In re Interest of Brelynn E. , 30 Neb. Ct. App. 723 ( 2022 )


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    Nebraska Court of Appeals Advance Sheets
    30 Nebraska Appellate Reports
    IN RE INTEREST OF BRELYNN E.
    Cite as 
    30 Neb. App. 723
    In re Interest of Brelynn E., a child
    under 18 years of age.
    State of Nebraska, appellee, v.
    Cindy E., appellant.
    ___ N.W.2d ___
    Filed March 15, 2022.    No. A-21-166.
    1. Juvenile Courts: Evidence: Appeal and Error. Juvenile cases are
    reviewed de novo on the record, and an appellate court is required to
    reach a conclusion independent of the juvenile court’s findings; how-
    ever, when the evidence is in conflict, an appellate court may consider
    and give weight to the fact that the trial court observed the witnesses
    and accepted one version of the facts over the other.
    2. Appeal and Error. An appellate court will not consider an issue on
    appeal that was not presented to or passed upon by the trial court.
    3. Pleadings: Parental Rights. The purpose of an exception hearing is
    to determine whether the State may be excused from the mandatory
    requirement of 
    Neb. Rev. Stat. § 43-292.02
    (1) (Cum. Supp. 2020) that it
    file a petition to terminate parental rights under certain circumstances.
    4. ____: ____. Under certain circumstances, the State is generally required
    to file a petition to terminate the parental rights of a child’s parents,
    subject to the outcome of an exception hearing.
    5. ____: ____. If a court determines that a statutory exception under 
    Neb. Rev. Stat. § 43-292.02
     (Cum. Supp. 2020) does not exist, then the State
    is required to file a petition to terminate parental rights.
    6. ____: ____. If a statutory exception under 
    Neb. Rev. Stat. § 43-292.02
    (Cum. Supp. 2020) exists, then the State is not required to file a petition
    to terminate parental rights but may do so anyway.
    7. Juvenile Courts: Parental Rights. For a juvenile court to terminate
    parental rights under 
    Neb. Rev. Stat. § 43-292
     (Reissue 2016), it must
    find that one or more of the statutory grounds listed in this section have
    been satisfied and that such termination is in the child’s best interests.
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    IN RE INTEREST OF BRELYNN E.
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    8. Parental Rights: Proof. 
    Neb. Rev. Stat. § 43-292
    (7) (Reissue 2016)
    allows for termination of parental rights when a juvenile has been in
    an out-of-home placement for 15 or more months of the most recent 22
    months. It operates mechanically and, unlike the other subsections of
    the statute, does not require the State to adduce evidence of any specific
    fault on the part of a parent.
    9. Parental Rights. The proper application of 
    Neb. Rev. Stat. § 43-292
    (7)
    (Reissue 2016) consists of counting the most recent 22 months preced-
    ing the filing of the petition to terminate parental rights, followed by
    counting how many of those 22 months the child was in out-of-home
    placement.
    10. Parental Rights: Proof. 
    Neb. Rev. Stat. § 43-292
     (Reissue 2016) pro-
    vides 11 separate conditions, any one of which can serve as the basis
    for termination of parental rights when coupled with the evidence that
    termination is in the best interests of the child.
    11. ____: ____. In addition to proving a statutory ground, the State must
    show that termination of parental rights is in the best interests of
    the child.
    12. Parental Rights: Words and Phrases. The term “unfitness” is not
    expressly used in 
    Neb. Rev. Stat. § 43-292
     (Reissue 2016), but the con-
    cept is generally encompassed by the fault and neglect subsections of
    that statute, and also through a determination of the child’s best interests.
    13. Constitutional Law: Parental Rights: Words and Phrases. In the
    context of the constitutionally protected relationship between a parent
    and a child, parental unfitness means a personal deficiency or incapacity
    which has prevented, or will probably prevent, performance of a reason-
    able parental obligation in child rearing and which caused, or probably
    will result in, detriment to the child’s well-being.
    14. Parental Rights: Parent and Child. In proceedings to terminate paren-
    tal rights, the law does not require perfection of a parent; instead, courts
    should look for the parent’s continued improvement in parenting skills
    and a beneficial relationship between a parent and a child.
    Appeal from the County Court for Buffalo County: John P.
    Rademacher, Judge. Affirmed.
    Michele J. Romero, of Stamm Romero & Associates, P.C.,
    L.L.O., for appellant.
    Patrick M. Lee, Deputy Buffalo County Attorney, for
    appellant.
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    IN RE INTEREST OF BRELYNN E.
    Cite as 
    30 Neb. App. 723
    Jennifer N. Rowling, guardian ad litem.
    Moore, Bishop, and Arterburn, Judges.
    Arterburn, Judge.
    INTRODUCTION
    Cindy E. appeals from the order of the county court for
    Buffalo County, sitting as a juvenile court, which terminated
    her parental rights to her child Brelynn E. Based on the reasons
    that follow, we affirm.
    BACKGROUND
    Cindy is the biological mother of Brelynn, who was born
    in August 2015. Cindy has two older children, one of whom
    resides with his paternal grandparents after she voluntarily
    relinquished her parental rights to him and the other of whom
    has been placed in a guardianship as a result of a prior juve-
    nile court case involving Cindy. These two children were not
    involved in the present juvenile court proceedings and, as a
    result, are not part of this appeal. In addition, the fathers of
    Cindy’s other children were not involved in the juvenile court
    proceedings below and are not part of this appeal. Wesley E.
    is the father of Brelynn; however, he relinquished his parental
    rights to Brelynn on September 28, 2020, during the course of
    the termination trial.
    Brelynn has been removed from Cindy’s care by the
    Department of Health and Human Services (the Department)
    on two occasions prior to the filing of the present case. Cindy
    had a voluntary case with the Department in May 2016, follow-
    ing reports that Wesley sexually assaulted Brelynn. Wesley was
    ultimately convicted of sexually assaulting Brelynn when she
    was approximately 9 months old. Brelynn was not in Cindy’s
    care for approximately 1 week. In June 2017, Brelynn was again
    removed from the home. She was returned to Cindy’s home
    in December 2017, but remained in the Department’s legal
    custody until June 2018. This removal was due to concerns
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    regarding Cindy’s mental health and regarding Cindy’s leaving
    Brelynn with inappropriate care­givers, including Cindy’s sister,
    whose husband was a registered sex offender.
    Because of the concerns about Cindy’s mental health, the
    Department contacted Dr. John Meidlinger, a licensed clini-
    cal psychologist, to complete an evaluation in July 2017.
    Meidlinger diagnosed Cindy with adjustment disorder, anxious
    mood, and post-traumatic stress disorder, as well as a person-
    ality disorder with narcissistic and avoidant features. In his
    evaluation, he expressed that he would want to see stability in
    all aspects of Cindy’s life before he felt that Brelynn should be
    placed with Cindy again. Specifically, he noted that if Cindy
    did not have mental health stability and regulation in place,
    Brelynn would not be able to trust Cindy and would develop
    patterns of codependency. In addition, in his opinion, Brelynn
    could become “[an] easy target[] for unscrupulous peers and
    adults.” According to Meidlinger, Cindy would continue to
    struggle with her mental health unless she worked more than
    once a week on identifying and implementing coping strategies
    for her mental health. In his opinion, Cindy does not have an
    ability to experience adversity and then turn the adversity into
    a useful path forward. He believes that it would be useful for
    her to be placed in a 24-hour inpatient facility to teach her the
    emotional skills that she needs. In addition, he expressed that
    part of Cindy’s narcissistic tendencies would be to seek exces-
    sive medical attention for a child as a way of getting attention
    for herself.
