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.

In the past seven years, Holick said, he has consulted or testified as an expert witness in more than 300 child-abuse cases throughout the U.S. as well as the United Kingdom, New Zealand, Australia, Germany and Canada. In almost every case, he has made the same finding: instead of blaming any injuries on abuse, he has diagnosed the child with a rare genetic disorder, Hypermobile Ehlers-Danlos syndrome, a condition that affects the connective tissues of the skin, bones and joints. A handful of studies on adults have linked EDS to bone fragility, and Holick argues that children with the disorder have weaker bones, which can fracture from normal handling. So far, his theory is not supported by the scientific literature, but Holick is convinced that “thousands, if not tens of thousands,” of parents worldwide have been falsely accused of fracturing their children’s bones. “It’s just terrible,” he told me. “I feel so sorry for these parents.”

In all the cases he has worked on, Holick has never concluded that a child was being abused. On the rare occasions when he didn’t diagnose EDS, he attributed the bone fractures to rickets or vitamin D deficiency. Many geneticists and bone specialists find it troubling that he diagnoses EDS in nearly 100 percent of the cases he examines. According to the National Institutes of Health, EDS affects, at the most, 0.02 percent of people worldwide. The rate at which Holick diagnoses the disorder “doesn’t fall into the mathematical probability of chance,” Brad Tinkle, a clinical geneticist at Peyton Manning Children’s Hospital, in Indianapolis, said. Holick retorts that his clients don’t come to him by chance; parents contact him after doing their own research and realizing that they or their children have symptoms of EDS. He adds that he hasn’t seen a single actual abuser pretending to have EDS and contacting him in search of a “get out of jail free” card.

Holick regularly diagnoses children with EDS without seeing them in person. “I already know on the phone they have EDS,” he said, adding that he questions the parents about potential symptoms. “I almost don’t have to ask. I know the answer.”...

In 2017, he co-published an article about his EDS work in the little-known journal Dermato-Endocrinology, where he is an associate editor. (He was unable to get more prestigious medical journals to publish the study.) In the study, Holick examined the cases of 72 children who the authorities believed had been abused. He diagnosed 67 of them with EDS. In a third of the cases, he based his diagnosis on physical exams of relatives of the children, not the children themselves.

“How can you do that without an exam?” Brendan Lee, the chair of the Molecular and Human Genetics department at Baylor College of Medicine and the director of the Skeletal Dysplasia Clinic at Texas Children’s Hospital, said. He added that hypermobile EDS “is a diagnosis that is made based on a constellation of clinical findings, which you have to do by examination and history.”

Lee and several other experts said that hypermobile EDS typically cannot be diagnosed in children younger than five. Because infants are usually very flexible, they will likely score high on elements of the test given to older patients to determine hyperflexibility, a key aspect of EDS. Also, symptoms of the condition do not usually manifest until later in childhood, or even adulthood. “I would not be comfortable, ever, telling a parent that an infant has (hypermobile) EDS,” Lee said.

There are four studies that Holick consistently cites to support his conclusions. I asked Rodney Grahame, the author of two of those studies and a former president of the British Society for Rheumatology, whether he finds Holick’s theory of a link between EDS and bone fractures in infants to be reasonable. “Not at all,” Grahame responded in an e-mail. “It may ‘stand to reason’, but it is not supported by published scientific research. In adults, other factors are at play including ageing and the menopause, alcohol, smoking which are factors associated with osteoporosis that are not present in infants.”

Cristina Eller Vainicher, the lead author on another paper that Holick frequently cites, said that she can’t entirely discount his thesis, because some studies have suggested that a subset of EDS patients experience fragility fractures during childhood. Still, she wrote in an e-mail, “This does not mean that we could state all children with hypermobile EDS are at high risk of fractures.”

Holick’s credibility as an expert witness is buttressed by a formidable scientific resume, mostly related to his work on vitamin D...

Holick, who is now 72, gives talks around the world on the importance of vitamin D. He was billed as a “legend” at the most recent annual meeting of the American Association of Clinical Endocrinologists. He has published more than 500 articles in peer-reviewed journals and more than 200 reviews and book chapters. Since 2011, other scientists have cited him almost 110,000 times, making him one of the most frequently cited researchers in the world...

