ARCHIVES PEDIATRIC$ &. ANOLESCENT}TEDICINE Copyright 1996 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to GovernmentUse.American Medical Association, 575 N. State St, Chicago, IL 60610. Volume 150(7), July 1996,pp 713-727 Abaut this lournal Gl Table of f,ontents | {' BroruseTnt: l) Armail Jumpstart I lHsave Artirle Text I HEnrail lrticle Text | &.Print Previeru &trinU citing Articles I The Adolescents Training and Learning to Avoid Steroids (ATLAS) Prevention Program: Background and Results of a Model Intervention [Article] Goldberg, LinnMD; Elliot, Diane L. MD; Clarke, Gregory N. PhD;MacKinnon, David P. PhD; Zoref , Leslie PhD; Moe, Esther PhD; Green, Christopher MEd; Wolf, Stephanie L. From the Department of Medicine, Oregon Health Sciences University, Portland (Drs Goldberg, Elliot, Clarke, Zoref , and Moe, Mr Green, and Ms Wolf); and Department of Psychology, Arizona State University, Tempe (Dr MacKinnon). Abstract tJ Objective: To develop and test a school-based intervention to prevent anabolic androgenic steroiduse among high-riskadolescent athletes. Desion: Nonrandom controlled trial. Setting: Two urban highschools. Participants: Fifty-six adolescent football players at the experimental school and 24 players at the control school. Intervention: Eight weekly, 1-hour classroomsessions delivered by the coach and adolescent team leaders,and eight weight-room sessions delivered by researchstaff. Links At.L:trsct f,ompleteReference Exte rnalResolve rBasic Outline a a a Abstract BACKGROUND THEORETICAL MODEL OF AAS USE HYPOTHESES SUBJECTS AND METHODS o PROGRAM DESIGN o SUBJECTS o RETENTION o DEMOGRAPHICS o ASSESSMENT o SELF-REPORT QUESTIONNAIRF o PREVENTION INTERVENTION r Classroom r Weight Room r Parents r ImplementerTraining o CONTROL CONDITION o DATA ANALYSIS RESULTS o BASELINE EQUIVALENCE o PROGRAM EFFECTS r Knowledge r Attitudes r Intentions a a
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ARCHIVESPEDIATRIC$ &.ANOLESCENT }TEDICINE
Copyright 1996 by the American Medical Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use. American Medical Association, 575 N. State
St, Chicago, IL 60610.Volume 150(7) , Ju ly 1996, pp 713-727
Abau t t h i s l ou rna l Gl Table of f ,ontents | { ' Broruse Tnt : l )
A rma i l Jumps ta r t I lHsave A r t i r l e Tex t IHEnra i l l r t i c l e Tex t | & .P r i n t P rev ie ru
& t r i nU c i t i ng A r t i c l es I
The Adolescents Training and Learning toAvoid Steroids (ATLAS) Prevention
Program: Background and Results of aModel Intervention
[Art icle]
Goldberg, L inn MD; El l io t , Diane L. MD; Clarke, GregoryN. PhD; MacKinnon, David P. PhD; Zoref , Les l ie PhD;
Moe, Esther PhD; Green, Chr is topher MEd; Wol f ,Stephanie L.
From the Department of Medicine, Oregon Health SciencesUniversity, Port land (Drs Goldberg, El l iot, Clarke, Zoref , and Moe, MrGreen, and Ms Wolf); and Department of Psychology, Arizona StateUn ivers i ty , Tempe (Dr MacKinnon) .
Abstract tJ
Object ive: To develop and test a school-basedin te rvent ion to p revent anabo l ic androgen ic s te ro id useamong h igh- r i sk ado lescent a th le tes .
Des ion : Nonrandom cont ro l led t r ia l .
Set t ing: Two urban h igh schools .
Part icipants: Fifty-six adolescent football players atthe experimental school and 24 players at the controlschool .
Intervent ion: Eight weekly, 1-hour classroom sessionsdel ivered by the coach and adolescent team leaders, andeight weight-room sessions del ivered by research staff .
The intervention addressed sports nutri t ion andstrength t ra in ing as a l ternat ives to s tero id use, drugrefusal ro le p lay, and ant is tero id media campaigns.
Outcome Measures: A pre intervent ion andpostintervention questionnaire that assessed att i tudestoward and intent to use steroids and other drugs;knowledge of drug effects; and diet, exercise, andrelated constructs.
