J-S19002-19

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* Retired Senior Judge assigned to the Superior Court.

NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT I.O.P. 65.37

IN THE INTEREST OF: S.N.R., A 

MINOR

APPEAL OF: S.R., MOTHER

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 IN THE SUPERIOR COURT OF

 PENNSYLVANIA

 No. 2758 EDA 2018

Appeal from the Order Entered August 15, 2018

In the Court of Common Pleas of Philadelphia County Family Court at 

No(s): CP-51-DP-0001387-2018

BEFORE: LAZARUS, J., KUNSELMAN, J., and STRASSBURGER*, J.

MEMORANDUM BY LAZARUS, J.: FILED MAY 17, 2019

S.R. (Mother) appeals from the order, entered in the Court of Common 

Pleas of Philadelphia County, adjudicating S.N.R. (Child), born September, 

2003, dependent, and finding Child the victim of abuse by Mother. 23 

Pa.C.S.A. § 6303. After our review, we affirm based on the opinion authored 

by the Honorable Joseph L. Fernandes.1

On April 2, 2018, the Philadelphia Department of Human Services (DHS) 

received a Child Protective Services (CPS) report that Mother was suffering 

____________________________________________

1 We note that the court appointed counsel for Child, as well as a guardian ad 

litem (GAL). Counsel for Child filed a letter to this Court indicating she would

not be filing a brief on behalf of Child. The GAL has filed a brief on appeal on 

behalf of Child, recommending this Court affirm the trial court’s order 

adjudicating Child dependent and finding child abuse as to Mother. Brief of 

Appellee S.N.R., at 16. The Philadelphia Department of Human Services 

(DHS) also filed a brief as a participant, requesting this Court affirm the trial 

court’s order. Brief for Participant, at 31. 
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from Munchausen syndrome by proxy.

2 The report stated that Mother had 

made multiple medical specialist appointments for Child, including 37 calls to 

Child’s primary care physician, 62 healthcare visits, and six emergency room 

visits in 2016, and 21 calls and 38 healthcare visits in 2017. DHS filed a 

dependency petition on June 7, 2018, alleging Child was without proper care 

or control and that Child was a victim of child abuse as defined at 23 Pa.C.S.A. 

§ 6303. Dependency Petition, 6/7/18, at 1.3 Mother and Se.R. (Father) are 

recently divorced. 

____________________________________________

2 Munchausen syndrome by proxy, a mental illness, now known as Factitious 

Disorder Imposed on Another (FDIA), is considered a form of child abuse by 

the American Professional Society on the Abuse of Children. 

https://my.clevelandclinic.org/health/diseases/9834-factitious-disorderimposed-on-another-fdia (last visited 4/17/19). “In this mental illness, a 

person acts as if an individual he or she is caring for has a physical or mental 

illness when the person is not really sick. The adult perpetrator has the 

diagnosis (FDIA) and directly produces or lies about illness in another person 

under his or her care, usually a child under 6 years of age.” Id.

3 The dependency petition alleged, inter alia, that 

[Child] had developed conversion disorder, which is a mental 

condition in which a person has blindness, paralysis, or other 

nervous system symptoms that cannot be explained by medical 

evaluation. The [CPS] report alleged that [Child] had developed 

ticks [sic] and automatic movements, and that [Child] began 

receiving mental health treatment through Children’s Hospital of 

Philadelphia (CHOP) with a social worker and psychiatrist in 2016 

because of her diagnosis; that [Child] had not shown any 

improvement and the ticks [sic] were still present; and that 

[Child] had been admitted to Cumberland Hospital for Children 

and Adolescents [Cumberland] in Virginia for inpatient mental 

health treatment as a result of her lack of improvement . The 

report alleged that [Child] remained at Cumberland Hospital for 
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On June 25, 2018, pursuant to a protective custody order, Child was 

removed from Mother’s care and placed in DHS’ custody. Order of Protective 

Custody, 6/25/18. On July 23, 2018, the court held an adjudicatory/child 

abuse hearing and heard testimony from Brian Brennan, M.D., a child abuse 

pediatrics fellow at Children’s Hospital of Philadelphia (CHOP). Both Mother 

and Father were present at the hearing, and Child participated by telephone. 

Doctor Brennan testified with respect to the issue of medical child abuse. 

The evidence established that for the first two years of Child’s life, 

medical visits were typical. N.T. Hearing, 7/23/18, at 31. Thereafter, medical 

visits increased exponentially, to 46 visits between the ages of two and five, 

and, by the age of five, Child had been prescribed twenty different 

medications. Id. at 28, 29-31. Child’s healthcare team at CHOP noted 

Mother’s behavior. CHOP characterized Mother as “hypervigilant” with Child, 

who was her only child. 

In 2014, Child was diagnosed with amplified musculoskeletal pain 

syndrome (AMPS), a syndrome that causes amplified pain response to 

____________________________________________

Children and Adolescents for five to six months beginning in July 

2017; that while hospitalized, Child showed great improvement 

and had lost all ticks [sic] and automatic behaviors; that when 

[Child] returned home around October 2017, she regressed and 

reverted to exhibiting automatic behaviors and ticks [sic]; and 

that since returning home, [Child] has made claims that she was 

sexually abused by [Father] and staff at Cumberland Hospital for 

Children and Adolescents. 

Dependency Petition, 6/17/18, at 2-4. 
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relatively innocuous physical contact. Despite the recommended treatment of 

“minimizing accommodations for the child” and “normaliz[ing] [Child’s] 

existence,” the increasingly frequent medical visits continued. 

In 2016, during the time Mother and Father were going through divorce 

proceedings, Child was diagnosed with Conversion Disorder.4 This diagnosis

led to inpatient admission to Cumberland Hospital for Children and 

Adolescents [Cumberland], a behavioral health hospital. Id. at 37-38. While 

there, and separated from Mother, Child showed marked improvement; she 

was discharged asymptomatic.5 Id. at 40-41.

