Cite as 2020 Ark. App.

455
ARKANSAS COURT OF APPEALS
DIVISION III
No. CV-20-111

Opinion Delivered: September 30, 2020

KRISTY SCHNEIDER AND

ERIK SCHNEIDER APPEAL FROM THE SALINE
APPELLANTS COUNTY CIRCUIT COURT
[NO. 63JV-19-271]
V.
HONORABLE GARY ARNOLD,
ARKANSAS DEPARTMENT OF JUDGE
HUMAN SERVICES AND MINOR
CHILD
APPELLEES AFFIRMED

WAYMOND M. BROWN, Judge

Appellants Kristy and Erik Schneider appeal the December 3, 2019 adjudication

order by the Saline County Circuit Court finding that their son, L.S., was dependent-

neglected due to abuse (Munchausen syndrome by proxy), neglect, and parental unfitness.

Appellants argue first that the DHS/Children’s Hospital interpretation of “Munchausen

Syndrome by Proxy, also known as factitious illness by proxy” accepted by the circuit court

is at odds with both the statutory requirement and the definitions accepted within the

medical profession. The application of this ad hoc definition also violates constitutional

guarantees. This misapplication fatally taints the allegations against both parties. Next,

they contend that the circuit court’s posthearing attempt to redefine the allegations violates
rules of procedure, constitutional requirements, and the court’s own pretrial guarantees.

Finally, they argue that the circuit court’s findings of facts are clearly erroneous. We

affirm.1

Appellants adopted L.S. in Pope County in September 2014. L.S. has been

diagnosed with a chromosomal abnormality, cognitive learning delay, seizure disorder,

reflux, rumination, and heart rate variability with a pacemaker. These medical conditions

required him to be seen and treated by several doctors at different clinics. In December

2018, he was admitted to Cincinnati Children’s Hospital for testing. He was eventually

placed in the pediatric intensive care unit (PICU) there due to issues with his heart rate

and blood pressure. He was subsequently transferred to the PICU at Arkansas Children’s

Hospital (ACH) between late 2018 to early 2019. While in PICU, he received feeding

through a feeding tube, known as a total parenteral nutrition (TPN). He also received a

pacemaker due to ongoing issues with his heart rate and blood pressure. An epinephrine

drip (EPI) was used at ACH to maintain L.S.’s heart function. Because the EPI was

ineffective, ACH suggested that it be removed, and appellants were informed that no one

knew what the outcome from removing the EPI would be. L.S. was discharged home on

TPN on January 11, 2019, with hospice services in place. L.S. remained on TPN and was

prescribed fentanyl and morphine.

1
This case was orally argued on September 16, 2020.

2
 Appellants concluded after meeting with ACH’s palliative-care team that L.S.’s TPN

would be withdrawn so that his natural death would occur. At the end of February 2019

L.S. returned to ACH for what was believed to be his final days alive. There was a send-off

parade for him, which included first responders from numerous agencies since it was

reported that he wanted to see as many first responders as he could before he died. L.S.

was taken off the TPN for nine days and appeared to look better than he had in months.

Appellants decided to put L.S. back on TPN, and he stayed in the hospital for about a

month. After his dismissal, he made several public appearances at baseball games, parades,

etc.

L.S. was seen at the Mayo Clinic in Rochester, Minnesota, between May 28, 2019,

and June 14, 2019. While at Mayo, he was seen by doctors in complex care, neurology,

cardiology, GI, pulmonology, nephrology, urology, genetics, and pain management. He

was placed on a new heart medicine, Digoxin, before he left Mayo. Mayo did not believe

that L.S. was a candidate for hospice care at the time of his dismissal. It was anticipated

that he would slowly wean off his pain medications; however, that did not take place until

sometime in August. On August 9, Dr. Travis Ayers placed an order to have a port placed

in L.S.’s chest. Dr. Spencer Lewis placed L.S.’s port on August 19, 2019, pursuant to Dr.

Ayers’s order.2

2
The port was subsequently removed in November, after approximately three
months.

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 L.S. was readmitted to ACH on September 4 due to a possible infection of his port.

He was discharged on September 6. DHS received a hotline report on July 20 concerning

all the Schneider children, except P.S. The allegation was that Kristy was causing the

children to be sick. DHS made contact with her on July 23 and went over the allegations.

DHS spoke with L.S. at school on September 3 and 9. They also talked to P.S. on

September 9. DHS spoke with school personnel on September 3 and sometime after

September 9. A new hotline report was received on September 11 alleging that Kristy was

misrepresenting the severity of L.S.’s condition, which was causing him unnecessary

medical care, and interfering with knowing how to care for him. It was also alleged that

Kristy was misrepresenting L.S.’s pain and providing false information between his

different medical providers. DHS removed L.S. from appellants’ custody that same day.

A petition for dependency-neglect was filed on September 13. It alleged that L.S.

was dependent-neglected and at substantial risk of serious harm as a result of abuse,

neglect, and parental unfitness. The supporting affidavit laid out additional facts and

indicated that L.S. was removed because the caretaker was unwilling or unable to meet his

needs for food, clothing, shelter and/or medical or mental healthcare. It also stated L.S.

was removed because the caretaker failed to protect L.S. from serious physical or

threatened harm. The medical affidavit of Dr. Karen Farst was also included with the

petition. She stated that the misrepresentations by Kristy were making it impossible to

accurately assess L.S.’s current condition and make accurate care and treatment plans. She

further stated that his medical conditions placed him at substantial risk for complications

4
if he is not provided an accurate treatment and care plan. The probable-cause hearing took

place on September 18, and in the order entered on October 31, the court found that

probable cause existed for DHS to remove L.S. and that the issues that led to removal still

existed, making it necessary for L.S. to remain in DHS’s custody.

