U.S.  Department of Health and  Human Services  
Office of Inspector General  
In Five States, There Was No 
Evidence That Many Children  in 
Foster Care Had a  Screening  for 
Sex Trafficking  When They 
Returned After Going Missing  
Suzanne Murrin  
Deputy  Inspector  General  for Evaluations  and  Inspections  
July  2022, OEI-07-19-00371   U.S. Department of Health and Human Services  
Office of Inspector General  
Report  in Brief  
July  2022, OEI-07-19-00371  
Why OIG  Did This Review   In Five States, There Was  No  Evidence That  
In  2020,  the  National  Center  for  
Many Children  in Foster  Care  Had  a  
Missing  and  Exploited  Children  
received  more  than  17,000   Screening  for Sex Trafficking  When They 
reports of  possible  child  sex  
Returned  After  Going Missing  
trafficking.   Traffickers  are  known  
to  prey  on vulnerable  children 
What OIG Found  
with low  self-esteem  and 
Key Takeaway  
minimal social  support,  and   In  5  States,  the case files  of  
histories  of abuse,  neglect, and  In  five States,  there was  no   65 percent  of  children  in  our  
traumatraits  that  are  common   evidence  that  many  children  in  review  (268 out  of 413  children)  
among children  in  foster  care.    foster  care received a  screening  did not  have evidence of a  
Because  of these childrens   to  determine whether  they  were  screeningfollowing  each childs  
heightened  vulnerability,   victims  of  sex  trafficking.   For   return  to  foster  careto  identify  
identifying  who  is,  or  is  at  risk  of   some of the children  who  were  whether  they  were victims  of sex  
becoming,  a  victim of  sex   screened,  their  case file  trafficking.  Such  screenings  are 
trafficking  is  a vital  step  to  documentation lacked   required by  Federal  law  and State 
providing children  in  foster  care  information to  ensure  that  the   policy.   Further,  we  found  that  for  
with  prevention and  treatment   children  were  accurately   male  children,  the  proportion  of  
services.   identified  as  possible  victims  of   case files  that  had no  evidence of  
sex  trafficking.   As  a result,  many   a screening  was  greater  than  for  
How OIG Did This Review   childrens  risks  and  potential  female children  (72 percent  of 
We identified five States  that   needs  may  have gone  males compared  to 59  percent  of 
(1)reported the largest  number unidentified  and unaddressed.   females).  
of  children in runaway  status  in
We  found  that  when screenings  
fiscal  year  2018,  and  (2)  required
occurred, they  often lacked the  information  needed to  ensure that  
children  to  be  screened for  sex
children  were  accurately  identified as  victims  of sex  trafficking.   
trafficking after  returning  from
Documentation  showed  instances in which (1)  screenings  did  not  include  
going missing from  foster  care.
comprehensive  questions  to  determine childrens  experiences  while 
From  these States, we selected a
missing  from  care;  (2)  screenings  did not  have evidence of followup  when  
random  sample of children.   We
children  did not  answer  screening questions;  and  (3)  screeners  relied  on  
reviewed foster  care case file
childrens self-disclosures  to  make determinations.  Additionally,  one-
documentation for  413  children
third  of screenings  conducted did not  have a  conclusion  documented  
to  determine  the  extent  to  which
(e.g.,  whether  the child was  a  victim  of sex  trafficking,  whether  more  
the  children in our  sample were
information  was  needed).   
screened (as  required)  to  identify
whether  they  were victims  of sex
Howeveralthough  such  screenings  are  not  requiredwe found  a  few  
trafficking.   Additionally,  we
examples of  screenings  that  included an  assessment  of childrens  future  
assessed  the  extent  to  which
risk  for  becoming  victims  of sex  trafficking.  
States  policies may have
contributed  to  the  screening Finally, we found  limitations  in States  oversight  mechanisms  and  policies  
practices  that  we observed. that  may  have contributed to  some of the poor  screening practices  we 
identified.  Some  States  lacked  in  their  ability  to  identify  whether  
screenings  for  sex  trafficking had  occurred,  limiting  the  States  ability  to  
oversee and ensure that  these screenings  were occurring when  required.     
Additionally,  although such  policies  are  not  required,  none of the States  
that  we  reviewed had policies  for  identifying children  in  foster  care who  
are  at  risk of  becoming  victims  of  sex  trafficking  when they  return to  
foster  care after  going missing.  
What OIG  Recommends and How the Agency Responded  
To  better  protect  children in foster  care  from  the  dangers  of  sex  
trafficking and ensure that  victims  of  sex  trafficking are identified and 
provided with needed support  services, we recommend that  the  
Administration for  Children and  Families:  
(1)  work with  States  to improve  compliance  with  requirements  to  screen  
children  who  return  to  foster  care after  going missing to  identify  whether  
they  are victims  of  sex  trafficking;  
(2)  encourage all States  to  evaluate  the value of adding an  assessment  of 
risk  for  sex  trafficking  when  children  return to  foster  care after  going 
missing;  and  
(3)  conduct  oversight  activities  to  identify  States  that  may  not  screen all  
children  for  sex  trafficking  when  they  return  to  foster  care after  going 
missing.  
ACF  concurred  with  all three  recommendations.  
 
   
TABLE OF  CONTENTS  
 
 
BACKGROUND ................................................................................................................................................  1  
FINDINGS ......................................................................................................................................................... 7  
In five States, there was no evidence that nearly two-thirds of children in our review received a  
required screening for sex trafficking when returning to foster care after going missing ........................... 7  
When screenings occurred, they often lacked important documentation  .........................................................  8  
States lacked mechanisms to ensure screenings were conducted and lacked policies directing staff to 
identify children who are at risk of becoming victims of sex  trafficking  when children return after 
going missing ........................................................................................................................................................................... 11  
CONCLUSION AND RECOMMENDATIONS ...........................................................................................  13  
Work with States to  improve compliance with requirements to screen children who return to foster  
care after going missing to identify whether they are victims of sex trafficking ............................................ 13  
Encourage all States to evaluate the value of  adding an assessment of risk for sex trafficking when  
children return to foster care after going missing  ..................................................................................................... 14  
Conduct oversight activities to  identify States that may not screen all children for sex trafficking  when 
they return to foster care after going  missing ............................................................................................................. 14  
AGENCY COMMENTS AND OIG RESPONSE  .........................................................................................  15  
DETAILED METHODOLOGY ....................................................................................................................... 16  
APPENDICES ..................................................................................................................................................  19  
Appendix A: Overview of State screenings for children who return to foster care after going missing  
to identify whether they were victims of sex trafficking  .......................................................................................... 19  
Appendix B: Agency Comments ........................................................................................................................................ 20  
ACKNOWLEDGMENTS AND CONTACT  ................................................................................................  26  
Acknowledgments  .................................................................................................................................................................. 26  
Contact ........................................................................................................................................................................................ 26  
ABOUT THE OFFICE OF INSPECTOR GENERAL ..................................................................................... 27  
ENDNOTES  ...................................................................................................................................................  28  
 
   
BACKGROUND  
OBJECTIVES  
To determine the extent to which:   
1.   children in foster care from five selected States were screened to determine 
whether  they were victims of  sex trafficking when they returned  after  going 
missing, as required; and   
2.   such screenings included an assessment of childrens risk of becoming  victims of  
sex trafficking, although such assessments are not required.  
 
Sex trafficking of children occurs across America  in all settings: rural, urban, and  
suburban.1   In 2020, the National Center for Missing and Exploited Children received  
more than 17,000 reports of possible child sex trafficking.2   Sex trafficking of children 
means  the recruitment, harboring, transportation, provision, obtaining, patronizing, or 
soliciting a child  under 18 years of age for the purpose of a  commercial sex act.3   A 
commercial sex act does not always include the exchange of  money.  For instance, 
items like food, shelter, and/or drugs may be offered in exchange for sex with a child.4  
Children in foster care who are victims of sex trafficking can be  negatively impacted  
by multiple physical and mental health issues that can have long-lasting  effects.  
Trafficked children are at risk of significant physical health impacts, including injury, 
unplanned pregnancies, and sexually transmitted diseases.5   Additionally, these 
children can experience mental health issues such as depression, substance abuse, 
self-destructive behavior, and suicidality.6  
Identifying children  who are, or are  at risk of becoming, victims  of sex trafficking is a  
vital step to  providing children in foster care prevention and treatment services.  
Traffickers are known to  prey on vulnerable children with low  self-esteem and minimal  
social support.7   These traits are common  among children in foster care because of  
their histories of abuse, neglect, and trauma.8    
In January 2022, the Department of  Health and  Human Services (HHS) announced the 
formation of the Task Force to Prevent Human Trafficking that will  facilitate  the 
implementation of the priority actions HHS has committed to in  the  Presidents 
National Action Plan to Combat Human Trafficking. 9, 10  The task force will  work to 
prevent human traffickingparticularly in high-need areaswhile integrating an 
equity lens into new public awareness strategies to better reach populations at  
disproportionate risk for human trafficking.  
 
