By Marilyn Lash, M.S.W. and Taryn Stejskal, Ph.D.

It’s a common belief that most marriages end in separation or divorce after a spouse has a traumatic brain injury. Certainly the physical, cognitive, social, behavioral and communicative changes caused by brain trauma can affect a couple’s relationship. These changes are just the primary losses. Additional changes, known as secondary losses, can range from loss of income, to loss of friends, jobs or careers. As roles and responsibilities formerly shared by a couple are reexamined and redistributed after a spouse is injured, the relationship between a husband and wife changes in many ways. 

There is very little scientific research on marital relationships so much is still unknown about the impact of a spouse’s brain injury on the marriage. Reasons for a marriage dissolving are always complex, but this may be even more so when one partner has a disability or impairment due to a brain injury.  So it is important to look at the findings from 3 research studies on this topic. 

• One study conducted by Thomsen in 1984 found a very high rate of 78% for marital breakdown. But it is important to note that this was a very select group of individuals who were studied. It examined only 9 couples who were 10-15 years post-injury. In addition, many of them had severe brain injuries and most were living in a residential assisted living program. So one must question how applicable these findings are today.
• The second study led by J.C. Arango-Lasprilla was more recent in 2008. It also was much larger, including 927 individuals who were injured. In contrast to the earlier study, the marital breakdown rate was only 15% within the first 2 years post-injury. This study offers much more hope for relationships to survive the stresses and challenges of daily living after a partner has been hurt. 
• The third study led by J. Kreutzer in 2007 not only found that 25% of relationships broke down but that this occurred an average of 4.1 years after a spouse’s injury. 

Research has found that several factors make a difference in whether couples stay together or separate after one of the partners has a brain injury. The highest rates of marital breakdown are found among younger couples and in shorter or more recent marriages. Another risk factor is domestic violence. Couples with a more severely injured member were also found to be at greater risk for separation or divorce. 

Much more research is needed to understand why some couples manage to stay together and others separate. But one thing is clear – research does not support the common belief that there is a much higher incidence of marital separation and divorce when one partner or spouse has a brain injury. 

Recommended Reading

Couples: Hope and Intimacy after Brain Injury

 By Taryn Stejskal, Ph.D.

By Irene Young

Challenges and rewards of caregiving

Most of us have had the blessing to watch our children take their first steps, to hear their first words, to witness their first everything and to embrace them as they overcome the obstacles in their life.  Imagine if you would that it wasn’t your child, but your husband, your sister, or someone who is very close to your heart. I have had a recent experience that most wives don’t usually get. I have been blessed for the last four years to watch my husband not only live, but overcome life’s obstacles after his traumatic brain injury. Caring for a loved one who has had a traumatic brain injury (TBI) is not glamorous, by any means. But by setting goals and making a schedule, you and your TBI loved one will be well rewarded. 

As the caregiver, you will be responsible for not just goal setting, but you will be essentially the cheerleader for your loved one.  So it is extremely important to train yourself to be happy and positive, even when you don’t want to be. And there will be times when you don’t want to be. The caregiver needs to give words of encouragement, such as “great job!” or “you were very close let’s try that again!”

Recovery from a brain injury

No one really knows if, when or even how much an individual will recover from a brain injury, but setting simple goals can be beneficial to the survivor and the family. Their goals need to be realistic. Start small and work your way up. If your loved one can only hold a spoon and doesn’t know what to do next, set a goal to work on lifting the spoon to his or her mouth. Keep a journal and maybe video tape your loved one working on goals, not to critique it or tell them what they did wrong, but to replay it when the goal is accomplished. When my husband used to say, “I’ll never be able to do that!” I used to read from the journal I kept that reminded him that at one time he was not able to eat on his own, but now he can.

Don’t expect too much at one time. 

This will only add to both your loved one’s frustrations as well as your own. It may take a little longer than expected, but stick with the same repetitive goals. Remember your loved one has to retrain his or her mind to do things that you already know. I can remember expecting my husband to be able to do a simple thing like hug me, but even a simple hug needed to be retaught to my husband. It took him a whole year to learn how to wrap his arms around me and my daughter and gently squeeze. But when this blessing finally happened, it was like a fourth of July celebration at our house with fireworks.

Know when “Enough is enough.”

I cannot tell you how important this is. Sure go ahead and push your loved one, but watch for signs that signal he or she has had enough, such as getting angry, throwing things, or irritability. These are pretty good signs that your loved one needs a break.  Keep in mind that their attention span may not be as long as it used to be. As  the caregiver, try to think of your adult loved one as a child; I know it’s hard, but it is sometimes easier to make goals and set time limits if you keep this in mind.

Get organized!

As the caregiver you also need goals – this includes goals on becoming organized. This was very hard for me to learn, but I soon realized that people with a TBI need structure and don’t usually like change, so I had to put myself on a schedule. If you have small children or if you want a life after TBI, I assure you that you will need a schedule as well.

Set time aside for your TBI survivor, time for your children and time for yourself – all of these people are very important.

Set time aside – for yourself and others

I physically wrote the time I scheduled for me from 5 a.m. to 7 a.m. in a date book. It was my time to paint my nails, read a book, spend time with God and anything else that was just for “me”. You are not being selfish when you schedule things just for yourself. On the contrary, you are taking care of yourself so that you can be physically and mentally able to take care of your family.

Then, I would have time set aside for my daughter to play a game, color, or just sit and talk with her. While my daughter was at school, it was time for my husband: getting him ready for the day, bathing, dressing, feeding and helping him with his physical, occupational, and speech therapies.

Once I got good at these tasks, I found that even though I had scheduled time for them, it didn’t take me nearly as much time as I had originally scheduled. This gave me a little bit of time in between for a much needed rest.

Being a caregiver is all worth it

Yes, caring for a loved one with a traumatic brain injury can be very exhausting at times, but the challenges never outweigh the rewards and blessings for both the caregiver and their loved one. Watching your loved one take their first steps, hearing their first words, and witnessing their first everything are beautiful memories that will be remembered for a lifetime.

Be patient, goals are easy to set, but not as easy to attain, it has taken my husband four years to be able to take six steps without the help of anyone. He can now bathe himself on his own, and do all of his personal hygiene. It may take him two hours, but the fact is that he does it without any help. Questions that used to take him two or three days to answer now take only one day. His greatest goal he says is being able to tell his daughter how proud he is of her achievements, which he does on a regular basis.  