The adjudication hearing took place November 14, 15, 20, and 21. Testimony and

exhibits consisted of thousands of pages. At the conclusion of the hearing, the court

instructed the parties to submit proposed findings of fact and conclusions of law, which

everyone did. Appellants filed objections to both DHS’s and the ad litems’ proposed

findings and conclusions. The court filed an order on December 3 granting DHS’s

motion. The order stated in pertinent part:

3. The Court finds by a preponderance of the evidence that the juvenile is

dependent-neglected and that the allegations in the petition are true and correct.
The Court grants the request of the Department that the pleadings conform with
the proof. The Court finds the juvenile was at substantial risk of serious harm from
abuse, neglect, and parental unfitness, as alleged in the Department’s Petition for
Dependency Neglect, pursuant to Ark Code Ann. §9-27-303 (18)(A)(ii); §9-27-303
(18)(A)(v); §9-27-303(18)(A)(vi). Specifically, as to abuse by mother, subjecting a
child to Munchausen syndrome by proxy, also known as factitious illness by proxy
(now also known as Pediatric Condition Falsification), when reported and
confirmed by medical personnel or a medical facility. With regard to neglect by
mother and father, the parents’ failure or refusal to provide the necessary nutrition
and medical treatment for the juvenile’s well-being. Specifically, as to parental
unfitness by mother and father, a fit parent would not exaggerate or misrepresent
symptoms to medical professionals and a fit parent would not acquiesce to another
caregiver’s false reporting. The dependency neglect finding is based on the evidence
presented at the hearing, which included the testimony of six medical providers, five
of whom were qualified as experts in their fields, and medical records. This
evidence established that [L.S.] has been portrayed by Kristy Schneider as being in
significant and persistent pain even though this is not corroborated by medical
providers. These representations resulted in the child being subjected to high doses
of narcotics (including fentanyl, Ativan and morphine), an unnecessary medical

5
procedure, and being denied nutrition, all of which threatened the child’s health
and potentially his life. Evidence also established that within days of being placed
in DHS custody, [L.S.] transformed from a wheelchair-bound child on artificial
nutrition, to an ambulatory child, able to eat normal food by mouth. The Court is
exercising its discretion under ARCP l5(b) to amend the pleadings to conform to
the proof with regard to specific findings based on testimony and evidence
presented in this hearing.

4. The Court makes the following findings of fact:

a. [L.S.], dob: 5-27-2009, was adopted by Kristy & Erik Schneider in 2014.

b. [L.S.] has been diagnosed with a chromosomal abnormality, cognitive

learning delay, seizure disorder, reflux, rumination, and heart rate variability
treated with a pacemaker.

c. The Court finds Dr. Aime Jones, a physician at the Mayo Clinic in Rochester,
Minnesota, to be an expert in the fields of pediatrics and complex care, and
finds her testimony to be very credible. The Court notes that she testified via
teleconferencing. Dr. Jones testified that she first learned of [L.S.] due to a
family-initiated request for consultation, and she first saw him on May 30, 2019
when [L.S.] and his mother came to the Mayo Clinic. At initial evaluation, Dr.
Jones found it interesting that medical outcomes were unusual based on the
history provided. Ms. Schneider described severe pain for [L.S.] that were not
observed in clinic. Dr. Jones asked Ms. Schneider to bring [L.S.] to clinic when
he was in severe pain so they could evaluate; she never did so. Dr. Jones
reported that a Pain Specialist documented that [L.S.] pointed to his stomach
and said he was in pain, but the staff found that the child was in no distress.
Dr. Jones stated that doctors treating children heavily rely on parents’
descriptions of their children’s pain and symptoms when deciding what
treatments are warranted. Dr. Jones said that the Mayo team felt strongly that a
careful wean of narcotics was needed in order to determine [L.S.’s] baseline
medical conditions. She also reported that Ms. Schneider had taken [L.S.] to the
Mayo emergency room because his PICC line had broken, and she had
requested the insertion of a port in the ER, but that request was denied. Dr.
Jones explained that a port is a surgically placed line in the chest, and that it was
not necessary in [L.S.’s] situation, and would subject him to risks of blood clots
and infection. Dr. Jones denied that [L.S.] had been diagnosed with
dysautonomia, a dysfunction of the nerves that regulate nonvoluntary body
functions such as heart rate, blood pressure, etc.

6
 Dr. Jones testified that she had conversations with [L.S.’s] primary care
physician in Arkansas, Dr. Meghan Repp. Dr. Jones said that it is common
practice for Mayo to communicate with a patient’s primary care physician, as
this fosters continuity of care. Dr. Jones told Dr. Repp that she had some
concerns about Ms. Schneider’s representations of [L.S.’s] pain and had
concerns her reports were not accurate. Dr. Jones informed Dr. Repp that Ms.
Schneider endorsed and requested a port, but that Mayo did not support or
agree with have a port placed in [L.S.]. Dr. Jones stated she confirmed this with
the other doctors at Mayo. Dr. Jones stated Mayo’s recommendation against a
port was documented in her medical notes. As well, Dr. Jones testified that Ms.
Schneider requested a referral for hospice, but Mayo did not agree that a hospice
referral was warranted and declined her request. Dr. Jones testified that Mayo
did not tell Ms. Schneider [L.S.’s] gut was broken or that [L.S.] had a poor
prognosis. Mayo Clinic did not recommend that [L.S.] return to Mayo Clinic
before trying oral feeds.

Dr. Jones said that although the Mayo Cardiology Department had discussed
future appointments for [L.S.], the GI department did not have any scheduled
appointments. In fact, Mayo recommended to Ms. Schneider that they contact
Cincinnati Children’s Hospital for requests for GI appointments due to
Cincinnati’s expertise in pediatric GI. Dr. Jones testified that Dr. Repp asked
her if Mayo recommend that [L.S.] had to be stable on digoxin before starting
his narcotics wean, and Dr. Jones told her this wasn’t accurate; rather, Mayo
recommended starting the narcotics wean immediately. Dr. Jones informed
Mrs. Schneider that if chronic pain was an issue for [L.S.], she recommended he
see a psychologist or their TENS unit. Dr. Jones mentioned that Ms. Schneider
had contacted Mayo since September 11, 2019, the date that [L.S.] was placed in
the custody of the Arkansas Department of Human Services, to try and schedule
a return appointment for him.

