Legislative change is required to protect children from corporal punishment

Paddling of children in the United States of America

Sadly, I’m not talking about the type of paddling traditionally done at the seaside.


You might think that spanking (smacking, as we would call it in the UK) and paddling (striking the buttocks with a wooden paddle) were punishments of a bygone era in schools, but not so here in the United States. I have been stunned to learn that physical punishment of children in schools is still permitted in many areas of the United States despite many decades of research showing that:

  • Children who are physically punished are at greater risk of serious injury and physical child abuse
  • Physical punishment of children puts them at risk of negative outcomes including mental health problems
  • Physical punishment of children makes it more likely that they will be defiant and aggressive in the future


Physical punishment
Physical punishment is the use of physical force with the intention of causing the child to experience bodily pain or discomfort so as to correct or punish the child’s behaviour. Physical punishment, often used interchangeably with corporal punishment, includes slapping, spanking or smacking and hitting with a hard object – such as a wooden paddle (often 60 cm long, 7.5 cm wide and over 1 cm thick), but it can also include things such as washing a child’s mouth out with soap and water, making a child kneel on sharp or painful objects, forcing a child to sit or stand in painful positions for a long period of time or compelling a child to engage in excessive exercise or physical exertion. Physical punishment is, thus, very different from physical restraint – that which is necessary to protect a child from self-harm or harming others.

Throughout the last two and a half weeks in the United States I have been particularly interested in the work of Dr Elizabeth Gershoff, in conjunction with Phoenix Children’s Hospital, into physical punishment in the United States.

Here in the United States nearly two thirds of parents of very young children reported using physical punishment and in schools many children continue to receive physical punishment in the form of paddling (up to three strikes on the buttocks by a wooden paddle). During 2009 over two hundred thousand children are estimated to have received physical punishment in schools in the United States and although this decreased from over a quarter of a million children during the 2004-2005 school year (where Mississippi, for example, physically punished over 45000 students and Texas physically punished over 57000 students) it is still a worryingly high number.


In some districts in Texas, for example, parents are asked, on enrolment of their child in school, whether physical punishment (paddling) of the child is to be allowed by the parent. A form must be completed with three options:

  • Yes, physical punishment of my child is allowed
  • No, physical punishment of my child is not allowed
  • Yes, physical punishment of my child is allowed but you must contact me first to discuss (allowing the parents the final decision or, in some cases, facilitating the parents attending the school to administer the physical punishment themselves or to administer the punishment at home)

Those people who I spoke to who have delivered physical punishment in schools are acting in accordance with the policy of the organisation that they work for and in accordance with the law. They believed, as did some parents I spoke to, that for some children paddling is the only effective deterrent from poor behaviour or punishment for any such behaviour that may occur.


What about the research?
Research has demonstrated that parents are more likely to use physical punishment if:

  • They strongly favour it and believe in its effectiveness
  • They were physically punished as children
  • They have a cultural background (for example religion, ethnicity, country of origin) that they perceive approves of the use of physical punishment
  • They are socially disadvantaged (for example low income, low level of education or living in a socially deprived area)
  • They report being frustrated or aggravated with their children on a regular basis
  • The child is under the age of 5 years
  • They are experiencing stress (such as financial hardship, relationship conflict), adverse mental health symptoms or low emotional well-being

However, the more parents use physical punishment the more aggressive their children become over time even when controlling for their initial levels of aggression, the frequency or severity with which children experience physical punishment is associated with increased childhood mental health problems and physical punishment is associated with poorer quality parent-child relationships.

Children who are physically punished are at risk of significant harm with those that have been smacked by their parents being seven times more likely to be seriously assaulted (for example punched or kicked) than those who have not been physically punished and 2.3 times more likely to suffer an injury requiring medical attention than those who have not been smacked.

There are a number of reasons that have been hypothesised as to why physical punishment is not effective as a disciplinary technique including that:

  • It does not teach children why their behaviour was wrong or what they should do instead
  • It teaches children that they should behave in certain ways or risk physical punishment if they do not, rather than teaching them the important, positive reasons for behaving appropriately
  • It indicates to children that it is acceptable to use physical force and aggression against another person
  • It can increase the likelihood of children behaving aggressively themselves in other social interactions
  • It may teach children to link violence with a relationship that is supposed to be built on the foundation of love


Worldwide perspective
A number of countries around the world have already prohibited physical punishment of children in all settings. For example:

Area Law
Sweden Children are to be treated with respect for their person and individuality and may not be subjected to corporal punishment or any other humiliating treatment(Parenthood and Guardianship Code, 1983)
Finland A child shall be brought up in the spirit of understanding, security and love. He shall not be subdued, corporally punished or otherwise humiliated(Child Custody and Rights of Access Act, 1983)
Norway The child shall not be exposed to physical violence or to treatment which can threaten his physical or mental health(Parent and Child Act, 1987)
Austria The use of force and infliction of physical or psychological suffering are not permitted(Section 146a, General Civil Code, 1989)
Denmark A child has the right to care and security. He or she shall be treated with respect as an individual and may not be subjected to corporal punishment or other degrading treatment(Parental Custody and Care Act, 1997)
Latvia Cruel treatment or a child, physical punishment and offences against the child’s honour and respect are not allowed(On Children’s Rights Protection, 1998)
Germany Physical punishment, the causing of psychological harm and other degrading measures are forbidden(Civil Law, 2000)
Ukraine Physical punishment of the child by the parents as well as other inhuman or degrading treatment or punishment are prohibited(Family Code of Ukraine, Article 150[7])
The Netherlands In the care and upbringing of the child the parents will not use emotional or physical violence or any other humiliating treatment(Article 1:247 of the Civil Code, 6 March 2007)
Costa Rica Parental authority confers the rights and imposes the duties to orient, educate, care, supervise and discipline the children, which in no case authorises the use of corporal punishment or any other form of degrading treatment against the minors(Article 143, Family Code, June 2008)


