     The summaries of the Colorado Court of Appeals published opinions
  constitute no part of the opinion of the division but have been prepared by
  the division for the convenience of the reader. The summaries may not be
    cited or relied upon as they are not the official language of the division.
  Any discrepancy between the language in the summary and in the opinion
           should be resolved in favor of the language in the opinion.


                                                                  SUMMARY
                                                               March 7, 2019

                                2019COA36

No. 18CA0118, People in Interest of S.K. — Juvenile Court —
Dependency and Neglect — Termination of the Parent-Child
Legal Relationship — Criteria for Termination; Health and
Welfare — Disability — Americans with Disabilities Act —
Reasonable Accommodations

     A division of the court of appeals considers how the

requirements to make reasonable accommodations found in the

Americans with Disabilities Act of 1990, 42 U.S.C. §§ 12101-12213

(2018), and section 504 of the Rehabilitation Act of 1973, 29 U.S.C.

§ 794 (2018), relate to termination of parental rights based on a

disabled parent’s lack of success with a treatment plan, unfitness,

and unlikelihood of change. The division concludes that a juvenile

court must consider reasonable accommodations in deciding

whether such a parent’s treatment plan was appropriate and

whether reasonable efforts were made to rehabilitate the parent.
COLORADO COURT OF APPEALS                                     2019COA36


Court of Appeals No. 18CA0118
Gunnison County District Court No. 16JV8
Honorable J. Steven Patrick, Judge


The People of the State of Colorado,

Petitioner-Appellee,

In the Interest of S.K., a Child,

and Concerning C.K. and S.R.,

Respondents-Appellants.


                              JUDGMENT AFFIRMED

                                   Division III
                            Opinion by JUDGE WEBB
                          Román and Freyre, JJ., concur

                            Announced March 7, 2019


David Baumgarten, County Attorney, Gunnison, Colorado, for Petitioner-
Appellee

Robert G. Tweedell, Guardian Ad Litem

Susan C. Baker, Office of Respondent Parents’ Counsel, El Prado, New Mexico;
James Plumhoff, Guardian Ad Litem, for Respondent-Appellant C.K.

Pamela K. Streng, Office of Respondent Parents’ Counsel, Georgetown,
Colorado; Barbara Remmenga, Guardian Ad Litem, for Respondent-Appellant
S.R.
¶1    In this dependency and neglect proceeding, S.R. (mother) and

 C.K. (father) appeal the juvenile court judgment terminating their

 parent-child legal relationships with S.K. (the child). To resolve the

 parents’ arguments on appeal, we must consider the requirements

 of the Americans with Disabilities Act of 1990 (ADA), 42 U.S.C.

 §§ 12101-12213 (2018), and section 504 of the Rehabilitation Act of

 1973, 29 U.S.C. § 794 (2018). The ADA, and in limited

 circumstances, section 504 require public entities to make

 reasonable accommodations for qualified individuals with

 disabilities.

¶2    A division of this court has considered this requirement of the

 ADA in the context of termination because an appropriate treatment

 plan could not be devised to address the parent’s mental

 impairment. See People in Interest of C.Z., 2015 COA 87, ¶ 1. But

 this case presents a different question under the ADA, which has

 not yet been addressed in Colorado — How does the requirement to

 make reasonable accommodations relate to termination based on a

 disabled parent’s lack of success with a treatment plan, unfitness,

 and unlikelihood of change? We conclude that a juvenile court

 must consider reasonable accommodations in deciding whether


                                   1
 such a parent’s treatment plan was appropriate and whether

 reasonable efforts were made to rehabilitate the parent.

¶3    Ultimately, we hold that the juvenile court properly considered

 reasonable accommodations for the parents’ disabilities as part of

 its conclusions that the parents’ treatment plans were appropriate

 and the Gunnison County Department of Health and Human

 Services (Department) had made reasonable efforts to rehabilitate

 them. These conclusions are supported by the record. We also

 reject the parents’ remaining arguments regarding parental fitness,

 likelihood of change, and a less drastic alternative to termination.

 Therefore, we affirm the termination judgment.

                   I. The Dependency and Neglect Case

¶4    In June 2016, the Department began receiving reports that the

 child, then less than three months old, was not gaining weight and

 the parents were not feeding her often enough. Later that month,

 the child was admitted to a local hospital for failure to thrive. The

 next day, the child was transferred to Children’s Hospital because

 she had lost more weight even while being fed every two hours by

 hospital staff.




                                    2
¶5     The medical team at Children’s Hospital believed that the

 child’s failure to thrive was a combination of organic and inorganic

 reasons. During the child’s stay, the medical team observed that

 the parents

     • continued to feed the child only two to three times a day;

     • did not spend the night with the child;

     • missed the child’s occupational therapy appointment;

     • placed unsafe items in the child’s crib; and

     • seemed to have difficulty retaining information regarding the

       child’s care.

 Based on these concerns, the Department initiated a dependency

 and neglect case and took custody of the child.

¶6     The parents both stipulated that the child was dependent and

 neglected because she was without proper care through no fault of

 their own. In August 2016, the juvenile court adopted treatment

 plans that required each parent to (1) consistently attend visits with

 the child; (2) meet with an in-home parenting support provider and

 learn skills to safely care for the child; (3) sign releases of

 information; (4) meet the child’s needs and provide her with an

 appropriate living environment; and (5) complete recommended

                                     3
 assessments, including neuropsychological and capacity to parent

 evaluations, to determine appropriate services.