Dr. Meg[han] Repp testified that she has been [L.S.’s] primary care physician
since April 2018. The Court finds Dr. Meghan Repp to be an expert in
pediatric medicine and finds her testimony to be very credible. Dr. Repp
testified that she relies on caregiver reporting and that if she is provided
misinformation it could result in an inappropriate treatment plan for a patient.
Dr. Repp started having concerns over the first 3-4 visits. Specifically, Ms.
Schneider showed Dr. Repp a photo of [L.S.’s] GJ site which appeared red and
possibly infected. When Dr. Repp examined [L.S.] in person the next day, the
site did not appear infected and Dr. Repp found this to be unusual. Ms.
Schneider, on more than one occasion, reported to Dr. Repp that [L.S.] had
swelling and vital sign abnormality-specifically low blood pressure and heart rate.

7
Dr. Repp never found swelling on [L.S.] upon examination, and had the school
nurse check his blood pressure and heart rate on multiple occasions and those
reports were normal. Dr. Repp had concerns that [L.S.] was malnourished and
recommended that Ms. Schneider try to increase either the number of calories
or the rate of [L.S.’s] feeds. Dr. Repp recommended she try this through either
his GJ tube or through oral feeds. Ms. Schneider consistently reported that
when she tried to increase the calories or rate of feeds it would cause abdominal
pain and distention. Dr. Repp found this unusual because she was
recommending small changes that typically do not cause any pain. Dr. Repp
provided support to the Schneider family when they made the decision to admit
L.S. to the hospital and have his TPN nutrition stopped in March of 2019. Dr.
Repp testified that she was never under the impression that the Schneiders felt
pressured by ACH to withdraw the TPN. Dr. Repp testified that she thinks the
reason [L.S.’s] health improved while he was at the hospital for his TPN
withdraw was because the hospital was allowing him to drink liquids and eat
popsicles upon request. During a home visit prior to his hospital admission, Dr.
Repp saw [L.S.] ask his mother for a popsicle. Despite the doctor’s
encouragement, he was not given a popsicle during her visit. Dr. Repp spoke
with Ms. Schneider after the TPN withdraw was stopped, and found it odd that
she made the comment that [L.S.] “did a bad job of dying.”

Dr. Repp testified at length about her concerns regarding Ms. Schneider’s
reports of pain for [L.S.]. She examined [L.S.] 23 times, and only on 2
examinations did she observe abdominal pain. On those 2 exams, the pain was
not severe and [L.S.] was able to be distracted from the pain. Dr. Repp stated
that Ms. Schneider continued to report abdominal pain and distention in the
months leading up to [L.S.] entering foster care. Dr. Repp testified that she had
very specific concerns regarding Ms. Schneider’s report of pain on August 28,
2019. Ms. Schneider contacted Dr. Repp’s office and reported significant pain,
to the point it was recommended she take [L.S.]to the ER if she is truly unable
to control his pain. Dr. Repp’s medical note states that Ms. Schneider reported
“he has been off his fentanyl and morphine for 2 weeks now, and ever since
getting below 50 mcg per day of fentanyl, he’s crying out about abdominal pain
during the day and night.” “She also states ‘we are at our breaking point.’” After
checking the next day, Dr. Repp learned that [L.S.] was not taken to the ER to
have his pain evaluated. Similarly, Ms. Schneider contacted Dr. Repp’s office on
September 3, 2019 with concerns that his port site was infected. Dr. Repp
testified that a port site infection could be very dangerous, and it was
recommended that she take [L.S.] to the ER to have the site evaluated. Dr. Repp
learned that [L.S.] was not taken to the ER, rather he was on a float the Saline

8
County parade the evening of September 3, 2019. He was taken to the ER later
the next day.

Dr. Repp testified that she had several conversations with Ms. Schneider
after she returned from the Mayo clinic in June 2019. Dr. Repp obtained the
records from Mayo prior to meeting with Ms. Schneider. Ms. Schneider also
provided Dr. Repp with Mayo records, but Ms. Schneider omitted the record
regarding pain management and recommending the narcotics wean. Dr. Repp
was concerned that Ms. Schneider failed to mention, at all, that Mayo
recommended weaning [L.S.’s] narcotics. Dr. Repp’s concerns regarding the
narcotics wean were documented in detail in her medical records. Ms. Schneider
informed Dr. Repp that Mayo recommended [L.S.] should be stable on his
digoxin prior to starting the narcotics wean. Dr. Repp found this unusual, and
when she contacted Mayo she learned this was not their recommendation. Ms.
Schneider informed Dr. Repp that Mayo, specifically Dr. Jones, recommended
[L.S.] have a port placed for his TPN feeds. Dr. Repp found this very unusual
because it was her understanding they were going to try and move away from
TPN and get [L.S.] back on feeds. Ms. Schneider informed Dr. Repp that Mayo
said [L.S.’s] gut was broken. Ms. Schneider informed Dr. Repp that once [L.S.]
was weaned from his narcotics, he was to return to Mayo for further gut testing,
and shouldn’t try oral feeds prior to the gut testing. Dr. Repp told Ms.
Schneider that she would confirm this with Dr. Jones, at which point Ms.
Schneider stated that maybe it wasn’t actually Dr. Jones who made the
recommendation for a port, but a nurse named Amy. Dr. Repp contacted Dr.
Jones who informed her that no one at Mayo recommended a port, and in fact
they strongly disagreed with [L.S.] receiving a port. Dr. Repp also checked with
Mayo clinic who informed her that [L.S.] did not have any future GI
appointments at Mayo, and they had recommended she return to Cincinnati
Children’s Hospital for any future gut motility testing. Dr. Repp testified at
length about her concerns that Ms. Schneider was resistant to weaning [L.S.’s]
narcotics. Dr. Repp testified that Arkansas Children’s Hospitalist, Palliative
Care, and Mayo Clinic had all discussed weaning narcotics, and ultimately it was
only at the insistence of Arkansas Children’s Hospital (ACH) that the wean was
initiated. ACH recommended admitting [L.S.] to the hospital for the wean, but
ultimately allowed Mr. and Ms. Schneider to do the wean at home. Dr. Repp
also recommended that [L.S.] see a psychologist to help him deal with pain
control but Ms. Schneider did not want to pursue this treatment because she
herself was a therapist and could handle [L.S.]. Dr. Repp testified that she has
had training in child abuse pediatrics, but that is not her specialty, and she
relied on both her training and communication with the child abuse
pediatrician at Arkansas Children’s Hospital (Dr. Karen Farst) regarding how to