Within Europe the Council of Europe, Parliamentary Assembly Recommendation 1666 (2004) has stated that:

The Assembly considers that any corporal punishment of children is in breach of their fundamental right to human dignity and physical integrity. The fact that such corporal punishment is still lawful in certain member states violates their equally fundamental right to the same legal protection as adults. Striking a human being is prohibited in European society and children are human beings. The social and legal acceptance of corporal punishment of children must be ended.


What about back in the UK?

Parents have not been explicitly prohibited from smacking their children. However, section 58 of the Children Act 2004 limited the use of the defence of reasonable punishment so that parents and those acting in loco parentis who cause physical injury to their children can no longer use the ‘reasonable punishment’ defence where they are charged with assaults occasioning cruelty, actual or grievous bodily harm. The defence of ‘reasonable punishment’ is only available to parents, or others acting in loco parentis (provided they are not expressly prohibited from using physical punishment, for example in schools), where the charge is one of common assault.

Physical punishment is prohibited in all maintained and full-time independent schools, in children’s homes, in local authority foster homes and Early Years provision. Section 58 of The Children Act 2004 limits the defence of Reasonable Punishment as follows:


(1)  In relation to any offence specified in subsection (2), battery of a child cannot be justified on the ground that it constituted reasonable punishment.

(2)  The offences referred to in subsection (1) are –

(a) an offence under section 18 or 20 of the Offences against the Person Act 1861 (c. 100) (wounding and causing grievous bodily harm);

(b) an offence under section 47 of that Act (assault occasioning actual bodily harm);

(c) an offence under section 1 of the Children and Young Persons Act 1933 (c. 12) (cruelty to persons under 16).

(3)  Battery of a child causing actual bodily harm to the child cannot be justified in any civil proceedings on the ground that it constituted reasonable punishment.

(4)  For the purposes of subsection (3) “actual bodily harm” has the same meaning as it has for the purposes of section 47 of the Offences against the Person Act 1861.

(5)  In section 1 of the Children and Young Persons Act 1933, omit subsection (7).


Effectively, physical punishment is illegal if it leaves a mark on a child or an implement (such as a cane or belt) is used to physically punish the child. A review of Section 58 of the Children Act 2004 took place in 2007 and it was concluded that no further changes were necessary.

I, however, remain concerned that Section 58 of the Children Act 2004 is not consistent with Article 19 of the United Nations Convention on the Rights of the Child as surely any physical punishment of a child constitutes physical violence and should, within our own legislative system, be classified as at least Common Assault.

An offence of Common Assault is committed when a person either assaults another person or commits a battery. An assault is committed when a person intentionally or recklessly causes another to apprehend the immediate infliction of unlawful force. A battery is committed when a person intentionally and recklessly applies unlawful force to another.


Why am I writing about corporal punishment?

In a research study designed to look at child protection and emergency medicine in the United States to see what we can learn back in the UK, why have I decided to write about corporal punishment?

Firstly, smacking of a child by a parent is still legal in the UK and secondly a number of children who attend emergency departments in the UK will have been physically punished by their parent(s).

Given the above risk factors for parents who are more likely to use physical punishment on their children and given the risks that this poses to the children concerned clinicians need to be vigilant to look out for signs that any such punishment was not reasonable, or to carefully consider whether the risks of a particular situation are significant enough that the child in question is at risk of significant harm and that such harm is greater than the harm already caused by a law which permits parents to physically punish their children at the current time.

Regardless of whether there is a statistically significant association or not between deaths from child maltreatment and the legal corporal punishment situation in a particular reason, it strikes me that if we are to succeed in reducing the number of cases of child death from child abuse and the number of cases of child maltreatment, given the role that society has in protecting those children, we must begin from a stand-point of taking the moral high ground which is that it is unacceptable to physically punish children, whatever the circumstances, and that there are much more effective and appropriate punishments to administer.

The position of a society where physical punishment of children is permitted yet child abuse is forbidden is no longer a tenable one. Reducing the number of cases of child abuse must begin with a clear message from society that physical punishment of children, whatever the circumstances, is unacceptable and that requires legislative change in a number of jurisdictions, including our own.



Crews’n Healthmobile: a beacon of good practice in holistic healthcare

Phoenix, Arizona is a city of 517 square miles and stretching 67 miles across. With a city population of around 1.5 million people and a Metropolitan Area containing 4.5 million people, Phoenix is the 6th most populous city in the United States of America.

Over 8000 children and young people aged 14-24 years are homeless in Phoenix each year. Regardless of the demographics of these individuals all of them are at increased risk of illness (both physical and mental), injuries, exploitation, sexual exploitation, trafficking and all other forms of abuse. Most of them lack health insurance and don’t have access to appropriate health care.