Resul ts : Compared wi th contro ls , exper imenta lsubjects were signif icantly less interested in tryingsteroids after the intervention, were less l ikely to want touse them even i f the i r f r iends used them, were less l ike lyto believe steroid use was a good idea, believed steroidswere more dangerous, had better knowledge ofalternatives to steroid use, had improved body image,increased the i r knowledge of d ie t supplements, and hadless bel ie f in these supplements as benef ic ia l .
Conclusions: Signif icant beneficial effects were founddespite the sample size, suggesting that the effect of theintervent ion was laroe. This outcome t r ia l demonstrates
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User S k i l l sr Bel iefs
o C O M M E N To REFERENCES
Recent History
The Adolescents Trainino ...
an effective anabolic androgenic steroid preventionprogram for adolescent athletes, and the potential of team-ado lescen ts 'hea l th .
based interventions to enhance
Arch Ped ia t r Ado lesc Med.1996; 150:7 t3 -72 I
Editor's Note: This prel iminary study provides reason for great expectations of reducedanabol ic androgenic s tero id use among h igh-r isk adolescent ath le tes. Adding the coach and peerleaders to the health care team might just be the key factor. I 'm eagerly await ing the long-termoutcomes.
Cather ine D. DeAngel is , MD
Although many investigators have studied the prevention of alcohol, tobacco, mari juana,and other i l l ic i t drug abuse, [1 ,2] there has been l i t t le research on the prevent ion of anabol icandrogenic steroid (AAS) use. The National insti tute on Drug Abuse recently sponsored its f irststudy of a program to prevent adolescent anabolic steroid use. We report the background andresul ts of th is program's implementat ion.
BACKGROUND IJ
Anabolic androgenic steroids are derivatives of the male hormone testosterone. Youngadults and adolescents use AASs to improve athletic abil i ty and muscular appearance, l3ldespite the fact that these drugs have many potential adverse side effects. 14-141 Use of AASs
Graph ics
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among h igh school a th le tes is current ly a major nat ional problem. 13,151 in prev iousresearch, we observed a steady increase in self-reported AAS use among Portland, Ore, highschool footbal l p layers, f rom 1.1olo in 1987 t16 l to 5.7o/o in 1991. gtz l
Early adolescence may be a crit ical t ime to prevent AAS use, because youths mayincorrectly interpret normal adolescent maturation as a benefit of AAS use. However, similarstrength and muscle size gains may represent normal changes associated with the typical 1O-fold increase in endogenous testosterone that occurs during male adolescence.
This school-based study targeted adolescent football players [18] because they are the highschool group wi th the h ighest prevalence of AAS abuse J: , ts1 and s ince envi ronmenta l in f luences(eg, teammates, coaches, and family) can be involved in a prevention program.
THEORETICAL MODEL OF AAS USE fJ
We developed a theoretical model of AAS use (Fisure r), guided by previous AAS and otherdrug research f indings. 116,20-261 We hypothesized that AAS use is a learned, goal-directedaction, reinforced by individual, peer, family, and community or school inf luences. 127-32)Indiv iduals are in f luenced by b io log ic mediators (eg, genet ics) ; the i r knowledge, sk i l ls , andatt i tudes regarding AAS risks and benefits; and psychosocial characterist ics.
Figure 1 . Proposed causat ive mode l o f anabo l ic androgen icsteroid (AAS) use. Rx indicates medicat ion; SES, socioeconomicstatus.
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A signif icant set of potential AAS mediators relates to an adolescent's peer groups. Stronglinks exist among peer drug use and personal drug use. 126,291Adolescent AAS users oftenoverestimate AAS use prevalence among peers, ;zr1 and a major reason for use was to becomebetter l iked by peers. [22] Conversely, negative peer reaction to drugs is a deterrent to drugabuse behaviors. 1zo1
Nonpeer and environmental pressures also affect AAS use. School pressure to "win at al lcosts" and student belief in greater parental acceptance of AASs are associated with adolescent
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AAS use. t21l Other factors include family drug abuse, inf luences of school, coaches, media,and sports f igures, socioeconomic factors, and drug availabi l i ty. Adults may indirectly encourageAAS use by their ambivalence, as adolescent users report, "My parents probably know I haveused steroids." ;22i In another survey, more than 20o/o of AAS users reported that teachers orcoaches actually encouraged use. ;: :1
Another nonpeer inf luence for adolescent AAS use is contact with individuals at nonschool(commercial) gyms. t22l The Department of Health and Human Services reports thatcommercial gyms are a source of steroid information for 75o/o of AAS users and a direct sourcefor obtaining AASs for 630/o of users. 1zz1
The risk of AAS use may potential ly be affected by adolescents' knowledge, att i tudes, andbeliefs, such.as understanding the social and physical consequences of AAS, ;ra3 and personal
susceptibi l i t ies to drug effects. t3sl Among high-risk adolescents, cri t ical knowledge deficitsabout steroid effects (testicular atrophy and stunted growth) and healthy alternatives (sports
nutri t ion and athletic strength training) were associated with greater intent to use AAS. t36l
Psychosocial inf luences, such as low self-esteem, have also been suggested as drug abuserisk factors. t37l However, AAS users report feel ing better about themselves, gaining self-esteem, and physical improvements as important reasons for init iat ing steroid use. [22] Teenswho use other drugs often have goals that are antagonistic to adult values, [38,39] such as"gett ing high." In contrast, AAS users have certain goals that are prosocial (eg, "enhanced"appearance, a th le t ic ism, and at tending co l lege) . To change at t i tudes regard ing AAS use, asuccessful prevention program needs to provide healthy alternatives to reach these posit ive
objectives.
