In Re: Mary E. P. ( 2013 )


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  •                   IN THE COURT OF APPEALS OF TENNESSEE
    AT NASHVILLE
    Assigned on Briefs August 23, 2013
    IN RE MARY E. P. ET AL.
    Appeal from the Juvenile Court for Maury County
    No. 85888, 85889    George L. Lovell, Judge
    No. M2013-00436-COA-R3-PT - Filed October 4, 2013
    The juvenile court terminated the parental rights of the mother and father on the grounds of
    substantial noncompliance with the permanency plans, persistence of conditions, and willful
    abandonment by failure to visit, and upon the determination that termination of their parental
    rights was in the best interests of the children. Both parents appeal. Finding the evidence
    clear and convincing, we affirm.
    Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Juvenile Court Affirmed
    F RANK G. C LEMENT, J R., J., delivered the opinion of the Court, in which A NDY D. B ENNETT
    and R ICHARD H. D INKINS, J.J., joined.
    Jacob J. Hubbell, Columbia, Tennessee, for the appellant, Christy P.1
    Cara E. Lynn, Columbia, Tennessee, for the appellant, Mark P.
    Robert E. Cooper, Attorney General and Reporter, Derek C. Jumper, Assistant Attorney
    General, James Stephens, and Mary Byrd Ferrara, Nashville, Tennessee, for the appellee,
    Tennessee Department of Children’s Services.
    Charles M. Molder, Columbia, Tennessee, for the minor children, Mary E.P. and Melodie
    E.P.
    1
    This court has a policy of protecting the identity of children in parental termination cases by
    initializing the last names of the parties.
    OPINION
    Christie P. (“Mother”) and Mark P. (“Father”) are the parents of Mary (born
    September 2004) and Melodie (born June 2006). The Department of Children’s Services
    (“the Department”) and the community offered many services to the family beginning in
    September 2004 after Mother alleged she could not take care of Mary, due to “people
    bothering her.”
    The Department filed a Petition to Adjudicate Dependency and Neglect and for Court-
    Ordered Services on August 28, 2007, after an increasing number of referrals indicated that,
    inter alia, Mother was often found at Wal-Mart begging for food and diapers; on one
    occasion she asked strangers to take her children; law enforcement was dispatched to the
    home; reports indicated the home was filthy and the children were dirty and without food or
    diapers; the children’s clothes and diapers were soiled, and Melodie often was not clothed.
    Mother, who suffers from paranoid schizophrenia, refused any treatment, and Father, who
    appears to be developmentally delayed, was rarely present at home and was seldom involved
    with the Department.
    A preliminary hearing was held on August 31, 2007, and the Juvenile Court of Maury
    County ordered that legal and physical custody of the children shall remain with the parents,
    subject to the requirements of an agreed upon safety plan. The safety plan required the
    parents to take the children to Daisy Daniels Daycare, yet the parents failed to do this due in
    part to Mother’s expressed paranoia of the daycare’s religious beliefs. Mother stated she
    wanted to switch the children to Kids Country 3 located in Columbia, and the Department
    agreed; however, when the Department subsequently contacted Kids Country 3, it was
    informed that the family only brought Mary to daycare, they did not mention Melodie.
    The parents were required to cooperate with the Department, but they failed to do so.
    On one occasion Mother scrunched down behind the couch and refused to answer the door.
    When the Department worker entered the home, Mother threw a bag of potato chips at the
    worker, began shouting profanities and referred to Child Protective Services as “the devil.”
    The safety plan also required Mother and Father not to take the children out in
    extreme hot or cold weather; however, on November 10, 2007, when the temperature was in
    the thirties, Mother walked from her home to the Columbia Wal-Mart with the children in
    a stroller wearing summer clothing. Mother contacted 911 and when the police officer
    arrived, Mother was trying to give the children’s clothes to the Wal-Mart greeter, talked
    irrationally and disclosed she had not been taking her medication. The children were
    shivering in wet summer clothes; Mother stated they had an “accident,” but would not
    elaborate. When a concerned citizen provided sweater jackets to the children, Mother became
    -2-
    perturbed and tried to give them back. Mother and children were transported to Maury
    Regional Medical Center where Dr. Daniels examined them. Dr. Daniels found Mother’s
    erratic behavior was not a result of the Phenobarbital levels and was not related to her
    psychosis. Moreover, the nurse stated the children appeared to be in diapers from the night
    before. In response, Mother stated she only had two diapers left and that “Mary is grown up
    and doesn’t need her anymore,” although Mary was only three years old. The children
    appeared filthy and Mary’s hair showed signs of head lice. Mother stated the only reason the
    Department keeps bothering her is because they accept referrals from “drugs addicts,
    prostitutes, and gay people.” Father was contacted at work; he stated he could not come to
    the hospital until the afternoon.