In 2000, an innovative partnership was formed between Phoenix Children’s Hospital, Children’s Health Fund and HomeBase Youth Services resulting in the Crews’n Healthmobile, a 35-foot Mobile Medical Unit (MMU) that brought free, comprehensive medical help directly to this special population living in Phoenix.

In October 2007, the Crews’n Healthmobile II hit the streets. This 38-foot MMU has three examination rooms and the latest technology to be able to provide point of care testing and link to the individual electronic patient record.


100% of the children and young people living on the streets of Phoenix are below the Federal poverty line. It is all too common for them to pay for food or a place to stay with sex as this may be the only ‘resource’ this incredibly vulnerable group of people have available to them. The Crews’n Healthmobile is a fantastic non-judgmental resource which takes free and comprehensive healthcare directly to the children and young people in whichever area of the city they may currently be in.

In addition to the mobile unit, Crews’n staff manage the UMOM Wellness Center on the campus of UMOM New Day Family Shelter. This shelter accepts people in family units of whatever they consider their family to be. The Center is non-judgmental and does not discriminate against people because of the family situation that they are living in. A significant number of the people using this service have substance misuse problems, have limited, if any, financial resources and many have escaped from violent and abusive relationships. At any one time there can be up to 500 children staying overnight in this shelter and the staff have a key role in helping to protect those vulnerable young people from abuse.

20% of the adolescents in the shelter programme hear voices and at least 40% of the girls have been sexually abused prior to coming there.

Working with families ‘on the edge’ means that professionals could be in a situation where a Child Protective Services referral could be warranted on an incredibly frequent basis but because the system is overwhelmed, because they need to maintain a working relationship with the families they are there to protect, support and re-integrate, and because these professionals may be the only stability that a family, parent or young person has, the staff are continually advancing their education, skills and knowledge so that they can provide immediate help to families in crisis to de-escalate incredibly volatile situations to ensure the protection of children and to help ensure that the healthcare needs of all members of the family are assessed and addressed with a friendly and welcoming approach.

Many of the families are living in a continual state of crisis, at least during the early stages following arrival at the shelter. They live in concrete worlds with no ‘sugar coating’ and the staff have to be realistic, pragmatic and clear with them. Many of them have so many people already trying to input into their lives that they don’t know if they are ‘coming or going’. If they don’t even know where dinner is coming from that night, or even if there will be a dinner that night, it is no wonder that they find it difficult to engage with a plurality of services many of which, not least the health insurance sector, can be difficult, or impossible, to understand.

The dedication and expertise of the Crews’n staff is amazing and their collective passion to do the best they can, and to provide the highest quality of care, for the children and families they interact with, regardless of what the ‘rules or regulations’ might try to prevent, hamper or interfere with, is outstanding and they are a clear beacon of good practice in holistic healthcare. The staff I met have clear tenacity to succeed whatever barriers may be placed in their way and there are lessons for all of us in the way that they conduct themselves and the way that they stay enthusiastic and dedicated despite significantly challenging working conditions.

If the city of Phoenix were to be overlaid across the North of England, the diameter at its widest part would stretch almost from Liverpool to Leeds. The need for a mobile health unit, such as the Crews’n Healthmobile, is clear in Phoenix not just because of the geography of the city but because of the socio-economic status of many people living within it, including those who are homeless, and the difficulties many people face accessing reliable public transport to get them to and from locations where their health needs can be cared for.

The sheer size of the Crews’n Healthmobile would make it difficult to manoeuvre around many UK cities but there are parallels than can be drawn from the fantastic service that the Crews’n staff provide to the children, young people and families in Phoenix, and the kind of exemplary service that children and families deserve to receive in the UK and it has made me think about how (or if) people living in very rural areas, away from metropolitan hubs, access the same high standard of care that others have available:

  • Those people that cannot access services distant from where they are situated should, wherever possible, have services provided to them at a location they can access even if that means breaking down traditional or long-standing barriers between different parts of the health sector or the interaction between health and social care
  • Those people who may not have English as their first language, or who may not understand the intricacies of the UK health service should be guided through the processes to help them to get the best possible care from the services they access.
  • Healthcare staff are not immigration police and should not be expected, or required, to place someone’s immigration status above urgent and emergency healthcare needs
  • Clinicians seeing children and young people should, where appropriate, consider incorporating the HEADSSS questions into routine assessments and signposting or providing any services which the young person may need as a result of the answers to those questions
  • Families, children and young people with complex and multiple needs, be they health, social care or a mixture of both, need one lead person to advocate on their behalf and to simplify and streamline the services offered and provided

This has been an incredibly action packed week and I’ve met a fantastic group of doctors, nurses, forensic interviewers, social workers and research staff. The services and projects I have been taken to and shown around with extreme enthusiasm by the staff working there were not necessarily ones that I ever thought that I would be visiting before I came to Phoenix but they have provided further evidence to me that there are some clear trends emerging about the children who are at risk of abuse in the two southern States that I have visited and there are some clear lessons that we can learn and build upon back in the UK.

Tomorrow is my last day in Arizona before I move on to Pennsylvania and the sunset this evening, having climbed 2608 feet to the top, was stunning from Piestewa Peak:


I leave the south of the United States tomorrow with enthusiasm and intrigue to see what the next week in the North East of the country will hold and with grateful thanks to everyone who has made this second week in Arizona so worthwhile.


