In Re: Travion L.M.B. ( 2013 )


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  •                  IN THE COURT OF APPEALS OF TENNESSEE
    AT KNOXVILLE
    May 13, 2013 Session
    IN RE TRAVION B. ET AL.
    Appeal from the Juvenile Court for Knox County
    No. 73540     Timothy Irwin, Judge
    No. E2012-01673-COA-R3-PT-FILED-AUGUST 19, 2013
    This is a termination of parental rights case focusing on Travion B. and Davion B., the minor
    children (“Children”) of Samantha B. (“Mother”). The Children were taken into protective
    custody by the Tennessee Department of Children’s Services (“DCS”) on January 24, 2011,
    after the younger child suffered a head injury. On October 6, 2011, DCS filed a petition to
    terminate the parental rights of Mother. Following a bench trial spanning four days, the trial
    court granted the petition upon its finding, by clear and convincing evidence, that Mother had
    committed severe child abuse. The court further found, by clear and convincing evidence,
    that termination of Mother’s parental rights was in the Children’s best interest.1 Mother has
    appealed. We affirm.
    Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Juvenile Court
    Affirmed; Case Remanded
    T HOMAS R. FRIERSON, II, J., delivered the opinion of the Court, in which C HARLES D.
    S USANO, J R., P.J., and D. M ICHAEL S WINEY, J., joined.
    Ben H. Houston, II, Knoxville, Tennessee, for the appellant, Samantha B.
    Robert E. Cooper, Jr., Attorney General and Reporter, and Alexander S. Rieger, Assistant
    Attorney General, Nashville, Tennessee, for the appellee, Tennessee Department of
    Children’s Services.
    1
    According to the petition for termination of Mother’s parental rights, Travion and Davion had
    different fathers whose identities were confirmed by paternity testing. DCS sought termination of the
    fathers’ respective parental rights through proceedings independent of this action.
    OPINION
    I. Factual and Procedural Background
    The injury giving rise to the allegation of severe child abuse in this action became
    apparent when Davion, who was six months old, was transported by ambulance to East
    Tennessee Children’s Hospital in the early morning hours of January 22, 2011. Davion was
    diagnosed with a subdural hematoma and bilateral retinal hemorrhages. His treating
    pediatrician, Dr. Marymer Perales, testified at the trial that these injuries were indicative of
    inflicted trauma, specifically by rotation or acceleration/deceleration forces inflicted by
    shaking. The older child, Travion, was sixteen months old at the time and was not alleged
    to have suffered abusive injury.
    Mother was sixteen years old when Travion was born and seventeen upon Davion’s
    birth. At the time of Davion’s injury, Mother and the Children had been residing with
    Mother’s friend, D.B., for two to three weeks in D.B.’s apartment. Also living in the home
    were D.B.’s two children and her mother, M.C. Mother and the Children slept together in
    the one bed in Mother’s bedroom. D.B. and her two children occupied the other bedroom
    while M.C. slept on the couch in the living room.
    On January 22, 2011, Davion awoke crying at approximately 2:00 a.m. Mother
    testified that she tried to comfort Davion for approximately ten minutes before he “shivered”
    for about five seconds and then threw his head back with his eyes rolling back in his head.
    Mother said she placed Davion on the carpeted floor to protect his neck and went into D.B.’s
    room to awaken her for help. As Mother explained, she picked up Travion, who was
    sleeping, and carried him as she went to D.B. for assistance. D.B. and M.C. both indicated
    at trial that Mother had neither child in her arms when she went to D.B.’s room.
    Mother and D.B. came back into Mother’s room where Davion remained on the floor.
    Testimony differed as to whether D.B. picked up Davion and attempted to rouse him when
    Mother and she returned to Mother’s room. At some point M.C. entered the room, picked
    up Davion, and attempted to rouse him. D.B., at Mother’s request, called 911 to summon
    emergency medical responders. Mother testified at the trial that thirty to forty-five minutes
    passed between the time Davion’s crying awakened her and the call to 911 was made. She
    admitted telling investigators on January 22, 2011, that only four or five minutes elapsed
    before she asked D.B. to call 911. Davion was transported by ambulance to East Tennessee
    Children’s Hospital.
    The Children were placed in the emergency protective care of DCS on January 22,
    2011. The trial court entered a protective custody order on January 24, 2011. On October
    -2-
    6, 2011, DCS filed a petition to terminate the parental rights of Mother as to the Children.
    Following a bench trial held over four non-consecutive days beginning March 8, 2012, and
    concluding August 2, 2012, the trial court found by clear and convincing evidence that
    Mother had committed severe child abuse against Davion and that it was in the best interest
    of the Children to terminate Mother’s parental rights. The trial court entered its final decree
    on January 2, 2013. Mother timely appealed.
    II. Issues Presented
    On appeal, Mother presents two issues, which we have restated as follows:
    1.     Whether the trial court erred by finding clear and convincing evidence that
    Mother had committed severe child abuse and by terminating Mother’s
    parental rights based on that ground pursuant to Tennessee Code Annotated §§
    37-1-102(b)(23)(A) and 36-1-113(g)(4).
    2.     Whether the trial court erred by finding clear and convincing evidence that it
    was in the Children’s best interest to terminate Mother’s parental rights.
    III. Standard of Review
    In a termination of parental rights case, this Court has a duty to determine “whether
    the trial court’s findings, made under a clear and convincing standard, are supported by a
    preponderance of the evidence.” In re F.R.R., III, 
    193 S.W.3d 528
    , 530 (Tenn. 2006). The
    trial court’s findings of fact are reviewed de novo upon the record, accompanied by a
    presumption of correctness unless the evidence preponderates against those findings. Id.;
    Tenn. R. App. P. 13(d). Questions of law, however, are reviewed de novo with no
    presumption of correctness. In re Bernard T., 
    319 S.W.3d 586
     (Tenn. 2010). The trial
    court’s determinations regarding witness credibility are entitled to great weight on appeal and
    shall not be disturbed absent clear and convincing evidence to the contrary. See Jones v.
