RECORD IMPOUNDED

SUPERIOR COURT OF NEW JERSEY

APPELLATE DIVISION

DOCKET NO. A-4375-15T3

NEW JERSEY DIVISION OF CHILD 

PROTECTION AND PERMANENCY,

Plaintiff-Respondent,

v. 

S.A.,

Defendant-Appellant,

and

A.N.,

Defendant.

__________________________________

IN THE MATTER OF A.N. and E.N., 

Minors.

__________________________________

Argued May 24, 2017 – Decided July 13, 2017

Before Judges Manahan and Lisa.

On appeal from Superior Court of New Jersey, 

Chancery Division, Family Part, Essex County, 

Docket No. FN-07-136-15.

NOT FOR PUBLICATION WITHOUT THE

APPROVAL OF THE APPELLATE DIVISION

This opinion shall not "constitute precedent or be binding upon any court." 

Although it is posted on the internet, this opinion is binding only on the 

parties in the case and its use in other cases is limited. R.1:36-3.
2 A-4375-15T3

Janet A. Allegro, Designated Counsel, argued 

the cause for appellant (Joseph E. Krakora, 

Public Defender, attorney; Ms. Allegro, on the 

brief).

Joseph Maccarone, Deputy Attorney General, 

argued the cause for respondent (Christopher 

S. Porrino, Attorney General, attorney; Andrea 

M. Silkowitz, Assistant Attorney General, of 

counsel; Mr. Maccarone, on the brief).

Melissa R. Vance, Assistant Deputy Public 

Defender, argued the cause for minors (Joseph 

E. Krakora, Public Defender, Law Guardian,

attorney; Ms. Vance, on the brief).

PER CURIAM

S.A. appeals from the Family Part's December 9, 2014 order, 

following a fact-finding hearing, determining that she medically 

neglected her daughter, E.N., who was born on August 10, 2000. 

She argues that the court's finding is not supported by 

substantial, competent, credible evidence necessary for the 

required finding of gross negligence, the court's statement of 

reasons was inadequate, and the court's finding of actual harm was 

speculative and unsupported by the record. The Division of Child 

Protection and Permanency (Division) and the Law Guardian urge us 

to reject these arguments. We agree with the Division and the 

Law Guardian and affirm.

S.A. and her husband, A.N., Sr., have two daughters, E.N. and 

her older sister by three years, A.N. At all times relevant to 
3 A-4375-15T3

this proceeding, A.N., Sr. was incarcerated.1 Although E.N.'s 

older sister was initially included in the complaint filed by the 

Division, the litigation was subsequently terminated with respect 

to her. She has remained a member of the household at all times.

This case revolves entirely around the medical care provided 

by S.A. for E.N., who was diagnosed with autism at a very young 

age.2 During her early years, E.N. functioned well and did not 

exhibit any significant behavioral problems, although she did not 

have speech. Beginning at about age ten, following the death of 

E.N.'s maternal grandfather, she began exhibiting aggressive 

behavior, which progressively became worse and more frequent, and 

was directed primarily at her mother. 

Beginning in the early part of 2012, when E.N. was eleven 

years old, a pattern developed regarding S.A's management of E.N.'s 

behavior. When severe episodes occurred, which were unmanageable 

by her mother, S.A. would take E.N. to an emergency room. E.N. 

 

1 A.N., Sr. is a party to these proceedings. Counsel was assigned 

to represent him. During the fact-finding hearing, his counsel 

was present and A.N., Sr. participated from prison by telephone. 

No findings were made with respect to him, and he is not involved 

in this appeal. 

2 After S.A. became involved with the Division, she reported at 

one point that E.N. was diagnosed when she was two-and-one-half 

years old; at another time she reported the diagnosis was made at 

age five; in her testimony at the fact-finding hearing, she said 

the diagnosis occurred when E.N. was four or five years old.
4 A-4375-15T3

would typically spend an extended period of time there, perhaps 

twelve to twenty-four hours. She would be restrained and 

medicated. The medical personnel would then discharge her with 

instructions to S.A. to follow-up with a primary care physician, 

more particularly a psychiatrist, who could prescribe appropriate 

medication to be taken on a long-term basis. Such a physician 

would also continue to see E.N. on a regular basis, evaluating 

her, and making any appropriate modifications in the medications 

prescribed or their dosages, to manage her autism and achieve the 

best possible results in maintaining her stability. 

