant improvements in the parental stress and quality of life of military parents.

METHODS

Participants

Twenty young adults aged 17-25 years with ASD (American Psychiatric Association, 2022) and 34 of their parents, all from military or veteran families, participated in the study. Inclusion criteria required young adults to score above 14 on the Social Communication Questionnaire-Lifetime (SCQ-L;27 completed by a parent, meet DSM-5 ASD criteria based on a symptom checklist,28 have a prior ASD diagnosis from a licensed professional, and have a parent currently or formerly serving in the military, armed forces, Coast Guard, or National Guard. Exclusion criteria included intellectual disability (IQ < 75) as measured by a standardized instrument,29 or severe mental health conditions such as active substance use disorders or suicidality that could compromise participation or safety. Recruitment was facilitated by a military pediatrician and the Exceptional Family Member Program at several military bases in Texas. Each young adult and parent received compensation for completing study measures.

Procedure

The study was approved by the Institutional Review Board at the affiliated university. Therapy sessions were conducted virtually. Informed consent was obtained from all participants. Recruitment spanned January to September 2024, with 32 young adults contacted and 20 ultimately enrolled (see Appendix 1 for demographics). Reasons for nonenrollment included lack of response to advertisements (n = 2), enrollment in a similar program (n = 1), not meeting the verbal IQ cutoff (n = 2), and scheduling conflicts (n = 6).

All but one young adult had both parents participate in the parent group, resulting in 37 total parent participants. Two pairs of siblings participated, and among the young adults, 95% were male and 5% female. Parent participants were mostly evenly split by gender (47% male, 53% female). Young adults had a mean age of 20.75 years (SD = 2.15) and were diagnosed with ASD at an average age of 8.65 years (SD = 6.34). Parents averaged 51.6 years old (SD = 7.34). Military service included representation from the Coast Guard (12%), Air Force (35%), Army (35%), and Navy (18%), with an average of 17.62 years (SD = 3.42) of service, 2.91 deployments (SD = 2.39), and 3.42 permanent change of station moves (SD = 1.88). Most young adults (90%) had never lived independently. Half of young adults held a high school diploma as their highest level of education. Among parents, 60% had a bachelor’s degree. Occupationally, 45% of young adults were students, and 43% of parents were employed full-time. Of the young adults, 15 were taking medications, the most common being Adderall (n = 5).

Measures

Social Responsiveness Scale, Second Edition (SRS-2; Constantino, 2013) is a 65-item self-report measure evaluating autism-related difficulties. Responses range from 1 (not true) to 4 (almost always true), producing a total score and five subscale scores (Social Awareness, Social Cognition, Social Communication, Social Motivation, and Restricted Interests/Repetitive Behaviors). T-scores (M = 50, SD = 10) are norm-referenced, with higher scores indicating more pronounced difficulties. Data were collected at baseline and post-treatment.

Adaptive Behavior Assessment System, Third Edition (ABAS-3; Harrison & Oakland, 2018) evaluates adaptive behavior through a caregiver-report format. It provides standard scores (M = 100, SD = 15) for Conceptual, Social, and Practical skills.

Behavior Rating Inventory of Executive Functioning, Adult Version (BRIEF-A; 30 is a 75-item rating scale assessing executive functioning challenges over the past month. It provides scores for a Global Executive Composite, divided into Behavioral Regulation and Metacognition indices, with nine subscales (e.g., Inhibit, Shift, Working Memory). Scores are expressed as T-scores (M = 50, SD = 10), with values above 65 years indicating clinical significance.

WHO Quality-of-Life Instrument, Short Form (WHOQOL-BREF; WHOQOL Group, 1998) is a 26-item measure assessing quality of life across four domains: Physical, Psychological, Social Relationships, and Environment. Responses range from 1 to 5, with higher scores indicating better quality of life.

Transition Readiness Scale—Adapted (TRS-A) is a 30-item scale that was modified in our previous work24 with permission from its developers31 where participants rate their own (or their young adults) readiness to transition to adulthood using a 4-point scale from “Not true for me (or for my young adult)” to “True for me (or my young adult).” Responses are then summed for a total score. Higher scores reflect greater readiness for the transition to adulthood.

Young Adults Only

Coping Self-Efficacy Scale (CSES; 32 is a 26-item scale where participants rate confidence in coping skills on a scale from 0 (cannot do at all) to 10 (certain can do). Higher scores reflect greater self-efficacy.

Difficulties in Emotion Regulation Scale—Short Form (DERS-SF; 33 ) includes 18 items assessing emotion regulation challenges, rated from 1 (almost never) to 5 (almost always). Higher scores indicate greater dysregulation.

Autism Spectrum Quality of Life (ASQoL; 34 ) is a 9-item measure of quality of life specific to autistic adults, with items addressing areas such as friendships and sensory challenges. Responses are scored on a 5-point Likert scale.

