Opinion
No. 1-16-2488
03-15-2017
In re A.S., Minor-Respondent-Appellee, (People of the State of Illinois, Petitioner-Appellee, v. Veronica S., Mother-Respondent-Appellant.)
NOTICE: This order was filed under Supreme Court Rule 23 and may not be cited as precedent by any party except in the limited circumstances allowed under Rule 23(e)(1). Appeal from the Circuit Court of Cook County. No. 15 JA 1175 The Honorable Robert Balanoff, Judge Presiding. JUSTICE PUCINSKI delivered the judgment of the court.
Justices Lavin and Cobbs concurred in the judgment.
ORDER
¶ 1 Held: circuit court's adjudicatory finding that respondent's daughter was a neglected and abused minor was not against the manifest weight of the evidence. ¶ 2 Following an adjudication hearing conducted in accordance with the Juvenile Court Act of 1987 (Juvenile Court Act or Act) (705 ILCS 405/1-1 et seq. (West 2012)), the circuit court found that A.S. was a neglected and abused minor. In the disposition hearing that followed, the circuit court concluded that A.S.'s mother, Veronica S., was unable to properly care for her daughter, and adjudicated A.S. a ward of the court. On appeal, Veronica challenges the circuit court adjudication determination, arguing that the court's findings of abuse and neglect are against the manifest weight of the evidence. For the reasons delineated herein, we affirm the judgment of the circuit court.
¶ 3 BACKGROUND
¶ 4 Petition for Adjudication of Wardship
¶ 5 Veronica is the natural mother of A.S., born May 8, 2008. George (aka "Jorge") B. is A.S.'s natural father. A.S. was born several weeks premature at approximately 32 weeks gestation. At the time of her birth, A.S. had elevated levels of bilirubin (hyperbilirubinemia) and a duplicated collecting duct, a condition that increases one's risk for urinary tract and kidney infections. Although these health issues had been resolved by approximately 2010, A.S. incurred a large number of visits to local emergency rooms and various outpatient medical clinics. As a result, on November 16, 2015, the State filed a petition for adjudication of wardship on behalf of A.S. In the petition, the State alleged that A.S. was "neglected," as that term is defined in the Act (705 ILCS 405/2-3 (West 2012)) because she was subjected to an environment that was injurious to her welfare (705 ILCS 405/2-3(1)(b) (West 2012)). The State further alleged that A.S. was "abused" as that term is defined in the Act because she was at "substantial risk of physical injury" (705 ILCS 405/2-3(2)(ii) (West 2012)). To support the claims of neglect and abuse set forth in its petition, the State alleged:
"Mother has taken the minor to University of Illinois at Chicago emergency room on at least fifty-five occasions, the vast majority of which do not indicate any pathology. Hospital personnel are concerned regarding a pattern of overutilization of medical
services coupled with missed appointments and refusal to act on physician recommendations. Hospital staff are recommending no contact between the mother and the minor during this minor's current hospitalization. Minor has also been diagnosed with unspecified disruptive, impulse-control, and conduct disorder. Mother has not followed through with mental health recommendations for minor. Mother is currently diagnosed with bipolar and post-traumatic stress disorder and is only partially compliant with her own mental health recommendations."¶ 6 In addition to the petition for adjudication of wardship, the State also filed a motion for temporary custody. In the latter filing, the State requested the court to enter a temporary custody order appointing a temporary guardian to care for A.S. The circuit court granted the motion, and the cause then proceeded to an adjudication hearing in accordance with the Act.
George was not involved in the underlying proceedings and is not a party to this appeal.