    Meidlinger noted his concerns about Cindy’s parenting abil-
    ity. His evaluation noted that Cindy continued to see Wesley
    after she was convinced Wesley was sexually abusing Brelynn
    and that Cindy went on to have another child with Wesley.
    Meidlinger testified that Cindy felt “justified” in leaving
    Brelynn in the care of her sister and brother-in-law, despite
    her brother-in-law’s also being a registered sex offender.
    Meidlinger observed Cindy with Brelynn and observed that
    Cindy did not engage well with Brelynn. He testified that
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    IN RE INTEREST OF BRELYNN E.
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    Cindy did not know “how to create space and interact with
    [Brelynn].” He also noted that Cindy could not manage minor
    tasks with Brelynn. Meidlinger expressed his concern that
    when Cindy and Brelynn were at his office, Cindy did not
    escort Brelynn to his office, despite Brelynn’s previously being
    sexually assaulted by a male. He also observed that Cindy did
    not appropriately interact with Brelynn in the way that she
    talked with Brelynn and did not know how to structure play-
    time with Brelynn. He was concerned about Cindy’s ability to
    make good judgments about Brelynn.
    Despite the involvement of the Department in Cindy’s and
    Brelynn’s lives from 2016 to 2018, it was the death of Cindy
    and Wesley’s other child, Kamdyn W., which precipitated the
    current case. Kamdyn was born in September 2018. When
    Kamdyn was approximately 2 months old, he suffered from
    a cold. Kamdyn was sleeping on a “Boppy” style pillow in
    Cindy’s bed, at a 45-degree angle, due to his cold, and he
    rolled off of the pillow onto his stomach. He was transported to
    the emergency room in an unresponsive condition. The cause
    of death was determined to be asphyxiation.
    Dr. Angela Kratochvil-Stava, a pediatrician who treated
    both Brelynn and Kamdyn, testified about the instructions she
    gave to Cindy about safe sleep for babies. She explained that
    after a baby is born, the parents are required to watch videos
    on safe sleep for babies. She testified that these videos instruct
    parents on the appropriate way for a baby to sleep, specifically
    that the baby is to be placed on his or her back in his or her
    own bed. Kratochvil-Stava further testified that if a baby has
    a cold, she advises the parents that the baby should remain
    on a firm mattress but that the head can be elevated by lifting
    up the mattress about 15 to 20 degrees by placing something
    underneath one end. Kamdyn suffered a cold when he was
    approximately 2 months old. Cindy told the officers inves-
    tigating the death that her doctor had instructed her to have
    Kamdyn sleep on a “Boppy” style pillow due to his cold and at
    a 45-degree angle. According to Cindy, one night, when he was
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    sleeping on this style of pillow, he rolled off of the pillow onto
    his stomach, which resulted in his death. ­Kratochvil-Stava
    denied advising Cindy to use this style of pillow to prop
    Kamdyn up.
    As part of the investigation of Kamdyn’s death, law enforce-
    ment investigated Cindy’s residence. Harley Amy, an investiga-
    tor with the Buffalo County sheriff’s office, observed that there
    were prescription medications in bottles, as well as loose medi-
    cations, within Brelynn’s reach. He testified that there was a
    bassinet in Cindy’s bedroom; however, the bassinet was full of
    items, including a basket of prescription medications and toys.
    In addition, there was cough medicine spilled in the bassinet
    that had not been cleaned up. He also observed that there was
    mold growing on items in the kitchen and that the residence
    smelled of feces and urine. Amy authored an affidavit request-
    ing removal of Brelynn based on the uncleanliness of the home
    and Kamdyn’s death. The affidavit also noted that Brelynn had
    been previously sexually abused.
    On November 6, 2018, the State filed a petition request-
    ing that Brelynn be adjudicated as a juvenile under 
    Neb. Rev. Stat. § 43-247
    (3)(a) (Reissue 2016). The State asserted that
    Brelynn had previously been in the care and custody of the
    Department from June 2017 to June 2018 following reports of
    Cindy’s inability to leave Brelynn with appropriate caretakers,
    an unsanitary home, and Cindy’s mental health issues which
    placed Brelynn at risk of harm. In addition, it was noted that
    Brelynn had been previously sexually assaulted by Wesley.
    Brelynn was removed from Cindy’s residence and was
    placed with her maternal grandmother, Carol Gaedeke, in
    November 2018. However, after approximately 10 days,
    Gaedeke requested that Brelynn be removed from her home.
    According to Gaedeke, she requested that Brelynn be removed
    in part due to conflict she was experiencing with Cindy along
    with the grief she was experiencing due to Kamdyn’s death.
    The Department then placed Brelynn into foster care. After a
    couple of shorter-term placements, Brelynn was placed with
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    IN RE INTEREST OF BRELYNN E.
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    a foster family in July 2019 who would consider providing a
    permanent home for Brelynn, should that be necessary. Later,
    on April 4, 2019, Gaedeke wrote an email to the court request-
    ing that if Cindy’s parental rights to Brelynn were to be ter-
    minated and Brelynn was to be adopted, Gaedeke would want
    to be considered for her adoption. The court noted that it did
    not consider or review the email and forwarded the email to
    the attorneys. Although Brelynn lived in more than one foster
    home, she was not again placed with Gaedeke; nor did she
    return to Cindy’s care. Cindy continued to have supervised
    ­visits with Brelynn throughout the pendency of the case.
    On March 9, 2020, Cindy filed a motion for an exception.
    She asked for the court to grant her an exception to the State’s
    duty to file a petition for termination of parental rights under
    
    Neb. Rev. Stat. § 43-292.02
    (3)(b) (Cum. Supp. 2020). She
    asserted that although more than 15 months had passed since
    Brelynn was in the care of a nonrelative, she had not had a
    reasonable opportunity to avail herself of the services deemed
    necessary in the case plan. The court did not hold a hearing on
    Cindy’s motion.
    Two days later, on March 11, 2020, the State filed a motion
    for termination of Cindy’s parental rights. The State alleged that
    Brelynn had been in the care and custody of the Department
    since November 2018. The State asserted that Brelynn had
    been previously removed from Cindy’s care from May 26 until
    May 31, 2016, and June 2017 until December 2017. The State
    asserted that the grounds for termination of Cindy’s parental
    rights were based on 
    Neb. Rev. Stat. § 43-292
    (5), (6), and (7)
    (Reissue 2016). The State alleged that Cindy was unable to
    discharge her parental responsibilities because of mental illness
    or mental deficiency and that there were reasonable grounds
    to believe that this condition would continue for a prolonged
    indeterminate period; that reasonable efforts to preserve and
    unify the family had failed to correct the conditions; and that
    Brelynn had been placed in an out-of-home placement for 15
    or more months of the most recent 22 months. On June 1,
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    2020, Gaedeke filed a complaint to intervene, stating that she
    wished to have permanent placement of Brelynn if Cindy’s
    parental rights were terminated.