Parents Only

Shortened Seven-Item Screen for Caregiver Burden (SCB) measures caregiver burden on a scale of 0-4, with strong psychometric validation in autism caregiver studies.35,36

Parental Stress Scale (PSS; Berry & Jones, 1995) is a 17-item scale that evaluates stress related to parenting using a 5-point Likert scale with higher scores reflecting greater stress.

The Autism Knowledge Questionnaire (AKQ) assesses knowledge of autism through 30 true/false items, with a “Don’t Know” option to discourage guessing37 with higher scores indicating better knowledge about autism.

Adapted Intervention

Guided by the EVF38 and CBPR principles, we culturally adapted the Launching! program to address the unique needs of military families (see Figure 1). Adaptations were informed by focus groups and individual meetings with the military ASD community.22 The eight EVF dimensions—Language, Persons, Metaphors, Content, Goals, Methods, Context, and Integration—shaped the adaptation process emphasizing military values such as resilience, mission readiness, and adaptability (see22 for a full overview of the adaptation process). Overall, the 12 week, virtual program includes separate weekly group therapy for the young adults and parents and individual coaching sessions for the young adults. Weekend webinars covered key transition topics such as self-advocacy, military health care options, relationships, finances, and legal rights. Family therapy sessions were provided at baseline, mid-treatment, and post-treatment.

Figure 1.

Figure 1.

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Conceptual diagram illustrating the bidirectional cultural adaptation language to Adulthood therapy program.

Therapist Training

Therapists in the program were master’s-level clinical psychology graduate students with over 3 years of manualized therapy experience. All cases were supervised by the sixth author, a doctoral-level clinical psychologist with 30+ years of autism research experience, and the first author, a licensed clinical psychologist. Therapists underwent a 2-hour orientation to the program and attended weekly 1-hour supervision meetings with the first author. Supervision included case discussions, feedback, problem-solving, and session preparation to ensure protocol fidelity and address treatment barriers. To enhance treatment fidelity and care quality, an autistic self-advocate and military pediatrician from our community advisory board participated in group supervision and therapy sessions, providing valuable insights to improve outcomes for adults with ASD.

Design and Statistical Analyses

Treatment outcomes were analyzed using one-way repeated measures ANOVA across three time points (baseline, mid-treatment, and post-treatment), with post-hoc comparisons to examine changes between specific time points. Effect sizes were calculated using Cohen’s d (pre/post-treatment mean difference divided by the pretreatment SD) and eta squared, which measures effect size in ANOVA models. Data with partial responses were addressed using multiple imputation following best practice guidelines to ensure accurate and unbiased results.39

RESULTS

Appendix 2 presents the results of repeated measures ANOVA and paired samples t-tests for standardized measures administered at baseline, mid-treatment, and post-treatment for young adults (n = 20) participating in the Military-adapted Launching! program. On the SRS-2, participants demonstrated significant improvements in Social Cognition from baseline to post-treatment (η = 0.52), with a mean difference of 2.40 (P = .016). No significant changes were observed in other subscales, including Social Awareness, Social Communication, Social Motivation, and RRB. On the ABAS-3, there was a significant improvement in the Social subscale from baseline to post-treatment (η =0.21), with a mean difference of −6.86 (P = .030). The Conceptual, Practical, and General Adaptive Composite did not significantly improve. On the BRIEF-A, participants showed significant improvements in behavioral regulation (BRI; η = 0.32) and global executive functioning (GEC; η = 0.26), with baseline to post-treatment differences of 4.91 (P = .006) and 4.19 (P = .016), respectively. On the general quality of life measure (WHOQOLBREF), no significant changes were observed. The autism-specific quality-of-life measures (ASQoL) also did not significantly change over the course of the study. The TRS-A showed significant improvements across all time points. Participants’ scores increased from baseline to post-treatment. The overall effect was significant, (F(20) = 11.37, P = .003, η = 0.36), indicating a large effect size. Pairwise comparisons revealed a significant increase from baseline to post-treatment (P = .003), with a mean difference of −8.43. Coping self-efficacy (CSES) showed significant improvement (F(20) = 4.51, P = .046, η = 0.18), with a mean difference of −20.05 (P = .046) from baseline to post-treatment. Difficulties with self-regulation (as measured by the DERS-SF) did not show significant changes.