    Garrett, 
    92 S.W.3d 835
    , 838 (Tenn. 2002).
    “Parents have a fundamental constitutional interest in the care and custody of their
    children under both the United States and Tennessee constitutions.” Keisling v. Keisling, 
    92 S.W.3d 374
    , 378 (Tenn. 2002). It is well established, however, that “this right is not absolute
    and parental rights may be terminated if there is clear and convincing evidence justifying
    such termination under the applicable statute.” In re Drinnon, 
    776 S.W.2d 96
    , 97 (Tenn. Ct.
    App. 1988) (citing Santosky v. Kramer, 
    455 U.S. 745
    , 
    102 S. Ct. 1388
    , 
    71 L. Ed. 2d 599
    (1982)). As our Supreme Court has instructed:
    -3-
    In light of the constitutional dimension of the rights at stake in
    a termination proceeding under Tenn. Code Ann. § 36–1–113,
    the persons seeking to terminate these rights must prove all the
    elements of their case by clear and convincing evidence. Tenn.
    Code Ann. § 36–1–113(c); In re Adoption of A.M.H., 215
    S.W.3d at 808–09; In re Valentine, 
    79 S.W.3d 539
    , 546 (Tenn.
    2002). The purpose of this heightened burden of proof is to
    minimize the possibility of erroneous decisions that result in an
    unwarranted termination of or interference with these rights. In
    re Tiffany B., 
    228 S.W.3d 148
    , 155 (Tenn. Ct. App. 2007); In re
    M.A.R., 
    183 S.W.3d 652
    , 660 (Tenn. Ct. App. 2005). Clear and
    convincing evidence enables the fact-finder to form a firm belief
    or conviction regarding the truth of the facts, In re Audrey S.,
    
    182 S.W.3d 838
    , 861 (Tenn. Ct. App. 2005), and eliminates any
    serious or substantial doubt about the correctness of these
    factual findings. In re Valentine, 79 S.W.3d at 546; State, Dep’t
    of Children’s Servs. v. Mims (In re N.B.), 
    285 S.W.3d 435
    , 447
    (Tenn. Ct. App. 2008).
    In re Bernard T., 319 S.W.3d at 596.
    IV. Severe Child Abuse
    The trial court terminated Mother’s parental rights on the statutory ground that she
    committed severe child abuse. Tennessee Code Annotated § 36-1-113(g)(4) (Supp. 2012),
    as relevant to this action, provides:
    (g) Initiation of termination of parental or guardianship rights may be based
    upon any of the grounds listed in this subsection (g). The following grounds
    are cumulative and non-exclusive, so that listing conditions, acts or omissions
    in one ground does not prevent them from coming within another ground:
    ***
    (4) The parent or guardian has been found to have committed
    severe child abuse as defined in § 37-1-102, under any prior
    order of a court or is found by the court hearing the petition to
    terminate parental rights or the petition for adoption to have
    committed severe child abuse against the child who is the
    subject of the petition or against any sibling or half-sibling of
    -4-
    such child, or any other child residing temporarily or
    permanently in the home of such parent or guardian . . . .
    Tennessee Code Annotated § 37-1-102(b)(23) (Supp. 2012) defines “severe child abuse,” in
    relevant part, as:
    (A)(i) The knowing exposure of a child to or the knowing failure to protect a
    child from abuse or neglect that is likely to cause serious bodily injury or death
    and the knowing use of force on a child that is likely to cause serious bodily
    injury or death . . . .
    As this Court has previously explained:
    a parent’s conduct is “knowing, and a parent acts or fails to act ‘knowingly,’
    when . . . she has actual knowledge of the relevant facts and circumstances or
    when . . . she is either in deliberate ignorance of or in reckless disregard of the
    information that has been presented to . . . her.”
    In re H.L.F., 
    297 S.W.3d 223
    , 236 (Tenn. Ct. App. 2009) (quoting In re R.C.P., No. M2003-
    01143-COA-R3-PT, 
    2004 WL 1567122
     at *7 (Tenn. Ct. App. July 13, 2004)).
    In its order terminating Mother’s parental rights, the trial court summarized its
    findings of fact regarding severe child abuse as follows:
    The Court is persuaded by the testimony from Dr. Perales that the
    incident causing this child’s injuries occurred at the time the mother and her
    two small children were alone in the bedroom, shortly before 911 was called.
    The child suffered a subdural hematoma and severe retinal hemorrhages.
    Those findings and the lack of obvious external trauma points to shaking as the
    cause of this child’s injuries. The injuries were not self-inflicted, not inflicted
    by the then-16-month-old brother, and did not occur during the normal course
    of child care. The court finds, by clear and convincing evidence, that [Mother]
    caused Davion’s injuries.
    Mother offered no explanation at all for the child’s injuries, other than
    a fall from a low couch onto a carpeted floor, and the child hitting his head on
    the tub. Her story was inconsistent, in many respects, from initial interviews
    to her testimony in Court. (Whether she went to D.B.’s room, or screamed for
    D.B. to come to [Mother’s] room; the length of time for the mother to call 911
    (4-5 minutes vs. 30-45 minutes); where mom was when Travion pulled Davion
    -5-
    off the couch, on the couch next to Davion, or in the love seat across from
    Davion; whether mom was even in the room when it happened; whether
    Davion cried or did not cry when pulled off the couch; whether or not others
    cared for Davion at all; when others cared for Davion (the day before, the
    week before, or two weeks before the incident; and whether Davion hit his
    head on a ceramic bathtub as opposed to a plastic baby tub, to name a few.)
