Substance Use & Misuse

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Influence of Parent–Adolescent Communication About Anabolic Steroids on Adolescent Athletes’ Willingness to Try Performance-Enhancing Substances Tonya Dodge & Paige Clarke To cite this article: Tonya Dodge & Paige Clarke (2015) Influence of Parent–Adolescent Communication About Anabolic Steroids on Adolescent Athletes’ Willingness to Try Performance-Enhancing Substances, Substance Use & Misuse, 50:10, 1307-1315, DOI: 10.3109/10826084.2014.998239 To link to this article: http://dx.doi.org/10.3109/10826084.2014.998239

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Date: 05 November 2015, At: 22:35

Substance Use & Misuse, 50:1307–1315, 2015 C Taylor & Francis Group, LLC Copyright  ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.998239

ORIGINAL ARTICLE

Influence of Parent–Adolescent Communication About Anabolic Steroids on Adolescent Athletes’ Willingness to Try Performance-Enhancing Substances Tonya Dodge and Paige Clarke Downloaded by [Florida State University] at 22:35 05 November 2015

Department of Psychology, George Washington University, Washington, DC, USA about AS may influence adolescents’ decisions to use other types of performance-enhancing substances.

Background: Performance-enhancing substances are used by adolescent athletes to help improve performance. Anabolic steroids (AS) are performanceenhancing substances that pose significant health problems when used by adolescents. Objectives: Objectives were to: (1) examine the extent to which parents and adolescents discuss AS and (2) test whether parent–adolescent communication about AS can generalize to, and influence, decisions to use other types of performance-enhancing substances. Method: Adolescent athletes (n = 244) completed an anonymous questionnaire that assessed the extent to which the adolescents discussed with their parents the performance outcomes and protective factors associated with AS, their intentions to use AS, and their willingness to try a newly developed, potentially illegal performance-enhancing substance. Data were collected during 2009–2010. Results: Adolescents reported relatively low levels of communication with their parents about anabolic androgenic steroids (AAS). Communication with parents about the performance outcomes associated with AS was a positive predictor of willingness to try a newly developed performance-enhancing substance (b = 0.31, p < .01) and intentions to use AS (b = 0.54, p < .01). Communication with parents about protective factors predicted willingness to try a new performance-enhancing substance (b = −0.24, p < .01), but not intentions (b = −0.20, p > .77). Conclusions/Importance: Parents should highlight the protective factors and avoid emphasizing the performance outcomes associated with AS in discussions with their adolescents. Discussions

Keywords Performance enhancing substances, anabolic steroids, willingness, adolescents, parent–adolescent communication

INTRODUCTION

Performance-enhancing substances (PES) are used by adolescents to enhance their athletic or physical performance. In the United States (US), some PES are legal and available over-the-counter, whereas others are illegal to use unless prescribed by a physician. Although there are different types of illegal PES (e.g., amphetamines, human growth hormone), the most commonly studied illegal PES among adolescent athletes is anabolic androgenic steroids (AAS).1 Although relying on self-reports for prevalence estimates may lead to a significant underestimation as discussed elsewhere (see, e.g., Petr´oczi & Naughton, 2011; Uvacsek et al., 2011), studies have documented that between 1% and 2.5% of adolescent athletes report having tried AAS (Lorang, Callahan, Cummins, Achar, & Brown, 2011; Naylor, Gardner, & Zaichkowsky, 2001), with some estimates as high as 12% (Bahrke, Yesalis, Kopstein, & Stephens, 2000). Adolescents who misuse AAS (i.e., use without a prescription) report doing so to help improve speed and muscle mass, to reduce recovery time following strenuous workouts, or to improve their appearance (Dodge & Jaccard, 2008; Hoffman et al., 2008; Tanner, Miller, & Alongi, 1995). Misuse of AAS carries considerable health risks including cardiovascular problems, endocrine

Portions of this paper were presented at the Society for Personality and Social Psychology Annual Convention. The authors wish to acknowledge the athletes, parents, and schools who made this research possible. Address correspondence to Tonya Dodge, Department of Psychology, George Washington University, 2125 G Street, NW, Washington, DC 20052, USA. E-mail: [email protected] 1 The term anabolic androgenic steroids (AAS) is used throughout the introduction of the paper. However, the term anabolic steroids (AS) is used wherever we are referring to the measure used in the present study because this is how it was phrased for adolescents (for ease of interpretation).

