Child trafficking is a prevalent and serious problem across the United States. The consequences of child trafficking are extremely harmful, and when unidentified and untreated, can have lifelong negative and sometimes fatal results. The issue of unidentified child trafficking is due in part to the lack of awareness of the hidden nature of child trafficking and a lack of effective and evidence-based screening protocols in place throughout the United States.^1,2 This study used a comparative analysis approach to analyze qualitative data collected by the research team in order to compare child trafficking screening and identification tools being used in 26 states across the country. Based on interviews conducted with child welfare leaders in 26 states, all but two states (92% of states interviewed) reported having screening protocols in place for identifying potential victims of trafficking. States reported utilizing task forces, work groups, advisory councils, and partnerships with University researchers to inform the selection and/or design of screening tools. Common challenges to implementing screening tools included the length of the tool, lack of inclusive language, and the lack of standardized training of reporters. Implications for selection and use of screening and identification protocols are discussed and include: the use of tools with established statistical reliability and validity, the need for a more expansive range of questions addressing risk and protective factors, indicators, and direct questions, as well as the need to implement an evidence-based, structured decision-making protocol.

The fastest growing criminal industry in the world,³ human trafficking generates $9.5 billion each year in the United States alone.⁴ Human trafficking is defined as “using force, fraud, or coercion to obtain commercial sex acts or other labor or services” (p. 4).⁵ Labor trafficking, which is labor or services, through the use of force, fraud, coercion for the purpose of subjection to involuntary servitude, peonage, debtbondage, or slavery. Sex trafficking is defined as the purpose of a commercial sex act induced by force, fraud, or coercion.⁶ The recent literature shows correlations between start of victimization and younger age^7–10 and the average age of entry into commercial sexual exploitation at 13.^7,10 Thus, there is an increasing focus among research and practice on identifying and preventing child trafficking. Child trafficking includes the commercial sexual exploitation, domestic, sex trafficking, and labor trafficking of minors.¹¹ The outcomes of child trafficking are detrimental, including high rates of posttraumatic stress disorder, depression, suicidal ideation, drug addiction, and somatic symptoms,^12,13as well as complex trauma from entrapment, relocation, witnessing the abuse of others, and experiencing physical, sexual, and psychological abuse.^14.

There are some factors that put youth and child at risk for trafficking and exploitation. Based on the existing literature, these risk factors associated with child trafficking include parental drug use/selling,^15,16 youth of color,^15,17 young age ¹⁵ history of Department of Community Based Services (DCBS) involvement,^15,16,18 history of sexual, physical, and/or emotional abuse^15–19 homelessness,^15–19 physical and/or emotional neglect,^15,19 domestic abuse of a mother,¹⁹ and being LGBTQIA+.^15,16 Children who experience child trafficking are at high risk for consequences including posttraumatic stress disorder, depression, suicidal ideation, drug addiction, and a multitude of somatic symptoms.^13,19 Specifically, most victims experience symptoms of complex trauma, resulting from events that include entrapment; relocation; exposure to the abuse of others; and extended physical, sexual, psychological abuse.¹⁴ The consequences for child trafficking are not only detrimental but can be fatal. For example, youth who have experienced trafficking are also at increased risk for suicide,^19,20 which is likely exacerbated by the difficulty in identifying these youth to ensure accurate clinical assessment and prompt follow-up care.²¹ 