In June 2018, approximately eighteen months after her discharge from 

Cumberland, Child was admitted to CHOP with severe paralysis; at this time, 

Dr. Brennan evaluated Child for medical child abuse. Id. at 87, 90-91. Doctor

Brennan testified:

[Child] did so well during her three months at Cumberland to the 

point she was asymptomatic and able to come home only to turn 

around within a month and—and decompensate to the point where 

she was having paralysis again and needing to be loaded into the 

____________________________________________

4 Conversion disorder, also called functional neurological disorder, is a 

condition in which abnormal movements or sensations (spells, weakness, 

tremors) are not due to injury or disease, but rather a result of a 

miscommunication of the nervous system and the body. 

https://my.clevelandclinic.org/health/diseases/17787-conversion-disorderin-children--adolescents (last visited 4/17/19). 

5 When Child returned from Cumberland, she made allegations of prior sexual 

abuse when she was five or six, against Father. These allegations were 

determined to be unfounded. N.T. Hearing, 8/15/18, at 21-22.
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car. And—and then her doctors had to come down to the parking 

lot to see her.

Id. at 46. Doctor Brennan noted the reference in Child’s medical records to 

concerns that Mother was “catastrophizing” and exaggerating Child’s 

symptoms and that Child was “over-medicalized.” Id. at 39-40, 87. He also 

expressed concern that Mother and Child were “enmeshed.”6 Id. at 44. 

Doctor Brennan testified that in his opinion, to a reasonable degree of 

medical certainty, Child suffered from medical child abuse. Id. at 42. He 

explained:

[M]edical child abuse is defined as a child who receives 

unnecessary and harmful or potentially harmful medical care at 

the instigation of the caregiver. What used to be known as 

Munchausen’s syndrome by proxy was kind of redefined relatively 

recently to exclude the intention of the caregiver. In [Child’s] 

case, [Child] has been provided multiple, multiple, multiple 

medical therapies and interventions that are potentially harmful 

and are unnecessary given what we — what we currently know. . 

. . In medical child abuse cases, it’s difficult from that one-time 

clinical perspective to see things until they reach a point where 

you take a . . . big step back and you look at the constellation of 

everything that’s going on and the severity of the— the 

psychopathology that the child is starting to exhibit that you really 

do start to . . . get that feeling that maybe this is something that 

you need to evaluate further[.]

Id. at 42-44. At the time of that hearing, Child was at CHOP and suffering 

from “functional paralysis,” which Dr. Brennan described as an inability to walk 

with no physical or organic explanation. He stated that Child is able to transfer 

____________________________________________

6 At the August hearing, both Mother and Child testified that they slept 

together on the living room sofa, and that they had done so for the past few 

years. N.T. Hearing, 8/15/18, at 55, 95-96. In fact, Mother testified that this 

sleeping arrangement had started when Child was nine years old. Id. at 96. 
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herself over to a wheelchair and that her legs move in her sleep. “And so, 

she’s able to do things that someone who was legitimately paralyzed from the 

waist down would be unable to do.” Id. at 91. At CHOP, Child was undergoing 

intensive psychotherapy. Id. at 92. At the conclusion of the hearing, the 

court ordered parental visitation at the discretion of the treatment team and 

Child, and scheduled a hearing for August 15, 2018.

At the August hearing, the court heard testimony from Child, Child’s 

GAL, Mother, Father, DHS, and CUA caseworker/Catholic Community Services

worker. Mother and Father were both represented by counsel. Also appearing 

were Child’s legal counsel and a Child Advocates Staff Attorney. At the 

conclusion of the hearing, and following the argument of counsel, the court 

adjudicated Child dependent pursuant to the Juvenile Act, 42 Pa.C.S.A. §§ 

6301-6365, found clear and convincing evidence of child abuse under section

6303 of the Child Protective Services Law (“CPSL”), 23 Pa.C.S.A. §§ 6301-

6386, and ordered the CPS report changed from indicated to founded. 

Mother raises three issues on appeal: 

1. Did the trial court err and/or abuse its discretion when it 

found that the [DHS] had met its burden of finding, by clear 

and convincing evidence, that Child was dependent? 

2. Did the trial court err and/or abuse its discretion when it 

found that the [DHS] had met is burden of establishing child 

abuse as to Mother by clear and convincing evidence?

3. Did the trial court err and/or abuse its discretion when it 

determined the [CPS] report was “founded” and changed 

the report from a “CY48” into a “CY49?” 
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Appellant’s Brief, at vi (slightly reworded for clarity).

Our standard and scope of review from an order in a dependency case 

are well settled.

We must accept the facts as found by the trial court unless they 

are not supported by the record. Although bound by the facts, we 

are not bound by the trial court’s inferences, deductions, and 

conclusions therefrom; we must exercise our independent 

judgment in reviewing the court’s determination, as opposed to 

its findings of fact, and must order whatever right and justice 

dictate. We review for abuse of discretion. Our scope of review, 

accordingly, is of the broadest possible nature. It is this Court’s

responsibility to ensure that the record represents a 

comprehensive inquiry and that the hearing judge has applied the 

appropriate legal principles to that record. Nevertheless, we 

accord great weight to the court’s fact-finding function because 

the court is in the best position to observe and rule on the 

credibility of the parties and witnesses.

In re C.M.T., 861 A.2d 348, 351 (Pa. Super. 2004) (citations omitted). 

Expert medical testimony established that it was Mother's actions—

insisting on invasive and unnecessary medical intervention—that resulted in 

Child’s ailments and diagnoses. Child was diagnosed with conversion disorder, 

and intensive behavioral health and psychiatry evaluation and treatment were 

recommended. However, Mother refused to accept that there was not a 

medical explanation for Child’s symptoms, and continued to interfere in her 

treatment, requesting more invasive testing and medications, including a 

lumbar puncture. Nevertheless, under Mother’s care, Child’s condition 

continued to deteriorate until she could no longer complete age-appropriate 

activities of her daily life. Mother continued to insist on unnecessary 

treatments and accommodations for Child, such as a chair lift and pain 
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medication. By the time of Child’s August 2017 hospitalization at CHOP, 

Mother was insisting on anti-seizure medications and cardiac monitoring.7

After our review of the parties’ briefs, the record, and the relevant law, 

we conclude that the trial court properly found Child was dependent and that 

Mother committed child abuse pursuant to 23 Pa.C.S.A. § 6303(b.1)(2)

(“[f]abricating, feigning, or intentionally exaggerating or inducing a medical 

symptom or disease which results in a potentially harmful medical evaluation 

or treatment to the child through any recent act.”).8

____________________________________________

7 The Child Protective Services Law (CPSL), 23 Pa.C.S.A. § 6301-6308,

provides, in relevant part: 

(b.1) Child abuse.--The term “child abuse” shall mean 

intentionally, knowingly or recklessly doing any of the following:

* * *

(1) Causing bodily injury to a child through any recent act or 

failure to act.