¶ 7 Adjudication Hearing
¶ 8 At the hearing, Doctor James Ronayne, a licensed pediatrician and an attending physician at the University of Illinois at Chicago's (UIC) Pediatrics Acute Care Clinic (Clinic), testified that he first became familiar with A.S.'s case on October 23, 2015, when he was approached by Doctor Joseph, a resident physician at the Clinic, who voiced "some concerns" that he had about A.S. and her mother. This was the second consecutive day that A.S. and her mother had come to the Clinic and Doctor Joseph wanted advice as to how to proceed. After conferring with Doctor Joseph, he then conducted a review of A.S.'s medical chart and "noticed that she had had a very large number of [hospital] visits" despite the fact that she was a generally healthy child. Doctor Ronayne testified that after reviewing A.S.'s chart and discussing the matter with Doctor Joseph, he then went to examine A.S. When he encountered A.S., he observed her coloring in a coloring book and "interacting well with [a] social worker." She did not appear to be sick and when he asked A.S. if she was feeling sick, she responded "no." He did, however, observe that A.S. was wearing a diaper, which was unusual given that she was seven-years-old at the time. Doctor Ronayne testified that he became concerned when A.S. began talking "about going to see other doctors." He noted that "she seemed to know some of the hospitals better than [he] thought she would," which was unusual. He explained that "[m]ost children just don't even know where they are, whether they are at UIC or U of C or some other hospital. They usually say, [']I'm in a hospital[']. But typically when [children] know the names of other hospitals, it's slightly concerning." ¶ 9 Although he initially conversed with A.S. outside of the presence of her mother, Doctor Ronayne testified that Veronica subsequently entered the room and that he noticed an immediate change in A.S.'s demeanor when she did so. He explained: "she appeared nervous; she stopped making eye contact, [and] stopped talking." After Veronica entered the room, she informed Doctor Ronayne that A.S. was "very sick," and requested him to perform a chest X-ray on her daughter. When he explained to her that there was not any reason for a chest X-ray given that A.S. did not have a cough or any apparent respiratory issues, Veronica became "agitated" and raised her voice. Veronica and A.S. ultimately left the Clinic without getting a chest X-ray. ¶ 10 Doctor Ronayne testified that after the pair departed, he went back and conducted a more thorough review of A.S.'s medical records "from birth until that day." The records revealed that A.S. had visited the emergency room at UIC Hospital on 55 occasions. She also had numerous visits to various outpatient clinics. In addition, he "saw a pattern" of Veronica taking A.S. to the emergency room for various complaints, including, "chest pain, or a fever, or behavioral issues" and then "not adhering to" recommendations for follow-up treatment, which Doctor Ronayne found to be "an inconsistency." He explained: "[t]ypically if a parent is repetitively seeking emergency care and they are referred over to a subspecialist and they are that concerned *** they typically follow up with subspecialists." As an example, Doctor Ronayne noted that A.S.'s medical records indicated that Veronica appeared to be concerned with her daughter's need for a diaper and received referrals to the Urology Department. He explained that Veronica did take her daughter to the Urology Department, but when doctors could find no physical cause for A.S.'s enuresis, a second referral was made to the Psychiatry and Developmental Behavioral Pediatrics Department. Veronica, however, failed to follow through with the referral and A.S. did not attend any of her scheduled appointments. On another occasion, Veronica brought her daughter to the emergency room with complaints of chest pain. A referral was made to the Cardiology Department; however, again Veronica failed to take her daughter for a follow-up appointment. Doctor Ronayne acknowledged that some of A.S.'s ER visits were warranted, noting that the few occasions on which A.S. suffered from urinary tract infections justified medical attention. In addition, A.S.'s pneumonia diagnosis also warranted medical treatment. Overall, however, he opined that A.S. was generally a healthy child and she did not possess any chronic medical conditions that would have warranted the high number of emergency room visits to which she was subjected. ¶ 11 Doctor Ronayne testified that there are serious risks associated with unnecessary trips to the emergency room. He explained that emergency room personnel generally "act more aggressively" in treating persons who present at the ER because they are acting under the assumption that an individual seeking emergency treatment may have a life-threatening illness. As a result, ER doctors generally utilize more testing procedures, including X-rays and CT scans to assess a patient. Those diagnostic imaging procedures, however, employ radiation, and there is an increased risk of cancer in individuals exposed to unnecessary radiation. Doctor Ronayne further testified that ER doctors are generally even more aggressive when treating repeat patients like A.S. He explained that ER doctors can be "more invasive with testing" or may even admit the patient in an effort to diagnose and provide relief to the individual repeatedly seeking emergency treatment. They may also administer antibiotics in an effort to treat the patient more aggressively, and unnecessary antibiotic administration can cause various complications, including a toxic megacolon and subsequent resistance to antibiotics. ¶ 12 Ultimately, based on his review of A.S.'s medical records, Doctor Ronayne was concerned that A.S.'s medical history was the result of "fabricated illness" or "Munchausen by proxy" disorder (Munchausen disorder), a type of medical abuse inflicted on a child by a parent "for some psychological benefit." Because he is not a psychiatrist, Doctor Ronanye acknowledged that he could not definitively diagnose Veronica with Munchausen by proxy