“It is easier to build strong children than to repair broken men” (Frederick Douglass, 1817-1895)

Frederick Douglass was an African-American statesman who, having escaped from slavery, became a leader of the abolitionist movement and campaigned throughout his life for equality of all people regardless of background, saying, “I would unite with anybody to do right and with nobody to do wrong”.

In 1855 Frederick Douglass had a series of dialogues with white slave-owners who could not, or would not, comprehend that slavery was morally wrong and it was during these communications that he wrote, “it is easier to build strong children than to repair broken men“.

This statement still holds true today and it is inextricably linked to issues surrounding early childhood experiences, child abuse and the development of individuals’ roles, and functioning, within society.

The Adverse Childhood Experiences (ACE) study is a collaborative research project, involving 17421 adults, between the Center for Disease Control and Prevention and Kaiser Permanente Preventative Medicine, San Diego, California (http://www.azpbs.org/strongkids/).


An ACE is growing up with one or more of the following in the household prior to age 18:

  • Recurrent physical abuse
  • Recurrent emotional abuse
  • Contact sexual abuse
  • An alcohol and/or drug abuser in the household
  • An incarcerated household member
  • Someone who is chronically depressed, mentally ill, institutionalised, or suicidal
  • Domestic violence
  • One or no parents
  • Emotional or physical neglect

You can calculate your own ACE score here (http://acestudy.org/ace_score)

Child abuse and trauma in the household leave a child incredibly vulnerable which has the potential, in early years, to disrupt the normal development of the brain. Adverse Childhood Experiences appear to be associated with a predictable path towards disease and disability. Recognising this path and tackling it at the earliest possible opportunity is crucial to give children the chance to develop as they ought to so that they can play as full a role in society in the future, in the healthiest possible state, that they deserve to.


An emerging multidisciplinary science of development supports an ecobiodevelopmental framework for understanding the evolution of human health and disease across the lifespan of an individual. Epidemiological studies, developmental psychologists and longitudinal studies of early childhood interventions have demonstrated significant associations between the ecology of childhood and a wide range of developmental outcomes and life course trajectories.

What happens in early childhood can matter for a lifetime and sadly the children of Arizona lead the nation in experiencing one or more adverse childhood experiences in the ACE study conducted in this State:

  • Living with someone who is mentally ill or who has suicidal ideation
  • Experiencing divorce or parental separation
  • Living sight someone who has an alcohol or drug problem
  • Being a victim or witness of neighbourhood violence
  • Experiencing socioeconomic hardship
  • Witnessing domestic violence
  • Having a parent in prison
  • Being treated or judged unfairly due to race or ethnicity
  • Experiencing the death of a parent

Here in Arizona, Phoenix Children’s Hospital have been spearheading a statewide ACE Consortium aimed at drawing attention to the crucial importance of ACEs and putting in place community projects to try to encourage parents to build Positive Childhood Experiences (PCEs) – protective factors that will enable children to succeed. Based on the findings of Arizona’s ACE study the following have been recommended strategies to reduce ACEs in this area and to build stronger Arizona communities:

  • Increasing public understanding of ACEs and their impact on health and well-being
  • Enhancing the capacity of families and healthcare providers to prevent and respond to ACEs
  • Improving the effectiveness of public-health campaigns by refining their messages regarding ACEs
  • Promoting identification and early intervention of ACEs through universal screening or assessment within child and family health systems

Early childhood intervention is arguably one of the best ways to improve the chances of children growing up to succeed as best they can and to have the best possible chances in life.

Vermont has already grasped the importance of combatting ACEs to build a healthy and successful society (http://acestoohigh.com) and I wonder which other States will follow suit in due course?

An individual with an ACE score of 4 has a three times higher risk of depression, is 5 times more likely to become dependent on alcohol, is 8 times more likely to experience sexual assault and is up to 10 times more likely to attempt suicide. An individual with an ACE score of 6 or higher is 46 times more likely to abuse intravenous drugs. An individual with an ACE score of 7 or higher is 31 times more likely to attempt suicide.

These are not just statistics – these are figures obtained from the longitudinal follow up of over 17000 adults and clearly show an association between adverse experiences in childhood and significant adverse outcomes during adult life.

Early experiences influence the developing brain, chronic stress can be toxic to this development, significant early adversity can lead to lifelong problems, early intervention can prevent the consequences of early adversity and stable, caring relationships are essential for health childhood development.

Tomorrow is my last working day in Arizona before I move on to Pennsylvania on Sunday. I’m spending the day with the Crews’n Healthmobile Team (http://www.phoenixchildrens.org/community/healthcare-outreach/crewsnhealthmobile) out in the community seeing the work that they are doing with the thousands of children who live on the streets of Phoenix as well as visiting a shelter for women and children, many of whom have fled from domestic violence and abusive relationships.


Thousands of young people live on the streets of Phoenix, many of whom are in desperate need of medical treatment being at risk of illness, injury, adverse mental health and all forms of abuse. Since 2007 the Crews’n Healthmobile 38-foot long Mobile Medical Unit, equipped with three examination rooms, has been able to bring free, comprehensive medical help to this vulnerable group of young people to try and provide them with the healthcare that they need as well as the support that they deserve to re-integrate them into society. Hopefully a society that cares for them more than the situation which led these vulnerable young people to end up on the streets in the first place.

