Jason Williams

RTI International, Durham, North Carolina, United States

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Publications (25)49.05 Total impact

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    ABSTRACT: This study examined gender differences in posttraumatic stress disorder (PTSD) symptoms and symptom clusters in the total U.S. active duty force. Data were drawn from the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel and based on 24,690 individuals: 17,939 men and 6,751 women from all services at 64 installations worldwide. The results indicated that women expressed more symptom distress than men across almost all the individual PTSD symptoms except for hypervigilance. Women also had significantly higher scores on all four PTSD Checklist, Civilian Version (PCL-C) factors examined, including Re-experiencing, Avoidance, Emotionally numb, and Hyperarousal. More women than men were distressed by combat experiences that had involved some type of hurt, such as being wounded, witnessing or engaging in acts of cruelty, engaging in hand-to-hand combat, and, to a lesser extent, handling dead bodies. Men who had been sexually abused had a greater number of symptoms and were consistently more distressed than women on both individual symptoms and symptom clusters. Gender differences were a predictor for the Emotionally numb factor in which men had higher scores after controlling for other demographics, combat experiences, sexual abuse history, and substance abuse. This study found that gender differences in PTSD symptoms of military personnel are both dependent on the type of trauma (combat vs. sexual abuse) experienced, the kind of combat exposures experienced, and the time when sexual abuse took place (before vs. after joining the military).
    142nd APHA Annual Meeting and Exposition 2014; 11/2014
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    ABSTRACT: Objectives. We characterized trends in mental health services utilization and stigma over the course of the Afghanistan and Iraq wars among active-component US soldiers. Methods. We evaluated trends in mental health services utilization and stigma using US Army data from the Health-Related Behavior (HRB) surveys from 2002, 2005, and 2008 (n = 12 835) and the Land Combat Study (LCS) surveys administered to soldiers annually from 2003 to 2009 and again in 2011 (n = 22 627). Results. HRB and LCS data suggested increased mental health services utilization and decreased stigma in US soldiers between 2002 and 2011. These trends were evident in soldiers with and without posttraumatic stress disorder (PTSD), major depressive disorder (MDD), or PTSD and MDD. Despite the improving trends, more than half of soldiers with mental health problems did not report seeking care. Conclusions. Mental health services utilization increased and stigma decreased over the course of the wars in Iraq and Afghanistan. Although promising, these findings indicate that a significant proportion of US soldiers meeting criteria for PTSD or MDD do not utilize mental health services, and stigma remains a pervasive problem requiring further attention. (Am J Public Health. Published online ahead of print July 17, 2014: e1-e9. doi:10.2105/AJPH.2014.301971).
    American journal of public health. 07/2014;
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  • Robert M Bray, Janice M Brown, Jason Williams
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    ABSTRACT: Population-based Department of Defense health behavior surveys were examined for binge and heavy drinking among U.S. active duty personnel. From 1998-2008, personnel showed significant increases in heavy drinking (15% to 20%) and binge drinking (35% to 47%). The rate of alcohol-related serious consequences was 4% for nonbinge drinkers, 9% for binge drinkers, and 19% for heavy drinkers. Personnel with high combat exposure had significantly higher rates of heavy (26.8%) and binge (54.8%) drinking than their counterparts (17% and 45%, respectively). Heavy and binge drinking put service members at high risk for problems that diminish force readiness and psychological fitness.
