NASP CQ 35-2 - Steroids in Adolescence

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NASP Communiqué, Vol. 35, #2
October 2006

Steroid Use in Adolescence: Information for School Personnel

By Sarita Gober, Malky Klein, Tzippy Berger, Cristina Vindigni & Paul C. McCabe, PhD, NCSP

Although steroid abuse is usually associated with professional athletes seeking to improve their competitive edge, it is also a dangerous form of substance abuse among adolescents. Both boys and girls, athletes and non-athletes, are susceptible, and the physical and psychological risks are significant. According to Monitoring the Future, a long-term national study on drug abuse in adolescents funded by the National Institute on Drug Abuse (NIDA), the 2005 prevalence rates for steroid use were 1.2%, 1.8%, 2.6% for 8th, 10th and 12th grade boys and 0.9%, 0.7%, 0.4% for girls, respectively. Equally alarming from an education standpoint, between 1998 and 2003, the percentage of 12th graders who perceived steroids as risky and disapproved their use dropped from 68% to 55%, despite increased health warnings (Johnston et al., 2006). School personnel who work with adolescents, as well as parents of teens, should have information about the neurobiological mechanisms of steroid effects and the possible relationship with psychological states such as mood, cognition, and suicidal behavior. Further, school support personnel such as school psychologists, counselors, and social workers should be aware of the implications of steroid use in their daily work with youth and young adults.

Overview

Anabolic-androgenic steroids (AAS) are man-made substances related to male sex hormones. Anabolic refers to muscle-building, and androgenic refers to increased masculine characteristics. Steroids are legally available only by prescription to treat conditions that occur when the body produces abnormally low amounts of testosterone, such as delayed puberty and some types of impotence. They are also used to treat body wasting in patients with AIDS and other diseases that result in loss of lean muscle mass. Smuggled in from other countries or manufactured in illegal labs, the most commonly used anabolic steroids include testosterone, nandrolone, methenolone, stanozolol, and methandrostenolone. Steroid use causes the body to retain nitrogen that is ordinarily lost via urinary excretions. This retention, used in combination with exercise, training, and high protein diets, can promote increased size and strength of muscles, improve endurance, and decrease recovery time between workouts.

Side Effects of Steroid Usage

Emotional and behavioral lability. According to the National Institute on Drug Abuse (NIDA), anabolic steroids, particularly those in high doses, increase irritability and aggression. Some steroid abusers report that they have committed property crimes, such as stealing from a store, damaging or destroying others’ property, or breaking into a house or a building. Abusers who have committed aggressive acts or property crimes generally report that they engage in these behaviors more often when they are actively taking steroids. Anabolic steroids have also been reported to cause other behavioral effects, including euphoria, increased energy, sexual arousal, mood swings, distractibility, forgetfulness, and confusion. Some studies of steroid usage have reported that a minority of their subjects develop behavioral symptoms that were so extreme that they disrupted their ability to function at work or in social settings. In a few cases, the subjects’ behaviors presented a threat to themselves and others. Other symptoms included increased risk-taking behavior, extreme egocentrism, cognitive rigidity, altered physical identity, increased feelings of superiority, and extreme mood changes (Gonzalez, McLachlan, & Keaney, 2001).

Physical changes and health risks. When excess testosterone from steroids is converted to estrogens, male users may suffer from gynecomastia, in which breast-like tissue develops. In the female body, anabolic steroids cause masculine effects, such as hirsutism (abnormal hair growth), deepening of voice, clitoral hypertrophy, and male pattern baldness, and are irreversible. Acne, increased libido, and menstrual irregularities also may occur. Steroids may affect growth and maturation. Rising levels of testosterone and other sex hormones normally trigger the growth spurt that occurs during adolescence. When these hormones reach certain levels, they signal the bones to stop growing. When a child or adolescent takes anabolic steroids, the artificially increased level of sex hormones can signal the bones to stop growing prematurely. Steroid abuse is associated with cardiovascular disease, including heart attack and strokes, even in athletes younger than 30 (NIDA, 2005). Continued use may lead to elevation in certain liver enzymes, which in turn can bring about cholestatic jaundice, a serious and potentially fatal condition. Steroids are also associated with liver tumors and a rare condition called peliosis hepatis, in which blood-filled cysts form in the liver. Both the tumors and the cysts sometimes rupture, causing internal bleeding.

Steroid Use Among Adolescents

Prevalence

According to NIDA, more teenagers are actively using steroid drugs while fewer are worrying about the dangers. According to NIDA Director Dr. Alan Leshner, steroid use has increased 50% in 8th graders and 10th graders since 1991. The period of risk of AAS dependence starts during secondary school. NIDA estimates that 500,000 young Americans are currently using steroids. Although most past research has focused on male users, the NIDA reports that national surveys indicate that girls account for about one-third of the high school students who abuse steroids. Many girls who take steroids have eating disorders, and those taking steroids are usually engaged in athletic activities. The primary reason offered by girls who use steroids is to lose fat and gain lean muscle.

