                               NUMBER 13-18-00457-CV

                                   COURT OF APPEALS

                       THIRTEENTH DISTRICT OF TEXAS

                          CORPUS CHRISTI - EDINBURG


                        IN THE INTEREST OF A.B.V., A CHILD


                       On appeal from the 267th District Court
                             of Victoria County, Texas.


                               MEMORANDUM OPINION

        Before Justices Benavides, Longoria, and Hinojosa
            Memorandum Opinion by Justice Hinojosa

        Appellee the Texas Department of Family and Protective Services (the

Department) filed a petition to terminate the parental rights of appellant A.N.V. 1 (Mother)

to her child A.B.V.        After a jury trial, the trial court rendered judgment terminating

Mother’s parental rights. By two issues, Mother argues that: (1) the evidence is legally




        1  In appeals involving the termination of parental rights, the Texas Rules of Appellate Procedure
require the use of an alias to refer to a minor. TEX. R. APP. P. 9.8. We may also use an alias “to [refer
to] the minor’s parent or other family member” to protect the minor’s identity. Id.
and factually insufficient to demonstrate grounds for termination; and (2) she received

ineffective assistance of counsel. We affirm.

                                 I.     BACKGROUND

A.     A.B.V. Experiences Health Issues

       Mother is a registered nurse with three children, the youngest of whom is A.B.V.

A.B.V. was born on August 4, 2016 and developed normally for the first months of her

life. In December, Mother brought A.B.V. to the doctor to treat a cough and an ear

infection. While there, A.B.V. was accidentally administered an HPV vaccine intended

for her older brother.

       Months later, A.B.V.’s condition declined, and on February 16, 2017, she was

admitted to Texas Children’s Hospital (TCH). A.B.V. was underweight and suffering from

hyponatremia, a potentially fatal condition evidenced by dangerously low sodium levels.

Despite extensive testing, doctors could not determine what was causing A.B.V.’s

condition.   Doctors gave A.B.V. a saline IV and a feeding tube, and her condition

improved. She was discharged five days later. In early March, A.B.V.’s primary care

physician removed the feeding tube.

       On March 17, Mother brought A.B.V. to Citizen’s Medical Center.           A.B.V.

remained underweight, and she again had dangerously low sodium levels.             After

admission, her condition stabilized and her sodium levels improved, though doctors could

not reach any definitive diagnosis. A.B.V. was discharged on March 22.

       On April 21, Mother again took A.B.V. to TCH. A.B.V. once more presented as

malnourished, underweight, and having dangerously low sodium levels.          Extensive

testing revealed no underlying medical cause for A.B.V.’s problems.
                                           2
B.    Department Intervention

      During the April hospitalization, doctors notified the Department that they

suspected Mother was either intentionally depriving A.B.V. of necessary nutrients or

giving her diuretics. On May 2, the Department intervened and separated Mother from

A.B.V., with Mother having only supervised visitation. A.B.V.’s condition improved, and

she was discharged on May 18 to foster care placement. The Department placed A.B.V.

with her maternal grandmother on June 6.

      On June 30, A.B.V.’s blood tests revealed her sodium level was 130, just below

the normal range of 135 to 145. Then, on July 2, A.B.V. had a supervised visitation with

Mother. The next day, A.B.V. became critically ill, and she was life-flighted to TCH.

Doctors found her to once again have dangerously low sodium levels. Once again,

A.B.V.’s condition improved while hospitalized.

      A.B.V. was discharged to foster care on July 20, and Mother’s supervised

visitations were discontinued. From that point, A.B.V. steadily gained weight, and her

previous problems with dangerously low blood sodium have not since recurred. In April

of 2018, A.B.V. was placed with her paternal grandparents, and she remains in good

health. The Department’s petition to terminate parental rights was tried to a jury in June

of 2018.

C.    Doctor Testimony

      1.     Dr. Paul

      David Leo Paul, M.D., a pediatric endocrinologist at TCH, consulted on A.B.V.’s

care during her second hospitalization in April of 2017. Dr. Paul evaluated A.B.V. for


                                            3
severely low sodium levels.        He explained that the condition, referred to as

hyponatremia, results in excessive water in the body relative to sodium. If left untreated,

a patient with hyponatremia could suffer a cerebral edema, a potentially lethal injury. Dr.