9
handle [L.S.’s] care. Dr. Repp testified that her training was clear in cases of
suspected Munchausen’s by Proxy cases that the doctors must start collaborating
with each other prior to questioning the caregiver about their suspicions. Dr.
Repp testified that earlier this spring [L.S.] was small, appeared malnourished,
was quiet and kind, often in a wheelchair and on oxygen. She has seen him 3
times since he entered foster care and he had gained approximately 7 lbs, was
walking and jumping, and was not on oxygen. In addition to her concerns
regarding the discrepancies in Ms. Schneider’s reporting of symptoms and Dr.
Repp’s examination of [L.S.], Dr. Repp also had concerns regarding the
Schneider family interactions. Specifically, she attended a farewell party for
[L.S.] at ACH, followed by a private Baptism ceremony at Arkansas Children’s
Hospital therapy pool. These events were scheduled after the decision was made
to remove TPN and the expected outcome was [L.S.’s] death. Dr. Repp was
concerned that [L.S.] was notably upset at the baptism, and neither Mr. nor Ms.
Schneider comforted [L.S.] at all, although at one point his brother did
approach him and comfort him. Dr. Repp testified that she agrees with Dr.
Farst’s pediatric diagnosis for [L.S.], Munchausen’s by Proxy.

Dr. Karen Farst, director of the Team for Children at Risk (hereafter TCAR)
at Arkansas Children’s Hospital, also testified at the hearing and was qualified as
an expert in the fields of pediatrics and child abuse pediatrics. The Court finds
her testimony to be credible. She stated that after reviewing [L.S.’s] medical
records from various providers, talking with his doctors and the Arkansas
Department of Human Services, and after [L.S.’s] transformation after he was
separated from his parents, she concluded that [L.S.] was a victim of
Munchausen by Proxy, which also is known as Pediatric Condition Falsification
or Medical Child Abuse. She emphasized that as a pediatrician, she can make
this diagnosis and that it is not a mental health diagnosis of the parents. She
was first asked to review [L.S.’s] medical case in January 2018, because there were
concerns by his treating physicians that that his symptoms were being
exaggerated by the parent. She reviewed his chart and talked with his doctors
and declined to make a report at that time. Dr. Farst was consulted again in
April 2019 for continuing concerns that Mrs. Schneider was exaggerating or
misrepresenting [L.S.’s] symptoms, but no report was recommended. At that
point, the family’s plan was to seek additional opinions regarding [L.S.’s]
condition from other providers outside Arkansas. After Texas Children’s and
Dallas declined to see [L.S.], Mayo agreed to see him outpatient in May 2019.
Dr. Farst said TCAR wanted input from other providers before making a
decision regarding whether a report to the hotline was needed. In making her
report regarding suspicion of Munchausen by Proxy, Dr. Farst primarily focused
on the time period of May 2019 to present. Records indicated that [L.S.] was

10
seen at outpatient clinics at Mayo for about two weeks in late May and early June
2019. [L.S.] saw a multitude of doctors at Mayo, and there was consistency in
reports from those doctors that Mrs. Schneider’s accounts regarding [L.S.’s]
symptoms did not match what the doctors were seeing. Mayo instructed Mrs.
Schneider to begin to wean narcotics to see how intestines were working. Once
[L.S.] returned to Arkansas, the parents did wean Fentanyl at home, but
continued to describe [L.S.’s] quality of life as poor due to pain. Ms. Schneider
told doctors at Arkansas Children’s Hospital that Mayo wanted to see [L.S.] back
and to finish testing, although Dr. Repp, [L.S.’s] PCP, later found this to be
untrue. Ms. Schneider insisted to the Palliative Care Team at ACH that Mayo
wanted him to have a port for longer term Total Parenteral Nutrition or TPN,
which is intravenous feeding, rather than continuing to use his PICC
(peripherally inserted central catheter) line. Based on Ms. Schneider’s
assertions, a Port was placed on August 19, 2019. Ms. Schneider continues to
tell Dr. Repp that [L.S.’s] quality of life is poor if he is on less than 50
micrograms of fentanyl. On August 27, 2019, DHS contacted Dr. Farst, because
the hotline had received reports from the community, with concerns about
[L.S.’s] wellbeing.

Farst reported that [L.S.] was admitted to ACH for a possible port infection
on September 4, 2019, and Mrs. Schneider continued to insist that [L.S.] was in
terrible stomach pain and that if his Gastrojejuno[s]tomy Tubes were clamped,
he had distension of his stomach and increased pain. Because of these
assertions, she argued against weaning him from Ativan, another narcotic.
While [L.S.] was hospitalized, a multi-provider meeting was held at ACH to
discuss concerns about [L.S.’s] condition and the parents’ possible
misrepresentations of his condition. Palliative care staff recommend[ed] that
[L.S.] begin to wean from the Ativan while in the hospital; parents were resistant
to this directive, and he was discharged on September 6, 2019, with instructions
to wean at home. On September 11, 2019, Palliative Care called mom to check
on [L.S.], and Mrs. Schneider told them that he was in significant pain and that
it was not the time to wean the Ativan. That day, a hotline report was made due
to concerns about Mrs. Schneider continuing to exaggerate symptoms, and [L.S.]
was admitted to the hospital in DHS custody.