    Dr. Perales ruled out the fall and the tub incident as possible causes of
    the child’s injuries by stating that this injury was not caused by the child
    himself or by a child of the same age as this child’s older brother, and by
    opining that this was inflicted, not accidental trauma. Mother placed herself
    alone with the child at the time the child became symptomatic. She indicated
    that, on two separate occasions, others had cared for her child, contrary to her
    first assertions to law enforcement and DCS. However her recollection of
    when those incidents occurred was very vague – they could have happened the
    day before and the week before the incident, or they could have happened the
    week before and two weeks before the incident. In any case, mother denied
    that Davion appeared in any way to be acting significantly differently after
    being cared for by others. She also denied that the child acted significantly
    differently after the fall and the bathtub incident. She had no concern
    significant enough to lead her to believe that Davion should see the doctor
    after either the fall or the bathtub incident, or after others cared for Davion.
    She had no reason to believe that he was injured significantly while in the care
    of others. This Court also has no reason to so believe.
    The Court considers it odd that [Mother] would leave Davion, in
    obvious distress, on the floor, and take the well child, Travion, with her to get
    help from [D.B.].
    The Court has known [Mother] for a long time, and is surprised to come
    to the conclusion that she could have hurt her child. However, the testimony
    of [M.C.], reluctantly given, that the mother threatened to throw the baby
    against the wall if he does not stop crying, together with the other facts, leads
    the Court to the conclusion that she did become frustrated and did something
    to Davion to cause his injuries. This conclusion is supported by [D.B.’s]
    testimony that she heard, that night, Davion crying and then stop. This Court
    did give much credibility to the testimony of [D.B.] and [M.C.], but the Court
    -6-
    does [sic]2 believe their testimony regarding the statements of the mother, and
    that the child stopped crying.
    [Mother] has had ample opportunity to acknowledge what this Court
    has found, that she injured her child, and has had ample opportunity to take
    advantage of mental health counseling to address the underlying issues leading
    her to such actions. She, however, has failed to do so.
    Based on the totality of the testimony, the trial court determined that the statutory
    ground of severe child abuse had been proven by clear and convincing evidence. Mother
    contends that the trial court erred in this finding because the court’s reliance on Dr. Perales’s
    testimony was misplaced according to recent developments in the medical research
    surrounding injuries caused by rotation or acceleration/deceleration trauma, commonly
    known as shaken baby syndrome. We disagree.
    Dr. Perales testified that she is a child abuse pediatrician at East Tennessee Children’s
    Hospital and that she treated Davion in the emergency room on January 22, 2011, as well as
    throughout his hospitalization. She said that a computerized axial tomography (“CT”) scan
    performed upon Davion’s admission revealed a left-sided subdural hematoma. She explained
    that a subdural hematoma is “blood in the area between the dura and arachnoid . . . but
    between two layers of the area between the brain and the scalp that is not a space that is
    necessarily always there, it’s just a potential space where blood vessels go through.”
    According to Dr. Perales, it is abnormal to find a subdural hematoma in a child, and trauma
    is a likely cause. She explained that on January 22, the subdural hematoma was acute,
    indicating that it was recent. The subdural hematoma had become subacute by the time a
    second CT scan was performed on January 24, 2011. Dr. Perales testified that there is
    usually a seventy-two hour window during which an acute subdural hematoma may resolve
    itself and become subacute. Based on everything she knew about Davion, Dr. Perales opined
    that his head injury occurred when he became symptomatic, which event was described by
    Mother as happening in the middle of the night a few hours before his hospitalization on
    January 22, 2011.
    Dr. Perales had previously treated Davion during a September 2010 hospitalization
    when he was diagnosed with bronchiolitis. She consulted with a neurologist at that time
    because Davion presented “high tone, or stiffness and jerkiness in his joints.” She testified
    that it was possible Davion sustained an injury to the brain prior to being treated in
    2
    In its ruling from the bench, the trial court stated about D.B. and M.C.: “I didn’t find those two
    witnesses very credible . . . . But there’s no reason to believe that they were lying when they said the crying
    stopped.”
    -7-
    September 2010. She was certain, however, that he did not have a subdural hematoma at that
    time because the CT scan taken during the 2010 admission did not indicate one. During the
    January 2011 admission, Dr. Perales observed that Davion’s tone was significantly lower.
    She opined that this reduction in tone may have been due to the head injury, as she would
    expect “low tone” in a child with such a condition.
    Upon Davion’s January 22, 2011 admission, Dr. Perales requested an ophthalmology
    consultation, which revealed that Davion had bilateral retinal hemorrhages in multiple layers
    and multiple quadrants of the eyes, indicating a greater likelihood of inflicted trauma. Dr.
    Perales maintained that Davion’s injuries were consistent with injuries caused by rotation or
    acceleration/deceleration. She opined that the injuries had been sustained by Davion within
    twenty-four hours of his hospitalization and that the injuries could not have been self-
    inflicted or inflicted by a sixteen-month-old child such as Davion’s brother. Instead, she said
    there were two possibilities for how trauma could have resulted in Davion’s injuries, one was
    by direct impact and the other by rotational or acceleration/deceleration forces. She found
    no sign of direct impact in this case, concluding that rotational or acceleration/deceleration
    forces had caused the injury.
    Dr. Perales considered the radiologist’s report when she reached her conclusion
    regarding Davion’s injuries. She said the radiologist believed there could have been a
    previous subdural hematoma and that the blood from the new hematoma was mixing with
    the prior injury. Dr. Perales explained that infants with subdural hematomas will sometimes
    form protective membranes around the bleeds. According to Dr. Perales, research exists
    suggesting that membrane formation could be a reason for some infants’ hematomas healing
    more slowly than others. When asked if an “old brain bleed” could have “rebled causing the
    subdural hematoma,” Dr. Perales answered:
    I guess in theory it could, the – if you read through my consult, though,
    as I took everything into consideration, I don’t believe I ever wrote that I felt
    that there was an old bleed there. I do acknowledge that from the first CT to
    the second CT there was increased space, but give into account that the
    previous CTs were normal, it’s not what I felt the process was. Or the
    progression was.