Paul observed nothing in A.B.V.’s medical history that would suggest a reason for A.B.V.’s

condition.

       Dr. Paul opined that A.B.V. was not receiving proper nutrition such as formula or

breast milk. Instead, he believed that A.B.V. was receiving low sodium fluid such as

water, diluted milk, or diluted juice. Dr. Paul determined that A.B.V.’s condition was

chronic, meaning that A.B.V. had not been receiving adequate nutrition for days if not

weeks. Dr. Paul learned that A.B.V. was accidentally administered the HPV vaccination,

but he was unaware of any reported instance of an HPV vaccination causing

hyponatremia.

       Dr. Paul stated that Mother reported difficulties with breastfeeding and bottle

feeding during previous hospitalizations. He also noted that Mother did not agree with

suggestions that she bottle feed A.B.V. while in the hospital. He stated that after Mother

was removed from the hospital, A.B.V. had no issues with bottle feeding, and her

condition improved.

       2.     Dr. Isaac

       Reena Isaac, M.D., is a pediatrician with TCH’s child protection medical team.

A.B.V.’s primary care team asked Dr. Isaac to evaluate whether A.B.V. was a victim of

medical child abuse. Dr. Isaac noted concerns with Mother’s resistance to medical

recommendations. In particular, Mother did not cooperate with efforts to quantify how


                                            4
much fluid A.B.V. was receiving from bottle feeding. Mother also did not cooperate with

the lactation consultant’s efforts to determine how much breast milk Mother was

producing.

        Dr. Isaac stated that Mother persistently referenced the administration of the HPV

vaccine to medical staff as having caused A.B.V.’s condition. According to Dr. Isaac, the

Center for Disease Control reports that common adverse events associated with the HPV

vaccine include fever, headache, and other mild reactions, which tend to disappear after

several days. Dr. Isaac stated that no adverse events were reported in 75% of the

eighty-eight reports of infants receiving an accidental HPV vaccine—the remaining events

constituted non-serious adverse reactions such as fever, vomiting, and diarrhea. 2

        Regarding the removal of A.B.V.’s feeding tube in March of 2017, Dr. Isaac learned

that Mother told A.B.V.’s primary care physician that the removal was recommended by

doctors at the hospital; conversely, Mother told doctors at the hospital that the removal

was recommended by A.B.V.’s primary care physician.

        Dr. Isaac recommended a trial separation so that the medical team could

adequately assess A.B.V.’s capacity to feed. Dr. Isaac stated that, after Mother was

removed from the hospital, “we were able to see that the baby took the bottle beautifully,

gained weight very quickly and actually began to thrive.”

        Dr. Isaac commented on A.B.V.’s readmission following placement with the

maternal grandmother:

        During that time, again, our understanding is that the maternal grandmother
        had the baby that month but mom was still in the vicinity, close vicinity of

        2 Dr. Isaac relied on reports made to the “Vaccine Adverse Event Reporting System,” which allows
physicians and caretakers to report adverse reactions to vaccinations.
                                                   5
      the maternal grandmother. At one point our reports were that she lived
      very nearby, if not next door. And—and the concern is that she continued
      to have some sort of maternal influence on [the care of A.B.V.]

Based on her observations, Dr. Isaac concluded that A.B.V. was a victim of medical child

abuse.

      3.     Dr. Lukefahr

      James Lukefahr, M.D., a child abuse pediatrician with the University of Texas

Medical School in San Antonio, reviewed A.B.V.’s medical records at the Department’s

request. Dr. Lukefahr described A.B.V.’s condition as a “failure to thrive” and “multiple

episodes where her serum sodium level dropped to dangerous levels.” Dr. Lukefahr

suspected that A.B.V.’s condition was caused by the administration of excessive amounts

of water and not enough protein or other nutrients. He explained that “the pattern was

repeatedly demonstrated to the point that there’s no question that these conditions or

these problems only occurred when [Mother] was around.”           He further explained,

“whenever [A.B.V.] was not in [Mother or maternal grandmother’s] care she gained weight

very briskly and her sodium levels and all of her other electrolyte levels remained

completely normal.”     Dr. Lukefahr concluded that A.B.V.’s condition resulted from

Mother’s abuse.