But Holick’s career has also been dogged by controversy. He came under fire for recommending the use of tanning beds based on research he’d done partly with funding from a foundation established by the Indoor Tanning Association, a relationship that I reported on in The Wall Street Journal. He also published a book called “The UV Advantage,” in which he urged people to soak up unfiltered sun two or three times a week. “Do not be afraid,” Holick wrote. “You are not going to die just because you go out in the sun.”...

“It seems so intuitively obvious,” he told me. “No one ever connected the dots. No one in the pediatric or child-abuse community ever made an effort to find other potential mitigating circumstances to explain these fractures, other than a rush to judgment.”

He testified in court on the family’s behalf, and the baby was returned to his parents. Word of Holick’s success began to spread. He now receives pleas for help from parents accused of abuse on almost a daily basis. Holick said he doesn’t charge for his services, though he does solicit donations for his Ehlers-Danlos research. About a quarter of the funding for his EDS research in the past four years — about $125,000 — has come from two families who had abuse charges dropped after Holick intervened in their cases, he said.

Holick is one of the most prominent and sought-after expert witnesses for the defense in child-abuse cases. He told me that about half the parents he assists end up with a positive outcome, such as getting their children back or having abuse charges dismissed. However, he has sometimes claimed a much higher success rate. “Before I started testifying in these court cases on behalf of the family 100% of these cases had been won by the prosecution,” he wrote as part of an unsuccessful plea to the editor of a medical journal to publish his study on EDS and child abuse. “Now that I am testifying on behalf of the family 90% of the cases have been won by the parents and their children have been returned to them without further incident.”...

“I truly believe you could be an angel put on this earth to show the justice and glory of the almighty,” a father from New Hampshire wrote to Holick in 2016. “The good you’re doing on this earth is amazing, incredible, inspiring, loving, noble, and even incomprehensible.”...

The mutual enmity between Holick and abuse experts at children’s hospitals is hard to overstate. Lori Frasier, the head of the Division of Child Abuse Pediatrics at Penn State Hershey Medical Center, started encountering Holick in court several years ago. Frasier told me that she was struck by Holick’s arrogance. “Maybe he is feeling like he is really, really smart and seeing something the rest of us can’t see,” she said. He might view himself as “a Copernicus of this century, or Galileo, fighting the status quo.”

Holick describes specialists like Frasier as zealots who, because of their training, see abuse behind nearly every mysterious injury that comes through the hospital door. “I naively assumed people want to be educated,” Holick said. “They don’t. They are child-abuse experts. They have to know.”

Unlike Holick, Frasier serves as an expert witness for both prosecutors and defendants, and recently testified in Nevada for a father accused of child abuse. (The father was acquitted in the case.) In May 2016, Holick appeared on a Philadelphia television station, saying that a baby’s injuries were likely the result of EDS and a vitamin D deficiency, not child abuse. Two days later, Frasier sent a concerned e-mail to Karen Antman, the dean of Boston University Medical School. “Dr. Holick makes statements regarding the infant’s medical condition that have no evidence base,” she wrote, noting that other experts had ruled out EDS in the case, and that even if the boy did have the condition there was no evidence it would make his bones fragile. “He is bringing the reputation of Boston University into disrepute.”

Antman replied with a defense of Holick and said she didn’t need to know the particulars of his expert work. “As a private citizen and a physician, Dr. Holick is entitled to provide consultative services and testify as an expert witness,” she wrote.  “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.”...

Seven months after Frasier complained to Holick’s dean, a pediatric geneticist at the Children’s Hospital at Albany Medical Center also raised concerns about him with B.U. Natasha Shur wrote in an e-mail to Holick’s department head, Alan Farwell, that Holick’s expert findings lacked scientific support. “I hope that you are interested in considering these issues, and the effect of BU and its involvement,” she wrote.’’

Nevertheless, she finds Holick’s assertions alarming. When she takes the medical histories of patients with EDS, she told me, they don’t mention frequent fractures or brittle bones. “My patients are the first ones to state, ‘I never fractured as a baby,’” she said. “They have had to deal with joint dislocations, joint pain, but as a whole have not had to deal with unexplained fractures.”...