disorder; however, he testified that the information contained in A.S.'s medical records was cause for concern. He explained that the sheer number of A.S.'s emergency room visits was particularly troubling and emphasized that she "had more presentations to the ER than 99.99 percent of the population at her age." Moreover, A.S.'s medical records indicated that hospital personnel spoke to Veronica in an effort to encourage her to stop taking A.S. to the emergency room; however, Veronica apparently did not abide by their recommendations. Doctor Ronanye further testified that A.S.'s "selective mutism" also supported his supposition that Veronica's behavior was caused by Munchausen by proxy disorder. He noted that A.S.'s medical records contained various notations regarding her selective mutism while in the presence of her mother. In addition, he had also personally observed A.S.'s selective mutism when he encountered her at the Clinic, explaining: "When I initially met with her, she was verbalizing like a typical[] normal child; and then when her mother came in the room, she stopped verbalizing." He testified that most children with selective mutism generally speak normally to their parents at home but do not speak in front of strangers because they experience anxiety outside of the home and around people with whom they are unfamiliar. A.S.'s presentation, however, was the "opposite" because she spoke freely with medical personnel and social workers, but stopped speaking in the presence of her mother. ¶ 13 On cross-examination, Doctor Ronayne confirmed that he only met A.S. and her mother once and that he did not observe any outward signs of physical abuse or neglect on A.S.'s person at that time. He further confirmed that A.S. did not verbally indicate that she was afraid of her mother. ¶ 14 Azalea Parrilla, a social worker, testified that she first met A.S. and her mother during their on October 22, 2015, visit to the Clinic. She explained that doctors at the Clinic had raised some concerns about A.S. and that she was asked to conduct an assessment to determine whether A.S. was the victim of any potential child abuse or neglect. Parrilla testified that after she introduced herself to Veronica and A.S., they proceeded to discuss Veronica's concerns about her daughter's health and her reason for seeking treatment at the Clinic. As she and Veronica conversed, Parrilla took note of A.S.'s demeanor, which she described as "closed off." She explained that when she attempted to interact with A.S. in her mother's presence, A.S. did not provide any verbal response. In lieu of a verbal response to Parrilla's questions, A.S. would simply nod to indicate "yes" or shrug to indicate she "didn't know." Given A.S.'s lack of verbal responses, Parrilla testified then she then sought to communicate with A.S. by using a dry erase board. She discovered that A.S. was able to write legibly and respond appropriately to her questions. As a result, Parrilla did not believe that A.S. suffered from any cognitive or developmental delays. Parrilla indicated that her encounter with A.S. and her mother on October 22, 2015, ended "cordially" and that Veronica agreed to meet with Parrilla again the next time that she and her daughter sought treatment from the Clinic. ¶ 15 Parrilla testified that she was notified the following day that A.S. and her mother had returned to the Clinic. She again met with Veronica at the Clinic and inquired about her concerns about her daughter's health. She also spoke to A.S., who again responded non-verbally to Parrilla's inquiries. Parrilla then told Veronica that the doctors at the Clinic were running behind schedule and asked if she could take A.S. into her office where A.S. could engage in an art activity. After receiving Vernonica's permission, Parrilla was then able to interact with A.S. outside of the presence of her mother. A.S. then began providing verbal responses to Parrilla's questions. Parrilla testified that she spoke to A.S. for approximately 30 minutes outside of the presence of her mother. During that time, Parrilla did not observe any cognitive, developmental or behavioral issues. She found it interesting, however, that A.S. behaved much differently outside of her mother's presence, explaining: "[A.S.] went from being shy and withdrawn in front of her mother and dependent to more independent. She spoke freely; she didn't really hesitate in answering questions verbally; *** she went from not speaking verbally at all to actually speaking verbally ***. She was smiling; [and] she seemed very comfortable in the setting." ¶ 16 Parrilla testified that Doctors Ronanye and Joseph entered the room while she was conversing with A.S. to conduct a brief physical examination. Parrilla remained in the room while the doctors examined A.S. and she noted that A.S. remained "very cooperative" throughout the exam and seemed "very comfortable and compliant with the doctors checking her stomach and checking her back." A.S. also continued to verbally engage with Parrilla during the exam and talked to Parrilla about school and told Parrilla that she did not feel sick. As the exam was underway, Veronica entered the room. Parrilla testified that she appeared to be very "suspicious and defensive" when she realized A.S. had been speaking and wanted to know what they had been talking about. ¶ 17 Parrilla testified that Veronica and A.S. ended up leaving the Clinic abruptly that day. She explained that when Doctors Ronayne and Joseph informed Veronica that there did not appear to be anything wrong with her daughter, Veronica responded that A.S.'s symptoms worsened at home. In response, the doctors proposed calling DCFS to schedule a home visit. Veronica, however, became very upset and angry and left the Clinic with her daughter. Parrilla testified that she called Veronica shortly after the pair departed from the Clinic. During the conversation, Veronica used a lot of profanity and seemed "offended" and "disgruntled" by the reference to DCFS. Thereafter, over the next few days, Veronica placed several threatening phone calls to Parrilla. During those conversations, Veronica stated that she "wanted to bash [Parrilla's] face in" and that she "hoped [Parrilla] got raped and murdered." Veronica also called Parrilla various derogatory names during those phone calls including, "bitch," "cunt," "whore" and "half-breed." Parrilla surmised that A.S. was present for at least one of those threatening phone calls, explaining that she heard Veronica issue various "directives" to her daughter while she was on the phone. ¶ 18 Parrilla testified that she ultimately contacted police after Veronica left her five threatening voicemail messages on October 30, 2015. In those messages, Veronica again threatened to "find [Parrilla] and bash [her] face in." After reporting Veronica's threatening phone calls to the authorities, Parrilla had no further contact with Veronica and A.S. ¶ 19 On cross-examination, Parrilla admitted that when she spoke to A.S. outside of Veronica's presence, she asked A.S. if she felt safe at home and that A.S. responded, "yes." Parrilla also admitted that she did not ask A.S. why she did not speak in the presence of her mother. She testified however, that she made a conscious decision not to pose that question, explaining: "Sometimes with children with selective mutism if you call out the fact that they don't speak in certain areas it makes them more self-conscious and anxious about it, and so they shut down again." ¶ 20 Anthony Heard, a licensed clinical social worker, testified that in 2015, he worked as a pediatric social worker. He explained that A.S.'s case was first brought to his attention in May 2015 when he was informed that Veronica had called a "nurse line" and had inquired "about a DCFS case." In response, on May 29, 2015, Heard returned Veronica's phone call, introduced himself, and explained the reason for his call. As soon as he mentioned DCFS, however, Veronica became very "suspicious" and "irritable" and accused Heard of "lying." After the brief unproductive phone call, Heard testified that he subsequently reviewed A.S.'s medical record "just to see if there was anything [he] needed to be aware of from the social work end." Upon doing so, he found some of the details contained in those records to be concerning. In particular, Heard noted that the records demonstrated that Veronica had brought A.S. to the emergency room "quite a few times" for conditions that "did [not] appear emergent." In addition, there were notations in the record that reflected that Veronica acted confrontationally toward medical personnel and that A.S. engaged in selective mutism and did not speak in the presence of her mother. Because Heard had a number of concerns after reading through A.S.'s medical records, he testified that he brought the case to the attention of the child protection team and the team agreed to "just monitor the case" and to attempt to make contact with Veronica the next time she sought medical treatment for her daughter. Accordingly, Heard placed a note in A.S.'s file requesting that he be contacted the next time that A.S. sought medical care. ¶ 21 Heard testified that he was subsequently notified that Veronica and A.S. appeared at the Clinic on two consecutive days: October 22, 2015, and October 23, 2015. He and Parrilla, his colleague, met with them on both days. He described A.S.'s demeanor as "quiet and withdrawn." He found it "unusual" that Veronica volunteered "without prompting" that her daughter had never been abused. Heard confirmed that following A.S.'s visits to the Clinic in October 2015, Veronica placed several calls to Parrilla. He explained that they shared office space and that he was able to overhear some of the conversations when Parrilla activated the speakerphone. Heard further confirmed that he heard Veronica issue verbal threats to Parrilla during those conversations. He specifically overheard Veronica threaten to "bash [Parrilla's] head in." He also heard Veronica state that she hoped Parrilla would be raped and killed. Heard testified that Veronica also made harassing telephone calls to him as well. During those phone calls, Veronica accused him of lying, cursed at him, and threatened to sue him. She also called him a "terrorist-looking motherfucker." Heard also made a police report in response to Veronica's threatening phone calls. ¶ 22 Heard testified that DCFS commenced an investigation into A.S.'s situation following her October 2015 visits to the Clinic. As part of the DCFS investigation, Heard recommended that A.S. have no contact with her mother. His recommendation was based on the behaviors that both Veronica and A.S. displayed during their Clinic visits as well as on his review of A.S.'s clinical records. He explained: "[A.S.] was documented to have a collection of symptoms that are consistent with a child who has experienced trauma. Nothing specific, but the combination of the medically unexplained eneuresis and the fact that she was selectively mute when her mother was present. *** [T]hen on top of that, the frequent emergency department visits related to symptoms that did not appear to warrant it." In addition, Heard emphasized that Veronica would frequently request additional testing even after being advised by medical professionals that A.S.'s condition did not warrant such testing. He concluded: "it's well-documented in the literature regarding factitious disorders that these are the types of things that place children at risk." ¶ 23 On cross-examination, Heard acknowledged that although Veronica threatened him and his coworker, he never heard her threaten her daughter. He also confirmed that when he encountered A.S. at the Clinic, she was dressed appropriately and that he did not observe any outward signs of physical neglect or abuse. Moreover, A.S.'s medical records did not contain any notations that Veronica acted violently toward her daughter in front of medical personnel. ¶ 24 Angela Scott, a supervisor in DCFS's Department of Child Protection, testified that A.S. was brought to the DCFS's attention on October 23, 2015, following her visits to the Clinic. Scott testified that she and Elizabeth Serrano, an investigator, were both assigned to the case. As part of the investigation, Scott and Serrano interviewed Veronica, various