Appendix 3 presents the results of repeated measures ANOVA and paired samples t-tests for standardized measures administered at baseline, mid-treatment, and post-treatment for military parents (n = 34) participating in the Military-adapted Launching! program. On the SRS-2, no significant improvements were observed across subscales from baseline to post-treatment. Adaptive scores (as measured by the ABAS-3) did not reveal significant changes in the Conceptual, Social, or Practical subscales, though there was a significant decrease in the general adaptive composite (GAC) from baseline to mid-treatment (P = .017). On the BRIEF-A, significant improvements were observed in the behavioral regulation (BRI) and global executive functioning (GEC) subscales. The behavioral regulation subscale (BRI) showed a large effect size (η = 0.28), with a significant reduction from baseline to mid-treatment (P = .003) and post-treatment (P = .004). The global executive scale (GEC) also improved significantly, with large effects (η =0.34), and pairwise comparisons revealed significant changes from baseline to mid-treatment (P = .001) and post-treatment (P = .001). In terms of overall quality of life (as measured by the WHOQOL-BREF), significant improvements were observed in the Social Relationships subscale from baseline to mid-treatment (P = .049) and post-treatment (P = .047), indicating parents’ quality of life related to social relationships improved significantly. Perceived transition readiness (as measured by the TRS-A) significantly improved, with a large effect size (η = 0.39). Pairwise comparisons revealed significant improvements from baseline to mid-treatment (P < .001) and from baseline to post-treatment (P < .001), indicating that parents perceived their young adult’s transition readiness having improved significantly from baseline to post-treatment. Parents demonstrated significant improvements in caregiver burden (SCB; P = .032) and Autism Knowledge (P = .047) from baseline to post-treatment; however, parental stress (PSS) did not show significant improvements.

DISCUSSION

This pilot study provides promising evidence for the efficacy of the Military-adapted Launching! program in enhancing social and executive functioning for young adults with ASD from military families, as well as improving parental outcomes, such as stress levels and quality of life. The results align with previous research highlighting the challenges faced by military families with ASD and the need for tailored interventions 16,18. Our findings indicate that the adapted program successfully targets areas of executive functioning and social cognition, areas often identified as critical for success in the transition to adulthood 4,5.

Notably, participants in the young adult group showed significant improvements in social cognition, as measured by the SRS-2, which is consistent with previous research suggesting that group interventions can enhance social outcomes for young adults with ASD 21. However, the lack of significant changes in other subscales of the SRS-2 (e.g., Social Awareness and Social Communication) suggests that specific aspects of social functioning may require additional focus or that the 12-week duration of the intervention may not have been sufficient for broader improvements. This finding mirrors those of studies by Magiati et al., 5 who noted that while interventions can lead to improvements in certain social domains, others may be more resistant to change without more intensive or prolonged interventions.

The significant improvement observed on the ABAS-3 Social subscale in the young adult group suggests that the intervention effectively enhanced adaptive functioning in social contexts, an essential outcome given the difficulties ASD individuals face in independent living and social integration 6. However, the lack of improvements in the Conceptual and Practical subscales warrants further investigation, as these domains are critical for long-term success in education and employment 7.

In terms of executive functioning, significant improvements were observed in the BRI and GEC subscales of the BRIEF-A, reflecting better behavioral regulation and global executive functioning. This is particularly relevant given the substantial role of executive dysfunction in the challenges faced by young adults with ASD 4,5. These findings align with the work of 23, which emphasizes the importance of executive functioning in navigating the demands of independent adulthood. However, the lack of significant changes in the MI subscale suggests that emotional regulation may need more focused attention in future adaptations of the program.

Despite improvements in some areas, the lack of significant changes in quality-of-life measures (WHOQOL-BREF and ASQoL) for young adults is consistent with findings from other interventions targeting ASD 15. Quality-of-life improvements often require more extensive or long-term interventions, particularly in individuals facing the compounded challenges of ASD and military family dynamics 12,13. The lack of improvement on the DERS-SF further underscores the complexity of emotional regulation in ASD, which may not be fully addressed by the current intervention model.

For military parents, significant improvements were observed in executive functioning (BRIEF-A), with reductions in BRI and GEC scores indicating better stress management and organizational abilities. These improvements are critical, as research has shown that the stress levels and executive dysfunction of caregivers are linked to the well-being of children and adolescents with ASD 16. The improvements in social relationships quality of life (WHOQOL-BREF) and perceived transition readiness (TRS-A) further highlight the intervention’s potential to improve family dynamics and support systems. These outcomes are consistent with the findings of 22, who demonstrated that parent-focused interventions can play a pivotal role in enhancing family well-being.

The improvements in caregiver burden (SCB) and autism knowledge (P = .047) are also noteworthy, suggesting that the program successfully provided parents with tools and resources to navigate the unique challenges of raising a child with ASD. However, the lack of significant improvements in parental stress (PSS) warrants further investigation, as interventions specifically targeting caregiver stress have shown mixed results in prior studies 4,19. Participants who benefitted most from the intervention were those whose parents demonstrated higher involvement and warmth throughout the program. Greater parental engagement was associated with improved transition readiness, executive functioning, and social adaptive skills in young adults, suggesting the critical role of family support in fostering positive outcomes.