Socio-Cultural Factors

Adolescents are increasingly aware of their bodies and others’ reactions to them. They often struggle with accepting their own appearance and strive for approval from others (Stout & Wiggins Frame, 2004). The media, peer pressure, and self-perception often serve as important factors influencing their decisions. Research suggests that these factors may also play a role in an adolescent’s decision to use steroids.

Pressure from media and parents. The media’s depiction of the ideal physique includes well-defined muscles and low body fat. Adolescent boys, who are in the midst of deciding who they want to be as adults, may internalize these messages and strive to attain this idealized appearance. Parental pressure in the form of negative comments and a focus on physical appearance was also correlated with motivation of adolescents to build muscles and take steroids. Internalization of these media and cultural biases leads to greater body dissatisfaction and is associated with steroid abuse.

Disturbance in body image. Body builders are at greater risk for disturbances in their body image (their internalized view of their physical appearance). The muscular physiques featured in the media are very difficult to achieve through healthy means, and may be a result of anabolic steroid usage, dehydration, and other unhealthy practices. Researchers describe a body image disorder called muscle dysmorphia (MD), which is an extreme preoccupation with one’s body, poor insight into actual body size or weight, and rigid dietary practices. It occurs in both males and female who weight train, as well as individuals who abuse anabolic steroids. MD is becoming more common among adolescents, and studies have shown that MD in adolescence can affect one’s body image well into adulthood. The disorder is associated with greater body dissatisfaction, depression, and perfectionism, and is similar to eating disorders in girls and women.

Mental Health Implications of Steroid Use in Adolescence

Although the adverse physical effects of steroid use have been widely reported, fewer studies have examined the psychological effects of steroid use. Recently media attention and congressional hearings have raised the question of a possible link between steroid use and suicide. Although this link has not been verified, a number of studies have established that steroid use can result in harmful psychological effects. Aggression is frequently cited as one consequence of steroid use, and high doses have been implicated in numerous instances of violence and aggression by athletes and body builders. While steroids can trigger negative reactions in any age group, it is during the teenage years that aggressive inhibitors are being developed. Steroids, such as testosterone, can interfere with brain development and may alter long-term capacity for aggressive inhibition.

Psychiatric symptoms. Other studies examining the psychiatric effects of anabolic steroids have found them to cause or intensify psychiatric symptoms, including affective and psychotic symptoms. Examples of psychotic features identified by researchers have included paranoid and grandiose delusions. Impulsive and manic behaviors have also been identified, such as a 23-year-old man who purchased a $17,000 sports car while using steroids — upon stopping to take the drug, he realized he could not afford the car and sold it, only to buy a $20,000 sports car the following year during another cycle of steroid use. One study found that mood changes occurred within days of initiating anabolic steroids, and other studies reported that their subjects experienced mania in association with steroid use. In another study comparing athletes who did and did not use steroids found that 23% of the athletes using anabolic steroids experienced one or more manic episodes, hypomanic episodes or major mood syndromes, such as major depression.

Effects of steroid withdrawal. Often, the cessation of steroid use can also result in adverse psychological effects. Depression is a common consequence of steroid withdrawal. If not treated properly, severe depression can result in suicide. Although suicide has been associated with steroid use, the direct relationship is not yet clear. Often suicides completed while the individual was actively using steroids occurred in conjunction with manic behavior and were more impulsive in nature. However, suicide completed during withdrawal was often premeditated and in association with severe depression. In either circumstance, anabolic steroids may have been one of the factors contributing to the completion of suicide.

Psychological factors in steroid use. Although causality has not yet been established, there may be certain psychological characteristics that influence the use of steroids by adolescents. Low self esteem has been found to predict body dissatisfaction among adolescent boys and girls, a trait which has been correlated with steroid use. However, there is no definitive evidence as to whether a particular personality characteristic predisposes an adolescent to steroid use or whether negative psychological symptoms emerge as a result of steroid use.

The study of steroid use and psychological effects is severely limited for a number of reasons. Most studies utilizing experimental trials can not use the high dose of steroids that may cause harmful psychological side effects, as it would be unethical and potentially lethal to do so. The common doses that are used by steroid abusers are 10 to 100 times higher than the amounts used in research. Further, the common practice of “stacking” — where users combine several different types of steroids to maximize their effectiveness — can be a large contributor to these psychological symptoms. However, stacking is not used in the controlled research studies. In addition, many athletes do not reveal the amount of steroids that they are taking to their physicians, or even whether they are using steroids at all. Therefore, doctors rarely associate psychiatric and psychological effects with steroids.

Implications for School-Based Mental Health Professionals

Awareness of the detrimental effects that steroids can have on individuals, particularly adolescents, is a key knowledge set for school-based mental health professionals. Given the growing popularity of steroid use among adolescents, school personnel need to be able to identify students who may already be taking steroids or those who may be at risk for taking them. A profile for students that may be taking steroids may include those who are athletes and those who report a poor body image.

