IN THE MATTER OF: Arielle McCabe
Lanier & Fountain, by Timothy R. Oswalt, for respondent
appellant.
James W. Joyner for petitioner appellee.
TIMMONS-GOODSON, Judge.
Karrie McCabe (“respondent”) appeals from an order of the
trial court adjudicating her minor daughter (“juvenile”) abused and
neglected. For the reasons stated herein, we affirm the order of
adjudication.
The facts pertinent to the instant appeal are as follows:
Respondent is the natural mother of juvenile, who was born 24 May
1999. On 18 January 2001, Thomas McCabe (“McCabe”), respondent's
former husband and the natural father of juvenile, served
respondent with a civil domestic petition of custody for juvenile.
On 9 February 2001, the Onslow County Department of Social
Services (“DSS”) filed a petition alleging juvenile to be abused
and neglected, on the grounds that juvenile was admitted to a
hospital on 29 January 2001 for a history of intermittent episodes
of cyanosis, or “blue spells.” Respondent told admitting hospital
physicians that juvenile's hands and feet, as well as the areaaround her mouth, had turned blue numerous times within the
previous days, and that respondent brought juvenile to the hospital
after she lost consciousness during the latest incident.
Respondent asserted that juvenile was particularly likely to
exhibit such symptoms when cold, and that she was lethargic and
unresponsive during such episodes. According to respondent,
juvenile had exhibited these symptoms since her “neonatal period.”
Treating physicians later diagnosed juvenile's condition as being
possibly induced by respondent. DSS therefore requested that
custody of juvenile be placed with McCabe, and that any visitation
between respondent and juvenile be supervised. The trial court
issued an order for nonsecure custody placing physical custody of
juvenile with McCabe.
The adjudication hearing was held before the trial court on 29
March 2001, at which time the following evidence was presented:
Dr. Elaine Kabeanfuller (“Dr. Kabeanfuller”), a pediatrician
specializing in the treatment of abused children, testified to a
form of child abuse known as Munchausen syndrome by proxy. Dr.
Kabeanfuller explained that Munchausen syndrome by proxy
was first described in 1977 by a Dr. Roy
Meadow. . . . [H]e was the first one to put
case reports out in the literature [and] since
then there have been hundreds of case reports
and many reviews and actual books written on
the subject. It is a case where we often see
children where they have . . . either a parent
or caretaker [who] will either simulate or
induce an illness in the child, present them
for medical care multiple times, [and] often
. . . deny any knowledge of . . . the symptoms
or the signs, what their etiology is and then
when that child is removed from that caretaker
or parent's care, these signs and symptomsabate and no longer occur.
Dr. Kabeanfuller testified that she became involved in the present
case in February of 2001 after the hospital physicians who were
treating juvenile requested her consultation on the case. After
observing juvenile, interviewing respondent and treating health
care professionals, reviewing juvenile's medical history as well as
records from juvenile's daycare providers, and consulting other
medical experts, Dr. Kabeanfuller opined that juvenile possibly
suffered from Munchausen syndrome by proxy. Dr. Kabeanfuller
specifically based her opinion on the fact that juvenile's cyanotic
episodes, witnessed by her daycare providers and reported by
respondent as occurring “every day” before juvenile's
hospitalization, occurred only after juvenile had been in the
exclusive care of respondent. Numerous medical procedures revealed
no organic abnormalities in the child, and juvenile never exhibited
any symptoms during her eleven days in the hospital. When she
later learned during her testimony that juvenile had shown no sign
of the symptoms reported by respondent since being removed from
respondent's care, Dr. Kabeanfuller altered her diagnosis from
“possible” Munchausen syndrome by proxy to “probable.”
Dr. Kabeanfuller further stated that juvenile also potentially
suffered from “Vulnerable Child Syndrome,” which she explained as
a syndrome we sometimes see in pediatrics
where a child who is otherwise well and
healthy is presented multiple times for
medical care by a parent or caretaker who is
convinced that the child is ill or has some
serious symptoms and requires a lot of
reassurance by the physicians or medical
personnel but in fact there is no organicdisease process going on in the child.