Identifying Child Trafficking

Though the issue of child trafficking and its outcomes is gaining attention in research and policy making, there remain significant discrepancies between these reported numbers. For example, in Kentucky, located in the southeast region of the United States, there have been 582 reported incidents of child trafficking involving 697 alleged victims.²² The Department of Juvenile Justice began screening for human trafficking in Kentucky in late 2015, and from 2015 to 2016, identified 236 youth who scored positive on the screeners for human trafficking, indicating a higher number of youth victims than were reported to the Kentucky DCBS during that same time period.²³ The discrepancy between these reported numbers highlights multiple challenges, including a lack of screening and assessment tools, lack of awareness about the issue, as well as a lack of awareness or reluctance of many exploited children to identify themselves as victims.^24,25 Currently, there is little evidence in the literature for a protocol to systematically identify child trafficking victims and to serve children affected by trafficking with targeted prevention, detection and identification, and treatment intervention. Furthermore, due to the current lack of specialized housing options for victims, the majority of youth currently identified as victims of trafficking can be found in juvenile justice settings, residential treatment programs, or on the streets¹⁹ However, the majority of service providers in these settings report that they have received little to no specialized training regarding trafficking, they do not have trauma-informed trafficking identification protocols, and they are in need of trafficking specific services to offer youth once they are identified.²⁶

There is a gap in trauma-informed, victim-centered responses to child trafficking due to a lack of an established protocol for identifying victims of child trafficking.^1,2 When child trafficking goes undetected and untreated, child victims are at high risk for negative long-term consequences, sometimes resulting in death.²⁷ The current study aims to examine child trafficking screening and identification tools and protocols used across the United States in order to inform the selection of an evidence-based, universal child trafficking screening and identification protocol to be utilized by child welfare agencies. The authors conducted a literature review and utilized a qualitative interview approach to answer the following research questions: 

1. What screening and identification tools are being used across the United States to identify child trafficking?
2. What are the characteristics of the existing child trafficking screening and identification tools?
3. What is an evidence-based approach for screening and identifying potential victims of child trafficking?

Participants

The authors obtained the names and contact information for each director of the child welfare agency in every state in the United States, plus the District of Columbia, Puerto Rico, and the U.S. Virgin Islands (n = 53). All 53 child welfare leaders were invited via email to participate in a semi-structured interview via phone call and 26 leaders (49.1%) agreed to participate. The child welfare leaders were asked the following questions regarding child trafficking screening and identification tools (CTSIT): 

1. What identification and screening tool does your state/agency use to identify potential child trafficking victims?
2. How did your state/agency decide on the current CTSIT being used? Who had input?
3. How was your selected CTSIT developed? Have you experienced any challenges or barriers to implementing it? If so, what were they? Can you send us a copy of your CTSIT to review?
4. Is the juvenile justice system in your state using a CTSIT? If so, tell me about it. Can you get a copy of it for us to review and/or put me in touch with your JJ person?
5. Do you have contacts for child welfare leaders/experts in other states/agencies that can answer these questions as well?  

Procedures

A literature review was first conducted regarding risk factors for child trafficking as well as screening and identification tools currently utilized in the United States to identify victims of child trafficking. Next, to inform the development of a child trafficking screening and identification protocol for at-risk youth, the authors reviewed existing CTSIT received personally from the interviewees or obtained from the government website.  

Comparative analysis: The authors utilized the comparative analysis method ²⁸ to examine the details of the 31 screening tools reportedly used by 26 states to screen children under the age of 18 for child trafficking. The authors defined units of comparison based on the framework of ecological risk and protective factors.²⁹ Thus, differences and similarities of screening tools were compared by the following distinct categories: Instrument development, psychometric properties; and question typologies including direct questions, indicators, and questions addressing risk factors and protective factors. The authors described the similarities and differences based on the above-mentioned units of comparison using a table.

Based on the 26 states interviewed (Table 1), 92.3% (n = 24) of states reported having protocols in place for identifying potential victims of trafficking. Two states (8%) reported they were not using a screening tool to identify child trafficking. The length of the screening tools ranged from 2-55 questions, demonstrating variability in the number of questions used to identify child trafficking. Of the 31 screening tools, 21 (66%) screened for sex trafficking, one screened for labor trafficking, seven (22%) screened for both labor and sex trafficking, and seven (22%) were general safety screeners and screened for neither labor nor sex trafficking. 

