Navigating the Transition: Behavior Analysts’ Insights on Supporting Autistic Children Moving From Intensive Behavior Intervention to Public School

Abstract

The partnership between Board Certified Behavior Analysts (BCBAs) and schools in transitioning autistic (We intentionally use both identity-first (e.g., “autistic child”) and person-first language (e.g., “child with autism”) to respect the diverse language preferences of autistic individuals, caregivers, and professionals.) children from Intensive Behavioral Intervention (IBI) to public school is not well-documented. This qualitative study used focus groups to explore the experiences of nine BCBAs with this transition, examining facilitators, barriers, current practices, and recommendations for improvement. BCBAs described relationship-building and rapport as essential for successful transitions but noted that limited collaboration, knowledge gaps, and compensation issues often hindered their efforts. To address these barriers, this study provides practical tools to help BCBAs implement best practices and strengthen partnerships with schools. These findings underscore the need for future research and policy development to enhance transition support for autistic learners and their families.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1007/s40617-025-01092-7.

Transitions are important developmental periods that shape adaptation and growth. They require individuals to adjust to new roles, environments, and expectations (Purtell et al., 2020). These changes can influence emotions, relationships, and future opportunities. For young children, the transition to school is a major milestone that affects their development and future success (Duncan et al., 2007). Moving into public school introduces new academic and social demands. Children often transition from a variety of early childhood settings, including home-based care, preschool programs, early intervention services, and intensive behavior intervention (IBI) programs. They must leave familiar environments and engage with new peers and adults, which can impact their ability to succeed in school depending on their cognitive, language, social, and emotional skills (Duncan et al., 2007).

For children receiving special education services, transitions can be even more complex. They may require additional support to ensure a smooth shift from early intervention to school-based services. Transition refers to a structured process in which school professionals and families collaborate to create consistency across settings (Rous et al., 2007). This process begins before a child enters school (e.g., preschool, kindergarten, or elementary grades) and continues through the adjustment period (Pianta et al., 1999). To help students adapt to new routines, expectations, and academic challenges (Rosenkoetter et al., 2001), draw on frameworks that emphasize coordinated support across environments.

A well-established framework often used to guide this process is Rimm-Kaufman and Pianta’s ecological and dynamic model of the transition to school (2000), which conceptualizes children’s development as occurring across interconnected settings, including home, school, and the broader community. The model positions supportive relationships and aligned practices across these environments as essential to easing transitions and promoting early learning. Recommended strategies include teacher–family communication, joint transition planning between preschool and kindergarten teachers, and classroom activities that build social and emotional connections, all of which contribute to students’ academic success and social competence (Cook & Coley, 2017; LoCasale-Crouch et al., 2008).

Several factors contribute to a successful transition, including high-quality classroom environments, well-trained educators, and alignment between preschool and elementary school expectations (Gooden & Rous, 2018). For children with disabilities, consistent instructional practices such as visual schedules, predictable routines, and shared behavior strategies play a key role in ensuring success in their new environments. Strong relationships, including open communication with families and collaboration among team members, and structured supports such as gradual fading of one-on-one assistance, classroom visits before the first day, and alignment of learning goals across settings further support the transition process (Mashburn et al., 2018). Effective transitions require collaboration among all involved parties, including teachers, caregivers, and service providers (Rimm-Kaufman & Pianta, 2000; Rous et al., 2007).

While all children may experience challenges during the transition to school, which places heightened demands on their social-emotional, pre-literacy, and attention skills (Rimm-Kaufman et al., 2009), autistic children often face additional difficulties. Differences in social communication, peer relationships, and adaptability to change can make this transition especially complex (Boulter et al., 2014; Forest et al., 2004). As a result, autistic children may require more comprehensive transition support to ensure a smooth and successful adjustment (Denkyirah & Agbeke, 2010; Forest et al., 2004).

The Role of Service Providers and BCBAs in School Transitions

Teachers, caregivers, and service providers play an important role in supporting school transitions by planning and implementing strategies well in advance, often starting up to 12 months before school entry (Forest et al., 2004). Early collaboration helps transition teams (e.g., caregivers, teachers, service providers, and administrators) understand both the sending and receiving environments to determine the level of support needed (Rous & Hallam, 2012). Service providers, such as speech-language pathologists, occupational therapists, and other professionals listed in a child’s Individualized Education Program (IEP), are often involved in school transitions. However, Board Certified Behavior Analysts (BCBAs) are not explicitly recognized as service providers under the Individuals with Disabilities Education Act (IDEA, 2004). As a result, their role in public schools varies across states and districts, leading to differences in how they contribute to transition planning and the extent of their involvement (McBain et al., 2020; Yingling et al., 2022).

Families of autistic children can pursue various services, including behavioral, educational, medical, and allied health interventions, to support their children’s communication and independence (Xu et al., 2019). Applied Behavior Analysis (ABA) is a widely used, evidence-based approach that can help autistic children develop language, adaptive, and academic skills (Anagnostou et al., 2014; Donaldson & Stahmer, 2014; Hyman et al., 2020). BCBAs play a central role in delivering ABA services, particularly through intensive behavioral intervention (IBI), which can improve developmental outcomes (Reichow et al., 2018; Sandbank et al., 2020).

As many autistic children transition from IBI to public school, BCBAs are uniquely positioned to support this process. Their expertise in assessment, skill acquisition, and behavior support makes them key contributors to individualized transition planning (BACB, 2020; Cox, 2012). BCBAs help children adjust to school by making transition plans, managing interfering behavior, and supporting skill generalization (Albaum et al., 2020). They also support continuity of care by working with families, teachers, and school teams to keep interventions consistent across settings (Nuske et al., 2019; Rivard et al., 2020; Then & Pohlmann-Rother, 2023).

Beyond direct planning, BCBAs can also support school readiness by training staff on individualized supports and behavior strategies (Giangreco et al., 2021). Given the intensive nature of IBI services, BCBAs often develop close working relationships with families and a deep understanding of each child’s learning profile (Council of Autism Service Providers; CASP, 2024), which can help bridge clinical and educational systems (Albaum et al., 2020; Shillingsburg et al., 2014). Although their level of involvement varies (McBain et al., 2020; Yingling et al., 2022), BCBAs can play a key role in supporting consistent, collaborative, and child-centered transitions to school (Shillingsburg et al., 2014).