¶7    The parents completed the capacity to parent and

 neuropsychological evaluations in the fall of 2016. An

 administrative review division, an outside entity that reviewed the

 Department’s work, advised the caseworker to rewrite the treatment

 plans to include recommendations from the evaluations.

¶8    In late May 2017, the Department moved to amend the

 treatment plans to include more specific language regarding the

 plans’ requirements. The proposed amendments included

 requirements for the parents to continue working with a parenting

 coach; comply with recommendations from the capacity to parent

 evaluator, including mental health treatment; and follow the

 recommendations of the neuropsychological evaluator, including

 therapy and inpatient substance abuse treatment for father and

 dialectical behavior therapy for mother. The Department also asked

 the court to appoint a guardian ad litem (GAL) for mother and

 father based on their mental illnesses or developmental disabilities.

¶9    A few weeks later, the juvenile court appointed a GAL for each

 parent and held an evidentiary hearing on the Department’s


                                   4
  proposal to amend the treatment plans. At the hearing, the parents

  argued that they were not opposed to having more specifics in the

  treatment plans, but that because the deadline to have permanency

  for the child was close and the Department had indicated it would

  be pursuing termination shortly, it was too late to amend the plans.

¶ 10   The child’s GAL also took the position that if the court was

  going to adopt the amended treatment plans, it would need to

  extend the permanency deadline. The Department responded that

  if amending the plans would require an extension of the

  permanency deadline, it would withdraw the request. In the end,

  the juvenile court denied the Department’s motion to amend the

  treatment plans and continued the existing plans in place.

¶ 11   The next month, the Department moved to terminate the legal

  relationships between the child and the parents. Before the start of

  the termination hearing, mother and father filed a joint motion

  asking the court to find that the Department had not made

  reasonable efforts to reunify them with the child, dismiss the

  termination motion, and amend the treatment plans to provide

  reasonable accommodations under the ADA. After a four-day




                                    5
  hearing, the court rejected the parents’ arguments, and in January

  2018, terminated their parental rights.

             II. Termination of Parental Rights and the ADA

¶ 12   Mother and father challenge the appropriateness of their

  treatment plans, the efforts that the Department made to reunify

  them with the child, and the extent of reasonable accommodations

  required under the ADA. Mother contends the juvenile court erred

  in concluding that her treatment plan was appropriate and the

  Department had made reasonable efforts to rehabilitate her in light

  of the ADA and section 504 of the Rehabilitation Act. Father

  contends the juvenile court erred in granting termination because

  the Department failed to make reasonable efforts to provide him

  with an appropriate treatment plan and reasonable

  accommodations under the ADA in creating and implementing his

  treatment plan. We reject these contentions.

                         A. Termination Criteria

¶ 13   As pertinent here, the juvenile court may terminate parental

  rights if it finds, by clear and convincing evidence, that (1) the child

  was adjudicated dependent and neglected; (2) the parent has not

  complied with an appropriate, court-approved treatment plan or the


                                     6
  plan has not been successful; (3) the parent is unfit; and (4) the

  parent’s conduct or condition is unlikely to change in a reasonable

  time. § 19-3-604(1)(c), C.R.S. 2018; People in Interest of C.H., 166

  P.3d 288, 289 (Colo. App. 2007).

¶ 14   The purpose of a treatment plan is to preserve the parent-child

  legal relationship by assisting the parent in overcoming the

  problems that required intervention into the family. People in

  Interest of K.B., 2016 COA 21, ¶ 11. Thus, an appropriate

  treatment plan is one that is approved by the court and is

  reasonably calculated to render the parent fit to provide adequate

  parenting to the child within a reasonable time and that relates to

  the child’s needs. § 19-1-103(10), C.R.S. 2018; People in Interest of

  M.M., 726 P.2d 1108, 1123 (Colo. 1986).

¶ 15   In determining parental unfitness and the likelihood that a

  parent’s conduct or condition will change, the court must consider

  whether reasonable efforts have been unable to rehabilitate the

  parent. § 19-3-604(2)(h); People in Interest of S.N-V., 300 P.3d 911,

  915 (Colo. App. 2011). “Reasonable efforts” means the “exercise of

  diligence and care” for a child who is in out-of-home placement.

  § 19-1-103(89).


                                     7
¶ 16   The reasonable efforts standard is satisfied when services are

  provided in accordance with section 19-3-208, C.R.S. 2018.

  § 19-1-103(89). Among other things, the Department must offer

  screening, assessments, and individual case plans; information and

  referrals to available public and private assistance resources; and

  visitation services. § 19-3-208(2)(b)(I), (III)-(IV). If funding is

  available, it must also provide mental health and substance abuse

  treatment services. § 19-3-208(2)(d)(IV)-(V).