    Trial on the motion for termination began on September 10,
    2020, and continued for 6 days over the next few months, end-
    ing on December 10. Numerous witnesses testified, including
    Meidlinger, Kratochvil-Stava, Gaedeke, and Amy. In addition,
    Cindy testified. We note that when Amy testified at trial, Cindy
    objected, citing the doctrine of oneness and affinity, because
    he was married to the State’s prosecuting attorney. She argued
    that Amy’s testimony should be stricken. The court overruled
    the motion. Several other mental health practitioners and case-
    workers, as well as Brelynn’s foster parents, also testified. In
    addition to the testimony recounted earlier, the following evi-
    dence germane to our decision was adduced:
    Samantha Keim, a child and family services specialist with
    the Department, testified that the Department received a phone
    call regarding an unresponsive child in Cindy’s home. During
    the course of the Department’s investigation, investigators
    learned that the house was not clean, that there were medica-
    tions within reach of Brelynn, and that further concerns existed
    regarding Cindy’s mental health. Keim explained that after
    Brelynn was removed from the home for the third time, in
    November 2018, it was determined that the initial goal of the
    case should be reunification. Keim testified that the unclean-
    liness of the home was alleviated and that the concerns for
    Cindy’s mental health were not “as extreme at that point.”
    However, she also testified that Cindy’s actions prevented
    reunification from occurring. Keim explained that in January
    2019, Cindy and her boyfriend at the time, Nathan Wheeler,
    began yelling and using profanities toward visitation super­
    visors. Another incident occurred in March 2019 in which law
    enforcement had to be called. Keim explained that the visita-
    tion worker requested Cindy to put Brelynn into a car seat and
    to adjust the car seat. Keim explained that Cindy then noticed
    the car seat was not attached and pushed the car seat, which
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    made Brelynn fall into the back of the driver’s seat. Cindy and
    Wheeler began yelling at the worker. Keim explained that law
    enforcement was called because Cindy and Wheeler refused
    to give Brelynn back to the visitation worker. The Department
    made a determination, based in part on these incidents, that
    Cindy needed to demonstrate an ability to act respectfully
    and to appropriately communicate with others in a moment
    of crisis.
    Brelynn worked with Jordan McCoy, a child, adolescent, and
    family counselor, beginning in August 2017, prior to the start
    of the current county court proceedings. After the start of the
    proceedings, from November 2018 until March 2019, McCoy
    saw Cindy and Brelynn for child-parent psychotherapy (CPP).
    McCoy explained that CPP is a therapy that focuses on the rela-
    tionship between a child and a caretaker and how the parent’s
    mental health impacts this relationship. McCoy observed that
    Brelynn struggled with anxiety, a heightened amount of wor-
    ries, and emotional dysregulation. In addition, Brelynn’s social
    and emotional development was lagging. McCoy also observed
    that Brelynn would attempt to control situations because she
    did not feel safe. She provided an example, that Brelynn would
    attempt to control getting her shoes on and what she wanted to
    eat. McCoy diagnosed Brelynn with other specified trauma and
    a stressor-related disorder. McCoy also explained that Brelynn
    presented with significant symptoms related to the trauma that
    arose from Wesley’s sexual abuse, as well as neglect and inse-
    cure attachment patterns with respect to Cindy.
    McCoy observed how Cindy’s mental health affected
    Brelynn. In McCoy’s opinion, Brelynn initially believed that
    adults were not safe or consistent. McCoy testified that when
    Cindy was consistent, Brelynn’s symptoms would improve,
    but that when Cindy was not consistent, Brelynn would strug-
    gle. McCoy also explained that after the death of Kamdyn,
    Brelynn’s mental health was linked to Cindy’s mental health,
    such that when Cindy would have a good mental health day,
    Brelynn would have a better mental health day. McCoy also
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    observed that Brelynn’s emotional needs were not being con-
    sistently met. McCoy testified that when Cindy’s mental health
    was not good, Brelynn would take on the role of caretaker in a
    role reversal. McCoy did witness progress with Cindy’s mental
    health at times but found that it was not consistent. McCoy
    testified that although Cindy reported that she had taken par-
    enting classes multiple times, she struggled with implementing
    the concepts she learned on a consistent basis. Cindy’s ability
    to parent and implement what she learned was dependent on
    her mental health. Cindy stopped seeing McCoy in March 2019
    after McCoy needed to redirect Cindy multiple times to focus
    on Brelynn’s needs as opposed to Cindy’s needs.
    Keim contacted Thomas Maxson, a mental health therapist,
    about Cindy’s beginning individual therapy in March 2019.
    Cindy testified that she did not like to work with Maxson
    because Maxson previously worked with Wesley and she did
    not believe his therapeutic style was beneficial to her. Maxson
    testified that Cindy told him that he was too intrusive and
    intense; however, Maxson also explained that this opinion
    arose only after he told Cindy his concerns about her moving
    to Hershey, Nebraska, in 2019, which would have required
    her to change providers and the effects that change may have
    regarding custody of Brelynn.
    Maxson diagnosed Cindy with major depressive disorder,
    borderline personality disorder, and post-traumatic stress dis-
    order. Maxson explained that borderline personality disorder
    is characterized by emotional dysregulation when relationships
    are cyclical between things going well one day and poorly
    the next. He also explained that typically, people who suffer
    from borderline personality disorder often have suicidal and
    self-harm ideation, difficulties with maintaining relationships,
    and emotional upheaval. Maxson reported that these disorders
    usually exist on a continuum and can be actively managed
    through work and application of what was learned in dialectical
    behavioral therapy (DBT). DBT is a specific type of interven-
    tion specifically created for people with suicidal ideation and
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    for people with borderline personality disorder. According to
    Maxson, DBT focuses on the skill deficits found in persons
    who suffer from borderline personality disorder. The therapeu-
    tic process is designed to teach the patient emotional regulation
    skills, interpersonal effectiveness in how to ask for what the
    patient needs, distress tolerance skills, and tolerating strong
    emotion without causing harm, in addition to mindfulness
    skills. Cindy provided a letter to Maxson in June 2019 that she
    would no longer work with him.
    Cindy began attending DBT with Jamie Babutzke, another
    mental health therapist, in April 2019. Babutzke diagnosed
    Cindy with major depressive disorder, recurrent; post-traumatic
    stress disorder; and borderline personality disorder. Babutzke
    testified that Cindy attended the DBT sessions and attempted
    to use what she learned in her everyday life, but Babutzke
    noted that it was a “process.” Babutzke explained that Cindy’s
    mental health would be cyclical, where she would have periods
    when she would do very well and periods that would not go
    as well. Babutzke observed in Cindy what she described as a
    “pervasive pattern of instability in interpersonal relationships,
    self-image, and impulsivity.” She also observed “recurrent sui-
    cidal behavior, gestures, and threats” that affected her instabil-
    ity due to “marked reactivity of mood, and trouble controlling
    anger.” She conceded that in the period nearest trial, Cindy
    had been less able to use the skills from DBT than she had in
    the past.
    Babutzke stated that she has not observed Cindy with her
    children and that her reports are based only on interactions
    with Cindy, visitation notes from the Department, and col-
    lateral contacts. She testified that she had conversations with
    Samantha Byrns, a therapist whom Cindy and Brelynn also
    worked with at the time, about addressing grief and loss so
    that Byrns could have more effective CPP with Cindy and
    Brelynn. After reviewing visitation notes, Babutzke conceded
    that Cindy had not provided emotional safety to Brelynn on
    several occasions.