Gaps in Literature

Successful school transitions for autistic children depend on interdisciplinary collaboration, school readiness, and caregiver involvement, yet barriers such as limited resources, poor communication, and insufficient autism-specific training in schools often hinder these efforts (Fontil & Petrakos, 2015; Gooden & Rous, 2018; Janus & Siddiqua, 2018; Quintero & McIntyre, 2011). While researchers have examined school transitions for autistic children, most studies focus on caregivers and educators rather than the role of BCBAs in this process (Fontil & Petrakos, 2015; Rivard et al., 2020). Rivard et al. (2020) highlight the importance of interdisciplinary collaboration, comprehensive transition planning, and strong family–provider–school partnerships in successful transitions from IBI to school. However, little is known about how BCBAs contribute to transition planning or facilitate collaboration between clinical and educational settings. Existing studies, such as Then and Pohlmann-Rother (2023), explore broader systemic factors affecting transitions, while Douglas et al. (2022) focus on caregiver coaching interventions rather than BCBA involvement.

Given their expertise in assessment, behavior support, and individualized planning, BCBAs are well-positioned to enhance school transitions. Research is needed to clarify their roles, identify barriers they encounter, and explore how they coordinate with schools and families during the transition process. Qualitative methods are particularly well-suited for this purpose, as they allow for in-depth exploration of BCBAs’ experiences, perspectives, and decision-making across systems.

Unlike traditional behavior-analytic methodologies, which focus on observable and measurable behaviors in controlled environments, qualitative approaches can capture the complexity of practice in natural settings. These methods illuminate the interpersonal, contextual, and systemic factors that influence service delivery. Recent scholarship has highlighted the value of qualitative inquiry in behavior analysis, particularly for examining practitioner perspectives and informing socially valid interventions. For example, Burney et al. (2023) argue that qualitative methods can deepen our understanding of applied practice, while Burney et al. (2024) discusses how qualitative approaches can clarify the environmental conditions that shape implementation.

By exploring these nuanced dynamics, qualitative research can identify challenges and uncover strategies that may not surface through quantitative approaches. Such insights are critical to improving transition practices and ensuring that autistic children and their families receive coordinated, effective support as they move between systems.

Conceptual Framework

The Transition Process for Young Children with Disabilities framework (Rous & Hallam, 2006; Rous et al., 2007) offers a comprehensive perspective on the multifaceted nature of transitions from IBI to public school settings. This framework underscores key factors that support effective transitions, including communication, relationships, and interagency collaboration. It posits that successful transitions depend on strong alignment among service providers, families, and educational teams (Rimm-Kaufman & Pianta, 2000; Rous et al., 2007), as well as on the presence of infrastructure such as clear policies and interagency agreements (Gooden & Rous, 2018).

Although the framework does not explicitly address the role of BCBAs, their work often parallels that of the service providers described within it. BCBAs collaborate with families and schools, develop individualized transition plans, and implement evidence-based strategies to address barriers in communication and coordination (Nuske et al., 2019; Rivard et al., 2020; Then & Pohlmann-Rother, 2023).

In this study, the framework informed the research design, particularly the development of interview questions focused on BCBAs’ experiences and perceived roles in the transition process. While the analysis followed an inductive thematic approach, the framework provided a lens for interpreting themes related to system-level support, collaborative dynamics, and continuity of services. Situating BCBAs within this conceptual model helps clarify how their practices align with broader transition principles and highlights opportunities to strengthen cross-system collaboration in support of autistic children and their families.

Study Purpose and Research Question

This study is part of a larger research effort aimed at understanding the transition of autistic children from IBI to public school. It specifically addresses this gap by examining the perspectives of BCBAs on the transition process. The research question that guided this exploratory study was, what do BCBAs report as the facilitators and barriers to the successful transition of young autistic children from IBI to public school?

Method

The research team included a faculty advisor with a doctoral degree in special education, who is a BCBA with extensive experience working with autistic children and families and a record of published qualitative research. The second team member was a senior Ph.D. student and BCBA with over seven years of clinical experience and qualitative research publications. Both team members completed institutional review board (IRB) training at their affiliated university.

Focus groups were used as the primary data collection method because they allowed BCBAs to discuss their experiences and build on each other’s insights. This approach was appropriate for an exploratory study, as it provided an interactive setting to examine facilitators and barriers to the transition of young autistic children from IBI to public school. Focus groups also encouraged participants to reflect on shared experiences, which may not emerge in individual interviews (Krueger & Casey, 2015).

This qualitative method effectively captured BCBAs’ perspectives on school transitions (Fielding & Fielding, 1986). It prioritized depth over breadth by grouping participants with similar roles to discuss common challenges and strategies (Ritchie & Lewis, 2003; Krueger & Casey, 2015). The group setting promoted open discussion, generating insights beyond those typically obtained through individual interviews.

Recruitment

To ensure response validity, the researchers employed purposeful sampling procedures (Teddlie & Yu, 2007) and pre-screening questions (Chandler & Paolacci, 2017; Hulland & Miller, 2018) to recruit eligible participants. Recruitment efforts included targeted emails, direct messages, and flyers shared on closed social media platforms (e.g., LinkedIn, administrator-run Facebook groups, non-public Instagram autism-related forums) to reach qualified behavior analysts while minimizing fraud from professional survey takers (Haidar et al., 2024). The researchers also leveraged professional networks, including professional applied behavior analysis associations in the USA, and direct outreach to clinical directors and supervisors of IBI providers in California, Illinois, and New York. Snowball sampling within the behavior analyst community further expanded the participant pool.

Interested BCBAs responded to recruitment efforts and completed a screener to confirm their eligibility (Chandler & Paolacci, 2017; Hulland & Miller, 2018). Inclusion criteria required participants to (a) be certified behavior analysts (i.e., BCBA, BCaBA, LBA), (b) provide 20 or more hours of intensive behavioral intervention per week (e. g., ABA therapy) to autistic children aged 8 years or younger, (c) have transitioned at least one autistic child to public school (Pre-K, Kindergarten, or elementary) within the past three years, (d) and willing to complete a 60-minute video recorded focus group.

The researchers initially aimed to conduct 2–3 focus groups with 5–8 participants each to account for potential no-shows despite offering incentives (Krueger & Casey, 2015). This sample size was selected to capture diverse experiences and achieve code saturation (Hennink et al., 2019), where no new themes emerge; 8–12 participants are generally sufficient to reach thematic saturation (Guest et al., 2006; Small, 2009; Tracy, 2024), while smaller focus groups of fewer than five participants allow for deeper insights and more manageable dynamics (Githaiga, 2016).