    The Department filed a Petition to Adjudicate Dependency and Neglect for Temporary
    Custody on November 14, 2007. The petition was supported by an Affidavit of Reasonable
    Efforts from Carrie Opalewski, Case Manager and CPS Investigator for the Maury County
    Office of the Department. The juvenile court found there was probable cause to believe the
    children were dependent and neglected, and a Protective Custody Order was approved and
    entered on the same date.
    A preliminary hearing was held November 15, 2007, and the juvenile court again
    found there was probable cause to find the children were dependent and neglected, and
    ordered the children remain in the custody of the Department. Further, the court ordered the
    parents to pay child support in accordance with statutory guidelines; Mother and Father be
    provided with separate attorneys; and for the Department to setup visitation between the
    parents and children. An adjudicatory hearing was set for December 10, 2007, and on March
    5, 2008, an Order Waiving Adjudicatory Hearing was entered.
    The children were placed in foster care with a family in Spring Hill, Tennessee, and
    currently remain with them. The foster parents received the girls when Mary was three years
    and Melodie was 18 months old. Mr. M., the foster father, testified they immediately had big
    concerns with the girls. The children would hit their heads on the wall or floor, pull out their
    hair and self-stimulate. Testing showed the children were significantly delayed academically;
    Mary was diagnosed with attention deficit hyperactivity disorder (ADHD), predominately
    inattentive and anxiety disorder and not otherwise specified, and Melodie was diagnosed with
    mood deficit disorder not otherwise specified and ADHD, combined type.
    The Department developed the first of many permanency plans on December 4, 2007,
    outlining several responsibilities and goals for the parents to regain custody of the children.
    The plans included, inter alia, the parents participate in psychological evaluations to ensure
    their mental health needs were met; participate in medication and psychiatric evaluations, and
    become compliant with medications if needed; participate in individual counseling and
    -3-
    individual counseling for parenting in order to become able to meet their children’s needs;
    and to improve their parenting skills by participating in therapeutic visitation and family
    counseling.
    In the interim, subsequent permanency plans were adopted in May 2008 through
    September 2010, and each one reiterated the requirements set forth in the initial plan, along
    with updated dates for completion of uncompleted tasks. Additional requirements added
    throughout the plans included, inter alia, Mother and Father maintain stable and appropriate
    housing and means of support for the family; focus on the children’s problems rather than
    their own; participate in children’s speech services, counseling appointments, educational
    meetings, and other services for the children; and be able to demonstrate age appropriate
    discipline and communication with the children. Throughout this period, the Department
    provided a variety of services to assist the parents in meeting their obligations under the
    permanency plans and remedying the conditions that resulted in foster care, which services
    will be addressed in detail later in this opinion.
    Due to the parent’s failure to cooperate, the Department filed a motion to suspend
    Mother and Father’s visitation. The juvenile court granted the motion on January 25, 2012.
    After making the determination that Mother and Father were not complying with the
    permanency plans and the conditions that existed when the children were taken into custody
    in 2007 persisted, on February 24, 2012, the Department filed a Petition to Terminate
    Parental Rights on the grounds of abandonment for failure to visit and failure to support,
    substantial noncompliance with permanency plans, persistence of conditions, and mental
    incompetence of Mother.
    The petition to terminate Mother and Father’s parental rights was set for trial in the
    Juvenile Court of Maury County on December 7, 2012. Despite notice of the proceeding,
    Mother and Father failed to appear for the first day of trial; however, their respective
    attorneys were in attendance. The court was informed that Mother was having blood work
    drawn the day of trial; however, the doctor’s office was less than an hour away and there was
    no appointment scheduled, but that the blood work had to be drawn before four in the
    afternoon. Father did not attend due to work. The court determined there was insufficient
    justification to continue the proceeding based upon the parents’ failure to appear at the time
    of trial, and the case was previously docketed with the consent of all parties.