    Dr. Perales further explained that subdural hematomas in infants can be asymptomatic.
    She noted that the subdural hematomas that are not so large as to require surgical evacuation
    usually heal on their own. When questioned regarding the principle of “rebleeding,” she said
    the research regarding rebleeding has focused primarily on geriatric patients who would
    sometimes reinjure a healing subdural hematoma and experience rebleeding as a result. She
    noted there was some application of this research to hydrocephalic babies, or those with fluid
    -8-
    on the brain, but that the research had not been applied to babies who suffered subdural
    hematomas during the birth process.
    During the trial, Mother denied ever shaking Davion. She recounted two incidents
    occurring approximately a week before his hospitalization that she believed could have
    caused his injury. The first was a fall from the couch in the apartment when Travion pulled
    Davion onto the floor by his bib. The second was a self-inflicted impact against the side of
    a bathtub when Davion flung back his head while she was giving him a bath. Mother’s
    testimony was unclear as to exactly when these incidents occurred, although she
    acknowledged telling investigators in January 2011 that the bathtub incident occurred on
    Tuesday, January 18. She initially testified at trial that the bathtub was a regular ceramic tub
    but later acknowledged having told investigators in January 2011 that it was a plastic tub.
    Mother further testified that Davion had been cared for by someone other than herself
    twice during the week before the injury. The first occasion was approximately a week before
    Davion was hospitalized. Mother and D.B. had gone to a club together, with Mother leaving
    Davion in the care of her best friend’s sister for about four hours. The second occasion was
    during the afternoon of January 21, 2011, when Mother drove with the Children’s maternal
    grandmother to purchase diapers and make a car payment, leaving Davion in D.B.’s care for
    about forty-five minutes. D.B. testified that she remembered Mother leaving to make the car
    payment that day but did not recall if she provided care for Davion while Mother was gone.
    M.C. testified that she was present at the apartment on January 21, 2011. She remembered
    D.B. caring for Davion while Mother left with the maternal grandmother. Mother at one
    point testified that she thought this trip with the maternal grandmother could have been the
    previous Friday, specifically January 14.
    Mother presented no expert witness at the trial. On appeal, Mother cites three
    authorities to support her assertion that recent developments in medical research should lead
    us to question Dr. Perales’s testimony regarding the cause of Davion’s injury. The first is
    a 2010 United States Supreme Court dissenting opinion in which a three-justice minority
    explained that recent medical research questioned whether in the first year of an infant’s life,
    the effects of shaken baby syndrome could be mimicked by the opening and rebleeding, upon
    minimal impact, of small subdural hematomas that were the natural result of the birth
    process. See Cavozos v. Smith, 
    132 S. Ct. 2
    , 11 (2011) (Ginsburg, J., dissenting) (opposing
    the majority’s holding that evidence was sufficient to uphold the jury’s finding that the victim
    died from shaken baby syndrome and subsequent criminal verdict against the defendant).
    The second authority Mother cites is a published opinion from a state intermediate
    appellate court in Wisconsin in which a criminal defendant convicted of first degree reckless
    homicide was granted a new trial, based on newly discovered evidence in the form of
    -9-
    research developments surrounding shaken baby syndrome. See State v. Edmunds, 
    746 N.W.2d 590
    , 592-94, 599 (Wis. Ct. App. 2008). The third authority is a 2009 Washington
    University Law Review article examining medical research that questions the “diagnostic
    triad” of “retinal bleeding, bleeding in the protective layer of the brain, and brain swelling”
    as sufficient grounds for a court to make a criminal determination of child abuse by shaken
    baby syndrome. See Deborah Tuerkheimer, The Next Innocence Project: Shaken Baby
    Syndrome and the Criminal Courts, 87 Wash. U.L. Rev. 1, 58 (2009).
    These authorities upon which Mother relies in support of her position do not constitute
    controlling authority for Tennessee courts. See, e.g., Culbreath v. First Tenn. Bank Nat’l
    Assoc., 
    44 S.W.3d 518
    , 526-27 (Tenn. 2001) (determining that cases from other jurisdictions
    and law review articles cited by the appellee were inapposite where other authorities
    controlled); Brooks Cotton Co., Inc. v. Williams, 
    381 S.W.3d 414
    , 422 (Tenn. Ct. App. 2012)
    (consulting a treatise on contract law and an Alabama Supreme Court decision as persuasive
    but not controlling authority). As these authorities undertake a review of developments in
    medical research in the context of criminal law, we determine such to be inapplicable to the
    case at bar.
    At trial, the parties stipulated that Dr. Perales was a child abuse pediatric expert. Dr.
    Perales personally examined and treated Davion before and after he was diagnosed with a
    subdural hematoma on January 22, 2011. Mother’s counsel cross-examined Dr. Perales
    regarding the possibility that Davion could have suffered reopening of earlier hematomas,
    or “bleeds,” and regarding Dr. Perales’s interpretation of the radiologist’s report that offered
    the possibility that blood from a “rebleed” was present on the January 2011 CT scans. Dr.
    Perales also testified as to the effect of developing medical research on her opinion of how
    Davion was injured. Her ultimate opinion to a reasonable degree of medical certainty was
    that Davion suffered an inflicted trauma at the time he became symptomatic, identified by
    Mother’s testimony as when the Children were alone with Mother in Mother’s room. Dr.
    Perales specifically opined that Davion’s injury could not have been inflicted by a sixteen-
    month-old child, by Davion himself, or in the course of providing routine child care. We
    determine that the trial court did not err in relying on Dr. Perales’s expert testimony.
    Mother also contends that the trial court erred in finding severe child abuse because
    two adults besides Mother, D.B. and M.C., had access to Davion during the twenty-four
    hours before he was hospitalized. As the trial court noted, Mother’s testimony regarding
    when she left Davion with other caretakers was vague and contradictory in relation to what
    she initially told investigators. Mother admitted at trial that she first told DCS Investigator
    Vickie Fox she had never left her children in anyone else’s care. She indicated she also told
    Knoxville Police Detective Damewood she had never left the Children with anyone because
    she “didn’t want to get looked at as a bad parent for leaving them.”