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Background |  1      
ACF  funding  and  oversight  of  State foster care programs  
Under Titles IV-B and IV-E of the Social Security Act,  the Administration for Children 
and Families (ACF) provides Federal  funding to States  and eligible Tribes (which we 
refer to collectively as States) to support child and family welfare, including programs 
that provide care and services for the over 670,000 children in foster care.11,  12,  13   To 
receive Federal funding, States are required to submit to ACF  a Child and  Family 
Services Plan (CFSP) every 5  years with annual updates, and a Title IV-E Plan, as 
necessary, to reflect new Federal requirements or changes within the State.14   State  
plans contain the official policies and procedures that individual States establish to  
fulfill the funding requirements of the respective programs.   Each State must  
designate an agency (State Agency)  responsible for administering child welfare and  
foster care  programs.15  
To help States achieve positive outcomes for children, ACF monitors  and  provides  
oversight to  State foster care programs  through various means.   ACF oversight  
includes reviewing and approving State plans and annual updates, providing technical  
assistance, and conducting program reviews.  ACF issues guidance, including program 
instructions,  that explain procedures and methods for operationalizing program 
policies, add details to program regulations or policy guide requirements,  and convey 
to grantees program guidance information on actions they are expected or required  
to take. 16   Working with the States, ACF conducts periodic reviews of each States 
foster care program, known as Child  and Family Services Reviews (CFSRs), to 
determine whether the  State is in substantial conformity with Title IV-B and IV-E 
State  plans  and program requirements, based  on outcomes and systemic factors 
specified in regulation.17   In making its assessment, ACF uses a compliance review  
instrument that assesses particular criteria and makes a determination based on the 
entirety of the review.  However, the CFSR  instrument does not specifically address 
screenings for sex trafficking.18   ACF  may conduct a partial review to address 
conformity with requirements outside of the  scope of the CFSR.19    
Preventing  Sex Trafficking  and  Strengthening  Families  Act  
The 2014 Preventing Sex Trafficking and Strengthening Families Act  (Preventing Sex  
Trafficking Act) was enacted in an effort to prevent and address sex trafficking of  
children in foster care.20   The Preventing Sex Trafficking  Act amends the Social  
Security Act by requiring States to develop policies and procedures for identifying, 
documenting in agency records, and determining appropriate services for children in  
the placement,  care,  or supervision of the State Agency whom the State has 
reasonable cause to believe are, or are at risk of  becoming, victims  of sex trafficking.21, 
22   Further, the Preventing Sex Trafficking  Act added requirements that States develop 
policies and  procedures for expeditiously locating any child  missing from foster 
care, and determining the childs experiences while absent from care, including  
screening the child to determine if the child is a possible sex trafficking victim.23  
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Background |  2      
ACF  report to Congress  
The Preventing Sex Trafficking  Act required ACF to submit a summary report to  
Congress about the sex trafficking  of  children in foster care.24   This ACF report, 
published in August 2019, provides an overview  of children who had run away from  
foster care and their risk of becoming  victims  of  sex trafficking.25   The report stated  
that a history of child maltreatment  is among the strongest risk factors for sex  
trafficking, including histories of child neglect and the experience of multiple forms of  
abuse (other than trafficking).  The report further highlighted  that children who go  
missing from foster care can have an increased susceptibility to trafficking  
victimization, especially those that have fewer resources and family relationships to  
fall back on while missing.  ACF cited  that studies of  older foster youth  found that  
nearly half report having run away from their placement at some point in their foster 
care experience.  Additionally, this report cited that the National Center for Missing  
and Exploited Children found that males remain a small percentage of children who  
are assessed for sex trafficking, although the identification of male child victims has 
increased.26  
In this report, ACF noted  that one method  for  screening  is the use of  indicator tools.   
Indicator tools  can be used to identify a child as being  at risk or at high risk of  
trafficking based on the number and severity of indicators identified.27   One tool ACF  
cited, the WestCoast  Childrens Clinics Commercial Sexual Exploitation-Identification 
Tool (CSE-IT), instructs screeners to score the concern level of numerous indicators 
across several categories.  Some of the indicators include whether the child:  
   runs away frequently;  
   has unstable housing (including multiple foster care placements);  
   has previous history of  abuse;  
   has significant change in appearance;   
   has tattoos/scarring/branding that indicates being treated as someones 
property;  
   has health problems or complaints related to poor nutrition;  
   has a significant change or escalation in substance use; and   
   receives or has access to unexplained money, credit cards, hotel keys, gifts, 
drugs, alcohol, or transportation.  
National Advisory  Committee on the Sex Trafficking of  Children 
and Youth in the United States  
The Preventing Sex Trafficking  Act also authorized the establishment of the National  
Advisory Committee on the Sex Trafficking of Children and Youth in the  United States 
(the Committee).28   The Committee was established in September 2017.  In September 
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Background |  3      
2020, the Committee published a report  titled  Best Practices and Recommendations  for 
States.29   The Committee provided recommendations to  States and Federal  
stakeholders with the goal of improving the Nations response to the sex trafficking of  
children.  The recommendations include improvements to training;  screening and 
identification;  service provision;  housing;  and many others.  The report also included  a  
section specific to child  welfare, with resources and examples of training;  policies and  
procedures;  and implementation.   In January 2022, the Committee issued a  
preliminary report  titled  Preliminary  State Self-Assessment Survey Overview, which 
summarized 29 States self-assessments of their progress implementing the  
recommendations made by the Committee.30, 31   In a final report, the Committee will  
evaluate the extent to  which States adopted the Committees recommendations.32    
Screening  for sex trafficking  
Accurately screening children to identify who  is  a victim of sex trafficking is an 
important step to providing  prevention and treatment services to  children  who return 
to foster care after going  missing.  Children often do not self-identify as trafficking  
victims and frequently do not disclose their abuse because of fear, shame, or loyalty 
to their abuser(s)it is not the responsibility of children  to recognize that they are 
being victimized; it is the responsibility of child-serving professionals to identify the 
vulnerabilities, risk factors, and indicators.33    
It is important that the screenings of children in foster care  for sex trafficking be 
documented in agency records.  Complete and accurate documentation is essential  to  
support a supervisor or colleagues ability to assure a childs safety, well-being, and  
permanence, and ensure that appropriate services are provided.  Additionally, such 
information is required for State agencies to meet Federal reporting requirements.34  
States may develop their own screening methods or use methods that  have been 
developed by other entities.  Some screening methods use behavioral or situational  
indicators, such as the WestCoast  Childrens Clinics CSE-IT,  that can be noted during  
conversations, observed during interactions, or identified from case records.  Others 
involve standardized interview questions or the  use of  a tiered approach in which 
positive responses on a  brief tool trigger more in-depth screening.  States may use 
the same method to identify victims of sex trafficking as they use to identify children 
at risk of becoming victims  of sex trafficking.   
Related  Work  
OIG has previous work evaluating the health and safety of children in foster care.  In 
May 2022, OIG published a national snapshot  of  how many  children were missing  
from foster care in each State, and  summarized  States policies and procedures to  
report and locate  children missing from foster care.35   In September 2021, OIG found  
that the Missouri foster care agency rarely attempted to reduce childrens risk of  
going missing, failed to  protect all children who  were missing from foster care, and  
did not  effectively use resources to assist in locating them.36   In March 2021, OIG  
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Background |  4      
found that some States lack oversight systems to ensure that  every child victim has a  
court representative, and found that some States have challenges that impede their  
ability to  appoint a representative to every child victim.37   In 2020, OIG found that 
contrary to Federal laws and regulationsKansas did not ensure that all  foster care 
group homes complied  with State licensing requirements related to the health and  
safety of children in those homes.38   In 2015, OIG found that in four States, nearly a  
third of children in foster care who  were enrolled in Medicaid did not receive at least  
one required health screening.39  
Methodology  
Scope and  State selection.   This evaluation focuses on screening children in foster 
care for sex  trafficking  when they return after  going missing  in five selected States: 
Illinois, Massachusetts, Minnesota, Pennsylvania, and Texas.   Each State defines which 
situations are documented as going  missing from foster care, including when children 
are missing, have been abducted, or have run away.  For this report, we refer to all  
children who are missing, have run away, or are otherwise absent as missing.   These 
States were selected using two criteria: (1)  the States reported the largest number of  
children in runaway status  in  their reporting to ACF  at  the end of  fiscal year 2018,  
and (2) the State policies required children to be screened for sex trafficking after 
returning from going missing from foster care.40, 41  
Sample selection.   From each of the selected States, we requested a list  of every 
child  who returned to the States foster care program after going missing from 
July  1,  2018, through June  30,  2019.  In the 5 states, these lists contained  2,629 
children.  We then selected about 100 children from each State, for a total sample of  
501 children.   Of the 501 children initially selected, 88 were excluded because they did  
not meet our evaluation criteria.  This resulted in a final sample of 413 unique 
children.   For each child selected, we requested that the State identify the last  episode 
of going  missing  that occurred during the review period.   See the Detailed  
Methodology for information on how many children were selected from each State.  
Data collection.   From each of the five selected States, we requested any  policies and  
procedures related to identifying children in foster care who  are victims  of sex  
trafficking, such as related State statutes, regulations, policy manuals, and procedure  
instructions.  
For each child in our review, we requested all documentation from foster care case 
files that demonstrated evidence of compliance with screening children to identify 
those who  are  victims  of sex trafficking.    
Data analysis.   We reviewed each selected States policies and procedures to  
determine its requirements related to screening children in foster care for  sex  
trafficking.  
For each child in our review, we reviewed all documentation for the childs final 
episode of going missing  during the review period  that  was submitted by the States.   
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Background |  5      
For each child, we determined  whether a screening occurred and whether a  
conclusion of the screening was documented (e.g., whether the child  was  at risk of sex  
trafficking, whether the child  was a victim of sex  trafficking, whether more information 
was needed).  We accepted any evidence of a screening that documented that the 
child was asked questions which would indicate whether the child was  a victim of sex  
trafficking.  This included conversations with the child about  the childs  experience 
while missing from care, interviews, or screening tools.  The selected States varied in 
the timeframe required to complete a screening of children who return to foster care 
after  going  missing (from one business day to unspecified).  We accepted any 
evidence of a screening that was specific to the childs episode of going  missing, 
regardless of how  long after the childs return to care it occurred.  
We verified  our findings with the States and gave them opportunities to provide 
additional documentation for any childrens case files that did not show evidence of a  
screening.   
Limitations  
Our evaluation was limited to the 413 children in our review  and the documentation 
the States submitted and cannot be generalized to all children that were missing from 
foster care during our review period.  It is possible that some children in our review  
received screenings that were not included in the documentation submitted; 
therefore, this study may have underestimated the provision of required screenings,  
conclusions of screenings, and plans for next steps for these children.  
Standards  
We conducted this study in accordance with the Quality Standards for Inspection  and  
Evaluation  issued by the Council  of the Inspectors General on Integrity and Efficiency.  
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Background |  6      
FINDINGS  
In five States,  there was  no  evidence that  nearly two-thirds  of  
children  in our review received  a  required  screening  for sex 
trafficking  when returning  to  foster care after going  missing  
In 5 States, the case files of  65  percent of children in our review (268  out  of 413 
children) did not have evidence that a screening  to identify  whether  they were  victims  
of  sex trafficking, as required  when a child returns to foster care after going missing.  
Of the States reviewed,  Pennsylvania had the highest percentage of case files with no  
evidence of screening.  At the other end of the spectrum, Texas  screened  83 percent  
of the  children, considerably  more  than each of  the other four States reviewed.  One 
possible  reason for the higher rate of screening in Texas is  that it  is the only State 
reviewed that has special investigators conduct the majority of screenings to identify 
children who are  victims of sex trafficking.42   See Exhibit 1 for individual State 
screening rates.  
Exhibit 1: The case files of many children in our review had no 
documentation of  a screening  to identify whether they were victims of sex  
trafficking, as required.   
Source:  OIG analysis  of documentation in foster care case files, 2022.   Our review  included 74  children from  
Pennsylvania, 91  children from Minnesota, 88  children from Massachusetts, 62 children from  Illinois, and 98 children  
from Texas.  
If States do  not screen children for sex trafficking when they return to foster care, 
indicators that children are at risk  or  victims of sex trafficking, may be missed.  In the  
documentation we reviewed, we found evidence that  numerous children who  were 
not screened for sex trafficking had risk factors or indicators of being trafficked.  
Multiple children had evidence of frequently going missing from foster carea risk  
factor for heightened risk of trafficking victimizationyet they did not receive a  
screening when they returned to care after going missing.  The documentation for 
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Findings |  7     
other children showed that the children received money from strangers, sold or used  
drugs, or became pregnant while missing; however, despite these risk factors  and  
indicators, there was no evidence that these children were screened for sex trafficking.  
W 
     e reviewed the case file documentation of  one child who had frequently gone 
missing from care and had previously been investigated as a possible victim of  
sex trafficking.  The documentation showed that  during the time this child was 
missing from foster care, the child was suspected to be with a man and other 
females who were known to be involved in sex trafficking.  Despite these risk  
factors, the childs case file did not contain evidence of a screening for sex  
trafficking  after the child had returned from going missing.  
For male children, the  proportion  of case  files that  had no  
evidence of a screening was  greater  than for  female children  
For male children, the proportion of  case files that had no evidence of a screening  
was greater than for female children.  The case files of  72  percent of male children 
(126 out of  174)  lacked  evidence of  such a screening, compared to  59  percent of  
female childrens files  (142  out of 239).  This is consistent with research which has 
indicated  that males are less likely to be assessed for sex trafficking than females.  See  
Appendix A  for individual State screening rates.  
Several male children reported experiences associated with risk or victimization of sex  
trafficking; however, without screenings, there was no evidence that these childrens 
needs for services or interventions were identified.  Several  male children had  
frequent histories of going missing from care, or previous concerns noted in their 
case files; however, they were not screened for trafficking.  The documentation 
reviewed for one child noted that he was frequently missing from his placement and  
often returned with high priced items, and another child reported that he received  
money from strangers and had to sleep on the floor while missing.  However, there 
was no evidence that either of these children were asked additional questions about  
these experiences, or any other questions to screen them for sex trafficking.43  
When screenings  occurred,  they often  lacked  important 
documentation  
Screenings identified during our review often had limited documentation to indicate 
whether the children were accurately identified  as victims of sex trafficking.  The lack  
of documentation was concerning because accurately identifying children as victims 
of  sex trafficking is a vital step to providing children in foster care  with  treatment  
services.  
There were concerning  instances where  the screenings did not  document the 
collection of  information needed to identify whether children were  victims  of sex  
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Findings |  8     
trafficking.   Additionally,  one-third  of  the  screenings conducted did not have a  
conclusion documented (e.g., whether children  were  victims  of sex trafficking).  
Howeveralthough such screenings are not requiredwe found a few  examples of  
screenings that included an assessment of childrens future risk for becoming victims 
of sex trafficking.  
Documentation  showed instances where screenings lacked the  
information needed to identify  whether the child was  a victim  of  
sex trafficking  
   Documentation showed instances  where screenings did not include 
comprehensive questions to determine childrens  experiences  while 
missing from care.   The documentation showed  instances in which  the 
questions screeners asked children did not provide the screeners with enough 
information to determine childrens experiences while missing from foster 
care.  For example, according to  case file  documentation, one screener asked  a 
child if the child had  engaged in risky behaviors while missing from foster 
care with no clarifications as to  what  risky 
behaviors may entail  or any additional  
O 
      ne  child  was documented as disclosing  
questions.  Some of  the more thorough 
having sexual activity while missing  from foster 
screenings included questions such as, Did  
care but said they could not remember any 
anyone ask you to do  anything in exchange for 
details.  There was no evidence that the  money, food, a place to stay, or anything  
screener noted any concern about what   else?; Where did you stay?; How did you 
happened to the child  while they were missing   get food?; Did anyone make you or ask you 
or asked the child any additional questions.   to do  anything that made you feel  
uncomfortable?;  Did anyone ask you to take 
or send inappropriate photos?  
   Documentation showed instances  where screenings  did not have  
evidence of followup when children did not answer screening questions.   
The documentation showed instances in which the  screeners did not  follow up 
when children refused to answer questions about sex trafficking and  their 
experiences while missing from foster care.  The case files for these children 
showed no  additional attempts by screeners to question the children or to  
gain the information through other approaches (e.g., a trauma-informed  
approach, which responds  to factors that can contribute to hesitancy to  
respond;  referring the child to  a Child Advocacy Center44).   These children may 
have experienced sex trafficking.   However, when screeners do not  get 
responses to screening questions, children may not be identified as  victims of  
sex trafficking  and  may not receive necessary services.  
   Documentation showed instances  where screeners  relied on  
self-disclosure to make determinations.   The documentation showed  
instances in which  screeners appeared to rely on childrens self-disclosure to  
determine that a child  was not a victim of sex trafficking, despite the presence 
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Findings |  9     
of risk  factors or indicators.  Children often do not self-identify as victims  for  
many reasons, and the goal  of screening should be to identify the 
vulnerabilities, risk factors, and indicators of sex  trafficking.  In multiple cases, 
the conclusion documented by the screener stated  that  the child  made no  
outcry  of abuse or trafficking.  In another case, the child stated he was not a  
victim of sex traffickinghe was the pimp  who was  trafficking others.  Despite 
this childs disclosure, there was no evidence that anyone discussed with this 
child the dangers and risks associated with being involved in sex trafficking,  
asked him questions about his safety, and no evidence of any attempts to 
intervene or to get him out of this ring.  
It is possible that the screeners discussed more with the children than what was 
documented in the case files; however, child welfare professionals rely heavily on the 
information that is included in childrens case files to provide coordinated care and to  
ensure that children are provided needed services.  When a comprehensive screening  
is not documented, other adults in a childs life (e.g., case supervisors, court-
appointed special advocates, new case workers who are  assigned to a childs case)  
cannot determine whether  the child is receiving needed services.   
Screenings  for children did  not always have a conclusion 
documented  
The documentation for a third of  the children who were screened  lacked  a 
documented conclusion, meaning  the outcome of the screenings  were unclear.  Of  
the 145 children whose case files evidenced that they were screened for sex  
trafficking, 48 childrens screenings (33 percent)  did not have a conclusion 
documented.  For these children,  the documentation did not indicate whether the 
child was a victim of sex  trafficking, nor did it indicate what, if  any, additional actions 
were needed to ensure the safety and well-being of the child.  Of the States reviewed, 
screenings from Illinois lacked documented conclusions most often.   This is likely  
because the screening tool Illinois uses does not  prompt the screener for a conclusion  
response.   See Appendix A for the number of documented conclusions for each State.  
A conclusion is essential to ensuring  that children receive critical supportive services 
to help address risks or trauma they may have experienced while missing  from care.   
Children  may benefit from supportive services such as therapy to address their  mental  
health needs, or a change in placement to reduce their  risk of going  missing in the 
future.   Additionally, documented conclusions help  ensure that States report  
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Findings |  10     
an  accurate number of children who  were identified as victims of sex trafficking, as 
required by Federal law.  
O      ne child,  whose case file we reviewed, reported during a screening that while 
missing from foster care the child sold drugs and stayed with an older, abusive 
boyfriend.  This child also had a history of frequently going  missing from care.  
There is no  evidence in the case file  as to whether the screener concluded that  
these indicators put this child at risk  of sex trafficking or not, or evidence that the  
screener made any attempts to gain additional  information about the childs 
experiences while missing from foster care.  
A  few  of  the screenings  documented an assessment  of  childrens  
risk  for becoming  victims  of sex trafficking  
The Preventing Sex Trafficking and Strengthening Families Act requires States to  
develop policies and procedures to  identify children who are at risk of becoming  
victims  of sex trafficking, as well as identifying those children who are already victims 
of sex trafficking.  Although this requirement does not specify that this identification 
of risk should occur when children return from going missing from foster care, we  
found  20 screenings in our review that included  such an assessment.   These examples 
demonstrated the potential value  of assessing the childrens risk factors when they 
return to foster care after going missing and offer examples of preventative services 
that  can be provided to  children  at risk of becoming victims of sex trafficking.  Some 
of these services included therapy, counseling, a more thorough assessment at a Child  
Advocacy Center, and placement in a more secure setting or a facility that specializes 
in sexually exploited  and trafficked youth.  Additionally, we found evidence of case 
workers, in these instances,  using this opportunity to educate children on the dangers 
of sex trafficking.  
States  lacked  mechanisms  to  ensure screenings  were conducted  
and  lacked  policies  directing  staff  to  identify children who  are at  
risk  of  becoming  victims  of  sex trafficking  when children return 
after going missing  
Three States  lacked oversight mechanisms  to  ensure screenings were 
being conducted.  Three States  had  limited  ability to identify whether 
screenings for sex trafficking occurred.  Easy identification of  completed  
screenings is important  for State foster care agencies to be able to  
oversee and ensure that screenings are occurring when required.  Three of  
the States reviewed did  not have a system for collecting and  storing  
screenings for sex trafficking  that allowed for easy identification of  
screenings.  These  States must review each case fileeither in paper or 
electronicallyto determine whether a screening has occurred.  This 
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Findings |  11     
method can be time consuming and makes it difficult to ensure that  
children receive required screenings.  Further, continuity of care in the 
event of case worker turnover relies on comprehensive documentation.   
Without documentation of screenings for sex trafficking, including details 
and conclusions of the screenings, it can be difficult for case supervisors 
and other management  to  be assured that case workers screened the 
children as required.  
Although they are not  explicitly  required  by Federal law  to have such 
policies, all five States lacked policies directing staff to identify  
children at risk of becoming victims of sex trafficking  when they  
return after going missing.    During our review, we found that many of  
the documented screenings did not  determine or discuss childrens risk of  
becoming victims of sex  trafficking.   Federal law requires foster care 
agencies to identify and  document in agency records children who are at  
risk of becoming victims  of sex trafficking.  Although this law does not  
require such identification to occur at the time  children are screened for 
sex trafficking when they return to foster care after going missing, critical 
attempts to  prevent children from becoming victims of sex  trafficking  
could be missed.  Though there is no Statewide policy  in Texas, the  States  
five largest counties require the use of the CSE-IT (WestCoast Childrens 
Clinics  Commercial Sexual Exploitation-Identification Tool) to screen 
children when they return to foster care after going missing.45   The CSE-IT 
is designed to assess childrens risk of becoming  victims.  These five 
counties in Texas require that children in foster care be screened with the  
CSE-IT tool  after returning from going missing from care.  
 