Finally, the perceived effects of AAS can reinforce user behavior. Most current AAS users aresatisf ied with the results of use. t22l Gains in muscle mass and strength inf luenced 97olo of AASusers to continue drug use, while former users were less enthusiastic about posit ive AASeffects. [22] However, i f such healthy alternatives as sports nutri t ion and state-of-the-arts t rength t ra in ing can be convinc ing ly shown to increase muscular development and st rength,then AAS use may be less desi rab le among th is target group.
The intervention was designed to address each of these putative AAS risk factors (r igure r).The classroom component employed successful strategies from drug prevention research 1:.,21and our investigations of school-based AAS prevention, 176,23,25) Since "scare tactics" areineffective, i4ol a balanced risk-benefit approach was chosen. t16,231 Nutri t ion and strengthtraining alternatives to AAS were also stressed, on the basis of evidence that these componentsmay alter adolescents' intent to use AAS. t23l
HYPOTHESES t I
In this prospective, control led study, we compared a school-based, AAS prevention programfor high school football players with a no-intervention control condit ion. We hypothesized that
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after the intervention, adolescents enrol led in the experimental intervention would exhibit(1) less intent to use AASs and other drugs; (2) more negative att i tudes toward perceived
benefits and reasons to use AASs; (3) lower rates of r isk factors for AAS abuse; (4) increasedknowledge of AAS effects; (5) increased knowledge of and higher rates of engaging in nutri t ionand strength training alternatives to AAS use; (6) greater perceived self-eff icacy regardingalternatives to AAS; and (7) greater satisfaction with personal body image.
SUBJECTS AND METHODS IJPROGRAM DESIGN !J
Two urban high schools part icipated: one school received the B-week experimentalprevention program, while the control school (96 km away) received no intervention.Experimental and control schools were similar with respect to total student enrol lment (7477 vs1640, respectively), 1993 football win-loss record (eight wins and one loss vs seven wins andtwo losses), family socioeconomic status, school attendance (89.6% vs 91.8o/o), averageparental education (median of some college for both), and student part icipation in the free lunchprogram (26.60/o vs 27.2o/o).
SUBJECTS !
A total of L73 varsity football players at the two high schools were invited to part icipate.
Subjects and parents or guardians signed a letter of informed consent. Of the 90 adolescentse l ig ib le to par t ic ipate in the exper imenta l condi t ion, 66 (73.3olo) consented, compared wi th 54(65.1olo) o f 83 adolescents on the contro l school team (ch i squared l t l=L.4, P>.05) .
RETENTION II
Fifty-six (84.8%) of the 66 experimental subjects and 24 (44.4o/o) of the 54 control subjectspart icipated in both assessments, for an overal l retained sample of B0 students. This was as igni f icant d i f ference in par t ic ipat ion across condi t ions (ch i squared I t1 :21.9, P<.001) . Becausethe majority of consenting but nonpart icipating adolescents fai led to complete the baselinequestionnaire, we could not examine how they differed from retained subjects. Nonetheless, thisdifference suggests caution when outcome findings are interpreted.
DEMOGRAPHICS +I
All part icipants were male. (raote r) presents the demographics for retained subjects, bycondit ion. Neither parental employment nor parental education was signif icantly different acrosscondi t ions. A l though median fami ly income was $30 000 to $40 000 for adolescents in theexperimental group vs $20 000 to $30 000 for control subjects, this was not a signif icantdifference across the complete samples.