                       B. The ADA and Section 504

¶ 17   Title II of the ADA, 42 U.S.C. §§ 12131-12134 (2018), prohibits

  a public entity from discriminating against a qualified individual

  with disabilities in the provision or operation of public services,

  programs, or activities. Tennessee v. Lane, 541 U.S. 509, 517

  (2004). Section 504 of the Rehabilitation Act applies the same

  requirement to entities that receive federal financial assistance.1

  See In re H.C., 187 A.3d 1254, 1265 (D.C. 2018). It provides that a

  qualified person with a disability shall not, “solely by reason of her

  or his disability, be excluded from the participation in, be denied


  1Although the juvenile court did not make a finding that the
  Department was a recipient, it has not argued otherwise on appeal.

                                       8
  the benefits of, or be subjected to discrimination under any

  program or activity receiving Federal financial assistance.” 29

  U.S.C. § 794(a).

¶ 18      The ADA was enacted not only to remedy discrimination in the

  form of intentional exclusion, but also to mandate reasonable

  modifications to existing policies and to otherwise reasonably

  accommodate individuals with disabilities. 42 U.S.C. § 12101(a)(5)

  (2018); C.Z., ¶ 12. Consequently, it imposes an affirmative duty on

  a public entity to make reasonable accommodations for qualified

  individuals with disabilities. 28 C.F.R. § 35.130(b)(7) (2018); C.Z.,

  ¶ 12.

                           C. Qualified Individual

¶ 19      Under the ADA, a qualified individual with a disability is an

               individual with a disability who, with or
               without reasonable modifications to rules,
               policies, or practices, the removal of
               architectural, communication, or
               transportation barriers, or the provision of
               auxiliary aids and services, meets the essential
               eligibility requirements for the receipt of
               services or the participation in programs or
               activities provided by a public entity.

  42 U.S.C. § 12131(2) (2018).




                                       9
¶ 20   A disability includes a mental impairment that substantially

  limits one or more major life activities of the individual. 42 U.S.C.

  § 12102(1)(A) (2018). A mental impairment, in turn, includes any

  mental or psychological disorder such as “intellectual disability,

  organic brain syndrome, emotional or mental illness, and a specific

  learning disability.” 28 C.F.R. § 35.108(b)(1)(ii) (2018).

¶ 21   Whether a parent is a qualified individual with a disability

  under the ADA requires a case-by-case determination. 2 See Colo.

  State Bd. of Dental Exam’rs v. Major, 996 P.2d 246, 249 (Colo. App.

  1999). While the Department must provide appropriate screening

  and assessments of a parent, the parent is responsible for

  disclosing to the Department and the juvenile court information

  regarding his or her mental impairment or other disability. And the

  parent should also identify any modifications that he or she believes

  are necessary to accommodate the disability.

¶ 22   The Department can accommodate, and the juvenile court can

  address, only disabilities that are known to them. See In re

  Hicks/Brown, 893 N.W.2d 637, 640 (Mich. 2017). In other words,


  2  If disability status is disputed, the juvenile court should make a
  finding.

                                     10
  before a public entity can be required under the ADA to provide

  reasonable accommodations, the entity must know that the

  individual is disabled, either because that disability is obvious or

  more likely because that individual, or someone else, has informed

  the entity of the disability. Id. (citing Robertson v. Las Animas Cty.

  Sheriff’s Dep’t, 500 F.3d 1185, 1196 (10th Cir. 2007)).

¶ 23   In this case, as the juvenile court recognized in its termination

  order, and the Department did not dispute, each parent has serious

  intellectual or developmental disabilities. Mother’s

  neuropsychological evaluation showed that she had a low average

  intelligence quotient (IQ) and a neurodevelopmental or

  neurocognitive disorder characterized by difficulties with complex

  attention and language. She also had an unspecified personality

  disorder with borderline traits. The neuropsychological evaluator

  diagnosed father with borderline intellectual functioning based on

  his IQ and possible symptoms of a premorbid anxiety disorder.

¶ 24   The juvenile court concluded that the parents’ low IQs and

  developmental disabilities severely limited their ability to provide

  appropriate care for the child. And it had previously appointed a

  GAL for mother and father based on each parent’s mental illness or


                                    11
  developmental disability. Under these circumstances, the parents’

  mental impairments were disabilities under the ADA. See C.Z., ¶ 14

  (concluding that borderline intellectual functioning and mental

  illness diagnoses that impeded the parents’ ability to parent the

  child were disabilities under the ADA).

       D. ADA’s Application to Treatment Plans and Reasonable Efforts

¶ 25      As past divisions of this court have recognized, the ADA does

  not restrict a juvenile court’s authority to terminate parental rights

  when the parent, even after reasonable accommodation of a

  disability, is unable to meet his or her child’s needs. Id. at ¶ 17;

  see also People in Interest of T.B., 12 P.3d 1221, 1223 (Colo. App.

  2000). But, while Title II of the ADA is not a defense to termination

  of parental rights, it applies to the provision of assessments,

  treatment, and other services that the Department makes available

  to parents through a dependency and neglect proceeding before

  termination. C.Z., ¶¶ 19, 22.

¶ 26      Courts in other jurisdictions have also determined that the

  requirement to make reasonable accommodations for a parent’s

  disability affects the scope of rehabilitative services offered to the

  parent.


                                     12
¶ 27   For example, the Alaska Supreme Court has recognized that

  family reunification services should be provided in a manner that

  takes a parent’s disability into account. Lucy J. v. State, Dep’t of

  Health & Soc. Servs., 244 P.3d 1099, 1115 (Alaska 2010). And it

  concluded that reunification services are contemplated within Title

  II of the ADA. Id. at 1116. Thus, it reasoned, whether reunification

  services reasonably accommodated a parent’s disability is included

  in the question whether reasonable efforts were made to reunite the

  family. Id.