    -10-
    Mother subsequently testified that she had left Davion with another caretaker twice,
    once with D.B. while she bought diapers at Walgreen’s with the Children’s maternal
    grandmother and upon a separate occasion when she and D.B. attended a club. Regarding
    the diaper-buying errand, Mother said she thought the trip to Walgreen’s occurred during the
    day on Friday, January 21, 2011, but she was unsure of the day. When asked if she would
    agree with what she initially told a DCS investigator, that the journey to Walgreen’s was a
    week before Davion’s hospitalization, she answered in the affirmative. She said that D.B.
    called her once during the Walgreen’s trip to report that Davion was crying and that she told
    D.B. she would be home immediately.
    Both D.B. and M.C. testified at the trial that Mother left the apartment once for a short
    time with the Children’s maternal grandmother on January 21, 2011. When asked if she
    provided cared for Davion while Mother was gone, D.B. was evasive, saying, “I might’ve.
    I’m not going to say I didn’t and I’m not going to say I did for sure because it’s been a long
    time ago.” M.C., however, testified that D.B. did render care for Davion while Mother was
    gone on January 21. M.C. further testified: “[T]hat was the only time I ever saw [Mother]
    leave the baby was that day she went with her mom. I mean, she was always there any other
    time.”
    Regardless of whether Davion was left in the care of D.B. for a short time during the
    day on January 21, 2011, Dr. Perales opined that to a reasonable degree of medical certainty,
    she believed Davion was injured when he became symptomatic, which Dr. Perales identified
    as when Mother said Davion “shivered,” threw his head back with his eyes rolling back in
    his head, and became limp at approximately 2:00 a.m. on January 22. Mother’s testimony
    places this occurrence as transpiring when she was alone in her room with the Children.
    Mother, D.B., and M.C. all testified that Mother placed Davion on the floor and went to
    D.B.’s room to wake her. It is undisputed that no one subsequently picked up Davion until
    at least when Mother returned with D.B. Davion was already symptomatic by that time.
    Also significant was M.C.’s testimony that she heard Davion cry at the time Mother
    awoke with him, which M.C. described as “in the middle of the night” on January 21, 2011.
    M.C. explained that she then heard the crying suddenly stop. Mother argues that the crying
    stopped because Davion went limp, not because Mother harmed Davion. M.C. further
    testified, upon review of a transcript of her interview with Detective Damewood, that she had
    once heard Mother threaten to slam the baby against a wall if he did not stop crying.
    The trial court stated it believed the cessation of crying coincided with when Davion
    became symptomatic and with when he was injured by Mother. This was not, however, the
    basis for the trial court’s ruling that Mother had committed severe abuse. Instead, the court
    found Dr. Perales credible in her expert opinion that the injury was inflicted and that it
    -11-
    occurred when Davion became symptomatic. It is undisputed that Davion had been
    exclusively in Mother’s care for many hours before he became symptomatic.
    To further support her position, Mother relies in part on State of Tenn. Dep’t of
    Children’s Servs. v. H.A.C., No. M2008-01741-COA-R3-JV, 
    2009 WL 837709
     at *4 (Tenn.
    Ct. App. Mar. 26, 2009), for the proposition that evidence of a mere possibility that a parent
    severely injured her child, coupled with the parent’s dubious explanations for the injury, are
    insufficient to find clear and convincing evidence of severe child abuse. In H.A.C., however,
    the child’s father had inflicted the injury, and this Court, determining there was insufficient
    evidence to support a finding that the mother knowingly allowed the father to harm the child,
    reversed the finding of severe abuse against the mother only. Id. Similarly, in In re Dakota
    C.R., No. W2010-01946-COA-R3-JV, 
    2012 WL 1418048
     at *11 (Tenn. Ct. App. Apr. 24,
    2012), also cited by Mother for essentially the same proposition, this Court determined there
    was insufficient evidence to find the father guilty of severe child abuse where there was no
    evidence presented to support that he knew the mother was capable of abusing the children.
    Mother’s reliance on these cases is unavailing, as the trial court found that Davion was in her
    sole care at the time of the injury.
    We conclude that the evidence does not preponderate against the trial court’s
    determination by clear and convincing evidence that Mother committed severe child abuse.
    The trial court did not err in terminating Mother’s parental rights based upon this ground.
    V. Best Interest of Children
    When a parent has been found to be unfit by establishment of a ground for
    termination, as here, the interests of parent and child diverge, and the focus shifts to what is
    in the child’s best interest. In re Audrey S., 182 S.W.3d at 877. Tennessee Code Annotated
    § 36-1-113(i) (2010) provides a list of factors the trial court is to consider when determining
    if termination of parental rights is in the child’s best interest. This list is not exhaustive, and
    the statute does not require the court to find the existence of every factor before concluding
    that termination is in a child’s best interest. In re Audrey S., 182 S.W.3d at 878. Further, the
    best interest of a child must be determined from the child’s perspective and not the parent’s.
    White v. Moody, 
    171 S.W.3d 187
    , 194 (Tenn. Ct. App. 2004).