   
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CONCLUSION AND  RECOMMENDATIONS  
From our review of case files for  children in foster care in  five States, many  children 
had no evidence of a  screening  for sex trafficking during a crucial period of their care.  
Children who are not screened or are poorly screened  may  not be accurately 
identified as victims  of sex trafficking  and may  be  at enhanced risk for future 
victimization.  Additionally, these children may not be receiving care that they need to  
recover from trauma that they may have experienced.   
In these five States, we  found that  the case file documentation for  two-thirds of  
children lacked evidence that they were screened  to identify whether they were 
victims of sex trafficking  following the childrens return to foster care, as required by 
Federal law  and State policy.  Additionally, we found that  one-third of the screenings  
conducted did not have a conclusion documented.  A conclusion is  essential to  
ensuring  that children receive critical supportive services to help address risks or 
trauma they experienced while missing from care.   Finally, we found that  most  
screenings did not include an  assessment of childrens future risk of becoming victims  
of sex trafficking after they returned  from going  missing, potentially missing critical  
opportunities  to  prevent  or reduce childrens risk.  
Our findings indicate that  although  States  have policies and procedures in effect to  
screen children returning to foster care for sex trafficking,  States  are often not  
complying with these policies and procedures.   As a result, ACF cannot  be assured  
that children in foster care are protected from the dangers of  sex trafficking, or that  
victims of sex trafficking  are identified and provided  with  needed support services.    
We recommend that  ACF:  
Work with  States  to improve  compliance with  requirements  to 
screen children who  return to  foster care  after going missing  to 
identify  whether  they  are  victims  of sex  trafficking  
To do this, ACF should provide proactive technical assistance to States to  improve 
compliance with requirements for: (1) screening children who  return to foster care 
after going  missing to identify who  is a victim of sex trafficking and (2)  documenting  
these screening conclusions.  Depending on the State, technical assistance could  
include working with the State regarding methods to collect screenings for sex  
trafficking  or assisting the State with developing oversight mechanisms to assess its 
compliance.   ACF should  consider consulting with internal and external offices with 
expertise  on  sex trafficking, such as the ACF  Office on Trafficking in Persons,  to 
develop the technical assistance.  
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Conclusion and Recommendations | 13     
Encourage all States  to  evaluate  the value of  adding  an  
assessment  of  risk  for  sex  trafficking  when children  return to  
foster  care  after  going missing  
As required by Federal law, every State should  have policies for identifying children in 
foster care who are at risk of becoming victims of sex trafficking.  Although the law  
does not specifically require an assessment of this risk when children return to foster  
care after going missing, ACF should encourage all States to evaluate the value of  
adding such an assessment, given childrens heightened risk for trafficking  at that 
time.   ACF should provide technical assistance to States to  develop effective and  
robust policies, as needed.   
Conduct  oversight  activities  to  identify States  that  may  not  
screen all  children  for sex trafficking  when they  return  to  foster  
care  after going  missing  
Our review found that many children in five States were not screened to identify 
whether they were victims of sex trafficking  when they returned after going missing, 
as required.   ACF should  conduct oversight activities to identify States that may not  
screen all  children  for sex trafficking  when they return from going  missing.   These  
oversight activities  could include  ACF developing  a process for and  conducting partial  
reviews of  States that appear to have vulnerabilities  in this area.  If the review reveals 
that the State is out of compliance with its IV-E State Plan,  ACF should establish a 
program improvement plan with  the State.   
We  acknowledge that  resource limitations make  a review  of  every State impracticable.   
OIG has provided ACF with information about States thatfrom the information in 
our reviewdo not  appear to conduct  these  screenings  as required, and ACF could  
use that information to prioritize  oversight.   
ACF could also consider the feasibility of  requiring information about sex  trafficking  
screenings in Child and  Family Services Plans or assessing sex trafficking  screenings in 
the measurement of one of the outcomes or systemic factors in future Child and  
Family Services  Reviews, making any regulatory changes necessary.     
 