Dr. Kabeanfuller noted that
[t]here's a continuum of an illness going from
Vulnerable Child all the way to Munchausen
syndrome where you have Vulnerable Child where
the child actually is well and the parent is
just overly concerned, and then the next, it
can evolve into a Munchausen syndrome by
proxy, um, type situation because you can have
a child whose parents or caretaker believes
that they're ill when they truly are not or
may, may evolve into a parent who creates
symptoms or fabricates a history in order to
present that child to various physicians and
receive various medical procedures.
The risk of morbidity or mortality associated with Munchausen
syndrome by proxy, according to Dr. Kabeanfuller, is fifteen to
thirty percent. This form of abuse may also lead to survivors
being “very fearful, and they often have some psychological
illnesses of their own, later on.” Dr. Kabeanfuller added that,
during her hospitalization, juvenile underwent extensive, painful,
and invasive medical procedures to determine the source of the
symptoms described by respondent.
Dr. Dale Newton (“Dr. Newton”), a pediatrician and expert in
child abuse, testified on behalf of DSS. Dr. Newton treated
juvenile during her hospitalization and concurred with Dr.
Kabeanfuller's diagnosis of Munchausen syndrome by proxy as
probable. Dr. Newton testified that he became juvenile's primary
treating physician when respondent dismissed juvenile's original
physician, Dr. Stephen Boyce Coker (“Dr. Coker”), after Dr. Coker
diagnosed juvenile as suffering from Munchausen syndrome by proxy.
During her hospitalization, juvenile underwent numerous medicalprocedures to screen out any possible organic abnormality. In Dr.
Newton's opinion, juvenile's cyanotic episodes were potentially
induced by either smothering or administration of a toxin. Dr.
Newton agreed with Dr. Kabeanfuller that returning juvenile to the
care of respondent would put juvenile at risk of harm.
Dr. Coker, a pediatric neurologist, gave further testimony.
Dr. Coker stated that he examined juvenile on 25 January 2001 when
respondent brought her to the hospital. Based on respondent's
reports of frequent cyanotic episodes, Dr. Coker originally
believed juvenile to be suffering from a form of epilepsy, but
changed his diagnosis to Munchausen syndrome by proxy after medical
procedures revealed no abnormalities and juvenile exhibited no
symptoms after five days in the hospital. After Dr. Coker advised
respondent of his diagnosis, she requested his removal as
juvenile's treating physician.
Stephanie Leger (“Leger”), a registered pediatric nurse,
testified that while juvenile was under her care at the hospital,
respondent attempted to induce a cyanotic episode in juvenile by
giving the child popsicles. Respondent asked Leger “what did [she]
think would happen when [respondent] put [the popsicles] in
[juvenile's] hand?” Respondent then placed two wrapped popsicles
in juvenile's grasp and asked Leger if she observed juvenile's
“feet . . . turning colors, her hands turning violet colors.”
Despite respondent's insistence that juvenile was “turning blue,”
Leger did not observe any blue or violet discoloration.
Respondent presented testimony by Dr. David Hannon (“Dr.Hannon”), a pediatric cardiologist. Dr. Hannon consulted with
juvenile's physicians during her hospitalization and diagnosed
juvenile as suffering from what he labeled as “benign paroxysmal
acrocyanosis.” Dr. Hannon explained
[t]hat's simply a linking of three terms,
benign would indicate that I believe that
children who do this do not have a serious
medical illness. Paroxysmal is just a medical
word meaning that it occurs very suddenly and
acrocyanosis means that [you're] blue but
distally blue in the hands and feet. So this
is not an established medical diagnosis
although I have written a small piece for an
educational thing to the American Academy of
Pediatrics on it mainly because I think that
it probably, well I know that something like
this does occur, whether my understanding of
physiology is correct or not, I can't say.
Dr. Hannon testified that he had witnessed two other patients in
the past who exhibited bluish discoloration similar to juvenile's.