(2) Fabricating, feigning, or intentionally exaggerating or inducing 

a medical symptom or disease which results in a potentially 

harmful medical evaluation or treatment to the child through any 

recent act.

(3) Causing or substantially contributing to serious mental injury 

to a child through any act or failure to act or a series of such acts 

or failures to act.

23 Pa.C.S.A. § 6303(b.1)(1)-(3).

8 We note also that the trial court found Child’s testimony not credible, found 

Father’s testimony credible, and made no determination with respect to 

Mother’s credibility. However, the court concluded that the evidence 

presented by the caseworkers and medical expert established that Mother 
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The trial court has comprehensively and correctly addressed Mother’s 

claims on appeal. Accordingly, we affirm the trial court’s August 15, 2018 

order on the basis of Judge Fernandes’ opinion.9 We direct the parties to 

attach the trial court opinion in the event of future proceedings.

Order affirmed.

Judgment Entered.

Joseph D. Seletyn, Esq.

Prothonotary

Date: 5/17/19

____________________________________________

posed a “grave threat” and that her visits would be suspended until further 

hearing and recommendation by Child’s treatment team. 

9 W note a typographical error on page 10 of the trial court’s opinion; the first 

word of the second paragraph should read “Mother’s,” not “DHS’s.” 
Circulated 05/10/2019 02:05 PM

FID: 5 J -FN-001206-2018 

CP·S 1-DP-0001387-2018 

APPEAL OF: S.R., Mother 2758 EDA 2018 

[n the Interest ofS.N.R., a Minor 

IN THE COURT OF COMMON PLEAS 

FOR THE COUNTY OF PHILADELPHJA 

FAMILY COURT DIVISION 

OPINION

1 

Fernandes, J.: 

Appellant S.R. ( .. Mother") appeals from the order entered on August 15, 2018, adjudicating S.N.R. 

("Child") dependent and finding child abuse against Mother. Carla Beggin, Esquire, counsel for 

Mother ("Mother's Counsel") filed a timely Notice of Appeal with a Statement of Matters 

Complained of on Appeal pursuant to Rule l 925(b) ("Statement of Brrors").' 

Factual and Procedural Background: 

DHS became involved with this family on April 2, 2018, when OHS received a Child Protective 

Services ("CPS") report alleging that Mother suffered from Munchausen syndrome by proxy; 

Mother made multiple specialist appointments for Child and took Child to be examined by doctors; 

Mother was initially viewed as an anxious Mother but in 2016, Mother made 37 calls to the office 

Child's primary care physician ("PCP"), 62 healthcare visits, and six emergency room visits for 

Child; in 2017, Mother made 21 calls and 38 healthcare visits for Child; Child developed a 

conversion disorder;' Child developed ticks and other automatic movements; Child began 

receiving mental health treatment through Children's Hospital of Philadelphia ("CHOP") with a 

I The trial court requested the Notes of Testimony for July 23, 2018, and August I 5, 20 l 8, on August 29, 2018. The 

!rial court received the Notes of Testimony for July 23, 2018, on August 30, 2018. The trial court made a subsequent 

request for the August IS, 20l8, Notes of Testimony on October 4, 2018, October 11, 2018, and October 17, 2018. 

The trial court received the Notes of Testimony for August IS, 2018, on October 23, 2018. 

1 Mother's Counsel filed the Notice of Appeal and Statement of Errors on September 11, 2018. Mother's Counsel's 

Proof of Service indicates that all parties were served by "first class United States mai � postage prepaid, e-fil ing 211d/or 

Courthouse mailbox." Trial Judge did not receive a copy of the Notice of Appeal and Statement of Errors from 

Mother's Counsel and was not made aware of this appeal until Trial Judge received a copy of the Appeal Docket Sheet 

&om the Superior Court of Pe1111Sylvania on October 4, 2018. 

, Conversion disorder is a meotal condition in which a person has blindness, paralysis, or other nervous system 

symptoms that cannot be explained by medical evaluation. (N.T. 07/23/18, pgs. 37-38). 

Page 1 of 14 
social worker and psychiatrist in 2016 due to her diagnosis; Child had not shown any improvement 

and the ticks were still present; Child had been admitted to Cumberland Hospital for Children and 

Adolescents (''CHCA") in Virginia for inpatient mental health treatment as a result of her lack of 

improvement; Child remained at CHCA for five to six months, beginning in July 20 l 7; while Child 

was hospitalized at CHCA, Child showed great improvement and Jost all ticks and other automatic 

behaviors; when Child returned home to Mother in October 2017, she regressed and reverted to 

exhibiting automatic behaviors and ticks; after Child returned home from CHCA, she claimed that 

she was sexually abused by Father and staff at CHCA; Mother removed Child from school two 

years prior; Child no longer took dance lessons; Child was enrolled in a home school program; 

Child had little social contact; Mother stated that Child's behavior was a result of Father's actions; 

Mother had previously gone to Child's PCP's office and told another physician that Child was 

having terrible migraines; ihar physician sent Child to a neurologist; Mother returned to the PCP's 

office and spoke to a different physician about another issue and this pattern continued for 18 

months until the PCP told Mother that she must address any issues with him only; since being 

given the limitation, Child's referrals to specialists lessened; Child has seen approximately 10-15 

specialists, including a psychiatrist, weight control physician, ophthalmologist. and neurologist; 

Child recently stated that she was having anxiety and trouble sleeping; Child was attending therapy 

with a social worker and psychiatrist; Child was considered overweight; Child has been prescribed 

medication for mental health concerns; Mother and Father were going through a divorce; Mother 

appeared to be anxious; Mother described Father as an abusive person; Mother stated that the 

family had been involved with children and youth services authorities in the past. This report was 

indicated. DHS visited Child and Mother o.t their home on the same day. When DHS spoke With 

Child, Child denied the allegations; she did not believe that Mother was making her sick to get 

attention and that the symptoms were real; Mother was the only person who understood what she 

was going through; she no longer interacted with Father after be announced that he was divorcing 