 Recommended reading

Life Changes: When a spouse or partner has a brain injury

 By Janelle Breese Biagioni and Marilyn Lash, M.S.W.

Information and tips to help spouses cope with feelings of loss and adjust to changes in roles when a husband or wife has a traumatic brain injury or blast injury. Explains importance of self-care and setting up a support system to cope with and relieve stress in families after TBI.

Helping Sons and Daughters: When a parent has a brain injury

By Marilyn Lash, M.S.W. and Janelle Breese Biagioni

Information on emotions and reactions of children when a parent has a traumatic brain injury (TBI).

Managing Care and Services after Brain Injury: A workbook for families and caregivers 

By Don Hood, B.A., Marilyn Lash, M.S.W., Ann Glang, Ph.D., and Bonnie Todis, Ph.D.

By Patricia Jackson, C.B.I.S. and Michael Davis, C.B.I.S. – C.E.

Case management over time

Since the 1960′s, the case manager has been a key organizer of services in traditional rehabilitative settings.  Case management has evolved over the years from a simple cost containment focus to a well-coordinated, systematic, comprehensive approach to quality cost-effective care.  Case managers today are routinely and almost universally involved in organizing and coordinating rehabilitative services and resources to maximize a person’s functional recovery after an injury.   

Most recently, the case manager has been recognized as a catalyst in the field of forensic or medical-legal rehabilitation.  Therefore neurolawyers are increasingly using professional case management services to ensure that their clients receive well-coordinated, quality care and treatment during the often lengthy process of litigation. Lawyers have a duty to provide comprehensive legal services, but they typically do not have the time to oversee the medical and rehabilitative aspects of a personal injury case. The provision of case management can have a direct positive impact on addressing the myriad of needs in a serious injury case.

Case managers, attorneys and personal injury claims

As more case managers are being employed by attorneys to oversee their clients’ case, it is important to clarify the role of a case manager in this specialty field of medical-legal rehabilitation.  A case manager is capable of wearing many hats.  This article describes how case management may be involved in a personal injury claim.   

The attorney weighs the benefits of involving a case manager right from the start.  Time is typically of the essence in catastrophic injury claims.  By using professional case management services to coordinate care that will maximize the client’s physical, cognitive and emotional functioning, the attorney can focus on the litigation process. 

The many roles of case managers

Case management assumes various roles throughout the different stages of a client’s recovery from an illness or injury. 

Hospital

In the acute medical arena, the case manager serves as a discharge planner and helps move an individual from the hospital to rehabilitation, home health care or outpatient therapies.  

Insurance Company

The insurance case manager serves mostly as a cost monitor to ensure that health care dollars are expended wisely.

Rehabilitation Program

Facility-based rehabilitation case managers usually serve on a team within that facility to guide therapies toward maximum potential recovery for the patient within the confines of their facility.

Forensic case manager

None of the case managers above are typically involved in the legal aspects of a patient’s case. The forensic case manager is concerned with every aspect of the above.  At the same time, the forensic case manager assures that the legal perspective is being addressed to maximize client recovery.  The personal injury attorney who utilizes the services of an experienced case manager is in fact assuring the client’s access to quality treatment and medical care.

Case manager as liaison

The weeks and months immediately following a traumatic injury are full of day-to-day stressors.  As a result, families usually are overwhelmed with information and decisions they may not be equipped to handle.  All too often, families do not feel fully informed or supported by many of the medical professionals whose expertise has preserved the life of their loved one in trauma.

If the attorney who has been retained in a personal injury case involves a case manager immediately, the family will benefit.  By using the expertise of an experienced rehabilitation professional, the case manager can assume a guiding role in the care of their loved one.

The attorney also benefits by identifying the case manager as the primary contact person for the family.  The case manager is able to field numerous questions and run interference.  This gives the attorney valuable time to proceed with the intricacies of the litigation process.

Families in trauma have special needs.  They can appear to be demanding at times.  But they may simply need someone to listen to their concerns, their ideas or even more importantly, their fears.  So first and foremost a case manager is a liaison for not only the client, but for the family, the rehabilitation team and the attorney, as well.

Case manager as advocate

Once given the opportunity to review medical records, discuss the case with all parties involved, and determine the priorities, the case manager can oversee a treatment plan, monitor progress, advocate as necessary and create a clear pathway through the rehabilitation maze.

The forensic case manager can objectively oversee the provision of services from a more holistic and client-centered approach.  The forensic case manager works in conjunction with the clinical case manager and the insurance case manager, but does not have their internal pressures or external financial obligations.

Attorneys who assign a case manager to their personal injury cases are assured that the:

• appropriateness and effectiveness of therapies and programming will be monitored, and

• care will be coordinated in the best interest of their clients’ long term needs.

If long term rehabilitation is necessary, the involved case manager has the ability to explore and identify possible funding sources early on.  Through their experience, case managers are familiar with federal, state and local resource systems available to the client.  The attorney may be a novice or have limited experience in that particular arena. Understanding the systems of Medicaid, Social Security, vocational rehabilitation, workers compensation, and the public schools is complex.  Gaining access to their services is a time-consuming process.  Rather than assume that task and breaking new ground, the attorney can rely on the case manager to fulfill this area of responsibility.

Case manager as negotiator

It is important for the client and family to have a skilled negotiator throughout the course of recovery.  The case manager is capable of creatively negotiating a proposed plan of care, length of stay, rates of service and when necessary, identifying appropriate vendors.  Negotiating services to develop a continuum of quality care is crucial as well as time consuming.  Whether it is acute care, outpatient rehabilitation or in-home care, the involvement of a case manager can make a difference.

Taking the long view or seeing the big picture

Where expert life care planning is necessary, identifying service providers and ensuring the implementation of the life care plan is a long term commitment.  The attorney who utilizes the expertise of a case manager is cognizant of the fact that a client’s needs continue long after the litigation process has ended.

There is no easy road to recovery following a catastrophic injury.  Recovery from traumatic injury can be a long arduous process, not only for the injured party but for the family as well. The family’s emotional needs can frequently be overlooked unintentionally while professionals focus on rehabilitation of the client.  The case manager functions as a support system for the family and as an educator and guide through the maze of rehabilitation.  

One of the most valuable tools a case manager brings to the table is the ability to listen.  A skilled case manager listens to concerns from all parties involved, pulls the information together, develops a plan and ultimately directs the implementation of that plan.  The case manager works closely with the rehabilitation team, medical consultants and the family.  By bringing forth the clinical perspective, the case manager helps the attorney strategize throughout the litigation process.

