These topics — drinking, drugs and sex, have become an everyday part of a school nurse’s life.

The student shifted in his seat, took a deep breath. He was breathing easier these days, he reported, and having less trouble keeping pace during gym class. His friends had noticed he smelled better, too. He had stopped smoking cigarettes, a habit he picked up more than 4 years ago. He’s 13. The boy, whom we’ll call Joe*, kicked his habit with the help of the school nurse at the middle school he attends in northern Delaware. The nurse, who did not wish to be identified — let’s call her Meg — is trained in the American Lung Association’s 10-week teen smoking cessation program, Not on Tobacco (NOT), and is currently helping several students quit smoking.

“Cigarette smoking is one of my biggest concerns for my student population,” she says, “because it’s not just smoking. With my students, the risky behavior starts with smoking first, then marijuana use, and eventually sex.”

These topics — drinking, drugs and sex, have become an everyday part of a school nurse’s life. Today’s school nurses, who number roughly 50,000, are as likely to be fielding complaints of upset stomachs and headaches as they are to be intervening on cases of extreme dieting, eating disorders and substance abuse , or answering questions about sex and birth control from kids as young as 12.

School nurses are often a first line of defense in an educational system where teachers’ attention can be stretched thin, and problems both physical and emotional may be untended. “School nurses are unique because we’re ‘safe’ — students trust us, and they know we’re not there to discipline them or hand out grades,” said Sandi Delack, a veteran school nurse and President-elect of the National Association of School Nurses, a nonprofit organization with more than 14,000 members.

“The nurse is often the person that students will sit and talk to, and once they decide we’re safe, they really open up. We’re very good at spotting when something’s going on with a child, and it can be something simple like a kid who needs some extra attention, or more serious like a parents’ divorce, a pregnant sibling, and sometimes physical abuse.”

When asked what most concerned her about the health of today’s students overall, Delack didn’t hesitate. “Mental health concerns — by far. We live in such a high-pressure society, and more kids than ever are dealing with anxiety, depression and the tolls of everyday stress,” she said. “I see the impact every single day, and while there are certainly other issues, like eating problems and drugs and drinking, you have to ask yourself — how much of this is related to what’s going on emotionally?”

 Delack’s assessment played out in conversations with nurses from a variety of schools — rural and urban, public and private, those with more than 1,000 students and as few as 200. At our request, ten school nurses, all of whom wished to remain anonymous, and whose names we have changed, kept weekly chronicles of the health concerns they tracked among their students for a month’s time. Issues of drinking and drugs, particularly the abuse of prescription drugs, cigarette smoking, drug testing, and sexual situations — in person and especially online — were noted again and again.

 Meg’s school has more than 750 6th-8th grade students from diverse socioeconomic backgrounds , and her chronicle reflects a startling array of teen health challenges faced in such a short period.

Week One: “Complete Denial”

The first week began in a way that surprised even Meg, an experienced registered nurse with more than 20 years of experience — 12 of them as a nationally certified school nurse consulting with 50-80 kids on an average day, and up to 110 on a busy one.

A 13 year-old boy was seeking Meg’s advice on matters related to a girl he was involved with. He had gone to her house after school, while her parents were still at work, and reported engaging in oral sex. He was considering taking things further, but wanted some advice from Meg about intercourse. What was new for Meg wasn’t the line of questioning, it was who was asking. “I usually have the girls come talk to me, she said. “Rarely do I have a boy want to confide in me and talk openly and honestly.”

And he certainly wasn’t alone. In the four weeks she kept track of her students’ inquiries, Meg reported several instances of sexually-active 12 and 13-year-olds, many of them seeking advice on contraception. “I recently talked with a mom who was aware that her 13-year-old daughter was having sex. I called her because…the students [in the school] were talking about her possibly being pregnant. Mom said she hadn’t pursued birth control for her daughter, but was willing to provide condoms.”