Dr. Farst explained that separating him from his parents while in the
hospital was a definitive way to determine his health baseline and to determine
his true condition. After being in the hospital starting on September 11, 2019,
[L.S.] made a profound transformation in the first two days. He was admitted to
the hospital in a wheelchair, on oxygen, allegedly in profound pain, receiving
TPN feeds and nothing by mouth and with GJ tubes. Dr. Farst reported that

11
[L.S.] initially stated that his abdominal pain was 10 out of 10 on the pain scale,
but his smile and demeanor belied that report. He was not showing any
guarding or tensing of his abdominal muscles when he reported pain. Medical
staff clamped his J-G Tubes and fed him macaroni and cheese, to his delight and
without any side effects. By the time of discharge on October 4, 2019, [L.S.] was
out of the wheelchair, eating solid foods exclusively, off oxygen, and receiving all
his medications orally. His J-G tube was removed after discharge, on November
5, 2019. He progressed from the fifth percentile in weight to the twentieth
percentile. Dr. Farst stated that given the parents’ history of exaggerating and
misrepresenting [L.S.’s] symptoms, triangulating between [L.S.’s] numerous
medical providers, and his transformation once in DHS custody, she had
concluded that he suffered from Munchausen by Proxy (also known as pediatric
condition falsification or child medical abuse.)

Dr. Farst was questioned by parent counsel regarding the validity of her
diagnosis of Munchausen by Proxy, given that she was not a mental health
provider and didn’t use the Diagnostic and Statistical Manual of Mental Health
Disorders to make her diagnosis. She explained that as a pediatrician, she was
making the diagnosis on the child rather than the parent, and that her diagnosis
was consistent with the medical literature on the issue, including the Squires
article that was introduced as Attorney ad Litem Exhibit number 1. Dr. Farst
also noted that to her knowledge the mother was the primary caregiver of [L.S.]
in the home, although the father was present in the home.

Dr. Carrie Brown, a palliative and complex care physician at Arkansas

Children’s Hospital, was qualified as an expert in palliative care and complex
care. The Court finds Dr. Brown’s testimony to be credible. Dr. Brown
testified that she first started treating [L.S.] around January 2018 due to his
complex medical issues. Dr. Brown was approached by a locum GI physician in
2018 who expressed concerns about Ms. Schneider accurately reporting [L.S.’s]
symptoms. As a result, Dr. Brown had conversation with Ms. Schneider about
the importance of accurately reporting symptoms and not exaggerating any
issues. Dr. Brown believed Ms. Schneider thereafter and thought her reporting
was accurate. Dr. Brown set aside what the locum doctor told her. Dr. Brown
testified that she was trained to believe the caregiver when they describe their
child’s symptoms and condition. In March 2019 [L.S.] was at home on hospice
care. Dr. Brown, Mr. and Ms. Schneider, and other medical professionals were
all involved in conversations about admitting [L.S.] to the hospital to stop his
TPN nutrition. Dr. Brown testified that the expected outcome of withdrawing
his nutrition would be death. Dr. Brown stated that based on the reports given
by the Schneiders regarding symptoms and quality of life, ACH agreed this

12
decision was an option for the family. Dr. Brown stated that Mr. Schneider was
present at these meetings and agreed with Ms. Schneider’s reporting and
comments. In spring 2019, Dr. Brown made the referral for [L.S.] to go to Mayo
clinic. When [L.S.] returned, the issues that Dr. Brown personally addressed
were urology, pain, and the narcotics wean. Ms. Schneider reported that Mayo
recommended start[ing] the narcotics wean once [L.S.] was stable on his digoxin,
in about 1-2 weeks. Ms. Schneider reported that once the narcotics wean was
complete, [L.S.] was to return to Mayo clinic for gut motility testing. Based on
this information, Dr. Brown recommended finishing the narcotic wean and
then sending [L.S.] back to Mayo. Ms. Schneider reported that [L.S.] could not
tolerate anything in his G-tube without it causing distress. Dr. Brown has seen
this in other patients, and believed Ms. Schneider’s report despite the fact that
she had not observed [L.S.] in distress. Dr. Brown also confirmed that [L.S.] did
report pain himself, although she was not sure if he was actually in pain. [L.S.]
was admitted to the hospital September 4-6 for a possible port infection. The
Ativan wean was discussed at the hospital at this time, and ACH recommended
weaning the Ativan at the hospital. Mr. and Ms. Schneider felt like ACH did
not trust them, and wanted to do the Ativan wean at home. [L.S.] was
discharged with Ativan wean instructions. Dr. Brown called Ms. Schneider on
September 11, 2019 to find out how the Ativan wean was going. Ms. Schneider
reported that it was not going well and [L.S.] was still having significant pain, not
tolerating the Ativan wean, and Ms. Schneider stated it was not discussed about
why the Ativan was being weaned right now. Ms. Schneider stated that Mr.
Schneider wanted to go to the Administration because communication had
stopped. Dr. Brown later learned that Ms. Schneider had filed a grievance
against her, but she did not know about the grievance when she placed the
phone call on September 11, 2019. Dr. Brown has not treated [L.S.] since she
found out about the grievance.