It is the attorney’s duty and obligation to provide clients with the best possible means available to ensure successful resolution to their case.  Financial recovery is only one aspect of a case.  Personal injury attorneys should also concern themselves with the more critical aspects of a case, i.e., emotional and physical well- being.  

An experienced forensic case manager is an asset to the plaintiff attorney’s case for many reasons, some of which have been described here.  Each personal injury case presents itself with a unique situation, specific needs and a vast range of priorities.  In collaboration with the attorney, the list of priorities can be defined, responsibilities delineated and an initial plan set in motion by the case manager.

Whether acting as liaison, advocate, negotiator or educator, the role of a forensic case manager is key in litigating personal injury claims in today’s legal arena.  Ethics dictate diligence by the plaintiff counsel.  Morally speaking, this diligence would serve the client equally as well in the pursuit of quality services, thus facilitating improved quality of the life for the client.

Bee, C.M.(1996) Damages/Running The Gauntlet From Soft Tissue to Head Injuries/From Chiropractor to Neurosurgeon. A non-published presentation.

Burke, W.H. (1995). The Rehabilitation Expert: Analysis and Management of Brain Injury and Other Neurologic Disorders. In Burke, W.H. (Ed.) The Handbook of Forensic Rehabilitation, Houston, TX: HDI Publishers.

Burke, W.H. (1995). The Forensic Analysis of Costs in Head Injury Claims. A non-published presentation. Insurance Defense network, Las Vegas, NV.

Evans, R. & Watke, M. (1995). Catastrophic Neurologic Injury: Improving Outcomes Through Case Management: The Case Manger, July/August / Sept. 83-88.

Fawber,H.& Zorger Orstein B. (1995). Case Management in Forensic Rehabilitation. In Burke, W.H. (Ed.) The Handbook Of Forensic Rehabilitation. Houston, TX: HDI Publishers.

Howe, R. (Ed.) Inside Case Management. 1 (11), 1 (12), 2 (6). 1995.

Mullahy, C. (1995). The Case Manager Is the Catalytic Collaborator in Managed Care. The Journal of Care Management. 1(1), June 7-9.

For more information from Lash and Associates Publishing/Training, Inc., see:

Brain Injury It is a Journey

By Flora Hammond, M.D. and Tami Guerrier

This brain injury book for families explains consequences of traumatic brain injury and gives strategies for coping with changes in the survivor’s physical abilities, memory, attention, thinking and emotions.

Head Cases

By Michael Paul Mason

Book on brain injury, blast injury and PTSD features chapters on adults, children and veterans discussing changes in memory, self-image, violence, suicide, family stress and war in Iraq.

By Patricia L. Jackson, B.S., C.B.I.S. and Michael W. Davis, C.B.I.S.- C.E.T

Is it really happily ever after? 

The Life Care Plan is designed to identify long term needs through a comprehensive assessment of the client’s medical, physical, behavioral and emotional status.  Once the data is evaluated, a Life Care Plan outlines what services the client will need over the course of a lifetime to maintain physical health and emotional well being.  Contrary to popular belief, after a Life Care Plan is deemed necessary and finalized, the client, a.k.a. the subject of the Life Care Plan, is not set for life. 

In reality, it is after a Life Care Plan is finalized that the real work begins.  The Life Care Plan is a necessary map to direct the client’s way along the path of life.  If it is taken at its worth, the client will have access to the supports that were identified to facilitate successful care over the long run.  Unfortunately in a majority of cases, the Life Care Plan simply finds its way into a file cabinet and is stored along with other medical and legal documents.  

Who are the players in the plan? 

Somewhere along the way a major component is overlooked.  The medical and rehabilitation specialists do their jobs by identifying the needs of the client.  The family hires legal representation to help them do the best they can for their loved one.  The attorney’s obligation is fulfilled by presentation of a comprehensive Life Care Plan in court.  The judge (and perhaps jury) recognize the severity of the injury and find in favor of the client.  The decision is made about a financial settlement that will ensure access to whatever services had been deemed necessary for care over the client’s lifetime.  And then, everyone goes home.

Money doesn’t guarantee services 

Although life care planning focuses on caring for the needs of the injured person, a financial award in itself does nothing to guarantee client services.  There is a huge gap in the system.  The family is not always aware of the how-to’s in the rehabilitation community, yet they are most often the ones left holding the “plan” so-to-speak.  Even experts within the system find that it can be difficult to access services.  It is a grave disservice to expect that a client’s family members will know how to work through the complexities of a system, including as the maze of rehabilitation services. 

The case manager is the missing link  

A case manager who specializes in the implementation of Life Care Plans can fill that void.  Working with the family, a case manager takes charge of the Life Care Plan to access and arrange the services identified for the client.  

The role of each person involved in the Life Care Plan process is defined and is important.  Each specialist is responsible for their area of expertise.  However, the reality is that every individual involved in the case has an ethical responsibility to see that what they recommend is in fact carried out.  

It is not enough to identify, acknowledge and provide financial resources to help the client.  The care the client deserves and is entitled to should not be compromised simply because no one is identified to assume responsibility for implementing the Life Care Plan.  A case manager assures that the finances are utilized in the way that they were designated, rather than leaving follow-up client care to chance.  The Case Manager doesn’t have all the answers, but will find the resources to get the answers that the client and family deserve.

Case managers can help fulfill the intent of a life care plan

Surely it is the intent of the judge and our legal system as a whole to provide financial support by way of a settlement when they find in favor of a client.  When utilized properly, a financial award will provide support and services for the client who has sustained a serious injury.  A financial award that is misused or used improperly not only doesn’t help or support the client, but it also causes greater harm by decreasing the client’s chance for success and an improved quality of life.  Misuse will also most likely create a host of secondary problems resulting from lack of proper medical and psychological care. 

A case manager can be the critical missing link.  By monitoring the client’s status and maintaining communication amongst all the parties involved, the client’s care will remain in the forefront as the true priority.  After all, quality client care is the true intent of any financial settlement. 

Patricia Jackson is a Case Manager and Michael Davis is the President and Senior Case Manager with Neurological Case Management Associates, specializing in the field of neurological rehabilitation, in Charleston, WV.

For more information from Lash and Associates Publishing/Training, Inc., see:

Adult Mini Tool Kit on Traumatic Brain Injury for Families

This Adult Mini Tool Kit is designed for lawyers and life care planners to give to families with information on traumatic brain injury. 