    Substance Use &amp Misuse 07/2013; 48(10):799-810. · 1.11 Impact Factor
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    ABSTRACT: Current military personnel are at risk of developing serious mental health problems, including chronic stress disorders and substance use disorders, as a result of military deployment. The most frequently studied effect of combat exposure is post-traumatic stress disorder (PTSD). High-risk behaviors, including alcohol use and aggression, have been associated with PTSD, but the optimal cutoff score on the PTSD Checklist (PCL) for determining the risk for these behaviors has not been clearly delineated. Using postdeployment active duty (AD) and Reserve component military personnel, the relation between various cutoff scores on the PCL and engaging in high-risk behaviors was examined. AD personnel, for every outcome examined, showed significantly greater odds for each problem behavior when PCL scores were 30 or higher compared to those with PCL scores in the 17 to 29 range. A similar pattern was shown for Reserve component personnel with respect to several problem behaviors, although not for alcohol use behaviors. The differences in problem behaviors for these two populations may be an indication that deployment experiences and combat exposure affect them differently and suggest that despite lower critical PCL scores, AD personnel may be at higher risk for developing problems as a function of the deployment cycle.
    Military medicine 10/2012; 177(10):1184-90. · 0.77 Impact Factor
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    ABSTRACT: We examined stress levels and other indicators of mental health in reservists and active-duty military personnel by deployment status. We used data from the Department of Defense Health-Related Behaviors surveys, which collect comprehensive, population-based data for reserve and active-duty forces. Data were collected from 18 ,342 reservists and 16, 146 active-duty personnel. Overall, with adjustment for sociodemographic and service differences, reservists reported similar or less work and family stress, depression, and anxiety symptoms than did active-duty personnel. However, reservists who had been deployed reported higher rates of suicidal ideation and attempts than did active-duty personnel who had been deployed and higher rates of post-traumatic stress disorder symptomatology than did any active-duty personnel and reservists who had not been deployed. The highest rates of suicidal ideation and attempts were among reservists who had served in theaters other than Iraq and Afghanistan. Our results suggest that deployment has a greater impact on reservists than on active-duty members, thus highlighting the urgent need for services addressing reservists' unique postdeployment mental health issues. Also, deployment to any theater, not only Iraq or Afghanistan, represents unique threats to all service members' mental well-being.
    American Journal of Public Health 06/2012; 102(6):1213-20. · 3.93 Impact Factor
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    ABSTRACT: Understanding the role of spirituality as a potential coping mechanism for military personnel is important given growing concern about the mental health issues of personnel returning from war. This study seeks to determine the extent to which spirituality is associated with selected mental health problems among active duty military personnel and whether it moderates the relationship between combat exposure/deployment and (a) depression, (b) posttraumatic stress disorder (PTSD), and (c) suicidality in active duty military personnel. Data were drawn from the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Over 24,000 randomly selected active duty personnel worldwide completed an anonymous self-report questionnaire. High spirituality had a significant protective effect only for depression symptoms. Medium, as opposed to high or low, levels of spirituality buffered each of the mental health outcomes to some degree. Medium and low spirituality levels predicted depression symptoms but only among those with moderate combat exposure. Medium spirituality levels also predicted PTSD symptoms among those with moderate levels of combat exposure and predicted self-reported suicidal ideation/attempt among those never deployed. These results point to the complex relationship between spirituality and mental health, particularly among military personnel and the need for further research.
    Depression research and treatment 01/2012; 2012:425463.
  • Laurel L. Hourani, Jason Williams, Robert Bray
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    ABSTRACT: Context: Deployment and trauma are associated with a number of mental health problems experienced by military personnel. Many of these co-occur, including posttraumatic stress disorder (PTSD), depression, suicidal ideation and attempt, alcohol and drug abuse, and anxiety. Although some of these comorbidities may be associated with combat-related traumas, others may be more associated with separate noncombat risk and protective factors. Such comorbidities pose increased treatment challenges; however, the prevalence and pattern of these comorbidities within the military are unknown. Objective: To (1) describe the prevalence and underlying structure of PTSD comorbid mental health conditions among active duty military personnel Design: Population-based, cross-sectional, anonymous survey Setting: 64 U.S. military installations worldwide Participants: 28,546 active duty military respondents from all branches of services stratified by gender, rank, and location Main Outcome Measures: Categorical models of comorbid PTSD conditions, including depression, generalized anxiety, serious psychological distress, suicidal ideation, and problem drinking Results: Almost 32% of personnel who met criteria for PTSD also met criteria for at least one of five other mental health problems; 75% of those with depression symptoms symptoms also met criteria for at least one of the other mental health problems. Latent class analysis models identified five classes of PTSD comorbidity among deployed personnel and four classes among nondeployed personnel. Separate profiles of risk and protective factors differentiated comorbid classes. Conclusion: Findings advance our understanding of the prevalence of co-occurring disorders with PTSD and how individual and military factors may influence both the risk of PTSD and co-occurring mental and substance use disorders.