D.    Mother’s Mental Evaluations

      1.     Dr. Jain

      Ashok Jain, M.D., a forensic psychiatrist, performed Mother’s court-ordered

psychiatric evaluation. Dr. Jain testified that Mother “exhibited significant entitlement

and narcissm.” He diagnosed Mother as suffering from various psychological disorders,


                                           6
including one disorder referred to interchangeably as either “Munchausen syndrome by

proxy” or “factitious disorder imposed on another” (FDIA). Dr. Jain explained that FDIA

manifests itself where a caregiver intentionally causes another—usually a young child—

to become ill in order to benefit herself, such as by obtaining sympathy and attention. Dr.

Jain testified that the common thread in FDIA cases is an unexplained pattern of illnesses

and hospitalizations that ceases once the parent is removed from the situation.

       2.     Dr. Chadwick

       Terri Chadwick, Ph.D., a licensed psychologist, performed a psychological

evaluation of Mother. Dr. Chadwick concluded that Mother was “suffering from several

clinical features that [were] impacting her ability to parent [A.B.V.]” In particular, Dr.

Chadwick determined that Mother showed symptoms of anxiety, emotionality, repressed

anger, and a personality disorder with features of narcissistic and antisocial attitudes.

E.     Mother’s Evidence

       Shayna Reyna, a registered nurse at Citizen’s Hospital, testified that Mother was

cooperative and her conduct towards A.B.V. was normal and appropriate.               Reyna

testified that Mother offered to breastfeed, and she supplemented A.B.V.’s diet with

formula when directed by medical staff. According to Reyna, Mother also fed A.B.V. by

syringe. On cross-examination, Reyna agreed it was somewhat concerning that there

had been no medical issues since Mother was denied access.

       Dana Harrison was Mother’s counselor, and she had seen her twenty-two times

since August 10, 2017. She took issue with Dr. Ashok’s diagnosis of FDIA because it

was based “on an assumption that the information that he received was true[.]”


                                             7
      Sharon Swize testified that she works with Early Childhood Intervention, an

organization that provides services to children with developmental delays. Swize worked

with Mother in March and April of 2017. Swize observed no overt signs of physical

abuse. She testified that Mother consistently met her appointments with Early Childhood

Intervention and that Mother took care in documenting her efforts to feed A.B.V.

According to Swize, Mother looked into procuring milk from a “milk bank” and improving

her own breastfeeding technique.       Mother also reported having administered “liver

detox” pills to A.B.V. without consulting a pediatrician, which concerned Swize. Swize

stated that she continued to see A.B.V. through the time of trial, and that she agreed that

A.B.V. had shown greater progress outside of Mother’s care.

      A.B.V’s maternal grandmother testified that after the Department intervened on

May 2, 2017, Mother was only allowed to see A.B.V. during supervised visitations at a

location designated by the Department and watched over by Department employees.

Maternal grandmother stated that she never allowed Mother to see A.B.V. outside of

those supervised visitations.

      Sylvia Hernandez, Mother’s friend, testified that she often took care of A.B.V.

during the early months of A.B.V.’s life. According to Hernandez, A.B.V. had no trouble

taking her bottle while in her care. However, Hernandez stated that after the HPV shot,

she noticed that A.B.V. was not eating and her eyes were “droopy.”

      Mary Jane Martinez, a friend of Mother, testified that she saw Mother breastfeed

A.B.V., and she also saw A.B.V. develop normally over the first months of her life.

According to Martinez, there was nothing out of the ordinary about A.B.V. until she was


                                            8
vaccinated against HPV, but afterward she saw A.B.V. in the hospital looking lethargic,

weak, and not wanting to eat.

F.      Jury Verdict

        The jury was instructed to consider whether the Department had established at

least one of three statutory termination grounds 3 and whether termination was in A.B.V.’s

best interest. The jury returned a general verdict that Mother’s parental rights should be

terminated, and the trial court rendered judgment accordingly. This appeal followed.

                               II.      SUFFICIENCY OF THE EVIDENCE

        By her first issue, Mother argues the evidence is legally and factually insufficient

to show statutory grounds for termination.