    At the conclusion of the first day of trial, the case was set to continue on December
    11; both parents appeared and participated in the second day of trial. The court heard
    testimony from numerous witnesses including Father; Pam Arnell, therapeutic family
    counselor and owner of Arnell’s Counseling; Allison Clanton, child and family therapist; Mr.
    -4-
    M., the children’s foster father; Meredith Worsham and Moon Unanorworv, Department
    family service workers; Holly Wunner, a Department resource parent support worker,
    formerly a Department family service worker; Marsha Boren, director of the CASA program
    in Maury County who has been involved with the case in its entirety; Elysse Beasley, a
    therapist who evaluated Mother in November 2011. Mother was in attendance but did not
    testify.2
    The juvenile court entered an Order Terminating Parental Rights and Granting Full
    Guardianship on January 8, 2013, finding the Department had proven three grounds by clear
    and convincing evidence: the grounds of substantial noncompliance with the permanency
    plans, persistence of conditions, and abandonment due to failure to visit. The court also
    found termination of Mother and Father’s parental rights was in the best interests of the
    children. Accordingly, Mother and Father’s parental rights were terminated.
    Mother and Father filed a timely appeal and both parents present the same four issues
    for our review: whether the trial court erred in finding three grounds for termination of their
    parental rights under Tennessee Code Annotated § § 36-1-13(g)(1) - (g)(3) and whether
    termination of parental rights is in the best interests of the children.
    S TANDARD OF R EVIEW
    Parents have a fundamental right to the care, custody, and control of their children.
    Stanley v. Illinois, 
    405 U.S. 645
    , 651 (1972); Hawk v. Hawk, 
    855 S.W.2d 573
    , 577 (Tenn.
    1993). This right is superior to the claims of other persons and the government, yet it is not
    absolute. In re S.L.A., 
    223 S.W.3d 295
    , 299 (Tenn. Ct. App. 2006).
    To terminate parental rights, a court must determine by clear and convincing evidence
    the existence of at least one of the statutory grounds for termination and that termination is
    in the best interest of the child. Tenn. Code Ann. § 36-1-113(c); In re Adoption of Angela E.,
    
    402 S.W.3d 636
    , 639 (Tenn. 2013) (citing In re Valentine, 
    79 S.W.3d 539
    , 546 (Tenn.
    2002)). The petitioner has the burden of proving that one statutory ground for termination
    exists. See Tenn. Code Ann. § 36-1-113(c)(1); Jones v. Garrett, 
    92 S.W.3d 835
    , 838 (Tenn.
    2002). In addition to proving one ground for termination, the petitioner must prove that
    termination of parental rights is in the child(ren)’s best interest(s). Tenn. Code Ann. §
    36-1-113(c)(2); In re F.R.R., 
    193 S.W.3d 528
    , 530 (Tenn. 2006); In re A.W., 
    114 S.W.3d 541
    , 544 (Tenn. Ct. App. 2003); In re C.W.W., 
    37 S.W.3d 467
    , 475-76 (Tenn. Ct. App. 2000)
    (holding a court may terminate a parent’s parental rights if it finds by clear and convincing
    2
    At the close of proof, the Department notified the court that it was voluntarily withdrawing the
    ground of failure to support.
    -5-
    evidence that one of the statutory grounds for termination of parental rights has been
    established and that the termination of such rights is in the best interests of the child).
    Therefore, a court may terminate a person’s parental rights if (1) the existence of at least one
    statutory ground is proven by clear and convincing evidence and (2) it is clearly and
    convincingly established that termination of the parent’s rights is in the best interest of the
    child. Tenn. Code Ann. § 36-1-113(c); In re Adoption of A.M.H., 
    215 S.W.3d 793
    , 810
    (Tenn. 2007); In re Valentine, 79 S.W.3d at 546.
    Whether a statutory ground has been proven by the requisite standard of evidence is
    a question of law to be reviewed de novo with no presumption of correctness. In re B.T., No.