¶ 28   Similarly, the Massachusetts Supreme Judicial Court

  determined that the ADA requires a department to accommodate

  the parent’s special needs in providing services before a termination

  proceeding. In re Adoption of Gregory, 747 N.E.2d 120, 125-26

  (Mass. 2001). And the Michigan Court of Appeals held that

  reunification services must comply with the ADA. In re Terry, 610

  N.W.2d 563, 570 (Mich. Ct. App. 2000).

¶ 29   The District of Columbia Court of Appeals also expressed its

  agreement with the numerous other courts that have held or

  assumed that the ADA’s requirement for public agencies to make

  reasonable accommodations applies to reunification services


                                    13
  provided by states to parents whose children have been removed in

  neglect proceedings. H.C., 187 A.3d at 1265. It explained that the

  requirement of reasonable accommodations was entirely consistent

  with, and perhaps subsumed within, an agency’s general statutory

  obligation to expend reasonable efforts to make reunification

  possible. Id.

¶ 30   The United States Departments of Health and Human Services

  and Justice have also provided guidance on this subject. See U.S.

  Dep’t of Health & Human Servs. & U.S. Dep’t of Justice, Protecting

  the Rights of Parents and Prospective Parents with Disabilities:

  Technical Assistance for State and Local Child Welfare Agencies and

  Courts under Title II of the Americans with Disabilities Act and

  Section 504 of the Rehabilitation Act (Aug. 2015),

  https://perma.cc/AHU2-P29Y (Technical Assistance Document).

  They explain that individuals with disabilities must be provided

  opportunities to benefit from or participate in child welfare

  programs, services, and activities that are equal to those extended

  to individuals without disabilities. Id. And, to achieve that goal,

  agencies must make reasonable changes in their practices and

  services to accommodate the individual needs of a disabled parent.


                                    14
  Id. The requirement to make reasonable accommodations extends

  to programs and activities of private and nonprofit agencies that

  provide services to children and families on behalf of a child welfare

  agency. Id. 3

¶ 31   Consistent with these federal guidelines, section

  19-3-100.5(5), C.R.S. 2018, provides, in turn, that reasonable

  efforts are satisfied when a Department offers services in

  accordance with section 19-3-208 and “when full consideration has

  been given to the provisions of section 24-34-805(2).” And section

  19-3-208(2)(g) requires that services provided under that section

  comply with the ADA and its implementing regulations.

¶ 32   Finally, section 19-3-507(1)(c), C.R.S. 2018, which governs

  dispositional hearings, provides that

             [i]f one or both of the parents have a disability,
             reasonable accommodations and
             modifications, as set forth in the federal

  3 In April 2018 — about three months after the court issued the
  termination judgment in this case — the General Assembly enacted
  legislation concerning family preservation safeguards for parents
  with disabilities. The legislation created section 24-34-805, C.R.S.
  2018. See Ch. 164, sec. 1, § 24-34-805, 2018 Colo. Sess. Laws
  1131. Section 24-34-805(2)(a)(III) states that a parent’s disability
  alone must not serve as a basis for denial or restriction of parenting
  time or parental responsibilities in a dependency and neglect
  proceeding except when it impacts the child’s health or welfare.

                                     15
             “Americans with Disabilities Act of 1990”, 42
             U.S.C. sec. 12101 et seq., and its related
             amendments and implementing regulations,
             are necessary to ensure the treatment plan
             components are accessible. If applicable, any
             identified accommodations and modifications
             must be listed in the report prepared for the
             dispositional hearing.

¶ 33   In sum, absent reasonable modifications to the treatment plan

  and rehabilitative services offered to a disabled parent, a

  department has failed to perform its duty under the ADA to

  reasonably accommodate a disability and, in turn, its obligation to

  make reasonable efforts to rehabilitate the parent. See

  Hicks/Brown, 893 N.W.2d at 640. And because of this failure, an

  unmodified plan or rehabilitative service does not satisfy the criteria

  for terminating parental rights under section 19-3-604(1)(c). See

  S.N-V., 300 P.3d at 915; see also People in Interest of D.G., 140 P.3d

  299, 304 (Colo. App. 2006) (concluding that the juvenile court erred

  in finding that the Department had provided appropriate

  rehabilitative services to a parent and, thus, in terminating parental

  rights).

¶ 34   For these reasons, when a parent involved in a dependency

  and neglect proceeding has a disability under the ADA, the



                                    16
  Department and the juvenile court must account for and, if

  possible, make reasonable accommodations for the parent’s

  disability when devising a treatment plan and providing

  rehabilitative services to the parent. And in deciding whether to

  terminate parental rights under section 19-3-604(1)(c), a juvenile

  court should consider whether reasonable accommodations were

  made for the parent’s disability in determining whether the parent’s

  treatment plan was appropriate and reasonable efforts were made

  to rehabilitate the parent.