hospital staff, and social worker Heard. Based upon the information they learned, A.S. was taken into protective custody on November 12, 2015. This decision was the result of a number of factors including Veronica's "verbalized distrust for systems," her history of taking her daughter to the emergency room "excessively" for complaints that "were not substantiated," as well as her history of displaying aggression toward hospital staff. ¶ 25 On cross-examination, Scott acknowledged that when she interviewed Veronica at her home, she found the residence to be both safe and appropriate. Moreover, A.S. "appeared to be comfortable in her mother's home." Scott confirmed that prior to the instant investigation, DCFS had not had prior contact with Veronica or A.S. She also confirmed that it was not unusual for people to display anger and distrust toward DCFS. ¶ 26 After presenting the aforementioned live testimony, the State entered a number of exhibits into the record including A.S.'s certified medical records from various medical facilities including, UIC Hospital, Mount Sinai Hospital Medical Center, Saint Anthony's Hospital, and MacNeal Hospital. Veronica's psychiatric records from Mount Sinai Psychiatry and Behavioral Health Clinic were also entered into evidence. Those records revealed that Veronica had been diagnosed with post-traumatic stress disorder (PTSD) and bipolar disorder and had not been consistent in obtaining treatment for her mental health issues. A certified copy of Veronica's conviction for misdemeanor telephone harassment, which stemmed from her harassment of Parrilla and Heard, was also entered into evidence. ¶ 27 After the State rested its case, Doctor Medeia Gartel, a psychiatrist at Mount Sinai Medical Hospital, was called upon to testify on Veronica's behalf. Doctor Gartel testified that she has treated Veronica on an outpatient basis off and on since 2010. She explained that Veronica initially sought psychiatric treatment in 2010 after her son attempted suicide. In addition to discussing her son's suicide attempt, Veronica also disclosed to Doctor Gartel that she had been molested by a family member when she was a child. Doctor Gartel testified that she has diagnosed Veronica with PTSD related to the molestation she suffered as a child and bipolar disorder. ¶ 28 Doctor Gartel testified that Veronica brought A.S. with her to some of her earlier treatment sessions. On those occasions, Doctor Gartel had an opportunity to observe interactions between Veronica and her daughter and found them to be "appropriate." She noted that A.S. could be hyperactive at times and that Veronica was patient with her. Doctor Gartel confirmed that Veronica has talked about her daughter during various treatment sessions and has expressed that "she loves her but also worries about her." In addition, Veronica has admitted that she is "very protective" of A.S. and "rarely trusts anybody to care for her daughter." This lack of trust toward others stems from Veronica's history of sexual abuse that she experienced as a child. Doctor Gartel testified that Veronica never discussed any medical issues pertaining to A.S. until DCFS began its investigation in October 2015. ¶ 29 Doctor Gartel acknowledged that she was familiar with the diagnosis "Munchausen by proxy," which she defined as an uncommon "factitious disorder inflicted o[n] others." She explained that "it's a condition when [a] caregiver, most frequently [the] mother but not necessarily, is seeking attention through the ward *** either by inflicting some harm and illness or just maybe exaggerating symptoms or altering tests." Individuals with the psychiatric disorder usually obtain and keep medical appointments for their wards because that is when they receive the attention that they are seeking. ¶ 30 Doctor Gartel testified that she was contacted by DCFS and, upon request, authored a letter about her treatment of Veronica. In the letter, Doctor Gartel indicated that she did not have knowledge of any actions undertaken by Veronica that endangered A.S. In her professional opinion, Veronica does not suffer from Munhausen by proxy disorder. ¶ 31 On cross-examination, Doctor Gartel acknowledged that Veronica has not been consistently compliant with her treatment. She explained that Veronica was supposed to attend therapy once per month, however, there "were interruption[s] in treatment" when she failed to show up for her treatment sessions. Doctor Gartel estimated that she has had "around 15" treatment sessions with Veronica since 2010 and confirmed that she did not know whether Veronica was taking her prescribed medications during the periods in which there were interruptions in treatment. She clarified that she oversaw Veronica's medical management and did not provide her with psychotherapy. Doctor Gartel also acknowledged that prior to being contacted by DCFS in October 2015, she had not seen Veronica since June 8, 2015. She confirmed, however, that Veronica did resume regular treatment after DCFS commenced its investigation. Doctor Gartel further confirmed that Veronica had not brought A.S. to a treatment session since 2010 and that she had not observed Veronica interact with her daughter since that time. Doctor Gartel admitted that she did not review any of A.S.'s medical records or speak to any of the social workers assigned to A.S.'s case before reaching her conclusion that Veronica was not afflicted with Munchausen by proxy disorder. She acknowledged that some of the troubling behavior that Veronica has displayed, including her paranoia and distrust of medical personnel and her angry outbursts toward social workers, likely stemmed from her diagnosed PTSD and bipolar disorder. ¶ 32 After the aforementioned evidence had been presented to the court, the parties delivered closing arguments. The court took the matter under advisement and upon review, concluded that A.S. was a neglected and abused minor. The court explained its decision as follows:
"The State has met [its] burden of proof by a preponderance of the evidence that the minor was neglected based on an injurious environment and abused based on a substantial risk of physical injury.