To mitigate fraudulent participation, targeted recruitment strategies were implemented, including single-use survey links sent via direct messages, metadata analysis (e.g., filtering duplicate IP addresses and reviewing response timestamps), and Completely Automated Public Turing test to tell Computers and Humans Apart (CAPTCHA). CAPTCHA is a security measure that presents a randomly generated sequence of distorted letters and/or numbers in an image next to a text box to ensure responses are entered by a human rather than an automated bot (Aust et al., 2013) verification. Finally, participant legitimacy was further ensured by verifying credentials (e.g., BCBA certification, highest level of education) and corresponding with respondents exhibiting suspicious response patterns.

Participants

As part of a larger study, 115 BCBAs completed an initial survey about their transition practices. From this group, 26 consented to participate in follow-up focus groups. Of these, 26 BCBAs consented to participate in focus groups, 16 scheduled a session, but a 44% attrition rate resulted in a final sample of nine participants. While five focus groups were initially planned, high dropout rates led to data collection from three focus groups with 2–3 participants each, supplemented by two individual interviews. For consistency, all sessions were referred to as “focus groups,” even those with a single participant. The final sample included FG1 (n = 1), FG2 (n = 3), FG3 (n = 2), FG4 (n = 2), and FG5 (n = 1). To maintain participant anonymity, only general demographic information is reported (see Table 1).

Table 1.

Focus groups: descriptive demographic information

Race	Number	Percentage
White	6	66.67%
White, Hispanic or Latino	1	11.12%
Black or African American	1	11.12%
Hispanic or Latino	1	11.12%
Gender
Female	7	77.78%
Male	2	22.23%
Highest Level of Education
Master's	8	88.89%
Doctorate	1	11.12%
Type of Certification
BCBA	9	100%
Year of Certification (Range)
2018-2019	4	44.45%
2021-2023	3	33.34%
2016-2017	2	22.23%
State
Texas	2	22%
North Dakota	2	22%
Illinois	2	22%
North Carolina	2	22%
Minnesota	1	11%
Location Type
Suburban	4	44.44%
Mid-size city	3	33.34%
Rural	2	22.23%
Setting of Services Provided
Home	5	55.56%
Multiple settings	3	33.34%
Clinic	5
School	1	11.12%
Client Caseload
1-5	7	77.78%
6-10	1	11.12%
16-20	1	11.12%
Years of Experience Range
2 to 7	7	77.78%
8 to 14	1	11.12%
15 to 17	1	11.12%

N = 9; BCBA Board Certified Behavior Analyst. Frequency and percentage data were sorted in descending order within each category

The focus groups demonstrated a diverse demographic composition. The majority identified as White (n = 6; 66. 67%), followed by an individual from two or more races (n = 1; 11.12%), Black or African American (n = 1; 11.12%), and Hispanic or Latino (n = 1; 11.12%). Female participants constituted the majority (n = 7; 77. 8%). In addition, the majority held a Master’s degree (n = 8; 88. 9%), while one possessed a Doctorate (n = 1; 11. 12%). All participants held a BCBA certification with initial board certification dates ranging from 2016 to 2023. Geographically, participants were spread across Texas, North Dakota, Illinois, North Carolina, and Minnesota. The majority of the participants resided in suburban areas (n = 4; 44. 44%) and primarily delivered services in home settings (n = 5; 55. 6%). Regarding caseload, the majority of the participants managed 1–5 clients (n = 7; 77. 8%). Finally, experience levels ranged from 2 to 17 years, with the majority (n = 7; 77. 8%) having between 2 and 7 years.

Procedures

The participating BCBAs identified their perceived facilitators and barriers for a successful transition process. The interview protocol (see SI-1) was developed on the basis of existing literature, focusing on the transition from IBI to public school. It followed a semi-structured format, as recommended by Savin-Baden and Major (2013).

Participation in the focus groups was convenience-based and were scheduled according to the participants’ availability using a Doodle poll, which offered multiple options across a 10-day period with five time slots per day. The first author conducted the focus-group interviews, which were recorded and transcribed using Zoom. Word-for-word transcripts were cleaned, de-identified, and stored in a password-protected cloud service. To ensure fidelity to the interview protocol and consistency across focus groups, the researcher not involved in conducting the interviews attended the sessions and reviewed the transcripts. Questions began broadly to encourage participants to explore their perspectives, then narrowed to elicit specific responses relevant to the research question. BCBAs shared their experiences, current practices, and views on successful transitions, drawing from their most recent transitions or prior experiences. Discussions covered planning, support, communication, collaboration, as well as challenges, barriers, facilitators, frustrations, and recommendations for an ideal transition.

The focus group sessions ranged from 35 to 65 minutes (M = 50), totaling 260 minutes of transcript data. The moderator followed qualitative research quality guidelines established by Elliott and Associates (2005), which emphasize transparency, reflexivity, and grounding findings in participant perspectives. To support a safe and inclusive environment, the moderator introduced a set of ground rules at the beginning of each session. These included reminders that participation was voluntary, that there were no right or wrong answers, that participants should speak one at a time, and that confidentiality of what was shared in the group would be respected. These ground rules, drawn from widely accepted focus group practices (Krueger & Casey, 2015), aimed to promote respectful dialogue and encourage participants to share their unique experiences and perspectives openly.

To enhance credibility, the researchers implemented a member checking process (Brantlinger et al., 2005). After transcription, each participant received a one-page summary of their focus group interview that included key themes and direct contributions. The summary followed the sequence of the interview protocol and included the main topics discussed, participant-specific responses, and preliminary interpretations. They were asked to review the summary to confirm its accuracy and had the opportunity to request clarifications, suggest corrections, or provide additional insights. Each participant received a $35 gift card following the focus group and an additional $15 gift card after completing the member check.

Credibility and Trustworthiness

This study adhered to qualitative research quality indicators established by Brantlinger et al. (2005). To ensure participant privacy, numerical identifiers were used in all transcripts, questionnaire data, and field notes. The identity key linking participant names to identifiers was stored separately and was accessible only to the primary researchers. All research materials, including audio recordings, transcripts, and field notes, were securely stored in a password-protected University Box™ folder.

To support analytic accuracy and transparency, the researchers used thick descriptions and selected direct quotes from participants to contextualize and substantiate each theme. These strategies helped ensure that the interpretations remained grounded in participants lived experiences and aligned with standards for methodological rigor in qualitative research.

