In the Interest of M.S., Minor Child

IN THE COURT OF APPEALS OF IOWA

No. 24-1688
Filed March 5, 2025

IN THE INTEREST OF M.S.,
Minor Child,

A.F., Mother,
Appellant.
________________________________________________________________

Appeal from the Iowa District Court for Linn County, Carrie K. Bryner,

Judge.

The mother appeals the termination of her parental rights. AFFIRMED.

David R. Fiester, Cedar Rapids, for appellant mother.

Brenna Bird, Attorney General, and Mackenzie Moran, Assistant Attorney

General, for appellee State.

Julie F. Trachta of Linn County Advocate, Inc., Cedar Rapids, attorney and

guardian ad litem for minor child.

Considered by Greer, P.J., and Langholz and Sandy, JJ.
2

GREER, Presiding Judge.

The juvenile court terminated the mother’s parental rights to M.S., born in

2021, pursuant to Iowa Code section 232.116(1)(h) (2023).1 On appeal, the

mother challenges the juvenile court’s conclusion the statutory ground was proved,

arguing M.S. could have been returned to her custody at the time of the termination

trial or, alternatively, that the Iowa Department of Health and Human Services (the

department) failed to make reasonable efforts at reunifying her with the child. She

also argues that the loss of her rights is not in the child’s best interests because of

the bond the two share.2

I. Background Facts and Proceedings.

M.S. is a child with physical challenges and developmental delays; he has

diagnoses of cerebral palsy, spastic quadriplegia, and chronic bronchopulmonary

dysplasia. Before the department became involved, the mother was M.S.’s sole

caretaker; the father did not provide care for M.S. and was not adequately informed

of his needs to be able to do so.

1In separate proceedings, the juvenile court also terminated the mother’s parental

rights to M.S.’s sibling, L.S. The juvenile court held separate termination trials and
issued termination orders at different times. The mother appealed the termination
of her rights to each child. We also file a ruling regarding the mother’s rights to
L.S. today. See In re L.S., No. 24-1738, 2025 WL _____, at *_ (Iowa Ct. App.
Mar. 5, 2025).
2 According to the termination order:

The father [was] very consistent throughout the case in his
belief that [M.S] needs more care than he is able to give due to
[M.S.’s] diagnoses. It is clear that [the father] loves [M.S.] and he
visits him weekly with [M.S.’s] sister (who is placed in the care of her
father). However, he believes that [M.S.] is flourishing where he is
and wants him to stay there.
The father consented to the termination of his parental rights. See Iowa Code
§ 232.116(1)(a). He does not appeal.
3

In March 2023, the department received a report alleging that while M.S.

was in the hospital being treated for dehydration and electrolyte imbalance, the

mother injected him with unprescribed insulin. According to the department’s

request for emergency removal:

Dr. Irene Morcuende, a resident at the University of Iowa
Hospitals and Clinics explained that they were doing an EEG for
[M.S.], which includes constant video monitoring. [M.S.] was
experiencing episodes of hypoglycemia, so they reviewed the video
tape. [It] shows that on 3/14/2023 at approximately 9:15 am, [M.S.]
was crying, and the [mother and her boyfriend] were at his bedside.
He had an IV in his left arm. The mother did something with it. She
asked the nurse about something when the nurse came in. The
nurse went to do something. The mother and the boyfriend went into
the bathroom together. When they came out, mom was holding a
needle. The video set up did not allow them to see [M.S.’s] lower
body. Mom’s back was blocking the video. However, it appears that
mom unwraps a needle, takes the cap off, draws something up into
the needle. Then, at 9:17 am, [M.S.] started to cry immediately as if
something had been injected into his body. Mom can then be seen
capping the needle, then walking out of the camera range.
Dr. Mahil Rao, the staff physician, explained that he informed
[the mother] that the hospital has a “high suspicion” that someone
has been injecting [M.S.] with insulin. He said that her reaction was
to become a “bit tearful,” but she did not say anything else about it.
The hospital put a one-on-one staff in the room on 3/16/2023.
Dr. Rao stated that [M.S.’s] blood sugars have been stable since
about 10:00 pm on 3/16/2023.
Dr. Roy Zhou, a physician with the University of Iowa’s Child
Protection Team, analyzed [M.S.’s] test results. The Endocrine
Team has also reviewed his test results. They are medically certain
that [M.S.] had been getting injections of a man-made insulin. He
explained that [M.S.] had high levels of insulin, but low levels of
C-Peptides. He said that can only happen if insulin is being injected.
He diagnosed [M.S.] with “Fictitious Hypoglycemia.” Their team has
concerns regarding the mother being the sole caretaker for the child.
They are concerned about “Medical Abuse by Proxy.”