    M2007-01607-COA-R3-PT, 
    2008 WL 276012
    , at *2 (Tenn. Ct. App. Jan. 31, 2008) (citing
    In re Adoption of A.M.H., 215 S.W.3d at 810).
    A NALYSIS
    I. P ERMANENCY P LAN AND THE D EPARTMENT’S E FFORTS
    This is not a case where reasonable efforts are excused;3 therefore, we must first
    determine whether the terms and goals of the permanency plans were reasonable and related
    to remedying the conditions which necessitated removal of the children and whether the
    Department exerted reasonable efforts to assist Mother and Father to achieve the goals and
    to be reunited with their children before examining the grounds at issue.
    “Because of the prominent role that the Department plays in the lives of so many
    dependent and neglected children, the Tennessee General Assembly has explicitly imposed
    on the Department the responsibility to make reasonable efforts to reunify children and their
    parents after removing the children from their parents’ home.” In re Tiffany B., 
    228 S.W.3d 148
    , 157-58 (Tenn. Ct. App. 2007) (citing Tenn. Code Ann. § 37-1-166). The Department’s
    first obligation in this regard is to establish permanency plans, the terms of which are
    “reasonable and related to remedying the conditions which necessitate foster care
    placement.” In re Valentine, 79 S.W.3d at 547 (quoting Tenn. Code Ann. § 37-2-
    403(a)(2)(C)). This statutory policy does not require that the Department’s effort to reunify
    the family be “herculean”; nevertheless, the Department’s employees “must use their superior
    insight and training to assist the parents in addressing and completing the tasks identified in
    the permanency plan.” In re Giorgianna H., 
    205 S.W.3d 508
    , 519 (Tenn. Ct. App. 2006).
    3
    The Department is not required to make reasonable efforts every time it removes a child. In certain
    aggravated circumstances, such as severe child abuse, the Department is relieved of this duty. Tenn. Code
    Ann. § 37-1-166(g)(4); Tenn. Code Ann. § 36-1-113(g)(7).
    -6-
    Reasonable efforts are statutorily defined as the “exercise of reasonable care and
    diligence by the department to provide services related to meeting the needs of the child and
    the family.” Tenn. Code Ann. § 37-1-166(g)(1). In cases like this one, the factors that courts
    use to determine reasonableness include: (1) the reasons for separating the parents from their
    children, (2) the parents’ physical and mental abilities, (3) the resources available to the
    parents, (4) the parents’ efforts to remedy the conditions that required the removal of the
    children, (5) the resources available to the Department, (6) the duration and extent of the
    parents’ efforts to address the problems that caused the children’s removal, and (7) the
    closeness of the fit between the conditions that led to the initial removal of the children, the
    requirements of the permanency plan, and the Department’s efforts. In re Tiffany B., 228
    S.W.3d at 158-59 (citing In re Giorgianna H., 205 S.W.3d at 519).
    Although the Department bears a heavy responsibility with regard to reunification, the
    road to reunification is a “two-way street.” State Dep’t. of Children’s Servs. v. S.M.D., 
    200 S.W.3d 184
    , 198 (Tenn. Ct. App. 2006). Parents desiring to be reunited with their children
    “must also make reasonable and appropriate efforts to rehabilitate themselves and to remedy
    the conditions that required the Department to remove their children from their custody.” In
    re Giorgianna H., 205 S.W.3d at 519. Accordingly, even though the Department bears a
    heavy responsibility to facilitate reunification, the Department does not bear the entire
    responsibility. S.M.D., 200 S.W.3d at 198.
    A. P ERMANENCY P LAN
    The children were removed from the parents’ custody due to the conditions in the
    home, Mother’s untreated mental health condition that prevented her from safely caring for
    the children, Mother and Father’s inability to provide for the children, inability to ensure the
    children’s medical and mental health needs were met appropriately and non-compliance with
    the court ordered safety plan. Because of the above concerns, the Department developed
    permanency plans with goals to ensure the children’s safety, and for the parents to address
    their issues, including: parenting skills, mental health of Mother, counseling and medication
    management for Mother, maintaining stable residence and source of income, and therapeutic
    visitations between the parents and children.