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Conclusion and Recommendations | 14     
AGENCY  COMMENTS  AND  OIG  RESPONSE  
ACF concurred with all three of OIGs recommendations.  
Regarding our first recommendation, ACF stated that through the Capacity Building  
Center for States (the Center), it will  continue to  work with States to improve 
compliance with requirements to screen children who return to foster care after going  
missing  to identify whether they are victims of sex trafficking.  The Center provides 
tailored technical assistance to States to improve outcomes and overall system 
functioning.  The Center already has developed a peer groupthe Preventing and  
Addressing Sex Trafficking in Child Welfare  peer groupthat promotes collaboration 
among child welfare professionals.  Additionally, the Center has developed related  
publications, learning experiences, videos, and other digital products.  
Regarding our second recommendation, ACF stated that it  will continue to encourage 
all  States to  evaluate the value of adding an assessment of risk for sex trafficking  
when children return to foster care after going missing.  ACF  again cited the resources  
available to  States through the Center.  ACF did  not specifically describe how it has, or 
will continue to, encourage States to  add an assessment of risk for sex trafficking  
when children return to foster care after going missing.  
Regarding our third recommendation, ACF stated that it  takes the duty to prevent  
trafficking seriously and will  work to emphasize this duty to State programs.  ACF  
stated that it has instructed its regional office staff to contact the appropriate officials 
in each of the five States identified  in this report as potentially not screening children 
for sex trafficking in accordance with Federal law.  Additionally, ACF stated that if it  
believes that a State is in noncompliance with this requirement, it would initiate a  
partial review and would implement a program improvement plan, as necessary.  ACF  
stated that it will continue to use its  existing regulatory review and oversight  
processes to further explore the scope of potential noncompliance and will continue 
to evaluate what, if any, regulatory changes may be needed.  
OIG appreciates ACFs continued efforts to  work  with States to  respond to and  
develop strategies for preventing sex trafficking of children in foster care.  
For the full text of  ACFs comments, see Appendix B.  
 