(Emphasis added.)

An investigative social worker spoke with the mother on March 17. The

mother initially denied giving M.S. any medication or injections during his hospital
4

stay. During the same conversation, she changed her statement, saying she gave

him some of his prescribed medications through his feeding tube. The mother

reported that nurses would get the medications ready and then she administered

them; she told the social worker that the nursing staff would be able to verify this.

She explained that she carries syringes with her and said she may have filled one

with water to inject into his feeding tube to push medication or unclog the tube—

she stated she may have done that without notifying any medical staff.

When the social worker spoke to hospital personnel, they agreed that it was

possible a nurse would prepare a medication and then allow the mother to

administer it. However, at the time the video showed the mother injecting M.S., no

nurse had prepared or approved an injection.

On March 20, the mother admitted to the social worker that while M.S. was

in the hospital, she gave him an injection that was not approved of or prepared by

nursing staff. The mother maintained that it was a steroid M.S. is prescribed

(Solu-Cortef) and that she gave him the injection because nursing staff informed

her the hospital was experiencing a shortage of it. The mother could not remember

what day she gave M.S. the injection; she denied having access to insulin.

Also on March 20, M.S. was removed from both parents’ custody while he

remained a patient at the hospital.3 The department also sought removal of L.S.—

M.S.’s older sister—from the care of the mother; L.S. was allowed to remain in the

father’s custody and was placed in his care.

3 The father informed the department that he was unable to provide M.S.’s care

because of the child’s special needs.
5

On March 21, a nurse told police officers—who were conducting their own

criminal investigation into the allegations—that she previously found an insulin pen

in M.S.’s bed. The nurse claimed that the mother said the needle was hers and

took it from the nurse.

The same day, the investigative social worker spoke with the mother’s

boyfriend. The boyfriend had previously denied being aware of the mother giving

M.S. medication in the hospital and stated he “always advised” her to allow the

nurses to do it. The boyfriend changed his story; he told the worker that the mother

got permission from a physician to give M.S. a shot of the steroid and admitted he

was present when she administered an injection. The boyfriend said they brought

the medication with them from home after hearing there was a shortage.

Department personnel, the mother, and members of M.S.’s medical team

from the University of Iowa met on March 30, 2023. The mother came prepared

with several questions about other explanations for why M.S. had high levels of

insulin with low C-peptide levels. According to the department’s social

investigation report assessment:

The team of doctors and social workers reviewed the
questions. All medical professionals present at this meeting stated
that none of these concerns, presented by [the mother], would
explain the high insulin levels and the corresponding undetectable
C-peptides. They all agreed that the[] only way for [M.S.] to have the
insulin and C-peptide levels that he had, was for someone to be
giving him an outside source of insulin.
They explained that Insulin and C-peptides go hand in hand.
They explained that it [is] like taking a stick and breaking it in half.
One of the halves would be insulin—the other would be C-peptide.
Basically, the levels should almost be at a one to one ratio. [M.S.’s]
levels were way off. The diagnosis that they have given is Fictitious
Hypoglycemia. The team also believes that [M.S.] received multiple
doses of insulin to be affected as he was. They believe that they can
confirm that exogenous insulin was given to [him]. The person that
6

had access to him at most times was his mother. They also stated
that a nurse found an insulin pen in [M.S.’s] bed on level 10—after
he had been transferred to the PICU [when he experienced the
hypoglycemic reaction]. The nurse stated that when the nurse asked
what it was, [the mother] claimed that it was hers. [M.S.] has 2
medications that come in a pen. He has a Gvoke and his HGH that
come in a pen. However, the description of the pen does not match
what the nurse found in [M.S.’s] bed.
The team also stated that the protocol for outside medications
is for them to be logged in and documented. Staff would then give
the medications. They also confirmed that there was no shortage of
Solu-Cortef or other steroid medications. [The mother] would not
have been told that there was a shortage. Also, Solu-Cortef is not a
scheduled medication. It is given as needed. Dr. Rao said that he
would not have given permission for [the mother] to give [M.S.] a
shot—and did not give her permission to do so.
They stated that [M.S.’s] low blood sugar levels completely
resolved after one on one staffing was implemented for [M.S.] This
meant that a hospital staff was in the room any time that [the mother]
was with him.