    We have concluded the above requirements and goals identified in the permanency
    plans were reasonable and related to remedying the conditions which necessitated the
    removal of the children from Mother and Father’s care and the resulting foster care
    placement. Accordingly, the plans satisfied the requisite criteria. See In re Valentine, 79
    S.W.3d at 547; see also Tenn. Code Ann. § 37-2-403(a)(2)(C).
    -7-
    B. R EASONABLE E FFORTS
    Prior to the children entering the Department’s custody in November 2007, the family
    was provided with several services from the Department and other community service
    providers since September 2004. Mother refused or would not cooperate with the various
    mental health treatment services offered, which included, therapy and psychiatric services
    for paranoia, and services from Centerstone and the Family Center. The parents were also
    provided services from Nurses to Newborns, the Caring Hearts program and Family Support
    Services, but failed to cooperate. Maury United Ministries transportation (MUMs) was an
    option for Mother; however, she abused the privilege and lost the service. In regards to the
    Department’s efforts to help satisfy the requirements of the court ordered safety plan, they
    attempted to monitor Mother’s mental health treatment, provided daycare services,
    counseling and therapeutic visitation opportunities.
    The Department continued many of the same services in efforts to help Mother and
    Father achieve the permanency plan goals. The Department attempted to assist Mother with
    her mental health requirements, which is the biggest barrier to returning the children to their
    parents, by making efforts to monitor Mother’s mental health treatment; however, Mother
    would not sign a release to obtain these records. Further, the Department arranged and paid
    for family counseling with Allison Clanton, but these visits had to be discontinued due to
    Mother’s disruptive behavior. The Department also arranged for therapeutic visitation
    opportunities for both parents with Arnell’s Counseling, but the parents routinely missed
    visits, cancelled visits, or simply did not appear.
    As for the children’s needs, the Department provided foster care placement in Spring
    Hill, Tennessee, where they remain. To help with the children’s emotional and mental health
    needs, Ms. Clanton provided individual therapy to each of the girls, family therapy to the
    children with their foster parents, collateral therapy with only the biological parents, and
    provided collateral therapy with only the foster parents.
    Considering the above facts and other relevant evidence we have not yet addressed,
    we have determined the Department exerted reasonable efforts to assist Mother and Father
    to achieve the stated goals.
    We now turn our attention to the statutory grounds at issue: substantial noncompliance
    with the permanency plans, persistence of conditions, and abandonment by failure to visit the
    children, to determine whether the evidence clearly and convincingly establishes one or more
    of these grounds.
    -8-
    II. G ROUNDS FOR T ERMINATION OF P ARENTAL R IGHTS
    A. S UBSTANTIAL N ONCOMPLIANCE WITH THE P ERMANENCY P LANS
    Noncompliance with the permanency plan is a statutory ground for termination of a
    parent’s rights. Tenn. Code Ann. § 36-1-113(g)(2). For noncompliance to justify the
    termination of parental rights, it must be “substantial” noncompliance. In re S.H., No.
    M2007-01718-COA-R3-PT, 
    2008 WL 1901118
    , at *7 (Tenn. Ct. App. Apr. 30, 2008). The
    issue of substantial noncompliance with the requirements of a permanency plan is a question
    of law; therefore, it is reviewed de novo with no presumption of correctness. In re Valentine,
    79 S.W.3d at 546.
    The first permanency plan was adopted on December 4, 2007. Pursuant to the first and
    subsequent plans, the goals of which remained consistent, Mother was to address her mental
    health needs with counseling and medication, the parents were to maintain stable residence,
    focus on the children’s problems rather than their own, attend counseling to improve their
    parenting skills, and attend therapeutic visitations with the children. Mother and Father
    accomplished none of the these goals.
    Meredith Worsham worked with the family from November 2009 until May 2011. She
    helped draft permanency plans for the family and stated the goals for the parents had not
    substantially changed during her time on the case. She testified both parents were
    substantially non-compliant for a number of reasons: Mother’s primary goal was to address
    her mental health issues; however, Mother did not attend counseling and, despite repeated
    requests from the Department, repeatedly refused to sign a medical release; the parents were
    not consistent with visitation or attending school meetings for the children; Father did not
    have stable employment, and their income was not enough to meet the needs of the family;
    and when asked specifically about Father, Ms. Worsham stated “[he] is not ensuring the
    girls’ safety” by leaving them alone with their mother.