This is not just something that affects children living in Phoenix. It is not restricted to children living in Arizona. It is not only about children living in the United States of America. There is a lesson and a message for all of our societies buried in this. Adverse Childhood Experiences have a terribly deleterious effect on children’s lives. Living in households where domestic abuse and violence are the norm has a significant and adverse effect on the development and mental health of children. Suffering from abuse, be it physical, emotional, sexual, exploitative, trafficking or neglect, can have a profound effect on the emotional well-being of children and their ability to grow up and realise their true potential as the future of our society.

It takes a community to protect a child and it is clear to me that society has a role that is more important than ever before to protect those children within it who are at risk of, or who have suffered from, significant harm. The challenge for this people and organisations responsible for resourcing societies is what weight they will place on the importance of positive childhood experiences and what resources will be provided to allow children to maximise their potential. The challenge for communities and the societies in which they function is whether or not they are prepared to accept the responsibility that society clearly has in protecting children for if they do not, and protecting children is seen as someone else’s business, how can we expect things to improve for the children who live within those communities?

Adverse Childhood Experiences certainly can last a lifetime. But they don’t have to.


Slavery in the Deep South and why our own Government ought to think more carefully about the draft Modern Slavery Bill

“The people of Texas are informed that, in accordance with a proclamation from the Executive of the United States, all slaves are free. This involves an absolute equality of personal rights and rights of property between former masters and slaves, and the connection heretofore existing between them becomes that between employer and hired labor. The freedmen are advised to remain quietly at their present homes and work for wages. They are informed that they will not be allowed to collect at military posts and that they will not be supported in idleness either there or elsewhere.”

Those were the words used by Major General Gordon Granger on 19 June 1865 when he read General Orders No. 3 to the people of Galveston effectively abolishing slavery in Texas. Following the end of the Civil War the Fourteenth Amendment to the Constitution of the United States gave equal protection under the law to all citizens. The Freedmen’s Bureau was established to assist the integration of former slaves into society in the South.

The history of slavery in the South, and the “equal but separate” legislation which stemmed from the emancipation is evident here in Texas and despite the legislation bringing an end to slavery it was not until during the next century that there was true progression towards equality.

I’ve been lucky enough to spend Easter Sunday being welcomed with open arms into a family celebration here in Texas and I’m incredibly grateful to everyone who has made me feel at home during this weekend. I’ve been fed delicious food all day, I’ve spent the afternoon on a ranch seeing the cattle and riding a (little!) horse bareback and I’ve spent this evening at a family supper (my contribution was making Yorkshire Puddings!) discussing the differences, and similarities, between our cultures in the UK and the close-knit strong family and social community here in northern Texas near the Oklahoma State border.

As part of my tour of this part of Texas I’ve had an opportunity to discuss my project with a number of people working in the education sector as well as people who have lived here in this area for the whole of their lives. One of the things that was a particularly poignant reminder of the history here in Texas was a visit to the local cemetery. The white part of the cemetery was large with well-tended to graves scattered amongst the trees:


The black part of the cemetery was down a dirt track in a field out of sight of the main road and was much more rustic. It was a clear reminder that it was not until the relatively recent past that the laws changed to allow people to be buried in whichever part that they wished despite the laws abolishing slavery in the 19th century and the prolonged inequality which followed:



Draft Modern Slavery Bill

The word slavery conjures up strong emotions, not just here in the United States of America. Our own Government back in the UK has drafted a Modern Slavery Bill (https://www.gov.uk/government/publications/draft-modern-slavery-bill), a draft Bill which, if enacted, is aimed at exposing this hidden crime, stopping it at source, bringing more perpetrators to justice and protecting and supporting victims.

I can understand why the Home Secretary has written the foreward using striking language in order to draw clear attention to the types of crimes set out in the draft Bill. But therein lies a problem – I think the tone of the foreward sets the whole tone for the rest of the Bill and, whilst I absolutely agree that the types of crimes that are contained within it should be legislated against, using such grand language without a clear definition within the Bill of modern slavery and continued jumbling of trafficking, slavery and exploitation throughout the documents means that this Bill is too focused on the major, headline cases which would probably have reached the news anyway and it risks, by the very nature of the language used and the emphasis it places on these crimes, doing not as much as ought to be done to firstly try to prevent cases of ‘modern slavery’, secondly to promote co-operation between, and training of, agencies involved in this work and thirdly to recognise those cases (which probably form a hidden majority) where the evidential aspects fall short of being able to prove that an individual has committed a crime ‘beyond all reasonable doubt’ but the evidence is clear that on the ‘balance of probabilities’ the individual has been exploited, trafficked or subject to other forms of modern slavery or is at risk of any of these occurring.

I worry that this draft Bill is too focused on legislation designed to bring perpetrators to justice and not focused enough on the early identification of potential victims or the support that will be provided for potential (or actual) victims. It also fails to describe with sufficient clarity the definitions of some of the terms used within it including slavery and servitude themselves.

