                      IN THE COURT OF APPEALS OF IOWA

                                     No. 17-1010
                                Filed August 16, 2017


IN THE INTEREST OF L.R.,
Minor Child,

M.R., Mother,
      Appellant.
_______________________________________________________________


         Appeal from the Iowa District Court for Muscatine County, Thomas G.

Reidel, Judge.



         A mother appeals from a dispositional order and the removal of her child

from her custody. AFFIRMED.




         Christine E. Boyer, Iowa City, for appellant mother.

         Thomas J. Miller, Attorney General, and Gretchen Witte Kraemer,

Assistant Attorney General, for appellee State.

         Mark J. Neary of Neary Law Office, Muscatine, guardian ad litem for minor

child.




         Considered by Danilson, C.J., and Tabor and McDonald, JJ.
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DANILSON, Chief Judge.

        A mother1 appeals from a dispositional order and the removal of her child,

L.R., from her custody. The mother contends there is not clear and convincing

evidence supporting the grounds for adjudication of the child as a child in need of

assistance (CINA), there was insufficient evidence to order the child’s removal,

and reasonable efforts to achieve reunification were not provided. Because the

record reflects the mother’s progress in addressing her mental-health issues has

not eliminated the imminent likelihood L.R. will suffer harm and will not receive

adequate care, we affirm.

         L.R., born October 2016, is under the age of one.                        The mother is

diagnosed with histrionic personality disorder, factitious disorder imposed upon

another with a rule out2, and borderline intellectual functioning. The mother’s

mental-health issues interfere with her ability to maintain stability in general life

functions and to process information, and they cause the mother to engage in

attention-seeking behavior. For example, the mother mismanages finances—

often buying unneeded clothing and toys for her children and then struggling to

retain money to pay rent and utilities bills. Additionally, the mother has frequently

moved residences and, when able, has kept an unreasonably large number of

animals in her home.


1
  The father does not appeal.
2
  Factitious disorder imposed upon another is a syndrome formerly known as Munchausen by
Proxy. As defined in the mother’s psychological evaluation report, “[t]he essential feature of
factitious disorder is the falsification of medical or psychological signs and symptoms in oneself or
others that are associated with the identified deception.” The report also explained that proof of
intentional falsification must be present for a diagnosis of factitious disorder imposed upon
another. The “rule out” means the disorder could not be certainly diagnosed because the mother
had not yet been directly caught knowingly administering unneeded medication to E.R., L.R.’s
older sibling. Following the evaluation, the mother admitted to knowingly administering seizure
medication to E.R. in a way that was not prescribed by doctors.
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          More concerning is the danger posed to L.R. due to the mother’s factitious

disorder imposed upon another. L.R.’s older sibling, E.R., was removed from the

mother’s care because the mother was administering seizure medication to E.R.

despite knowing the medication was not needed.            A department of human

services (DHS) worker reported the mother overfeeds L.R. and feeds L.R.

inappropriate food, causing L.R. to vomit. Instead of taking L.R. to a pediatrician,

the mother took L.R. to a chiropractor to address the vomiting. The mother did

not heed the advice of professionals when told she was overfeeding L.R., and

she directed L.R.’s daycare provider to continue feeding L.R. the same quantity

of food. The mother also directed the daycare provider to continue treating L.R.

for eczema when L.R.’s eczema had already cleared up.

          L.R. was adjudicated a CINA on May 3, 2017, pursuant to Iowa Code

section 232.2(6)(c)(2) and 232.2(6)(n) (2017). After a hearing held July 6, the

district court concluded the mother had not made the necessary progress in

addressing her mental-health issues to ensure L.R.’s safety and entered a

dispositional order removing L.R. from the mother’s care.3        The mother now

appeals.

          Our review of child-in-need-of-assistance proceedings is de novo. In re

J.S., 846 N.W.2d 36, 40 (Iowa 2014). “In reviewing the proceedings, we are not

bound by the juvenile court’s fact findings; however, we do give them weight.

Our primary concern is the child[ ]’s best interests.” Id. “CINA determinations

must be based upon clear and convincing evidence.” Id. at 41.



3
    L.R. was placed in family foster care with E.R.
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       Pursuant to Iowa Code section 232.2(6)(c)(2), a CINA means a child “who

has suffered or is imminently likely to suffer harmful effects as a result of . . . [t]he

failure of the child’s parent, . . . to exercise a reasonable degree of care in

supervising the child.”     And section 232.2(6)(n) defines a CINA as a child

“[w]hose parent’s . . . mental capacity or condition, . . . results in the child not

receiving adequate care.” In the adjudicatory order, the district court explained:

              [T]he mother has histrionic personality disorder, which
       caused her to misinterpret [E.R.]’s behaviors and to exaggerate
       those behaviors and make decisions based upon a desire for
       attention which put [E.R.] in harm’s way, and caused [E.R.] to
       experience traumatic events. The mother is still suffering from that
       diagnosis. She has a significant history of lying, which includes
       lying about a pregnancy. The court finds that the mother lied to
       medical professionals about [E.R.]’s health, misinterpreted [E.R.]’s
       health, and the mother failed to follow doctor’s directions in the
       treatment of [E.R.] All of these issues are still present and create
       an imminent risk to [L.R.]