Ketchup on the Baseboard: Rebuilding Life After Brain Injury

By Carolyn Rocchio

By Carolyn Rocchio

Mild brain injury is a real problem for families

Many service members and veterans have returned from war with undiagnosed mild brain injuries or concussion.  Greater emphasis is now being placed on case management and coordination of services for service members and veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom after sustaining traumatic brain injury in response to the July 12, 2006 report from the Department of Veterans Affairs Office of Inspector General (1). This need was reinforced by testimony before the House Veteran’s Affairs Subcommittee on September 28, 2006 with the presentation of alarming data about the large numbers of blast injuries resulting in changes in neurosensory deficits (2).

Traumatic brain injury has become the “signature” injury of Operation Enduring Freedom and Operation Iraqi Freedom. As of January 2006, the Department of Defense reported more than 11,852 returning wounded had exposure to blast injuries (2). It is reasonable to conclude that many additional service members/veterans who have been exposed to blasts without bodily injury are later experiencing classic signs of mild brain injury.

Mild brain injury is a significant problem in the general population in this country as well. According to data from the Centers for Disease Control and Prevention 1.1 million Americans are seen annually in emergency departments with mild brain injury and countless numbers are never screened or diagnosed.(3)

Coming home isn’t always easy

Many service members/veterans return home with the expectation that their lives will resume as they were prior to deployment. Such is not the case for many who have been exposed to blasts. Without information and resources to guide and support the service member/veteran and family, a “mild” brain injury can take a serious toll on the family. It is critical that service members/veterans be screened for a mild brain injury when exposed to blast injury and given appropriate follow up and treatment. Equally important is educating the family members who will ultimately become the support team once the veteran completes treatment. Families must be made aware of the nature and consequences of mild brain injury and provided with tools to provide support in the months and possibly years to follow.

Social workers should be aware of informational resources to assist families being seen in VA facilities, both inpatient and outpatient. Many educational resources and publications exist to educate families. In turn, families must be taught how to access community resources and be prepared for changes and characteristics common to mild brain injury. Some of the more common characteristics that may be present on discharge or develop later include:

• headache
• fatigue
• dizziness
• memory problems
• sleep disorders
• problems concentrating
• ringing in ears
• irritability
• visual changes
• sexual dysfunction
• sensitivity to light, sound and odors

Even though some or many of the characteristics above may exist, the overall appearance of the individual can still be unchanged unless there are other physical injuries. This appearance of well-being can be misleading for family members, friends, and others. Even the service member/veteran is not always aware of the less visible cognitive changes. This can lead to frustration when the family is not patient and supportive.

A mild brain injury can be tricky to diagnose

Mild brain injury is often difficult to diagnose as changes in brain structure are seldom captured by CT or MRI scanning. This lack of physical evidence of an injury can result in labeling the individual as “faking” or malingering, when in fact there have been molecular changes in the brain that affect how the individual thinks and acts. A neuropsychological assessment is the key piece of information that can explain how the injury has affected the individual’s functional capabilities. Ideally the service member/veteran, family members and the neuropsychologist should meet to discuss the findings and establish ways the family can support and promote emotional well being of the service member/veteran and other family members.

All members of the family undergo a difficult adjustment once the service member/veteran returns home. There may have been many role reversals with family members assuming new responsibilities while the service member was deployed. After a brief honeymoon period, when everyone is delighted that the service member has returned, things can go down hill very rapidly. This can happen when others see the subtle changes, but do not understand the cause. At this point, it is not uncommon for the service member/veteran to develop a secondary emotional response to these changes. This can create new problems, that without professional intervention, may escalate into family dysfunction and even violent behaviors. This secondary emotional response often becomes even more disabling than the original insult when support is not available. This can lead to a psychiatric referral that further exacerbates this issue. Persons with mild brain injury often describe themselves as feeling “crazy” because they do not understand the changes they are experiencing.

Risks at home

Families need to be extremely vigilant when there are small children in the home. Irritability and impaired behavioral control can result in children becoming the target of the service member/veteran’s temper when seemingly minor interactions become emotionally charged. Older children may need help understanding why the parent who was once loving and supportive becomes moody and irritable for no apparent reason.

Trying to return to work can be fraught with problems. While the initial return to a job may be met with exhilaration and a sense of camaraderie with old colleagues, problems may surface over time. The service member/veteran may find things that were once easy are now far more difficult. The pace of work is slower. Fatigue is a major factor. Interaction with coworkers can become argumentative and problematic.

Seizure activity can develop some months or even years after a blow to the head. Often these seizures are not convulsive, but more likely to be partial complex temporal lobe seizures which manifest as a change in behavior. The service member/veteran may complain about foul odors, become more sensitive to light or sound, pace the floor and even have hallucinations. Any symptoms should be reported with a follow up evaluation to determine if seizure activity is present.

What can be done to lessen these problems?

Structure is important for reestablishing a daily routine. Military personnel have one advantage in that they are very disciplined and used to taking orders from others. Until the routine is going smoothly at home, the spouse, parent or significant other may need to be the authority figure and help set up a structure. It is not uncommon for a brain injury to affect a person’s ability to initiate a daily routine. This can be particularly difficult when moving from the highly structured military regime back to a more relaxed home setting.

Some helpful strategies for family caregivers include:

• Use day planners, post it notes, and written lists to minimize problems related to memory loss.
• Use watches with alarms, egg timers or electronic timers to keep track of time related tasks.
• Organize all possessions, shelves, drawers, etc with everything in an assigned place to prevent the frustration of locating lost or misplaced items.
• Build in time for relaxation, meditation and/or yoga and Tai Chi to reduce stress.
• Encourage social interaction, but make sure all friends, families and others are aware of the service member/veteran’s persistent problems and ways to interact more successfully.
• Find support groups. The assurance of others with similar residual affects of mild brain injury can be extremely important. Some VA centers with brain injury programs sponsor such groups. Information about community based support groups for individuals with brain injuries and their families can be obtained by contacting the Brain Injury Association of America at 800-444-6443 for referral to the group nearest the family.
• Plan time each day for rest or a nap to offset the effects of long term fatigue. Many will experience disrupted sleep and may require medication to insure restful sleep occurs.
• Model calm when things become emotionally charged. In the event that violence is an issue, make sure family members leave the area to avoid being injured until calm is restored.
• Seek professional help from a person familiar with mild brain injury in planning the work environment to ensure a successful return to work.
• Ask about the use of alcohol and nonprescription drugs before discharge. Alcohol and street drugs can have negative effects when medications are prescribed for conditions such as seizures. In general, any use of alcohol has an exaggerated affect on a person with brain injury. Use of alcohol and other substances is best reinforced if guidance is provided in discharge summaries so family members can rely on professional direction in written form.
• Ask about driving safety due to changes in perception, judgment, visual, and attention deficits. Driving should not be resumed until the service member/veteran is evaluated by a Certified Driving Educator, where emphasis is more on cognitive functions than the mechanical ability to operate a vehicle.