    Tennessee Code Annotated § 36-1-113(i) lists the following factors for consideration:
    (1) Whether the parent or guardian has made such an adjustment
    of circumstance, conduct, or conditions as to make it safe and in
    the child’s best interest to be in the home of the parent or
    guardian;
    -12-
    (2) Whether the parent or guardian has failed to effect a lasting
    adjustment after reasonable efforts by available social services
    agencies for such duration of time that lasting adjustment does
    not reasonably appear possible;
    (3) Whether the parent or guardian has maintained regular
    visitation or other contact with the child;
    (4) Whether a meaningful relationship has otherwise been
    established between the parent or guardian and the child;
    (5) The effect a change of caretakers and physical environment
    is likely to have on the child’s emotional, psychological and
    medical condition;
    (6) Whether the parent or guardian, or other person residing with
    the parent or guardian, has shown brutality, physical, sexual,
    emotional or psychological abuse, or neglect toward the child,
    or another child or adult in the family or household;
    (7) Whether the physical environment of the parent’s or
    guardian’s home is healthy and safe, whether there is criminal
    activity in the home, or whether there is such use of alcohol or
    controlled substances3 as may render the parent or guardian
    consistently unable to care for the child in a safe and stable
    manner;
    (8) Whether the parent’s or guardian’s mental and/or emotional
    status would be detrimental to the child or prevent the parent or
    guardian from effectively providing safe and stable care and
    supervision for the child; or
    3
    Effective July 2012, after the filing of the petition in the instant case, The Tennessee General
    Assembly amended Tennessee Code Annotated § 36-1-113(i)(7) to substitute “alcohol, controlled substances
    or controlled substance analogues” in place of “alcohol and controlled substances.” See 2012 Pub. Acts ch.
    848, § 8.
    -13-
    (9) Whether the parent or guardian has paid child support
    consistent with the child support guidelines promulgated by the
    department pursuant to § 36-5-101.
    As the State concedes in its brief on appeal, analysis of whether it was in the
    Children’s best interest to terminate Mother’s parental rights presented a “close” call.
    Having found by clear and convincing evidence that Mother committed severe child abuse
    by inflicting Davion’s head injury and recognizing Mother’s positive efforts to maintain a
    relationship with the Children through visitation and support, the trial court stated the
    following in its oral ruling from the bench:
    I have it a very close call. And [Mother’s counsel] said that we have to
    take chances, we have to take risks, but I can’t take this kind of risk. I can’t
    take the risk that there wouldn’t be another fit, I can’t risk that things will be
    going as good in the future for [Mother] as they are now.
    In its decree, the trial court made the following factual findings regarding the statutory
    factors listed in Tennessee Code Annotated § 36-1-113(i):
    1.      The mother has not made any significant adjustment in her
    circumstances since the children came into the custody of the
    Department of Children’s Services so as to make the children
    safe in her home. Mother has not addressed her own issues so
    that she can attend to the needs of the children. Mother has not
    acknowledged her role in causing the injury to Davion, and
    absent that she cannot prove any adjustment in her
    circumstances to make it safe to place her children with her.
    2.      Mother has not effected any significant adjustment, much less
    a lasting adjustment after appropriate and timely services put in
    place by the Department of Children’s Services to address the
    mother’s parenting. Mother lost control and injured her child.
    She has not cooperated with mental health services to attempt to
    address the issues which led to her loss of control and [to] try to
    ensure that such loss of control does not happen again. Given
    the time these children have been in custody and the time
    devoted to attempting to resolve the various family issues, it
    does not reasonably appear that such an adjustment is possible.
    -14-
    3.    Mother has continued to visit the children with regularity and
    respond to their needs during visits, and appears to love her
    children.
    4.    Mother clearly has a meaningful relationship with these
    children.
    5.    Changing caretakers at this point, after about one-half of
    Travion’s life and nearly all of Davion’s life would be
    detrimental to the children’s emotional, psychological and
    medical conditions, especially Davion.
    6.    Based on the Court’s finding that [Mother] severely abuse[d]
    Davion [B.], factor 6 weighs against [Mother].
    7.    Although the mother’s home is physically safe for the children,
    the Court’s concern is mother’s continued drug use during the
    time that she had these children, up to the day before the
    incident in question. Of further concern is [Mother’s] attempts
    to have [D.B.] lie to DCS and law enforcement regarding
    [Mother’s] drug usage.
    8.    Mother’s emotional/mental status weighs against the mother as
    she failed to meaningfully participate in counseling, even to
    address the trauma associated with losing children to the custody
    of the Department of Children’s Services. Her prognosis for
    change is poor given her resistance to any sort of disclosure
    during counseling. Mr. Ownby’s testimony makes clear that
    [Mother] continues to minimize her involvement in causing
    Davion’s injuries and continues to deny responsibility. Her
    emotional/mental inability to acknowledge her role in causing
    the injuries prevents her from making progress to provide a safe
    home for the children.
    9.    Mother has paid support for these children while in the custody
    of the Department of Children’s Services.
    10.   Ending the parent-child relationship will benefit the children as
    they will now be able to move on with their lives knowing that
    -15-
    their mother will not be in their lives and they can unreservedly
    attach to appropriate [sic].
    The trial court therefore concluded that it was in the Children’s best interest to terminate
    Mother’s parental rights. Upon our careful review of the entire record, we agree.
    Mother had a history of investigation and monitoring by DCS for marijuana use
    during both pregnancies, although she completed outpatient treatment during her second
    pregnancy. When Ms. Fox, who testified at the trial, and Detective Damewood went to
    D.B.’s apartment after Davion was hospitalized on January 22, 2011, they found a baggie of
    marijuana on top of the dresser in Mother’s bedroom. Mother admitted that she smoked
    marijuana in the early evening of January 21, 2011. She denied, however, that the marijuana
    found in her room belonged to her, insisting it was not on the dresser when she was last in
    the apartment. Mother admitted missing an appointment with investigators to take a drug
    screen shortly after Davion’s hospital admission. She refused to take a drug screen when
    present at court for the preliminary hearing on January 26, 2011. It was undisputed that after
    January 2011, Mother consistently submitted to drug screens required by DCS and
    consistently tested negative for illegal substances.
    Mother acknowledged that she had reviewed transcripts of two telephone calls made
    by D.B. to Mother without Mother realizing that investigators were recording the
    communications. In one conversation, Mother addressed the presence of drugs by telling
    D.B.: “You don’t know where it came from, you don’t know whose it is, and you’ve just
    never seen it before. Just please say you don’t know whose it is, you don’t know where it
    came from, you don’t think I smoke, please.”