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Agency Comments and OIG Response | 15     
DETAILED  METHODOLOGY  
State  policies  
We  collected State policies and procedures from five States related to  identifying  
children in foster care who are  victims  of sex trafficking from the five selected States.  
We reviewed each selected States policies and procedures to determine its 
requirements related to  screening children in foster care who are victims  of sex  
trafficking.  We then sent the list  of requirements to each State for verification.   
Population and  sample  selection  
From each of the selected States, we requested population  data on every child who  
returned to the States foster care program after going missing from July  1,  2018, 
through June  30,  2019; however, one StatePennsylvaniawas unable to provide the 
requested population.   
Pennsylvanias foster care program is administered by each county and it was 
determined to be too burdensome and time consuming to request the needed data  
from each county to identify the population of children we requested.  Instead, the 
Pennsylvania State foster care agency used the biannual data  it collects from the 
counties to identify the population.  Pennsylvania identified  101 children who possibly 
met our evaluation criteria, but this is likely not the entire population of children who  
met these criteria.  We collected and reviewed the submitted case file documentation 
for each of the 101 children and determined that 74 children met our evaluation 
criteria.  
Illinois, Massachusetts, Minnesota, and Texas each provided the requested population 
of children, from which we selected a simple random sample of 100 children from 
each State.   We collected and reviewed the submitted case file documentation for 
each child.    
For the purpose of this report we define child as anyone in foster care that the State 
policies required to be screened for sex trafficking after returning from going missing.  
The policies in Illinois, Massachusetts, and Minnesota require children in foster care  
up to age 21 to be screened for sex trafficking  when they return from going missing.  
The policies in Pennsylvania require such screenings for children up to age 18.  The 
policies in Texas also require such screenings for children in foster care up to age 18; 
however, officials in Texas stated that because the screening is interview-based, the 
child must also be able to communicate verbally/sign.  For that reason, we included  
children age 4 and older.  
To allow ample time for the screening to occur, the child must have been 6  months 
less than the age limit for required screening at the date of  the childs return  to foster  
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Detailed Methodology |  16     
care  (e.g., a child in Illinois must have been 20.5 years old or younger on the date the 
child  returned to foster care to be included in our review).   
After reviewing the documentation, we identified that Illinois had used incorrect  
criteria to  identify the population of children, so many children in the sample were 
ineligible to  be included in our evaluation.   Specifically, children who were not missing  
from foster care, but rather were in unapproved placements, were included in the 
population; however, these  children are not required to be screened for sex  
trafficking, per Illinoiss policies, so they were ineligible for inclusion in our evaluation.   
Due to the issues identifying accurate populations of children in Pennsylvania and  
Illinois, findings in these States are not projectable to  all children who returned to  
foster care after going missing.  We, therefore, did not project any of the findings in 
this report.  See Exhibit  2 for details  on each State-identified population and  sample 
sizes.  
Exhibit 2: State-identified population of children in foster care who returned  
to the States foster care program after being missing from July 1, 2018, 
through June 30, 2019.  
Identified   Final Sampled  
Population of   Ineligible Sampled   Children in Our 
State   Children   Sample Size   Children   Review  
Illinois   430   100   38   62  
Massachusetts  949   100   12   88  
Minnesota   200   100   9   91  
Pennsylvania   101*   101   27   74  
Texas   949   100   2   98  
     Total   2,629   501   88   413  
*Due to data  limitations, Pennsylvania identified  children who possibly met our evaluation criteria, but this is likely  not  
the entire  population of  children who met these criteria.  
Source:  OIG analysis  of State data and documentation  in foster care case files, 2022.  
Data analysis  
We reviewed the foster care case file  documentation to determine whether each 
sampled child received a screening to identify whether the child was a victim  of sex  
trafficking.  Additionally, we reviewed the foster care case file documentation to  
determine, for the children who received a screening, whether the conclusion  of the  
screening  was  documented  and addressed both risk and victimization  of sex  
trafficking.  
Many of the children included in our review went missing from foster care multiple 
times during our review  period.  For each child, we reviewed  the most recent  return to  
foster care after going missing that occurred from July  1,  2018, through June  30,  2019.  
We evaluated  any  screenings  related to  sex trafficking for each child  following  the 
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Detailed Methodology |  17     
childs most  recent return  to foster care, if any were found in the documentation 
submitted by the State.  
In the cases for which a  child refused to answer screening questions, we determined  
these attempts to screen counted as a screening (i.e., the State met its requirement  to  
screen that  child after the child  returned to foster care).  However, in the absence of  
any further attempts to  screen the child or any notations of additional actions or 
services needed by the child, we determined these cases to not have a conclusion of  
the screening documented.  
We used  State-provided  data to determine whether a child was male or female.  For 
the children for whom the State did not provide such data, we used the case file 
documentation to  identify the pronouns that were used to refer to the child and/or  
that the child used to refer to themselves.  We then based our identification of male 
and female children on the pronouns that were used.  We specifically analyzed gender 
based on previous research that indicated that  male children are less likely to be 
screened to  identify whether they are victims of  sex trafficking.   
Other characteristics have also been identified  as increasing risk for sex trafficking  
victimization.   ACF cited research that has identified children living in poverty; lesbian,  
gay, bisexual, and transgender youth; and minority-race youth to be at  increased risk  
of trafficking; however, these findings may reflect the populations studied rather than 
underlying differences.46   Additionally, the data  we collected for this evaluation  did 
not reliably identify these characteristics.  Therefore, we did  not request or analyze 
additional demographic characteristics for this evaluation.   
Additionally, we conducted a structured interview with ACF staff  who are responsible 
for providing oversight to States regarding children in foster care.  The structured  
interview included questions about the oversight ACF conducted to ensure States 
identify children in foster care who are, or are at  risk of becoming, victims of sex  
trafficking  and related  guidance ACF has provided States.  Additionally, we asked  
about the feedback and/or technical  assistance ACF provided to States related to  
preventing and addressing sex trafficking  of children  in foster care.  We collected  
copies of any documentation available regarding the feedback and technical  
assistance provided.  
 
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Detailed Methodology |  18     
APPENDICES  
Appendix A:  Overview  of  State screenings  for children who 
return to  foster care after going  missing  to  identify whether  
they were victims  of  sex trafficking  
Source: OIG analysis of  documentation in foster care case files, 2022.  
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Appendix A | 19     
Appendix B:  Agency Comments  
Following this page are the official comments from ACF.  
   
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Appendix B | 20     
Office of the Assistant Secretary  | 330 C Street, S.W., Suite 4034  
Washington, D.C. 20201 | www.acf.hhs.gov  
          June 8, 2022  
 
Ms.  Suzanne Murrin  
Deputy Inspector  General  
U.S.  Department  of  Health and  Human  Services  
330  Independence  Avenue,  SW  
Washington,  DC   20201  
   
Dear  Ms.  Murrin:  
 
I  am  writing  to  provide  the  Administration  for  Children  and  Families  (ACF)  response to  the  
Office  of  Inspector  Generals  (OIG)  draft report  titled  In Five States, There Was No Evidence 
That Many Children in Foster Care  Had a Screening for Sex Trafficking When They Returned 
After Going Missing  (OEI-07-19-00371),  which  contains  recommendations  for the  Childrens  
Bureau.  We  appreciate  the opportunity to review  and comment on the  report.  Below  you will  
find our  response to each recommendation.  
 