Lynn Dees, a pediatric APRN under Dr. Carrie Brown at ACH, testified that
she first met [L.S.] around January 2018. The Court finds Lynn Dees testimony
to be credible. Lynn Dees testified that she became close with Ms. Schneider
during the course of treating [L.S.], and she was involved in the conversations
about the narcotic wean after the Mayo visit in May-June 2019. Ms. Schneider
reported that the narcotic wean was progressing, but that [L.S.’s] pain was
worsening. In a medical note dated August 3, 2019, Ms. Schneider reported to
Lynn Dees that Mayo told her the plan was to go back in the next 4 months or
so to try and test [L.S.’s] GI system. The note reads “I know they will test his gut
again, but there truly didn’t seem to be much optimism because the system was
broken even before this all began in December.” The note also reads “we are
certainly on TPN for the foreseeable future-until we return to Mayo and get

13
more information-and thus we hope we could transition to a port as soon as
possible.” Lynn Dees testified that Ms. Schneider stated Mayo first brought up
the port to her, and this was also reflected in Lynn Dees medical notes. Lynn
Dees contacted the pediatric GI doctor at ACH to let him know that Ms.
Schneider was requesting a port, and that the palliative care team’s
understanding was that [L.S.] was to return to Mayo once he was off narcotics to
pursue GI motility testing. Lynn Dees testified that Ms. Schneider reported if
she clamped the bags attached to [L.S.’s] GJ tubes, it would create abdominal
distention.

Dr. Travis Ayers testified and was found to be an expert in the field of
pediatric gastroenterology. The Court finds Dr. Ayers to be a credible witness.
Dr. Ayers stated that he first met [L.S.] about a year ago and still cares for him
today. Dr. Ayers testified that after [L.S.] was seen at Cincinnati Children’s
Hospital, he oversaw [L.S.’s] TPN orders. Dr. Ayers explained that [L.S.]
currently has reflux and rumination, but that the rumination is being addressed
by [L.S.’s] psychologist, Dr. Brandi Whitaker. Dr. Ayers emphasized that, as a
pediatric gastroenterologist, he relies on the parents’ reporting of symptoms
when making decisions. He stated that every time he saw [L.S.] and his mother,
Ms. Schneider would tell him that, “We know his gut doesn’t work.” After
[L.S.] returned from the Mayo Clinic, Mrs. Schneider reported that Dr. Spencer
Lewis, an interventional radiologist, wanted to place a port. Thereafter, on
August 9, 2019, Dr. Ayers placed the order for the port.

Dr. Ayers stated that there was always a suspicion that [L.S.] could tolerate
oral feeds. When [L.S.] was admitted to ACH on September 11, 2019, Ayers
told the staff to clamp his G-J tubes. [L.S.] didn’t have abdominal pain from the
tubes being clamped, so Dr. Ayers authorized oral feeds for him. Dr. Ayers
stated that [L.S.] would eat “macaroni and cheese until he was blue in the face.”
Eating was clearly giving him pleasure and there were no side effects. Dr. Ayers
ordered a slow withdrawal of the TPN. Dr. Ayers reported that [L.S.] is
significantly better. He was jumping around the room, excited about eating, and
talking nonstop. Ayers indicated that [L.S.’s] port was removed on November
18, 2019.

Dr. Spencer Lewis, an interventional radiologist with Arkansas Children’s

Hospital, was called as a witness by defendant, and the Court finds him to be a
credible witness. Dr. Lewis testified that he placed [L.S.’s] port on August 19,
2019, pursuant to an order by Dr. Ayers. Dr. Lewis explained that a port is
placed under the skin and can last years. The port is placed under general
anesthesia and the surgery usually takes about 1 to 1 ½ hours. He stated that if

14
 TPN was needed for a long time, then the port is appropriate. He said that the
port could have been placed by either radiology or by general surgery. Dr. Lewis
stated that he was aware that the port had been removed recently.

5. The Court finds that the father, Eric Schneider, contributed to the
dependency-neglect of the juvenile. Father is a caregiver of the juvenile and lived in
the home. By his own description, Mr. Schneider is the “leader of the house,” and
stated that he makes the final decisions on major issues in the family. He
participated in the meeting where it was determined that TPN would be withdrawn,
participated in the decision to have a port placed in the juvenile, and met with the
cardiologist at Mayo Clinic, and by his own testimony does not think that his wife
misrepresented or exaggerated any symptoms of [L.S.]. He testified that he was
frustrated with ACH in September 2019 because he felt they were not treating
[L.S.’s] gut problems or working with the family on his Ativan wean. Upon further
questioning Mr. Schneider acknowledged that once [L.S.] entered foster care, the
only change in [L.S.’s] treatment was to clamp his tubes and later feed [L.S.] food.
Mr. Schneider is not a fit parent who can meet the juvenile’s medical, emotional,
and physical needs. He has not demonstrated that he can protect his child from
unnecessary medical treatment. Mr. Schneider’s reliance upon Young v. Ark. Dept. of
Human Servs., 2018 Ark. App. 270, is misplaced as Young is distinguishable from this
matter. Here, Mr. Schneider, by his own testimony, participated in decisions that
ultimately affected the medical treatment of his son.

6. Defendants’ argument at this hearing is that the juvenile’s change in medical

condition was based on the fact that he completed his narcotics wean shortly before
entering foster care, and that is the basis for his recovery. The Court finds this
argument implausible, based on the testimony presented at this hearing. The Court
finds that the parents’ misrepresentation of the juvenile’s medical condition, to
multiple doctors over an extended period of time, resulted in unnecessary medical
treatment and procedures. Most notably, the juvenile had a port placed in his
chest. This is a surgery that was done under general anesthesia-the juvenile later had
to have the port removed under general anesthesia once he was placed in foster care

7. Counsel for Ms. Schneider argues that the Department has not met its
burden with regard to his client, because a mental health provider has not
diagnosed her with Munchausen by Proxy. However, the statute in question, Ark.
Code Ann.§ 9-27-303 (3)(A) vii (j) defines abuse as “Any of the following
intentional or knowing acts, with or without physical injury. . .(j)Subjecting a child
to Munchausen syndrome by proxy, also known as factitious illness by proxy, when
reported and confirmed by medical personnel or a medical facility.” The statute
does not require that a mental health professional make the diagnosis; it only

15
 requires that the conditions be reported and confirmed by medical personnel, and
Dr. Farst meets this condition. (See also Parker v. Ark. Dept. of Human Servs., 380
S.W.3d 471 (2011).)

