259: Which Screening Tool Should I Use, with Dr. Corey Rood

Ending Human Trafficking Podcast

Dr. Sandra Morgan and Dr. Corey Rood discuss what screening tools are, their prevalence in prevention and identification of human trafficking, and how diverse human trafficking screen tools are due to the complex nature of human trafficking and exploitation.

Corey Rood, MD

Dr. Corey Rood is the Medical Director of Child Abuse Pediatrics with the Department of Pediatrics at UC Irvine, the CAST medical clinic, and the Child Abuse & Prevention Team at Miller Children’s and Women’s Hospital in Long Beach. He is an Assistant Professor of Pediatrics with the UC Irvine School of Medicine. As a Child Abuse Pediatrician, his work focuses on the diagnosis, care, and management of potentially abused and neglected children. Dr. Rood’s clinical and research interests and expertise include commercially sexually exploited children (CSEC) including human trafficking, both international and domestic. Dr. Rood’s research endeavors include recent studies on sexting and online sexual solicitation exposure amongst adolescents with suspected sexual abuse, and human trafficking screening of adolescent patients.

Key Points

• Screening tools are a set of questions to define a specific characteristic.
• There is no one screening tool for human trafficking since human trafficking is a complex issue that requires adjustments based on the target population.
• Validated screening tools should be developed with the target populations characteristics, such as age, language, and mental development.
• Screening should be viewed as a conversation starter that is culturally sensitive, trauma informed, and victim centered.

Resources

• WestCoast Children’s Clinic Commercial Sexual Exploitation Identification Tool (CSE-IT)
• Vera Institute of Justice Trafficking Victim Identification Tool (TVIT)
• EP. 169 – Dr. Jodi Quas: Communicating with Child Victims of Trauma
• EP. 216 – Wisdom from a Sexual Assault Nurse Examiner
• EP. 217 – What to Know When Talking to Child Trafficking Victims
• Anti-Human Trafficking Certificate program

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Transcript

Dave [00:00:00] You’re listening to the Ending Human Trafficking podcast. This is episode number 259, Which Screening Tool Should I Use with Dr. Corey Rood.

Production Credits [00:00:10] Produced by Innovate Learning, maximizing human potential.

Dave [00:00:30] Welcome to the Ending Human Trafficking podcast. My name is Dave Stachowiak.

Sandie [00:00:36] And my name is Sandie Morgan.

Dave [00:00:38] And this is the show where we empower you to study the issues, be a voice, and make a difference in ending human trafficking. Today Sandie, I’m so glad for us to be able to have an expert on the show who’s going to help us to learn even more about looking at this through the lens of children. So many complex situations, of course, that emerge. And I’m so grateful for the experts that take their time to teach us. I’m pleased to introduce to you Dr. Corey Rood. He is a medical director of child abuse pediatrics with the Department of Pediatrics at the University of California, Irvine, the Cast Medical Clinic, and the Child Abuse and Prevention Team at Miller Children’s and Women’s Hospital in Long Beach, California. He is an assistant professor of pediatrics with the UC Irvine School of Medicine. As a child abuse pediatrician, his work focuses on the diagnosis, care and management of potentially abused and neglected children. His clinical and research interests and expertise include commercially sexually exploited children (CSEC), including human trafficking, both international and domestic. His research endeavors include recent studies on sexting and online sexual solicitation, exposure among adolescents with suspected sexual abuse, and human trafficking screening of adolescent patients. Corey, such a pleasure to have you on the show. Thanks for taking the time to be here.

Corey [00:01:59] Yeah, thanks for having me, Dave and Sandie. It’s exciting to be able to talk about this topic and to be on the podcast.

Sandie [00:02:05] Maybe we’re going to have to have you another time because I do want to talk about your research on sexting and online solicitation. But today our subject is screening tools. I think this is this is an area where there are a lot of people who could be using screening tools, but they aren’t either because they’re not available or it never occurred to them that it fit their particular environment. So let’s start off with what is a screening tool?

Corey [00:02:37] Yeah, that a great question. And I agree with you that many people are interested and I often get asked about screening tools and just understanding what a screening tool is can help answer a lot of those questions. So a screening tool, even outside of the medical setting, is really a set of questions that are used to get to a specific conversation, or more specifically, to solicit information to make either a diagnosis or a designated definition for a specific individual, or they can even be used on companies and other sort of other entities. But basically, it’s a set of questions to define a specific characteristic. And in medicine, that specific characteristic is also often a diagnosis or a definition. And screening tools are used specifically for the purpose of diagnosis or even prevention.