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    Byrns, a therapist who specializes in trauma treatment, also
    treated Cindy and Brelynn and engaged in CPP with them
    beginning in September 2019. Cindy and Brelynn had switched
    providers after ending the relationship with McCoy. However,
    Byrns testified that there were numerous delays in starting
    CPP. Byrns believed that Cindy did not trust her and that as a
    result, Cindy did not complete an initial interview in a timely
    fashion. According to Byrns, Cindy wanted Byrns neither to
    have access to the Department’s case file and intake form
    nor to communicate with the Department. Byrns testified that
    Cindy frequently wanted to discuss personal issues with Byrns
    which prevented them from completing CPP. Byrns expressed
    her concerns that the issues that Meidlinger pointed out 3 years
    earlier were still present.
    Dr. Narayana Koduri, a psychiatrist, began seeing Cindy
    in January 2020. Koduri diagnosed Cindy with post-traumatic
    stress disorder, major depressive disorder, and borderline per-
    sonality disorder. According to him, Cindy had a psychiatric
    appointment approximately once per month and based on his
    observations of the refill records, Cindy was taking her medi-
    cine appropriately. He acknowledged that Cindy had 15 prior
    hospitalizations due to mental health issues. While under his
    care, Cindy was twice hospitalized in 2020, which hospital-
    izations, in his opinion, were linked to grief- or stress-related
    responses by Cindy. He noted that although it was concerning
    that Cindy’s condition had on those occasions deteriorated
    to the point of requiring hospitalization, he was encouraged
    that Cindy recognized when she was experiencing symptoms,
    which prompted her to seek inpatient help.
    Kratochvil-Stava testified as to Cindy’s parenting when
    Brelynn was younger. She explained that when Brelynn was
    9 months old, she would need to cough a lot, and Kratochvil-
    Stava’s observation was that Cindy and Wheeler were very
    aggressive to get these “cough[s] out.” Kratochvil-Stava
    testified that when Brelynn would cough while seated in
    her car seat, Cindy and Wheeler would flip the car seat
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    over to get her “to cough out whatever was bothering her.”
    ­Kratochvil-Stava expressed some concerns over whether there
    was proper supervision of Brelynn, because Brelynn needed to
    get stitches after falling out of bed and suffered a burn from
    touching a hot stove. Kratochvil-Stava also spent significant
    time educating Cindy on what a healthy genital area looks like,
    because Cindy asked Kratochvil-Stava to conduct an anatomy
    check each time Cindy brought Brelynn in.
    There was significant testimony regarding Cindy’s taking
    Brelynn to excessive doctor appointments. Keim observed that
    Cindy took Brelynn to the doctor very often for small things
    and that often, the doctor would report that there was nothing
    wrong. S.C., a foster parent for Brelynn, testified that during
    the 7 months Brelynn was in her care, Brelynn had 14 differ-
    ent doctor appointments, mostly regarding holding her stool.
    Another foster parent, K.W., believed that the number of doc-
    tor appointments that Cindy scheduled for Brelynn was exces-
    sive. According to both of these foster parents, Brelynn would
    struggle with attending doctor and dentist appointments only if
    Cindy was also there. At doctor appointments, S.C. observed
    Cindy express anger about issues that affected only Cindy and
    were not relevant to Brelynn. All of the foster parents testified
    that Cindy was not accurate in the reporting of health issues
    to Brelynn’s doctor. Cindy would often give accounts regard-
    ing Brelynn’s health conflicting with the reports given by the
    foster parents.
    Brelynn had constipation issues that necessitated doctor
    appointments for her. Kratochvil-Stava testified that she treated
    Brelynn with oral medication for constipation but that it was
    often insufficient. At one point, Brelynn would need either
    to take a suppository or to undergo an invasive procedure at
    the hospital. S.C. and her husband were able to give Brelynn
    a suppository without any issues. However, Cindy was not
    able to do so, because Brelynn became agitated. Cindy called
    ­Kratochvil-Stava and stated that there would be no more sup-
    positories for Brelynn. Because Cindy did not want to go
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    forward with the suppository, Brelynn needed to undergo an
    invasive procedure. Before the procedure, Brelynn needed
    to drink a certain liquid medicine that children are typically
    not able to drink. Kratochvil-Stava explained that if a child is
    unable to drink the medicine, a tube would need to be inserted
    that would run from the child’s nose to the child’s stomach.
    Brelynn was able to drink the medicine after Cindy was able
    to convince her. Kratochvil-Stava opined that the constipation
    issues were behavioral issues that had to do with Brelynn’s
    controlling when she would stool. These issues largely resolved
    during periods when visitation was suspended.
    Both the caseworkers assigned to the case and the foster
    parents who testified reported that Cindy had difficulties being
    honest with them. Keim testified that she could not determine
    if information she received from Cindy about her mental health
    appointments and Brelynn’s medical condition was truthful or
    accurate. Keim needed to contact the provider to confirm the
    accuracy of information provided. She testified that informa-
    tion she received from Cindy was often not accurate. Hope
    Holmes, a child and family services specialist employed with
    the Department, testified that during the time she was assigned
    to the case, Cindy had difficulties maintaining honesty with
    the Department.
    The caseworkers employed with the Department had dif-
    ficulties working with Cindy throughout the case. Keim had
    ­negative interactions with Cindy, including that Cindy would
    yell at her, would call her supervisor to complain, and was dis-
    honest with her. Holmes also explained that there were a number
    of visitation workers assigned to the case because the workers
    reported difficulties in working with Cindy. She also explained
    that Cindy would make complaints to the Department about
    caseworkers which would also necessitate changing the work-
    ers involved with Cindy. Holmes also explained that she spent
    time encouraging Cindy and the foster parents to be able to
    communicate with each other, but was not successful.
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    There were concerns expressed about Cindy’s ability to
    lead a stable lifestyle. From July 2019 until the time of trial,
    Cindy had five different jobs. At times, she worked very few
    hours per week, while at other times, she worked full time.
    Cindy accounted for the frequent changes by saying that she
    was prioritizing her visits with Brelynn as opposed to work-
    ing. Holmes testified that Cindy’s pattern with parenting was
    also one of instability. She noted that when the Department
    worked with Cindy in 2017, there were concerns regarding the
    cleanliness of the house, and that the cleanliness of the house
    was also an issue in 2018. Holmes also testified that in her
    opinion, she has concerns about Cindy’s ability to pay her rent
    and bills without relying on community resources. She noted
    that even though Cindy lives in subsidized housing where
    her rent is low, she has still had to seek assistance paying for
    utilities and transportation. Holmes also expressed concern that
    despite having years of therapy and counseling, Cindy contin-
    ued to experience events which exacerbated Cindy’s mental
    health struggles.
    Holmes also noted that whenever the Department lessened
    its involvement in Cindy’s day-to-day life, her circumstances
    would regress, often back to what things were like before any
    Departmental involvement. Holmes expressed concern that
    Cindy would be unable to maintain long-term stability. She
    noted that Cindy was able to show stability in her mental
    health and employment at various points during the pendency
    of the case, but could not sustain her progress for a signifi-
    cant period.
