This chapter discusses the case study of adolescent with a substance use disorder. Confidentiality is defined as an agreement between patient and provider that information discussed during the encounter will not be shared with other parties without patient permission. A confidentiality statement must be provided to adolescents at every healthcare visit. The confidentiality statement assures adolescents that information provided to the pediatric primary care provider (P-PCP) during the office visit is a standard of care that supports full disclosure and trust between the adolescent and the P-PCP, without punitive consequences for the adolescent. P-PCPs must be knowledgeable about the laws in the state in which they practice to provide accurate information to the adolescents with admitted substance use problems. The key to intercepting these behaviors is effective office-based screenings and an immediate intervention with prompt referral to treatment and interprofessional collaborative initiatives at the national, state, and local community levels.

This chapter describes the problem of gang membership along with its assessment; diagnosis; levels of prevention/intervention; primary, secondary, and tertiary strategies for dealing with the behavior; and parenting tips. Youth gangs, which can be formal or informal, typically consist of at least three members and have a distinguishable name, hand sign, or symbol. One of their primary objectives is criminal activity, which differentiates them from other youth social groups such as fraternities, sororities, or social clubs. Identifying a gang member is not an easy task. The best place to identify and refer is in primary care or school health. However, at-risk youth and gang-involved youth may not attend school or have primary care providers. Possible diagnoses may include conduct disorder, antisocial personality disorder, and substance abuse.

This chapter describes the problem of sexual aggression along with its assessment; diagnosis; levels of prevention/intervention; primary, secondary, and tertiary strategies for dealing with the behavior; and additional resources. Sexually aggressive children are children age 12 years or younger who sexually act out in an aggressive manner towards persons who are younger or who are perceived as vulnerable, or both. Child sexual aggression is a complex phenomenon, and theories have only partially explained its occurrence. These have included sexual aggression as a response to sexual abuse victimization; learned behavior from exposure to sexuality and/or violence; early exposure to pornography and advertising; substance abuse; heightened sexual arousal to children; and exposure to family violence and aggressive role models. Health care providers need to differentiate unusual sexual behaviors in children from offending behaviors, and should be able to identify early problematic behavior and refer these children for appropriate early interventions.

This chapter discusses the problem of stalking along with its assessment; diagnosis; levels of prevention/intervention; primary, secondary, and tertiary strategies for dealing with the behavior; and additional resources. Stalking has been referred to as a pattern of behavior directed at a specific person that would cause a reasonable person to feel fear. Adolescent relationship abusers commonly use stalking to monitor their partner’s activities during and even after the relationship. Stalking behavior can be found in youth with autistic spectrum disorder (ASD) who unintentionally stalk without realizing the implications of their behaviors. There is no one specific mental health disorder. While some stalkers have substance abuse disorders, depression, psychosis, or borderline personality disorder, it is important to discern whether and how the disorder relates to stalking behavior. Health care professionals need to be knowledgeable of this crime, the behaviors, and the impact it has on victims.

This chapter describes the problem of LGBTQI2 (lesbian, gay, bisexual, transgender, questioning, intersex or two-spirit) along with its assessment; diagnosis; levels of prevention/intervention; primary, secondary, and tertiary strategies for dealing with the behavior; and additional resources. Sexual orientation, usually identified as heterosexual, homosexual, or bisexual, includes components of identity, attraction, and behavior in a person’s emotional, sexual, and/or relational attraction to others. Gender identity is a person’s sense of being male, female, or something else, whereas gender expression is how a person expresses his or her gender identity. Gender nonconforming youth are those whose gender expression differs from how their family, culture, or society expects them to act, behave, and dress. Stigmatization creates many issues for LGBTQI2 youth, including homelessness, altered body image, social anxiety, depression, suicidality, substance abuse, posttraumatic stress disorder, and other mental health issues.

Substance abuse and dependence are among the most prevalent disorders diagnosed in the United States. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), combined abuse and dependence into one disorder that utilizes a continuum from mild to severe. The most common substance abuse disorders in the United States are alcohol use disorder, tobacco use disorder, cannabis use disorder, stimulant use disorder, hallucinogen use disorder, and opioid use disorder. Primary treatment for substance abuse is to promote the prevention or delayed initiation of substance use through parent and child education and positive reinforcement. Secondary prevention is aimed at at-risk youth and those who are at the level of experimentation or limited use, and who scored negative on the CRAFFT or ‘once or twice’ on the Screening, Brief Intervention, Referral for Treatment (SBIRT).

Parents of children in kinship care perhaps carry the most pronounced stigma of any birth parent group. This chapter explains the complex and diverse relationships that exist among birth parents, their children, and the kinship caregivers who have stepped in as surrogate parents. It explores the devastation caused by substance abuse with an opioid-dependent mother of three young children who struggles to regain her life. The chapter then describes a young mother who is in and out of the multigenerational home where her child resides. It also discusses the case of a middle-aged man who has been diagnosed with stage IV lung cancer and is in hospice care. Finally, a young mother who has neither the resources nor the maturity to raise her children is described. Each of these cases represents opportunities for advanced practice nurses (APNs) to accurately assess health issues and render comfort and care.

Neonatal Abstinence Syndrome (NAS) describes neonates exposed to opioids and other substances in–utero such as benzodiazepines. Neonatal Opioid Withdrawal Syndrome (NOWS) describes neonates exposed to opioids only in utero. Currently mechanisms of withdrawal from opioids and other substances in the newborn is not well understood but in animal models it appears that it is distinctively different from adult withdrawal. This occurs because of the neonate’s immature neural development, decreased neuro processing, variable levels of the opioid and neurotransmitters as well as the pharmacokinetics between the mother, fetus and placenta. Both screening and testing are used to assist with the diagnosis of NAS/NOW in the neonate. Cases where non-pharmacologic treatments does not work, then medication-assisted treatment should be initiated. The American academy of pediatrics recommends using medication from the same class of drug the infant was exposed to in-utero.

Depressive disorders include major depressive disorder, persistent depressive disorder (dysthymia), disruptive mood dysregulation disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, and depressive disorder due to another medical condition. The common feature of depressive disorders is the presence of sad, empty, or irritable mood, which is associated with somatic and cognitive changes that interfere with functioning at home, in school and/or with peers. The risk in children/teens is increased if one or more parents are depressed. Depression is a risk factor for other high-risk behaviors and often precedes substance abuse by about four years. Depression is often misdiagnosed as ADHD in young children as they may present with inattention, impulsivity, and hyperactivity. This chapter provides a brief overview of depression and discusses the assessment and evidence-based management of depressive disorders in children and teens.