Dr. Hannon stated that he was “not particularly surprised” that
juvenile had shown no further discoloration since her removal from
respondent's care, because benign paroxysmal acrocyanosis tends to
“have a spontaneous resolution.” Dr. Hannon conceded that benign
paroxysmal acrocyanosis and Munchausen syndrome by proxy are not
mutually exclusive, and that juvenile might be suffering from both.
Dr. James Gant (“Dr. Gant”), juvenile's primary pediatrician,
testified on behalf of respondent. Dr. Gant stated that juvenile
had been his patient since birth, and that she had grown and
developed normally. Dr. Gant referred juvenile to Dr. Coker
because of the descriptions that we have from
the day care center, there's a note in her
chart from the day care workers and they
described lethargy and some other symptoms
that didn't seem to fit with the cardiac typeof problem and so my main concern was that she
had possibly a seizure disorder because she
was lethargic either during or after and they
said “unresponsive” and I don't know, you
know, for a fact, that's what she was because
we didn't witness the episode.
Dr. Gant agreed with Dr. Hannon's diagnosis of benign paroxysmal
acrocyanosis, but nevertheless recommended a psychological
evaluation for respondent because she was “so hysterical and
anxious and nervous and overly, almost paranoid about us taking the
baby away and how things were going” and that “if you are
histrionic or [overly] anxious or nervous, that does affect the
child and it [a]ffects how they respond.” Dr. Gant testified that
he had spoken with respondent about the fact that her two other
children were no longer in her custody. When asked about
Munchausen syndrome by proxy, Dr. Gant responded “that's something
that I don't know that I can say.” Dr. Gant also admitted that he
considered “taking a restraining order out on [respondent]” because
she was at our office so many times and she
was very histrionic, um, it was causing a lot
of problems because we couldn't actually keep
functioning, but we were trying to support her
and the only reason we didn't was because I
know she was stressed out. I knew she was
very anxious and I felt like, well maybe this
would help her deal with it a little bit, um,
so we just kind of kept, I talked to all the
other physicians in the practice and we all
agreed that, you know, we'd kind of just work
with her. And she did come in numerous times
when we didn't have appointments or things
like that.
Ann Bell (“Bell”), a pediatric nurse employed by Dr. Gant's
office, testified that she witnessed a cyanotic episode in
juvenile. On 27 August 2000, respondent brought juvenile to theoffice. Bell stated that juvenile
was sitting on the table, the exam table, in
her diaper . . . and she was fine and then all
of a sudden she just started to turn blue
[and] she got cold. And I felt her legs and
her arms and I went and got [a physician].
[The blue color] started from the very tips of
her fingers and her toes and it just gradually
went up to the trunk of her body and she had
some bluish tinge around her lips.
Bell stated that the discoloration lasted from fifteen to twenty
minutes, during which juvenile remained active and exhibited
otherwise normal behavior.
Kathy Moore (“Moore”), a child care provider at juvenile's
daycare, testified that juvenile twice exhibited symptoms of
cyanosis after being dropped off at the school by respondent.
Moore stated that juvenile was lethargic and “kind of out of it”
with a “purple color and she was purple toned on her arms, her
legs, and around her mouth.” In both instances, juvenile's skin
remained discolored for at least thirty minutes. Moore never
observed these symptoms in juvenile at any other time of day.
Debra Lewis (“Lewis”), a social worker with DSS, testified that,
since juvenile's removal from respondent's care, there have been no
further reports of any cyanotic episodes by juvenile.
Upon consideration of the evidence, the trial court found and
concluded that there was clear, cogent and convincing evidence that
respondent abused and neglected juvenile, and that it was in the
best interests of juvenile to remain in the custody of her father.
From the adjudication of abuse and neglect, respondent appeals.
__________________________________________________ Respondent argues on appeal that the trial court erred in
determining that juvenile was abused and neglected, asserting that
there was insufficient evidence to support such a determination.
We disagree and affirm the order of adjudication of the trial
court.
When an appellant asserts that an adjudication order of the
trial court is unsupported by the evidence, this Court examines the
evidence to determine whether there exists clear, cogent and
convincing evidence to support the findings. See N.C. Gen. Stat.