Although I understand why this title has been chosen (it is headline-grabbing, it clearly sets out how appalling this situation is and it makes clear that a tolerant and modern society would not accept such atrocities) but by the very nature of the words used I think it has the potential to mean that more subtle cases and cases where the evidence is weaker and needs more time to be considered and collated may be lost in the system as people will be very focused on the major cases which are likely to attract a lot of media attention, rather than being focused on the other cases which are probably more commonplace. Within the documents themselves there is a lack of consistency of the use of the terms ‘slavery’, ‘trafficking’ and ‘exploitation’. Unless a more consistent approach is standardised at the outset this will create confusion and will lead to cases being missed or not properly investigated. I would favour the terms ‘human trafficking’ and ‘exploitation’ to be included prominently in the title of the Bill alongside ‘slavery’. It would also be beneficial to make explicitly clear that the provisions apply to both adults and children (even though this is clearly the case) as this would be a continual reminder to professionals that people of all ages can suffer from these types of abuse.


Draft Committee Bill

The House of Lords and House of Commons Joint Committee on the Draft Modern Slavery Bill have produced a revised “Committee Bill” which is radically different from the original Government Bill that was consulted upon: (http://www.publications.parliament.uk/pa/jt201314/jtselect/jtslavery/166/166bill.pdf).


There are a number of aspects of this Committee Bill which I believe are an improvement on the Government’s original draft Bill but there is still further work to be done.


In my view the title of the Committee Bill still needs changing to include the terms “trafficking” and “exploitation” rather than just “modern slavery”. For the same reasons which applied to the Draft Government Bill I think exclusion of these two words from the title risks cases not being reported as practitioners, from all backgrounds, may not think that the cases they are dealing with meet the definition of “slavery” and may not, therefore, recognise or respond appropriately to the less ‘headline grabbing’ cases.


The pre-amble currently reads as follows:
“Make provision about slavery and human trafficking; to make provision for an Anti-Slavery Commissioner; and for connected purposes”.

I believe this needs to be changed to the following:
“Make provision about slavery, human trafficking and exploitation; to make provision for an Anti-Slavery Commissioner; and for connected purposes related to adults and children”


PART 1, Section 7(2)(a)
I would still like to see this section reference not only Section 1(1)(a) of the Protection of Children Act 1978 but also sections 1(1)(b) and 1(1)(c) such that as well as being an offence under the new Act to take, or permit to be taken, indecent photographs, or pseudo-photographs, of a child, it would also be a new offence under this new Act to distribute, show or possess with the intention to distribute or show such photographs. Whilst the person committing an offence under sections 1(1)(b) and 1(1)(c) of the Protection of Children Act 1978 may not know the child involved, I still believe that this is a form of exploitation in its broadest sense and it would be beneficial to include these additional two offences under the umbrella of a revised Draft Bill so that attention is drawn to them and so that their importance is not apparently diminished by non-inclusion.


PART 2, Sections 15(2) & 18(4)
These sections as currently written would potentially permit a person subject to a Modern Slavery Prevention Order to work with Vulnerable Adults and I therefore would like to see this section strengthened to include prohibition of work with vulnerable adults. This may need a reference to the Protection of Freedoms Act 2012 +/- Parts 2 and 3 of Schedule 4 to the Safeguarding Vulnerable Groups Act 2006.


PART 3, Section 24(1)
The mechanism by which an advocate shall be appointed needs clarification. If an advocate is appointed under the provisions set out in Subsections 5 (a) to (e) of Section 24, there ought to be reference to the need to identify, via the appropriate legal routes set out in the Children Act 1989, an alternative person who does have parental responsibility for the child in question. This reference could take the form of statutory guidance rather than primary legislation but it would be helpful as it is not clear to what extent (if any) it is anticipated that the advocate would have parental responsibility over the child when some of the responsibilities (especially those set out in Section 24(4)(b)) relate specifically to the types of activities normally carried out by someone with Parental Responsibility and in light of the statements made in Section 24(8) and 24 (11)(a).


PART 4, Section 33(1)
The current section 33(1)(d) ought to be moved to a new section 33(1)(e) and the current section 33(1)(d) replaced with, “recognition of victims” such that the new Independent Anti-Slavery Commissioner (“the Commissioner”) would be obliged to encourage best practice in the recognition of victims as well as the prevention of modern slavery and the protection of victims.


PART 4, Section 33(2)(d)
It is crucial that this section is made mandatory, not optional, so that the Commissioner would be required to provide information, education or training.


PART 4, Section 33(2)(g)
This section needs revising to, “involved in the recognition or prevention of modern slavery and protection of victims” so that the Commissioner may engage with and make recommendations to persons and organisations involved in the recognition of victims as well as the prevention of these crimes.


The new Draft Committee Bill is definitely an improvement on the Government’s initial draft but it is crucial that any further revisions of either of the Draft Bills, moving forwards, recognise that slavery is an extremely emotive issue, as is clear here in the United States, and it is also crucial that the use of the term slavery does not result in less headline-grabbing cases being missed or still un-recognised. Training and education to recognise potential cases of “modern slavery” must be mandatory and standardised and it is vital that “trafficking” and “exploitation” are more prominently featured in the title of further revisions.

A new law would be a good way to better recognise victims of trafficking, exploitation and slavery but any new law must ensure that both society as a whole as well as the professionals working within it are able to recognise and respond to cases sooner and with more efficiency and effectiveness than may be the case in some areas at the present time.