The first known treatment for E.N.'s autism was at Newark 

Beth Israel Medical Center in September 2011. On March 25, 2012, 

S.A. brought E.N. to the emergency room at the Rutgers University 

of Medicine and Dentistry Hospital of New Jersey (University 

Hospital), when she was having a severe episode of agitated and 

combative behavior. This followed an emergency room visit the 

previous day at Clara Maass Hospital.

Over the next two years, E.N. was brought to the University 

Hospital emergency room on eleven additional occasions for 

agitated and combative behavior arising from her autism condition.3 

The Division received its first referral in this matter on June 

 

3 E.N. was also brought to that emergency room on two other 

occasions for unrelated medical issues.
5 A-4375-15T3

11, 2013, from Perform Care. The referent reported that S.A. had 

taken E.N. to the emergency room on multiple occasions due to her 

uncontrollable bouts of aggression. The referent also indicated 

that S.A. was not administering medication prescribed to E.N. 

Further, although it had been recommended by various clinicians 

that S.A. submit an application for services to the Division of 

Developmental Disabilities (DDD), she had not done so.

A Division worker met with S.A. and emphasized the importance 

of utilizing all medical services available to E.N. Over the 

ensuing weeks, the Division continued to check in with S.A. to 

assure that she and E.N. would attend a scheduled appointment with 

University Hospital's behavioral healthcare's crisis clinic. The 

Division worker also assisted S.A. in completing the necessary 

paperwork for DDD services. On August 8, 2013, the Division 

determined E.N. was safe under S.A.'s care.

A second referral was made by E.N.'s school on November 21, 

2013, regarding her poor attendance. The Division investigated 

and concluded that the allegation of educational neglect was 

unfounded. During these contacts, the Division worker took the 

DDD application packet from S.A. and sent it to DDD. Apparently, 

DDD never received the application at that time. 

A third referral was made on February 7, 2014, by Dr. Tolga 

Taneli, the Director of the Child and Adolescent Psychiatric 
6 A-4375-15T3

Division, Department of Psychiatry, at University Hospital, and 

Lolita Patel, a crisis clinician at University Hospital. They 

reported that S.A. and E.N. frequently visited the emergency room, 

but S.A. was apparently not following up with any of the hospital's 

recommendations. It was also apparent at that time that the DDD 

application had not been received by the appropriate party. The 

Division ultimately found the allegation of medical neglect to be 

established, but not substantiated. See N.J. Div. of Child Prot. 

& Permanency v. V.E., 488 N.J. Super. 374, 388-89 (App. Div. 2017).

The Division referral that evolved into the present 

litigation was made in the early morning hours of June 25, 2014, 

by staff at the Clara Maass Medical Center. It was reported that 

S.A. brought E.N. to the emergency room because she was being 

"violent and self-abusive." Emergency room personnel wanted to 

admit E.N. for seven days of in-patient care, but S.A. refused, 

saying "the child has been admitted 3 times this year already and 

it does not help her." The referent indicated that he was familiar 

with S.A. and E.N. because they had come to the emergency room for 

similar crisis situations in the past few years.

A Division worker interviewed S.A. When asked whether E.N. 

was taking any medications, S.A. indicated that E.N. had been 

admitted at the Trinitas Regional Medical Center for several months 

in early 2014 and had been prescribed Depakote and Seroquel upon 
7 A-4375-15T3

discharge. However, S.A. stated that she stopped giving E.N. 

these medications because she believed they were ineffective and 

were causing side effects that made E.N. more aggressive. 

Importantly, S.A. acknowledged that she did not consult with any 

medical personnel prior to stopping these medications for E.N.

Because S.A. would not consent to placing E.N. in in-patient 

care, a "hospital hold" was invoked. Jesus Carhauchin, a Division 

worker who had been involved in one of the prior referrals, was 

contacted and assumed the investigation for the Division. The 

following day, E.N. was transferred from Clara Maass to Bergen 

Regional Medical Center. She was discharged from that facility 

on July 2, 2014, but returned to the emergency room with S.A. 

later that afternoon due to another onset of violent behavior. 

E.N. was referred to Hoboken Medical Center the next day and

was transferred there when a bed became available on July 7. On 

July 10, Carhauchin met with Partnership for Children of Essex 

(PCE) to discuss future treatment for E.N. At this meeting, it 

was explained to S.A. that staff from University Hospital, Hoboken 

Medical Center, Bergen Regional Medical Center, and Trinitas had 

all recommended that E.N. receive a "Residential Facility Level 

of Care." S.A. declined to provide her consent, stating that she 

needed additional time to consider it.
8 A-4375-15T3

E.N. was discharged from Hoboken Medical Center on July 11, 

but she became violent and agitated upon arriving home. S.A. took 

her to the University Hospital emergency room where she was treated 

and returned home the same day. Following yet another episode, 

E.N. was taken to Trinitas Hospital emergency room on July 18, and 

admitted there the next day.