Kristy filed a notice of appeal on December 9. She also filed a notice of objection of

the court’s amendment to allegations and motion for vacation of the adjudication order.

In the motion, she challenged the sufficiency of the evidence to support dependency-

neglect based on Munchausen syndrome by proxy, she contended that her due process was

violated when the court made the posttrial amendments, and she also claimed the court’s

amendment violated Arkansas Rule of Civil Procedure 15(b). She asked the court to vacate

it adjudication order. Erik filed a notice of appeal and objection that same day. His

objection was almost identical to Kristy’s objection. DHS and the ad litems filed a joint

response to the motions and objections on December 23. The court filed orders on

December 31 denying appellants’ motions for vacation of the adjudication order. It stated

that the petition alleged abuse, neglect, and parental unfitness and the evidence at trial

supported the petition for dependency-neglect, but provided more detail and illustrations

than what had been initially pled. It said that it allowed appellee to amend its pleadings to

conform to the evidence and that appellants did not object or move for a continuance. It

further found that appellants failed to allege or even demonstrate how they were

prejudiced by this amendment. Kristy filed a supplemental notice of appeal on January 6,

2019, to include the court’s December 31 order. Erik’s supplemental notice of appeal was

filed on January 7. This appeal followed.

16
 Adjudication hearings are held to determine whether the allegations in a petition

are substantiated by the proof.3 Dependency-neglect allegations must be proved by a

preponderance of the evidence.4 In dependency-neglect cases, the standard of review on

appeal is de novo, but we do not reverse the circuit court’s findings unless they are clearly

erroneous or clearly against the preponderance of the evidence. 5 A finding is clearly

erroneous when, although there is evidence to support it, the reviewing court on the entire

evidence is left with a definite and firm conviction that a mistake has been made. 6 In

reviewing a dependency-neglect adjudication, we defer to the circuit court’s evaluation of

the credibility of the witnesses.7

Arkansas Code Annotated section 9-27-303(18)(A) defines a “dependent-neglected

juvenile” as any juvenile who is at substantial risk of serious harm as a result of abuse,

neglect, parental unfitness, along with other acts or omissions. Abuse has been defined as

intentionally or knowingly “[s]ubjecting a child to Munchausen syndrome by proxy, also

known as factitious illness by proxy, when reported and confirmed by medical personnel or

3
Ark. Code Ann. § 9-27-327(a)(1)(A) (Supp. 2019).
4
Ark. Code Ann. § 9-27-325(h)(2)(A)(ii).

5
Ward v. Ark. Dep’t of Human Servs., 2018 Ark. App. 376, 553 S.W.3d 761.

6
Id.

7
Id.

17
a medical facility.”8 The statute does not require that actual physical injury occur. Neglect

is defined as the failure or refusal to provide the necessary food, clothing, shelter, or

medical treatment necessary for the juvenile’s well-being; as well as the failure to take

reasonable action to protect the juvenile from abuse, neglect, or parental unfitness when

the existence of this condition was known or should have been known.9 There is no

statutory definition for parental unfitness.

Appellants’ first point on appeal is actually several different points rolled into one.

Appellants first challenge the definition of Munchausen syndrome by proxy as explained to

the court by Dr. Farst. Dr. Farst explained that the term has evolved to include several

instances of child abuse implemented directly or indirectly by the caregiver. She stated that

as a pediatrician, her focus was on the abuse suffered by the child, not on the caregiver.

Appellants’ argument regarding Dr. Farst’s testimony centers on the fact that she did not

rely on the DSM10 or any other psychological or psychiatric diagnosis in relation to Kristy.

According to appellants, this is at odds with both the statute and definition accepted

within the medical profession. Based on the statutory language found above, there is no

requirement that Kristy has to be diagnosed with Munchausen syndrome by proxy before a

child can be found to be dependent-neglected based on it. To the extent that appellants

claim that Dr. Farst’s diagnosis had to be in line with the DSM before a diagnosis could be

8
Ark. Code Ann. § 9-27-303(3)(A)(vii)(j).
9
Ark. Code Ann. § 9-27-303(36)(A)(ii)–(iii).
10
Diagnostic and Statistical Manual of Mental Disorders.

18
made, there is no indication in the statute that DSM has been adopted as authority for this

statute. As written, the statute requires only that the diagnosis be reported and confirmed

by medical facility or medical personnel. Here, Dr. Farst met this requirement.

Additionally, Dr. Meghan Repp stated that the literature now tells medical professional to

recognize the implications of Munchausen syndrome by proxy from the child’s perspective.

She further stated that when she uses the terms, she “really means what is happening to the

child, not what the psychological diagnosis is of the parent.” Dr. Repp testified that words

like “child medical abuse” and “pediatric condition falsification” are synonymous with

Munchausen syndrome by proxy. She indicated that although she did not make the

diagnosis in this case, she agrees with Dr. Farst’s diagnosis. The court heard each side’s

position, including appellants’ insistence that Munchausen syndrome by proxy had to be

based on a diagnosis of Kristy. In the end, the court found that no such diagnosis is

required. We cannot say that this finding is clearly erroneous.

Appellants also contend that Dr. Farst’s testimony disregarded the statutory

requirement that a child be intentionally or knowingly subjected to Munchausen syndrome

by proxy. However, regardless of the standard Dr. Farst chose to use during her testimony,

the court was presented with the statutory language and was aware of the requirement that

in order for Kristy’s actions to be considered abuse, they had to be intentional or knowing.

