1. THE DISABILITY EXPERIENCE CONFERENCE The Development of a Reliable Biomeasure for Detecting Self- Regulation Behaviors in Adults with TBI: A Pilot Study Ashlee B. McKeon, BPhil. University of Pittsburgh Rehabilitation Counseling

2. BACKGROUND  Each year, 1.7 million people sustain a traumatic brain injury ([TBI]; Centers for Disease Control and Prevention, 2006)  One of the leading causes of death and disability  Silent epidemic- Public health concern  Anywhere from 76- 97% of individuals with a TBI experience self- regulation difficulties (Sherer et al., 1998)  Hallmark deficit  Leads to barriers  Independence  Functioning in major life areas  Negative outcomes (Ylvisaker et al., 2007)  Decreased participation  Decreased quality of life (QoL) and life satisfaction  Impact on daily living is clear

3. BACKGROUND (CONT.) Interventions typically delivery within clinic settings Easily controlled; highly structured Weaknesses: May not be a natural representation of functioning Not the true environment where dysfunction manifests Lack of generalizability- not ecologically valid Inconsistent research outcomes Deficit resistance to interventions Interventions can be effective, and potentially superior when delivered outside of the clinic (McCue, Fairman, & Pramuka, 2010) Biofeedback has been shown to be highly efficacious across a wide range of disabilities for increasing self- regulatory ability (Association for Applied Psychophysiological and Biofeedback, 2011a) Use of technology to train awareness of biological systems Naturalistic delivery capability Facilitates independence through fading of technology

4. RATIONALE Clinic- based rehabilitation interventions may be inappropriate for TBI cohorts Lack of self- awareness Inability to generalize learned skills Weaknesses of current interventions suggest a need for rehabilitation professionals to consider novel intervention options for individuals with TBI that are more ecologically valid Natural occurrence of deficits Assistance is most needed Real- world interventions may yield greatest outcomes Existing research is scarce, despite high rate of self- regulation deficits experienced The proposed research is the first stage in developing a TBI- specific in- vivo intervention using biofeedback for increasing self- regulatory ability

5. METHODS Initial and critical development task Identification of appropriate biomeasures and device Scholarly paper results Literature search Device inclusion criteria Pilot testing Healthy controls; N= ≤ 10 Clinic setting Accurate detection of emotional dysregulation Completion of challenging tasks elicit emotional response task breakdown Continuous recording of biomeasures Comparison to gold standard Pilot data will guide future research efforts

6. ANTICIPATED RESULTS Correlation of clinician judgment (behavioral dysregulation) with biomeasure recordings (physiological change) Accurate detection of emotional dysregulation Potential to intervene at the level of emotional response, before behavioral output Eventually train individuals to self- manage Development of a set of algorithms for accurate detection If anticipated results are found, future research aims will be carried out using persons with TBI

7. FUTURE RESEARCH EFFORTS PROJECT PHASERESEARCH AIM Study 1: Healthy volunteers; in- clinicFeasibility of biofeedback to accurately detect emotional dysregulation in healthy controls in the controlled clinic setting when compared to gold- standard of clinician behavioral observation Study 2: Adults with TBI; in- clinicReplication of Study 1 protocol with individuals with TBI Study 3: Adults with TBI; in- vivoEvaluation of biofeedback’s ability to detect emotional dysregulation in participants’ natural environment Study 4: Adults with TBI; in- vivo; full EMI deployment Ability for biofeedback to deploy a full ecological momentary rehabilitation intervention when emotional dysregulation is detected

8. DISCUSSION This project will evaluate the ability for an innovative technology- based rehabilitation service delivery model to accurately detect emotional dysregulation in healthy volunteers Pilot study participant benefits: Enhanced awareness of situations that cause dysregulation Increased knowledge of the link between physiological changes, emotions, and behaviors It is expected future research task outcomes will yield additional benefits Increased independence/ self- management skills Increased QoL Increased participation in major life areas Decreased maladaptive behaviors Increase self- management skills and enhance environmental participation

9. ACKNOWLEDGEMENTS PhD clinical advisor: Dr. Michael McCue PhD technical advisor: Dr. Dan Ding University of Pittsburgh IGERT Team: Mary Goldberg, MS; Dan Ding, PhD; Rory Cooper, PhD National Science Foundation Grant #DGE 1144584 Integrative Graduate Education & Research Traineeship (IGERT) fellowship

10. REFERENCES Association for Applied Psychophysiology and Biofeedback. (2011a). About biofeedback. Retrieved from http://www.aapb.org/i4a/pages/index.cfm?pageid=3463 Association for Applied Psychophysiology and Biofeedback. (2011b). Disorders and treatment. Retrieved from http://www.aapb.org/i4a/pages/index.cfm?pageid=3404 Brain Injury Association of America. (2011). About brain injury. Retrieved from http://www.biausa.org/about-brain-injury.htm Centers for Disease Control and Prevention. (2006). Traumatic brain injury in the united states: Emergency department visits, hospitalizations, and deaths, 2002-2006. Retrieved from http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf Gartha, I. (1976). What is biofeedback? Canadian Family Physician, 22(1), 105- 106. Henry, J., Phillips, L., Crawford, J., Ietswaart, M., & Summers, F. (2006). Theory of mind following traumatic brain injury: The role of emotion recognition and executive dysfunction. Neuropsychologia, 44(1), 1623- 1628. Heron, K., & Smyth. (2010). Ecologically momentary interventions: Incorporating mobile technology into psychosocial and health behaviour treatments. British Journal of Health Psychology, 15(1), 1-39.

11. REFERENCES (CONT.) Levine, B., Deirdre, D., Schwartz, M., Boutet, I., Stuss, D. (2000). Assessment of strategic self- regulation in traumatic brain injury: Its relationship to injury severity and psychosocial outcome. Neuropsychology, 14(4), 491- 500. McCue, M., Fairman, A., & Pramuka, M. (2010). Enhancing quality of life through telerehabilitation. Physical Medicine and Rehabilitation Clinics in North America, 21(1), 195- 205. Ownsworth, T., McFarland, K., & Young, R. (2002). The investigation of factors underlying deficits in self- awareness and self- regulation. Brain Injury, 16(4), 291- 309. Sherer, M., Bergloff, P., Levin, E., High, W., Oden, K., & Nick, T. (1998). Impaired awareness and employment outcome after traumatic brain injury. Journal of Head Trauma Rehabilitation, 13(1), 52- 61. Ylvisaker, M., Turkstra, L., Coehlo, C., Yorkston, K., Kennedy, M., Sohlberg, M., & Avery, J. (2007). Behavioural interventions for children and adults with behaviour disorders after tbi: A systematic review of the evidence. Brain Injury, 21(8), 769- 805. Yucha, C., & Gilbert, C. (2004). Evidence- based practice in biofeedback and neurofeedback. Retrieved from http://www.aapb.org/files/public/Yucha-Gilbert_EvidenceBased2004.pdfhttp://www.aapb.org/files/public/Yucha-Gilbert_EvidenceBased2004.pdf