Data Analysis

The researchers applied qualitative thematic analysis to explore BCBAs’ perspectives on school transitions. Qualitative methods provide valuable insights into participant experiences that may not be fully captured through traditional behavior-analytic methodologies (e.g., Burney et al., 2024). A systematic and iterative thematic analysis was conducted following Braun and Clarke’s (2006, 2019, 2021) six-phase framework.

Two researchers independently familiarized themselves with the focus group transcripts through repeated readings to develop a strong understanding of the content and context (Braun & Clarke, 2006). During this phase, each researcher took preliminary notes to capture initial observations and early ideas for potential codes (Braun & Clarke, 2021). They then independently conducted initial coding by identifying and labeling meaningful features of the data (Braun & Clarke, 2006, 2019). The researchers met to compare codes, resolve discrepancies, and refine a shared coding framework through discussion and consensus.

After initial coding, the research team reviewed the data to identify preliminary themes by examining similarities and differences across the transcripts (Braun & Clarke, 2006). A final codebook was created that included code names, definitions, and representative examples (see SI-2). Both researchers re-coded the entire dataset using the finalized codebook while remaining open to the emergence of new insights (Braun & Clarke, 2019). After re-coding, they met again to review how codes had been applied, discuss any inconsistencies, and resolve differences through collaborative discussion. All discrepancies were addressed through dialogue until full consensus was reached.

To enhance the credibility of the findings, the research team conducted member checking by inviting participants to review summaries of the themes. Each participant received a one-page document that included a plain-language summary of the key findings, including thematic headings and illustrative quotes. They were asked to comment on whether the interpretations aligned with their experiences and whether any perspectives were missing or misrepresented. All nine participants responded. Seven confirmed the summaries as accurate, and two offered clarifying notes that were incorporated into the analysis. No new themes emerged from this process. Although Braun and Clarke (2021) caution against using member checking within reflexive thematic analysis due to its underlying assumption of a single truth, this step was included to promote transparency and participant engagement.

Findings

Our qualitative analysis revealed multiple themes, including current practices, facilitators, barriers, and recommendations related to the transition of autistic children from IBI to public school (see Fig. 1).

Fig. 1.

Thematic map for qualitative analysis

Current Practices: “It’s Mostly Communicating with the Parent”

Communication Practices

 BCBAs reported typically initiating communication with the child’s educational team and family, as one participant noted, “Typically it’s the BCBA.” Another BCBA shared their experience, stating, “Well, in my case, I had to open the connection with the school. I got the approval from the family and after that I started to call…the director…the social worker.” However, according to participants’ report, BCBAs often encountered resistance when attempting to engage with schools and typically relied on caregivers to initiate or facilitate communication. This reliance highlights the central role of caregivers in the collaboration process, which, based on the perspectives of the BCBAs interviewed, rarely occurred without initiation from either the caregiver or the BCBA.

According to the participants, when schools were unresponsive, the lack of collaboration posed additional challenges and, in some cases, hindered the child’s transition into a new educational setting. As one BCBA explained, “It felt like all the work we did with the child was wasted. I could not share some of those things (behavior interventions and strategies) or model for the staff members.” Another BCBA remarked, “One teacher refused to talk to me, even though she had not met me before. It almost seemed like she didn’t have time for me, or didn’t want to take the time to hear what I had to say.”

Collaboration Dynamics

Insights from the focus group interviews with BCBAs revealed wide variation in their involvement and collaboration during the transition process. Some BCBAs described actively supporting transitions by providing hands-on coaching to school staff, while others worked closely with special education teachers or regularly attended classroom sessions to observe and offer guidance. Participants suggested that differences in school responsiveness may be influenced by BCBA practices, school policies, available resources, or teachers’ prior experiences with behavior analysts. Some BCBAs also reported feeling excluded from school-based collaboration. As one explained,

When it comes to the schools in my state, they don’t want people in the schools. They don’t want BCBAs, RBTs, they don’t even want parents coming to the classroom. And so there is no collaboration with that.

Another BCBA added, “It’s not very common for BCBAs to be allowed to observe the child in school per se.” However, experiences of exclusion were not universal. Several BCBAs described both inclusive and exclusionary transition experiences, noting that these often varied by child, school, or context. Transitions were described as “successful” or “unsuccessful” depending on the perceived level of collaboration with educational teams and caregivers. Participants also emphasized that their ability to collaborate was often shaped by factors outside their control. They also identified several external factors that limited collaboration, including restrictive school policies, lack of administrative support, philosophical differences between ABA and school-based practices, language barriers, and funding or billing constraints. One BCBA noted that communication challenges sometimes arose with caregivers as well, requiring them to advocate on the family’s behalf. As this participant explained,

It's mostly communicating with the parent and the parent acting like they’re lost. They don't get a lot of communication from the school…they don’t know how the process works or what services their child gets.

Parental Involvement

Many BCBAs reported relying on caregivers to initiate school visits and facilitate collaboration with the child’s future educational team. IBI programs often include a parent-coaching component, through which BCBAs support caregivers in making various decisions, including initiating the transition process. As one BCBA shared: “It’s usually pretty mutual. We do weekly parent meetings and weekly parent coaching.” Although transition conversations may begin early, approaches to parent coaching and education around the process varied across participants. Some BCBAs emphasized the use of proactive coaching sessions to help caregivers build the skills and knowledge needed to support a successful transition. As one BCBA explained, “Coaching the parents on what needs to be done to ensure that they are going to be successful… providing the skills to the child prior to going to school.” However, according to several participants, not all caregivers are equally receptive or willing to engage in collaboration, which they believed affected the child’s adjustment to their new setting. As one BCBA reported, “The parents waited until the last minute, and we couldn’t help the child prepare, and we didn’t give the school anything.”

Facilitators: “You Have to Work Really Hard to Build that Rapport and Gain Buy-in”

Rapport Building

The BCBAs described rapport-building as a central factor in what they perceived as successful school transitions. They emphasized the value of establishing strong relationships with school staff, caregivers, and the child. As one participant shared, “When I think of a successful transition, I think of the one that was a little bit more welcoming to our team. . . so where we built some more of that rapport.”