The June 25, 2014 allegation was ultimately substantiated by 

the Division, which found that S.A. "[d]eprive[d] a child of 

necessary care which either caused serious harm or created a 

substantial risk of serious harm." See N.J.A.C. 10:129-7.4(a)6. 

In its report, the Division referred to Dr. Taneli's July 3, 2014 

letter, which explained: "Having gotten to know [E.N.] and her 

outpatient providers intimately over the past years, our child 

[and] adolescent psychiatric team concludes that [E.N.] is in need 

of residential care at this time, if any degree of stability is 

to be attained."

The Division also found that S.A. refused to consent to pursue 

this level of care, and the only medical care E.N. had received 

in the past three years was through her many emergency room visits 

and hospital stays. The Division determined that S.A. had not 

been properly administering the medications that E.N. was 

prescribed. The Division also emphasized how various services, 

including PCE, Associates Mental Health Disability, Perform Care,
9 A-4375-15T3

and DDD were offered to S.A., but she was non-compliant with their 

recommendations. Having substantiated the referral, the Division 

filed for care and supervision of E.N. and her sister on August 

5, 2014.4

Although we include in the sequence of events the fact that 

S.A. resisted efforts to secure a residential placement for E.N., 

that was not the basis for the ultimate finding of medical neglect. 

Indeed, S.A.'s reason for resisting was her continuing hope that 

with additional home care services, she would be able to keep her 

daughter, whom she loves, at home with her. The basis for the 

medical neglect finding was the long course of conduct, spanning

more than two years, during which S.A. repeatedly failed to follow 

recommendations by medical providers that would have had the best 

prospect for stabilizing E.N. on a long-term basis. 

Instead, E.N. took it upon herself to discontinue medications

without medical advice, and failed to establish a relationship 

with a treating psychiatrist who could see E.N. on a regular basis 

to assess her condition, monitor and adjust her medications as 

necessary, and provide such other medical care as would be 

indicated. This could only be achieved through an ongoing and 

 

4 On this same date, S.A. provided PCE with verbal consent to 

begin securing an appropriate residential placement for E.N. E.N. 

has ultimately been placed in the Bancroft Residential Facility. 
10 A-4375-15T3

stable course of psychiatric care. However, S.A. persistently 

failed to comply with this advice and these multiple 

recommendations, opting for crisis management through emergency 

room visits and emergency admissions. This provided only temporary 

relief and temporary stabilization of E.N.'s condition. Without 

the required follow-up, it was inevitable that the cycle would 

recur, which it did over and over again.

At the fact-finding hearing, the Division presented the 

testimony of Dr. Taneli and caseworker Carhauchin. The Division 

also placed into evidence voluminous documentary materials. S.A. 

testified in her own behalf, but presented no other witnesses.

Dr. Taneli was qualified without objection as an expert in 

the field of child and adolescent psychiatry. He had personally 

seen E.N. on a number of her emergency room visits at University 

Hospital, and he was familiar with the records of all of her other 

visits there. Dr. Taneli noted that in six of the twelve emergency 

room visits at University Hospital for aggressive behavior 

resulting from E.N.'s autism, in-patient treatment was 

recommended. On four of those occasions, it was accomplished with 

S.A's consent. On one occasion, a bed was not available. On the 

remaining occasion, S.A. refused.

Throughout the course of these emergency room visits, the 

common thread was the recommendation made to S.A. that she obtain 
11 A-4375-15T3

a stable primary care psychiatric physician for ongoing treatment. 

Dr. Taneli explained that an emergency room is "not a place where 

treatment can be effectively set up or completed." In an emergency 

room, a "set of medicines that we end up using are agitation 

medicines, sometimes injectable medicines or if she agrees by 

mouth." This will reduce agitation in the short term, but it is 

not the kind of ongoing treatment that is required to achieve 

optimum stability. He explained the necessity for ongoing care 

and medication as follows:

Q. What is your understanding of [S.A.] 

giving E.N. medication?