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T. DODGE AND P. CLARKE

dysfunction, increases in aggression, and use of alcohol and other drugs (Casavant, Blake, Griffith, Yates, & Copley, 2007; Dodge & Hoagland, 2011; Dunn & White, 2011; Lumia & McGinnis, 2009). The adverse health consequences posed by the misuse of AAS and other illegal PES have led to a general consensus among the medical community and high school organizations that efforts be made to prevent adolescents’ use of these substances (Committee on Sports Medicine and Fitness, 2005; National Federation of State High School Associations, 2012). The most well-known prevention program targeting illegal PES use among adolescent athletes is the Adolescent Training and Learning to Avoid Steroids (ATLAS) program (Goldberg et al., 1996). ATLAS is a team-based program designed to reduce AAS misuse, and the program content is delivered primarily by coaches or teammates. Results from the only published evaluation of ATLAS showed that high school football players randomly assigned to receive the ATLAS program reported lower intentions to use AAS at an immediate post-intervention assessment and were less likely to have used AAS at a 1-year follow-up than players assigned to the control condition (Goldberg et al., 1996). Although the ATLAS program has shown success at reducing AAS misuse among high school football players (Goldberg et al., 1996), there are several limitations to relying exclusively on team-based prevention programs. One is that adolescent athletes often change teams and such transitions mean that athletes will encounter new teammates and coaches. So, even if a team or peer-based intervention is effective at establishing a team norm that opposes misuse of AAS and other illegal PES, the adolescent will likely leave this environment and enter a new one with different norms and expectations regarding the misuse of AAS and other illegal PES. Another limitation of relying exclusively on teambased programs is that coaches or peers who deliver program information may unintentionally send conflicting messages. For example, a coach may emphasize to his/her athletes the importance of getting stronger and bigger as a way to improve. If the coach simultaneously delivers a message against misuse of AAS, the athlete may come to see these two messages as conflicting. As a result, the AAS misuse message may be weaker in these instances; precisely the instances where misuse is most attractive (i.e., sports where muscle mass is advantageous). Therefore, prevention programs targeting AAS specifically, and illegal PES generally, should address the limitations inherent in team-based programs. One way to address these limitations is to develop either a stand-alone program or an add-on component that can work in conjunction with existing interventions. These stand-alone or add-on programs should have program content delivered by a source other than coaches or teammates. Furthermore, the source should be in a position to send consistent messages about use of illegal PES that transcend changes in coaching and team affiliation. Parents meet these criteria and there is considerable evi-

dence in other areas of adolescent health that parent-based interventions are effective at reducing adolescent risk taking. PARENT-BASED INTERVENTIONS

Parent-based interventions (PBIs) have been successfully used to reduce a number of adolescent risk behaviors and associated outcomes (Guilamo-Ramos, Jaccard, Dittus, & Bouris, 2006; Guilamo-Ramos et al., 2011; Hutchinson, Jemmott, Jemmott, Braverman, & Fong, 2003; Turrisi, Jaccard, Taki, Dunnam, & Grimes, 2001). The goal of many PBIs is to increase the amount of communication that occurs between parents and adolescents regarding the risk behavior. For example, one PBI designed to reduce drinking among college students provided information to parents about the importance of discussing with their adolescent refusal skills and consequences associated with alcohol consumption (Turrisi et al., 2001). Parents were encouraged to have these discussions before their adolescents left for college and to continue them throughout the first year of college. An evaluation showed that adolescents randomly assigned to receive the PBI reported lower drinking tendencies and fewer negative drinking outcomes during their freshman year compared to adolescents assigned to a control condition (Turrisi et al., 2001). This study along with others (Fang & Schinke, 2013; Guilamo-Ramos et al., 2006, 2011; Hutchinson et al., 2003) highlights the utility of developing PBIs that increase parent–adolescent communication as a way to prevent risk taking and its associated outcomes. PARENT–ADOLESCENT COMMUNICATION ABOUT AAS: IMPLICATIONS FOR PREVENTION