Mother on Facebook; prior to the divorce, Child rarely interacted with Father because he was either 

working or rarely at home; Child was supposed to begin therapy sessions with Father but Mother 

told her that if she did not get better, Father would get full custody, which caused her a lot of 

anxiety; Child accused Father of sexually abusing her when she was about five or six years old, 

but was unable to give DHS further detail as to Father's actions other than that he came into her 

bedroom at night. During the interview, Child began making clicking noises with her mouth and 

Page 2 of 14 
Child stated that she could not control the sounds because she had conversion disorder; she began 

exhibiting the symptoms of the disorder a few years ago; the symptoms were due to stress at school 

and manifested after an incident in school where a fellow student sprayed mace into the air; she 

had pseudo-seizures; she sometimes had outbursts of stating the phrase "woo-hoo" and became 

paralyzed; staff at the hospital told her doctors that she was getting better but they lied and that she 

faked her improvement so that she could be discharged from the hospital. When DHS spoke with 

Mother, who also denied the allegations of the report, Mother stated that after the incident where 

the student sprayed mace· in the air, Child developed ticks and pseudo-symptoms of physical 

disorders and illnesses; she had taken Child to many specialists to help care for Child and that 

could not be done without a referral from the PCP due to insurance restrictions. OHS later learned 

that Mother and Child had Personal Choice medical insurance.' Mother also stated that she never 

saw Father touch Child inappropriately; Child bad not told her about the sexual abuse until recently 

via text message; Child never told her in detail about what happened with Father, but she was sure 

Child told the therapist. OHS assessed the home and determined that it was appropriate; however, 

DHS learned that although Child has her own bed and bedroom, Child and Mother slept in the 

living room in their own recliners. When DHS asked Child about the sleeping arrangements, Child 

explained that she could not sleep in her room because she was sexually assaulted by Father in her 

bedroom. 

On May I, 2018, DHS spoke with Father, who denied sexually assaulting Child, and he stated that 

he believed the allegations were a part of a plot for custody of Child by Mother; he was accused 

of many things since he initiated divorce proceedings againgt Mother two years ago; he believed 

he was accused of things whenever he did sometbmg to further the separation from Mother; this 

recent al legation arose two weeks after he signed the family home over to Mother; he believed that 

the allegations stemmed from the fact that he would not relinquish his parental rights to Child nor 

would he reunite with Mother; he could not have sexually abused Child because he was never 

allowed to be alone with Child; Mother was overly possessive of Child; he never went into Child's 

bedroom at night; he worked most nights as a firefighter and, except for one visit, had not seen 

Child outside of a hospital in the last two years; he was concerned about Child; Child had over 300 

exams, laboratory tests, and other specialty services since she was nine years old; he visited Child 

4 Personal Choice insurance does not require a referral to see a specialist. 

Page3 of14 
while she was at CHCA and she was doing well there; Child regressed when she returned to 

Mother's care. 

On May 11, 2018, Child attended a forensic interview at the Philadelphia Children's Alliance 

("PCA"). When Child arrived, she told staff that she could not see anything because of her 

conversion disorder; however, Child was observed on video using her cellular telephone. Child 

kept her eyes closed throughout the entire interview. Child initially could not explain anything in 

detail that happened to her, but eventually stated that about five to eight years ago Father came 

into her bedroom and touched himself inappropriately before penetrating her. Child stated that she 

couldn't remember if this was a recurring event; she only recently remembered; she used to be 

strongly bonded with Father until two years prior; when Father separated from Mother, he began 

treating Mother poorly; she only disclosed to Mother because Mother told her that if she did not 

get her mental health and school issues under control, she would be sent to live with Father; she 

did not want to live with Father. When the interview ended, Child opened her eyes and was seen 

in the waiting area using her cellular telephone and listening to music. 

On May 25, 2018, DHS received correspondence from Child's mental health treatment team at 

CHOP. The correspondence indicated that Mother had been hypervigilant about Child's health 

since she was a baby, even going so far as sleeping on the floor of Child's room, next to her crib, 

which was unwarramed because Child was a healthy baby; Mother's hypervigilance caused a strain 

on ber marriage and Father disengaged from the family as Mother and Child became more and 

more enmeshed and continued to meet eaca other's emotional needs; Child began exhibiting 

somatic symptoms around age eight, after Father moved out of the home for an extended period 

of time; Child was eventually diagnosed with amplified musculoskeletal pain syndrome ("AMPS") 

after multiple visits to various specialists; Child began treatment for anxiety in 2014 and that 

anxiety triggered Child's AMPS; Child and Mother attended therapy sessions together for years 

without Father; Child began exhibiting conversion disorder symptoms in 2016; after Father moved 

out of the home in 2016, Child began suffering from pseudo-seizures, full body paralysis, and the 

inability to open her eyes and/or mouth, in addition to AMPS; Child's symptoms became so 

debilitating that she could no longer attend school or participate in age-appropriate activities; 

Father began participating in therapy while Child was at CHCA and it was recommended that the 

sessions continue once Child was discharged from CHCA; the focus of the therapy sessions 

Page 4 of 14 
between Father and Child was to reengage Father in the family unit and to decrease Child's 

conversion disorder symptoms by diluting the enmeshment between Child and Mother so that 

Child could develop age appropriate autonomy and independence; after Child's symptoms 

regressed after she was discharged from CHCA. Mother removed Child from public school and 

enrolled Child in a cyber-school against the recommendation of Child's treatment team; Child was 

still attending therapy sessions with Father, however, her symptoms prevented her from attending 

sessions; when Father suggested petitioning the Domestic Relations Branch of Family Court to 

revisit his and Mother's shared custody arrangement, the therapy sessions resumed; when Child's 

symptoms did not decrease, the treatment team suggested that Child return to residential treatment; 

Child made accusations th.at Father sexually assaulted her shortly thereafter and Father's therapy 

sessions with Child ceased; the treatment team expressed concerns that while Mother did not 

strictly meet the definition of factitious disorder imposed on another, there was significant illness 

exaggeration and symptom reinforcement occurring; Child did not have any social interactions 

and Chi Id and Mother's lives appeared to revolve around Child's physical symptoms and suspected 

ailments; Mother may be purposely attempting to keep Child from Father due to her own fear of 

loss and very significant enmeshment with Child; Child was caught in a destructive conflict 

between Father and Mother to the point that Child's well-being was being impacted. 