Tomorrow I’ll be leaving northern Texas and heading to Arizona. I am sure this new location will provide an interesting comparison with the large number of things I’ve seen, experienced and learned this week – things which would not have been possible without the generosity of the professionals I’ve been working with and the kindness and welcome of the family I’ve been staying with over Easter, for which I am hugely grateful.

Presidential Proclamation – April 2014 is child abuse prevention month

I spent this morning lecturing at Dell Children’s Medical Center talking about Paediatric Emergency Medicine work in the UK as well as some of the child protection cases we see through our Emergency Departments.


I particularly focussed on issues to do with substance abuse, alcohol, deliberate self harm and mental health presentations and the association is crucial to recognise – that is that some children present in this way because of previous, or on-going, abuse.

We discussed the Rochdale Child Sexual Exploitation cases (YP1-6 and YP7) and talked about the failures which allowed these cases to go on, unrecognised and unstopped, for far too long (http://www.rbscb.org/professionals/serious-case-reviews/default.aspx).

It is clear to me that, whilst there are a number of different methods of responding to alleged cases of child abuse between our different countries and there are significant differences in the way that legal cases may be handled, there are a huge number of similarities in the way that the clinical aspects of these cases present to Emergency Departments (and other facilities) and the importance of peer review of cases, shared learning from system failures and multi-professional education cannot be underestimated.

There is some great research going on here looking at very detailed analysis of children who have been through child protective services and I’m hopeful that in the future we might be able to start doing some collaborative work, at least on a small scale to begin with, that will provide a fascinating insight into the similarities and differences between two distinct geographical settings.

I was pleased to be able to attend the educational Journal club at lunchtime today – I say pleased as my experience of such events in the NHS is that they are often hurriedly put together, poorly attended and held over lunch in a seminar room or office somewhere. Not so with the event I attended today which was fully funded by the hospital and held at a local golf club. Stereotypical, I know, and the irony was not lost on me but I have to say that with a very tasty lunch inside me and a few swings of a 7 iron in between discussions of papers, I was impressed that the discussions managed to stay focussed, that the event was properly educational and that it also had a clear team-building element to it as well. And, of course, I’m now (again) very full of Tex-Mex food. I may just turn into a Taco or Slider by the time I return home!

On a more serious note, I’ve come to the USA at the right time – April 2014 is National Child Abuse Prevention Month as proclaimed by Barack Obama himself:


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In the United States of America, every child should have every chance in life, every chance at happiness, and every chance at success. Yet tragically, hundreds of thousands of young Americans shoulder the burden of abuse or neglect. As a Nation, we must do better. During National Child Abuse Prevention Month, we strengthen our resolve to give every young person the security, opportunity, and bright future they deserve.

We all have a role to play in preventing child abuse and neglect and in helping young victims recover. From parents and guardians to educators and community leaders, each of us can help carve out safe places for young people to build their confidence and pursue their dreams. I also encourage Americans to be aware of warning signs of child abuse and neglect, including sudden changes in behavior or school performance, untreated physical or medical issues, lack of adult supervision, and constant alertness, as though preparing for something bad to happen. To learn more about how you can prevent child abuse, visit www.ChildWelfare.gov/Preventing.

Raising a healthy next generation is both a moral obligation and a national imperative. That is why my Administration is building awareness, strengthening responses to child abuse, and translating science and research — what we know works for kids and families — into practice. I also signed legislation to create the Commission to Eliminate Child Abuse and Neglect Fatalities, and we are providing additional resources and training to State and local governments and supporting extensive research into the causes and long-term consequences of abuse and neglect.

Our Nation thrives when we recognize that we all have a stake in each other. This month and throughout the year, let us come together — as families, communities, and Americans — to ensure every child can pursue their dreams in a safe and loving home.

NOW, THEREFORE, I, BARACK OBAMA, President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim April 2014 as National Child Abuse Prevention Month. I call upon all Americans to observe this month with programs and activities that help prevent child abuse and provide for children’s physical, emotional, and developmental needs.

IN WITNESS WHEREOF, I have hereunto set my hand this  thirty-first day of March, in the year of our Lord two thousand fourteen, and of the Independence of the United States of America the two hundred and thirty-eighth.



The President says that in the USA every child should have every chance in life, every chance at happiness, and every chance at success. Of course that is true, but it really ought to be the case that wherever they live, whatever their background and whatever culture they are being brought up in, children, who are the future of our global society in its most general terms, receive the safeguarding that they deserve, the support and chances that they need and the full and unwavering protection of the State when things go wrong. It is not just in the USA that children deserve this protection but it is a tall order trying to achieve that across the board and we have to start somewhere. Why not here (https://www.childwelfare.gov/Preventing/)?

I’ve never known there to be a Government supported Child Abuse Prevention month in the UK – supported at the highest level in line with the clear public message such as that given out by the President in the USA and I can’t help but wonder what the reaction would be if we held such a similar event in the UK? I know from speaking to people outside of medicine who often want to know what it is like to be a doctor working with children that they want to hear about children getting beads stuck in their noses or ears, children who have amusing stories to explain their injuries, children who have become mobile money-boxes from swallowing coins and children who our teams have managed to grasp from the very limits of existence and who are now leading normal lives when the alternative outcome could have been a very sad one indeed. But what people don’t want to hear about is when those cases are interspersed with a potential, or actual, case of child abuse. It simply isn’t a pleasant subject to hear about and I’m sure that many metaphorical hands are put over ears at that moment.