There is considerable evidence showing that perceived performance outcomes of AAS misuse (e.g., using AAS will make me faster) and perceived health and social consequences of AAS misuse (e.g., using AAS will make me feel like a cheater) serve as risk and protective factors, respectively (Dodge & Jaccard, 2008; Hoffman et al., 2008; Lorang, Callahan, Cummins, Achar, & Brown, 2011; MacKinnon et al., 2001; Tanner et al., 1995). Furthermore, recent theorizing on how to build more effective AAS prevention programs has pointed out that a parentbased component might be a fruitful avenue for prevention researchers to pursue (Bahrke, 2012). Therefore, a first step in developing an effective PBI targeting AAS misuse is to identify the extent to which parents are discussing performance outcomes and protective factors. An additional question is whether discussions about AAS misuse, one type of illegal PES, can influence decisions to use other types of illegal PES. THE PRESENT STUDY

Despite the success of PBI at reducing adolescent risk taking and associated outcomes, there have been no published studies to date that have extended PBI to the

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PARENT–TEEN COMMUNICATION ABOUT ANABOLIC STEROIDS

prevention of AAS misuse. Although the ATLAS program included a parent-based component, the focus of this component was to educate parents about proper nutrition and to answer questions about the intervention (Goldberg et al., 1996). It was unrelated to using parents as a source of information about AAS or other illegal PES (Goldberg et al., 1996). Furthermore, there is no data that examines whether an anti-AAS misuse message could generalize to, and protect adolescent athletes from, misuse of other types of illegal PES. While there is evidence that adolescents who received the ATLAS intervention reported less use of other illicit drugs (e.g., marijuana, amphetamines) at a 1-year follow-up (Goldberg et al., 2000), the extent to which an anti-AAS message extends to other types of illegal PES has not been tested. Therefore, the purpose of the present study is to lay groundwork for the development of a PBI aimed at reducing misuse of AAS specifically, and illegal PES generally, among adolescent athletes. There are three specific study objectives: (1) identify the extent to which parents and adolescents are discussing the topic of AAS, (2) test whether communication about AAS influences intentions to use, and (3) test whether communication about AAS influences willingness to use other types of illegal PES. These two latter study objectives lead to the following set of hypotheses. Hypothesis 1a: Communication about performance outcomes associated with AAS will be a statistically significant positive predictor of intentions to use AAS in the future. Hypothesis 1b: Communication about protective factors (i.e., health and social consequences) associated with AAS will be a statistically significant negative predictor of intentions to use AAS in the future. Hypothesis 2a: Communication about performance outcomes associated with AAS will be a statistically significant positive predictor of willingness to use a newly developed potentially illegal PES. Hypothesis 2b: Communication about protective factors associated with AAS will be a statistically significant negative predictor of willingness to use a newly developed potentially illegal PES.

METHODS Recruitment and Procedures

Two-hundred and forty-four adolescent athletes (male = 118, female = 121, not reported = 5) in grades 7–12 (age M = 15.8 years, SD = 1.3) were recruited from three high schools in the northeastern US. The principal investigator contacted athletic directors to describe the study and invite athletes to participate. Necessary school approval was obtained prior to questionnaire administration. Enrollments at the schools ranged from about 750 to about 2,800. The percentage of students who qualified for free or reduced priced lunches at participating schools ranged between 34% and 67% (National Center for Education Statistics, 2013).