¶ 35   What constitutes a reasonable accommodation will be based

  on an individual assessment. C.Z., ¶ 25. 4 For example, the

  Technical Assistance Document explains that many parents, with

  or without disabilities, may require training to develop appropriate

  parenting skills. When, as here, a parent has a cognitive or other

  mental disability and needs help acquiring parenting skills, child

  welfare agencies may need to provide “enhanced or supplemental

  training, to increase frequency of training opportunities, or to

  provide such training in familiar environments conducive to


  4 The juvenile court should also make a finding whether reasonable
  accommodation has occurred.

                                    17
  learning” and “incorporate the use of visual modeling or other

  individualized techniques to ensure equal opportunity to participate

  in and benefit from the training.” Technical Assistance Document

  10, 15. Technical Assistance Document 5; see also H.C., 187 A.3d

  at 1266.

¶ 36   Even so, in considering whether reasonable accommodations

  can be made for a parent’s disability, the juvenile court’s

  paramount concern must remain the child’s health and safety.

  C.Z., ¶ 32. In other words, the ADA does not protect a parent who,

  even by virtue of his or her disability, poses a safety risk to others.

  Id. Nor does the requirement to make reasonable accommodations

  lower the standards for parents with disabilities. Technical

  Assistance Document 5.

¶ 37   Of course, the juvenile court’s assessment of what constitutes

  a reasonable accommodation must take into account the child’s

  best interests and need for permanency. See State in Interest of

  K.C., 362 P.3d 1248, 1253 (Utah 2015). For example, the

  requirement to make reasonable accommodations under the ADA

  does not force the court indefinitely to extend the time that a parent

  is given to participate in rehabilitative services. Id. (recognizing that


                                     18
  the ADA does not afford a parent the right to extend a reunification

  plan indefinitely).

¶ 38   As well, the duty to make reasonable accommodations does

  not require a public entity to make modifications that would

  fundamentally alter the nature of its services, programs, or

  activities. C.Z., ¶ 25; see also 28 C.F.R. § 35.130(b)(7). Rather, the

  ADA requires only accommodations that are reasonable. K.C., 362

  P.3d at 1253; see also Pruett v. Arizona, 606 F. Supp. 2d 1065,

  1079 (D. Ariz. 2009). A modification is reasonable if it is used

  ordinarily or in the run of cases and will not cause undue hardship.

  See Nat’l Fed’n of the Blind v. Lamone, 813 F.3d 494, 507 (4th Cir.

  2016). Thus, for example, an accommodation may not be

  reasonable if it would require a prohibitive cost or extraordinary

  effort on the part of the public entity. Id.

¶ 39   In the end, what constitutes a reasonable accommodation will

  vary from case to case based on the child’s health and safety needs,

  the nature of the parent’s disability, and the available resources.

¶ 40   Having reached this conclusion, we must next determine

  whether the juvenile court properly determined that the Department




                                     19
  had made reasonable accommodations for mother’s and father’s

  disabilities.

                  E. Standard of Review and Application

¶ 41   Whether a juvenile court properly terminated parental rights

  presents a mixed question of fact and law because it involves

  application of the termination statute to evidentiary facts. People in

  Interest of L.M., 2018 COA 57M, ¶ 17 (citing People in Interest of S.N.

  v. S.N., 2014 CO 64, ¶ 21). The credibility of the witnesses; the

  sufficiency, probative value, and weight of the evidence; and the

  inferences and conclusions to be drawn from these evidentiary facts

  are within the juvenile court’s discretion. People in Interest of

  A.J.L., 243 P.3d 244, 250 (Colo. 2010). Hence, we will not set aside

  a juvenile court’s factual findings when they have support in the

  record. Id. at 249-50. However, when deciding mixed questions of

  fact and law, we review the legal conclusions de novo. L.M., ¶ 17.

                   1. The Juvenile Court’s Conclusions

¶ 42   The juvenile court considered the many services offered to the

  parents and concluded that the Department had provided services,

  including parenting instruction, that reasonably accommodated the

  parents’ limitations. It also determined that the parents’ treatment


                                    20
  plans were appropriate and that the Department had made

  reasonable efforts to rehabilitate the parents.

                    2. The Parents’ Treatment Plans

¶ 43   Mother first argues that the juvenile court erred in finding that

  her plan was appropriate because it did not include a requirement

  that she attend training to learn how to meet the child’s heightened

  medical needs. The record shows that the child had heightened

  needs. In the beginning of the case, the child was diagnosed with a

  variety of medical conditions, including failure to thrive as an

  infant, severe protein calorie malnutrition, gastroesophageal reflux,

  umbilical granuloma (a lesion), anisocoria, tongue tie (which could

  make feeding and weight gain difficult), passive smoke exposure,

  and a high-risk social situation.

¶ 44   Although the child’s conditions had improved, her pediatrician

  continued to characterize her as a medically complicated child. He

  explained that the child had multiple medical conditions, including

  abnormal eye movement (nystagmus), a developmental delay, delay

  in growth, and the possibility of a serious metabolic disorder.

¶ 45   While mother’s treatment plan did not specifically require her

  to attend medical training for the child, it did include a provision


                                      21
  that required her to be able to safely care for the child by working

  with an in-home parenting support provider. This provision

  effectively required mother to participate in a service that would

  prepare her to care for the child’s needs.