In later discussions with police officers, the mother maintained that she had given

M.S. one injection while he was in the hospital and that it was the prescribed

steroid—not insulin. When confronted with the fact that the hospital was not low

on the steroid, the mother said a nurse told her they were. The mother admitted

that she followed the hospital’s procedure of checking M.S.’s other outside

medication into the hospital pharmacy; she could not explain why she would not

have followed the same procedure for the steroid. The mother told the officer she

kept the steroid with her so she could “continue doses as they’d been given at

home.” The officer suggested that if the mother thought the hospital did not have

the needed medication, it would make more sense for her to check it in to the

hospital pharmacy—so it could be administered to M.S. even if the mother was on

a walk, which she sometimes took. The mother responded she would not have

left M.S.’s room when he needed the medication, but the police officer reminded
7

her that the steroid was prescribed “as needed”—it was not given as a scheduled

dose. In other words, the mother could not anticipate when M.S. would need an

injection of the steroid. The officer also asked the mother about the needle device

found in M.S.’s bed after he was transferred to another unit; the mother seemed to

admit the needle was hers but stated it was a “poker” that she used to prick M.S.

for blood sugar tests. She stated it came with his glucometer and was not an

insulin pen. After the police officer went back and spoke to the nurse again, the

nurse reaffirmed that what she found was a “medicine pen”—not a poker. She

reported that she twisted the dial, pushed a button, and medicine came out of the

needle.

Based on its investigation, the department issued a founded child abuse

report. And the mother was criminally charged with two felonies: child

endangerment causing serious injury and administering harmful substances.

Throughout the department’s involvement with the family, the mother

maintained she did not inject M.S. with insulin. She similarly repeated this denial

to the mental-health professionals who conducted evaluations of her. As a result,

in July, the juvenile court authorized the department to release some information

surrounding its investigation of the March incident to the mother’s future

evaluators. The mother obtained at least one additional evaluation after the court’s

order, but she did not tell the department beforehand, so the department’s

information was not shared with the person performing the evaluation.

The mother received mental-health diagnoses of unspecified depressive

disorder and unspecified anxiety disorder. She was not diagnosed with factitious

disorder imposed on another (formerly referred to as Munchausen syndrome by
8

proxy).4 The mother participated in cognitive behavioral therapy, but there were

concerns it was not addressing any root problems—the mother reported to the

guardian ad litem (GAL) that her therapist made statements that she did not know

how the mother kept going with the stress of the department’s involvement and

suggested the mother watch a documentary about a young girl whose parents

were wrongly accused of medical abuse.

The mother had fully supervised visits with M.S. until November. In the lead

up to the permanency review hearing, the department and GAL each filed reports

raising concerns about the mother’s continued interactions and involvement with

M.S. In the GAL’s November 1, 2023 statement to the court, she stated:

This case was opened due to [the mother] medically abusing
[M.S.] and forcing him to undergo unnecessary medical procedures.
Even with [M.S.’s] removal from [the mother’s] care and services in
place, this is still a concern. [M.S.] must undergo a sleep study at
the CDD in Iowa City due to her continued influence. [The foster
mother] reports [the mother] continues to control what medical
supplies [M.S.] receives . . . . [The mother] controls what medical
equipment or therapy equipment is purchased through insurance,