Based on themes emerged from interviews with child welfare leaders (Table 2), leaders reported that their states/agencies most commonly utilized task forces, work groups, and advisory councils to give input and recommendations on the decision-making of screening tools (n = 15, 57.7%). Task forces, multidisciplinary teams, and advisory boards were the most commonly reported forums for receiving input regarding instrument selection and/or development (n = 17, 65%). Though 7 of the 26 child welfare leaders reported uncertainty about if and what tool was being utilized by their state’s juvenile justice system, those who were aware of the protocol by the juvenile justice system reported primarily that the same screening tools were utilized across both systems (n = 4, 15.4%). Lastly, child welfare leaders from these 26 states reported that challenges to screening for child trafficking consisted mostly of the lack of a standardized use of the screening tool in place, resulting in inconsistent reporting (n = 4, 15.4%).

Results of the comparative analysis

Instrument development and psychometrics. Two of the 31 tools (from Colorado and Virginia) were removed from analysis because of incomplete data and disrupted communication due to COVID-19. The remaining 29 child trafficking screening tools (Table 3) were primarily developed by statewide multidisciplinary teams (n = 18; 56%). The remaining screening tools were developed by departments of human services, a program manager, a criminal justice coordinating council, research centers, a children’s clinic, and adapted from previous research.^30–32 Though 5 tools were adapted from previous research, the modified tools were not statistically validated. Of the 29 tools, the majority did not indicate evidence of statistical validation/psychometric testing, and testing reported acceptable interrater and test-retest reliability and concurrent and convergent validity.

Question typology

Direct questions: Many of the screening tools evaluated (n = 19; 61.2%) included at least one question that directly asked if the child experienced human trafficking (e.g., Sometimes, young people who are away from home can be taken advantage of and asked to do sexual activities in exchange for something of value. These activities can include dancing, stripping, posing for photos, or sex of any kind. While you were away, did anyone ever ask you to do something like that?”). Victims of human trafficking might not want to or know how to answer, especially a child victim of trafficking. Asking a child directly if they are a victim of trafficking may contribute to false negative responses often due to a lack of awareness or reluctance of many exploited children to identify themselves as victims. Research suggests that collecting information about risk factors and indicators of trafficking might do better to predict outcomes for both sex and labor trafficking.¹

Indicators: Indicators are commonly known as “Red flags” and include questions such as, “[Has] multiple hotel cards; staying in hotel is known trafficking; pictures taken in hotel rooms.”³³ Screening tools involving indicators are detailed questions designed to gather information about potential trafficking or exploitation for agencies to determine a screening decision.³³ Of the 31 screening tools, 22 (71%) screening tools included at least one question recognizing indicators (e.g. Minnesota’s Child Protection Screening of Sexual Exploitation and Sex Trafficking Flowchart includes, “[Has] access to money/large amounts of cash, clothes, or other expensive belongings youth could not afford on their own”).  

Risk factors: Many of the screening tools evaluated (n = 15; 48.4%) included both direct questions paired with questions that addressed risk factors (e.g., Connecticut’s One-Page Decision Map includes “Does the child have a history of multiple runaways/AWOLS?” and “Has it been reported that the child is spending time in or has the child been recovered from a hotel known for prostitution, a trap house, or another known area of prostitution?”). A total of 18 (50.1%) screening tools included risk factors (e.g., Iowa’s High Risk Victim Screening Tool includes “History of, or current concern about sexual abuse, physical abuse or neglect?”). 

Protective factors: The literature on protective factors that combat the risk of child trafficking and the effects of trauma is limited in comparison to the literature on risk factors. However, recent studies,^34,35 have shown support for the impact that significant interpersonal relationships can have on positive outcomes in youth. Youth who have experienced exploitation were found to have sustaining and supportive peer relationships and relationship stability to mitigate the adverse effects of trauma surrounding exploitation. The authors found it critical to evaluate the way screening tools are addressing protective factors to 1) find additional support for determining risk, and 2) build on the individual strengths and systemic supports that impact the child victim to promote safety and resiliency. Of the 29 screening tools evaluated, 22.6% (n = 7) included at least one question that addressed protective factors. For example, Alaska’s Guide for Assessing Runaway or Missing Minors includes a question that seems to get at a protective factor in regard to support, “Who helped you while you was gone? What type of help was offered?” and Kentucky’s Assessment and Documentation Tool includes, “Does the child have a secure attachment to an adult caregiver?” . 