Summary

Mild brain injury can create significant disruption in the lives of the person with the injury as well as members of the family. To insure a more successful recovery, it is critical that there be a thorough assessment to determine what areas of the brain have been injured and the effects on everyday functioning. Additionally, once cognitive deficits have been identified, it is important that strategies to compensate for these deficits be developed. Lastly, family education and resources must be provided. A well informed and supportive family is the major component of successful community reentry.

References:

 (1) Health Status of and Services for Operation Enduring Freedom, Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation. Report Number 05-01818-165. VA Office Office of Inspector General. Washington, DC , July 12, 2006.

(2) Zamperi, Thomas. Chrm. Director Government Relations, The Blind Veterans Association. Testimony: The House Veterans Affairs Subcommittee. September 28, 2006.

(3) Langlois J, Rutland-Brown W, Thomas K. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.

Recommendation reading

Mild Traumatic Brain Injury Workbook

By Douglas J. Mason, Psy.D

Workbook for adults, veterans and families on mild traumatic brain injury and concussion symptoms with strategies and exercises for improving attention, memory and executive functions.

Brain LASH

By Gail Denton, Ph.D.

Book helps adults and families understand mild brain injury symptoms with strategies for physical, cognitive and emotional changes after concussion.

By Janelle Breese Biagioni

You have undoubtedly heard the saying – “You can do this the easy way or you can do it the hard way!” However, what if the task at hand, as in grief, is already hard? The reality is there is no easy way to grieve. When grieving a loss – whether it is a death, catastrophic injury, chronic illness or transitional loss – the journey is hard, long, and difficult. Furthermore, the grief journey can be longer and more difficult if we do not engage in the process.

Avoiding the pain…

It is natural to want to avoid painful situations and for us to encourage others to do the same. Unfortunately, we also live in a society that supports the myth that “moving away from the pain” is the best way to move life forward or get things back to normal after a tragedy. As an example of how society supports this, consider the following: How many employers do you know whose human resource policies allow an employee more than three days bereavement leave if a death occurs in the family? And, how many of those employers have an open-ended list of people that qualify as important enough to warrant giving bereavement leave to an employee should someone on that list die? Not many – if any! The provision is usually for the death of an immediate family member as in father, mother or a sibling.
But what about the person whose family are their friends? Are they not entitled to time off when their “stand-in mother” dies just because they don’t share the same blood? There are many individuals whose family is not close, or who are not on good terms with their family and therefore, garner their day-to-day support from friends. In essence, these friends have become their family.

The meaning of time…

Commercially, we are flogged with the perception that anything worth having is instantaneous – high-speed email, fast food, digital pictures, instant messaging and on and on. It is no wonder that society holds the false expectation that when tragedy strikes, people should “heal fast” and “get back to normal as soon as possible” so they are fun to be around again! For those who have traveled the journey of loss, we can tell you – it is not that easy.

The more accurate and supportive phrase for the bereaved is “time heals all”. Keep in mind however, that time doesn’t heal in the sense that it “fixes” what is broken. It heals in the sense that by taking all the time we need to feel, remember and acknowledge the reality of our loss, we are able to move forward in life. In fact, it is the only way to heal and to move life forward.

Recognize and respect the loss…

To engage in the grief process is to suspend life and to be fully aware of each aspect of the loss, including secondary losses. For example, if you are catastrophically injured, you may not have the ability to return to work and as a result have limited or no income. The loss of financial security is a secondary loss. Each loss and every aspect of the loss can be a source of pain and must be grieved. Unfortunately, you cannot grieve the losses simultaneously – each loss needs to be worked through individually and yes, this takes time.

The good news is that by engaging fully in the grieving process we can come to terms with the loss and eventually renew our capacity to love, laugh and plan for the future. As difficult as it sounds, there is no way to the other side of grief except to go through it. Take time to heal – for however long that takes! You are worth it!

 Recommended reading:

A Change of Mind: One Family’s Journey through Brain Injury 

By Janelle Breese Biagioni 

Book on marital stress and adjustment by a family when a spouse has a brain injury. Discusses emotional trauma for family, grieving, mourning, parenting, and caregiving after severe head trauma.

 by Barbara Stahura

An injury to the brain is unlike any other injury 

In my favorite photo of us, we’re astride Ken’s BMW motorcycle in our Tucson driveway. Ken is laughing at the camera as I, sitting behind him with arms clasped around his waist, kiss his ear. We wore none of our usual protective equipment—full-face helmets, boots, jackets, gloves—because we had jumped on the bike strictly for the photo. Months later, Ken was wearing all his gear when he took his other motorcycle, a Ducati sport bike, to run some errands. But when a white sedan turned suddenly in front of him, there was nothing he or his equipment could do to prevent what happened next. Ken hit the passenger side near the back wheel; helmet striking steel, face smashing into helmet, brain slamming into skull. He crashed to the asphalt. The sedan disappeared.

An injury to the brain is unlike any other. Along with physical functions, the brain controls awareness, personality, temperament, and cognitive processes like memory—all those things that commingle to form a “self.” And while that self does not necessarily reside in the brain, the brain is the part of us that animates it. So a traumatic brain injury can kidnap the dear self of someone you love, dragging him far from shore as a riptide does a swimmer, sometimes beyond rescue, even though in reality he is holding your hand or smiling at you across the dinner table.

The shock of seeing him in the hospital and hearing the words “brain injury”

The day of the accident, exactly nine months after our wedding, Ken left around noon and had planned be home in a couple of hours. Instead, I found myself at the University of Arizona Medical Center’s ICU around 7 p.m., staggered by the sight of my husband. There was a ventilator tube in his mouth; a cervical collar around his neck; a stitched cut above his left eyebrow; left eye purple and swollen shut, right eye nearly so; nostrils filled with crusted blood; broken right hand captured in a sling; left hand tethered to the bed rail. Naked under a single sheet and his face streaked with dirt, Ken moaned and tossed in delirium.