The BCBAs in this study also discussed the importance of collaboration, including observing classrooms and sharing intervention strategies with teachers, as part of their rapport-building efforts. They reported that when school personnel were receptive to forming relationships, transitions tended to proceed more smoothly. While BCBAs acknowledged that building trust required time and sustained effort, they emphasized its value. As one BCBA shared, “You have to work really hard to build that rapport and gain buy-in. Sometimes it takes a year or two for them (schools) to realize okay, actually these people can help us.” These reflections, however, represent the BCBAs’ perspectives and do not include input from school personnel.

In addition to their efforts to engage with school staff, the BCBAs in this study emphasized the importance of developing strong relationships with children and their families to support successful transitions. They described trust and open communication with caregivers as essential for effective collaboration and noted that these relationships often positioned them as a key support during the transition process. Several BCBAs described forming close connections with families; as one participant explained,

Lots of families come to trust us more than any kind of other provider in their life. Because we are such an integral part of both our kiddos and their own lives…We get to know them very well and they almost rely on our recommendations and our kind of insight and that type of thing.

The BCBAs also emphasized the importance of building trusting relationships with the autistic children themselves as part of the transition process. These insights reflect the perspectives of the participating BCBAs and do not capture the views of the children or their families directly. One participant described how establishing rapport helped children feel supported and better prepared for school, “So getting them to that point where they know that I have their best interest… That takes some time to build that rapport. I would say strong rapport and pairing was essential for the transition.”

BCBA As a Resource and Advocate

The BCBAs reported that transitions tended to go more smoothly when they were actively involved and when school personnel viewed them as valuable contributors to the process. When given the opportunity, they offered input and recommendations to support the child’s adjustment to the new environment. One participant shared an example,

We transitioned a first grader to full-day inclusion. The school said, hey, I know you’re still working with her after school. Would you mind contracting with us and coming into the school to provide support and coaching. . . train the paras and the teacher.

Additionally, the BCBAs described advocating for children and families as a key part of supporting smoother transitions. One participant shared their proactive efforts, “I pushed to go to the IEP… I pushed… what we did with them. I was able to get the parents on board to where we did part-time (IBI) and part-time school.”

Individualization, Cultural Responsiveness, and Alignment 

The BCBAs in this study spoke about the importance of maintaining consistent communication with caregivers, regularly revisiting transition plans, and tailoring interventions to match each child’s learning style. Some participants noted the benefits of involving extended family members in parent training to promote continuity and support at home. They also addressed the need to recognize cultural differences and ensure that intervention goals were aligned with the family’s values, as one BCBA explained,

There are some cultural differences that may help the transitioning process… for example, for the Hispanic families, they are really interested in parent training not only for them but also for other family members. So, I think working with all those members of the family helps connect the values of the family and the cultural values with the specific programs… it helps a lot in preparing the transition.

Several BCBAs noted that integrating cultural values into transition planning made families more likely to engage with and follow through on the recommended supports, which in turn contributed to more successful transitions. This culturally responsive approach not only strengthened their relationships with families but also allowed BCBAs to tailor supports more effectively to each child’s background and home environment. As a result, transitions were described as smoother and more aligned with family dynamics. One participant also described how cross-system knowledge supported curriculum development and school readiness. Having clinic staff with prior experience in education helped bridge gaps between settings. As this BCBA explained, having team members who were familiar with the school system and classroom teaching allowed them to create transition activities that supported both academic skills and a smoother adjustment to the school environment and said,

In the clinic, we hired someone who previously worked in kindergarten and elementary school, perhaps as a school aide. Their fluency in naturalistic teaching and extensive knowledge of school activities made a significant difference. Having that person on the team was a key asset in running activities that children will encounter in school.

Finally, several BCBAs described how transition success was supported by gradual shifts in programming and the intentional use of school readiness strategies once children demonstrated readiness. These strategies included creating designated “school readiness classrooms,” simulating large group instruction, reducing reinforcement density, minimizing one-on-one support, implementing block scheduling, and organizing structured social skills groups. In these settings, staff systematically reduced their proximity during independent work, helping children adjust to the less individualized support typical in school environments. As one BCBA explained,

For the learners that we were getting ready to transition to school, we had them group in one classroom and we called it school readiness classroom. There we decreased discrete trial training, we tried to scale back on having the RBT or the tech right next to the learner try to get them used to working independently without someone shadowing them, fade prompts, and decrease the dependency for a physical presence being right next to them.

Barriers: “The School Didn’t Understand What I do and Didn’t Really Welcome me”

Access Barriers

Two BCBAs described challenges commonly faced by school districts, particularly in rural areas, where limited staffing and resources often hinder effective transition planning. One participant commented on the difficulty of initiating collaboration with nearby districts, stating, “They don’t have a ton of resources. Again, it’s a lot of small towns.” Physical distance also emerged as a significant obstacle. Some families lived too far from service providers to participate in parent training or more intensive transition supports. As one BCBA shared, “We have clients from 1 to 2 hours away from here.”

These geographical barriers contributed to a shortage of qualified staff, including certified BCBAs, making it harder to implement individualized and collaborative transition practices. In addition to geographic isolation, language differences also complicated transitions for some families. One BCBA explained, “Another barrier that we found was that we have a couple of families who didn’t speak English.” In such cases, BCBAs often found themselves serving as informal translators between families and school personnel, adding another layer of complexity to an already challenging process.

Knowledge Gaps and Philosophical Mismatch 

Across interviews, BCBAs identified a significant lack of shared understanding among caregivers, educators, and behavior analysts about the special education system, the role of BCBAs, and funding structures. This disconnect often hindered effective collaboration during transitions. One participant noted that many behavior analysts have “very little understanding of the special education system in general.” Similarly, schools were often unfamiliar with the scope of IBI services and the support provided before children enter public education. As one BCBA reflected,

It’s been a real learning curve, not always smooth sailing or encouraging. I’ve been there for this kid and their family for three years, giving it my all. But then…I’m just out of the loop when it comes to their transition and then hearing later that the child is really struggling at school…. But because the school didn’t understand what I do and didn’t really welcome me, the kid didn’t get the support they needed to succeed.

Participants also described philosophical misalignment between IBI programs and school-based practices. Several BCBAs shared that schools were often unreceptive to feedback from external providers. One explained, “Schools are generally unreceptive to feedback or information offered from sources out of district, such as our intensive clinic setting.” Another described the challenge of aligning programming, “There’s this gap… because there wasn’t much communication before the transition.”