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A self-administered questionnaire was distributed during the fall sports season at one school and during the spring sports season at two schools (as determined by the athletic director and school administrators). Administration occurred during the early part of the season at all schools. Adolescents on the roster for an in-season sport were invited to participate, but only athletes that returned a signed parental consent form were allowed to participate. All adolescents who returned a signed parental consent form agreed to participate in the study. Questionnaires were distributed by the research team either just before or immediately following a practice. Adolescents were instructed to avoid putting any personally identifiable information on the questionnaires. To further improve anonymity, completed questionnaires were placed in unmarked envelopes and dropped into a bin that contained other questionnaires. Coaches did not assist with the administration or collection of questionnaires. The study was approved by an Institutional Review Board, and adolescents who participated were compensated with a $15 gift card. Sample Characteristics

The sample was 74.2% White, 12.3% Black, 0.8% Middle Eastern, 5.3% mixed race, and 3.3% described their race as other. About 6% of adolescents reported being Hispanic. The most commonly played sports by females included softball (N = 68), basketball (N = 41), and soccer (N = 38). The most commonly played sports by males included football (N = 54), baseball (N = 49), and track (N = 38). Measures

Behavioral Intentions Intentions were measured with the following item adapted from previous research with this population (Dodge & Jaccard, 2008): “I intend to use anabolic steroids in the next 6 weeks.” Response options ranged from 1 (strongly disagree) to 7 (strongly agree). Willingness to Use Behavioral willingness captures the extent to which an adolescent would engage in a risk behavior given the opportunity to do so. A great deal of research has demonstrated willingness to be a good predictor of risk behaviors among adolescents (Gibbons, Gerrard, & Blanton, 1998; Stock, Litt, & Arlt, 2013). Consistent with this research (Gibbons et al., 1998; Stock et al., 2013), adolescents were presented with a scenario and answered questions based on the scenario. The scenario was created to reflect a risk-conducive context, and the questions reflected escalation in risk (Gerrard, Gibbons, Stock, Vande Lune, & Cleveland, 2005; Gibbons et al., 2010) and is similar to willingness measures used in our previous work (Dodge, Stock, & Litt, 2013). The scenario read: “A new performance enhancing substance has been developed and it is claimed that the substance increases a person’s physical capacities (e.g., strength, muscle mass, power, or endurance) significantly. Because this

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TABLE 1. Means and standard deviations

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Willingness

Intention

Mean (SD)

N

Male Female Ethnicity Hispanic Non-Hispanic

1.72 (1.26) 1.50 (1.06)

118 121

2.10 (1.27) 1.59 (1.16)

15 218

White Black Other

1.56 (1.09)a 1.57 (1.02)a 2.92 (2.03)b

181 30 12

Site A Site B Site C

1.69 (1.18) 1.60 (1.19) 1.51 (1.10)

80 82 82

Mean (SD) Gender 1.30 (1.01) 1.24 (1.02) 1.67 (1.40) 1.24 (0.97) Race 1.18 (0.85) 1.53 (1.46) 1.67 (1.56) Site 1.50 (1.44) 1.23 (0.98) 1.18 (0.74)

Perf. outcomes

Prot. factors

N

Mean (SD)

N

Mean (SD)

N

117 121

1.32 (0.60) 1.24 (0.59)

118 121

1.93 (0.87) 1.94 (0.94)

118 121

15 217

1.84 (0.97) 1.24 (0.55)

15 218

2.27 (1.05) 1.92 (0.90)

15 218

180 30 12

1.21 (0.50) 1.41 (0.73) 1.47 (0.93)

181 30 12

1.90 (0.90) 2.10 (0.85) 2.15 (1.02)

181 30 12

80 81 82

1.30 (0.66) 1.24 (0.48) 1.30 (0.63)

80 82 82

1.89 (0.89) 2.07 (0.92) 1.88 (0.92)

80 82 82

Note: Perf. outcomes = performance outcomes; Prot. factors = protective factors; Other = race other than White or Black; Columns with different subscripts reflect statistically significant differences.

substance is so new, it has not yet been listed as an illegal substance but is expected to be. The side effects of this substance, if any, are not known.” Adolescents reported how willing they would be to try this substance: (1) just once and (2) for 4 weeks. Responses ranged from 1 (not at all willing) to 7 (very willing). A mean of the items was computed to reflect willingness to try the PES. The two items were correlated r = .74, p < .01.