A CT scan showed two minimal contusions on Ken’s brain. The neurologists told me worse injuries invisible to imaging machines were likely. The brain floats within the skull, and if the head’s momentum stops suddenly, as Ken’s did when it came to an instant halt against the car, the brain rebounds within its bony home in a motion called coup contrecoup. Neurons are sheared off: Millions of connections in that tiny, internal universe can, like exploding stars, blink out of existence in an instant.

My husband now speaks but can not communicate 

That Ken had suffered a traumatic brain injury (TBI) became apparent when he could talk again, four or five days after the collision. Much of his speech consisted of parroting words in a sing-song voice. After developing aspiration pneumonia, he tried to cough but couldn’t cough deeply enough for relief. Smiling at him and stroking his forehead, I said, “Bummer.” He sang back, “Bummer, bummer, bummer,” much as a toddler would.

Next, he began repeating nonsense phrases. The first was, “Happiness is, happiness is,” in a gentle rhythm. I added, “Happiness is a warm puppy,” which he chanted for a while and gradually transformed to “Happiness is a warm country.” But as Ken began to speak in complete sentences, I grew more alarmed.

“I have to rewire your circuitry so I can manage you better,” he told me in all delusional sincerity. He claimed his staid, seventy-seven-year-old parents were members of a steel drum band; no, wait, a plastic drum band. He insisted he had to get up and care for his patients (he’s a software engineer) and that Scott, his chiropractor, repaired his motorcycles. One night, when he couldn’t even sit up without help, he somehow clambered over the bed rail, wandered down the hall, and fell, hitting his head. Fortunately, he incurred no further injury. The nurse who called me said he kept repeating, “I have to find the motion. My wife and I have to find the motion.” He didn’t know where he was or what was happening. Even worse, he didn’t know that he didn’t know—a very bad sign.

After this incident, Ken was placed in a Vail bed, a mesh-sided, enclosed bed that zips from the outside. Much better than putting him in restraints, the nurse told me.

Ken’s short-term memory also had been damaged. He recognized everyone who came to visit but for weeks could not recall that anyone but me ever had. His speech therapist hung signs in his room as memory aids: “I was in a motorcycle vs. car accident on December 29″ and “My wife’s name is Barbara.” She also started a memory book for him, to which I added photos of our wedding, his kids, our house, and our cat, along with affirmations proclaiming good health and normal life.

During the first few weeks, even though Ken carried on long—if sometimes weird and oddly chatty—conversations, he never really engaged with anyone. He spoke animatedly, but his gaze was distant, unconnected. Although physically in the room, he was not present; he existed in some inward place, unable to transcend the damage to his frontal lobes.

He is s different person – is this my husband?  What will it be like to live with a person with a brain injury?

His rehab team warned me that impulse control is often a casualty of TBI, and Ken was no exception. Still weak and in danger of falling, he moved too quickly for safety. He gobbled his food. I became a nag, perhaps too protective but terrified of another injury. I reminded him again and again to slow down, be careful. Stubbornly, he refused, brushing away my concern like a pesky fly. Once, I cried in frustration, fearful that he would choke on huge forkfuls of dinner. He simply looked past me with distant eyes and continued bolting his food.

A month after the accident, Ken developed a pulmonary embolism and was transferred from rehab to an acute care hospital. One morning, he called me from there. “I don’t know where I am,” he whispered. “I think I’ve been kidnapped by foreign nationals.” I stood in our kitchen, phone to my ear, stunned. Just yesterday, he had sounded so normal again. Where was the man who had looked so intensely into my eyes as he said, “I do”? Smart, articulate, an enthusiastic reader, an excellent computer programmer and woodworker, the real Ken had disappeared, replaced by someone who looked just like him but was missing essential ingredients. Should I have applied for his Social Security disability, as his case manager had advised? Would I forever be his caregiver, exhausted, frightened, and missing him?

If I could only see inside his brain

I wanted more than anything to look inside Ken’s brain, to see what the scanning machines could not, to find his lost self among the blasted neurons and bring him home. I researched TBI on the Internet, read books about it, and found many chilling and many encouraging stories about survivors. I pestered Ken’s doctors and therapists with questions—Would Ken’s brain heal? How much? When? —but of course, no one could provide the answers. There was nothing to do but move through the days.

When a reason for hope appeared, I clung to it—the first time Ken hugged me, remembered our phone number and called me at home, recalled a visit from neighbors the night before. And when hope lagged, I read reminders I’d hung around our house: “Relentlessly Optimistic.”

Two days before his homecoming, my husband made an omelet—perfect and golden—just as he used to make for us every Sunday. All by himself. It was part of his occupational therapy. I took photos, the last one showing Ken standing in the rehab kitchen, proudly displaying his creation. We ate it for lunch. Later that day, he couldn’t remember the word “omelet.”

Nine months post-accident, Ken still fights headaches and fatigue, and fears he’ll always be wobbly on his feet. His memory is better, although the right word often eludes him, but he still wrestles with once-easy tasks, thanks to damaged cognitive functions. He has sold his two remaining motorcycles, returned to work, and vows he won’t abandon himself or me by giving up. Nearly released from the riptide, my husband, resolute and a little scared, struggles to free himself for good. When we vacationed along the Pacific Ocean, we walked the beach every day. I watched Ken cheering the surfers cresting their waves, and I silently cheered him, praying his determination would be enough to return him all the way to shore.

This essay originally appeared in the Jan.-Feb. 2005 issue of Science & Spirit

See more articles by Barbara Stahura about returning warfighters with TBI:

http://www.barbarastahura.com/SoldiersBrainInjury.pdf

http://www.barbarastahura.com/silentinjurycomeshome.html

And about her experience with her husband, Ken:

http://www.newsweek.com/id/37348

Recommended reading

It’s After Brain Injury: Telling Your Story

By Barbara Stahura and Susan Schuster, M.A., CCC-SLP

This workbook guides survivors of brain injury and blast injury through the powerful healing experience of telling their own stories with simple journaling techniques. By writing short journal entries, survivors explore the challenges, losses, changes, emotions, adjustments, stresses, and milestones as they rebuild their lives.

By Diana Lund in Illinois

Brain injury often goes undiagnosed – it’s just an accident!