Structured decision-making protocol: A structured decision-making (SDM) process consists of a guided screening tool to help reporting parties determine if the report meets criteria for assignment and the appropriate tracking of assignment.³⁶ Two of the screening tools evaluated in this study use an SDM process for identifying child trafficking victims. Only 2 out of the 31 screening tools included questions that addressed risk and protective factors, indicators, and asked direct questions. Tennessee’s SEE - Sexual Abuse screens for sex trafficking, is conducted by child welfare workers, and has unreported establishment of statistical validity and reliability. Consisting of 30 questions, the SEE - Sexual Abuse form addresses risk factors with questions such as, “Has the child had incidents of inappropriate sexual behaviors?” and addresses protective factors such as, “Is the child’s caregiver protective in regard to ensuring the safety of the child and preventing further sexual abuse by another person?”. The screening tool addresses indicators with questions such as “Does the child express fear of going home? Why specifically?” and starred items that ask direct questions including, “Has the child been made available by the alleged perpetrator to others for purposes of sexual gratification or prostitution?” and “Has the victim, the caregiver or any third party (friend, relative, etc.) received money, items or services in exchange to have sex with the victim or gain access to the victim?”. Affirmative responses to these risk-related questions then prompts additional questions from the CSEM - Commercial Exploitation of a Minor to screen for indicators of commercial exploitation. 

Virginia and Florida both utilize the Human Trafficking Screening Tool (HTST). The screening tool screens for both labor and sex trafficking, is conducted by child welfare workers, and has established concurrent validity and consistent reliability.³² Consisting of 51 questions, it begins with questions addressing risk factors as a reason for screening (e.g. [Has] history of running away or getting kicked out 4+ times in addition to history of sexual abuse) and addresses indicators as items trigger drop-down questions (e.g., Do you have any scars or brands that were made intentionally, not from an accident or injury? If ‘no,’ skip to Item 23; if ‘yes,’ ask Item 22a). Assessing evidence of forced labor, one question also addressed a protective factor of planning for the future, such as “When you think about the future, what do you want to do when you get older?”). At the end of the screening tool, more direct questions are asked (e.g. “Have you or someone else received something of value like money, a place to stay, food, clothes, gifts, favors, or drugs in exchange for your performing a sexual activity?”). At the end of the screening tool, the child welfare worker indicates either the likelihood of the youth being a victim of trafficking by stating “definitely not,” “likely not,” “not sure,” “likely is,” or “definitely is.” If the child welfare worker indicates “not sure,” “likely is,” or “definitely is,” then a report is made to a human trafficking hotline. 

The findings in this study will help increase awareness of the issue of child trafficking and improve the ability of systems to identify and respond to child trafficking. Reflecting the literature, many of the tools included items addressing risk factors and indicators, as well as direct questions on child trafficking. However, very few screening tools included items addressing protective factors, and even fewer tools included items integrating the multiple screening categories of risk and protective factors, indicators, and direct questions. This type of expansive questioning through a structured decision-making protocol may be more effective in predicting risk and likelihood that trafficking occurred. Additionally, important findings revealed that states are using a variety of tools and methods to screen and identify victims of human trafficking. The vast majority (82.8%) of the screening tools being utilized lack psychometric testing or were not published. Some child welfare leaders interviewed reported that this lack of psychometric validation was a primary challenge in screening for child trafficking. Only 3 states reported capitalizing on existing resources and partnerships from and with University researchers. However, a few states have identified and are currently using a validated measure that could be considered by other states, and perhaps as a national, universal identification tool for child welfare agencies.