4 “Factitious disorder” is defined as:

a psychological disorder that is characterized by the intentional
feigning, exaggeration, or induction of the symptoms of a disease or
injury in oneself or another and that is accompanied by the seeking
of excessive medical care from various doctors and medical facilities
typically resulting in multiple diagnostic tests, treatments,
procedures, and hospitalizations.
Factitious disorder, Merriam-Webster, https://perma.cc/W64Z-M7YV. As stated
in the note to the definition:
Factitious disorder typically involves self-imposed actions and the
disorder may also be referred to as factitious disorder imposed on
self or especially formerly as Munchausen syndrome. Less
frequently, a person’s actions are directed towards inducing
symptoms in another individual (usually the person’s child). In these
cases, the disorder is typically referred to as factitious disorder
imposed on another or especially formerly as Munchausen
syndrome by proxy.
Id.
9

and some of these items are expensive and can prevent [M.S.] from
being able to access other therapy equipment for years due to the
cap on funding. [L.S.’s] play therapist reports she is very concerned
about [L.S.’s] emotional and mental well-being, and the impact
ongoing contact with [the mother] is having on her. When visits with
[the mother and L.S.] were suspended for three weeks, [L.S.] was
noted to be calmer and more well-adjusted. When visits resumed,
she immediately displayed acting out behaviors. Even with a
provider and nurse present, there continue to be concerns during
visits. The children are giving direct signs of their discomfort during
visits and interactions with [the mother]. It is not in their best interest
to continue to force them to have interactions with [the mother].

In its November 3, 2023 permanency review order, the juvenile court

temporarily suspended the mother’s visits with M.S. pending a later contested

hearing. The court also suspended the mother’s right to attend M.S.’s medical

appointments or make medical decisions for him.

The contested hearing took place on December 11 and 18.5 In its written

ruling, the court suspended the mother’s visits, concluding they were “clearly

harmful to the children.” The court explained:

Visits between the mother and the children have remained
fully supervised throughout this case. Visits were suspended in the
fall for approximately three weeks after [L.S.] had brought a medical
syringe and a tube of medical grade lubricant home from her
mother’s house after a visit. Thereafter, visits have been in the
community or the provider office. On November 2, 2023, the Court
again suspended visits pending contested hearing due to concerns
for the children’s physical, mental and emotional health. [The
daycare director] where [L.S.] attends daycare, testified that [L.S.’s]
behaviors changed after visits with her mother resumed. [L.S.] was
exhibiting disruptive behavior, was obstinate, and was not sleeping
during naps. [L.S.] was also having accidents (not making it to the
bathroom) when visits were occurring. It would take her two to three
days to regulate once she had a visit. [The daycare director] noted
that since the visits have been suspended again, her behaviors have
stopped. In fact, the day after visits were suspended, [L.S.] slept
through her nap and was cooperative the whole week. [L.S.] had

5 We do not have a transcript of this proceeding.
10

also told her in October that she didn’t see her mom all the time
because her mom had hurt her and her brother and it “made her sad.”
[L.S.’s] play therapist, Kim Korte, testified that she has been
seeing [L.S.] weekly since August. She unequivocally recommended
that visits between [L.S.] and her mother stop at this time. She noted
that in sessions, [L.S.] can become quite distressed exhibiting
trauma responses and is either numb or hyper and silly. She has
displayed avoidance, emotional dysregulation, high anxiety and high
stress. [L.S.] has a pattern of “feeding” baby dolls with a bottle that
she says is hot sauce, pee and poo, then says it’s a “secret” and
shuts down. On one occasion, [L.S.] said that her mom hurt her
brother, then shut down and wanted to end the session. Ms. Korte
saw a lot of distress and emotional dysregulation at that time.
Notably, she has noted a change in [L.S.] since visits have been
suspended again. She testified that [L.S.] is now calm and regulated
and has been very happy and bright. Ms. Korte recommends that
[L.S.] be allowed the opportunity to work through her trauma without
visits so that she is not further traumatized until she has processed
the trauma. She believes that the mother needs to be in therapy at
the same time so that she will then be able to provide [L.S.] what she
needs emotionally and physically. Ms. Korte recommended that
once [L.S.] has addressed her trauma, therapy with mom should
occur to ensure that she is ready to meet [L.S.’s] needs, then they
should begin family therapy. It would be detrimental to force [L.S.]
to have visits at the time and would damage her trust in adults. [L.S.]
cannot heal if she doesn’t feel safe.
[The department case manager] testified that at a visit she
attended, mom was very controlling and wouldn’t let [M.S.] be
interactive. She noted [M.S.] had a very flat affect with his mom. It
was very concerning to her that the mother chose to feed [M.S.] a
hot dog when it was not on the list of foods that he could have
especially given that his diet was very “liquid-y” at the time with only
pureed foods being given. [The case manager] testified that the
mother also interferes with the child’s physical therapy and
occupational therapy appointments. The mother checks [M.S.’s] “my
Chart” [online medical chart] multiple times a day and thinks that the
doctors are withholding information from her. Further, the mother
has scheduled both children for medical appointments and tests that
have been unnecessary.
[The case manager] also relayed an interaction she had with
[L.S.] in which [L.S.] threw a Care-bear against a wall stating,
“mommy [mother’s name] hurts babies.” After visits were suspended
then reinstated, the mother was not allowed to take [L.S.] to the
bathroom alone after [L.S.] stated that her mother wiped her too hard
and she was sore in her private area. [The case manager]
recommended that the mother’s visits remain suspended and also
testified that [M.S.] is blossoming since visits have been suspended.
11