I had a granduncle who, according to the family lore, was accident-prone. When he hammered, he missed the nail, struck his thumb and dented the wall. When he swung an ax, the tree fell his way. Relatives recounted that he broke every bone in his body and some bones more than once. He’s had several accidents on the job at the quarry, several home accidents and several car accidents – including a car accident on the first day he got his license back after several years of not driving. Good-hearted Alfred was hoodwinked by gypsies; they stole his wallet and later he let them into his home and they stole the contents of that too. The extended family thinks of him as having been normal – he played a savvy game of pinochle – with a string of bad luck. Now, I think that there must be some tie to brain injury; all those falls and mishaps are characteristic of a person with brain injury.

People think I’m normal but I have a brain injury

People call me normal too. My face and body are symmetrical and I’m mainly coordinated again. In conversation, I give relevant responses enunciated clearly. Only I can tell my wit is missing and my vocabulary shortened. Inside I scramble to keep up, to sound normal, to appeal natural. During the silence of night, I long to shed my deep-seated, lost feeling.

It won’t leave. All experience provokes it.

At a bike club’s invitational, I am handing out t-shirts at the registration table when a slim man, approximately my age – fortyish, approaches. His words startle me. “There you are. I’ve been looking all over for you.”

The rider obviously knows me, but I have no recollection of him. Not unusual, I play along. Possibly something he says or does will generate a flicker of familiarity in my brain. “Well, you found me,” I respond.

He continues, “I wanted to make sure you saw me so that I get credit for participating.”

Evidently, I’d pressured him into supporting our charity event. I want to show gracious acceptance of his financial gift. “Consider yourself with credit,” whoever you are.

“Have a good ride.”

Pleased with my acknowledgment, he departs. He has no idea I don’t know who he is. The next time I see him and don’t remember him, I’ll pretend again. And by god, I hope that I give him his credit.

Hiding my confusion after TBI

My confusion doesn’t always slip smoothly past others. At the end of a work day, in the block-long and block-wide company parking lot, the search for my car begins. Wandering down aisle after aisle, I run into a coworker who asks, “Can’t find your car?”

“Yeah, I’ve forgotten where I parked it.” Again.

Empathizing with me, she replies, “Oh, I’ve been scatter-brained like that before.

That’s normal. Good luck on finding it soon.”

Explaining my behavior after brain injury

People want to idenfity with their chums and naturally, try to explain others’ behavior by self comparison. If they have acted this way once before, then my behavior is normal.

They miss the totality of my existence; I make a string of mistakes—one after another after another. They are not seeing behavioral exceptions, but the rule.

Not only that, but the tips of our icebergs are all that we have in common. Upon finding her car, the placement jogs memories of having parked there. My experience is more like a valet had parked my auto; I can’t access parking-the-car memories. Having no internal record of the recent past feels frightening and hollow, like watery remembrances swirling down a tub with a leaky plug, abandoning me naked and cold.

Is a life lived if it is not recorded? Did “I” really exist?

Repeatedly telling me, “I understand,” minimized and invalidated my experience, no matter how well intended, no matter how much I wished it true. Out of frustration, I sometimes blurted out to the caring person, “But, I’m not normal.”

Typically, I heard back, “It can’t be that bad. I forget things, too.”

Unable to explain myself in enough detail on such short notice disconnected us further.

Mild brain injury is not so “mild”

Particularly after the first year of mild traumatic brain injury from a car accident, I had silent and invisible disablements, indiscernible to my daily contacts. If my acts weren’t flagrant, they’d lump me into slightly-off-my-game normal. Too many of the same errors and the tone would change to, “Okay, stop doing this. Stop being different,” with possibly some sardonic ribbing. Even people who knew I had a brain injury tended to discount the diagnosis in favor of my having control over my brain’s functionality.

Why should someone who looked normal not be held to the same standards as everyone else? I began to feel that it would have been better if I had a visible defect, like a black-and-blue shaved scalp.

Like my girlfriend Jill’s nasty head gash from a car collision. The doctors stapled her flesh back together. People became sympathetic and compassionate when they saw the dried blood, the jagged cut and the metal holding her brain in. I watched her for signs of a more profound injury, brain injury, which, fortunately, I could not find.

Unlike her, I looked unscathed after my closed head injury. The broken part of me was encased behind a smiling, pretty face, and mostly, my internal discontinuity appeared singularly as within-most-social-limits. No extra care needed here.

That’s just nonsense. When the brain, the master controller of operations, goes down, it can take years of intricate and delicate work to get that system running again. The healing process takes longer than the injured person’s acquaintances care to remain attentive. People prefer to think that you are fully recovered. They fill in erroneous reasons for unusual behavior. I didn’t return their phone calls because I chose to ignore them, not because I’d lost the inner nagging voice to remind me to call. I didn’t answer their email because they were unimportant to me, not because I hadn’t formulated an answer yet. Word spread around the office about my poor attitude and bad work ethic. My brain’s damage unrecognized, the gossip exacerbated my problems.

Normal is not the answer

After enough “You’re Normal’s”, I cringed at the glossing-over, uninvolved response. “You’re normal,” a superficial slap in the face, “You’re normal. You’re normal,” a platter of platitudes, stung deeply. Each day I strained toward attaining the far away goal of normal I supposedly already had. Suggesting ways to remember where I parked my car, reminding me about an unanswered phone call, or trying to calm me down when I over-reacted, would have eased my load until I could learn to compensate for my faults. Increasingly isolated, I came to resent “normal” people living blindly to my abnormal life. Another normal-looking brain injured woman I’d met tried to commit suicide because she couldn’t overcome problems that friends and family didn’t view as sizeable.

Nothing irked me more, no single misunderstanding damaged my social life more, than the misnomer of normal. Whoever would have guessed during my young, smart life that, someday, I would aspire to be normal, and afterward, daily, people would assure me that I was.

Work to include others authentically. Diversity enriches our lives.

By Kimberly Carnevale

Faking a disability or handicap is unethical and unacceptable

Recently, I’ve gained a new and unexpected clientele – business owners who believe that their establishment had been visited by (and in many cases, damaged by) “imposter” service dogs.

“Imposter” or “fake” service dogs are a growing problem throughout America. This is the canine version of illegally parking in a handicapped parking space. Many people have forgone any type of morality and have obtained vests and attached patches to illegally gain entry to public places with their pet dogs.

“This is the canine version of illegally parking in a handicapped parking space.”

Some offenders believe that their dog should be allowed to go with them everywhere and can’t see the harm in passing off just one dog. They know it is illegal, but do it anyway. Others believe they are justified because they have a disorder. Having their pet dog with them eases symptoms and they may even carry a doctor’s note.