Recommendation 1:   Work with states to improve compliance with requirements to screen 
children who return to foster care after going missing to identify whether they are victims of  
sex trafficking.  
 
ACF  Response:  ACF  concurs  with this recommendation.   Through the Capacity Building 
Center for States (the Center),  we will continue to work  with states to improve compliance  
with  requirements  to screen children who return to foster care after going missing to identify 
whether they are victims of sex trafficking.  
 
The Center  assists state and territorial child welfare agencies with building capacity to improve 
child welfare practices and achieve better outcomes for children, youth, and families.  The  
Center develops and delivers a variety of services that span the child welfare continuum,  
including those focused  on the  prevention  of trafficking,  and  that can support  trafficking  
assessment  and screening  for children who return to foster care after being  missing.   Current 
available services  to states  include:    
  Tailored technical  assistance to states and territories to  improve outcomes and 
o
overall system functioning.  At the request of  a jurisdiction or the Childrens Bureau,
customized  assistance is available to jurisdictions to support  prevention of sex 
trafficking and implementation of any relevant federal guidance.  In collaboration
with the state (and counties as appropriate) and  the Childrens Bureau, the Center
can assist child welfare  agencies  in implementing performance improvement efforts 
and is available to support the development of programs and services that prevent 
and address trafficking and screen  children who return to foster care after  being
missing. 
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening
 
for Sex Trafficking When They Returned After Going Missing, OEI-07-19-00371        Appendix B | 21  Deputy Inspector General Murrin   Page 2 
  Facilitation  of peer-to-peer connections through peer groups,  such as the  Preventing 
o
  and Addressing Sex Trafficking in Child Welfare Peer Group, promotes 
collaboration among child welfare professionals responsible for coordinating the 
response  to sex trafficking and the  multidisciplinary partners they work with,
including law enforcement, courts, service providers, and other role-specific
professional groups, including the State Foster Care Managers and State Liaison 
Officers.  Membership is open to individuals who meet  the criteria  and must be 
approved by the Childrens Bureau.  Through the Centers peer groups, collaboration
is promoted, and problem solving among peers  is prioritized.  Peers identify 
challenges and share best practices across areas of interest and need, and topics 
discussed  have and may include  implementation of federal guidance and services
and supports to prevent sex trafficking and assessment of risk for children who
return to  foster care after going missing. 
  Supporting identified needs and enhanced service delivery through existing Center- 
o
developed publications, learning experiences, videos, and other digital products.
Products that support  jurisdictions in responding to and developing strategies for 
preventing sex trafficking of youth, including related to requirements  to screen
children who return  to foster care  after going missing, include: 
  At Risk for Sex Trafficking: Youth Who Run Away From Foster Care  
explores  how data can be used to learn more  about youth who run away from 
state custody and how this knowledge can inform interventions.
  Child Welfare Response  to Child and Youth Sex Trafficking, Parts 1, 2, and
3 builds capacity to identify and serve survivors  of child and youth sex
trafficking in order to support the Preventing Sex Trafficking and
Strengthening Families  Act (Pub. L. 113183) provisions.  It contains a
series of four discrete, interconnected training modules and  includes digital
stories from  the perspectives of survivors, workers, caregivers, and providers.
An accompanying introductory webinar and training for  trainers are available 
on the  Childrens Bureaus learning  management system CapLEARN. 
  Child Welfare Virtual Expo: Building Capacity  to Address Sex Trafficking 
and Normalcy. The 2016 Virtual Expo supported child welfare agencies,
courts, and tribes  in meeting the mandates  of Pub. L. 113183.  This event 
featured recognized leaders from national and  state programs, sex trafficking
survivors and advocates,  and young adults formerly in foster care.  Videos,
handouts, and resources are available through the learning experience on
CapLEARN.
  Collaborating With Youth-Serving Agencies  to Respond to and Prevent Sex 
Trafficking of  Youth  provides  state and local  child welfare agencies with 
information on partnering with other  agencies to address sex trafficking and
meet the requirements of Pub. L. 113-183. 
  Identifying Minors and Young People Exploited Through Sex Trafficking: A 
Resource for Child Welfare Agencies  provides information and guidance 
about sex  trafficking and  identification of sex trafficking victims.  
  Resources for State Implementation  of  the Anti-Trafficking Provisions  of
P.L. 113183: The Preventing Sex Trafficking and Strengthening Families 
Act of 2014  (recorded webinar) provides information on resources  
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening
for Sex Trafficking When They Returned After Going Missing, OEI-07-19-00371        Appendix B | 22   Deputy Inspector General Murrin    Page 3  
developed to support  states  as they  implement requirements from Pub.  L.  
  113183 aimed at preventing sex trafficking and improving the child 
welfare response to trafficking victims.   
  Identification of existing resources and jurisdictional strategies for meeting 
o
compliance requirements  related to the screening of  children who  return to foster
care after going missing to identify whether they are victims of sex trafficking.  
  Dissemination of  information and resources to public child welfare agencies to
o
support  compliance with requirements to screen children who return to foster
care after going missing to identify whether they are victims of sex trafficking
via  the Centers  webpage, general dissemination  messages through its primary 
listserv, targeted  dissemination  messages to specific peer groups via listservs, 
including a Pub.  L. 113-183: Preventing Sex Trafficking Constituency Group
listserv, and through direct communication with  child welfare agency contacts
through the Centers  tailored services.   
 
Recommendation 2:   Encourage all  states to evaluate the value of adding an assessment of 
risk for sex trafficking when children return to foster care after going missing.  
 
ACF  Response:  ACF  concurs  with this recommendation.   We will continue to encourage  
all states to evaluate the value of adding an assessment of risk for sex trafficking when 
children return to foster care  after going missing.  
 
As noted, on behalf of  the  Childrens Bureau, the  Center assists state and territorial  child welfare 
agencies with building  capacity to improve child welfare practices and achieve better outcomes 
on behalf of the Childrens Bureau.  The Center  develops and delivers a  variety of services  that  
span the  child welfare continuum  including those  focused on prevention of  trafficking and 
supporting  jurisdictional  enhancements related to  assessment and response to trafficking risk  for  
children who return  to foster care  after being missing.   Available services to states  include:   
  Tailored technical  assistance to states and territories  including services to  support  the 
o
prevention of sex trafficking and implementation of  related  risk assessments for 
children returning to  foster care after going missing.  In collaboration with the state 
(and counties as appropriate)  and the  Childrens  Bureau, the  Center  is  available to 
support the  development of programs and services that  respond to federal legislation
and prevent and  address sex  trafficking.  
  Facilitation  of peer-to-peer connections through peer groups  such as  the Preventing 
o
and Addressing Sex Trafficking in Child Welfare Peer Group,  which promotes 
collaboration among child welfare professionals  responsible for coordinating the 
response to sex trafficking and the  multidisciplinary partners  with whom  they work.
Through the Centers peer groups,  including role-specific groups like the State
Foster Care Managers, peers identify challenges and share best practices across areas
of interest and need.  Topics  are  discussed  and focus on  problem-solving  and may
include services and supports to  prevent sex  trafficking and assessment of risk for
children who return  to foster care  after going missing.  
  Identification of existing resources and jurisdictional strategies  that demonstrate the 
o
value of, as well  as  examples of  processes and  tools for  assessing risk for trafficking
particularly for  children who return to foster care after going missing. 
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening
for Sex Trafficking When They Returned After Going Missing, OEI-07-19-00371        Appendix B | 23   Deputy Inspector General Murrin    Page 4  
  Dissemination of  existing  information and resources to public  child welfare agencies
o
  related to  evaluating  the value  of  assessing risk for trafficking,  particularly for 
children who return to foster care after going missing, via  the Centers  webpage; 
general dissemination  messages  through its primary listserv;  targeted dissemination 
messages to  specific peer groups via listservs;  and indirect communication with 
public  child welfare agency contacts through its tailored services.  
 
Recommendation 3:   Conduct oversight activities to identify states that may not screen all 
children for sex trafficking when they return to foster care after going missing.  
 
ACF Response:   ACF  concurs  with this recommendation.  We  have  instructed  regional office  
staff to contact the appropriate officials  in each  of the five states  identified in the  report as  
potentially not screening  children for sex trafficking in accordance with section  
471(a)(35)(A)(iii) of the Act.   The regional offices will remind these state officials of the title  
IV-E plan requirement and work with them  to ensure they are meeting it.  However, we caution
that a  review of case file documentation alone does not capture the  full extent of practice  for a 
particular case.   In our  experience, this shows how successful a state is at documenting items in 
case files rather than how these requirements were implemented and carried out through 
casework practice.   We developed  the case review process for the Child  and Family  Services
Reviews (CFSRs) with this in mind (the process includes not  only a review of case file
documentation, but also interviews  with those  involved in the case). 
 