A. I think [S.A]'s relationship or work with 

the medicines was mostly ambivalent. That is, 

sometimes she was prepared to go through 

stretches of medicines. I think sometimes 

they were helpful. Other times there was a 

good number of side effects, but in terms of 

arriving to the ER with an established 

provider or a stretch of care was missing. 

That is, throughout the many visits there 

wasn't, for example, one person who we would 

identify as the doctor who treats E.N.

Q. And why is that significant when 

you're talking about a child with autism?

A. Because it interrupted the medicine 

treatments. It created gaps in prescriptions 

where it would be -- there would be times of 

no medicine and it took away the ability to 

make judgments on benefits and side effects 

that would then lead to other trials if, for 

example, treatments failed or if they 

succeeded, for the continuation of that 

treatment.
12 A-4375-15T3

. . . .

Q. And this inconsistency, what harm, 

if any, did that cause to the child?

A. It left her in -- in -- it left her with 

many visits for aggression that probably would 

have been reduced if there were stretches of 

well-being.

Dr. Taneli testified that the record did not indicate that 

E.N. was getting regular psychiatric care throughout the two-year 

period during which she had presented at the emergency room on 

twelve occasions for severely aggressive and agitated behavior

caused by her autism. He stated: "Some visits there had been 

many months of no treatment and other visits there had been months 

of treatment by some providers then by others." But there had not 

been a particular doctor that was following her on a consistent 

basis. 

Referring to medical records, Dr. Taneli pointed out that 

S.A. readily acknowledged on various occasions that she had stopped 

giving E.N. prescribed medications. Indeed, in her testimony at 

the fact-finding hearing, S.A. acknowledged that she had no regular 

primary care psychiatric physician for E.N. over the years. In 

her testimony, she could not remember what medications had been 

prescribed from time to time, but she readily acknowledged that, 
13 A-4375-15T3

without medical advice, she often stopped giving those medications 

to E.N.

At the conclusion of the hearing, the judge rendered his 

decision. He began by acknowledging that in a case such as this 

it is necessary "to look at the totality [of] the circumstances 

as opposed to a particular finite point in time." The beginning 

point in the judge's assessment was "around 2010 or 2011." He 

elaborated as follows:

The child was out of control for a very, 

very long period of time and there was nothing 

done but -- except when there was an absolute

total crisis bringing the child to the 

emergency room. That's not treatment. That's 

calming down a crisis. That's . . . 

stabilizing the situation, but that's not 

treatment. That's not ongoing treatment that 

this child clearly needed.

This child had special needs. I mean, 

you know, if the child was sick, you wouldn't 

wait until the child was to the point of dying 

and bring him to an emergency room. You need 

to get continuing treatment.

This child had autism. She was having 

problems in school. She was out of control 

at school. She was out of control at home. 

And going to the emergency room every month 

is not the answer to getting this child 

consistent treatment. She clearly needed some 

type -- it seemed to me that she clearly needed 

medication and there was no consistent 

medication.

And if there were problems with the 

medication, there had to be follow-up with 

doctors. There had to be a doctor following 
14 A-4375-15T3

her that she saw monthly. No one is going to 

treat her with medication unless she saw a 

doctor regularly, monthly for medication 

monitoring.

Nobody is going to give psychotropic 

medication to anyone without seeing them at 

least once a month and there wasn't that 

consistency for this child to make sure she 

was getting the appropriate meds to stabilize 

her so that she could manage in school. Maybe 

some of these hospitalizations and emergency 

rooms wouldn't have been necessary. 

I find there's actual harm here. This 

child should have been getting regular 

treatment as opposed to crisis treatment only 

and that really wasn't enough.

I mean it's very telling when it says 

"Patient has not been on medications. Was 

taking Depakote and Seroquel. Dose unknown." 

Mother didn't know how much since -- she's 

been on it since April, because mom stopped 

medication because of a new tremor. Whether 

or not the tremor was related to medication, 

there's no showing that she went to a doctor 

to get off there.

Mom stopped medication on her own because 

she stated she did not notice any improvements 

in her behavior. But she didn't get any 

recommendation from another doctor to change, 

alter, increase, decrease, change a different 

medication.

I mean getting medication for a couple 

of days or a week that the hospital gives you 

when you go to a hospital, is not regular 

psychiatric care. This is not the kind of 

treatment this child needed for years and 

didn't get.