The Federal law is very clear. For any type of service dog to accompany its partner in public, it must be trained to do specific tasks. There are an alarming number of handlers who have not done any required training of their dogs or learned the laws that govern service dog use. There is a difference between a pet and a service dog. Passing off any dog that is not specifically trained as per the Americans with Disability Act, state, and local laws is illegal and is a federal offense with carries federal penalties.

Emotional support dogs

These dogs serve a great and positive purpose, but they are not service dogs according to the law and are not permitted public access (Source: Psychiatric Service Dogs).

“Service animals are animals that are individually trained to perform tasks for people with disabilities such as guiding people who are blind, alerting people who are deaf, pulling wheelchairs, alerting and protecting a person who is having a seizure, or performing other special tasks. Service animals are working animals, not pets”—United States Department of Justice, Civil Rights Division)

If a dog does nothing more than accompany a person into an establishment to “keep them focused” or “ease anxiety”, they are not in compliance with Federal law that plainly states and specifically requires task training. There are many tasks that a psychiatric service dog can learn to do to meet the legal requirements. (A full list is available at: http://www.iaadp.org/psd_tasks.html )

Imposters avoid the costs of training

It costs $15,000-$20,000.00 to train a service dog. Untrained pet dogs are simply not equipped to deal with many unforeseen public distractions that service dogs have been carefully and meticulously prepared for.

“The high cost reflects intensive and high level training that takes hundreds of hours that ensure the dog to be obedient and able to perform its job in a variety of situations.”

A growing number of imposters are simply (and illegally) mail ordering vests, slapping on patches and claiming their pet dog to be a service dog. They then have the audacity to dare anyone to confront them, claiming protection under the Americans with Disabilities Act – the very law that they are in violating.

There are also unscrupulous businesses making a profit on these fake service dogs, by offering to “certify” or “license” them – at a cost. There is no such “certification” or “licensing” approved by the Federal government. Many of these businesses set up their own standards and charge a fee online, without ever having seen the dog.

“…He admitted that he was not disabled, and that his dog was not (or ever would be) a service dog – he simply wanted to get a vest and claim service dog status to get into a no pets facility”

Where’s the harm?

Congress is fully aware of this issue and is currently reviewing a bill that tightens the ADA’s definition of a service dog and increases the severity of penalties in response to this growing, and potentially dangerous problem. They are coming down hard on offenders who are bending the ADA.

“…there are plenty potential disasters waiting to happen when close attention is not paid to the careful socialization and intense training that a service dog needs in order to be safe and effective in a public environment.”

Pet dogs that have not received the proper socialization, high-level obedience, and distraction training are apt to misbehave (or even bite) in high stress environments. Stores, movie theaters, restaurants and other public places are filled with stressors that most dogs have never encountered in their lives as a pet. There are no short cuts to introducing a dog to such things. Precise attention and hundreds of hours of careful training and socialization are the keys to producing a calm, consistent, and properly behaved service dog.

“…ill behavior from imposters give real service dogs a bad rap, and service dog handlers are having even more difficulties with access.”

Business owners have rights too

Business owners who have had experiences with imposter service dogs can be less than jubilant when a real service dog comes into their establishment, leaving the business-client relationship strained. It is critical that business owners be made aware of these imposter dogs, to learn how to protect their clientele and their business interests, while abiding by the law and protecting the rights of real teams.

To think that many people are “cheating,”  by passing off untrained (or barely trained) pets as service dogs, when so many handlers are spending incredible amounts of money and taking the time to properly train their service dog to the level of a highly-obedient and task-trained canine, is infuriating. The immorality of this issue propels me to set out on a new mission to right a tremendous wrong.

Business owners who suspect they have been invaded by an “imposter” service dog are not expected or required to sit idly by while damage occurs or the smooth running of an establishment is interrupted.

“Current law provides for stiff federal penalties (including heavy fines and jail time)—even for first time offenders.”

There are legal steps that can be taken to stop these imposters in their tracks and help recoup damages. If you are in doubt as to whether a dog is a real service dog, you may legally ask the following:

1. Do you have a documented disability? (Note: you may not ask what the disability is.)
2. Is that a trained service dog? If the answer is yes, and you still doubt the validity of the team; you may ask what tasks the dog has been specifically trained to do for the person with disabilities.

Any properly trained team has been fully versed in the law, knows their rights and responsibilities and will have no issue answering such questions. Alternatively, if a person balks at answering these questions, or becomes unreasonably defensive; you may be dealing with an imposter. You may want to consider phoning the police to intervene.

If the dog enters your establishment and exhibits any type of behavior not expected of a service dog (urinating/defecating, damaging goods, sniffing/bothering other customers, barking, growling, snapping, etc.) you are well within your rights to ask them to leave. If the dog or its equipment is not clean (visibly dirty or emits an unpleasant odor), you are within your rights to ask them to leave. If the handler gives you any trouble; call the state police barracks nearest your location. For illegal handlers with “imposter” or “non-task trained” dogs; beware – Uncle Sam, the entire service dog community, and myself are onto you, and we’re cracking down.

***Note: This article is not about, nor designed to discriminate against, any program and/or owner-trained, physical or psychiatric service dogs that have been well trained to fully meet federal requirements; and handlers who have learned and fully versed themselves in federal, state and local law. This is an alert about the vastly growing problem of people who are illegally, and often intentionally, passing off their pet dogs without learning about governing laws, or providing any specialized training and task work for their dogs as required by law).

About the author:

Kimberly Carnevale is an author, disability advocate, and motivational speaker. She is the President and founder of Canine and Abled, Inc. (the award-winning program featured on TV, magazines and in her first book). She is invited to speak nationally on service dog law, business service dog education (including policy and procedure revision/implementation), and corporate motivation.

Kimberly presents her award winning educational and character-building assembly to schools, scout troops and other youth organizations throughout the country, and has been published numerous times nationally and internationally as an expert in her field.

Ms. Carnevale is available to advocate for the rights of service dog handlers (who fully meet the requirements of “disabled” and “service dog” as per the ADA), and to businesses who need employee sensitivity, service dog, and/or disability training, or feel they have encountered “imposter” service dogs in their establishment.

Kimberly also consults in service dog training/acquisition, helps assist people with disabilities train their dogs to the title of service dog, and has plans to build a breeding/training/provision center in the near future. She can be contacted through her website: http://www.canineandabled.com/