Sandie [00:03:38] So when I was working in on a pediatric unit night shift, I quickly learned that night nurses must be smarter than day nurses because my decision tree of when to call and wake up the pediatrician was longer. And when I started looking at screening tools around human trafficking, I began to understand that it’s kind of like a decision tree. If you see this, then you climb that direction and if you don’t, then you go off this way. And sometimes people feel like they have to have all the answers before they pick up the phone. But I don’t think that a screening tool is directive in that respect. It helps you refine your understanding of what you’re seeing, depending on whether you’re the receptionist at the front office at a school or you’re the physician in the examining room. Obviously, your screening tool is a lot longer than mine and the kind of tools that are available for addressing human trafficking, what do they look like? What can we find right now?

Corey [00:05:01] Well, Sandie, I agree. Human trafficking screening tools, they’re complex. And the reason they’re complex is it’s a complex topic. I agree with you in a sense of unlike screening tools where a diagnosis, for example, we use screening tools to diagnose everything from, you know, certain cancer diagnoses or predispositions, maybe adverse childhood experiences, even squashed questions like risk factors like smoking and so forth in medicine to get to a very pointed diagnosis or pointed intervention. Human trafficking, on the other hand, is such a complex issue. Many of the people who are taking the questions are at the screening or don’t even know themselves or recognize that they are being trafficked or exploited. So the approach is very diverse. And so there isn’t one screening tool fits all sort of approach to human trafficking. So there are a number of tools out there, depending on the institution in which you work and where you encounter potential victims, whether that’s you work in government or you work in the justice system or you work in medicine or you work in the labor field. The way in which you screen and the persons you are screening is so diverse. But you’re trying to come to a general understanding of a vulnerability or exploitation. The questions can vary from tool to tool.

Sandie [00:06:39] So give us a couple of examples.

Corey [00:06:41] So, there are a number of tools out there. Most of them target sexual exploitation or sex trafficking, most of them target adult populations. But there are a few that target children. So there’s the child sex trafficking screening tool or the CST often referred to in medicine because it was tested and and validated in emergency rooms, specifically targeting adolescents and children. There’s a West Coast Children’s Clinic commercial sexual exploitation tool, and there are quite a smattering of other tools developed by individual agencies, such as specific health programs and justice programs such as the Vera Institute, the Urban Institute, Massachusetts Medical, all these different institutions that have developed screening tools as well.

Sandie [00:07:41] We’ll put all those links in the show notes so that people can go and take a little deeper dive. But you said something really important about screening tools. I have seen people sort of create their own screening tools in certain situations with no background, and maybe the next step might not be the best practice step. And so you use the term validated. Can you tell us what a validation process looks like and what we can hope to assume if we’re using a validated tool?

Corey [00:08:20] Yeah, so validity is important any time you are using questions in an organized format, like a screening tool to get the answer that you are hoping to solicit. So, if I want to feel that the questions I’m asking are reliable and that the answers I’m getting therefore mean the conclusion that I want the validity is necessary. And the way that works is there are a number of steps to validation. The first step is using what’s called establish– you basically establish face validity. So you start with an expert, start with someone who knows about, in this case, knows about human trafficking in its various forms and manifestations domestically, maybe internationally, depending on who you’re targeting. Use those experts to help you develop the questions targeting the individuals that you want to screen. So you’re correct, Sandie, having someone who is experienced and knowledgeable as an expert. The second step is to once you’ve put together those questions, you can even involve a what’s called a psychometrician, which is basically a person who helps develop questions, understanding the psych behind the way we ask questions. Once you have those questions put together, then you need to pilot them. You need to have a group of individuals who may not necessarily be your target population, but are a population of individuals who can go through the questions and answer them and give you feedback. And the number of individuals to do that can be a lot, hopefully not too few. But in general, it’s recommended that you have about 10 to 20 pilot individuals for every question in your tool so it can add up. But you want to have a good chunk of people pilot it and give you feedback. And then you take all of that information from your pilot, you clean up the data, you run some statistics specifically with a statistician or if you know statistics yourself and you’re good at them and make sure that there’s internal consistency in the questions you’re asking to make sure that, as you ask them, that they are lining up between all of your pilot individuals, and then compare those results to what you know is the prevalence or the general prevalence or the general occurrence in the general population. So if I want to validate the screening tool on child sex trafficking, I will follow those steps. And then knowing that there is specific statistics out there about prevalence of child sex trafficking in the community, I will see if my tool is reaching those same prevalence rates. And that’s a good way to validate our tool and feel confident that it’s reliable.