In some cases, educational teams reportedly held negative or uninformed views about ABA, leading to resistance or dismissal of services. As one BCBA recalled,

The educational team was not cooperating. Like they were just doing so much work to not be on the same page with us! When we proposed to update the child’s BIP [behavior intervention plan] the educational team was like, well, he actually needs neurological feedback therapy! They clearly spent time researching why he didn’t need ABA.

Even in more collaborative settings, BCBAs noted challenges in gaining support for specific intervention approaches. Differences in perspectives about how to teach skills and manage behavior created additional barriers. One participant shared,

Sometimes in schools with positive behavior support, it takes too long for kids to receive reinforcement. There was a pushback to change the mindset in the classroom regarding how teachers responded to problem behavior. It seemed like a lot of work to learn new methods, so some reverted to using reprimands.

Navigating State Laws, Policies, and Billing Structures

Participants in the focus groups described how varying regulations across states and institutions influenced the type and intensity of services children received during transitions. Although all parties may share the goal of supporting a successful transition, systemic differences often limited collaboration. BCBAs from states like Texas and Minnesota described unique regulatory contexts. For instance, BCBAs in Minnesota reported needing licensure through mental health boards and supervision by a psychologist, which they felt contributed to misunderstandings about the scope and teaching methods used in IBI. One BCBA shared how their state’s restrictions limited collaboration with school personnel and said,

They’re not really looking for outside providers to come in. I was a public-school teacher for 10 years before I became a BCBA. It generally operates like a closed ecosystem.

Additionally, participants noted that access to transition-related funding varied across districts. In some cases, this variability either enabled or restricted cross-institutional collaboration and individualized transition practices. As one BCBA stated,

Some of the schools in my state operate in a very, like, restricted manner where an outside professional can come in for an hour a month or like they have these very specific guidelines about how much another provider can be inside the classroom.

All participants identified billing and payment for ABA services in school settings as a major challenge. One BCBA noted, “People need to be paid… sometimes that’s not available.” The limited availability of funding for IBI services outside of home or clinic-based settings was a shared concern. As one participant explained, “You can participate in these activities but at your own expense.” Another added, “For most insurances, it was really, really hard to bill outside of a clinic setting.” The classification of IBI as a medically necessary service, coupled with constraints imposed by insurance reimbursement policies, often created practical barriers that restricted the implementation of essential transition supports.

Participants also described how Medicaid regulations vary by state, influencing whether and how intensive behavioral intervention (IBI) services can be reimbursed both within and beyond clinical settings. One BCBA explained, “Funding issues hinder follow-up,” when asked about transition support after a child enters school. Another added, “BCBA interactions with schools are considered non-billable, limiting our role.” These financial and policy constraints often restrict the extent to which BCBAs can engage in classroom-based interventions and transition support. This limitation was reported to affect the direct teaching of school readiness skills, particularly when insurance restrictions required reframing intervention goals to avoid overlap with academic instruction. As one BCBA explained, “Sometimes we have to reframe for the insurance companies how we define the skills we teach in the clinic to make them sound non-academic.” Another shared, “There were parts of the transition that we really didn’t have a lot to do with, like the educational goals and things like that, you know, that were kind of out of our scope.”

Clinical settings can also influence the timing and effectiveness of school transitions for autistic children. Tensions may arise when a child demonstrates readiness for school yet continues to qualify for insurance-covered ABA services. This creates a dilemma between maintaining clinical intervention and supporting a timely transition to the school environment. One BCBA reflected on this conflict,

In my last experience, the company’s values did affect my ability to transition students to school on timelines that I felt were most appropriate. So, when I realized that this child is making much progress and I say at this point in time, let’s start titrating them out, if that period of time did not align with their authorizations, then I got a lot of push back.

Recommendations: “There is a lot of Need for Education for What BCBAs do”

Advocating for Collaboration, Alignment, and Empowerment

BCBAs consistently underscored the value of early transition planning and collaboration with educators to better understand the individual needs of each learner. One participant encouraged schools to involve BCBAs sooner in the process, stating, “To make it (transition) better, let us get in early.” Many participants described active, two-way collaboration as essential to effective transitions, particularly when school teams were open to engaging with BCBAs prior to the child’s enrollment. Several BCBAs expressed a desire for educators to spend more time observing children in their current settings to gain a fuller picture of their strengths and learning profiles. As one BCBA noted, “I would love for the school team to even spend like a full day with us… I think it would provide a deeper understanding of what the kid is capable of doing.”

BCBAs in this study also expressed a strong desire to advocate for their involvement in facilitating collaboration between caregivers and the child’s educational team. They pointed to the value of their established rapport, as well as their deep understanding of the child, the family, and cultural context, in supporting a smooth and individualized transition. Excluding BCBAs from the process was viewed as a potential barrier to success. As one participant explained, “I think it’d be very, very difficult and detrimental to the kids’ success, especially if they’re transitioning from ABA services.”

In addition to advocating for their role, participants discussed the importance of empowering parents and focusing on what some participants referred to as relational “soft skills,” such as empathy and active listening, to support more effective transitions. Several BCBAs described coaching caregivers and helping children prepare for the expectations of school environments as critical components of the process. One participant summarized this multifaceted approach, “Initiating communication and showing interest in understanding the school’s dynamics… building rapport with schools and teachers, helping parents, listen to them to be part of the process.”

Procedural Alignment and Training

Participants described the need for training on both sides of the transition process: strengthening BCBAs’ understanding of school systems and educating school personnel about ABA practices. They also recommended developing a more structured transition process that includes clear steps and assessment tools to promote consistency, accountability, and effective support while minimizing disruptions. One participant reflected on the challenges of informal practices, stating, “I think we need a more structured process with steps or assessments. Many of us are playing it by ear.”

Participants also discussed the need to strengthen their own understanding of school systems and transition-related procedures. One BCBA pointed to gaps in training, particularly around educational policy and documentation, noting, “BCBAs do not have the education or training on the IEP process or an understanding of district or statewide curricula.” Another added, “I wasn’t really trained on the nitty gritties of transition and would love to find some continuing education units (CEUs) on it if I have time.” In addition, participants recommended addressing biases and misconceptions to improve collaboration across settings. One BCBA explained, “There is a lot of need for education for what BCBAs do and what disability is for teachers.” Another reinforced the need for targeted training, stating, “Training for educators to try to change the misconceptions about ABA.”