Amount of Communication Two scales were developed to assess parent–adolescent communication: one assessed the amount of communication about performance outcomes associated with AS and the other assessed the amount of communication about protective factors. At the beginning of the communication section for mothers [fathers], adolescents were instructed to indicate whether they would be thinking about their mother, stepmother, or female guardian [father, stepfather, or male guardian] and were instructed to place an “X” over the section if they did not have a female [male] caregiver. Nearly all of the adolescents reported thinking about their biological mothers (96%). Likewise for fathers, nearly 93% reported thinking about their biological fathers in the section that referred to communication with fathers. The stem for a majority of the questions for the performance outcomes and protective factors subscales read, “I have discussed with my mother [father] how using Anabolic Steroids. . .” Response options included 1 (not at all), 2 (somewhat), 3 (a moderate amount), and 4 (a lot). Performance outcomes. Three items assessed performance outcomes, “. . .could make me faster,” “could give me more energy,” and “could help me train harder.” These were selected because past research has found that these beliefs serve as risk factors for the misuse of AS (Dodge & Jaccard, 2008; Hoffman et al., 2008; Tanner et al., 1995).

Inspection of inter-item correlations (ranged r = .47 to .90 p < .01) and a factor analysis (one factor explained 71% of the variance) suggested considerable overlap in the amount of communication with mothers and fathers about performance outcomes. Furthermore, when two subscales were computed separately for mothers and fathers, they were highly correlated (r = .53, p < .01). Therefore, the items were combined by taking a mean (scale reliability α = 0.91). Protective factors. The following nine items assessed protective factors: “. . .could cause me to have problems with my heart,” “could cause me to be addicted,” “could cause me to experience long term side effects,” “could make it hard for me to know my true level of ability,” “is wrong.” A slightly different stem was used for the following: “I have talked with my mother [father] about how. . .,” “I would disappoint others if I used Anabolic Steroids,” “I would feel like a cheater if I used Anabolic Steroids,” and “to turn down a weightlifter who offers me Anabolic Steroids,” and “to turn down a friend who offers me Anabolic Steroids.” These items were selected because previous research has shown them to be protective factors for misuse of AS (Dodge & Jaccard, 2008; Hoffman et al., 2008; Lorang et al., 2011; MacKinnon et al., 2001). Again, inspection of inter-item correlations (ranged r = 0.38 to .94 p < .01) and a factor analysis (one factor explained 64% of the variance) suggested considerable overlap in the amount of communication with mothers and fathers about protective factors. Furthermore, when two subscales were computed separately for mothers and fathers, they were highly correlated (r = .79, p < .01). Therefore, the items were combined by taking a mean (scale reliability α = 0.93). Past Substance Use Adolescents reported whether they had ever used. Adolescents also reported the extent to which they used

PARENT–TEEN COMMUNICATION ABOUT ANABOLIC STEROIDS

a legal PES during the past year. Responses ranged from 0 = never, 1 = once or twice, 2 = once or twice/week, 3 = 2–4 times/week, 4 = nearly every day. Demographic Information Adolescents were provided with a list of sports and were instructed to check all sports teams to which they belonged. Adolescents also reported gender, age, ethnicity, and race.

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Data Analytic Plan

To identify the amount of parent–adolescent communication about AS, means and standard deviations were calculated in SPSS (IBM Corp., 2012). A modified bonferonni procedure (Jaccard, 1998) was used when testing for group differences (see Table 1). Hypotheses were tested by running a path analysis in Mplus using MLR estimator, which results in estimates of path coefficients, standard errors, and a chi-square test statistic that are robust to nonnormality (Muth´en & Muth´en, 2007). Covariates included in the analyses were data collection site and past use of a legal PES because these were statistically significantly related to the outcome variables in bivariate analyses. Another model was run that also included gender, race, and ethnicity as covariates; none of which were statistically significant predictors and the results were similar to the first analysis. RESULTS Descriptive Statistics