¶ 46   Next, mother argues that her treatment plan was

  inappropriate because it did not require her to engage in couples

  counseling with father. Mother correctly notes that several

  witnesses identified concerns about bickering between the parents

  during visits. Both the court-appointed special advocate (CASA)

  assigned to the case and a separate CASA who intermittently

  supervised visits described such behavior. The child’s occupational

  therapist likewise reported that the parents bantered, which she

  characterized as more explosive than arguing, during her sessions.

¶ 47   True, the parents’ expert recommended that they participate in

  individual and couples therapy geared for adults with learning and

  mental health needs. However, this recommendation came about

  as a result of mother’s evaluation that was conducted the same

  month of the termination hearing.

¶ 48   In contrast, the professionals who evaluated the parents

  earlier in the case believed that mother should engage in


                                    22
  therapeutic services. And the record does not show that they or the

  other treatment professionals working with the parents

  recommended couples counseling. As a result, mother’s argument

  that the treatment plan was inappropriate because it did not

  include a requirement that she engage in couples counseling with

  father falls short. See People in Interest of A.E., 749 P.2d 450, 452

  (Colo. App. 1987) (recognizing that the appropriateness of a

  treatment plan’s requirements must be assessed in light of the

  realities extant at the time of its adoption).

¶ 49   Finally, mother asserts that the treatment plan was

  inappropriate because it did not include accommodations for her

  intellectual disability and was not amended to include

  individualized treatment after the Department learned of her

  diagnoses from the neuropsychological evaluator. However,

  because mother fails to identify what accommodations or

  individualized treatment should have been incorporated into the

  plan, we are unable to consider this assertion.

¶ 50   Father asserts that his treatment plan was inappropriate

  because it did not account for his disabilities. But, like mother in

  her final assertion, he does not identify what additional components


                                     23
  or accommodations should have been included in the plan. As a

  result, we are also unable to consider father’s argument.

¶ 51   For these reasons, we discern no error in the juvenile court’s

  determination that the parents’ treatment plans were appropriate.

   3. Reasonable Efforts and the Provision of Rehabilitative Services

¶ 52   We first address mother’s and father’s assertion that the

  Department did not make efforts to implement the

  recommendations contained in their capacity to parent and

  neuropsychological evaluations. Then we conclude that the record

  does not support this assertion.

¶ 53   The therapist who completed the capacity to parent evaluation

  recommended that mother and father engage in therapeutic

  services to treat their mental health issues. Specifically, she

  believed that mother needed to address her childhood experiences

  and depression, disordered personality, relationship issues, and

  poor social skills. The therapist believed that father’s therapy

  should focus on his childhood experiences, feelings of emotional

  distress, symptoms of anxiety, and sleep disturbances, as well as

  other feelings regarding losing control and feeling misunderstood.

  The psychologist who completed the neuropsychological evaluations


                                     24
  believed that mother would benefit from dialectical behavior therapy

  to treat her personality disorder because it would fit within the

  limits of her neurocognitive deficits.

¶ 54   The record shows that both parents received mental health

  services. Mother completed a mental health assessment and began

  seeing a therapist sometime in 2016. The caseworker also tried to

  coordinate dialectical behavior therapy for mother after receiving

  the neuropsychological evaluation. However, mother missed the

  first module that was necessary to start treatment and was unable

  to participate in the program. Father participated in individual

  therapy during the case.

¶ 55   In addition to therapeutic services, the psychologist opined

  that mother’s deficits in complex attention and language warranted

  accommodations. He recommended that her neurocognitive

  disorder be accommodated by giving her additional time to complete

  tasks, making sure that she was able to explain a concept in her

  own words, communicating with her in a written format, and giving

  repeated instructions.

¶ 56   Many of these accommodations were made during the

  parenting instruction and coaching provided to the parents. For


                                     25
  example, the child’s occupational therapist began working with the

  parents in May 2017 — first for one hour each week and then two

  hours each week. During each session, the occupational therapist

  tried to mimic a home environment and worked on skills such as

  feeding; play that incorporated motor, perceptual, and cognition

  skills for the child; and a pre-nap routine. The occupational

  therapist explained that she assessed whether skills or information

  needed to be repeated for the parents.

¶ 57   The occupational therapist also tried different methods for

  helping the parents learn developmental skills for the child,

  including giving them a “help chart” that broke down each month of

  a child’s development; modeling the task that she wanted them to

  do or the behavior (such as cruising) that she wanted to see from

  the child; and giving direct feedback when the parents got

  something right.

¶ 58   Besides working with the child’s occupational therapist, the

  parents also received between two to four hours of parent coaching

  each week beginning in March 2017. The parenting coach

  explained that she tried different styles of teaching, including

  offering instructions or recommendations as well as role modeling


                                    26
  how to handle the situation. She would also give the parents

  handouts with information they could take home, read, and return

  with a sheet that they had filled out based on the information that

  they read.

¶ 59   Additionally, the CASA assigned to the case testified that while

  she was not allowed to coach the parents during visits, she would

  ask follow-up questions to see if they understood the information

  that was given to them during visits with the child.

¶ 60   The psychologist explained that father, who had an extensive

  drug history which included daily methamphetamine use for six to

  seven years, was taking a large dose of prescribed Xanax and had

  possibly migrated from one substance to another. Thus, he

  recommended that father participate in an inpatient substance

  abuse program. The psychologist also recommended that father

  receive coordination of care between his mental health therapist, a

  psychiatrist who was prescribing the Xanax, and his primary care

  physician.