    K.W., one of Brelynn’s prior foster parents, testified as to
    her experience with Cindy and Brelynn. When Brelynn was
    2 years old, she moved into K.W.’s home. K.W. testified that
    Brelynn was fearful and anxious when Brelynn first moved
    into her home and was toilet trained. However, when visita-
    tions occurred with Cindy, Brelynn began to have regressions
    with respect to using the restroom. K.W. testified that when
    Brelynn would return from visitations with Cindy, Brelynn
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    was not always fed or clean. K.W. observed that Cindy pro-
    vided inaccurate information at doctor appointments. In addi-
    tion, at one doctor appointment when K.W. was the only one
    in the room with Cindy and Brelynn, Cindy told Brelynn,
    “[D]on’t worry, Brelynn, Mommy and Daddy won’t hurt you,
    but someone in this room may.” K.W. testified that soon after
    that, she decided not to be Brelynn’s foster parent any longer
    because she was afraid of Cindy.
    S.C. also testified as to her difficulties with Cindy and
    Brelynn. When Brelynn came to live with S.C.’s family,
    Brelynn needed to control her environment. S.C. explained that
    when visits with Cindy stopped, Brelynn’s behavior changed.
    According to S.C., Brelynn was “fixated on whether or not
    Cindy was okay.” S.C. also testified that when Brelynn lived
    with her, Cindy “tried to control our house.” Examples of
    Cindy’s trying to control included stating what diapers to
    use or what milk Brelynn could drink. S.C. also testified that
    Cindy would report to the Department different information
    from the doctor than she in fact received from the doctor. S.C.
    testified that the reason she decided to not continue as a foster
    parent for Brelynn was because she did not want to work with
    Cindy over an extended period of time.
    T.J., who was one of Brelynn’s foster parents at the time of
    trial, testified as to her experience with Cindy. Brelynn began
    living with T.J. when Brelynn was 3 years old. When Brelynn
    began living with T.J., Brelynn was “afraid of everything.”
    T.J. testified that Brelynn struggled when she saw Cindy,
    especially with respect to using the restroom. Upon com-
    ing to T.J.’s home, Brelynn expressed her desire to be potty
    trained, which was accomplished within a week. However,
    when Brelynn was returned from a visit with Cindy, she
    would be wearing “Pull-ups.” Brelynn would demand to be
    put back into underwear upon her return. T.J. explained that
    she attempted to communicate with Cindy; however, Cindy
    stopped communicating information to her. T.J. also observed
    that Brelynn did not always want to visit with Cindy and that
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    since visitations with Cindy stopped, Brelynn was happier and
    acting better.
    Cindy’s mother, Gaedeke, testified as to her relationship
    with Cindy and Brelynn. She explained that she was the
    original placement for Brelynn in November 2018. However,
    she explained that Cindy and she had a “breakdown in com-
    munication” where Cindy was attempting to direct Gaedeke
    how to take care of Brelynn. She believed that she was capable
    of taking care of Brelynn. Gaedeke explained that during the
    pendency of the case, she had not been contacted to have
    placement again. She believed that Cindy’s mental health had
    improved through the pendency of the case, and she had no
    concerns about Cindy’s ability to parent Brelynn.
    Cindy testified as to her own progress throughout the case.
    She believes that the goals in the present case should be the
    same as those in the last case, which ended in reunification.
    She explained that in her opinion, she has met the goals of hav-
    ing a clean home and healthy relationships. She believes that
    her mental health has greatly improved since she completed
    DBT. She also believes that Koduri is a much better fit for her
    mental health and believes that he has provided “the best med
    management [she had] ever had.” She also explained that she
    has been on medication, consistently, throughout the pendency
    of the case.
    Cindy also addressed several issues regarding her mental
    health. She conceded that her first mental-health-related hos-
    pitalization occurred when she was 12 or 13 years old. She
    also acknowledged that she has had auditory or visual hallu-
    cinations for at least 12 years. She explained that she has had
    numerous therapists or counselors during this case because she
    has, at various points, believed that her right to confidential-
    ity was not being upheld. She also questioned the accuracy of
    some of the reporting to the Department. She explained that
    she stopped seeing McCoy because she did not believe she
    could trust McCoy but then, after transferring CPP to Byrns,
    later requested McCoy to work with her again.
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    She acknowledged that she “was horrible” in her behavior
    toward caseworkers and others at the beginning of the case,
    but believes that her mental health has improved. She con-
    ceded that she had an anxiety attack in April 2018 leading
    to ­inpatient treatment. She also conceded that in 2019, she
    became “very depressed and tried to commit suicide” and as a
    result was hospitalized. According to Cindy, she was hospital-
    ized three times in 2020 due to her mental health, with the last
    time occurring in August 2020. Koduri explained that Cindy’s
    hospitalizations were results of suicidal thinking with respect
    to grief reactions. However, Koduri observed that these were
    not suicidal attempts.
    Cindy addressed the testimony that she took Brelynn to
    doctor appointments too often. She testified that in her previ-
    ous case, the Department believed that Cindy was not meeting
    Brelynn’s medical needs adequately. She testified that Keim
    previously told her that “it is better to take your child to the
    doctor and have them tell you that it’s nothing and go home
    than for it to be something and not have taken them in.” She
    also believed that the Department and foster parents were
    ignoring signs and symptoms of Brelynn’s having urinary tract
    infections. According to Cindy, the tests for whether Brelynn
    had such an infection was noninvasive and she would often
    test positive.
    Cindy also testified as to the impact of therapy with Brelynn.
    According to Cindy, Brelynn preferred McCoy because the
    style of therapy was more conducive to their relationship. She
    explained that there were a number of cancellations for her
    therapy appointments with Byrns. She explained about an inci-
    dent where Byrns canceled the day of the appointment, which
    upset Brelynn. Cindy explained that when the COVID-19 pan-
    demic occurred, Byrns was unable to conduct therapy sessions
    because of technology issues. She acknowledged that there
    were difficulties in establishing her relationship with Byrns
    after leaving McCoy as a therapist. However, she believed
    these difficulties were because of Brelynn’s struggles to transi-
    tion from McCoy to Byrns.
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    On January 29, 2021, the county court entered its exten-
    sive order terminating Cindy’s parental rights to Brelynn. The
    court determined that the State presented clear and convincing
    evidence to substantiate terminating Cindy’s parental rights
    pursuant to § 43-292(5), (6), and (7) and that termination was
    in the best interests of Brelynn. The court noted that Cindy’s
    testimony lacked credibility, based on its observations and on
    Cindy’s having admitted to lying to individuals involved in this
    case. The court also noted that numerous witnesses testified as
    to Cindy’s lack of honesty during the case.
    The court first determined that the State had proved that
    Cindy is unable to discharge her parental responsibilities to
    Brelynn because of mental illness which will continue for
    a prolonged and indeterminate period. The court found that
    Cindy’s mental health history led her to numerous inpatient
    stays, suicidal thoughts, poor judgment, and abusive and unsta-
    ble relationships. In so finding, the court noted the expert
    testimony of Meidlinger and several of the therapists who had
    provided counseling to Cindy. It noted their opinions which
    indicated that given the severity of the mental health conditions
    from which Cindy suffers together with her record of being
    unable to sustain long-term progress, meaningful improvement
    of her mental health condition could not be expected.