Less than 1% of adolescents in the sample reported having used AS during their lifetime. Reports of legal PES use were considerably higher, with nearly 14% of adolescents reporting use of a legal PES within the last year. Males were statistically significantly more likely to have used a legal PES within the last year (M = 0.47, SD = 1.02) than were females (M = 0.08, SD = 0.44; F (2,234) = 9.48, p < .01). Means and standard deviations of major study variables are shown in Table 1. Correlations are shown in Table 2. Amount of Communication

Adolescents reported talking more with their parents about protective factors (M = 1.95, SD = 0.91) than about performance outcomes (M = 1.28, SD = 0.59). This difference was statistically significant (t (243) = 12.77, p < .01). Tests of Study Hypotheses

Goodness-of-fit statistics suggested good model fit (Jaccard & Wan, 1996), with chi-square = 7.45, df = 6, p > .28, the comparative fit index (CFI) > 0.97, the root mean square error of approximation (RMSEA) < .04, and the standardized root mean square residual (SRMSR) < .03. Results of the path analysis (see Table 3) showed that communication about performance outcomes was a statistically significant positive predictor of intentions to use AS (b = 0.54, p < .01), but communication about pro-

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tective factors was not (b = −0.02, p < .77). Results also showed that communication about performance outcomes was a statistically significant positive predictor of willingness to use (b = 0.31, p < .01) and communication about protective factors was a statistically significant negative predictor of willingness to use (b = −0.24, p < .01). Therefore, results of the path analysis provided support for Hypotheses 1a, 2a, and 2b, but failed to support Hypothesis 1b. DISCUSSION

This is the first published study to our knowledge that examines parent–adolescent communication about AS. Results show that the amount of communication between parents and adolescents about AS is relatively low as means on the communication scale fell between 1 and 2, which corresponded to discussing the topic between “not at all” and “somewhat.” Adolescents’ intentions to use AS were predicted by communication about the performance outcomes such that the more frequently adolescents recalled discussing performance outcomes with their parents, the stronger were his/her intentions to use AS in the next 6 weeks. However, protective factors had no statistically significant influence on adolescents’ intentions to use AS in the next 6 weeks, which was surprising to us. These data also showed that the influence of parent–adolescent communication about performance outcomes and protective factors associated with AS could generalize beyond intentions to use AS, and influence adolescents’ willingness to use a newly developed, potentially illegal PES. The more frequent adolescents recalled communicating with their parents about the performance benefits of AS, the more willing they were to use a new PES. In addition, the more frequent adolescents recalled communication with their parents about protective factors associated with AS, the less willing they were to use the new PES. CONTRIBUTIONS TO THE LITERATURE

Results from this study offer suggestions for future research and contribute to the literature on adolescent decision making with respect to PES use. We offer two possibilities for why communication about protective factors was not a statistically significant predictor of intentions to use AS, and future research should test these possibilities. One possibility for the null effect may be the way in which parents conveyed the protective information. For example, when refusal skills are incorporated into interventions, it is often taught using scenarios or through role play (e.g., Wolfe, Crooks, Chiodo, Hughes, & Ellis, 2012). Likewise, parents may have lacked confidence in their knowledge about the health complications, which was one facet of the protective factors as assessed here. Indeed, among parents of elite Austrian athletes, only about one-third of the parents demonstrated good knowledge of the health side effects associated with doping (Blank, Leichtfried,

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TABLE 2. Correlations of major study variables

1. Willingness 2. Intention 3. PES use 4. Gender 5. Age 6. Perf. outcomes 7. Prot. factors

1

2

3

4

5

6

7

— 0.31∗∗ 0.45∗∗ −0.10 −0.04 0.09 −0.08

— 0.24∗∗ −0.03 0.00 0.34∗∗ 0.14∗

— −0.25∗∗ 0.18∗∗ −0.04 −0.02

— −0.22∗∗ −0.07 0.00

— −0.11 −0.08

— 0.48∗∗

—

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Note: PES use = use of legal performance-enhancing substance in the past 12 months; Perf. outcomes = performance outcomes; Prot. factors = protective factors; ∗ = p < .05, ∗∗ = p < .01.