Meg says most parents she speaks to are in “complete denial,” and don’t have an appreciation for the ways that risky behaviors like drinking alcohol, smoking and having sex are often interrelated in a teen’s life.

According to a 2004 report released by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, teens who smoke cigarettes are nine times more likely to meet the medical criteria for past year alcohol abuse or dependence and 13 times more likely to meet criteria for abuse and dependence on an illegal drug compared with teens who don't smoke.

And while fewer teens are smoking today than any time since the early 1990s, the numbers are still high. According to the 2008 Monitoring the Future Survey, 20 percent of 8th graders and 44 percent of 12th graders have smoked during their lifetime. The American Lung Association states that half of adults who smoke had developed the habit by their 18th birthday, and 90 percent had started by the age of 21.

A school nurse from a large K-12 public school in Kentucky put a fine point on the dilemma she faces when students come to her for help with smoking, remarking that “One student wanted to quit and was frustrated that the nicotine patch can’t be sold to her — smoking isn’t healthy, but the patch isn’t approved for underage smokers!”

The CASA report also illustrates a connection between early sexual activity and other high-risk behaviors. Compared to teens with no sexually active friends, teens who report that half or more of their friends are sexually active are more than six times likelier to drink and more than five times likelier to smoke. Additional data from the Center for Disease Control and Prevention’s 2007 Youth Risk Behavior Survey showed that more than 1 in 5 sexually active high schoolers (22 percent) reported using drugs or alcohol during their most recent sexual encounter.

Week Two: “I Don’t Expect My Students to Steal Medication”

It didn’t take long for teen abuse of prescription medicines to surface in Meg’s chronicle — it happened during the second week, and was an issue for most other nurses participating in this story. For many, this behavior — one that has become so prevalent among teens that nearly 20 percent admit to abusing a prescription medicine during their lifetime — is still somewhat new and surprising. “I really didn’t expect my students to be stealing prescriptions from their grandparents’ medicine cabinets, and I don’t expect them to take medicines from their friends’ houses,” said one nurse from a large public high school in Ohio. Research from the Partnership for a Drug-Free America shows that the majority of teens who have abused prescription drugs say they got them from their home or a friend’s home.

The nurses reported direct experience with students — some as young as 12 years old—abusing a wide variety of pharmaceuticals, from narcotic pain medicines like Vicodin, Percocet and codeine, as well as stimulant drugs prescribed for Attention Deficit Hyperactivity Disorder (ADHD), like Ritalin and Adderall, which the students use as a performance enhancer, to improve academic performance. “The students think the pills will make up for skipped classes or missed lectures, and they’re wrong,” said one nurse from California.

Research on the abuse of prescription stimulants has brought new concerns to light, especially as students make the transition from high school to college. A recent study released by the National Survey on Drug Use and Health showed that full-time college students who were nonmedical users of Adderall — indicating use without a prescription and not as treatment for ADHD or a related condition — are almost 3 times as likely to have used marijuana in the past year and 8 times as likely to have tried cocaine. Nearly 90 percent of college students who had used a prescription stimulant were past-month binge drinkers, and more than half are heavy alcohol users.

Karen, a school nurse in a northeastern college town, keeps her eye on her students’ older friends, especially those in college, many of whom “drink and use marijuana, in some cases very openly and with the blind eye of parents nearby,” Karen said. “If a high school student remains alcohol-free, temptation for this to change becomes stronger as they approach and enter college.”

Week Three: “A Targeted Kid”

Monday morning of week three finds Meg facing a teen who had a confrontation with his mother over the weekend, after she smelled an odor she suspected — and a home drug test confirmed — was marijuana. She reports that the student was already in an Alternative Classroom setting due to disruptive behavior, and that he has a medical diagnosis of ADHD.

Upon contacting the boy’s mother, Meg was met with resistance — the mother was upset that Meg knew what had happened. “She didn’t want the school to find out, and felt like her son was already a targeted kid.” Meg learned from the school’s guidance counselors that a few months prior, the boy had skipped school and been caught by the police. She also found out that his siblings had a history of suicide attempts, drug use, and teen pregnancy.