One of the things that I have thought for quite some time is the reason that child protection and child abuse work is still, I believe, considered in many places to be a socially unacceptable thing to discuss is because it is not talked about enough. Cancer used to be the same thing many years ago – but now with really great information campaigns and public awareness, cancer is a word that is acceptable to use. I hope, in time, that child abuse will be an acceptable thing to talk about as it is only by raising awareness and getting people to think about its existence that we will have any real hope of combatting it, so that we won’t need to talk about it in such a way in the future. For combatting it is only something that society can do. We as health professionals can recognise it when it happens, we might be able to pick up warning signs which, if unaddressed, may put a child at risk of significant harm but, fundamentally, it is only society itself, through support for each other and earlier recognition of families and communities approaching crisis points, that we can really deal with the issue.

So, what would be the impact of having a Child Abuse Prevention month or event in the UK – targeted not just at professionals but on everyone in every community? An interesting idea, I think.

Child Protection Services, Texas

Eleven hours after setting off from London (due to 70mph headwind for most of the journey) I arrived in Austin, Texas. The B1/B2 visa allowed a swift passage through immigration and once I’d mastered driving an automatic on the right side of the road and dealing with multiple on-roads and off-roads linking to the IH35 and 183 I finally made it to my base for the week I’ll be spending here.

The last two days have been a fascinating insight into the way that Child Protective Services work in Texas. Last year 156 children died in Texas as a result of child abuse or neglect. The population of Texas is 26.4 million people.



Estimated figures for the UK indicate that at least one child died every week from neglect or other forms of abuse. The population of the UK is just over 63.2 million people.

So why does Texas have a much higher rate of child deaths from abuse and neglect? Or, perhaps more importantly from this project’s point of view, what has changed to make those 156 deaths, tragic as they are, the lowest number in Texas since 2000?

The answer is clearly multi-factorial but education and community awareness must play an important role – a huge amount of work is being done by the fantastic staff at the Children’s Advocacy Center in Austin, Texas, educating professionals and the public alike about recognition of potential features of child abuse so that the community and services within it can try to intervene earlier to protect those children who are at risk of significant harm. When suspected cases do occur, or when children witness violent or horrendous crimes, the Child Protection Team are on-call 24 hours a day, 7 days a week to provide the assessment, treatment and follow-up services for the child and family. Once a child has been to the center they can continue to use the services offered there for the rest of their life if they wish to.

The highly efficient Child Abuse Resource and Education Team at Dell Children’s Medical Center, Austin (http://www.dellchildrens.net/services_and_programs/child_abuse_resource_and_education_care_program) are one of the most professional teams I have had the pleasure to come into contact with. Inter-agency collaboration and networking is at the heart of what they do and, despite being a small team of clinicians (nurse practitioners and a medical director) I have witnessed the expertise that they offer and highly-skilled input that they give to cases of suspected, possible or obvious child abuse and neglect.

The warmth by which I have been welcomed into their team is very much appreciated and I’ve certainly already got several ideas, based on my experiences so far, that we can easily implement back at home which ought to help better standardise the way that discussions take place around child protection cases.

Tragedies in child protective services, such as the cases of Victoria Climbie (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf) and Peter Connelly (https://www.gov.uk/government/publications/haringey-local-safeguarding-children-board-first-serious-case-review-child-a) are not restricted to the UK and I cannot help but think that the equally tragic death of Christopher Wohlers in Texas bears an unfortunate similarity to some of the aspects of the cases involving Victoria and Peter. Christopher was just 20 months old when he was beaten to death yet a week before he tragically died he was brought to a hospital, also badly beaten. In common with Victoria’s case, interagency communication difficulties were present.

A chair, dedicated to the memory of Christopher, is a permanent feature at the entrance to the purpose-built Child Protection Center in Austin:



I’ve already seen that there is much we can learn from the way that inter-agency communication takes place here in Austin and there are very simple things that we can do to ever improve the quality of the child protection care we give to children and their families.

But what of the legislative system, what is the impact of mandatory reporting on referral rates to child protective services and why is it that there is such a difference between the way that children are treated in the UK legislative system compared with that in Texas? I’ve had a real opportunity to explore some of these key issues with professionals from law enforcement services, State prosecutor services and the District Attorney’s office and, with some pondering on my part, I’ll come back to these in a future posting.

Until then, its time to go and work off the (very large, family-sized) donut I’ve just polished off! Texans don’t shy away from generous food portions…!


Press release of my project plan

Press release of my project plan


Well, the time has come! I’m sat at Heathrow Airport waiting for my flight to Austin, Texas. The flying time today will be just over 10 hours and, once I’ve picked up the car and found the hotel, it will be an early night for me before starting work first thing in the morning.

I’ve had a really good two days in Brussels and managed to network with one of the Royal College Presidents and a Professor of Paediatric Emergency Medicine from Paris – both of whom have shown great interest in the project I’m about to undertake.

I’ll have a little bit of time on the plane to put the finishing touches to the lecture I’m delivering at Dell Children’s Medical Center on Wednesday and I’m really looking forward to getting stuck in and meeting my first hosts tomorrow morning.

So, I’ll see y’all in Texas!