    The court also found that reasonable efforts to preserve and
    unify the family had been made. The court noted that three
    primary goals were identified for Cindy to achieve, those
    being a safe and suitable living environment characterized
    by a clean home and healthy relationships, the maintenance
    of mental health, and the acquisition of the ability to meet
    Brelynn’s needs. The court found that Cindy struggled with
    having healthy relationships, had not maintained stability in
    her mental health, and had not been able to consistently meet
    Brelynn’s needs. The court noted several instances of Cindy’s
    engaging in behaviors contrary to Brelynn’s needs. Therefore,
    despite significant efforts made by the Department to achieve
    reunification, Cindy had not progressed satisfactorily. Finally,
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    the court also found that Brelynn had been placed out of her
    parental home for over 16 of the past 22 consecutive months
    at the time of the State’s filing of the motion for termination
    of parental rights and had remained in out-of-home placement
    since that filing.
    The court found that it was in the best interests of Brelynn
    for Cindy’s parental rights to be terminated. The court found
    that Cindy engaged in a pattern of failing to make good deci-
    sions for herself and Brelynn. After noting that Brelynn had
    been out of Cindy’s care on three separate occasions, the court
    concluded that Cindy had not shown improvement in her par-
    enting skills and mental health. The court found that Cindy
    had not established a beneficial relationship with Brelynn. The
    court explained that Cindy struggled to compose herself in
    engaging with professionals and that there were concerns she
    did not focus on Brelynn’s needs. The court determined that
    based on the testimony of Brelynn’s therapists, Brelynn’s emo-
    tional development and social development were lagging due to
    Cindy’s inability to find mental stability and appropriately pri-
    oritize Brelynn’s needs. The court noted the opinions of McCoy
    and Byrns, who testified they believed that Brelynn’s anxiety
    and stressors would resolve with consistent support, but found
    that Cindy was unwilling or unable to provide that support.
    Cindy now appeals to this court.
    ASSIGNMENTS OF ERROR
    Cindy’s assignments of error, consolidated, reordered, and
    restated, are that the county court erred when it denied Gaedeke
    placement of Brelynn during the pendency of the case, when
    it did not hold a hearing on Cindy’s motion for an excep-
    tion, and when it allowed the testimony of Amy. In addition,
    Cindy assigns that the county court erred when it found that
    the State proved by clear and convincing evidence statutory
    grounds to justify the termination of her parental rights and
    that it was in the best interests of Brelynn for her rights to
    be terminated.
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    STANDARD OF REVIEW
    [1] Juvenile cases are reviewed de novo on the record, and
    an appellate court is required to reach a conclusion independent
    of the juvenile court’s findings; however, when the evidence is
    in conflict, an appellate court may consider and give weight to
    the fact that the trial court observed the witnesses and accepted
    one version of the facts over the other. In re Interest of A.A. et
    al., 
    307 Neb. 817
    , 
    951 N.W.2d 144
     (2020).
    ANALYSIS
    Denial of Placement.
    Cindy argues that the county court erred in not plac-
    ing Brelynn with Gaedeke during the pendency of the case,
    because she requested placement of Brelynn and it is the
    Department’s policy to prioritize placement of a child with
    family members.
    [2] However, we do not reach this assignment of error upon
    appeal. After Gaedeke had asked for Brelynn to be removed
    from her home, Gaedeke sent an email requesting only that
    she be considered for placement in the event that Cindy’s
    parental rights were terminated. Gaedeke later filed a com-
    plaint to intervene; however, her complaint to intervene was
    filed after the State sought termination and reiterated only
    that should Cindy’s rights be terminated, she wished to be
    considered for Brelynn’s permanent placement. She did not
    request temporary placement of Brelynn during the pendency
    of the case, nor did she petition the court for temporary place-
    ment. There was no pending motion in front of the county
    court asking the court to consider Gaedeke as a placement for
    Brelynn. As such, the court was never asked to consider plac-
    ing Brelynn with Gaedeke during the pendency of the proceed-
    ings. An appellate court will not consider an issue on appeal
    that was not presented to or passed upon by the trial court.
    In re Guardianship & Conservatorship of J.F., 
    307 Neb. 452
    ,
    
    949 N.W.2d 496
     (2020). Accordingly, we do not address this
    assignment of error.
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    Exception Hearing.
    Cindy argues that Brelynn was in the care of the State for
    more than 15 of the most recent 22 months before the State
    filed its petition and that she filed an exception because she
    needed more time to accomplish the goals contained within her
    case plan. She then argues she is entitled to a hearing on her
    motion for an exception under 
    Neb. Rev. Stat. § 43-292.03
    (1)
    (Reissue 2016). Cindy is correct insofar as she argues that
    the statutory language of § 43-292.03(1) mandates a hearing.
    However, we find no prejudice to Cindy by the court’s not hav-
    ing an exception hearing.
    Briefly, we review the relevant statutory language regarding
    an exception hearing. Under subsection (1) of § 43-292.02, a
    petition shall be filed on behalf of the State to terminate the
    parental rights of a juvenile’s parents if a juvenile has been
    in foster care under the responsibility of the State for 15 or
    more months of the most recent 22 months. Subsection (3) of
    § 43-292.02 provides that the petition is not required to be filed
    if the child is being cared for by a relative; the Department has
    documented in the case plan or permanency plan a compel-
    ling reason for determining that filing the petition would not
    be in the best interests of the child; or the family of the child
    has not had a reasonable opportunity to avail themselves of
    the services deemed necessary in the case plan or permanency
    plan approved by the court if reasonable efforts to preserve and
    reunify the family are required.
    Section 43-292.03(1) states that within 30 days after the
    15-month period under subsection (1) of section 43-292.02,
    the court shall hold a hearing on the record and shall make a
    determination on the record as to whether there is an exception
    under subsection (3) of § 43-292.02 in the particular case. If
    there is no exception, the State shall proceed as provided in
    subsection (1) of § 43-292.02.
    [3-6] The Nebraska Supreme Court has explained that the
    purpose of an exception hearing is to determine whether the
    State may be excused from the mandatory requirement of
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    § 43-292.02(1) that it file a petition to terminate parental rights
    under certain circumstances. In re Interest of Clifford M. et
    al., 
    261 Neb. 862
    , 
    626 N.W.2d 549
     (2001). Under certain cir-
    cumstances, the State is generally required to file a petition
    to terminate the parental rights of the child’s parents, subject
    to the outcome of the exception hearing. See 
    id.
     If the court
    determines that a statutory exception does not exist under
    § 43-292.02, then the State is required to file the petition. See
    id. However, if a statutory exception under § 43-292.01 exists,
    then the State is not required to file the petition but may do
    so anyway. See id. The Supreme Court further explained that
    a parent’s due process rights are not deprived just because an
    exception hearing has not been held. See id. Instead, when there
    is a full opportunity to appear and present defenses at a hearing
    regarding the termination petition, a court does not deprive the
    parent’s due process rights. The court found that although an
    exception hearing may afford a basis for relieving the State of
    its statutory obligation to file a petition to ­terminate parental
    rights, no language in either § 43-292.02 or § 43-292.03 pre-
    vents the State from petitioning to terminate parental rights.
    See In re Interest of Clifford M. et al., supra.
    Cindy is correct insofar as there was no exception hearing in
    the present case despite the mandatory directive of the statute.