    Child-family therapist, Allison Clanton, spent more than two years working with the
    family. She provided individual therapy to the girls, family therapy to the children with their
    foster parents, collateral therapy with only the biological parents, and provided collateral
    therapy with only the foster parents. Ms. Clanton stated she was forced to ask Mother to
    leave and cut Father’s session short, due to Mother being disruptive, disrespectful and
    behaving in an extremely erratic manner. Mother refused to return and complete the session,
    and Father did not return either. Ms. Clanton’s opinion is that while Father does not show
    serious deficits in providing structure, he prioritizes structuring for Mother over his children,
    and that creates a severe deficit.
    -9-
    Pam Arnell, therapeutic family counselor and owner of Arnell’s Counseling, began
    working with the parents in September 2011 with the goals of teaching them parenting skills,
    providing them with therapeutic visitation and help with bonding during visitation. The
    parents were required to travel from Mt. Pleasant to the Publix in Spring Hill to pick up the
    children for visitations; however, Ms. Arnell testified the parents routinely missed visits,
    cancelled visits, or simply did not appear, even though the parents scheduled the visits.
    Mother and Father gave various reasons for their absences, including sleeping late, medical
    appointments, illness and not having the money for gas. The Department provided a gas-card
    for the family but receipts were not returned, as directed by the Department, but due to the
    parents’ noncompliance with this requirement, the case manger was unable to provide further
    financial assistance. The Department authorized 32 hours of visitation during September
    2011, Mother and Father only used 6 of those hours to visit the children; 28 hours were
    authorized for October, and only 12 were used; 6 hours were authorized for November, and
    only 1 was used; 21 hours were authorized in December and only 2 hours and 45 minutes
    were used.
    When the parents did attend visitation, Ms. Arnell stated Father was more active and
    responsive with the children than Mother, and that Mother spent more time complaining
    about the Department. During one visit, Mother slung a tub of pretzels at Ms. Arnell; the
    container and pretzels hit Ms. Arnell and the children. When asked if Mother could safely
    care for the children, Ms. Arnell testified she would have concerns for the children’s safety,
    their emotional needs being met, their academia being achieved and medical needs being met
    if Mother was to have them on her own. When asked the same question about Father, Ms.
    Arnell stated that if he did not have to care for Mother and could spend as much energy on
    the children in learning what was appropriate, “I think it would be better compared to the
    current situation of both of them being together.” Father admitted as much when he told Ms.
    Arnell that he recognized it would be easier, “but I can’t divorce her.” Ms. Arnell closed the
    case in November 2011 due to the parents’ non-compliance and Mother’s threats against Ms.
    Arnell.
    Father acknowledged the goals of the parenting plans remained consistent and that
    some of the goals had not been met. He admitted to having at least six different jobs since
    2007, and at certain points was not making enough money to make child support payments.
    He testified that Mother and he had lived in at least seven different residencies since the girls
    came into the Department’s custody and that he refused to advise the Department when they
    changed addresses, even though he was aware he was required to do so. When asked about
    Mother, he conceded that he realizes others have concerns with her mental condition, but
    stated he does not have any such concerns.
    -10-
    The foregoing, and other evidence in the record, clearly and convincingly established
    Mother and Father were in substantial noncompliance with the permanency plans. Therefore,
    we affirm the trial court’s finding that the parents failed to substantially comply with the
    requirements of the permanency plan.
    B. P ERSISTENCE OF C ONDITIONS
    Tennessee Code Annotated § 36-1-113(g)(3) specifies the essential elements for the
    “persistent conditions” ground for termination of parental rights. It provides that grounds for
    termination exist when:
    (3) The child has been removed from the home of the parent or guardian by
    order of a court for a period of six (6) months and:
    (A) The conditions that led to the child’s removal or other
    conditions that in all reasonable probability would cause the
    child to be subjected to further abuse or neglect and that,
    therefore, prevent the child’s safe return to the care of the
    parent(s) . . . , still persist;
    (B) There is little likelihood that these conditions will be
    remedied at an early date so that the child can be safely returned
    to the parent(s) . . . in the near future; and
    (C) The continuation of the parent . . . and child relationship
    greatly diminishes the child’s chances of early integration into
    a safe, stable and permanent home;
    Id.