    Mother explained that when she began residing with D.B., she had intended a
    temporary arrangement while she awaited availability of an apartment of her own. On the
    day the Children were removed from her custody, she signed a lease for an apartment. She
    had been living in that apartment ever since. Mother reported that she began employment
    with Taco Bell in July 2011. By the time of trial, she was working forty to fifty hours a week
    for a wage of $7.70 an hour. This wage rate represented one pay raise, and she had been told
    she would receive a promotion soon. She indicated that approximately fifty percent of her
    paychecks went to pay child support.
    Mother further testified that since placement in DCS custody, Travion had been
    attending speech therapy appointments, which she regularly arranged her work schedule to
    attend. Although Mother initially visited with her children weekly, the visitation later
    averaged once every two weeks as DCS reduced the number of visits. Mother established
    -16-
    a room for the Children in her apartment, which space included two beds, a dresser, a
    television, and “a lot of toys.”
    Emily Heird testified that she worked as a mental health therapist at Solution Source
    and that Mother was referred to her by DCS for counseling regarding the issues surrounding
    the Children’s removal. Mother met with her four times in 2011 on June 15, June 28,
    September 27, and November 14. The therapist reported that after the June sessions, she
    gave Mother “some space” because a court hearing was approaching and Mother wanted to
    wait for more counseling until she knew the status of her case. Mother, however, did not
    contact Ms. Heird again until Ms. Heird sent Mother a letter on August 22, indicating that
    she would have to close the case if she did not hear from Mother within two weeks. Mother
    then called Ms. Heird and scheduled the September 27 appointment. Ms. Heird stated that
    Mother failed to call or appear for two scheduled appointments in October. She also
    cancelled an appointment scheduled for November 1. Mother kept her November 14
    appointment, but by the end of November 2011, Ms. Heird discharged Mother from
    counseling as unsuccessful when Mother’s insurance terminated coverage. Ms. Heird
    stressed that she would have been willing to work with Mother to continue counseling if
    Mother had made an effort to do so.
    Ms. Heird explained that she was unsuccessful in addressing issues in any depth with
    Mother inasmuch as Mother was guarded, reserved, and could not identify goals she wanted
    to pursue in counseling. Ms. Heird opined that Mother made appointments to “appear
    compliant with DCS requirements.” Mother became more talkative and open in later
    sessions, but Ms. Heird said Mother did not address the trauma of having the Children
    removed from her custody.
    Ms. Foster testified that she is Mother’s aunt and the Children’s great aunt. The
    Children were placed in her home as a kinship foster placement at the time DCS removed
    them from Mother’s custody. They had resided continuously in her home since that time.
    Those living in her home also included her husband and their eleven-year-old daughter.
    While Ms. Foster was at work during the week, her mother cared for the children in the
    Fosters’ home. She said that both Children were healthy at the time of trial and that Davion
    had been released from the care of his neurologist. She reported that when the Children first
    came into her home, Davion was small for his age and experienced difficulty sitting up. He
    also suffered from acid reflux and projectile vomiting. As Davion developed the ability to
    accept various foods, these problems were resolved. By the time of trial, he was on target
    for his age and enjoyed a healthy appetite.
    Ms. Foster further testified that in addition to Mother’s supervised visitation with the
    Children, Mother kept in touch with the Children via telephone calls and text messages sent
    -17-
    to Ms. Foster and her husband. She noted that both Children recognized Mother’s
    photograph on Ms. Foster’s phone when Mother would call. They enjoyed talking to Mother.
    She felt that the Children had grown to love her family and that Davion was “definitely
    attached” to them. She opined that Travion remembered living with his mother and had a
    greater connection to Mother.
    Ms. Foster further explained that everyone in her immediate family enjoyed having
    the Children in the home and that it had become “natural” to have the Children reside there.
    When asked if she and her husband desired to adopt the Children if they became available
    for adoption, Ms. Foster answered, “Absolutely.” She asserted that if she and her Husband
    adopted the Children, it would be best for the Children to maintain some contact with
    Mother.
    The Children’s maternal grandmother (“Grandmother”) testified that Mother and the
    Children lived with her from November 2010 through part of January 2011 before Mother
    moved in with D.B. Grandmother said that at the time of trial, Mother had a two-bedroom
    apartment arranged as though the Children were present all the time. The home was stocked
    with toys, diapers, and clothing for the Children. Grandmother, present during several visits
    between Mother and the Children at Mother’s house, described a typical visit:
    [T]he boys come in and they act like they’re home. They take off their shoes,
    she feeds them, she plays with them, she teaches them things. I’ve seen her
    correct them or set them in time-out, and she’ll explain to them if they’re doing
    something they’re not supposed to do. They’re very, very attached to their
    mother.
    Grandmother denied ever having observed Mother roughly discipline the Children or having
    heard Mother threaten to hurt the Children in any way.
    Carlos R. Ownby testified that he was the Pastor at Bakertown Ministries, which
    assisted residents of subsidized housing. He had known Mother since she moved into
    Bakertown Ministries in January 2011. After Mother had been at Bakertown for about two
    months, she began assisting with the ministry by helping to prepare food, clean up, and care
    for children. Pastor Ownby said he was impressed with Mother’s maturity and was glad to
    have her help in chaperoning twenty-three children at a vacation Bible school. He observed
    Mother during two visits with the Children at Mother’s apartment and indicated he noticed
    a close, loving bond between Mother and the Children.
    Pastor Ownby also testified that Mother told him the Children were removed because
    of an accident when Travion pulled Davion off the couch. He said he understood that “there
    -18-
    was some question as to whether the Department of Children’s Services felt like she took the
    appropriate action at the appropriate time.” When asked if he would still have confidence
    in allowing Mother unsupervised access to children in his ministry if he were to learn that
    the court found Mother to have committed severe child abuse, Pastor Ownby said he would.