    139st APHA Annual Meeting and Exposition 2011; 11/2011
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    ABSTRACT: The U.S. military has traditionally had high rates of alcohol misuse and alcohol-related problems, necessitating effective treatment programs that minimize participant burden. Web-based interventions have shown promise as efficient treatment options for college students and adults but have not been widely evaluated in the military. This study evaluated the efficacy of two web-based alcohol interventions originally created for civilians and then adapted for U.S. military personnel. Two web-based alcohol interventions, Alcohol Savvy and Drinker's Check-Up, were adapted for use among military populations. The interventions were evaluated using a convenience sample of 3,070 active-duty military personnel at eight installations. Following a baseline survey, participants were assigned to one of three treatment conditions: (a) Alcohol Savvy, (b) Drinker's Check-Up, or (c) control (no program participation). Follow-up surveys were completed by 1,072 participants 1 month following baseline and by 532 participants 6 months following baseline. At 1-month follow-up, participants who completed the Drinker's Check-Up intervention had significant reductions in multiple measures of alcohol use relative to controls. Positive outcomes were found for average number of drinks consumed per occasion, frequent heavy episodic drinker status, and estimated peak blood alcohol concentration. These reductions in alcohol use at the 1-month follow-up were maintained at the 6-month follow-up. There were no statistically significant changes in alcohol use for participants who completed Alcohol Savvy. This study expands the literature on the effectiveness of web-based treatment for alcohol misuse. Findings indicate that web-based programs (Drinker's Check-Up in particular) can significantly decrease several indicators of alcohol use in U.S. military personnel.
    Journal of studies on alcohol and drugs 05/2011; 72(3):480-9. · 1.68 Impact Factor
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    ABSTRACT: To describe the prevalence and overlapping combinations in past thirty-day cigarette use, smokeless tobacco use, and cigar use in the active duty U.S. military. Data were taken from the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. A total of 28,546 service members participated for a response rate of 70.6%. Analyses showed that 41.2% of active duty service members used one or more forms of tobacco in the past month. Cigarette use only was most prevalent (21.3%); other combinations were much lower ranging from 0.7% to 13.5%. Multinomial regression modeling yielded no consistent patterns in sociodemographic groups with higher risk of using one or more types of tobacco concurrently. Frequency and quantity of cigarette use were related to tobacco use patterns. From 60% to 67% of smokers were daily users of cigarettes only or cigarettes in combination with other tobacco types. The majority of cigarette users (54%-69%) smoked 15 or fewer cigarettes/day regardless of tobacco use patterns, but those who smoked at heaviest levels were most likely to use all 3 tobacco types (19%). Four of 10 service members place themselves at increased risk of tobacco-related illness and disease by using one or more types of tobacco. Daily cigarette smokers and very heavy smokers are at highest risk of using multiple tobacco types. Further research is needed to better understand the levels of use and the reasons for use of multiple types of tobacco.