Discussion

The BCBA participants in this study reported following many recommended transition practices and demonstrated awareness of facilitators, barriers, and strategies that align with research on effective school transitions. They adopted a strength-based approach in their partnerships with caregivers, which emphasized family involvement to enhance intervention effectiveness and generalization (Callahan et al., 2019; Hume et al., 2021; Turnbull et al., 2015).

They also built rapport with families and acted as trusted advocates during transitions (Dockett & Perry, 2007; Rivard et al., 2020). The participants reported using family-centered practices and developing personalized transition plans, consistent with best practices for school transitions (Fenlon, 2005; Pianta & Kraft-Sayre, 2003). They also valued culturally responsive practices, which they perceived to enhance family engagement and ensure that transition plans addressed both the child and their family needs (Khanlou et al., 2017). When possible, they supported transitions by communicating with schools, coaching caregivers, and providing necessary educational tools (Granger et al., 2012). Additionally, they involved caregivers in the decision-making processes and assessed their needs to develop individualized transition plans (Bailey et al., 2011; Pianta & Kraft-Sayre, 2003).

These findings suggest that the BCBAs in this study supported caregivers in initiating school transitions, echoing recommendations in the literature (Fenlon, 2005; Pianta & Kraft-Sayre, 2003). Participants described creating meaningful connections between IBI and the home, similar to recommended practices that encourage school-home collaboration to promote continuity across settings (Dockett & Perry, 2007; Kim & Sheridan, 2015). As noted in transition research, they also advocated for collaboration among schools, IBI providers, and families to maintain service continuity and reduce family stress during transitions (Dockett & Perry, 2007; Fontil & Petrakos, 2015; Pianta & Kraft-Sayre, 2003; Rivard et al., 2020). These findings align with the Transition Process for Young Children with Disabilities framework, which emphasizes communication, collaboration, and coordinated infrastructure. Although BCBAs are not explicitly identified within the model, their described practices parallel those of other service providers involved in transition planning. Framing their work within this model highlights opportunities for greater integration and cross-system collaboration.

Although transition research emphasizes the importance of consultation between families, teachers, and service providers (Janus et al., 2008; Rous et al., 2010), the BCBAs in this study wanted more direct partnerships with schools before transitions began. They viewed the inconsistent collaboration with receiving schools as a barrier to successful transitions for autistic children receiving IBI. This challenge aligns with research on difficulties in aligning supports across settings during the preschool-to-kindergarten transition (Cohen-Vogel et al., 2020; Iruka et al., 2020; Purtell et al., 2020). A lack of awareness among receiving schools about students’ preschool experiences further complicates these efforts (Purtell et al., 2020).

Financial constraints also limit teachers’ and service providers’ ability to participate in transition meetings, which can reduce opportunities for coordination (Early et al., 2001; Janus et al., 2008; Rous & Hallam, 2006; Rous et al., 2010). Resistance to ABA, limited collaboration, and procedural misalignments create additional obstacles for children transitioning into public school (Cohen-Vogel et al., 2020; McCormick et al., 2020). Despite their efforts, BCBAs face systemic barriers that limit interdisciplinary collaboration and transition planning. Since IBI services are classified as medically necessary, BCBAs in this study were credentialed healthcare providers who billed private insurance and Medicaid for compensation (Powell, 2022). This funding structure limited the participating BCBAs’ ability to bill for academic services, transition planning, and collaboration with schools. Insurance policies also restricted reimbursement for non-client activities, such as professional training, making it difficult for BCBAs to engage in team-based planning.

While collaboration is essential for successful transitions, it remains an underdeveloped area of competence in pre-service and in-service ABA training for BCBAs (Kelly & Tincani, 2013; Layden, 2023). Effective collaboration requires understanding the school context and strong communication with educators, service providers, and families (Bambara & Chovanes, 2021; Giangreco et al., 2021). The focus group discussions revealed that BCBAs often learn about transition practices, special education, and teacher collaboration through hands-on experience rather than coursework (Light-Shriner et al., 2023); alas, structured training could better prepare BCBAs to work across settings and improve transition outcomes for autistic children (Sheppard et al., 2013).

To fulfill their role in transition planning, BCBAs must seek education beyond behavior analysis, maintain professional standards, and broaden their expertise in special education and interdisciplinary teamwork while staying within their scope of competence (Brodhead et al., 2018; Johnston et al., 2017). BCBAs can also assist with interdisciplinary teamwork, provide professional development on evidence-based strategies, and serve on school committees to align behavioral supports with educational goals (Layden, 2023).

Finally, BCBAs can improve the transition process by creating a shared framework that aligns professionals around student-specific goals, ensuring clear roles and joint decision-making (Giangreco, 1996). They can eliminate discipline-specific jargon, making collaboration more accessible for educators, families, and service providers (Critchfield et al., 2017). Additionally, they can establish a common vocabulary within behavior analysis to promote consistent and effective implementation of interventions across settings (Cihon et al., 2016).

Implications for Policy

Addressing systemic barriers and strengthening collaborative approaches can improve the school transition experience for autistic children and their families (Cook & Coley, 2017). A coordinated approach supports individualized transitions that meet each child’s needs and promote successful school integration. The Every Student Succeeds Act (2015) mandates that districts develop formal coordination plans with early childhood providers to enhance accountability, knowledge transfer, and program alignment (Council of Chief State School Officers, 2017).

Recognizing IBI as part of the service continuum for autistic individuals and mandating transition plans for children receiving IBI can streamline the transition process for families. This approach could mirror the Part C to Part B transition framework under IDEA and provide clear guidance for both schools and IBI providers (IDEA, 2004, §303. 211).

Although federal law does not explicitly designate BCBAs as related service providers, behavior-analytic practices align with IDEA’s requirement for scientifically based interventions (Code of Federal Regulations [CFR], 2006, §300. 35; Giangreco et al., 2021). As a result, educational teams can incorporate ABA services provided by BCBAs to enhance educational programs and support transitions from IBI. Formal recognition of BCBAs as related service providers in schools could reduce systemic barriers and improve collaboration during transitions from IBI.

Implications for Practice and Resources

Addressing these challenges requires CEU-based training on educational settings, interdisciplinary collaboration, and special education law. For example, training on educational settings could include practical workshops on how to effectively adapt behavior intervention plans (BIPs) within a classroom environment, how to support students with behavioral challenges in inclusive settings, and how to collaborate with teachers and administrators to align educational goals. Additionally, CEU-based workshops on special education law, including understanding IEPs and 504 plans, would ensure BCBAs are informed about the legal requirements for supporting students with disabilities in school.