The mother argued that she was taking the child for needed medical care. However, that ignores that she continued to visit emergency rooms despite being told to follow up at clinics and that she often failed to follow the recommended treatments for the concerns that the doctors did have. Ms. Sanders was often given written guidelines for when it was appropriate to use the emergency room. Additionally, the evidence was clear that the mother has mental—mental health diagnoses that she failed to treat which may have contributed to her actions.
Dr. Ronayne, an expert in pediatrics, and all the witnesses were credible. Nothing in the testimony of Dr. Gartel contradicts Dr. Ronayne's testimony but supports the conclusion that the mother failed to treat her own mental health problems on a consistent basis. Dr. Gartel never had all the information to make any conclusion regarding any mental health illness the mother had in relation to her daughter's excessive medical treatments. ***
One of the fallacies of the mother's arguments is that the emergency department of a hospital was the best place to take [A.S.] for medical care; rather, as Dr. Ronayne testified, that emergency rooms act more aggressively than a clinic because the assumption is that an emergency department patient is assumed to have a life-threatening condition and is more likely to be given drugs and tests. These ER visits put [A.S.] at increased risk for mortality and morbidity.
Although no one has diagnosed [A.S.] as a victim of fabricated illness, it's clear by Dr. Ronayne's testimony that the other exhibits—and the other exhibits that she received excessive medical care and that her mother was driving the excessive medical care.
Dr. Ronayne also identified behavior that indicated fabricated illness, including the selective mutism, insistence for testing despite assurances that there was nothing to test for, and failure to follow up on a declared mental condition. All of these were present in this case.
The fact is that the average number of times a child visits an ER is once a year. [A.S.], age 7 visited the UIC emergency department 55 times, more than 99 percent of the population, while being a relatively healthy child. This does not include treatments at the other hospitals and clinics. Any issues identified due to [A.S.]'s premature birth had
been resolved by 2010 *** [and A.S.] received unnecessary testing and visits to the ER. When there might have been legitimate concerns regarding the minor's mental health, the mother failed to follow up with treatment and actually hindered treatment by her actions.¶ 33 After the circuit court delivered its adjudicatory findings, the cause proceeded to a disposition hearing. At the conclusion of the hearing, the court found that Veronica was unable to properly care for her daughter and that it was in A.S.'s best interest to be made a ward of the court. ¶ 34 This appeal followed.
Regardless of the mother's feelings towards treatments, suggestions, and DCFS involvement, there was no reason for the mother to threaten the very people who tried to help her child and certainly not while [A.S.] was present. In fact, the mother's angry outbursts and threats, her untreated mental health diagnoses put [A.S.] at risk, as the mother is the sole and primary caretaker."