¶ 61   Father resisted these recommendations. The caseworker

  testified that father refused her efforts to coordinate care between

  his mental health provider, his psychiatrist, and his primary care


                                    27
  physician. And he would not agree to participate in inpatient

  treatment. The caseworker further explained that the Center for

  Mental Health controlled the Department’s funding for inpatient

  treatment and would not provide it unless one of their treatment

  providers supported the recommendation. Father’s psychiatrist was

  one of the center’s treatment providers and did not support the

  recommendation.

¶ 62   The parents’ arguments that the Department offered limited

  and delayed visitation services and parenting education fare no

  better. True, the parents were only able to start parenting classes

  offered through CASA in the month before the termination hearing.

  Still, supervised visitation services and, later, hands-on parenting

  instruction were offered throughout the case.

¶ 63   Visitation services began at the Department in July 2016.

  During these initial visits, the caseworker provided direction —

  verbal instructions as well as demonstrations — when the parents

  appeared to have a deficit in their understanding of the child’s

  needs. In early September 2016, visits moved to a CASA office; the

  next month, visits moved to a different CASA office that was closer

  to the child’s placement. The CASA who supervised visits from


                                    28
  October 2016 through February 2017 and then again in July 2017

  testified that she provided feedback to the parents during visits.

  She also knew that the parents had been given a schedule of the

  child’s routine.

¶ 64   The Department initially arranged for the parents to have a

  one-hour visit twice each week, but later increased the schedule to

  two four-hour visits each week. The caseworker also arranged for

  the parents to be present for a surgical procedure for the child that

  involved a muscle biopsy, EEG, and MRI. Because the procedure

  occurred in Denver, she gave the parents money for gas and food,

  rented the parents a hotel room, and supervised them while they

  spent time with the child both pre- and post-operation.

¶ 65   Recall, the parents received several hours of parent coaching

  and occupational therapy sessions with the child each week. True,

  parent coaching was implemented about seven months after the

  court adopted the treatment plan and the occupational therapy

  sessions began two months later. Still, the parents had seven and

  five months, respectively, to engage in these weekly services before

  the termination hearing.




                                    29
¶ 66   The record also does not support the parents’ assertions that

  the professionals providing parenting education were unqualified to

  coach disabled parents and gave them conflicting information. The

  child’s occupational therapist had experience working with

  individuals with disabilities — she had done volunteer work with

  the Board for Developmental Disabilities, worked at a school for

  children with disabilities, and had previously worked with other

  parents who had developmental disabilities to teach them the skills

  for managing their child’s care.

¶ 67   Although the occupational therapist had not reviewed the

  parents’ evaluations, the caseworker did tell her about some of the

  evaluators’ recommendations. Additionally, the occupational

  therapist explained that it became apparent to her that modeling

  behaviors and calling out interaction styles to the parents, as well

  as giving more education about the child’s developmental level,

  would be helpful. She did both.

¶ 68   The parenting coach conceded that this was the first time she

  had worked with parents who had intellectual deficits or delays.

  However, the caseworker asked the parenting coach to make




                                     30
  accommodations for the parents such as demonstrating how to

  properly feed the child. And the parenting coach did so.

¶ 69   The caseworker agreed that the occupational therapist and the

  parenting coach had different approaches to working with the

  parents. She noted that the occupational therapist used hands-on

  demonstration, while the parenting coach would step back, observe,

  and then integrate instruction and demonstration. And, as the

  juvenile court recognized, these providers may have given mixed

  messages about whether to use a bottle or sippy cup with the child.

  Yet, as the court concluded, the record does not show that these

  providers otherwise gave conflicting instructions to the parents.

¶ 70   Mother further argues that the Department did not make

  reasonable accommodations because it only sought to amend the

  treatment plan and implement the recommendations from her

  neuropsychological evaluation after it had decided to pursue

  termination. The caseworker admitted that she had discussed an

  adoptive home for the child in November 2016. She also

  acknowledged that the Department had decided to pursue

  termination of parental rights as early as January 2017. However,

  the caseworker clarified that the Department did not file for


                                   31
  termination for another six months because she found the

  parenting coach and wanted her opinion. And as the juvenile court

  concluded, the record did not suggest that the Department had

  withdrawn services or reduced visits based on its earlier

  consideration of termination.

¶ 71   Finally, we note that father asserts that the Department failed

  to provide him with adequate assessments, treatment, and other

  relevant services to enable him to meet the child’s basic needs. Yet,

  he does not explain why the assessments that the Department

  provided — the capacity to parent and neuropsychological

  evaluations — were insufficient or identify other assessments that

  were needed. And apart from his arguments that have already been

  addressed, he does not identify other treatment or services that

  would have accommodated his disability and enabled him to parent

  the child.

¶ 72   For these reasons, the juvenile court properly concluded that

  the Department made reasonable efforts to rehabilitate the parents

  and provided services that reasonably accommodated the parents’

  disabilities. Thus, we will not disturb its conclusion on appeal.




                                   32
             III. Parental Fitness and Likelihood of Change

¶ 73   Mother contends the juvenile court erred in finding that she

  was an unfit parent and her conduct or condition was unlikely to

  change in a reasonable time. The record shows otherwise.