§§ 7B-805, 807 (2001); In re Allen, 58 N.C. App. 322, 325, 293
S.E.2d 607, 609 (1982). If there is competent evidence, the
findings of the trial court are binding on appeal. See id; In re
Smith, 56 N.C. App. 142, 149, 287 S.E.2d 440, 444, cert. denied,
306 N.C. 385, 294 S.E.2d 212 (1982). Such findings are moreover
conclusive on appeal even though the evidence might support a
finding to the contrary. See In re Hughes, 74 N.C. App. 751, 759,
330 S.E.2d 213, 218 (1985). “The trial judge determines the weight
to be given the testimony and the reasonable inferences to be drawn
therefrom. If a different inference may be drawn from the
evidence, he alone determines which inferences to draw and which to
reject.” Id.
Under section 7B-101 of our General Statutes, an abused
juvenile includes “[a]ny juvenile less than 18 years of age whose
parent . . . [c]reates or allows to be created a substantial risk
of serious physical injury to the juvenile by other than accidental
means[.]” N.C. Gen. Stat. § 7B-101(1) (2001). A neglectedjuvenile is one who
does not receive proper care, supervision, or
discipline from the juvenile's parent,
guardian, custodian, or caretaker; or who has
been abandoned; or who is not provided
necessary medical care; or who is not provided
necessary remedial care; or who lives in an
environment injurious to the juvenile's
welfare; or who has been placed for care or
adoption in violation of law. In determining
whether a juvenile is a neglected juvenile, it
is relevant whether that juvenile lives in a
home where another juvenile has died as a
result of suspected abuse or neglect or lives
in a home where another juvenile has been
subjected to abuse or neglect by an adult who
regularly lives in the home.
N.C. Gen. Stat. § 7B-101(15) (2001).
After reviewing the record, we conclude that there was clear,
cogent and convincing evidence to support the trial court's
findings and conclusions concerning respondent's neglect and abuse
of juvenile. Three physicians, two of whom were experts in the
area of child abuse, testified that juvenile was the victim of
Munchausen syndrome by proxy, a form of child abuse with a
substantial risk of morbidity and even mortality. During her
hospitalization, juvenile repeatedly underwent numerous extensive,
painful, and invasive medical procedures to determine the source of
symptoms reported by respondent. Dr. Newton opined that respondent
potentially induced these symptoms by either smothering juvenile or
administering a toxin. None of the medical procedures revealed any
organic abnormalities in juvenile, and she never exhibited any
symptoms or “blue spells” during her eleven-day stay at the
hospital. Nor has there been any resumption of symptoms since
juvenile was removed from respondent's care. The only cyanoticepisode witnessed in its entirety by an individual other than
respondent occurred at Dr. Gant's office and was witnessed by Bell.
Bell confirmed, however, that juvenile remained active and alert
during this episode. In contrast, juvenile's daycare providers
testified that juvenile was lethargic and unresponsive during such
episodes, which only occurred shortly after juvenile was dropped
off by respondent and the onset of which were never witnessed by
the daycare providers.
Although the evidence presented by Dr. Hannon did raise
conflicting inferences as to the cause of juvenile's cyanotic
episodes, Dr. Hannon conceded that benign paroxysmal acrocyanosis
and Munchausen syndrome by proxy are not mutually exclusive, and
that juvenile might be suffering from both. The trial judge
weighed the conflicting inferences and determined that juvenile was
the victim of Munchausen syndrome by proxy. Because there was
evidence to support these findings, they are binding on appeal.
See Hughes, 74 N.C. App. at 759, 330 S.E.2d at 218. The evidence
and the trial court's findings clearly demonstrated that there
existed a substantial risk of serious physical injury to juvenile,
and that juvenile lived in an environment injurious to her welfare.
In conclusion, we hold that there was clear and convincing
evidence to support the trial court's adjudication of neglect and
abuse by respondent. We therefore affirm the adjudication of the
trial court.
Affirmed.
Judges BRYANT and GEER concur.
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