“Academic freedom is not just about saying what you want,” John Leventhal, the medical director of the Yale-New Haven Children’s Hospital Child Abuse Program, said. In an article for the Journal of the American Medical Association last year, Leventhal and his co-authors said that academic medical centers should take some responsibility for the testimony of physicians who promote “flawed theories” in child-abuse cases. “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?” he wrote...

It wasn’t until later, after reviewing relevant literature in the field, that Sege determined that he could not validate the link between EDS and infant bone fractures. “I believe this is his firmly held belief,” Sege, who is now a professor at the Tufts University School of Medicine, said of Holick. “It is not backed by evidence.”

Still, Sege said, one comment of Holick’s unnerved him: Holick told him that he doesn’t recommend that parents in potential abuse cases test for osteogenesis imperfecta, the disease known to cause injuries that look as though they might be the result of abuse. Holick acknowledges advising against testing for the disorder. “It’s incredibly rare,” he said, and the test “will come back negative,” adding to the impression that “you are a child abuser.”

“That is a real red flag,” Sege said. “I am a doctor. I test for all things out there before I go to the thing that is my invention. I test for everything I can. It is alarming to tell someone not to get a test because it might impact your court case.”

In May 2017, Boston Medical Center banned Holick from using “its facilities to treat or evaluate patients under the age of thirteen for any reason,” the hospital said in a statement for this article. It said that its “medical leadership” made the decision, but didn’t explain why. Holick said that complaints about his child-abuse work prompted the edict...

This past January, Holick received a phone call so unsettling that he doesn’t even remember who was on the other end. The caller said that the child of a family Holick helped in an abuse case was in the hospital with a serious brain injury, and the father had been arrested.

“Look what you’ve done,” the caller said, according to Holick.

The child was one of Jenn and Robbie Ray’s twins. Officials in South Carolina had agreed to a plan to gradually reunite the family. They‘d had three weekends of unsupervised visits. Now the local newspaper featured a mug shot of Robbie Ray in orange prison garb...

But I believe that what likely happened is just like he was stating: that he was innocently swinging his child in the swing and bumped the head. Unfortunately, the pediatrician and or emergency doctor didn’t actually connect dots and didn’t realize that, if that infant or child has EDS, and if they’re having trauma, they should be more concerned about a brain bleed and not to have sent that child home.”

The explanation is, in many ways, typical of how Holick views these cases. He is quick to declare that a trivial accident has resulted in injuries that can be explained by his diagnosis, that the child has received incompetent medical care from less knowledgeable doctors and that the authorities have rushed to judgment.

Holick’s description of the incident, however, is largely inaccurate. The girl was 8 months old, not 2 years. Robbie wasn’t “innocently swinging his child in the swing.” By his account, he had strapped the baby into a motorized Fisher-Price swing, with the seat about a foot off the floor, while he sat on the couch and fed the other child. He didn’t drive the baby to the hospital; he called 911, and an ambulance took her. In a recording of that call, Robbie seems to be sobbing as he tries to awaken his unconscious daughter. “What’s wrong with her?” he asks the 911 operator. “What happened?”...

Nor could Holick’s comment that she “bumped her head” explain the damage to the rest of her body. Her right leg was broken near the thigh. A photograph from the hospital shows the infant lying on her back, with one eye swollen shut and bruises on her right eye and nose. There appears to be dried blood on her left hand.

Holick said that he called Jenn Ray to find out what happened, and that he’s confident the latest injuries weren’t caused by abuse, either, but were another complication of EDS.

Holick will be watching the Ray case from Boston. Mistakes happen in medicine, but he realizes that one high-profile misstep on his part could greatly damage his credibility.

“I’m very, very concerned this could upend this whole activity, if even one of the cases of the hundreds turns out to be a child-abuse case,” he said. But he acknowledged the possibility that the case might not turn out as he would like. “You know, these types of things are going to happen,” he said.

In another conversation, he reflected on the impact of his crusade to reunite families divided by child-abuse allegations. “To date,” he said, “almost all of the kids I helped return to parents are happy and well.”

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.