On May 29. 2018, DHS learned that since 2016, Chlld had 25 x-ray examinations, three magnetic 

resonance imaging (''MRI") examinations, and two ultrasounds. Each examination showed that 

Child was experiencing pseudo-symptoms. Child's therapist stated that Mother was in denial of 

Child's strengths and limitations and felt that Child's health would improve once Father was no 

longer involved in her care; however, Father had not been involved for months and Child's 

symptoms had only increased. 

On May 31, 2018, OHS received correspoedence from Child's PCP. PCP stated that Child hsd an 

extreme number of office and emergency department visits; Child was examined by a large number 

of subspecialists; Child had been withdrawn from school and ceased all activities normal for a 

child her age; there were no organic causes for any of Child's symptoms; he referred Child for 

inpatient treatment at CHCA after medication and outpatient treatment did not work and that after 

Child regressed upon returning home, be questioned her about the regression and she stated that 

she hated hospitals so much that she did everything she could to be discharged, which suggested 

Page5ofl4 
� .... 

. . �

that Child was able to control her symptoms; Child reported that she was sexually abused by 

hospital staff and Father; the hospital found no credibility in her statements regarding allegations 

of abuse ar the hospital; he was concerned that Child's case showed signs of Muncbausen 

syndrome by proxy and that Child and Mother were in collusion around Child's symptoms; Child 

was completely dysfunctional and in need of change ofber environment, either in an institutional 

or foster care placement PCP included a list of the number of visits to both the office and 

emergency room, telephone calls made by Mother regarding Child's health between 2009 and 

2017, and a list of specialists that Child has been examined by so far. 

Currently, Child is overweight and has been diagnosed with conversion disorder. Child is receiving 

treatment through CHOP and is on a 504 plan for special education accommodations in school due 

to her conversion disorder diagnosis. Mother is currently unemployed and was previously 

employed as a medical professional at CHOP. Mother has a history of mental health issues. DHS 

learned that Mother previously received therapy through Counseling Or Referral Assistance 

("CORA") in 2017; however, she stopped attending after six sessions. Mother has previously been 

diagnosed with anxiety and depression. On June 7, 2018, OHS filed a dependency petition for 

Child. 

On July 23, 2018, and August 15, 2018, an adjudicatory, child abuse and permanency hearing was 

held for Child. The trial court heard testimony from the DHS investigator, the CUA case manager, 

a physician from CHOP, Mother, Father, and Child. The trial coun adjudicated Child dependent 

and found clear and convincing evidence that Child was a victim of child abuse under 23 Pa.C.S.A. 

§6303(b.1)(2). The trial court discharged the temporary commitment to DHS and fully committed 

Child. The trial court ordered CUA to do a home evaluation and clearances on Mother's home. 

The trial court referred Mother for a parenting capacity evaluation ("PCE"), BHS for a consultation 

and/or evaluation. The trial court also ordered Mother to provide verification of employment and 

found Mother to be a grave threat to the best interests of Child thereby suspending her visits and 

telephone contact with Child. If Mother was not employed, Mother was to be referred to ARC for 

employment. Furthermore, the trial court founded the CY48 and turned it into a CY49. On 

Septem her l I, 2018, Counsel filed tbis appeal on behalf of Mother . 

Page 6ofl4 
Discussion: 

On appeal, Mother states that the trial court erred and/or abused its discretion when: 

1. It found that DHS, by clear and convincing evidence, had met its burden to establish that 

child abuse existed as to Mother. 

2. It .. founded" the CPS report of April 2, 2018, as to Mother. 

3. It found that OHS, by clear and convincing evidence had met its burden to find Child 

dependent. 

For the purpose of this opinion, Mother's issues will be consolidated to read: Did the trial court 

err or abuse its discretion when it found by clear and convincing evidence that Child was a victim 

of child abuse under 23 Pa.C.S.A. §6303 and therefore met the definition of a dependent child 

under the Juvenile Act? An issue is waived on appeal where it is not specifically presented in the 

Appellant's Pa.R.A.P. l925(b) statement. In re C.P., 901 A.2d 516, 522 (Pa. Super. 2006); See In 

re J.E.D .. 879 A.2d 288, 293, fn. 7 (Pa. Super. 2005). lt should be noted that Mother did not appeal 

the finding of grave threat, thereby suspending her visits and telephone contact with Child. As 

such, Mother has waived her right to appeal the finding of grave threat and visit suspension. 

Child abuse is defined at 23 Pa.C.S.A. §6303 (b.1 )(2) as fabricating, feigning, or intentional! y 

exaggerating or inducing a medical symptom or disease, which results in a potentially harmful 

medical evaluation or treatment to the child through any recent act 5 The existence of child abuse 

must be found by clear and convincing evidence but the identity of the abuser need only be 

established through prima fade evidence. In re L. Z., 111 A.3d 1164, 1174 (Pa. 2015). Prima facie 

evidence of abuse is established under 23 Pa.C.S.A. §6381( d) as: 

Evidence that a child has suffered child abuse of such a nature as would ordinarily 

not be sustained or exist except by reason of the acts or omissions of the parent ... 

responsible for the welfare of the child shall be prirna fade evidence of child abuse 

by the parent ... responsible for the welfare of the child. 

This statutory section applies if the abuse is of a nature that would ordinarily not be sustained or 

exist except by reason of the acts of the parent and that the parent is proved to have had 

responsibility for the welfare of the child at the time of abuse. In re LZ., 111 A.3d at 1170. 

'This is commonly referred to as "Munchausen Syndrome by Proxy" or "factitious disorder." The Opinion will refer 

to lhe act as medical child abuse. 

Page 7 ofl4 
Mother alleges that the trial court erred in finding child abuse by clear and convincing evidence. 

DHS obtained an OPC after the CHOP Child Abuse Clinic determined that Child was suffering 

from medical child abuse. (N.T. 08/lS/18, pg. 20). It was established from the testimony of Dr. 