To assess and improve outcomes, BCBAs can implement structured planning meetings, transition monitoring, and alignment strategies between IBI and school settings. Individualized transition protocols, targeted school staff training, and structured family engagement can further support success. Tools such as tailored planning frameworks (Sands & Meadan, 2022) and communication contracts can enhance alignment and accountability. To support practitioners to improve interdisciplinary collaboration and transition planning we compiled a list of practical transition recommendations that foster collaboration (see Table 2; Rous et al., 2010), a list of collaborative transition planning tools that BCBAs can develop (see Table 3), and a sample transition planner (SI-3).

Table 2.

Practical recommendations to foster a collaborative transition process

Start Early and Plan Gradually

• Initiate transition planning at least 6–12 months before school entry.

• Break the transition into manageable phases with clear milestones.

• Establish consistent communication channels.

• Schedule regular transition meetings with all concerned constituents.

• Use shared communication tools (e.g., digital logs, email summaries) to keep everyone informed.

Align Goals and Practices

• Collaborate with IEP teams to ensure consistency between IBI goals and school expectations.

• Involve teachers in setting behavior intervention goals that align with classroom routines.

Provide Hands-On Training for School Staff

• Offer observation opportunities for teachers in IBI settings.

• Conduct practical, student-specific training for paraprofessionals and teachers.

Empower Families as Key Partners

• Educate families on how to advocate for services and support in school.

• Include families in decision-making and ensure their voices are heard during transitions.

Create Sustainable Support Systems

• Develop gradual fading plans for BCBA involvement as the school team gains confidence.

• Implement peer support systems within schools for ongoing teacher support.

Monitor and Adjust Transition Plans

• Collect and review data regularly to make necessary adjustments.

• Use feedback from all parties involved to refine support strategies.

Table 3.

Collaborative transition planning tools for BCBAs

• Shared calendar with optimal timeline for meetings, assessment updates, IEP alignment
• Transition timeline template to plan activities 6-12 months before school entry and 3-month post transition
• Role clarification chart outlining BCBA, teacher, and family responsibilities
• Individualized transition profiles
• Student Profile “handbook”: communication preferences, reinforcers, behavioral supports, sensory needs, and social interests
• Behavior Support Plan (BSP) adaptation guide for integrating strategies into school routines

IEP is an individualized educational program; see SI-2 for a transition timeline template

Implications for Research

There remains a significant gap in understanding the roles of various team members involved in transitioning autistic children from intensive behavioral intervention (IBI) to public school in the United States. Future research should explore the perspectives of caregivers, teachers, and school administrators to gain a more comprehensive view of the transition process. Comparing current BCBA-led practices with recommended guidelines (Gooden & Rous, 2018; Rous & Hallam, 2012) could help establish benchmarks for professional development. Given that transition is a process rather than a single event, studies should also examine how alignment between IBI providers and receiving schools influences outcomes over time. Additionally, research is needed to investigate BCBAs’ perceptions of their own competence, familiarity with instructional models, and understanding of special education law. To strengthen these efforts, future studies should incorporate multiple stakeholder perspectives and use triangulation to validate findings and capture the complexity of transition planning across contexts.

Limitations

This study presents several limitations that should be considered when interpreting the findings. First, the use of purposeful sampling may introduce sampling bias, as BCBAs who chose to participate may not fully represent all perspectives, potentially leading to an under- or overrepresentation of certain viewpoints. Moreover, the variability in focus group sizes and the inclusion of two individual interviews, along with three focus groups with differing participant numbers, could have led to uneven data distribution and variability in richness, particularly affecting group dynamics. Furthermore, our study began with 26 participants and concluded with 9, despite continuous engagement, flexible scheduling (including weekends and varied time slots), and a $50 incentive. Given that all participants were full-time employees, attrition may reflect the challenges of sustained participation in qualitative research alongside professional responsibilities (Patton, 2015).

Future studies may explore additional retention strategies, such as shorter sessions. Additionally, the study defined IBI solely by the numbers of hours delivered (20–40 hours) per week of ABA services, without considering service modalities or distinctions between transitions into preschool, kindergarten, or elementary school, which are each guided by different policies. This lack of differentiation suggests the need for future research to explore various transition processes and include other members of the transition team to capture a broader perspective.

Another limitation arises from the reliance on self-reported data rather than direct observation or analysis of transition documentation. This approach introduces potential biases, including response bias and social desirability effects, which can distort the understanding of actual practices (Rosenman et al., 2011). Furthermore, while many of the insights shared centered on relationships between BCBAs, parents, and educators, the study reflects only the perspectives of BCBAs and therefore does not capture how these relational dynamics were experienced by families or school personnel. Finally, although rapport, pairing, and trust are widely understood within the field and are foundational components of BCBA training and practice we did not ask participants to explicitly define these terms. This may limit the nuance of interpretation across contexts. Future research could explore how BCBAs conceptualize and operationalize rapport and trust to inform training and practice in diverse settings.

Conclusion

Successful transitions between home and school for autistic children depend on collaboration among teachers and service providers (McLeskey et al., 2018). However, the transition from IBI to public school and the role of the BCBA in this process have been largely overlooked in research, leaving their potential to support the entire team underutilized (Fenlon, 2005; Pianta & Kraft-Sayre, 2003; Pianta et al., 2001). Because BCBAs are often classified as healthcare providers, they face limitations in being compensated for collaborative work that occurs outside direct service or after a child has transitioned. These findings point to the need for clearer funding structures and guidelines that support BCBA involvement in transition planning. Training programs should address interdisciplinary collaboration and special education systems to better prepare BCBAs for this role. At the policy level, formally recognizing behavior analysts as part of the transition team could promote more coordinated, family-centered support across home and school settings.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contributions

Ban S. Haidar: Conceptualization, methodology, data collection, data analysis, manuscript writing, and revisions. Hedda Meadan: Supervision, conceptualization, manuscript review, and revisions.

Funding

This research received no specific grant from any funding agency, commercial, or non-profit sectors.

Data Availability

The data generated and analyzed in this study are not publicly available to protect the confidentiality and privacy of the participants.

Declarations

Ethics Approval

This study (protocol # 24277) was approved by the Institutional Review Board (IRB) at the University of Illinois at Urbana-Champaign.

Consent to Participate

Participants consented to participate.

Conflict of Interest

The authors declare no conflicts of interest related to this study.