Wednesday, July 31, 2019

Child abuse expert witness

A Boston hospital has notified the Massachusetts medical board that it has restricted the work of a world-renowned endocrinologist criticized for espousing controversial theories as an expert witness for people accused of child abuse.

The action against Dr. Michael Holick is cited on his profile page on the board’s website under “health care facility discipline.” The listing is intended to alert members of the public who visit the site that Boston Medical Center, where Holick practices, has restricted his rights or privileges.

Last September, ProPublica and The New Yorker reported that Holick had testified in hundreds of child abuse cases worldwide and almost always blamed broken bones and other injuries on a rare genetic disorder. At the time, Boston Medical Center said that it had barred Holick from treating or evaluating children under age 13 beginning in May 2017. But Holick continued evaluating children in suspected abuse cases as part of an approved research project, and it now turns out that the discipline was not reported to the board until this past February.

A hospital spokesman, in an email last week, wrote that the filing with the medical board “is consistent with” the information it provided ProPublica last year. The spokesman, David Kibbe, also indicated that Holick is still allowed to evaluate children who participate in his research project.

The medical board requires hospitals to report disciplinary actions within 30 days of taking them. When asked about the 21-month gap between the hospital barring Holick from treating children and the report to the medical board, Kibbe responded, “We complied with our reporting obligations.” He offered no further explanation.

A spokesman for the Massachusetts Board of Registration in Medicine said the details of the hospital action against Holick are confidential.

Holick, who did not respond to calls or emails seeking comment for this story, is best known in medical research circles for pioneering work related to vitamin D. He discovered the active ingredient in the vitamin, leading to treatments for bone disease in kidney patients. He also figured out that orange juice helps the body absorb vitamin D, a finding that led to the U.S. Food and Drug Administration approving vitamin D-fortified orange juice. 

Earlier this decade, Holick began working as an expert witness in child abuse cases in the U.S. and abroad. He has consulted or testified in more than 300 cases, always on behalf of the accused. As of last September, he had never concluded that a child was abused, and he had almost always attributed the injuries to Hypermobile Ehlers-Danlos syndrome, a condition that affects the connective tissues of the skin, bones and joints and has been linked to bone fragility in adults.

The ProPublica-New Yorker article focused on a social services investigation in South Carolina that found that 3-week-old twins had allegedly been abused. The parents consulted Holick, who concluded that both babies had Ehlers-Danlos, and that fractures attributed to abuse could have been caused by bone fragility associated with the genetic condition. Nearly eight months later, one of the twins suffered a severe brain injury and the child’s father was charged with abuse to inflict great bodily injury upon a child. That criminal case is pending.

“Thousands, if not tens of thousands,” of parents worldwide have been falsely accused of fracturing their children’s bones, Holick told ProPublica last year. “It’s just terrible. I feel so sorry for these parents.”

His work has drawn rebukes from other physicians who specialize in treating patients with the genetic disorder. They cite a lack of research supporting Holick’s view that Ehlers-Danlos can cause broken bones in very young children. Holick has also been criticized for diagnosing the condition in children he didn’t examine in person.

Boston Medical Center is the teaching hospital affiliated with Boston University School of Medicine, where Holick is a longtime faculty member. A spokeswoman for the medical school said Holick remains on the faculty.

Boston University has defended Holick’s right to testify about his Ehlers-Danlos theory in court. The dean of the medical school, Karen Antman, in a letter to another physician critical of Holick, wrote that she didn’t need to know the details of his expert defense work. “As a member of the Boston University School of Medicine faculty, academic freedom allows Dr. Holick to espouse his views without censorship from the University,” she wrote.






































Courtesy of a colleague


  1. Leventhal JM, Edwards GA. Flawed Theories to Explain Child Physical Abuse: What Are the Medical-Legal Consequences? JAMA. 2017 Oct 10;318(14):1317-1318.

    Over the last 2 decades, a small number of pediatricians, radiologists, neurosurgeons, pathologists, attorneys, and journalists have advanced scientifically unsupported theories both in publications and in the courtroom to explain the findings of physical abuse of children. These individuals have not only obscured facts about child abuse but also generated controversy and confusion among both the public and the medical community about the diagnosis of child physical abuse and, in particular, the diagnosis of abusive head trauma.