    Marsha Boren, Director of the CASA program in Maury County, has been on the case
    for its entirety, more than five years at the time of trial. According to Ms. Boren, not a single
    issue that brought the children to custody has been resolved. Persistent issues include:
    Mother’s mental health issues and her lack of compliance with treatment, her refusal to work
    with service providers, her limited parenting skills, lack of ability to focus on the children’s
    needs over her own, and Father’s inability to meet the needs of the family. She stated she
    never questioned the parent’s love for the children, but “the question is in their ability to
    provide for them and care for them appropriately.”
    Therapist Elysse Beasley evaluated Mother in November 2011. When speaking of
    Mother’s parenting ability, Ms. Beasley stated “attending to the needs, keeping them safe,
    protecting them, I felt that her touch with reality was such that would be very difficult for her
    -11-
    to do, if not impossible.” Ms. Beasley also stated that “I do not believe that she has the
    capability at this time, and not likely to have it in the future either,” and that Mother does not
    have the ability to function as a parent.
    For Father’s part, he repeatedly refused to accept the fact Mother has a serious mental
    illness that requires medical attention. Father also refused to acknowledge that Mother poses
    a risk to the children if left alone, and has refused to terminate his relationship with Mother.
    See In re Eric J.P., M2012-02082-COA- R3-PT, 
    2013 WL 1788547
    , at *4 (Tenn. Ct. App.
    Apr. 24, 2013) (Wherein the court terminated the mother’s parental rights due, in part, to the
    fact the mother would not end her relationship with the father, and refused to accept the fact
    he sexually abused her daughter, and that he posed a similar risk to the other children).
    The evidence in this record, which we summarized earlier, clearly and convincingly
    established that Mother and Father made no material changes to the conditions that existed
    when the children were removed in 2007, there is little likelihood that these conditions will
    be remedied at an early date so that the children may be safely returned to the parents in the
    near future, and the continuation of the parent and child relationship greatly diminishes the
    children’s chances of early integration into a safe, stable and permanent home. For these
    reasons, we affirm the trial court’s finding that the Department proved the “persistent
    conditions” ground for termination of Mother and Father’s parental rights by clear and
    convincing evidence, pursuant to Tennessee Code Annotated § 36-1-113(g)(3).
    C. A BANDONMENT BY F AILURE TO V ISIT
    Tennessee Code Annotated § 36-1-113(g)(1) provides that parental rights may be
    terminated based upon the ground of abandonment for willfully failing to visit the child. This
    form of abandonment is defined as when a parent “willfully failed to visit . . . the child for
    the period of four consecutive months preceding the filing of the petition to terminate that
    parent’s rights.” Tenn. Code Ann. § 36-1-102(1)(A)(i).
    Failure to visit a child is “willful” when a parent is aware of his or her duty to visit,
    has the capacity to do so, makes no attempt to do so, and has no justifiable excuse for not
    doing so. In re Audrey S., 
    182 S.W.3d 838
    , 864 (Tenn. Ct. App. 2005). However, where the
    failure to visit is not willful, a failure to visit a child for four months does not constitute
    abandonment. R.G.W. v. S.M., No. M2009-01153-COA-R3-PT, 
    2009 WL 4801686
    , at *8
    (Tenn. Ct. App. Dec.14, 2009) (citing In re Adoption of A.M.H., 
    215 S.W.3d 793
    , 810 (Tenn.
    2007)). “A parent who attempted to visit and maintain relations with his child, but was
    thwarted by the acts of others and circumstances beyond his control, did not willfully
    abandon his child.” Id.
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    Tennessee Code Annotated § 36-1-102(1)(E) states that, “‘willfully failed to visit’
    means the willful failure, for a period of four (4) consecutive months, to visit or engage in
    more than token visitation.” “[T]oken visitation,” is visitation, which “under the
    circumstances of the individual case, constitutes nothing more than perfunctory visitation or
    visitation of such an infrequent nature or of such short duration as to merely establish
    minimal or insubstantial contact with the child.” Tenn. Code Ann. § 36-1-102(1)(C).