If ACF believes that a state is not in  compliance  with the  requirement in  section  
471(a)(35)(A)(iii) of the Act, ACF would initiate  the existing  partial review process as described  
in regulation at 45 CFR 1355.32(d).  If ACF then determines that the  state  is out of compliance  
with the  title IV-E plan, we would then notify the state and work with them to implement a  
program improvement  plan.  If  the state remains out of compliance,  the state could be subject to  
penalties  related to the extent of noncompliance  as described in regulation at 45 CFR 1355.36.  
 
ACF does not yet have enough information to determine  whether  amending  ACF regulations to 
require states to report information  about sex trafficking screenings in  the Child and Family  
Services Plan (CFSP) or to assess sex trafficking screenings as part of  the CFSRs  is necessary, 
but we take  the duty to prevent  trafficking seriously and will work to emphasize  this duty to state  
programs.   As  OIG acknowledges, in relying on case file documentation, the study may have  
underestimated how many children received required screenings.  We will continue to use our  
existing regulatory review and oversight processes as described above to further  explore the  
scope of potential noncompliance  and will continue to evaluate what, if  any, regulatory changes  
may be needed.  
 
 
 
 
   
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Again, I appreciate  the opportunity to review  and comment  on this  draft  report.  Please direct any  
 follow-up  inquiries to our OIG liaison Scott Logan, Office of Legislative  Affairs and  Budget, at 
(202) 401-4529. 
 
            Sincerely,  
 
 
 
             
January Contreras   
Assistant Secretary  
Administration for Children and Families  
U.S. Department of Health and Human Services  
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening
for Sex Trafficking When They Returned After Going Missing, OEI-07-19-00371        Appendix B | 25  
ACKNOWLEDGMENTS  AND CONTACT  
Acknowledgments  
Abbi Warmker, a Deputy Regional Inspector General for Evaluation and Inspections in 
the Kansas City regional office, served as the team leader for this study.  Others in the 
Office of Evaluation and Inspections who conducted the study include Haley Lubeck  
and Andrea Staples.  Office of Evaluation and Inspections headquarters staff  who  
provided support include Althea Hosein, Kevin Manley, and Christine Moritz.  
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including  Jessica Swanstrom.   
This report was prepared under the direction of  Brian Whitley, Regional Inspector 
General for Evaluation and Inspections in the Kansas City regional  office, and  Dana 
Squires, Deputy Regional Inspector General.  
Contact  
To obtain  additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found  
on the OIG website at  oig.hhs.gov.  
Office of Inspector General  
U.S. Department of Health and  Human Services  
330 Independence Avenue, SW  
Washington, DC 20201  
 
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Acknowledgments and Contact | 26     
ABOUT THE  OFFICE  OF INSPECTOR  GENERAL  
The mission of the Office of Inspector General (OIG), as mandated by Public Law  
95-452, as amended, is to protect the integrity of the Department of Health and  
Human Services (HHS) programs, as well  as the health and welfare of beneficiaries 
served by those programs.  This statutory mission is carried out through a nationwide  
network of audits, investigations, and inspections conducted by the following  
operating  components:  
The Office of  Audit Services (OAS)  provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work  
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and  contractors in carrying out their respective responsibilities and are 
intended to  provide independent assessments of HHS programs and operations.   
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS.  
The Office of Evaluation and Inspections  (OEI)  conducts national  
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable  
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental  
programs.  To promote impact, OEI reports also  present practical recommendations 
for improving program operations.  
The Office of Investigations  (OI)  conducts criminal, civil, and  administrative 
investigations of fraud and misconduct related to HHS programs, operations, and  
beneficiaries.  With investigators working in all 50 States and the District  of  Columbia, 
OI utilizes its resources by actively coordinating  with the Department  of  Justice and  
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil  
monetary penalties.  
The Office of Counsel to the Inspector General (OCIG)  provides 
general legal services to  OIG, rendering advice and opinions on HHS programs and  
operations and providing all  legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS  
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also  negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities. 
In Five States, There Was No Evidence That Many Children in Foster Care Had a Screening  
for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   About OIG | 27     
ENDNOTES   
 
1  The Administration for Children and Families (ACF),  Guidance to States on Addressing Human trafficking of Children and 
Youth in the United States,  September 2013.  Accessed at https://www.acf.hhs.gov/cb/resource/human-trafficking-guidance  
on April 24, 2019.  
2  National Center for Missing and Exploited Children (NCMEC),  Child Sex Trafficking Overview,  2021.  Accessed at 
http://www.missingkids.org/content/dam/missingkids/pdfs/CST%20Identification%20Resource.pdf  on November  5,  2021.  
3  The Trafficking Victims Protection Act of 2000, as amended  (P.L. 106-386,  Oct. 28, 2000) includes definitions codified  at 22 
U.S.C.  7102.   Sex trafficking is defined as the recruitment, harboring, transportation, provision, obtaining, patronizing, or  
soliciting of a person for the purpose of a  commercial sex  act.  Severe forms of trafficking in persons includes sex trafficking 
in which the  person induced to perform such act has not attained 18 years of age.   Commercial sex act means  any sex act  
on account of which anything of value is given to or received by any person.  22 U.S.C.  7102(12),(11),  and (4), respectively.  
4  NCMEC,  Child Sex Trafficking Overview, 2021.  Accessed at  
http://www.missingkids.org/content/dam/missingkids/pdfs/CST%20Identification%20Resource.pdf  on November  5,  2021.  
5  ACF,  Report to Congress: The Child Welfare System Response to Sex Trafficking of Children, August 2019.  Accessed at 
https://www.acf.hhs.gov/sites/default/files/documents/cb/report_congress_child_trafficking.pdf  on April  26, 2021.  
6  ACF,  Report to Congress: The Child Welfare System Response to Sex Trafficking of Children, August 2019.  Accessed at 
https://www.acf.hhs.gov/sites/default/files/documents/cb/report_congress_child_trafficking.pdf  on April  26, 2021.  
7  ACF,  Guidance to States on Addressing Human Trafficking of  Children and Youth in the United States, September 2013.   
Accessed at  https://www.acf.hhs.gov/cb/resource/human-trafficking-guidance  on April 24, 2019.  
8  ACF,  Guidance to States on Addressing Human Trafficking of  Children and Youth in the United States, September 2013.   
Accessed at  https://www.acf.hhs.gov/cb/resource/human-trafficking-guidance  on April 24, 2019.  
9  HHS, Secretary Becerra Announces New HHS Task Force to Prevent Human Trafficking,  January 2022.  Accessed at 
https://www.hhs.gov/about/news/2022/01/31/secretary-becerra-announces-new-hhs-task-force-to-prevent-human-
trafficking.html  on February 2, 2022.  
10  The White House,  The National Action Plan to Combat Human Trafficking (NAP), December 2021.  Accessed at  
https://www.whitehouse.gov/briefing-room/statements-releases/2021/12/03/fact-sheet-the-national-action-plan-to-combat-
human-trafficking-nap/  on February 2, 2022.  
11  45 CFR  1355.20.  For Title IV-B, State means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico,  
Guam, the Virgin Islands, the Commonwealth of the Northern Mariana Islands, and American Samoa.  For Title  IV-E, State  
means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, and  
American Samoa.    
12  For eligibility requirements for Tribes, see 42 U.S.C.  628,  632(b)(2), and 679c.  Tribes  refers to Indian Tribes and Tribal 
organizations as defined in 25 U.S.C. 450(b).  
13  States reported that more than 670,000 children were served by the foster care system in fiscal year 2019the fiscal year  
that most closely aligns with this evaluations review  period.  ACF, The AFCARS Report.  Accessed at  
https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport27.pdf  on August 12, 2021.  The most recently  available  
data shows that States reported over 630,000 children were served by the foster care system in fiscal year  2020.  ACF,  The 
AFCARS Report.  Accessed at  https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport28.pdf  on 
December  29,  2021.   
14  45 CFR  1357.15(b) and 1356.20(c)(2).  
15  42 U.S.C.  671(a)(2).   
 