A.      Standard of Review

        The distinction between legal and factual sufficiency lies in the extent to which

disputed evidence contrary to a finding may be considered. In re A.C., 560 S.W.3d 624,

630 (Tex. 2018). In conducting a legal-sufficiency review, the reviewing court cannot

ignore undisputed evidence contrary to the finding but must otherwise assume the

factfinder resolved disputed facts in favor of the finding. In re J.F.C., 96 S.W.3d 256, 266

(Tex. 2002). Evidence is legally sufficient if, viewing all the evidence in the light most

favorable to the fact-finding and considering undisputed contrary evidence, a reasonable

factfinder could form a firm belief or conviction that the finding was true. Id.


        3 Those grounds are as follows: (1) whether Mother knowingly placed or knowingly allowed A.B.V.
to remain in conditions or surroundings which endangered the physical or emotional well-being of A.B.V.,
see TEX. FAM. CODE ANN. § 161.001(b)(1)(D) (West, Westlaw through 2017 1st C.S.); (2) whether Mother
engaged in conduct or knowingly placed A.B.V. with persons who engaged in conduct which endangered
the physical or emotional well-being of A.B.V., see id. § 161.001(b)(1)(E); or (3) whether Mother failed to
comply with her family service plan, which prescribed tasks that Mother was to complete to obtain the return
of A.B.V. See id. § 161.001(b)(1)(O).
                                                     9
       We perform “an exacting review of the entire record” in determining whether the

evidence is factually sufficient to support the termination of a parent-child relationship.

In re A.B., 437 S.W.3d 498, 503 (Tex. 2014). If, in weighing disputed evidence, the

factfinder could have reasonably resolved the conflicts to form a firm conviction that the

allegations constituting the grounds for termination were true, then the evidence is

factually sufficient, and the termination findings must be upheld. In re C.H., 89 S.W.3d

17, 18–19 (Tex. 2002).      On the other hand, evidence is factually insufficient if the

disputed evidence a reasonable factfinder could not have credited in favor of a finding is

so significant that the factfinder could not have formed a firm belief or conviction that the

finding was true. In re J.F.C., 96 S.W.3d at 266.

B.     Applicable Law

       Because of the fundamental rights at issue, due process requires that parental

termination be supported by clear and convincing evidence. In re S.M.R., 434 S.W.3d

576, 580 (Tex. 2014); In re K.M.L., 443 S.W.3d 101, 112 (Tex. 2014).              Clear and

convincing evidence is “the measure or degree of proof that will produce in the mind of

the trier of fact a firm belief or conviction as to the truth of the allegations sought to be

established.” TEX. FAM. CODE ANN. § 101.007 (West, Westlaw through 2017 1st C.S.);

In re J.F.C., 96 S.W.3d at 264.

       Before parental rights may be involuntarily terminated, the trier of fact must find

two elements by clear and convincing evidence: (1) that the parent committed one of

the statutory grounds for termination found in section 161.001(b)(1) of the family code;

and (2) that termination is in the child’s best interest. TEX. FAM. CODE ANN. § 161.001(b)

(West, Westlaw through 2017 1st C.S.); In re E.N.C., 384 S.W.3d 796, 803 (Tex. 2012).
                                          10
       Relevant to this proceeding, section 161.001(b)(1) provides that termination of

parental rights is warranted if the trier of fact finds by clear and convincing evidence, in

addition to the best interest finding, that the parent has:

       (D) knowingly placed or knowingly allowed the child to remain in conditions
       or surroundings which endanger the physical or emotional well-being of the
       child;

       (E) engaged in conduct or knowingly placed the child with persons who
       engaged in conduct which endangers the physical or emotional well-being
       of the child; [or]

       ....

       (O) failed to comply with the provisions of a court order that specifically
       established the actions necessary for the parent to obtain the return of the
       child who has been in the permanent or temporary managing
       conservatorship of the Department of Family and Protective Services for not
       less than nine months as a result of the child’s removal from the parent
       under Chapter 262 for the abuse or neglect of the child[.]

TEX. FAM. CODE ANN. § 161.001(b)(1)(D), (E) & (O).