Increase awareness. One of the main problems concerning adolescents and steroid use is that adolescents are unaware of the many negative side effects. Some adolescents even have false information about what steroids can do to their body, such as increasing their height and aerobic performance. In addition, many adolescents begin taking steroids because they want to improve their physical appearance — they are often unaware that in order to increase their muscle size and strength, they must perform exercise in addition to using steroids. The first step for school personnel is to increase the awareness of these effects among adolescents. Peer counseling may also be effective, because peers are a major source of information concerning steroids. In addition, healthcare providers need to play a larger role as an information source to adolescents regarding the adverse effects of steroids.

Address body image concerns. Individual counseling with a cognitive behavioral approach is often recommended for students with body image concerns, and Ellis’ rational emotional behavior therapy in particular has been suggested. Another recommended approach is group counseling within the school, as peer groups can have positive effects on adolescent behavior change. It can be particularly valuable for boys to learn about peers who feel the same way within an atmosphere of support.

Involve parents. Parents also play a significant role in the life of their teenager. School personnel can organize informational and support groups to raise awareness about the seriousness of body image disorders and steroid use among parents. Intervention strategies are available for parents who suspect steroid use among their children, including talking to their children about the unrealistic body images in society, refraining from criticizing their appearance, and helping them look for other sources of self-esteem instead of their bodies.

Involve teachers and coaches. School mental health professionals can help ensure that teachers and coaches have the appropriate outlook on body image and that they set appropriate goals in encouraging their students. Coaches need to establish a no-tolerance policy for steroid use, no matter how competitive the sport may be, or how pressured the coaches feel to produce a winning season.

ATLAS. A NIDA-funded drug abuse prevention program called ATLAS has been implemented in a number of schools and is reported to have reduced steroid use among more than 1,500 football players from 31 high schools in the Portland, OR area. The program educates student athletes about the harmful effects of anabolic steroids and provides nutrition and weight-training alternatives to steroid use. The weight-training component includes seven hands-on sessions that teach the students proper weight training techniques. These sessions are designed to help student athletes build the muscular strength needed to achieve their athletic goals without using steroids.

Need for Vigilance

School-based mental health professionals can assess the needs in their school and modify the type of program that is appropriate for their student body. Given the dangers of anabolic steroids, as well as the growing number of adolescents who use them, it is crucial that school personnel — and parents — be vigilant regarding students who are at-risk or are using steroids, and implement appropriate interventions.

Resources

Burnett, K.F., & Kleiman, M. E. (1994). Psychological characteristics of adolescent steroid users. Adolescence, 29(113), 81-90.

Goldberg, L., Elliot, D.L., Clarke, G., MacKinnon, D.P., Moe, E. et al. (1996). Effects of a multi-dimensional anabolic steroid prevention program: The A.T.L.A.S. (Adolescents Training and Learning to Avoid Steroids) Program. Journal of the American Medical Association, 276, 1555-1562.

Gonzalez, A., McLachlan, S., & Keaney, F. (2001). Anabolic steroid misuse: How much should we know? International Journal of Psychiatry in Clinical Practice, 5, 159-167.

Government Reform Minority Office: Committee holds hearing on steroids in baseball, 108th Cong., 2nd Sess. (2005). Retrieved March 13, 2006, from http://www.democrats.reform.house.gov/story.asp?bolSu pressHeaders=1&ID=816&Issue=Steroid+Use+in+Sports

National Institute on Drug Abuse (NIDA) (2005). www.steroidabuse.org

Pope, H.G., & Katz, D.L. (1988). Affective and psychotic symptoms associated with steroid use. The American Journal of Psychiatry, 145, 487-490.

Pope, H., Phillips, K., and Olivardia, R. (2000). The Adonis Complex: The secret crisis of male body obsession. New York: The Free Press.

Ricciardelli, L.A., & McCabe, M.P. (2003). Sociocultural and individual influences on muscle gain and weight loss strategies among adolescent boys and girls. Psychology in the Schools, 40, 209-224.

Sharma, M. (2005). Anabolic steroids and other performance enhancing drugs. Journal of Alcohol and Drug Education, 49(2), 89-90.

Stout, E.J., & Wiggins Frame, M. (2004). Body image disorder in adolescent males: Strategies for school counselors. Professional School Counseling, 8, 176-181.

Wilson, D. (2005, March 10). After a young athlete’s suicide, steroids are called the culprit. New York Times. Retrieved from www.nytimes.com

This handout is adapted from a longer article published in the May 2006 issue of the Communiqué, the newspaper of the National Association of School Psychologists. Sarita Gober, Malky Klein, Tzippy Berger, and Cristina Vindigni are students in the Graduate Program in School Psychology at Brooklyn College – CUNY. Paul McCabe, PhD, NCSP, is an Associate Professor in the Graduate Program in School Psychology at Brooklyn College – CUNY, Brooklyn, NY.

NASP Communiqué, Vol. 35, #2 October 2006