Because Veronica does not challenge the circuit court's disposition finding, we need not recount the evidence presented by the parties during the disposition hearing. --------
¶ 35 ANALYSIS
¶ 36 On appeal, Veronica solely challenges the circuit court's adjudication determination and argues that the court's findings of abuse and neglect are against the manifest weight of the evidence. She emphasizes that none of the State's witnesses ever observed any signs of physical abuse or neglect on A.S.'s person and that her residence was found to be safe and appropriate during the DCFS investigation. Veronica argues that she was merely an overprotective mother and that her concern for her daughter's physical wellbeing does not support a finding of abuse and neglect. ¶ 37 The State and Public Guardian, in turn, both respond that the circuit court properly found that A.S. was an abused and neglected minor. Both parties emphasize that the record demonstrated that Veronica breached her duty to provide a safe and nurturing environment for A.S. when she repeatedly sought unnecessary emergency medical treatment for her daughter for non-emergent medical conditions; failed to follow up with prescribed treatment recommendations; failed to tend to her own mental health needs; and threatened the social workers who were trying to help her child. ¶ 38 "The Juvenile Court Act is a statutory scheme, created by the legislature, the purpose of which is to secure for each minor subject thereto the care and guidance which will best serve the minor's safety and moral, emotional, mental and physical welfare, and the best interests of the community." In re Austin W., 214 Ill. 2d 31, 43 (2005); 705 ILCS 405/1-2(1) (West 2012). In order to effectuate this purpose, the Act sets forth the procedures and criteria to be used in deciding whether a minor should be removed from her parent's custody and made a ward of the court. In re A.P., 2012 IL 113875, ¶ 18; In re A.W., Jr., 231 Ill. 2d 241, 254 (2008). The best interest of the child is the standard applicable to all proceedings under the Juvenile Court Act. In re A.P., 2012 IL 113875, ¶ 18; In re Z.L. 379 Ill. App. 3d 353 (2008); see also In re M.W., 386 Ill. App. 3d 186, 196 (2008) ("The best interest of the child is the paramount consideration whenever a petition for adjudication of warship or any other proceeding is brought under the Juvenile Court Act of 1987"). In a juvenile proceeding, the intent is to determine the status of a minor child on whose behalf proceedings have been brought, not to assign criminal or civil liability to any party. In re R. B., 336 Ill. App. 3d 606, 614 (2003). Specifically, in an adjudicatory hearing, the issue is to determine whether or not a minor is abused or neglected. In re Austin W., 214 Ill. 2d at 43; 705 ILCS 405/2-21(1) (West 2012). It is the State's burden to prove allegations of abuse or neglect by the preponderance of the evidence. In re A.P., 2012 IL 113875, ¶ 17; In re L.H., 384 Ill. App. 3d 836, 841 (2008). A preponderance of the evidence is that amount of evidence that leads the trier of fact to find that a condition is "more probable than not." In re N.B., 191 Ill. 2d 338, 343 (2000). The trier of fact, in turn, is afforded broad discretion in determining whether a minor is abused or neglected (In re Audrey B., 2015 IL App (1st) 142909, ¶ 32), and as such, its determination will not be reversed unless it is against the manifest weight of the evidence (In re Tyianna J., 2017 IL App (1st) 162306, ¶ 51; In re L.H., 384 Ill. App. 3d at 841). A finding is against the manifest weight of the evidence only if the opposite conclusion is clearly apparent. In re Arthur H., 212 Ill. 2d 441, 464 (2004); In re Adam B., 2016 IL App (1st) 152037, ¶ 35; In re Christopher S., 364 Ill. App. 3d 76, 86 (2006). ¶ 39 As set forth above, the Act seeks to protect neglected and abused minors. 705 ILCS 405/2-3 (West 2012). Pursuant to the Act, an abused minor includes any child "under 18 years of age whose parent * * * (ii) creates a substantial risk of physical injury to such minor by other than accidental means which would be likely to cause death, disfigurement, impairment of emotional health, or loss or impairment of any bodily function." 705 ILCS 405/2-3(2)(ii) (West 2010). The Act, in turn, defines a neglected minor as any child "under 18 years of age who is not receiving the proper or necessary support, education as required by law, or medical or other remedial care recognized under State law as necessary for a minor's well-being, or other care necessary for his well-being, including adequate food, clothing and shelter, or who is abandoned by his or her parent or parents * * * ." 705 ILCS 405/2-3(1)(a) (West 2012). The term neglect also encompasses "any minor under 18 years of age whose environment is injurious to his or her welfare." 