    However, the State may choose to file the termination petition
    after the 15-month period regardless of the outcome of the
    exception hearing. At the termination trial, the State presented
    evidence that Cindy was unable to make progress on her case
    plan goals despite the length of time the case was pending.
    The State also asserted that termination of Cindy’s parental
    rights was appropriate because Cindy was unable to discharge
    her parental responsibilities due to her mental health or mental
    deficiencies. It is reasonable to infer that even if there was an
    exception hearing and an exception had been found, the State
    would have chosen to file the termination petition rather than
    allow Cindy additional time to work toward reunification.
    Additionally, because, in the present case, there was a full
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    hearing on the termination petition and Cindy had an opportu-
    nity to appear and present defenses, Cindy’s due process rights
    were not implicated. Therefore, we find no error in the court’s
    decision not to hold an exception hearing.
    Investigator Amy’s Testimony.
    Amy testified about the investigation that he and law enforce-
    ment conducted with respect to Kamdyn’s death at Cindy’s
    residence. Prior to his testimony, Cindy objected because the
    deputy county attorney prosecuting the case was married to
    Amy. Cindy asserted the doctrine of affinity and oneness as
    a basis for her challenge. The county court took the objec-
    tion under advisement and allowed Amy to testify. Cindy later
    argued that the basis of her objection was that there was a
    conflict of interest in having the prosecuting attorney question
    her own husband. Cindy argued that Amy’s testimony should
    have been stricken. The court found that the objection to the
    testimony of the witness was not a proper remedy; rather, the
    proper remedy would be a motion to disqualify the prosecutor.
    The court also noted that a motion to disqualify the prosecut-
    ing attorney was not made. As a result, the court overruled the
    motion to exclude Amy’s testimony. On appeal, Cindy reiter-
    ates her argument that there was a conflict when Amy testified
    while married to the prosecuting attorney. She asserts that the
    court erred when it allowed Amy to testify. However, she now
    asserts in the alternative that the prosecuting attorney should
    have been recused.
    The issue of whether the prosecuting attorney should have
    voluntarily recused herself is not properly before us. An appel-
    late court will not consider an issue on appeal that was not pre-
    sented to or passed upon by the trial court. In re Guardianship
    & Conservatorship of J.F., 
    307 Neb. 452
    , 
    949 N.W.2d 496
    (2020). The initial objection and the argument before the
    county court focused on whether the testimony was admis-
    sible. Only upon appeal does Cindy now argue that the pros-
    ecuting attorney should have recused herself from the case.
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    Accordingly, we do not address whether there was error in
    that regard.
    Cindy does not provide any case law to support her argu-
    ment that Amy’s testimony was inadmissible due to his rela-
    tionship with the prosecuting attorney. Our review of the case
    law also does not reveal any authority on this issue. We focus
    on whether Cindy’s due process rights were violated by allow-
    ing the testimony of Amy. On the record before us in this case,
    we cannot find that Cindy suffered prejudice based on the evi-
    dence adduced. Amy’s testimony focused on the initial encoun-
    ter with Cindy and an investigation of her residence following
    Kamdyn’s death. This testimony was duplicative of evidence
    received in the form of the Department intake reports that were
    received which detailed the condition of the home and the
    events surrounding Kamdyn’s death. In other respects, it was
    duplicative of the testimony of the pediatrician who testified
    about treating Kamdyn. Therefore, we do not find that Cindy
    was prejudiced by allowing Amy to testify.
    We are troubled by the fact that the attorney called her hus-
    band to testify as a witness and more troubled by the fact that
    according to the prosecuting attorney’s statements, this is not
    the first case where she has called her husband to testify. The
    Supreme Court has long held that there should not be anything
    in the way of private interest to possibly sway the judgment of
    a prosecutor in prosecuting persons whose guilt is so doubt-
    ful or to tempt him or her to depart from a disinterested and
    conscientious discharge of his or her duty. Ress v. Shepherd, 
    84 Neb. 268
    , 
    120 N.W. 1132
     (1909). We also note that as early as
    1993, an ethics advisory opinion for lawyers was issued stating
    that a county attorney whose spouse is a police officer should
    not personally prosecute any case in which his or her spouse
    will be called as a witness. See Neb. Ethics Adv. Op. No. 93-5
    (1993). Given the prosecuting attorney’s statements during the
    case that she has worked on many cases where her husband has
    testified, we note that it would be the better practice for the
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    attorney to recuse herself in such cases in order to foreclose
    any questions of impropriety.
    However, pursuant to the specific facts of this case, we do
    not find that there was any prejudicial error to Cindy by virtue
    of the court’s decision to receive Amy’s testimony. Therefore,
    we find this assigned error to be without merit.
    Statutory Grounds.
    [7] Cindy argues that the county court erred in finding the
    State proved by clear and convincing evidence that statutory
    grounds existed to terminate her rights. For a juvenile court to
    terminate parental rights under § 43-292, it must find that one
    or more of the statutory grounds listed in this section have been
    satisfied and that such termination is in the child’s best inter-
    ests. In re Interest of Becka P. et al., 
    27 Neb. App. 489
    , 
    933 N.W.2d 873
     (2019). The State must prove these facts by clear
    and convincing evidence. 
    Id.
    [8] The county court found that the State presented evidence
    to satisfy § 43-292(5), (6), and (7). Section 43-292(7) allows
    for termination when the juvenile has been in an out-of-home
    placement for 15 or more months of the most recent 22 months.
    It operates mechanically and, unlike the other subsections of
    the statute, does not require the State to adduce evidence of
    any specific fault on the part of a parent. In re Interest of Becka
    P. et al., supra. In a case of termination of parental rights based
    on § 43-292(7), the protection afforded the rights of the parent
    comes in the best interests step of the analysis. In re Interest of
    Becka P. et al., supra.
    [9] Cindy concedes that Brelynn had been out of the home
    for 15 of the most recent 22 months at the time the motion to
    terminate parental rights was filed; nevertheless, she argues that
    an exception should be provided to the “‘hard and fast’” cal-
    culation of the timeframe. Brief for appellant at 40. However,
    the proper application of § 43-292(7) consists of counting the
    most recent 22 months preceding the filing of the petition to
    terminate parental rights, followed by counting how many of
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    those 22 months the child was in out-of-home placement. In
    re Interest of Kindra S., 
    14 Neb. App. 202
    , 
    705 N.W.2d 792
    (2005). Here, Brelynn was removed from Cindy’s residence in
    November 2018. At no time was she returned to Cindy’s care.
    The State filed its motion for termination of parental rights on
    March 11, 2020, and the termination trial was held between
    September 10 and December 10. When the motion for termina-
    tion was filed, Brelynn had been out of the home for about 16
    months. By the last day of trial, Brelynn had been out of the
    home for over 24 months. Accordingly, we find no error in the
    county court’s determination that the State had proved the nec-
    essary elements of § 43-292(7).
    [10] Section 43-292 provides 11 separate conditions, any
    one of which can serve as the basis for termination when cou-
    pled with the evidence that termination is in the best interests
    of the child. In re Interest of Sir Messiah T. et al., 
    279 Neb. 900
    , 
    782 N.W.2d 320
     (2010). Because we conclude that the
    State presented clear and convincing evidence that grounds to
    terminate existed under § 43-292(7), we need not address the
    other statutory grounds.