       Also, as noted by the court at the conclusion of the dispositional hearing,

the mother has continued to exhibit concerning behavior with respect to L.R.’s

medical care. The court stated:

                As stated, [E.R.] is actually at an age where she’s able to
       verbalize, where she’s visible in the community, and [L.R.] does not
       have those benefits or strengths as this point in time. We also must
       understand that while [the mother] has been caring for [L.R.], she
       has been under the watchful eye of many, many individuals. The
       fact that she would not go to date as far as she did with [E.R.] is
       reasonable in light of all that observation.
                But nonetheless she has taken actions that show that there’s
       still a strong temptation for that and a strong likelihood that that will
       only escalate for her coming up with a full diagnosis for the child
       that could place the child in danger, . . .
                We’ve heard about the overfeeding, vomiting, the false
       information given to the daycare about the child’s mobility. It’s
       concerning to the Court that she elected to take the child for the
       vomiting disorder to the chiropractor rather than the pediatrician.
       The Court thinks the only rational reason for that would be that she
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       was concerned the pediatrician would acknowledge or readily be
       able to diagnose that she was not properly feeding the child . . . .
              Additionally, we have a condition of eczema that is cleared
       up, and yet she is still, as recently as May 31st, directing the
       daycare provider to continue to treat this disorder that no longer is
       existing.
              Furthermore, she had made a comment to the DHS worker,
       Ms. Blake, that the child had a follow-up appointment for whooping
       cough, despite the fact that that was never diagnosed.
              ....
              The Court finds in this case that [L.R.] cannot be protected
       from harm and that that would justify an adjudication . . .

       We find the record supports adjudication under section 232.2(6)(c)(2) and

(n). While the mother’s participation in services and progress is commendable,

the evidence in this case reveals the child is still at risk for adjudicatory harm.

The mother has exhibited an inability to heed the advice of professionals

regarding appropriate child care and to provide stability, and has engaged in

behavior reflecting a continuing problem with properly analyzing, reporting, and

treating L.R.’s medical needs and health.        Although the mother has not yet

exhibited life-threatening behavior with respect to L.R.—as she did with E.R.—we

find the mother’s actions viewed cumulatively indicate L.R. is at imminent risk of

harm and likely to receive inadequate care until such time the mother has fully

learned to cope with her factitious disorder imposed upon another. See In re

J.E., 723 N.W.2d 793, 798 (Iowa 2006) (“We have previously said ‘our statutory

termination provisions are preventative as well as remedial.’ They are designed

to prevent probable harm to the child . . . .” (citation omitted)). We therefore affirm

L.R.’s adjudication as a CINA and the court’s dispositional order removing L.R.

from the mother’s custody and care.
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      The mother also challenges the district court’s finding that DHS has made

reasonable efforts toward reunification. See In re C.B., 611 N.W.2d 489, 493

(Iowa 2000) (“The State must show reasonable efforts as a part of its ultimate

proof the child cannot be safely returned to the care of a parent.”). This claim

alleges the State presented no evidence that the mother was not making

sufficient strides in her current counseling and the State failed to provide

treatment specifically for factitious disorder imposed upon another.

      DHS is providing the mother a myriad of services including assessment

and safety services; weekly parenting skill development, including resource

allocation and referral; supervised interactions and transportation; family team

meetings;   psychiatric   evaluation;   parent/child   interaction     therapy;   and

coordinating L.R.’s medical and reviewing L.R.’s medical records. The mother is

also receiving services from the Healthy Opportunities for Parents to Experience

Success program, the family development and self-sufficiency program, and

Iowa 1st Five.    Most significantly, the mother has participated in individual

therapy since July 2016 and began the Systems Training Emotional Predictability

Problem Solving (STEPPS) program in April 2017.

      The mother contends DHS has not made reasonable efforts because it

has not offered services to specifically address her factitious disorder imposed

upon another. However, the mother is being offered a great deal of services,

including mental-health counseling.      Additionally, the STEPPS program is

specifically designed to address borderline personality disorders. We are not

able to determine which diagnosis or potential aliment should be treated first and,

accordingly, cannot reach the conclusion that the State’s many and varied
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services are insufficient. By all indications, the State has taken reasonable steps

to date and the mother has not made sufficient strides. However, we also agree

that if removal continues, at some point in time it may be necessary to require

further psychiatric evaluation to rule out or diagnose with finality the mother’s

factitious disorder imposed upon another, and if diagnosed with the condition, to

specifically address such a diagnosis. At this juncture, we agree with the district

court’s finding that reasonable efforts have been established.

          We conclude clear and convincing evidence supports the district court’s

adjudication of L.R. as a CINA, removal of L.R. from the mother’s care, and the

finding that reasonable efforts toward reunification are being made. We therefore

affirm.

          AFFIRMED.