The mother also testified. The Court found the mother had an
answer for all of the concerns that had been brought forth but did not
find these explanations to be believable. In fact, the Court is very
concerned that the mother has absolutely no insight into the
concerns presented. The actions of the mother in many instances
have put her children in danger, especially [M.S.] who has many
special needs. It appears to the Court that the mother seeks
attention through her medical needs and those of her children,
whether real issues or those brought to medical professionals solely
by mother’s report. She is placing her children in danger through
those actions as well as the behavior described by [the case
manager] and alluded to by [L.S.] in daycare and in therapy sessions.
Most important, the testimony by Ms. Korte and [the daycare director]
was incredibly persuasive in determining that [L.S.] is experiencing
emotional and mental harm from visits with her mother.

Visits remained suspended through the termination trial, which took place over two

days: January 19 and February 6, 2024.

At trial, the mother maintained she did not inject M.S. with insulin. Her

criminal charges were still pending. She testified she appealed the founded child

abuse report, which was also still pending. When asked about what happened in

M.S.’s hospital room on March 14 and to explain the inconsistent statements she

had given since, the mother testified that the video from M.S.’s hospital room

showed her taking M.S.’s rectal temperature—not giving him an injection. The

following exchange occurred on direct examination:

Q. You had previously told other folks that you gave [M.S.] a
shot of a steroid? A. Yes, but that was not what was in the video.
Q. So are you saying you gave him a shot that was not
approved by medical professionals that was on a different day the
hospital’s not even aware of? A. It’s not—it was that morning but
before the video, and it’s not that—it’s not a medication that wasn’t
approved. It was a medication that was prescribed by the doctors.
Q. But as was noted in the reports, you did not check that
medication into the pharmacy like you did the other two medications
that you checked? A. I—the hospital was aware that I had brought
that medication because I had had that conversation with the doctor.
I’m not sure what the hospital protocol is in that situation, but if
somebody had asked me for it, I would have given it to them.
12

Q. But I think you do know the protocol because you did check
two medications into the pharmacy, but you did not check the steroid
into the pharmacy. A. I gave them the medications they asked
for. . . .

From the time of M.S.’s removal from the mother’s custody, M.S. had not

experienced any issues with his blood sugars. He was thriving in the care of the

foster parent—his mobility and speaking were improving, and he had experienced

generally good health.

The juvenile court did not issue its termination order until October 2, 2024.

When it did, it concluded M.S. could not be returned to the mother’s custody and

termination was in the child’s best interests, ruling:

[M.S.], age two at the time of trial, has been out of his parent’s
care since March 20, 2023. Services to work toward reunification
were available to the mother. While the mother did cooperate in
mental health services, she did not allow the evaluators to have the
appropriate information to ensure that her mental health issues were
diagnosed appropriately. Even during fully supervised visits, the
mother continued to place the child in danger through the foods she
attempted to feed him, medical items accessible to him and his
sibling, and continued attempts to give him medications even after
ordered not to do so. Further, she continued to push medical
professionals to schedule unnecessary medical tests for the child
and also continued to purchase unnecessary medical equipment for
the child. [The mother] often portrayed herself as a victim in this case
when in fact she had victimized her son. The mother cannot be
considered a safe placement at this time or any time in the
reasonable future. There have been no trial home placements.