Sandie [00:11:33] That is so helpful. And I see two things here. First of all, the idea of being able with that pilot to understand what is actually happening or not happening, but being able as a practitioner to ask knowledgably, how was this piloted? I saw a study on a prevention tool that was piloted in an AP class among juniors and seniors in high school. Well, my population of trafficked kids were mostly a little younger and certainly didn’t qualify to be in the AP class. So that wasn’t helpful for me, but it was really important for me to find that out. I also, I can’t help myself because I love the word psychometricians. I like it that I know how to say it. And for two reasons. Number one, I always have students who feel like they have to change their career to fight human trafficking. They have to go become a social worker. Or as many of you who have listened to Derek Marsh, call me a tree hugger. You don’t. You can be a brilliant mathematician or become a psychometricians. Do you love statistics? I think Dr. Jodi Quas qualifies in that area and has been on the podcast. So I want people who are looking for ways to get involved to begin to see how you use your strengths, not just change over and be like me. OK, so I got to throw my 50 cents in there. Let’s talk about what you’re looking for in a good screening tool for those particular populations.

Corey [00:13:28] Specifically, what am I as– I’m a pediatrician. I’m a medical provider. What is it that I want to find out either about my patient or my patient’s experiences to either help them avoid it in the future or they screen negative and I can reassure myself that they haven’t experienced or they’re not currently a victim. I need to know what it is that I want to find out. So if it’s that my patient is being sex trafficked or being sexually exploited, then I need to, you know, form my questions so that they target that specific vulnerability or that victimization process. If I want to find out if my adolescent patients or youth are being labor exploited, then I need to target my questions specifically towards labor. And there may be an overlap. And maybe I want both. So I need to decide as a provider what I want to know about the individuals I serve and then put together either use a tool that’s already validated that has those targets built into them. Or, I may need to combine and go combine a couple of different validated screening tools and go through a validation process of my own so that I can specifically target the question or the topics that I’m interested in.

Sandie [00:15:05] So you’re saying then there isn’t a one size fits all? I can’t just buy a survey, give it, and then I know these kids are safe. These are not.

Corey [00:15:15] Yeah. Right now, with regard to human trafficking, there really isn’t a one size fits all. There are some great tools that are coming out and have come out recently in the past three to five years that are combining this idea of screening for sex trafficking, screening for labor trafficking. We’re working on one now that we–being a couple of my colleagues and I here in Southern California–that combines other vulnerabilities and risk factors as well as teen dating violence. And so the idea is that, is there something comprehensive? Not exactly at this time, but there may be in the near future. And so one size fits all in human trafficking screening tools is not yet available. And so people who are interested in screening or who have populations can adapt and build as long as they follow a good structured process.

Sandie [00:16:10] So one of the things, well, I’ve got like six questions now. So when you’re thinking about culture and developmental age, how, because you’re a pediatrician, how do you use a screening tool when you’ve got such huge differences between a 10 year old, a 12 year old, and a 16 year old?

Corey [00:16:39] Fantastic question. And I don’t know there’s the one simple answer, Sandie. But it definitely has to be addressed because–

Sandie [00:16:47] But, people are using tools that way. You know that.

Corey [00:16:50] Yes, they absolutely are. And unfortunately, the findings, their conclusions from those are not necessarily as reliable and they have significant consequences.

Sandie [00:17:03] Tell me some of those consequences.

Corey [00:17:05] Well, we know, you know, in human trafficking if you get a false negative, in other words, you in other words, you do the screening tool and it comes back negative and you think, oh, good, they’re not being exploited. But it wasn’t in a language they understand or it wasn’t in you know, it wasn’t at a fifth grade reading level. And maybe that’s all they can read or maybe they are developmentally delayed and can’t read. And so you just gave it to them and all they did was just circle the nose. And so your your reliability is lost because it’s not adapted to their specific language, age, developmental level. So that can be incredibly damaging because maybe they are being exploited and they’re incredibly vulnerable if they’re younger, if their developmentally delayed, or they don’t speak the language. We know those are vulnerabilities. And yet we feel comfortable that our screening tool ruled them out, even though our screening tool was not specifically adapted to them.