And I'm sorry, but this -- you know, it 

came to a head at that point where they said 
15 A-4375-15T3

she needs to be immediately put in hospital, 

but you know, it isn't like this is a big 

surprise that there's problems. I mean I find 

that, you know, these issues and these 

problems -- and [S.A.] seems to be confusing 

the different dates. I mean I didn't find her 

a very good historian about what was going on 

or what took place or who was doing what.

He concluded:

I didn't find her testimony to be -- it 

was very cogent or helpful to the court in 

this matter and I do find this was a child 

that really needed more intensive [treatment]

as recommended by the hospital. It was 

recommended and she never got that kind of 

treatment that she needed and it created the 

situation that caused the instability. 

. . . . 

That's not the way to treat and stabilize 

a child. I don't find that appropriate. I 

do find that's medical neglect.

Appellate courts "have a strictly limited standard of review 

from the fact-findings of the Family Part judge." N.J. Div. of 

Youth & Family Servs. v. I.H.C., 415 N.J. Super. 551, 577 (App. 

Div. 2010). "[A]ppellate courts 'defer to the factual findings 

of the trial court because it has the opportunity to make firsthand credibility judgments about the witnesses who appear on the 

stand; it has a feel of the case that can never be realized by a 

review of the cold record.'" N.J. Div. of Youth & Family Servs. 

v. M.C. III, 201 N.J. 328, 342-43 (2010) (quoting N.J. Div. of 

Youth & Family Servs. v. E.P., 196 N.J. 88, 104 (2008)). Moreover, 
16 A-4375-15T3

"[b]ecause of the family courts' special jurisdiction and 

expertise in family matters, appellate courts should accord 

deference to family court factfinding." Cesare v. Cesare, 154 

N.J. 394, 413 (1998). "A trial court's interpretation of the law 

and the legal consequences that flow from established facts are 

not entitled to any special deference." Manalapan Realty v. 

Manalapan Twp. Comm., 140 N.J. 366, 378 (1995). 

As relevant here, Title 9 defines an "abused or neglected 

child" as

a child whose physical, mental, or emotional 

condition has been impaired or is in imminent 

danger of becoming impaired as the result of 

the failure of his parent . . . to exercise a 

minimum degree of care . . . in supplying the 

child with adequate . . . medical or surgical 

care.

[N.J.S.A. 9:6-8.21c(4)(a).]

The standard in deciding whether a parent has failed to 

exercise a minimum degree of care is one of gross negligence. G.S. 

v. Dep't of Human Servs., 157 N.J. 161, 178-79 (1999). Parental 

conduct that is "inattentive or even negligent [does] not meet the 

requisite standard of willful or wanton misconduct." N.J. Dep't 

of Youth & Family Servs. v. J.L., 410 N.J. Super. 159, 168 (App. 

Div. 2009). A parent may fail to exercise a minimum degree of 

care where he or she knows of the dangers inherent to a particular 

situation. N.J. Div. of Youth & Family Servs. v. V.T., 423 N.J. 
17 A-4375-15T3

Super. 320, 329-30 (App. Div. 2011) (citing G.S., supra, 157 N.J.

at 181-82). This is so because the focus of Title Nine is not on 

the "'culpability of parental conduct' but rather 'the protection 

of children.'" Dep't of Children & Families v. E.D-O., 223 N.J.

166, 178 (2015) (citing G.S., supra, 157 N.J. at 177).

Courts must consider the totality of the circumstances. N.J. 

Div. of Youth & Family Servs. v. P.W.R., 205 N.J. 17, 39 (2011).

We consider whether the child has suffered actual harm and in the 

alternative, we consider whether there is "some form of . . . 

threatened harm to a child." E.D.-O., supra, 223 N.J. at 181

(alteration in original) (citing N.J. Dep't of Youth & Family 

Servs. v. A.L., 213 N.J. 1, 25 (2013)).

We are satisfied from our review of the record that the 

judge's findings are well supported by substantial, competent, 

credible evidence in the record. This includes voluminous 

documentary materials, the uncontroverted expert testimony of Dr. 

Taneli, and S.A's own testimony, in which she acknowledged the 

very deficiencies which underpin the finding of medical neglect. 

The record supports the conclusion that consistent primary care 

psychiatric treatment was required, that emergency room physicians 

repeatedly recommended to S.A. such a course of treatment, and

that S.A. knew or should have known that such a course of treatment 

was medically necessary for E.N., but she deliberately failed to 
18 A-4375-15T3

follow that course. As a result, E.N. was actually harmed because 

she could not achieve optimal stabilization of her condition 

without consistent treatment and medication monitoring.

Affirmed.