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Table 1. Demographic Characterist ics in Control andExperimental Subjects Retained From Intake to PostinterventionAssessments
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Signif icant differences between part icipants at the two schools were found only for truancydays (P<.01) . However / one s ign i f icant d i f ference among 26 compar isons is consis tent wi thchance (wi th a Bonferroni -corrected a lpha of P<.002) .
ASSESSMENT 1I
All part icipants were assessed twice, 9 weeks apart: just before the f irst interventionsession, and in the week after the f inal intervention session. Confidential, code-numberedquestionnaires were administered by research staff in group sessions at schools. Parents,coaches, and other school personnel were not present during the assessment and did not haveaccess to questionnaires or the coding l ist. Subjects in both condit ions were provided with a freemovie theater pass each t ime they completed the questionnaire. Adolescents who part icipatedin the experimental protocol also received T-shirts with the research study logo.
SELF-REPORT QUESTIONNAIRE tJ
The principal assessment instrument was a 299-item, self-report questionnaire, developedfor this investigation with the use of i tems employed in earl ier studies. 16,22,231Most of the 299individual i tems or questions were combined into different factors, each factor representing aconstruct of interest from the causative model (r igure t). Most constructs were measured by amin imum of three ind iv idual quest ions. The quest ionnai re assessed AAS and other drug use,att i tudes, and behavioral intent to use AAS. Items that evaluated the use of other i l l ici t drugsand a lcohol were f rom ongoing, nat ional surveys of Amer ican h igh school seniors . 14. t l Otherconstructs assessed included knowledge of nutri t ion and exercise and norms of drug use;exercise and dietary patterns; peer tolerance of AAS and other drug use and support of health-
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promoting behaviors; body image; self-esteem; need for achievement; mood (eg,
depression and anxiety); anger and impulsivity; and subjective satisfaction with thecomponents of the intervention. (raote z) summarizes the general ly posit ive psychometricpropert ies of constructs measured by this instrument.
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Table 2. Internal Consistency of Constructs in Self-ReportQuest ionnai re
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PREVENTION INTERVENTION 1I
The intervention scheme is shown in (r igure z). The program consisted of 16 sessions over Bweeks. E ight weekly , l -hour sess ions were held in a c lassroom set t ing, de l ivered by the coachand peer leaders. Classroom sessions were observed by research staff to confirm coach andpeer-leader adherence to the protocol. On the same day each week, another eight sessionswere delivered in the high school weight room by Adolescents Training and Learning to AvoidSteroids staff ski l led in weight l i f t ing instruction.
Figure 2. Model of anabolic androgenic steroid preventionintervention.
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Classroom -ti
The eight c lassroom sessions addressed the topics l isted in (raote:) . Instruct ion addressed
alternat ives to AAS use, ie, sports nutr i t ion and proper strength training techniques. Previous
data suggest that intent to use AASs is lowered with this approach, with the greatest impact on
those with higher ini t ia l desire to use these substances. t23l Refusal ski l ls to decl ine offers of
AASs or other i l l ic i t drugs 142,431were taught and pract iced, as simi lar strategies have been
successful in reducing smoking rates in teens. t43l Students also prepared ant i-AAS media
messages ( ie, posters and mock television and radio announcements). Approximately 600/o of
the curr iculum was peer- led, as this appears to increase program effect iveness. [42,44] The
object ives of the weight room curr iculum also were reviewed in the classroom component.
Table 3. Content of the Anabol ic Androgenic Steroid Prevent ionIntervent ion
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A major emphasis of the sports nutri t ion component was to have athletes consumeadequate amounts of total energy and protein. A pocket-sized sports nutri t ion guide,
summarized in (raote s), emphasized dietary intake for adolescent athletes in the program. Thisincluded recommendations for adequate energy intake, lower fat (<30o/o of total energy intake),higher carbohydrates, and relatively high protein (approximately twice the recommendeddietary al lowance of O.B g/kg of body weight for sedentary adults). Nutri t ional supplements anddrugs also were reviewed, factual information was presented, and inf lated claims for theseproducts were debunked.
Weight Room 1l
The in tervent ion prov ided addi t ional weight room equipment ( re ta i l va lue, approx imate ly
$3000) to supplement and enhance the exper imenta l h igh school t ra in ing fac i l i ty . By enhancingthe school weight room, we sought to keep adolescents exercising in a school-supervisedenvironment with less outside inf luence. Eight weekly 1-hour weight-room sessions promotedski l l t ra in ing. Sessions were d iv ided in to three d i f ferent phases. The in i t ia l phase (sess ions 1through 3) promoted muscular endurance wi th low-weight , h igh-repet i t ion weight l i f t ing. Thesecond phase (sessions 4 through 6) focused on higher-weight and lower-repetit ion training forstrength. The last phase (sessions 7 and B) concentrated on power exercises, includingdemonstrations of plyometric techniques.