    He had observed no indication that Mother was using drugs while assisting in his ministry.
    Jessica Hume testified that she was the DCS case manager for the Children until
    accepting a different position. She remembered speaking with Mother in July 2011
    concerning a possible trial home placement. As explained by Ms. Hume, the “lingering
    issue” preventing trial home placement was that Mother did not successfully complete
    individual therapy. Ms. Hume supervised visits between Mother and the Children first at the
    DCS office and then at Mother’s apartment. She said Mother regularly attended the visits
    and provided appropriate snacks and activities. She noted that the Children appeared happy
    with Mother and that Travion would run to greet Mother upon arrival. Ms. Hume reported
    personally administering drug screens to Mother “a good handful of times,” with Mother
    never failing the screens.
    Leigh Anne Goldstine testified that she was a clinical therapist with Foothills Care,
    Inc., which office received a referral to provide therapeutic visitation for Mother and the
    Children. According to a court report she had prepared, dated November 9, 2011, Mother
    and the Children visited twenty-five times between when the case was opened on April 15,
    2011, and the date of the court report. Mother began with sixteen visitation hours a month.
    This was subsequently decreased to ten hours monthly, followed by six hours a month at
    DCS’s direction. Ms. Goldstine said that the visits were positive experiences, with the
    Children eager to see Mother. Mother was always prompt and was well prepared with many
    snacks and activities. She said Mother created a regular routine without being prompted.
    Mother disciplined appropriately by redirecting attention and using “time out” when needed.
    Ms. Goldstein did not perform a formal bonding assessment. She indicated this was because
    she felt it evident from the beginning that Mother and the Children were bonded.
    At the close of the trial, Stacy Eckard, the guardian ad litem appointed by the trial
    court (“GAL”), opined that she believed termination of Mother’s parental rights was in the
    best interest of the Children. The GAL explained that she had been involved with the
    Children before their coming into protective custody, first as Travion’s GAL and then as the
    GAL for both Children. The GAL agreed with witnesses who testified that Mother was
    appropriate with and attentive to the Children and that Mother believed it her responsibility
    to care for them. The GAL was convinced, however, that the State had met its burden of
    showing severe child abuse and that Mother had failed to make any adjustment to ensure that
    no such incident would happen again. Of concern was Mother’s failure to address her own
    mental and emotional state in therapy. The GAL expressed additional concern regarding
    -19-
    Mother’s past marijuana use. She noted that the Children’s pre-adoptive home was with
    relatives who had stated their intention of maintaining a relationship between Mother and the
    Children.
    We note, as did the trial court, that some factors weigh in favor of maintaining
    Mother’s parental relationship with the Children. Several witnesses for Mother, including
    the Children’s maternal grandmother, a prior DCS case manager, and a therapist who
    provided therapeutic visits between Mother and the Children, testified that Mother and the
    Children enjoyed a strong parent-child bond. Mother furthered this relationship after the
    Children were removed from her custody by being attentive and well prepared during
    visitation. Mother also maintained appropriate housing and employment, enabling her to pay
    child support, which she did.
    The factors weighing against Mother and in favor of terminating her parental rights,
    however, pose an overriding concern that the Children would not be safe in Mother’s future
    care. The circumstance causing the Children to be removed from Mother’s custody was the
    traumatic injury to Davion, which we have concluded the trial court properly found to be the
    result of severe child abuse by Mother. By failing to address both her role in causing
    Davion’s injury and any underlying mental or emotional issues that caused her to resort, even
    in a moment of frustration, to injuring her child, Mother has failed to show significant and
    lasting adjustment in her circumstances that would ensure the safety of the Children.
    Although Mother demonstrated that she consistently tested negative for drug use after the
    preliminary hearing, her history of marijuana use when pregnant, admitted marijuana use
    hours before Davion’s January 2011 hospitalization, and attempt to persuade D.B. to lie
    about such use all weigh against her ability to provide a safe environment for the Children
    as well. The State presented undisputed testimony that the Children were healthy, happy, and
    well adjusted in their kinship foster home. Ms. Foster testified that she and her husband
    wished to adopt the Children. As the trial court determined, changing caretakers at this point
    in the Children’s lives, after having lived with the Fosters since ages sixteen months and six
    months, respectively, would be detrimental to their emotional, psychological, and medical
    conditions.
    On appeal, Mother relies on In re D.P.M., S.H., & Y.M.P., No. M2005-02183-COA-
    R3-PT, 
    2006 WL 2589938
     at *12-14 (Tenn. Ct. App. Sept. 8, 2006), to support her position
    that termination of a mother’s parental rights due to a finding of severe abuse is inconsistent
    with the children’s best interests where a close bond exists between the mother and children.
    In In re D.P.M, this Court considered, in addition to the close bond between the mother and
    child, the child’s therapist’s opinion that the child’s connection to her nuclear family was of
    utmost importance to the child. Id.; see also In re D.P.M., S.H., & Y.M., No. M2007-02741-
    COA-R3-PT, 
    2008 WL 4693725
     (Tenn. Ct. App. Oct. 23, 2008) (affirming the trial court’s
    -20-
    second ruling terminating the mother’s parental rights as in the best interest of the children).
    We do not find Mother’s reliance on In re D.P.M. (2006) to be persuasive when applied to
    the facts of the case at bar.
    We conclude that the evidence does not preponderate against the trial court’s
    determination, by clear and convincing evidence, that terminating Mother’s parental rights
    was in the best interest of the Children.
    VI. Conclusion
    The judgment of the trial court terminating the parental rights of Mother is affirmed.
    Costs on appeal are taxed to the appellant, Samantha B. This case is remanded to the trial
    court, pursuant to applicable law, for enforcement of the trial court’s judgment and collection
    of costs assessed below.
    _________________________________
    THOMAS R. FRIERSON, II, JUDGE
    -21-