C.     Analysis

       Because only one statutory ground is necessary to support termination, we first

focus our attention on section 161.001(b)(1)(E). Subsection E uses the term “endanger,”

which means “to expose a child to loss or injury or to jeopardize a child’s emotional or

physical health.” See In re S.R., 452 S.W.3d 351, 360 (Tex. App.—Houston [14th Dist.]

2014, pet. denied) (citing In re M.C., 917 S.W.2d 268, 269 (Tex. 1996)).              Under

subsection E, the evidence must show the endangerment was the result of the parent’s

conduct, including acts, omissions, or failure to act. Id. (citing In re J.T.G., 121 S.W.3d

117, 125 (Tex. App.—Fort Worth 2003, no pet.)). Termination under subsection E must

be based on more than a single act or omission; the statute requires a voluntary,

                                             11
deliberate, and conscious course of conduct by the parent. Id.

       The Department presented the testimony from three medical doctors who

separately concluded that Mother was causing A.B.V.’s condition by depriving her of

adequate nutrition. As set out above, their conclusions were based on multiple objective

factors and the ruling out of other potential causes. In that regard, the evidence tended

to show that A.B.V. displayed a general pattern of symptoms arising only when Mother

had access to A.B.V.—symptoms that could be induced by giving A.B.V. diuretics or

water-diluted food. Further, Mother declined doctors’ advice to bottle-feed A.B.V. in the

hospital, and she resisted efforts to quantify the amount of breast milk A.B.V. was

receiving.   While Mother maintained that A.B.V. was refusing the bottle, multiple

witnesses testified that after Mother was removed from the hospital, A.B.V. readily

accepted the bottle from nurses. A.B.V. flourished and experienced no serious medical

issues after Mother’s access was restricted.

       The placement of a feeding tube improved A.B.V.’s condition during her first

hospitalization, but there was testimony that Mother was dishonest in requesting A.B.V.’s

primary care physician to remove the tube. Mother also admitted that she administered

“liver detox” pills to A.B.V. without consulting a pediatrician.    There was additional

testimony that Mother sent a letter encouraging A.B.V.’s foster mother to administer a

“baby detox bath.” Finally, a psychiatrist diagnosed Mother with FDIA, a condition which

is consistent with the medical doctors’ belief that Mother was intentionally causing A.B.V.

to become ill.

       Viewing these circumstances and the supporting evidence in the light most


                                            12
favorable to the jury’s verdict, a reasonable factfinder could form a firm belief or conviction

that Mother engaged in conduct which endangered the physical well-being of A.B.V. See

In re J.F.C., 96 S.W.3d at 266; In re S.G.S., 130 S.W.3d 223, 238 (Tex. App.—Beaumont

2004, no pet.) (concluding that the jury could reasonably have found that parents

endangered their infant child by denying adequate nutrition where the child was critically

ill at six weeks of age from lack of nourishment); see also In re S.W., No. 02-05-00417-

CV, 2006 WL 2988736, at *5 (Tex. App.—Fort Worth Oct. 19, 2006, no pet.) (mem. op.)

(per curiam) (concluding that the evidence was legally sufficient to support an

endangerment finding where there was testimony that appellant “attempted on multiple

occasions in the past to admit her children to area hospitals when the children were not

in need of medical treatment” and displayed traits of narcissism in therapy).              We

therefore conclude the evidence is legally sufficient to support termination pursuant to

section 161.001(1)(b)(E) of the family code.

       We next consider the disputed evidence to resolve the question of factual

sufficiency. At trial, Mother and her witnesses testified that she was a caring mother,

and she had diligently sought a solution to A.B.V.’s unexplained medical issues. They

suspected that A.B.V.’s exposure to the HPV vaccine was to blame, because A.B.V.

experienced no issues prior to inoculation. Mother believed that A.B.V.’s problems were

further caused by A.B.V.’s poor coordination in breastfeeding and resistance to bottle

feeding. However, the Department presented testimony by medical professionals that

A.B.V.’s symptoms were not consistent with an accidental HPV vaccination. There was

also evidence that A.B.V. had no trouble bottle feeding after Mother’s access was


                                              13
restricted.