Parents +l
Parents and guard ians of s tudent ath le tes were involved v ia the i r son 's homeworkassignments and a s ing le 1.5-hour evening parent meet ing on program goals , fac i l i ta ted byAdolescents Training and Learning to Avoid Steroids staff. Parents received a family sportsnutr i t ion booklet s imi lar to the adolescents ' gu ide.
Implementer Training t l
Peer leaders were selected by coaches and trained by research staff to faci l i tate small-groupactivit ies during each classroom session. Coaches also presented information and supervised thesessions. Coach and team leader manuals provided step-by-step instructions and activit ies. Weemployed peer leaders because they have been found to be rel iable sources of information 1aa;and in other drug prevention studies were associated with reduced subject drug use. i31,451Also, our previous research [2s] documented a high degree of acceptabil i ty of peer leaders inthe team set t ing.
CONTROL CONDITION TJ
The control school football team received none of the components described above.Informal postintervention debriefing of the control school coaches showed that no other anabolicsteroid materials or teachings were provided to students during the course of the investigation.
DATA ANALYSIS II
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Because of some group difference at baseline, and because subjects were not randomlyassigned to treatments, i t is important to test program effects under different assumptionsabout how the schools would change in the absence of program exposure. The program effectswere tested under two assumptions about the change in the dependent measure over t ime ifthe program had no effect. t46l The f irst method, the condit ional model, tests for effectsassuming that the dependent var iab le in each condi t ion would regress to mean levels . Thesecond method, the uncondit ional model, tests for effects assuming that group differences wil lnot change over t ime. In the condit ional model, the posttest dependent variable is regressed onthe program exposure variable. In the uncondit ional model, the difference between posttest andpretest f indings is the dependent variable. The most convincing program effects are those thatare s ign i f icant under both models .
RESULTS "]
(raule +) presents basel ine equivalence and program effect est imates for seven dependent
variables of intent ions, knowledge, att i tudes/ norms, bel iefs, and ski l ls. There are several
individual constructs under each of these seven headings. The stat ist ical s igni f icance between
the groups at basel ine and the stat ist ical s igni f icance of the program effects are shown in this
tab le .
Tab le 4 . Cond i t iona l and Uncond i t iona l Program Ef fec ts
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The only demographic variable that differed between program and control groups wasstudent truancy. As shown in (raote +), several of the dependent measures also weresignif icantly different between program and control groups at baseline ( indicated by footnotes).There were differences between groups in knowledge of alternatives to AAS use, beliefs thatAASs are not dangerous, knowledge of energy content in foods, peer tolerance of drug use, andnorms among fr iends. These baseline differences make it important to test for program effectswith alternative methods to adjust for baseline differences.
PROGRAM EFFECTS 1I
The effect of the Adolescents Training and Learning to Avoid Steroids intervention wasassessed by observing change in the constructs predicted to be affected by the program, asdetai led in the causative model (r igure t). Also evaluated were constructs presumed to remainstable over t ime (eg, socioeconomic status, peer drug use, media or professional athleteinfluences, etc).
As described in the analysis section, program effects were estimated with uncondit ional andcondit ional analyt ic models. These program effect estimates and their statist ical signif icance areshown in (raute +). The means for individual constructs are shown in (raote s). Because ofhypotheses predict ing posit ive intervention effects on the dependent variables, we use one-ta i led tests (a lpha=.05) for the level o f s tat is t ica l s ign i f icance. A l though s ign i f icant programeffects were not observed for al l constructs, the direction of most of the effects was consistentwith posit ive program effects. In many cases there were crossover effects such that theprogram group was higher at baseline but lower than the control group at the posttestevaluat ion.
Table 5. Adolescents Training and Learning to Avoid SteroidsConstruct Meansx
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Knowledge t l
There were substantial beneficial program effects on many of the eight knowledgemeasures, including knowledge of alternatives to AAS use, knowledge of dietary supplements,protein powders, and ergogenic drugs, factors inf luencing AAS use, the effects of steroids, andknowledge of drug use in general. Although there were no signif icant program effects onknowledge of proper exercise techniques or energy intake from food, the pattern of effects wasin the correct direction (favoring the students in the intervention group).