Schaiter, F¨urhapter, & Schobersberger, 2013). In a different study, Mazanov, Backhouse, Connor, Hemphill, and Quirk (2013) found, with a sample of Australian athlete support personnel, that family members reported the lowest levels of knowledge when compared to other athlete support personnel. When our results are viewed in conjunction with existing research it seems likely that our parents may have lacked knowledge or confidence in this area, which might have resulted in a relatively unconvincing discussion of information about health risks. Thus, when parents are given no direction about how to discuss protective factors, their default strategies may simply be ineffective. Therefore, one direction for future research would be to pinpoint where parents feel help is needed in crafting communications with their adolescents about PES. Another possibility for the unexpected null finding may be that intentions are relatively unaffected by protective factors. That is, adolescent athletes may already know that using AS would disappoint others or lead to health problems. Furthermore, a number of published studies have reported that improving adolescents’ refusal skills have no statistically significant protective effect on alcohol, tobacco, or marijuana (Elder, Sallis, Woodruff, & Wildey, 1993; Giannotta, Vigna-Taglianti, Galanti, Scatigna & Faggiano, 2014; Wynn, Schulenberg, Maggs, & Zucker, 2000). The domain of PES use may be another instance where teaching refusal skills are ineffective. Therefore, future research should identify whether, and when, protective factors can influence intentions to use AS.

Finding that communication about protective factors associated with AS was related to a reduction in willingness to use a new, potentially illegal PES, but unrelated to intentions to use AS is consistent with the dualprocess view of adolescent decision making in risk contexts. There is growing consensus that adolescents’ decisions to engage in risk behavior is a reflection of relatively deliberate and controlled plans as well as less deliberate reactions to opportunities to engage in risk behaviors (Dodge et al., 2013; Gerrard, Gibbons, Houlihan, Stock, & Pomery, 2008; Reyna & Farley, 2006). Finding that the amount of parent–adolescent communication had slightly different effects on intentions than on willingness contributes additional empirical support for this dual-process perspective. IMPLICATIONS FOR PREVENTION

This is the first study to document that content tied specifically to AS may generalize to other types of illegal PES. This implies that developing a PBI that focuses on educating parents about a single illegal PES, like AS, has the potential to influence decisions to use other substances that parents have not specifically addressed. This is critical because educating parents about many different types of PES would likely result in an amount of information far too great for parents to learn and then pass on to their adolescent. Finding that communication with parents about performance outcomes associated with AS was associated with an increase in adolescents’ self-reported intentions to use

TABLE 3. Results of path analysis predicting adolescents’ willingness and intentions Willingness

Intentions

Unstandardized estimate SE Standardized estimate p < Unstandardized estimate SE Standardized estimate p < PES use Site 1 Site 2 Perf. outcomes Prot. factors

0.60 0.34 0.15 0.31 −0.24

0.14 0.16 0.14 0.12 0.07

0.46 0.31 0.14 0.17 −0.21

.01 .05 .28 .01 .01

0.34 0.37 0.01 0.54 −0.02

0.12 0.18 0.11 0.17 0.07

0.26 0.35 0.01 0.30 −0.02

.01 .05 .93 .01 .77

Note: p < = p-value associated with unstandardized estimate; PES use = use of legal performance-enhancing substance in the past 12 months; Perf. outcomes = performance outcomes; Prot. factors = protective factors; SE = standard error. R-squared for willingness = 0.25, p < .01; the R-squared for intentions = 0.18, p < .01.

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AS and willingness to use a new potentially illegal PES is consistent with other research on this topic. Specifically, in an evaluation of the ATLAS program, MacKinnon and colleagues (2001) found that the intervention arm, where adolescents learned about why athletes might take AS, led to an increase in the number of reasons adolescents reported they would use AS which, in turn, led to an increase in intentions to use AS at the 1-year postintervention follow-up. Therefore, the findings from the present study, when viewed in conjunction with existing research imply that parents should avoid highlighting the performance outcomes associated with AS misuse; at least until a better understanding of how the information can be communicated that does not increase risk of using a PES is gained. Additionally, discussions should emphasize the protective factors such as the health and social consequences of misusing AS. STRENGTHS AND LIMITATIONS