Twenty-six states participated in interviews and provided data in regard to the research study’s questions about child trafficking screening and identification tools, which is a 52% response rate. This average response rate may be due to the fact that child welfare leaders were too busy to respond to the request due to routine job demands and/or additional job demands as a result of COVID-19. The response rate could indicate response bias, such as consciously or subconsciously reporting inaccurate but socially desirable responses. Further, certain child welfare experts with strong opinions or knowledge on the subject might have been more likely to respond to the interview request. On the other hand, this response rate could also indicate that many of those states are not utilizing any tools or protocols for identifying potential victims of child trafficking. Thus, the results should be interpreted with caution. 

Additionally, it is important to note that due to COVID-19 related challenges and priorities impacting child welfare organizations, comparative analysis could not be completed with all states, as many child welfare leaders were understandably focused on COVID-19 related crisis management and/or may not have been working in their offices during the timeframe of the study. As a result, many child welfare leaders were unable and/or unavailable to respond to the follow-up questions or interview requests regarding the screening and identification tool provided. Thus, the sample includes only a subset of states in the final analysis.

Interviewees in this sample were recruited only across the United States and therefore the results of this study cannot be generalized to other countries. To enhance the scope of generalization on the protocols for screening for and identifying child trafficking victims, additional research should be expanded to other countries for comparison purposes. 

Research

Because children are not only influenced by personal characteristics but also family, school, peers, and community environments, further research on child trafficking screening and identification tools (CTSIT) should take a broader view of the multiple ecosystems influencing the risk and protective factors of children. Continuing CTSIT research through the lens of the Ecological Risk and Protective Theory²⁹ might include a comparative analysis with variables that account for multiple ecosystems. For example, future comparative analyses might examine how CTSIT capture risk-related variables such as antisocial behavior (individual), poor parental monitoring (family), associations with peers involved in child trafficking (peer), academic failure (school), and low socioeconomic status (community). Additionally, examining protective factors can aid in assessment and treatment planning for potential victims. These protective factors can include well-developed interpersonal skills (individual), resilience characteristics (individual), close and supportive relationship with at least one family member (family), close and supportive relationship with at least one friend (peer), positive school experiences (school), and belonging to a supportive community (community). Analyzing the multiple ecosystems considered in screening and identification tools will help determine and enhance the efficacy of selected CTSIT.

In addition to utilization of an ecological theoretical framework to evaluate CTSIT, future research should also include an evaluation of implementation strategies, such as the Structured Decision Making (SDM) process. Although the SDM approach appears to be promising based on preliminary examination, it is currently utilized in conjunction with less than a handful of psychometrically validated tools. As such, it is critical to evaluate the SDM process to determine its efficacy in identifying potential victims of child trafficking within the child welfare system. 

Practice

It is important to refine strategies for better identifying child trafficking because of the negative and often long-term consequences. Therefore, early identification is key. Identification is critically important, and a good screening and assessment policy can contribute to effective early identification, and in turn, is key to preventing child trafficking. The authors recommend that child welfare leaders and workers receive training regarding the risk factors for child trafficking and utilize tip sheets (see Appendix A for authors’ Tip Sheet) as efforts toward preventing child trafficking. In addition, the design and implementation of prevention and early identification programs should be informed by the current research on risk factors for child trafficking.

Upon the analysis of child trafficking screening and identification tools, the authors found the Human Trafficking Screening Tool (HTST) to be a statistically reliable and valid tool in identifying potential victims of child trafficking. The HTST screens for both labor and sex trafficking, established statistical reliability and validity,³² and has a structured decision-making process (including risk and protective factors, indicators, and direct questions) with clear instructions for child welfare workers on when and how to make a report of child trafficking. The authors recommend the HTST for child welfare use accompanied by a structured decision-making process to include: Phase 1) Address risk and protective factors regarding child trafficking, Phase 2) Affirmative responses leading to questions regarding indicators of child trafficking, and Phase 3) Asking direct questions (Figure 1).