Brian William Brennan of CHOP ("'Physician")

6 that Child suffered from medical child abuse 

based on the extensive medical history of Child. (N.T. 07/23/I 8, pg. 42, 49-50). Child was first 

evaluated by Physician in June 2018, after Child presented at the sexual abuse clinic at CHOP 

based on the allegations of sexual abuse by Father and tbe sraffat CHCA. (N.T. 07/23/18, pgs. 24- 

25). 

7 DHS has determined that the sexual abuse allegations made by Child were unfounded. (N .T. 

08/15/18. pg. 29). After review of Child's medical records, Physician observed that Child had 

visited her PCP approximately 156 times, Mother made twice as many phone calls to the PCP as 

visits, and Child visited 15 different subspecialists. (N.T. 07/23/18, pgs. 29-30, 33-34). When 

Child began seeing a therapist for behavioral health around age 7, Child's medical utilization of 

medical appointments decreased during that time period. (N.T. 07/23/18, pgs. 35-36). By Child's 

pre-teen years, Child had been diagnosed with asthma, reflux, Severs Disease.! AMPS9, and 

conversion disorder. (N.T. 07/23/18, pgs. 34, 37, S 1). Following Child's diagnosis of AMPS, Child 

was diagnosed with conversion disorder where Child began having pseudo-seizures 10 involving 

leg movements and arm flailing. Child also had selecti ve mutism, paralysis of the legs, and bizarre 

hallucinations including people in the room that were not present, people threatening to kill her, 

and bubbles on the sun. (N.T. 07123/18, pgs, 38-39). In regards to Child's paralysis, there is no 

medical explanation and it can be described as a functional paralysis. (N.T. 07123/18, pg. 91 ). 

Child was treated for her diagnosis at the CHCA behavioral health program in Virginia for three 

months (N,T. 07/2j/l8, pga. 40-41). Child .... as dfachAcgcd from CHCA aner three months When 

she appeared to have completely recovered. (N.T. 07/23/18, pg. 41). Child and Mother have 

' indicated that Child claims to have faked improvement by improving her symptoms in order to be 

6 All parties besides Mother's CoUDSel stipu!J!ied to Physician's CV and expertise in pediatrics aod child abuse 

pcdioui�. (N.T. 071.23/18, pg. 12). The trial court accepted Physician as an expert by knowledge. (N.T. 07123/18, pg. 

23; OHS Exhibit 1). 

• Physician performed a verbal and cursory physical examination of Child, but Child was unable to cooperate with a 

general urinary exlllll. (N.T. 07f.?3/J8, pg. 25), Physician also reviewed Child's medical records and spoke with both 

Child and Mother regarding Child's bi.story. (N.'f. 071.23/18, pgs. 25-26, 27·28). 

• Severs Disease is the il'lflammation of the growth plate, commonly seen in the shoulders of little league pitciien. 

(N.T. 07123/lS. pgs, 51·52). 

9 AMPS is a syndrome where relatively innocuous contact leads to an amplified pain response. (N.T. 07123/18, pgs, 

34-35). 

re Physician indicated that Child was having pseudo-seizures because Child did not have EEG patterns that indicated 

·,: ,, an aaual seizure, (N.T. 071231\S, pg. 38). 

Page 8 of 14 
discharged from CHCA because Child did not want to remain in inpatient care. (N.T. 08/15/18, 

pgs. 16-17, 32-33, S0-51):Child claimed that her symptoms began reoccurring after her tteatment 

at CHCA because she had to attend family therapy with Father and the stress of reruriring to school. 

(N.T. 08/15/18, pg. 52). Child's only organic pathological finding was the Severs Disease, which 

Child was treated for through physical therapy, but Child's records indicate that Child was 

experiencing symptoms not proportional to what is commonly seen in Severs Disease. {N.T. 

07/23/18, pgs. 51-53). Many of Child's issues were self-resolving, butChild's medical records 

indicates that phone calls from Mother regarding the described ailments were not consistent with 

the physical exam on the following day. (N.T. 07/23/18, pg. 89). Physician noted that the most 

concerning issue regarding Child was that Mother and Child appeared to be enmeshed and that 

Child's behaviors related to the conversion disorder were enabled by Mother. (N.T. 07123/18, pgs. 

44-45). Additionally, Child's symptoms appeared to be amplified by Mother's presence, which 

was most noticeable during Child's stay at CHCA, where Child was discharged asymptomatic. 

(N.T. 07123/18, pgs, 45-46). Physician noted that if Child were to be reunified with Mother, it 

would be likely that Child would begin having symptoms of conversion disorder again. (N.T. 

07!23/18, pgs. 46-47). Additionally, if Child were to remain in Mother's care, there is a risk for 

Child's psychopathology to amplify over time and become more elaborate with more medical 

intervention. (N.T. 07/23/18, pg. 47). Child's medical record indicates an exaggeration and 

instigation of Child's symptoms, all consistent with medical child abuse. (N.T. 07/23/18, pg. 54). 

}£_ i Through review of Child's medical records, concerns of medical child abuse have been raised by 

other medica1 professionals. (N. T. 07$/18, pg. 69). On more than one occasion, Mother has overexaggerated Child's symptoms. (N.T. 07/23/18, pg. 87). Mother was not always compliant with 

the medical recommendations given to Child. (N.T. 07123/18, pgs. 37, 80-81, 83). Mother has been 

the primary historian throughout Child's medical treatment in terms of reporting symptoms and 

illnesses to medical professionals. {N.T. 07123/18, pg. 88). Mother is also the primary caretaker of 

Child. (N.T. 08115/18, pg. 22; OHS Exhibit 3). Before Child was born, Mother worked as an 

emergency medical technician ("EMT"} for CHOP and it is common for parents in medical child 

abuse cases to have a medical background of some sort {N.T. 07123/18, pg. 44). Child has had far 

more medical interaction than would be typical of another child at the same level of health. (N.T. 

07n.3/l 8, pg. 78). Mother was aware that a doctor who worked with Child's PCP was concerned 

that Child was "over doctored." {N.T. 08/15/18, pg. 81). Mother claimed that she never forced 

Page 9 of 14 

;'· 
Child to go to the doctor when she did not want to go. (N.T. 08/15/18, pg. 73). Child's symptoms 

and medical care align with the ongoing custody litigation between Mother and Father (N.T. 

08/15/18, pg. 35). Mother blames Father for Child's symptoms. (N.T. 08/15/18, pg. 8�87). 