¶ 74   An unfit parent is one whose conduct or condition renders him

  or her unable or unwilling to give a child reasonable parental care.

  People in Interest of D.P., 160 P.3d 351, 353 (Colo. App. 2007).

  Reasonable parental care requires, at a minimum, that the parent

  provide nurturing and safe parenting sufficiently adequate to meet

  the child’s physical, emotional, and mental health needs. People in

  Interest of A.J., 143 P.3d 1143, 1152 (Colo. App. 2006).

¶ 75   In determining whether a parent can become fit within a

  reasonable time, the court may consider whether the parent made

  any changes during the dependency and neglect proceeding, the

  parent’s social history, and the chronic or long-term nature of the

  parent’s conduct or condition. D.P., 160 P.3d at 353. A reasonable

  time is not indefinite and must be determined by considering the

  child’s conditions and needs. A.J., 143 P.3d at 1152.

¶ 76   As mother points out, the occupational therapist agreed that

  mother had shown improvements in some of the daily routines with


                                    33
  the child. The parents’ expert witness also observed that mother

  showed significant changes between her evaluation by another

  expert a year earlier and the expert’s parent-child interactional

  evaluation in October 2017.

¶ 77   Despite this progress, the parents’ expert did not believe that

  the child could safely be reunited with the parents. The caseworker

  also agreed that mother had tried during the case, but still believed

  that mother had not been able to develop a parenting relationship

  with the child and continued to struggle with empathy for others.

  Both the caseworker and the CASA who supervised visits described

  mother treating the child like she was a doll. The caseworker

  elaborated that while mother loved the child, she was unable to

  keep her safe, nourish her, and provide her with appropriate

  stimulation.

¶ 78   Similarly, the parenting coach opined that mother could not

  safely parent the child. She expressed concern that mother would

  not be able to keep up with the child’s growth and development

  because it would take too long for mother to learn information and

  consistently implement it and, by that time, the child’s needs would

  change.


                                    34
¶ 79   During the pendency of the case, mother received a deferred

  criminal sentence for child abuse involving bodily injury to another

  child. Father had also told the parents’ expert that he had

  concerns about the child returning to his home because mother

  could be short-tempered and impatient. The psychologist who

  evaluated mother expounded that the traits of mother’s borderline

  personality disorder included a tendency to impulsively get very

  angry and to have unstable and intense interpersonal relationships.

¶ 80   Mother asserts that the record shows that she could become a

  fit parent in a reasonable time with coaching geared towards

  individuals with disabilities. The parents’ expert believed that the

  parents could be successfully reunited with the child if they

  received additional services. However, the expert estimated that the

  treatment would take a minimum of six additional months.

¶ 81   In contrast, the caseworker opined that the child needed a

  permanent home. Because the child was under the age of six when

  the petition was filed, the expedited permanency planning

  provisions applied and required that she be placed in a permanent

  home within twelve months of her initial out-of-home placement.

  §§ 19-1-102(1.6), 19-1-123, 19-3-703, C.R.S. 2018; People in


                                    35
  Interest of M.T., 121 P.3d 309, 313 (Colo. App. 2005). And the

  psychologist who evaluated mother opined that mother’s personality

  disorder was a longstanding pattern of personality characteristics

  and dysfunction that were unlikely to change over time.

¶ 82   Given this record, we discern no error in the juvenile court’s

  conclusions that mother was an unfit parent and her conduct or

  condition was unlikely to change in a reasonable time.

               IV. Less Drastic Alternative to Termination

¶ 83   Finally, father contends placing the child with the paternal

  grandmother was a viable less drastic alternative to termination.

  Again, the record does not support him.

¶ 84   When considering termination under section 19-3-604(1)(c),

  the court must also consider and eliminate less drastic alternatives

  to termination. M.M., 726 P.2d at 1122. This determination is

  implicit in, and thus intertwined with, the statutory criteria for

  termination. Id. at 1122-23. As a result, the determination is

  influenced by the parent’s fitness to meet his or her child’s needs.

  People in Interest of A.R., 2012 COA 195M, ¶ 38.

¶ 85   But the juvenile court must give primary consideration to the

  child’s physical, mental, and emotional conditions and needs when


                                    36
  considering less drastic alternatives to termination. § 19-3-604(3);

  D.P., 160 P.3d at 356. Thus, placement with a grandparent is not a

  viable alternative to termination if the grandparent lacks

  appreciation of the parent’s problems or of the child’s conditions or

  needs. People in Interest of D.B-J., 89 P.3d 530, 531 (Colo. App.

  2004).

¶ 86   The record shows that an out-of-state home study of the

  paternal grandmother resulted in her being denied for placement of

  the child. The grandmother had a medical condition that would not

  allow her to care for the child without assistance and she wanted

  either father or both of the parents to help her care for the child.

  However, father was unable to adequately feed the child,

  understand her cues, or attend to her needs. And, as previously

  discussed, mother was also unable to meet the child’s needs.

¶ 87   For these reasons, the record supports the juvenile court’s

  determination that there was no less drastic alternative to

  termination and we will not disturb it on appeal.

                              V. Conclusion

¶ 88   The judgment is affirmed.

       JUDGE ROMÁN and JUDGE FREYRE concur.


                                    37