    The purposes of this Viewpoint are to describe the inappropriate use of scientifically unsupported theories to explain abuse, to review some of these alternative theories, to highlight how the use of such theories can affect the outcome of child abuse cases, and, most important, to clarify that there is no significant controversy about the diagnosis of physical abuse and abusive head trauma in clinical medicine. Rather the existing controversy in the courtroom and media has been created by the use of scientifically unsupported explanations.

    Flawed explanations of child abuse fall into 3 categories. One category includes legitimate diagnoses that should be considered in the differential diagnosis of a child with injuries. These conditions might occasionally mimic abusive injuries. One example is the rare household fall that results in life-threatening injury or death. Another example is osteogenesis imperfecta, a well-defined genetic disease that predisposes to multiple fractures and is sometimes confused with abuse. Carefully obtained history, thorough physical examination, imaging studies, laboratory tests, and when appropriate, scene investigation by child protection agencies, law enforcement authorities, or both can reliably differentiate these conditions from abusive injuries.

    A second category includes other legitimate diagnoses that lack scientific support as explanations of injuries. Examples include vitamin D deficiency and Ehlers-Danlos syndrome, both of which have been used as alternative explanations for fractures due to abuse in young children. Ehlers-Danlos syndrome has emerged more recently in the courtroom and in news media accounts as an explanation for multiple fractures in infants even though evidence for this causal mechanism is lacking and any association remains a speculative hypothesis.

    The third category includes fabricated diagnoses, such as “dysphagic choking” and “temporary brittle bone disease.” Dysphagic choking has been used to explain fatal abusive head trauma, and temporary brittle bone disease has been used to explain multiple abusive fractures. Both of these are purely speculative diagnoses that lack any scientific support.

    Proponents of these flawed theories argue that alternative diagnoses can look just like physical child abuse. They argue that if an alternative diagnosis is possible then it is not possible to conclude that abuse occurred. If it is not possible to conclude that abuse occurred, then no crime has been committed and there is no need to provide child protection. Some have even suggested that the shaken baby syndrome does not exist, despite documented admissions of shaking by perpetrators of abusive head trauma whose victims died or sustained serious neurological injuries. (continued)

  2. (continued) Some of these proponents of flawed theories have written articles about abuse or abusive head trauma; however, these articles have included unproven hypotheses, case reports with omitted facts and misrepresentations, descriptions of conditions that are fallacious, and commentaries or letters without supporting evidence. Such publications have then been cited or used in court to assert that there is no evidence base to support the diagnoses of abuse and abusive head trauma.

    Some of these proponents have faculty appointments at academic medical centers, and these centers should bear responsibility for medical testimony given by their faculty. If medical faculty at these institutions testified under oath that smoking did not cause cancer or that HIV did not cause AIDS, would such testimony be tolerated?

    Although the American Academy of Pediatrics has published recommendations about expert testimony, it does not cover irresponsible testimony. Such testimony involving child physical abuse, however, was addressed by Chadwick and Krous. They stated that irresponsible testimony includes using unique theories of causation, providing unique or very unusual interpretations of medical findings, alleging nonexistent findings, misquoting flagrantly, and making false statements and deliberate omissions. Academic medical centers should consider using these criteria to set standards for medical testimony, and professional societies should do likewise.

    The US justice system is not perfect. There is reason to believe that innocent people have been wrongfully convicted of child abuse and likewise that guilty people have been acquitted. Physicians provide critically important guidance for legal decisions regarding potential abuse. The high stakes of these decisions underscore the importance for all physicians and others to base their medical testimony on solid science. The use of flawed theories has serious consequences, including failure to hold guilty parties responsible and failure to protect children at risk of returning to an abusive environment.

    Is there considerable controversy regarding the diagnosis of abusive head trauma in clinical medicine as opposed to the courtroom? The short answer is no. In 2009, the American Academy of Pediatrics published a statement advising pediatricians to use “‘abusive head trauma’ rather than a term that implies a single injury mechanism, such as shaken baby syndrome, in their diagnosis and medical communications.” The statement confirmed that abusive head trauma was a valid diagnosis and that injury mechanisms include shaking alone, blunt impact alone, or shaking and blunt impact together. Since then, additional clinical studies have appeared confirming that each of these mechanisms can cause abusive head trauma. Currently, in addition to the American Academy of Pediatrics, the World Health Organization, and the Centers for Disease Control and Prevention, many other organizations in both North America and Europe have publicly acknowledged the validity of abusive head trauma. Clearly, there is a consensus regarding the validity of abusive head trauma in clinical medicine. Studies of documented perpetrator admissions4 and of confessed abuse vs witnessed unintentional injuries confirm this consensus. The only controversy remains in the courtroom and in the media. (continued)