705 ILCS 405/2-3(1)(b) (West 2012). Although the phrase injurious environment is a "broad and amorphous concept," it "is understood to include 'the breach of a parent's duty to ensure a safe and nurturing shelter for the children.' " In re Alexis H., 401 Ill. App. 3d 543, 557 (2010) (quoting In re A.W., 231 Ill. 2d at 254). In general, neglect has been "defined as the failure to exercise the care that circumstances justly demand and includes both willful and unintentional disregard of parental duties." In re L.H., 384 Ill. App. 3d at 841; see also In re Adam B., 2016 IL App (1st) 152037, ¶ 34; In re Gabriel E., 372 Ill. App. 3d 817, 822 (2007); In re In re Christina M., 333 Ill. App. 3d 1030, 1034 (2002). Cases involving allegations of neglect and abuse are sui generis and must be resolved by evaluating the unique facts and circumstances present in each case. In re Arthur H., 212 Ill. 2d at 463; In re Jordyn L., 2016 IL App (1st) 150956, ¶ 29. ¶ 40 It is well-established that a child who does not receive appropriate medical evaluations or care is a neglected and abused minor under the Act. In re Adam B., 2016 IL App (1st) 152037, ¶ 38; In re Erin A., 2012 IL App (1st) 120050, ¶ 7; In re Stephen K., 373 Ill. App. 3d 7, 20 (2007). In this case, the testimonial and demonstrative evidence presented at the adjudication hearing established that A.S. was not the recipient of appropriate medical care. A.S.'s medical records established that she had visited the emergency room 55 times, which far exceeded the normal number of hospital visits that children her age have had. Doctor Ronayne, in pertinent part, testified that A.S. "had more presentations to the ER than 99.99 percent of the population at her age." Troublingly, A.S.'s ER presentations were mostly for non-emergent conditions. In addition, those emergency room visits occurred even though Veronica had been admonished to cease seeking unnecessary emergency medical treatment for her daughter. Doctor Ronayne explained that there are risks associated with unnecessary trips to the emergency room because emergency room personnel are trained to "act more aggressively" in treating individuals who seek treatment. Accordingly, Veronica's behavior thus the effect of potentially subjecting A.S. to unnecessary testing procedures, hospitalizations and medications. ¶ 41 The record further established that there were multiple instances in which Veronica received referrals for subsequent evaluation or treatment for her daughter yet failed to follow through with those recommendations. See, e.g., In re Adam B., 2016 IL App (1st) 152037, ¶¶ 38-40 (upholding the circuit court's abuse and neglect findings where the evidence established that the respondent mother "did not follow-up with the recommendations and treatments" to ensure her son's physical and mental well-being). In addition to seeking inappropriate emergency treatment for non-emergent conditions and failing to abide by suggested follow-up treatment, the record indicates that Veronica also made claims about her daughter's health that were unfounded. Doctor Ronanye testified that when Veronica brought A.S. to the Clinic in October 2015, she speculated that her daughter had pneumonia and requested that he perform a chest X-ray. A.S., however, did not present with any respiratory issues that would suggest a pneumonia diagnosis or warrant a chest X-ray. Moreover, when A.S. was examined outside of the presence of her mother and began verbalizing, she did not report feeling sick. Given the record, we are unable to conclude that the circuit court's finding that Veronica's behavior subjected her daughter to inappropriate medical care is against the manifest weight of the evdience. ¶ 42 Veronica's history of engaging in erratic and hostile behavior toward individuals seeking to help her daughter also supports the court's finding that A.S. was an abused and neglected minor. See, e.g., In re A.W., 231 Ill. 2d at 261-62 (concluding that the circuit court's finding that the minors were neglected because they were subjected to an injurious environment was not against the manifest weight of the evidence based in part, on the fact that the respondent father had a history of engaging in angry outbursts and issuing threats of violence to various individuals including DCFS personnel concerned with the minors' wellbeing). At the adjudication hearing, social workers Parrilla and Heard testified that they were both the recipients of Veronica's harassing and threatening phone calls. During those phone calls, Veronica used profanity, derogatory language and issued threats. According to Parrilla, at least one of those phone calls was placed in the presence of A.S. Parrilla and Heard were both compelled to file police reports in response to Veronica's harassment, and Veronica subsequently pled guilty to telephone harassment, a misdemeanor offense. Although Veronica's psychiatrist, Doctor Gartel, opined that Veronica was not afflicted with Munchausen by proxy disorder, she did testify that much of Veronica's behavior, including her aforementioned hostility toward social workers and her "overprotective" behavior in seeking out medical care for her daughter stemmed from her PTSD and bipolar diagnoses, both of which Veronica did not appropriately manage. The evidence thus supports a finding that Veronica's mental health issues impacted her ability to successfully parent A.S. See, e.g., In re Faith B., 349 Ill. App. 3d 930, 933 (2004) (recognizing that children of parents who suffer from psychiatric illness may be found to be abused and neglected under the Act where there is a "nexus between the illness and [the] risk of harm to the children"). ¶ 43 Ultimately, after considering the totality of the evidence, we are unable to conclude that the circuit court's findings that A.S. was exposed to an injurious environment (705 ILCS 405/2-3(1)(b) (West 2012)) and was at substantial risk for injury (705 ILCS 2/3(2)(ii) (West 2012)) are against the manifest weight of the evidence. We therefore affirm the circuit court's adjudication order.
¶ 44 CONCLUSION
¶ 45 The judgment of the circuit court is affirmed. 23 ¶ 46 Affirmed.