Physician indicated that Child's proper course of treatment moving forward should be inpatient 

psychiatric care and for Mother, since the medical child abuse involved is conversion disorder, the 

recommendation is behavioral health therapy. (N.T. 07/23/18, pg. 48). Physician also indicated 

that Mother declined to attend psychotherapy when recommended in 2014, although Mother 

claimed that she did attend therapy. (N.T. 08/15/18, pgs. 78-79). The trial court found Physician's 

testimony very compelling and credible. Based on the testimony on July 23, 2018, and August 15, 

2018 the trial court found clear and convincing evidence that Mother's prolonged intentional 

exaggeration of Child's symptoms resulted in medical child abuse under 13 Pa.C.S.A. §6303{b.l). 

Furtb.ennore, there was prima facie evidence that Mother is the perpetrator of child abuse under 

23 Pa.C.S.A. §638\(d) since Mother was the primary caregiver for Child. Mother was unable to 

rebut the presumption. Consequently, the trial court did not err or abuse its discretion in finding 

child abuse. 

DHS's next issue on appeal asked whether the trial court erred in adjudicating Child dependent 

based on clear and convincing evidence. A "Dependent Child" will be adjudicated dependent if 

the trial court determines, by clear and convincing evidence. that Child is without proper parental 

care or control, subsistence, education. as required by law, or other care or control necessary for 

Child's physical, mental, or emotional health, or morals. A determination that there is a lack of 

proper parental care or control may be based upon evidence of conduct by the parent, guardian, or 

other custodian. Clear and convincing evidence has been defined as testimony by credible 

witnesses who clearly relate facts that are so clear, direct, weighty, and convincing as to enable 

the trier of fact to come to a clear conviction without hesitance of the truth of precise facts in issue. 

In Interest n[J,M, 166 A.3d 408, 427 (Pa. Super. 2017) (citing In Re Nol'osielsld, 992 A.2d 89, 

ti, 

:, I 07 (Pa. 2010)). The purpose of the Juvenile Act is to preserve the unity of the family whenever 

possible. 42 Pa.C.S.A. § 6301(b)(l). Nonetheless, a child will be adjudicated dependent when the 

child is presently without proper parent.al care and the care is not immediately available. In re R. T.. 

592 A.2d 55, 57 (Pa. Super. 199\)(citing In Re LaRue,366A.2d 1271 (Pa. Super. 1976)). Superior 

Court has defined proper parental care as the care which is geared to the particularized needs of 

Page 10 of14 
! ... the child and. at a minimum, is likely to prevent serious injury to the child. In re C.R.S .• 696 A2d 

840, &41 (Pa. Super. l 997) (citing In lnierest of.Justin S., 543 A.2d 1192, 1200 (Pa. Super. l 988)). 

A CY48 report is deemed to be founded if there has been any judicial adjudication based upon a 

finding that a child who is a subject of the report bas been abused. J. G. v. Dept. of Public Welfare, 

795 A.2d l 089, 1092 (Pa. Commw. Ct. 2002). 

Mother alleges that the trial court erred in adjudicating child dependent by clear and convincing 

evidence. OHS obtained an OPC after the CHOP Clu1d Abuse Clinic determined that Child was 

suffering from medical child abuse. (N.T. 08/15/18, pg. 20). lt was established from the testimony 

of Dr. Brian William Brennan of CHOP ("Physician") that Child suffered from medical child abuse 

based on the extensive medical history of Child. (N.T. 07/23/18, pg. 42, 49-50). Child was first 

evaluated by Physician in June 20l8, after Child presented at the sexual abuse clinic at CHOP 

based on the allegations of sexual abuse by Father and 1he staff at CH CA. (N. T. 07 /23/18, pgs. 24- 

25). DHS has determined that the sexual abuse allegations made by Child were unfounded. (N.T. 

08/15/IS, pg. 29). After review of Child's medical records, Physician observed that Child had 

·... visited her PCP approximately 156 times, Mother made twice as many phone calls to the PCP as 

visits, and Child visited IS different subspecialists. (N.T. 07/23/18, pgs. 29-30, 33-34). When 

Child began seeing a therapist for behavioral health around age 7, Child's medical utilization of 

medical appointments decreased during that time period. (N.T. 07123/18, pgs. 35-36). By Child's 

pre-teen years, Child had been diagnosed with asthma. reflux. Severs Disease, AMPS, and 

conversion disorder, (N .T. 07 /23/18, pgs. 34, 37, S 1 ). Following Child's diagnosis of AMPS, Child 

was diagnosed with conversion disorder where Child began having pseudo-seizures involving leg 

movements and arm flailing. Child also had selective mutism, paralysis of the legs, and bizarre 

hallucinations including people in the room that were not present, people threatening to kill her, 

and bubbles on the sun. (N.T. 071.23/18, pgs, 38-39}. In regards to Child's paralysis, there is no 

medical explanation and it can be described as a functional paralysis. {N.T. 07123/18, pg. 91). 

Child was treated for her diagnosis at the CHCA behavioral health program in Virginia for three 

months (N.T. 07123/18, pgs. 4041). Child was discharged from CHCA after three months when 

she appeared to have completely recovered. (N.T. 07/23/18, pg. 41). Child and Mother have 

indicated that Child claims to have faked improvement by improving her symptoms in order to be 

.. 

discharged from CHCA because Child did not want to remain in inpatient care. (N.T. 08115/18, 

Page 11 of 14 

.;..-

.-.. - � : 

L.: 
I· 

f .. · 

:· :, 

pgs. 16-17, 32.:n, S0-51 ). Child claimed that her symptoms began reoccurring after her treatment 

at CHCA because she had to attend family therapy with Father and the stress of returning to school. 

(N.T. 08/15/18, pg. 52). Child's only organic pathological finding was the Severs Disease, which 

Child was treated for through physical therapy, but Child's records indicate that Child was 

experiencing symptoms not proportional to what is commonly seen in Severs Disease. (N.T. 

07/23/18, pgs, 51-53). Many of Child's issues were self-resolving, but Child's medical records 

indicates that phone calls from Mother regarding the described ailments were not consistent with 

the physical exam on the following day. (N.T. 07123/18, pg. 89). Physician noted that the most 

concerning issue regarding Child was that Mother and Child appeared to be enmeshed and that 

Child's behaviors related to the conversion disorder were enabled by Mother. (N. T. 07 n.3/ 18, pgs. 