Figure 1 Structured decision-making process.

As reflected in interviews with child welfare leaders across the United States, the authors similarly recommend that child welfare agencies utilize a multidisciplinary advisory council and/or task force to select and implement a child trafficking screening tool and approach/protocol. According to state child welfare leaders, successful HTST task forces include law enforcement, child welfare leaders, service providers, juvenile justice, health care providers, judges, and victims/survivors of trafficking. The authors recommend the multidisciplinary advisory council/task force select a statistically validated tool (e.g., HTST), taking into consideration the length of a tool, and inclusivity of the tool (e.g., culturally inclusive, includes overlooked populations such as males, LGBTQIA+, etc.). Finally, the authors recommend partnering with the Department of Juvenile Justice to collaborate on utilizing the same CTSIT and protocol. 

Policy

Along with early identification and prevention efforts, traffickers must be held accountable with appropriate charges. Labeling sex trafficking of minors as child sexual abuse without acknowledging the commercial element may allow perpetrators to be charged with offenses that carry less severe penalties.³⁷ Appropriate charges for child trafficking can help to strengthen crime victims’ services in general. This can also help law enforcement’s victim identification practices at all levels, including state and local anti-trafficking task forces. The authors recommend that child welfare leaders partner with University researchers to aid in their process of selecting, developing, and testing screening and identification tools and protocols. As reflected in the responses of only 3 states partnering with Universities, this type of partnership could support child welfare agencies’ ability to more rigorously evaluate their identification tools and processes.

Children and youth who are victims of trafficking often have prior histories of many forms of abuse through their exploitation and have a high vulnerability for re-traumatization through the juvenile justice system. The criminalization process, instead of effective victim services, can cause re-traumatization and perpetuate exploitation through the reinforcement of a criminal self-concept.^38–40 Thus, to close the gaps of services for child trafficking victims, it is critical that the child welfare and juvenile justice systems collaborate on screening for and identifying child trafficking. The authors suggest more funding focus on the selection and testing of protocols for the child welfare and juvenile justice systems. 

On a national level, the authors suggest a partnership between child welfare agencies and the United States Department of Health and Human Services’ Children’s Bureau in selecting screening and identification tools and implementing protocols for identifying victims of child trafficking. During the Children’s Bureau’s National Convening on Trafficking and Child Welfare in 2015,^41,42 gave presentations on the Commercial Sexual Exploitation Identification Tool (CSE-IT) and Human Trafficking Screening Tool (HTST). This is a step in the right direction and the Children’s Bureau has great potential to continue conversations on screening and identification tools with child welfare agencies as well as partnering to aid effective statewide identification and prevention efforts. The authors suggest the Children’s Bureau engage in an initiative to help support child welfare agencies in their protocols for identifying child trafficking by utilizing existing resources to inform the selection of evidence-based and trauma-informed structured decision-making protocols.

Child trafficking is a sweeping issue across the United States. The consequences of this form of childhood trauma going unidentified and untreated are staggering. This study calls attention to the need for child welfare leaders in the United States to improve their ability to accurately identify and respond to child trafficking in order to enhance child trafficking awareness campaigns and prevention strategies. An evidenced-based and trauma-informed structured decision-making protocol for this population is recommended is efforts to raise awareness on the issue of child trafficking and provide effective services that avoids re-traumatization and ultimately prevents this heinous crime. Additionally, findings suggest the use of statewide task forces and advisory councils, as well as partnerships with University researchers, to collaboratively establish protocols and select instruments that include expansive and inclusive questions to identify child trafficking. To accurately identify child trafficking, the authors recommend child welfare leaders select psychometrically validated screening and identification tools. An evidence-based, trauma-informed identification protocol established across the United States has the potential to intervene and prevent the fastest growing criminal industry in the country and reduce the consequences of child trafficking.

None.

The authors declare that they have no known competing interests.

None.

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