       In weighing the disputed evidence, the fact-finder could have reasonably resolved

the conflicts in the evidence to form a firm conviction that Mother endangered A.B.V. by

depriving her of adequate nutrition. See In re C.H., 89 S.W.3d at 18–19; see also In

Interest of G.H., No. 02-14-00261-CV, 2015 WL 3827703, at *37 (Tex. App.—Fort Worth

June 18, 2015, no pet.) (mem. op.) (en banc) (finding the evidence factually sufficient to

support termination even where mother was described as a “loving, wonderful person

who loves . . . all of her children” where there was evidence that mother had psychological

problems and had provided her children methamphetamine); In re E.P.C., 381 S.W.3d

670, 684 (Tex. App.—Fort Worth 2012, no pet.) (concluding that there was factually

sufficient evidence that father endangered his infant child by failing to provide her with

sufficient nutrition where child was diagnosed with failure to thrive but steadily gained

weight following removal).    Accordingly, we conclude that the evidence is factually

sufficient to support termination pursuant to section 161.001(1)(b)(E) of the family code.

See In re J.F.C., 96 S.W.3d at 266.

       Having concluded that the evidence is legally and factually sufficient to support at

least one statutory ground for termination, we overrule Mother’s first issue.

                       III.   INEFFECTIVE ASSISTANCE OF COUNSEL

       In Mother’s second issue, she contends that she received ineffective assistance of

counsel.

A.     Standard of Review and Applicable Law

       A parent’s right to counsel in parental termination suits “embodies the right to

effective counsel.” In re M.S., 115 S.W.3d 534, 544 (Tex. 2003); see In Interest of
                                        14
E.R.W., 528 S.W.3d 251, 261 (Tex. App.—Houston [14th Dist.] 2017, no pet.) (concluding

that the right to effective counsel extends to non-indigent parents who have retained

counsel). In a parental termination case, we apply the test enunciated in Strickland v.

Washington to assess whether a parent’s right to effective assistance of counsel was

violated.   In re J.O.A., 283 S.W.3d 336, 341–42 (Tex. 2009) (citing Strickland v.

Washington, 466 U.S. 668, 687 (1984)). Under Strickland, the parent must satisfy a two-

prong test:   (1) that counsel’s performance was deficient, and (2) that the deficient

performance prejudiced the defense. Id. at 342; In re M.S., 115 S.W.3d at 545.

       We look to “the totality of the representation and the particular circumstances of

each case” in evaluating effectiveness. In re M.P.A., 364 S.W.3d 277, 290 (Tex. 2012).

We must give deference to counsel’s performance, indulging a strong presumption that

counsel’s conduct falls within the wide range of reasonable professional assistance. Id.

Counsel’s performance falls below acceptable levels of performance when the

“representation is so grossly deficient as to render proceedings fundamentally unfair.” In

re M.S., 115 S.W.3d at 545. The parent’s burden is to show that “counsel’s performance

fell below an objective standard of reasonableness.” In re J.O.A., 283 S.W.3d at 343.

B.     Analysis

       Mother asserts that trial counsel was deficient in failing to develop an alternate

theory of causation for A.B.V.’s medical problems.      In particular, Mother cites chart

notations entered by a Dr. Georges Jeha at TCH, who wrote that he could not rule out

adrenal insufficiency as the cause of A.B.V.’s problems. Dr. Jeha noted that A.B.V. failed

her adrenal stress test, with a peak level of 16.7 units, whereas 18 units or above were

required to pass the test. Mother maintains that because her trial counsel did not call
                                         15
Dr. Jeha and otherwise advance this adrenal insufficiency theory, his representation fell

below the objective standard of reasonableness demanded of constitutionally effective

counsel. See id.

       Mother’s argument fails for two reasons. First, Dr. Jeha’s chart notations were

not entirely—or even mostly—favorable to Mother. Dr. Jeha described his encounter

with A.B.V. in detail, noting that she was an eleven-month-old female with recurrent low

sodium, which “was determined at last admission” to be “due to decreased sodium intake,

possibly medical neglect,” and who was “now admitted again for” dangerously low

sodium, with child protective services “again” involved. And while Dr. Jeha did not rule

out adrenal imbalance as a potential cause for A.B.V.’s problems, he felt the “most likely”

cause of A.B.V.’s condition was “not enough salt intake.” To address her symptoms, he

primarily recommended reassessing A.B.V.’s diet as well as her “social situation.”