44-45). Additionally, Child's symptoms appeared to be amplified by Mother's presence, which 

was most noticeable during Child's stay at CHCA, where Child was discharged asymptomatic. 

(N.T. 07/23/18, pgs. 4546). Physician noted that if Child were to be reunified with Mother, it 

would be likely that Child would begin having symptoms of conversion disorder again. (N.T. 

07/23/18, pgs. 46-47). Additionally, if Child were to remain in Mother's care, there is a risk for 

Child's psychopathology to amplify over time and become more elaborate with more medical 

intervention. (N.T. 07123/18, pg. 47). Child's medical record indicates an exaggeration and 

instigation of Child's symptoms, all consistent with medical child abuse. (N.T. 07/23118, pg. 54). 

Through review of Child's medical records, concerns of medical child abuse have been raised by 

other medical professiomls. (N .T. 07123/l 8, pg. 69). On more than one occasion. Mother has over· 

exaggerated Child's symptoms. (N.T. 07123/18, pg. 87). Mother was not always compliant with 

th.einedical recotmna1datiO!loS given to Child. (N.T. 07123/18, pgs, 37, 80-81, 83). Mother has been 

the primary historian throughout Child's medical treatment in terms of reporting symptoms and 

illnesses to medical professionals. (N. T. 07 /23/18, pg. 88). Mother is also the primary caretaker of 

Child. (N.T. 08115118, pg. 22; DHS Exhibit 3). Before Child was born. Mother worked as an 

emergency medical technician ("EMT') for CHOP and it is common for parents in medical child 

abuse cases to have a medical background of some sort. (N.T. 07123/18, pg. 44). Child has had far 

more medical interaction than would be typical of another child at the same level of health. (N.T. 

07/23/ l 8, pg. 78). Mother was aware that a doctor who worked with Child's PCP was concerned 

that Child was .. over doctored." (N.T. 08/15/18, pg. 81). Mother claimed that she never forced 

Child to go to the doctor when she did not want to go. (N.T. 08/15/18, pg. 73). Child's symptoms 

Page 12of 14 
,:·--· 

... !"-. 

and medical care align with the ongoing custody litigation between Mother and Father (N.T. 

08/15/18, pg. 35). Moth.er blames Father for Child's symptoms. (N.T. 08/15/18, pg. 86-87). 

Physician indicated that Child's proper course of treatment moving forward should be inpatient 

psychiatric care and for Moth.er, since the medical child abuse involved is conversion disorder, the 

recommendation is behavioral health therapy. (N.T. 07/23/18, pg. 48). Physician also indicated 

that Mother declined to attend psychotherapy when recommended in 2014, although Mother 

claimed that she did attend therapy. (N.T. 08/15/18, pgs, 78-79). DHS indicated the CPS report as 

to Mother based on medical evidence and the fact that Mother was the primary caretaker of Child. 

(N.T. 08/15/18, pg. 22). In addition to Child's medical history, Mother's home is in question 

because although Child bas a bedroom. Child chooses to sleep on a couch in the living room next 

to Mother and has done so for several years. (N.T. 08/15/18, pg. 23). Mother also testified that she 

believed placement outside of the home is appropriate for Child, if Child is placed in a specialized 

treatment facility. (N.T. 08/15/18, pg. 88). Consequently, Mother is in agreement with the trial 

court's disposition decision. Placement outside the home is the least restrictive setting for Child to 

receive the specialized treatment needed. The record reflects that there was clear and convincing 

evidence 10 adjudicate Child dependent as it is unsafe for Child to return to Mother's care. Mother 

does noc have the present ability to care for Child's physical, mental, or emotion.al health. The trial 

court found the DHS witnesses credible. Therefore, the trial court did not err or abuse its discretion 

in finding Child dependent and determining the CPS report founded. 

Conclusion: 

For the aforementioned reasons, the court found that DHS met its statutory burden by clear and 

convincing evidence regarding the finding that Child was a victim of medical child abuse pursuant 

to 23 P .C .S .A. §6303(b. l )(2). DHS also met its statutory burden by clear and convincing evidence 

that Child met the definition of a dependent child under the Juvenile Act. Accordingly, the order 

entered on August 15, 2018, should be affirmed. 

Page 13 of 14 
IN THE COURT OF COMMON PLEAS 

FOR THE COUNTY OF PHILADELPHIA 

FAMILY COURT DMSION 

In the Interest of SN.R, a Minor 

APPEAL OF: S.R., Mother 

CP-5I-DP-0001387-2018 

FID: 51-FN-001206-2018 

2758 EDA 2018 

CERTIFICATE OF SERVICE 

1 hereby certify 1hat this court is serving a copy of this duly executed Opinion upon all counsel on 

November 28, 2018. The names and addresses of all persons served are as follows: 

Lindsey Cordes, Esq. 

City of Philadelphia Law Department 

I 515 Arch Street, l � Floor 

Philadelphia, Pennsylvania 19102 

Lindsey.Cordes@phila.gov 

Attorney for D.H.S. 

Shane Thompson, Esq. 

1706 Race Street. 4

111 Floor 

Philadelphia, Pennsylvania 19103 

J\norney for Father 

Barry Kassel, Esq. 

Supp¢rt Cemer for Child Advocates 

1617 John F. Kennedy Blvd.. Suite 1200 

Philadelphia. Pennsylvania 19103 

bkassel(ii1sccalaw.org 

Attorney for Child 

Jalaine Stokes. Esq. 

Defenders Association of Philadelphia 

1441 Sansom Street 

Philadelphia, Pennsylvania 19102 

jstokes@philadefender.org 

Guardian Ad Litem 

Carla Bcggin. Esq. 

1800 John F. Kennedy Blvd., Suite 300 

Philadelphia, Pennsylvania 19103 

begginlaw@mac.com 

Attorney for Mother 

Law Clerk to the Hon. Joseph L Fernandes 

First Judicial District of Pennsylvania 

Family Division 

1501 Arch St., Room 1431 

Philadelphia. Pa. 19102 

T: (215) 686-2660 IF: (215) 686-4224 

Ariel.bruce@courts.phila.gov 

Page 14 of 14