Attitudes d
There were substantial program effects on several of the six att i tude measures/ includingthe "win at al l costs" att i tude, and drugs as a way to solve al l problems. There was evidence ofa program effect for drugs as a way to lose weight and others'att i tudes about losing.
Intentions t l
For both intentions measures, intervention students became less l ikely to intend to useAASs, while control students were even more l ikely to intend to use AASs. The importantconstruct " intent to use AASs as a reward" ( ie, for obtaining a col lege scholarship or a f irst-teamposit ion) had a statist ical ly signif icant program effect.
Body Image tJ
Under both analysis models, players exposed to the intervention were more l ikely thancontrol players to increase their bel ief that they had a "good" body.
Norms of AAS/Drug Use !
The student's perception of the number of other persons who use AAS showed a signif icant,posit ive program effect. The effects for other norms/ and peer tolerance of drugs, were in thecorrect direction but did not reach a signif icant level. The extent to which respondents learnedabout AAS and other drug use prevention from their peers increased more among interventionsubjects than control subjects.
Ski l ls u
Program effects on resistance ski l ls measures were in the desired direction but were notstatist ical ly signif icant.
Beliefs tl
Beliefs about the media's inf luence on AAS use and beliefs about the posit ive consequencesof AAS use had large and statist ical ly signif icant program effects, Other beliefs, such as reasonsnot to use AASs, beliefs about penalt ies for AAS, and beliefs about parent att i tudes regardingAAS, were not signif icantly affected by the program. Preintervention and postintervention scores
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for these constructs suggest that these beliefs were well understood by the interventiongroup before the Adolescents Training and Learning to Avoid Steroids program.
COMMENT + I
We describe a theoretical model for AAS use, a prevention program to reduce putative r iskfactors for use of AASs by adolescent athletes, and the posit ive results of an init ial tr ial of thisintervention. A strength of this program is that i t was delivered by the coach and peer leaders inthe h igh school set t ing, wi th the use of scr ip ted manuals . A l though the weight t ra in inginstructor was provided by the study's investigators, the remainder of the intervention wasschool suppor ted and del ivered. This suggests that th is in tervent ion may be easi ly implementedin schools outside of an experimental study.
Despite the relatively small sample, signif icant effects were detected, suggesting that themagnitude of the intervention is high. The lowered intentions to use AASs among subjects in theintervention school are encouraging. Many posit ive effects were noted for constructs central tothe theory underlying the prevention program, including knowledge of AAS effects, improvedbody image, developing more realist ic norms regarding AAS use, improved understanding ofa l ternat ives to AAS, and less re l iance on supplement powders and p i l ls .
Conclusions about the long-term effects of our intervention on AAS use, and the impact ofmediat ing factors on outcome, wi l l requi re a larger sample and a longer fo l low-up per iod. Weare currently in the f irst year of a 4-year randomized outcome study, in which we are applyingthe resul ts of th is in i t ia l t r ia l to a much larger populat ion of approx imate ly 3500 to 4000student-ath letes in 31 h igh schools .
Some factors may l imit our confidence in these results. These include the sample size, theuse of one school per condit ion, and differences in retention between control and experimentalcondit ions. Other factors, such as high preintervention levels of AAS knowledge and highlynegative beliefs regarding AAS use, suggest that i t would be even more diff icult to havesignif icant program effects in this sample of athletes. This preintervention "cei l ing effect" inanti-AAS knowledge and att i tudes suggests that the greatest program effects wil l be found instudents who have fewer negative beliefs and att i tudes about AAS use and less knowledge. Thistr ial appears to be a signif icant step toward the development of an effective AAS preventionprogram for adolescent athletes.
Accepted for publication June 19, 1995.
This project was supported in part by grant DA-07356 from the National Insti tute on DrugAbuse (Dr Goldberg) .
We thank Wi l l iam Bukoski , PhD, Debbie Walker , Frank Geske, Ron August , and the coaching.staff, students, and administration of Franklin (Port land, Ore) and McKay (Salem, Ore) HighSchools. We deeply appreciate the technical support of Denise Schoenherr.
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Reprint requests to Section of Health Promotion and Sports Medicine, Oregon HealthSciences University, 3181 SW Sam Jackson Park Rd, CB 615, Port land, OR 97201-3098 (DrGoldberg) .
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Adolescent Heal th Serv ices; Anabol ic Stero ids; Ath let ics; Body Image; Prevent ive Heal th