       More importantly, Mother neglects to mention that her alternate causation theory

was fully explored at trial through the testimony of other witnesses.         In particular,

Mother’s trial counsel drew out testimony that was substantially similar to Dr. Jeha’s chart

notations when he cross-examined the Department’s chief caseworker, Megan Morales,

about possible alternate causes of A.B.V.’s medical condition. Morales recited her own

notes concerning a conversation she had with Dr. Grace Kim. According to Morales’s

testimony, Dr. Kim relayed her belief that while most aspects of A.B.V.’s case “fit[] the

picture of total body salt and fluid depletion which is most likely caused by the mom,” she

could not rule out with absolute certainty the possibility that A.B.V.’s problems stemmed

from a “possible adrenal insufficiency.”     Ultimately, Dr. Kim recommended another


                                            16
hormone test to rule out this possibility. Morales related her understanding that A.B.V.

underwent multiple adrenal tests, passing the first and barely failing the second, and upon

passing a third test in September of 2017, adrenal insufficiency was ruled out.

       The topic of adrenal functions and testing was further developed through the

testimony of Dr. Paul. Dr. Paul agreed that A.B.V. failed an adrenal stress test, which

revealed that A.B.V.’s peak cortisol levels were fifteen and a half units, which was slightly

below the normal baseline. He also agreed that adrenal cortisol insufficiency is a known

cause of low sodium levels. However, he stated that cortisol insufficiency was “rarely”

found to be the cause of low sodium “in a child like this.” Dr. Paul testified that A.B.V.’s

average day-time cortisol levels were all within normal limits, and A.B.V. never showed a

severe cortisol deficiency during any of her hospital stays. Mother’s counsel cross-

examined Dr. Paul at length concerning the reliability of the hospital’s cortisol testing and

the possibility that a cortisol deficiency was to blame for A.B.V.’s problems, but ultimately

Dr. Paul testified that he considered A.B.V.’s day-to-day cortisol production to be

adequate, and he did not believe that a cortisol deficiency was causing A.B.V.’s

symptoms. Rather, his “fairly strong” belief was that Mother was the source of A.B.V.’s

issues.

       Similarly, Dr. Lukefahr agreed that A.B.V. showed a slight deficiency on her cortisol

stress test and that adrenal insufficiency is a known potential cause of low sodium. He

believed, though, that A.B.V.’s cortisol levels were only slightly below normal and didn’t

appear to be “clinically significant.” In his view, A.B.V.’s low cortisol test “was really more

of sort of just a lab variation,” and Mother most likely caused A.B.V.’s problems.


                                              17
      Based on the comprehensive fashion in which this alternate causation theory was

brought before the jury, and the limited potential that Dr. Jeha’s views would have

impacted Mother’s defense, we cannot conclude that Mother’s trial counsel was

constitutionally deficient in failing to bring him before the jury. See In re M.S., 115

S.W.3d at 545; see also Rodriguez v. Tex. Dep’t of Family & Protective Servs., No. 03-

10-00361-CV, 2011 WL 3435736, at *3 (Tex. App.—Austin Aug. 4, 2011, pet. denied)

(mem. op.) (finding mother’s trial counsel reasonably effective in a termination case where

counsel developed testimony that mother was loving and that there were other possible

medical causes of her child’s injury, however unlikely).

      Lastly, Mother argues that her previously retained counsel was deficient in failing

to forward her counseling records to the Department. Mother does not identify any way

in which this omission prejudiced her case.        Rather, Mother concedes that, in all

likelihood, her most recent trial counsel did in fact forward her counseling records to the

Department before trial. Therefore, we conclude that Mother has failed to demonstrate

adequate prejudice under the second prong of Strickland. See In re J.O.A., 283 S.W.3d

at 342.

      Having concluded that Mother failed to demonstrate both prongs of Strickland, we

overrule Mother’s second issue.

                                   IV.    CONCLUSION

      We affirm the trial court’s judgment.

                                                              LETICIA HINOJOSA
                                                              Justice

Delivered and filed the
14th day of February, 2019.
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