The court ruled termination was in M.S.’s best interests and granted the State’s

petition to terminate the mother’s parental rights pursuant to section 232.116(1)(h).

The mother appeals.

II. Standard of Review.

“In termination-of-parental-rights cases, we review the proceedings de

novo.” In re R.M.-V., 13 N.W.3d 620, 624 (Iowa Ct. App. 2024) (citation omitted).
13

“We are not bound by the juvenile court’s findings of fact, but we do give them

weight, especially in assessing the credibility of witnesses.” Id. (citation omitted).

III. Discussion.

The juvenile court terminated the mother’s parental rights to M.S. under

section 232.116(1)(h), which allows termination when all the following occurred:

(1) The child is three years of age or younger.
(2) The child has been adjudicated a child in need of
assistance pursuant to section 232.96.
(3) The child has been removed from the physical custody of
the child’s parents for at least six months of the last twelve months,
or for the last six consecutive months and any trial period at home
has been less than thirty days.
(4) There is clear and convincing evidence that the child
cannot be returned to the custody of the child’s parents as provided
in section 232.102 at the present time.

The mother challenges only the fourth element—whether M.S. could be returned

to her custody at the time of the termination trial. See In re A.M., 843 N.W.2d

100, 111 (Iowa 2014) (interpreting “at the present time” to mean at the time of the

termination trial). As part of this challenge, the mother argues the State failed to

make reasonable efforts to return M.S. to her custody and points to the suspension

of her visits with the child. See In re C.B., 611 N.W.2d 489, 493 (Iowa 2000) (“[T]he

State must show reasonable efforts as a part of its ultimate proof the child cannot

be safely returned to the care of a parent.”); In re C.G., No. 23-1234, 2024

WL 260926, at *1 (Iowa Ct. App. Jan. 24, 2024) (recognizing that “[a]t its core, a

parent’s reasonable-efforts challenge functions as a challenge to a component of

the statutory grounds”).

We understand the mother’s “reasonable efforts” argument to be an

assertion that the court wrongly allowed the department to suspend her visits with
14

M.S. in November 2023, which negatively impacted her ability to reunify with the

child leading up to the termination trial. The mother resisted the department’s

request to suspend her visits and participated in a contested hearing on the issue.

As far as we can tell, she never framed the issue as involving “reasonable efforts,”

but we think she did enough to preserve error on the claim.

Still, we cannot reach the merits of the mother’s argument that the juvenile

court was wrong to suspend visits because we do not have a transcript of the

contested hearing. Without it, we cannot review the evidence upon which the

juvenile court made its decision. “If the appellant intends to argue on appeal that

a finding or conclusion is unsupported by the evidence or is contrary to the

evidence, the record on appeal must include a transcript of all evidence relevant

to such finding or conclusion.” Iowa R. App. P. 6.803(1). “It is the appellant’s duty

to provide a record on appeal affirmatively disclosing the alleged error relied upon.”

In re F.W.S., 698 N.W.2d 134, 135 (Iowa 2005). And the failure to provide the

record prevents us from deciding in the mother’s favor on this issue. See id.

at 135–36.

While bypassing the mother’s reasonable-efforts challenge, we consider

whether the State proved M.S. could not be returned to the mother’s custody at

the time of the termination trial. The mother notes that she followed court orders,

obtaining mental-health and psychological evaluations and participating in therapy

as required. She complains that, despite this, the court and the department

decided she was unsafe because she refused to admit to her treatment providers

that she injected M.S. with insulin. She suggests this is a violation of her

constitutional right against self-incrimination. See U.S. Const. amend. V. But this
15

argument fails. First, the mother never invoked her Fifth Amendment right; she

has steadfastly maintained she did not inject M.S. with insulin (even while her

explanation of what the video shows varies). And second, even if she invoked the

Fifth Amendment, that does not free her from the consequences that follow for

failure to take responsibility for her actions. See In re R.B., 832 N.W.2d 375, 378

(Iowa Ct. App. 2013) (“[T]he government need not make the exercise of the Fifth

Amendment privilege cost free.” (alteration in original) (citation omitted)). While

“[t]he State may not penalize [the mother] for noncompliance with a court order

impinging on [her] right against self-incrimination,” “this is as far as the Fifth

Amendment privilege extends.” In re C.H., 652 N.W.2d 144, 150 (Iowa 2002). “A

parent’s failure to address his or her role in the abuse may hurt the parents’

chances of regaining custody and care of their children.” Id. “[T]hese

consequences lie outside the protective ambit of the Fifth Amendment.” Id.