    Best Interests.
    [11] Cindy also argues that the county court erred in find-
    ing that it was in Brelynn’s best interests to terminate Cindy’s
    parental rights. In addition to proving a statutory ground, the
    State must show that termination of parental rights is in the
    best interests of the child. In re Interest of Becka P. et al.,
    supra. A parent’s right to raise his or her child is constitution-
    ally protected; so before a court may terminate parental rights,
    the State must show that the parent is unfit. Id. There is a
    rebuttable presumption that the best interests of the child are
    served by having a relationship with his or her parent. Based
    on the idea that fit parents act in the best interests of their
    children, this presumption is overcome only when the State has
    proved that the parent is unfit. Id.
    [12,13] The term “unfitness” is not expressly used in
    § 43-292, but the concept is generally encompassed by the
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    fault and neglect subsections of that statute, and also through
    a determination of the child’s best interests. In re Interest of
    Kendra M. et al., 
    283 Neb. 1014
    , 
    814 N.W.2d 747
     (2012).
    In the context of the constitutionally protected relationship
    between a parent and a child, parental unfitness means a per-
    sonal deficiency or incapacity which has prevented, or will
    probably prevent, performance of a reasonable parental obliga-
    tion in child rearing and which caused, or probably will result
    in, detriment to the child’s well-being. 
    Id.
    [14] The best interests analysis and the parental fitness anal-
    ysis are fact-intensive inquiries. And while both are separate
    inquiries, each examines essentially the same underlying facts.
    In re Interest of Becka P. et al., 
    27 Neb. App. 489
    , 
    933 N.W.2d 873
     (2019). In proceedings to terminate parental rights, the law
    does not require perfection of a parent; instead, courts should
    look for the parent’s continued improvement in parenting skills
    and a beneficial relationship between a parent and a child.
    
    Id.
     In cases where termination of parental rights is based on
    § 43-292(7), the Supreme Court has held that appellate courts
    must be particularly diligent in their de novo review of whether
    termination of parental rights is in fact in the child’s best inter-
    ests. In re Interest of Becka P. et al., supra.
    We first note that Brelynn has been removed from Cindy’s
    care on three separate occasions, including the present case.
    Following Wesley’s sexual abuse of Brelynn, Cindy volun-
    tarily allowed removal of Brelynn from her residence. Despite
    the fact that Cindy believed Wesley was sexually abusing
    Brelynn, he continued to reside with Cindy for a period of
    time thereafter. Brelynn was removed the second time because
    there were concerns regarding an unsanitary home, Cindy was
    leaving Brelynn with inappropriate individuals, and Cindy
    was struggling with her mental health. Although the first two
    removals resulted in reunification, the same issues surfaced
    in the present case. Law enforcement reported an unsanitary
    home, including that there was medicine in reach of Brelynn
    and that the home smelled of feces and urine. One’s history
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    as a parent speaks to one’s future as a parent, and past parent-
    ing outcomes should not be ignored. See In re Interest of Sir
    Messiah T. et al., 
    279 Neb. 900
    , 
    782 N.W.2d 320
     (2010).
    The evidence demonstrated that Cindy continued to struggle
    with her mental health. She reported that she has been suffer-
    ing auditory and visual hallucinations for more than 12 years
    and acknowledged recurring instances of deterioration requir-
    ing hospitalization. Although she believes that she is making
    progress in resolving her mental health issues, the county court
    found that she lacked credibility, and the remaining evidence,
    including the testimony of numerous mental health practition­
    ers, showed that she continued to struggle. On appeal, we give
    weight to the fact that the lower court observed the witnesses
    and accepted one version of the facts over the other. In re
    Interest of Lisa W. & Samantha W., 
    258 Neb. 914
    , 
    606 N.W.2d 804
     (2000).
    Cindy has been hospitalized over 20 times regarding her
    mental health issues, most recently in August 2020. These
    hospitalizations have occurred due to anxiety attacks and,
    more troubling, suicidal thoughts. The evidence at trial showed
    that following Kamdyn’s death, Cindy’s and Brelynn’s mental
    health became linked. When Cindy would struggle with main-
    taining her mental health, Brelynn would likewise struggle.
    Cindy understood the importance of the principles that she
    learned in therapy but repeatedly struggled to implement these
    principles. Brelynn would act as a caregiver to Cindy during
    Cindy’s periods of decompensation, a scenario not healthy for
    either Brelynn or Cindy.
    The mental health struggles led to physical symptoms in
    Brelynn. Cindy’s inability to have stability in her mental health
    led Brelynn to demonstrate controlling behaviors. These con-
    trolling behaviors included her being constipated to the point
    where she needed to be in the hospital for an invasive proce-
    dure. According to McCoy, if Brelynn had stability in her life,
    her controlling behaviors would abate. This is corroborated by
    the testimony of Brelynn’s foster parents, who testified that
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    Brelynn’s controlling behaviors were tempered after not hav-
    ing visitations with Cindy. In addition, Cindy’s mental health
    issues, including narcissism, led her to take Brelynn to doctor
    appointments more frequently than she should.
    The testimony from the foster parents demonstrated that
    Brelynn has thrived while outside of Cindy’s care. The foster
    parents testified that when they took Brelynn to doctor or den-
    tist appointments without Cindy, Brelynn would not be anx-
    ious. It was only when Cindy also attended that Brelynn would
    become agitated about attending these appointments. After
    returning from visits with Cindy, Brelynn regressed in her abil-
    ity to be toilet trained. She also returned from visits in dirty
    clothes or inappropriately dressed. Although different thera-
    pists testified that Cindy and Brelynn have a bond together,
    they also testified that Cindy struggled with being able to care
    for Brelynn or put Brelynn’s needs above her own.
    Not all of the evidence is negative toward Cindy. Evidence
    was adduced which demonstrated that Cindy made efforts
    toward self-improvement and in her parenting skills. Unfortu­
    nately, those efforts have not resulted in her becoming capable
    of being able to satisfy her parental obligations and provide for
    Brelynn’s well-being on a consistent basis. The testimony of
    Cindy’s caseworkers, counselors, and support workers estab-
    lished that Cindy would remain in need of significant assist­
    ance for an indeterminate period of time and that she was not
    appreciably closer to having the ability to meet her parental
    obligations as of the time of trial. At the time of trial, Brelynn
    had been out of the home for over 2 years. Children cannot,
    and should not, be suspended in foster care or be made to
    await uncertain parental maturity. In re Interest of Jahon S.,
    
    291 Neb. 97
    , 
    864 N.W.2d 228
     (2015). Termination of Cindy’s
    parental rights, therefore, is in Brelynn’s best interests, as it
    will prevent her from further languishing in foster care while
    awaiting Cindy’s uncertain ability to attain the skills necessary
    for parental maturity.
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    CONCLUSION
    Based on the foregoing, we conclude that the county court
    did not err by not holding an exception hearing or by receiving
    Amy’s testimony. Since there was no request during the pend­
    ency of the case to have Brelynn placed with Gaedeke prior
    to termination of Cindy’s parental rights, we do not address
    this assignment of error. We also conclude that the State proved
    that grounds for termination of her parental rights existed
    under § 43-292(7) and that their termination was in the best
    interests of Brelynn. Accordingly, we affirm the order of the
    county court.
    Affirmed.