    We have reviewed the record and find the evidence clearly and convincingly supports
    the conclusion that Mother and Father only engaged in token visitation during the relevant
    period and the visitation did not produce a meaningful visit to establish a meaningful
    relationship or bond between the parents and the children. Thus, the parents willfully failed
    to visit the children for the determinative four months. See Tennessee Code Annotated § 36-
    1-102(1)(C) and (E).
    We, therefore, affirm the trial court’s ruling that Mother and Father abandoned the
    children by failing to visit the children as defined in Tennessee Code Annotated §
    36–1–102(1)(A)(i).
    II. B EST INTERESTS OF THE C HILDREN
    The Tennessee General Assembly has provided a list of factors for the court to
    consider when conducting a best interests analysis. See Tenn. Code Ann. § 36-1-113(i)(1)-
    (9). The nine statutory factors, which are well known and need not be repeated here, are not
    exclusive or exhaustive, and other factors may be considered by the court. See In re M.A.R.,
    
    183 S.W.3d 652
    , 667 (Tenn. Ct. App. 2005). Moreover, not every statutory factor need apply;
    a finding of but a few significant factors may be sufficient to justify a finding that
    termination of the parent child relationship is in the child’s best interest. See In re M.A.R.,
    183 S.W.3d at 667. The child’s best interest is to be determined from the perspective of the
    child rather than the parent. See State Dep’t of Children’s Servs. v. L.H., No.
    M2007-00170-COA-R3-PT, 
    2007 WL 2471500
    , at *7 (Tenn. Ct. App. Dec. 3, 2007) (citing
    White v. Moody, 
    171 S.W.3d 187
    , 194 (Tenn. Ct. App. 2004)).
    Allison Clanton, the children’s therapist, testified the children’s Global Assessment
    of Functioning (GAF)4 scores had improved since they entered foster care. She described
    GAF as “a 0 to 100 scale that gives other clinicians or physicians an idea of how impairing
    . . . the diagnosis is.” Mary initially scored a 55 and Melodie a 50, which indicates “serious
    4
    The GAF ranks mental functioning on a scale of 0-100, with the range of 0 to 30 being catatonic
    or near death and the score of 90 or greater being manic . . . [and an] average range of 60-70. Ivey v. Trans
    Global Gas & Oil, 
    3 S.W.3d 441
    , 447 n.12 (Tenn. 1999).
    -13-
    to moderate symptoms.” Mary’s score improved to 67 and Melodie’s to 65, which Ms.
    Clanton explained indicates improvement but “some mild symptoms” remain. Ms. Clanton
    stated the relationship dynamics were significantly different when comparing the attachment
    assessment of the girls with their biological parents compared to their foster parents. Ms.
    Clanton stated she is concerned Mother could become so agitated she might accidently harm
    the children “because she does become very physically agitated.” However, when speaking
    of the foster parents, Ms. Clanton feels they are “the strongest factor for the girls’
    improvement.”
    Ms. Clanton said the children have clearly come to love and trust the foster parents;
    they have made progress academically, emotionally, behaviorally, and physically, and that
    she would be concerned the progress would be reversed if they were returned to their Mother
    and Father. She testified the foster parents showed great skill in nurturing the children, and
    if they were removed, “they’re likely to experience grief and loss issues.” Mr. M, the
    children’s foster father, testified the girls have developed a strong bond with their biological
    child, and that he and his wife love Mary and Melodie, and if given the opportunity, would
    adopt the children.
    In this case, the evidence clearly and convincingly established that Mother and Father
    failed to make an adjustment in circumstance to provide a safe and stable home for the
    children. See Tenn. Code Ann. § 36-1-113(i)(1). Further, to allow the children to return to
    the parents would subject the children to more uncertainty and instability. Moreover, it would
    require the removal of the children from environments where their conditions have
    dramatically improved and they are much happier and healthier. Id. § 36-1-113(i)(5).
    Considering these relevant factors from the children’s perspective, the evidence
    clearly and convincingly established that it is in the children’s best interests that Mother and
    Father’s parental rights be terminated.
    I N C ONCLUSION
    The judgment of the trial court is affirmed, and this matter is remanded with costs of
    appeal assessed against the parents/appellants.
    ______________________________
    FRANK G. CLEMENT, JR., JUDGE
    -14-