Although the court did not specifically find that Kristy’s actions of misrepresentations were

intentional or knowing, in the absence of a showing to the contrary, this court must

presume that a court acted properly and made the findings necessary to support its

19
judgment.11 Here, there was ample of testimony where the court could conclude that

Kristy’s actions of misrepresenting information to the medical professionals were done

either intentionally, knowingly, or both.

Appellants ask this court to overturn Parker v. Arkansas Department of Human

Services,12 to the extent it stands for the proposition that Munchausen syndrome by proxy

can be found despite the absence of a diagnosis of the caretaker. However, we decline this

invitation. The statute has no such requirement and Parker is in line with the statute.

Appellant argues that a diagnosis of the caretaker is required by the DSM, but as stated

earlier, there is no indication that the legislature intended for it to be the authority for this

particular statute.

Appellants also contend that Dr. Farst’s testimony and definition regarding

Munchausen syndrome by proxy have constitutional ramifications. Appellants mentioned

these constitutional challenges in their proposed findings of facts and conclusions of law,

but the court never ruled on the issues. As a matter of fact, the adjudication order is silent

on appellants’ constitutional issues. It is well settled that to preserve arguments for appeal,

even constitutional ones, the appellant must obtain a ruling below.13 In their reply,

appellants equate the court’s grant of appellees’ petition as overruling all of appellants’

objections, including their constitutional ones. However, granting a petition and

11
Pelayo v. Sims, 2020 Ark. App. 258, 600 S.W.3d 114.
12
2011 Ark. App. 18, 381 S.W.3d 471.
13
Chacon v. Ark. Dep’t of Human Servs., 2020 Ark. App. 277, 600 S.W.3d 131.

20
obtaining a ruling are not one in the same, and appellants have failed to cite this court to

any legal authority which states otherwise.

We hold that the circuit court correctly found that L.S. was dependent-neglected as

a result of abuse (Kristy subjecting him to Munchausen syndrome by proxy), neglect (by

appellants due to their failure or refusal to provide the necessary nutrition and medical

treatment to L.S.), and parental unfitness (a fit parent would not exaggerate or

misrepresent symptoms to medical providers and a fit parent would not acquiesce to

another caregiver’s false reporting). Based on the evidence, the court correctly found that

Erik played a role in L.S.’s dependency-neglect status. Therefore, we affirm the court’s

dependency-neglect findings as against both appellants.

Next, appellants argue that the circuit court’s posthearing attempt to redefine the

allegations violates rules of procedure, constitutional requirements, and the court’s own

pretrial guarantees. This argument has no merit. When DHS filed its affidavit, it alleged

that L.S. was dependent-neglected due to abuse, neglect, and parental unfitness. The court

granted DHS’s petition based on abuse, neglect, and parental unfitness. In the order

denying appellants’ motion to vacate the adjudication order, the court indicated that the

reasons for dependency-neglect did not change, but that the evidence adduced at the

hearing elaborated more on what was initially pled. Although the court said that it granted

DHS’s request to amend the pleadings to reflect the evidence, no amendment was

necessary because DHS had already stated its theory for dependency-neglect against

appellants and stood on its petition and supporting affidavit.

21
 To the extent that an amendment was necessary, the court was within its bounds to

grant the amendment. Arkansas Rule of Civil Procedure 15(b) governs the amendment of

pleadings to conform to the evidence and states that pleadings can be amended at any

time, including after judgment. If a party objects to the amendment, the court may still

allow the amendment in its discretion. The court may also grant a continuance to allow

the objecting party to meet such evidence. Here, DHS moved to have the pleadings

conform to the evidence after it concluded its case and Kristy moved for dismissal. Kristy

objected to the amendment based on improper notice. The court did not rule on the

pleadings until the adjudication order. The circuit court stated that it was using its

discretion to allow the amendment, which it is permitted to do. Although a court may

allow an objecting party a continuance, it is not required to do so. A circuit court’s

decision regarding the amendment of pleadings to conform to the evidence will not be

reversed absent a manifest abuse of discretion, 14 and the party seeking reversal on that

ground must show the manifest abuse.15 Prejudice from the circuit court’s ruling must also

be demonstrated.16 Both appellants have failed to demonstrate how they would have

presented their cases differently had they known that the court would allow DHS to amend

14
Ison Props., LLC v. Wood, 85 Ark. App. 443, 156 S.W.3d 742 (2004).

15
Hickman v. Kralicek Realty & Constr. Co., 84 Ark. App. 61, 66, 129 S.W.3d 317,
320 (2003).

16
Honeycutt v. Honeycutt, 2017 Ark. App. 113, 516 S.W.3d 750.

22
its pleadings. Thus, we hold that there was no abuse of discretion in allowing the

amendment.

In an earlier hearing, the court informed DHS that it had to notify appellants what

theory it was basing its petition for dependency-neglect on. DHS stated that it was

standing by its petition and supporting affidavit. The court in turn told DHS that it would

be limited to what it had indicated to the attorneys it was going to prove. Here, as the

court suggested in its December 31 order, the allegations against appellants did not change,

those allegations were just elaborated upon during the hearing. Thus, there were no due-

process violations as appellants were fully aware that DHS sought to have the court declare

L.S. dependent-neglected as a result of abuse, neglect, and parental unfitness.

Finally, appellants argue that the court’s findings of facts are clearly erroneous. It

appears that appellants want this court to reweigh the evidence in their favor. Under our

standard of review, we do not act as a super fact-finder, and it is not reversible error for the

circuit court to weigh the evidence differently than how appellants ask the evidence to be

weighed.17 The circuit court’s findings are supported by the record. Accordingly, we

affirm.

Affirmed.

ABRAMSON and SWITZER, JJ., agree.

Jeff Rosenzweig, for appellants.

Andrew Firth, Office of Chief Counsel, for appellee.

17
Allen v. Ark. Dep’t of Human Servs., 2018 Ark. App. 136, 540 S.W.3d 742.

23
Kimberly Boling Bibb, attorney ad litem for minor child.

24