LIMITATIONS

This pilot study has several limitations that must be considered when interpreting the findings. First, the small sample size (n = 20 for young adults and n = 34 for parents) limits the generalizability of the results. Although significant improvements were observed in certain outcome measures, the sample size may not have been sufficient to detect smaller or more subtle effects, especially in certain subscales (e.g., Social Awareness, Social Motivation). Second, the lack of a control group makes it difficult to attribute the observed improvements solely to the Military-adapted Launching! intervention, as other factors such as maturation or external life events could have influenced the results. Third, the reliance on self-report measures, particularly for subjective outcomes like quality of life and coping self-efficacy, introduces the potential for response bias, as participants may have over- or under-reported changes in their experiences. Additionally, the intervention’s adaptability to different military contexts (e.g., frequent relocations, varying family dynamics) was not thoroughly examined, limiting the ecological validity of the findings. Finally, the relatively short duration of the intervention and the follow-up period (baseline to post-treatment) does not provide insight into the long-term sustainability of the observed effects.

FUTURE DIRECTIONS

Future research should address the limitations of this study by conducting larger-scale trials with diverse military populations to enhance generalizability. A randomized controlled trial design would help establish causality and provide a more robust measure of the intervention’s efficacy. Additionally, incorporating objective measures, such as behavioral assessments and clinical interviews, could strengthen the validity of the findings. Long-term follow-up studies are also needed to evaluate the sustainability of the intervention’s effects over time. Future work could explore how the intervention can be adapted further for specific subgroups within the military-dependent population, considering factors such as age, gender, and the nature of the family’s military experience. Furthermore, investigating the impact of the intervention on other co-occurring challenges, such as anxiety and depression, would be valuable in broadening the scope of mental health support for young adults with ASD. Finally, further research should focus on refining parent support components of the program, particularly how to sustain improvements in caregiver burden and parenting skills beyond the treatment period.

In conclusion, the Military-adapted Launching! program demonstrates promising efficacy for addressing key areas of social, executive, and adaptive functioning in young adults with ASD, as well as reducing parental stress and improving family dynamics. However, the results also underscore the need for further refinement, particularly in addressing broader aspects of social functioning, emotional regulation, and quality of life. Future research should explore longer-term outcomes and assess the impact of more intensive interventions to fully address the multifaceted challenges faced by military-dependent families with ASD.

Supplementary Material

usaf099_Supplementary_Data
usaf099_supplementary_data.zip (57.7KB, zip)

ACKNOWLEDGMENTS

The authors wish to thank our community advisory board and all of the young adults with ASD and their military and veteran families for their helpful participation, their feedback, and their service to our country.

Contributor Information

Antonio F Pagán, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, UTHealth Science Center at Houston, Houston, TX 77054, USA.

Jordan Kenemore, Department of Psychological Sciences, University of Texas, Rio Grande Valley, Edinburg, TX 78542, USA.

Maj Mark Ahlenius, Madigan Army Medical Center Jackson Ave, Joint Base Lewis-McChord, WA 9040A, USA.

Linda Hernandez, Department of Clinical, Health, and Applied Sciences, University of Houston-Clear Lake, Houston, TX 77058, USA.

Stephen Armstrong, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, UTHealth Science Center at Houston, Houston, TX 77054, USA.

Katherine A Loveland, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, UTHealth Science Center at Houston, Houston, TX 77054, USA.

Ron Acierno, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, UTHealth Science Center at Houston, Houston, TX 77054, USA.

SUPPLEMENTARY MATERIAL

Supplementary material is available at Military Medicine online.

FUNDING

This research was funded by the University of Texas Health Science Center Houston, Department of Psychiatry and Behavioral Sciences Career Development and Research Excellence (CaDRE) Program in Psychiatry, the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health, through the UTHealth-CCTS (grant no.: 5TL1TR003169-05 and T32TR004904), and the Eunice Kennedy Shriver National Institute Of Child Health & Human Development of the National Institutes of Health under Award Number K99HD118079). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

CONFLICT OF INTEREST STATEMENT

None declared.

DATA AVAILABILITY

The data underlying this article will be shared on reasonable request to the corresponding author.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

This study was approved by University of Texas Health Science Center Houston Institutional Review Board (IRB) (HSC-MS-23-0758).

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INSTITUTIONAL CLEARANCE

Does not apply.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by A.F.P. The first draft of the manuscript was written by A.F.P., and K.A.L. and R.E.A. commented on previous versions of the manuscript. L.H., J.K., S.A., and M.A. all assisted with data analysis and data collection. All authors read and approved the final manuscript.

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Associated Data

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Supplementary Materials

usaf099_Supplementary_Data
usaf099_supplementary_data.zip (57.7KB, zip)

Data Availability Statement

The data underlying this article will be shared on reasonable request to the corresponding author.

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