Sandie [00:18:06] And some of this I think it’s down to common sense. And you learn when you start working with recently recovered victims that some of the questions we asked off the top of our heads when we picked somebody up was, well, did you have anything to eat today? And the girl said, yes. And then the next person said, so, what did you eat? And she pulls candy wrappers out of her pocket because that’s what she grabbed from the hotel desk on her way out. So what we ask is just so as important as asking anything. And what if we think, oh, we’ve got that, OK, and so then nobody goes and gets her breakfast? Lots of risks for those consequences. That’s what you see, right?

Corey [00:18:57] Well, yeah. And in your same analogy. Did you eat today? Sure. The what and the when and how much and are you hungry now? Those are all pertinent questions that get at the same idea. Give us more context.

Sandie [00:19:17] So one of the things that I think is a huge blessing about living in Orange County is we have such a multicultural county and I can go two miles and be in a culturally relevant Asian population and then go the other direction. And my Spanish is European Spanish. But I can’t understand the the gal at my grocery store. So those kind of of language and culture issues in Orange County, and you’re a physician, how do you manage that when you’re trying to get to identify an actual, for want of a better word, diagnosis or decision?

Corey [00:20:05] Well, it’s crucial for this conversation regarding screening, because screening is in and of itself, the purpose of screening is a conversation starter. The purpose of screening is not to elicit a disclosure, as many people think it is. I just want the answer. Yes or no. Instead, seeing screening as as a conversation starter, that conversation needs to be culturally sensitive, trauma informed, victim centered, you know, in case you are speaking with a victim. So beginning with understanding as much as you can about your client or your patient before you even start the process is incredibly helpful in case you need a different language, in case you need it translated into a different language or an interpreter, in case the person administering the tool, if it is administered in person, is also culturally aware. Is it OK for them to be alone? How should they address the individual? All those things. The more comfortable and the more appropriate your screening is for these individuals, taking into account their age and their culture and maybe their religion and their language and all those things that go into their identity, the more reliable your results are going to be from your tool, because they’re going to feel comfortable. They’re going to potentially and studies show that they’re going to be more honest and more open about the conversation that you’re trying to solicit from your tool.

Sandie [00:21:54] OK, so this just slides right into this next piece of our conversation. Who does the screening? Because if everybody in Orange County has to go to Dr. Corey Rood, we’re not going to screen very many people. I got a call years ago when I was task force administrator from a high school nurse who had met me at a training. And she said, so I think you need to come and do some training here. I have 12 high school girls who are pregnant and 10 of them don’t know who the father is. Do you think this might be something? So we went and had some conversation and we actually did identify some CSEC victims. But people didn’t know what questions to ask. They they didn’t know who to ask. And when they did ask those questions, they weren’t really sure who to call from an administrative point of view. She knew to call me because she had my card in an old drawer and that was happenstance. We have to be more structured and at least have a few things that set off some red flags or whistles or whatever, so that it does then make it to a more professional level.

Corey [00:23:13] Yeah, I fully agree. With any screening, who should be doing it is all part of the structured plan of implementation before you even go live with the tool in your workspace or with a group of teenagers or individuals or your patients. There needs to be a plan of rolling it right, going live, rolling it out. And in that plan you identify who is it within our clinic or workspace that is going, who are these individuals who are going to do the screening? And even down to the question of, are we going to be screening in person or are we going to be using an electronic device, a tablet or paper and pencil to implement our screening tool? Who’s going to review those answers if we do allow them to screen on their own? Where is that information going and how are we reviewing it? How are we collecting it and interpreting it? So beginning with that plan and identifying those individuals. Those individuals who do implement the screening tool should be trained on how screening tools worked as a basic training, how to implement them, but also with this specific population, with their vulnerabilities and victimization and understanding of what human trafficking, CSEC, labor trafficking look like. And that needs to be accompanied by trauma informed, culturally sensitive training so that they understand how to respond to victims being uncomfortable with the screening, uncomfortable with the consenting process, and making sure they pick up on cues of cultural sensitivity.

Sandie [00:25:05] So you’re a pediatrician and when you’re talking about trauma informed training and I’m doing you’re teaching me how to do screenings with children, what are the most important components of trauma informed when you’re talking about working with kids?