  3. Continued) Another concern is whether physicians who care for abused children are correctly diagnosing abusive head trauma. In a 2003 study examining the incidence of abusive head trauma, investigators identified all cases of traumatic brain injury resulting in death or admission to an intensive care unit in North Carolina among children younger than 2 years. An expert panel then reviewed these cases to determine if the correct diagnosis of inflicted vs noninflicted injury had been made. Of the 152 cases identified over 2 years, 53% were classified as inflicted injuries. Only 2 cases were reclassified by the research team; both cases had been classified by the medical examiner as “undetermined.” One was reclassified as inflicted traumatic brain injury and the other as noninflicted injury. Based on this study, abusive head trauma was correctly diagnosed and not overdiagnosed. No data were provided about cases of abusive head trauma that might have been missed.

    Physicians who care for injured children must continue to use a scientific approach and careful clinical judgment in diagnosing abuse because it is critically important to get the diagnosis right. The same scientific approach and careful clinical judgment should be used by those who have advanced scientifically unsupported explanations of the findings of abuse. Denying that abusive head trauma occurs, quoting publications that describe flawed theories as if they are scientifically supported, and using fabricated diagnoses are actions that have no place in science or medicine. Furthermore, these flawed theories have no place in law or journalism. Advocacy of theories based on misrepresentation, omission, or both makes a mockery of scientific reasoning and does a disservice to children, families, and justice.

    Physicians, researchers, academic medical centers, journalists, and legal scholars have a responsibility to repudiate scientifically unsupported theories that falsely purport to explain child abuse and abusive head trauma.

  4. Castori M. Ehlers-Danlos syndrome(s) mimicking child abuse: Is there an impact on clinical practice? Am J Med Genet C Semin Med Genet. 2015 Dec;169(4):289-92. doi: 10.1002/ajmg.c.31460. Epub 2015 Oct 9. Erratum in: Am J Med Genet A. 2016 Jul;170(7):1947.

    Ehlers-Danlos syndrome is a heterogeneous group of heritable connective tissue disorders characterized by increased fragility of various non-ossified tissues. It is usually ascertained due to abnormal skin texture, scarring complications, vascular fragility, or chronic symptoms, such as fatigue and musculoskeletal pain. Sometimes, Ehlers-Danlos syndrome remains undetected until the patient, usually in the pediatric age, shows extensive or severe mucocutaneous injuries after only minor traumas. In this scenario, the misdiagnosis of Ehlers-Danlos syndrome with child abuse is a possibility, as occasionally reported in the literature. Recently, more attention was posed by lay people between the possible association of Ehlers-Danlos syndrome and bone fragility. Literature and personal experience show a strong association between Ehlers-Danlos syndrome, generalized joint hypermobility and reduced bone mass density in older children and adults, especially fertile women. The existence of a true increased risk of fracture in Ehlers-Danlos syndrome is still a matter of debate in children and adults with little and conflicting evidence. In case of suspected child abuse, Ehlers-Danlos syndrome is certainly on the differential for bruising, especially in EDS types with marked cutaneous and capillary involvement. In suspected child abuse cases, careful examination of the index case and her/his extended family is routine, as well as exclusion of other disorders such as osteogenesis imperfecta. The hypothesis of Ehlers-Danlos syndrome as an alternative explanation for infantile fractures remains speculative.

  5. David L. Chadwick, Henry F. Krous. Irresponsible Testimony by Medical Experts in Cases Involving the Physical Abuse and Neglect of Children
    Child Maltreat. 1997;2(4):313-321.

    Irresponsible testimony by medical experts is a growing problem exemplified by three particularly egregious cases reported herein. The types of irresponsible testimony include the witness's absence of proper qualifications, use of unique theories of causation, use of unique or very unusual interpretations of medical findings, alleging nonexistent medical findings, flagrant misquoting of medical journals or widely used texts, making false statements, and deliberate omission of pertinent facts or knowledge. Criteria to qualify as an expert witness in child abuse and neglect are proposed. Finally, physicians, lawyers, and their respective professional licensing boards and societies are urged to develop a process by which such testimony is exposed, peer reviewed, and used in credentialing.