These results must be viewed in light of the limitations inherent in the study design. The sample consisted of adolescent athletes from the northeastern US, so the extent to which these findings generalize to adolescent athletes in other regions of the US or in other countries is unknown. For example, a recent study highlighted the emphasis that individuals in the US place on winning in sports (United States Anti-Doping Agency, 2010). Therefore, in cultures or contexts where sport serves a purpose other than to win (e.g., to be healthy, to develop interpersonal skills), the pathways established here may not generalize. The data were collected during 2009–2010, so the passage of time should be kept in mind as one is interpreting the results. The study relied on adolescents’ reports of communication, and adolescents may have over or under-reported how often they engaged in discussions about AS. However, research has found that it is adolescents’ perceptions and recall of communication that are important when predicting how influential parent–adolescent communication is for adolescent risk taking (Guilamo-Ramos et al., 2007). The dependent measures were intentions and willingness to use, not actual use. While actual use would be a stronger test of the hypotheses, the base rates of illegal PES use are small and would necessitate a prohibitively large sample for the present purposes. Thus, we chose outcome variables that have established histories of serving as good proxies for adolescent risk taking behaviors (Dodge & Jaccard, 2007; Gerrard et al., 2008; Gibbons et al., 1998; Webb & Sheeran, 2006). The findings reported here provide the confidence needed for researchers to invest in larger scale data collection efforts. Finally, the amount of communication with mothers was too highly correlated with the amount of communication with fathers to allow us to test for differential effects of maternal and paternal communication on intentions and willingness. Furthermore, the items that comprised each dimension (performance outcomes and protective factors) were highly correlated with one another, which prevented us from exploring which items might be most influen-

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tial in predicting intentions or willingness. Although these items were based on published research (Dodge & Jaccard, 2007, 2008; Dodge, Litt, Seitchik, & Bennett, 2008; Goldberg et al., 1996), the items assessing performance outcomes were primarily positive whereas those assessing protective factors were primarily negative aspects of use. Future research could develop more nuanced approaches to explore the extent to which it is the underlying beliefs that are important, whether it is the valence of each belief or some combination that most strongly affects intentions and willingness. This would help inform parents of whether the goal of conversations should be to affect the likelihood (e.g., using AS is not particularly effective for making you faster), affect the valence (e.g., you are overestimating the importance of speed), or both. Despite these limitations, there are strengths of this study that deserve mention. The sample consisted of adolescent athletes, a population at increased risk for misuse of PES. The ages of adolescents in the sample reflects an opportune time for intervention. This is because the typical age of first use for AS is about between 17 and 20 years (Dodge, Turrisi, Williams, & Yesalis, 2014; Karazsia, Crowther, & Galioto, 2013), making early adolescence a potentially important time for intervention. CONCLUSIONS

A recent review of the risk factors for AS and implications for intervention approaches highlighted the potential impact of developing and incorporating a parentbased component to prevention programs targeting AS use among adolescents (Bahrke, 2012). We feel results of this study offer an important first step in developing a PBI to help prevent misuse of illegal PES. Future research should build upon these findings by developing and testing the effectiveness of a PBI designed to reduce misuse of illegal PES. Such a PBI could be either a stand-alone program or serve as an add-on component to existing interventions. Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. This project was funded by a Social Science Research Grant awarded by the World-Anti-Doping Agency. THE AUTHORS Tonya Dodge, Ph.D., is an Associate Professor in the Department of Psychology at The George Washington University. Her research interests are in understanding decision-making processes related to substance use with a particular emphasis on anabolic steroid use among adolescents.

Paige Clarke, M.A., is a doctoral student in the Applied Social Psychology program at The George Washington University. Her research focuses on identifying psychological mechanisms that underlie substance use behaviors.

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T. DODGE AND P. CLARKE

GLOSSARY

AAS: Anabolic Androgenic Steroids AS: Anabolic Steroids PES: Performance Enhancing Substances ATLAS: Adolescent Training and Learning to Avoid Steroids Program PBI: Parent Based Intervention

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