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Endnotes  | 28    
 
16  ACF,  Program Instructions.  Accessed at  https://www.acf.hhs.gov/cb/laws-policies/program-instructions  on August 12, 2021.  
17  42 U.S.C.  1320a2a.  ACF,  Monitoring.  Accessed at  https://www.acf.hhs.gov/cb/training-technical-assistance/monitoring  
on August  12, 2021.  
18  ACF,  CFSR Round 4 Onsite Review Instrument and Instructions, 2021; and  CFSR Statewide Assessment, 2021.  Accessed at 
https://www.cfsrportal.acf.hhs.gov/resources/round-4-resources/cfsr-round-4-instruments-tools-and-guides  on 
January  27,  2022.  The CFSR includes assessments of child safety, permanency, and child and family well-being.  It also  
measures State performance on seven systemic factors, including the  effectiveness of (1) the statewide child welfare  
information system; (2) the case review system;  (3) the quality assurance system; (4) staff and provider training; (5) the service  
array and resource development; (6) the agencys responsiveness to the community; and (7) foster and adoptive parent 
licensing, recruitment, and retention.  ACF,  CFSR General Factsheet.  Accessed at  https://www.acf.hhs.gov/cb/fact-sheet/child-
and-family-services-reviews-fact-sheet  on January  27,  2022.  
19  45 CFR  1355.32(d).  ACF, Child Welfare Policy Manual,  5.1.  
20  P.L. No. 113-183 (Sept. 29, 2014),  101(a)(3)(C)(i), codified at 42 U.S.C.  671(a)(35)(A)(i).  
21  42 U.S.C.  671 (a)(9)(C)(i).  States were required to demonstrate that they developed these policies and procedures by 
September 29, 2015, and implemented these policies and procedures by September 29, 2016, 1 and 2 years after the  
Preventing Sex  Trafficking and Strengthening Families Act enactment, respectively (42 U.S.C.  671(a)(9)(C)(i) and (ii)).  
22  This requirement  applies to any child or youth in the placement, care or  supervision of the title IV-E  agency who is at-risk  
of becoming a  sex trafficking  victim or who is a sex trafficking victim (including those not removed from  home; those who 
have run away from foster care and under age 18 or such higher age elected under 475(8); and youth not in foster care who 
are receiving services under the Chafee  Foster Care Independence  program (CFCIP) (477)), and at the option of the agency,  
youth under age 26 who were  or were never  in foster care.   ACF,  ACYF-CB-IM-14-03.   Accessed at  
https://www.acf.hhs.gov/sites/default/files/documents/cb/im1403.pdf  on March  21, 2022.  
23  42 U.S.C.  671(a)(35)(A)(i) and (iii).   
24  P.L. No. 113-183 (Sept. 29, 2014),  105.  
25  For the purposes of the foster care  program, a sex trafficking victim is defined as either (a) a victim of sex trafficking, 
which is the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose  
of a commercial sex act; or (b) a victim of severe forms of trafficking in persons, which includes a commercial sex act, in  
which the person induced to perform such act has not attained 18  years of age, regardless of force, fraud, or coercion  (42  
U.S.C.  675(9)).  
26  ACF,  Report to Congress: The Child Welfare System Response to Sex Trafficking of Children, August 2019.  Accessed at 
https://www.acf.hhs.gov/sites/default/files/documents/cb/report_congress_child_trafficking.pdf  on April  26, 2021.    
27  ACF,  Report to Congress: The Child Welfare System Response to Sex Trafficking of Children, August 2019.  Accessed at 
https://www.acf.hhs.gov/sites/default/files/documents/cb/report_congress_child_trafficking.pdf  on April  26, 2021.    
28  P.L. No. 113-183 (Sept. 29, 2014),  121; codified at 42 U.S.C.  1314b.  
29  National Advisory Committee on the Sex Trafficking of Children and Youth in the United States,  Best Practices and 
Recommendations for States, September 2020.  Accessed at 
https://acf.hhs.gov/sites/default/files/documents/otip/nac_report_2020.pdf  on September  25, 2020.  
30  National Advisory Committee on the Sex Trafficking of Children and Youth in the United States,  Preliminary State Self-
Assessment Survey Overview, January 2022.  Accessed at 
https://www.acf.hhs.gov/sites/default/files/documents/otip/NAC%20Preliminary%20State%20Self-
Assessment%20Survey%20Overview_January%202022.pdf  on April 4, 2022.   
31  According to the report, the  Committee will statutorily sunset in January 2022.  However, the Committee has been 
authorized to operate  as a discretionary advisory committee  for an additional 24 months.  Through this extension, the  
Committee will submit a more comprehensive report that is inclusive of responses and updates received  from States after  
December 10,  2021, and that analyzes the narrative information that States submitted.   
 
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for Sex Trafficking When They Returned After  Going Missing, OEI-07-19-00371   Endnotes  | 29    
 
32  P.L. No. 113-183 (Sept. 29, 2014),  121(e)(d)(3)(E); codified  at 42 U.S.C.  1314B(d)(3)(E).  
33  National Advisory Committee on the Sex Trafficking of Children and Youth in the United States,  Best Practices and 
Recommendations for States, September 2020.  Accessed at 
https://acf.hhs.gov/sites/default/files/documents/otip/nac_report_2020.pdf  on September  25, 2020.  
34  The State must report to ACF on an annual  basis the total  number of children who are sex trafficking victims.  The number  
of children who were sex trafficking victims prior to entering foster care  and while in foster care must be  reported to the  
Adoption and  Foster Care Analysis and Reporting System (AFCARS).  P.L.  No. 113-183 (Sept. 29, 2014),   102 and 103;  
codified at 42  U.S.C.  679(c)(3)(B) and 679(c)(3)(E).  
35  OIG,  National Snapshot of State Agency Approaches To Reporting and Locating Children Missing From Foster Care, May 2022.   
Accessed at  https://oig.hhs.gov/oas/reports/region7/72006095.pdf  on June  15, 2022.  
36  OIG,  Case Study: Missouri Efforts To Protect Children Missing From Foster Care, September  2021.  Accessed at 
https://oig.hhs.gov/oei/reports/OEI-07-19-00372.pdf  on October 20, 2021.  
37  OIG,  ACF Cannot Ensure That All Child Victims of Abuse and  Neglect Have Court Representation, March 2021.  Accessed at 
https://oig.hhs.gov/oei/reports/OEI-12-16-00120.pdf  on July 7, 2021.  
38  OIG,  Kansas Did Not Ensure That Group Homes for Children in Foster Care Complied With All State Health and Safety  
Requirements, July 2020.  Accessed at https://oig.hhs.gov/oas/reports/region7/71906087.pdf  on September 8, 2021.  
39  OIG,  Not All Children in Foster Care  Who Were Enrolled in Medicaid Received Required Health Screenings, March 2015.   
Accessed at  https://oig.hhs.gov/oei/reports/OEI-07-13-00460.pdf  on July  7, 2021.  
40  States report annually to the Adoption and  Foster Care Analysis and Reporting System (AFCARS).  They report the  
placement status of each child in their foster care  program on September 30one status that can be reported is runaway  
status.  We used fiscal year 2018 AFCARS datathe most recent at the timeto make the State selection.  
41  At the time we selected States for this evaluation, not every  State had yet developed policies and procedures for screening 
children to determine if they  are possible sex trafficking victims after locating children  missing from foster care, as required  
by the Preventing Sex Trafficking Act.  
42  In the Texas Department of Family and Protective Services  (DFPS), a special investigator is a DFPS staff member with  a law  
enforcement background and experience in criminal investigations.  Texas DFPS,  Special Investigations.   Accessed at  
https://www.dfps.state.tx.us/Investigations/special_investigations.asp  on November 4, 2021.  
43  We specifically analyzed gender based on previous research that indicated that male  children are less likely to be screened 
to identify whether they are victims of sex trafficking.  Other  characteristics  have also been identified as increasing a  childs  
risk for sex trafficking victimization.  ACF cited research that has identified children  living in poverty; lesbian, gay, bisexual,  
and transgender youth; and minority-race youth to be at increased risk of trafficking; however, these findings may reflect the  
population studied rather than underlying differences.  Additionally, the data we collected for this evaluation did not reliably  
identify these characteristics.  Therefore, we  did not request or analyze additional demographic characteristics for this  
evaluation.  ACF,  Report to Congress: The Child Welfare System Response to Sex Trafficking of Children, August 2019.  Accessed  
at  https://www.acf.hhs.gov/sites/default/files/documents/cb/report_congress_child_trafficking.pdf  on April 26, 2021.  
44  Child advocacy centers are  community-based, child-friendly, multidisciplinary services for children and families affected by  
sexual abuse or severe physical abuse.  These  centers have trained  interviewers who know the right questions to ask in a way  
that does not retraumatize the child, and the centers provide a  coordinated, comprehensive response to victims and their  
caregivers.  ACF,  Child Advocacy Centers.  Accessed at  https://www.childwelfare.gov/topics/responding/iia/investigation/  
multidisciplinary/advocacy/  on July  6, 2021 (webpage no longer active).  National Childrens Alliance,  How The CAC Model 
Works,  2022.  Accessed at https://www.nationalchildrensalliance.org/cac-model/  on February 1, 2022.  
45  The five counties were Bexar,  Dallas, Harris, Tarrant, and Travis.  
46  ACF,  Report to Congress: The Child Welfare System Response to Sex Trafficking of Children, August 2019.  Accessed at 
https://www.acf.hhs.gov/sites/default/files/documents/cb/report_congress_child_trafficking.pdf  on April  26, 2021.  
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