“I understand a parent wanting to keep these things private, but it’s so important for the school to know what’s going on at home,” Meg wrote. “I told this mom, like I tell all my parents, that I don’t run to the principal’s office when a kid is in trouble — it’s not my role to complicate matters for my students. I’m an advocate, and we can really help enhance the therapy her son is getting outside of school if we know his situation.”

Week Four: Sex and the Cell Phone

Regardless of where the school nurses were located, each and every one mentioned the relatively new phenomenon of “sexting” as a looming — or present — threat on their radar.

During Meg’s final week of writing for this story, a 12-year-old girl, Michelle, came into her office. She was upset and wanted to talk about an argument she’d had with her grandmother, who is also her legal guardian. The previous week, a fellow student’s mother called the grandmother to report that her 13-year old son had received a racy text message on his cell phone—a nude photo of Michelle. Despite Michelle’s insistence that someone had snapped the photo in the locker room while she was changing for gym class and sent it to the boy, the message content proved otherwise. Michelle had, in fact, taken and sent the photo herself.

For some, sexting — the practice of teens taking nude photos and sending them by text message to their friends — sounds like the latest evidence of the fact that teens often make bad decisions. “Teens don’t think in advance about the consequences, and they live in the here and now,” Meg noted. But the uproar over sexting has hit fever pitch in some states following tragic cases of suicide, school expulsion, and even legal charges of child pornography and sex offenses.

A 2008 survey conducted by the National Campaign to Prevent Teen and Unplanned Pregnancy and the website CosmoGirl.com showed that 20 percent of teens ages 13-19 and 33 percent of young adults (ages 20-26) have sent nude photos via text message. The same study indicates that 48 percent of teens say they have received a suggestive text message. Forty four percent of teens say it’s common for them to be forwarded a sexually suggestive message intended for someone else.

The results can be devastating. In the summer of 2008, 18-year old Jesse Logan committed suicide following months of bullying and taunting after a nude photo she’d texted to her boyfriend was circulated throughout her Cincinnati high school.

“Every generation of teens does things that are sexually inappropriate, but we’ve never had the technology we have now, which makes it possible for the impact of actions like sexting to be far-reaching and even permanent, said Dr. Elizabeth Schroeder, Director of Answer, a national organization at Rutgers University providing comprehensive sexuality education. “It freaks people out to think about talking with fifth and sixth graders about this, but if we wait until it’s too late to talk about consequences, we’re just putting a band-aid on a big gaping wound.” At least ten states are grappling with measures to crack down on sexting — some are imposing child pornography charges on those who send the messages, an offense that can result in a lifetime listing on the state’s list of registered sex offenders; others are mandating counseling and classes on sexual harassment and misconduct.

“The real message to parents is that we have to help our kids set boundaries — whether it’s sexting or some other expression, we need to sit down and ask them — is this the kind of impression you want to project for yourself?” Schroeder added.

Conclusion: Advice from the School Nurse

At the end of a month spent journaling their experiences, the nurses were asked to share some advice for their students, and for their parents.

•  I tell my students all the time to respect themselves. Without that, they can’t respect others or know how they should be treated.

•  Own up to your actions! I know it’s hard to admit you did something, but if you lie about it, the consequences are worse.

•  Get involved — and stay involved — in your child’s life. Know who their friends are and what they’re doing. Set boundaries and stick with the rules.

•  Please take time to talk to someone about your child if you notice risky behaviors. The schools need to educate the kids, but we have to address health and mental health issues first, with the kids and their families.

“All my kids are good kids,” said Meg. “Some have great parents, and others don’t have anyone to look up to, no role models. Someone needs to believe in these kids and be there for them. If their basic emotional needs aren’t being met, they can’t learn. Helping provide that support can be one of the toughest — and best — parts of my job.”