Corey [00:25:26] Trauma informed can be can be boiled down to basically it’s not as simplistic as this, but the basic idea is that the persons who so in our medical clinic, those who interact with the children and their parents, specifically the patients, need an understanding of what trauma is, the various forms in which children can experience trauma, and then how that may affect their behavior, their interactions with individuals, their reasons for presentation, sort of how does trauma manifest in children and then approaching children, adolescents, with this understanding that they may be coming from a history or an experienced trauma and that trauma may be a single event, it may be complex, compounded over years, multiple events, but stepping back and realizing my patient may have experienced a various degree of trauma and I need to be sensitive to that in the way in which I approach them and understand their behaviors and their responses should include that potential.

Sandie [00:26:44] I really appreciate that. And I, I especially feel like with our kids in school, teachers see things that they don’t always identify. And I, I always go back to studying Finkelhor and the two responses to shame, because often shame is a big part of the trauma response. And kids who have those kinds of experiences may just decide, well, you think I’m bad, so I’m going to act out bad. But, the other response is, I’m going to prove I’m not. And so you have a straight-A student and nobody sees that that can be a trauma response. And I wonder how screening tools, because they’re more nuanced, might go below those stereotypical presenting factors.

Corey [00:27:40] Yeah, the classic example I give is you have a teenager who presents with an event, maybe they’re brought in by a parent or even the police, and there’s been some, you know, some event they’ve maybe got in trouble or they’ve been some things happen. There are two ways to walk into that room. Did this event very likely involved behaviors that they exuded, their own behaviors. There are two ways to walk into that room. I tell my medical students and residents, you can walk into that room and say to the teenager, OK, what did you do this time? Or you can walk into that room and say, OK, so tell me what happened to you or tell me what happened? Tell me your story. Start from the beginning. There are two very different approaches. One is going to come across, if that child has experienced trauma and is going to come, the first is going to come across as accusatory and they very well may be the victim of the incident that occurred. The second is simply soliciting a narrative with this understanding that they could very well be the victim and this is not necessarily their fault. So having that open mind, nonjudgmental and starting the conversation there.

Sandie [00:29:04] Wow. So fast forward because our time’s almost out. What can we hope to expect by refining and having more screening tools? Why should we invest in screening tools in this field?

Corey [00:29:21] Well, first of all, the field has, we have so little information, Sandie, about who are the victims and on all these characteristics of where they are and where they are coming from or where they’re going, their vulnerabilities, how they became exploited. In order for us to fully comprehend the complexities of exploitation and trafficking victimization, we really need to be asking more information from survivors. We need to know their stories. And the best way to do that, as I said, screening tools should be conversation starters. The best way to do that is to have a reliable tool that could start a conversation with people who are going to listen, taking that information and building our general knowledge so that we can use these tools and the information we gather from them to prevent this from happening in the first place. Before we can even get to that prevention, we need to understand what’s going on. And that’s how screening tools can can get us there.

Sandie [00:30:38] I love it. What a great way to end this conversation, which is really just beginning more conversations about this. And I hope that this podcast results in increasing the demand for validated screening tools. And we can we start using them more and more in all kinds of places where we’re encountering these kids and adult victims as well. I wish we had more time because I would like to explore the labor trafficking component of developing tools. But probably your work on that in a few months, we might have a better conversation anyway.

Corey [00:31:19] Absolutely.

Dave [00:31:20] Thank you, Sandie. Thank you, Corey, for this important conversation. So many things I have come away from this conversation I hadn’t thought of before. I hope this conversation has also been helpful to you listening. If you would like to dive in more, please find the notes at endinghumantrafficking.org. All the details will be there, of course, will be linking up to Corey’s work as well. And we’re inviting you to take the first step while you’re online, if you have not before, or perhaps you’re just tuning in for the first or second time, welcome. I hope you’ll hop online and download a copy of Sandie’s guide, The Five Things You Must Know: A QuickStart Guide to Ending Human Trafficking. It’s a free resource that will help you explore the five critical things that Sandie and her work at the Global Center for Women and Justice thinks that you should know before you join the fight against trafficking. You can get access to that by going over to endinghumantrafficking.org. That’s also a great place to begin to learn about the Anti-Human Trafficking Certificate program that’s offered here at Vanguard University. Details on that at endinghumantrafficking.org. And we’ll be back in two weeks for our next conversation. Sandie, always a pleasure. Thanks for the time.

Sandie [00:32:28] Thank you, Dave.

Dave [00:32:29] Take care, everybody.