(citation omitted). The mother may have been faced with a dilemma regarding

whether to speak honestly with her treatment providers, but that dilemma does not

trigger constitutional protection. See id.

While the mother attended therapy, she did not complete any treatment to

address the underlying issues that led to department’s and juvenile court’s

involvement with the family. We view the conflicting version the mother presented

over the medical problem involving the injection of insulin as one factor in our

analysis. So, M.S. could not safely be returned to the mother’s custody at the time

of the termination trial. See id. at 151 (finding that because the father “fail[ed] to

complete any form of treatment, we cannot conclude [he] has fixed his problems

and is now fit as a parent”); In re H.R.K., 433 N.W.2d 46, 50 (Iowa Ct. App. 1988)
16

(noting “the requirement that the parents acknowledge and recognize the abuse

before any meaningful change can occur is essential in meeting the child’s

needs”); In re E.S., No 23-0544, 2023 WL 3335326, at *2 (Iowa Ct. App.

May 10, 2023) (affirming termination of parental rights when children were

removed from father’s custody after a child protective assessment found the father

sexually abused an older half-sibling and the father “completed mental-health and

psychosexual evaluations [but] did not follow through with the recommended

intensive treatment and continued to deny the abuse occurred”).

Next, the mother argues termination of her parental rights is not in M.S.’s

best interests. In making this determination, we use the structured best-interests

framework provided in Iowa Code section 232.116(2). See In re P.L., 778 N.W.2d

33, 37 (Iowa 2010) (requiring the court to “base its best-interest determination on

the legislative requirements contained in section 232.116(2), rather than upon the

court’s own value system”); see also Iowa Code § 232.116(2) (requiring the court

to “give primary consideration to the child’s safety, to the best placement for

furthering the long-term nurturing and growth of the child, and to the physical,

mental, and emotional condition and needs of the child”). “[A] child’s safety and

his or her need for a permanent home [are] the defining elements in a child’s best

interests.” In re H.S., 805 N.W.2d 737, 748 (Iowa 2011) (citation omitted). And

we consider “the child’s long-range as well as immediate interests.” In re J.E., 723

N.W.2d 793, 798 (Iowa 2006) (citation omitted). The mother cannot provide M.S.

with the safe home that he needs and deserves. While the mother participated in

some therapy during the more than ten months between when M.S. was removed

from her care and the termination trial, she did not address the issues that led to
17

department involvement. By the end of the termination trial in February 2024, M.S.

had been removed from the mother’s custody for more than ten months and had

not seen the mother in more than three months. He was thriving in the home of

his foster family, reaching new developmental milestones and experiencing fewer

medical issues. Termination of the mother’s parental rights is in M.S.’s best

interests.

Finally, the mother argues we should forego termination because there is

clear and convincing evidence that the loss of her rights would be detrimental to

M.S. due to the closeness of the parent-child relationship. See Iowa Code

§ 232.116(3)(c). The mother recognizes that the bond between her and M.S. had

suffered by the time of the February 2024 termination trial due to the suspension

of visits. But she suggests that because those visits were wrongly suspended, we

should not discount the bond they shared earlier in M.S.’s life, when the mother

was the sole caretaker of the high needs child. As the parent resisting termination,

the mother has the burden to show application of this permissive exception is

warranted. See In re A.S., 906 N.W.2d 467, 476 (Iowa 2018). And she has not

done so; M.S.’s long-term needs outweigh the hardships of termination. We

decline to apply a permissive exception to save the parent-child relationship.

We affirm the termination of the mother’s parental rights to M.S.

AFFIRMED.