    Nicotine & Tobacco Research 04/2011; 13(8):691-8. · 2.48 Impact Factor
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    ABSTRACT: Measurement invariance is typically assumed when assessing drinking-related constructs across distinct groups of respondents. However, measurement properties of motivations related to mood maintenance and stress relief may differ in those experiencing symptoms of depression or anxiety. Invariance of social and coping drinking motives were explored with a sample of 4133 junior enlisted Air Force and Navy personnel. Measurement did not differ in those with depression symptoms. In contrast, those with anxiety symptoms differed in measurement of both motives. The impact of non-equivalence was demonstrated with a mediation model in which anxiety and depression predicted drinking motives, which in turn predicted heavy drinking. Incorporation of the partial invariance of the social motives factor attenuated the estimate of the mediated effect of social drinking motives by almost half compared to the estimate with invariance assumed. These results suggest that lack of measurement invariance could seriously bias or alter conclusions from tests of theoretical models and highlight the need for researchers to carefully consider the measurement properties of their constructs prior to model estimation.
    Addictive behaviors 05/2010; 35(5):444-51. · 2.25 Impact Factor
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    ABSTRACT: Studies have not examined the factor structure or measurement invariance of posttraumatic stress disorder (PTSD) symptomatology using population-based data. Confirmatory factor analysis of the PTSD Checklist-Civilian Version (PCL-C) was conducted in a representative sample of U.S. active duty military personnel (N = 15,593). Consistent with prior research, a 4-factor model consisting of reexperiencing, avoidance, emotional numbing, and arousal factors was superior to four alternative models. Measurement invariance was found for factor loadings, but not observed item intercepts when comparing personnel with and without a recent deployment (<or=12 months). Findings indicate differences in the level of observed responses across deployment subgroups that exceed what would be expected for individuals with similar PCL latent factors scores. Implications of results are discussed.
    Journal of Traumatic Stress 02/2010; 23(1):91-9. · 2.72 Impact Factor
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    ABSTRACT: The present study examined drinking rates of U.S. Navy and Air Force trainees during the month before attending basic training and after the ban on drinking alcohol was lifted during advanced training. Surveys were obtained at five training bases (one U.S. Navy, four U.S. Air Force) from 6,298 persons for a response rate of 65%. Analyses were based on 4,962 young adults ages 18-25 (82% male) who gave valid responses about pre-basic drinking. Findings showed a rate of 43.1% heavy episodic drinking during the month before basic training, 15.8% by infrequent heavy episodic drinkers (five or more drinks per occasion at least once, four or more for women), and 27.3% by frequent heavy episodic drinkers (five or more drinks per occasion, four or more for women, at least once a week). Pre-basic frequent heavy episodic drinkers averaged 7.9 drinks per occasion and nearly 15 heavy episodic drinking days during the month. In contrast, heavy episodic drinking following basic training was substantially lower: 12.0% for infrequent heavy episodic drinkers and 9.0% for frequent heavy episodic drinkers. Comparisons with the U.S. Department of Defense Health Related Behaviors Survey suggest that post-basic frequent heavy episodic drinking rates are likely to increase over time but not to pre-basic levels. Pre-basic infrequent and frequent heavy episodic drinkers were more likely than nondrinkers or non-heavy episodic drinkers to initiate or re-initiate frequent heavy episodic drinking. Frequent heavy episodic drinking after basic tended to occur 1-6 weeks after the ban on alcohol use was lifted. Selection and socialization help explain heavy episodic drinking of U.S Navy and U.S. Air Force trainees.
    Journal of studies on alcohol and drugs 01/2010; 71(1):15-22. · 1.68 Impact Factor
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    ABSTRACT: This study explored the mediating mechanisms of two Web-based alcohol interventions in a sample of active duty United States military personnel. Personnel were recruited from eight bases and received the Drinker's Check-Up (N=1483), Alcohol Savvy (N=688), or served as controls (N=919). The interventions drew on motivational interviewing and social learning theory and targeted multiple mediators including social norms, perceived risks and benefits, readiness to change, and coping strategies. Baseline data were collected prior to the intervention and follow-up data on alcohol consumption were gathered 1 month and 6 months after program completion. Two mediation models were examined: (1) a longitudinal two-wave model with outcomes and mediators assessed concurrently at the 1-month follow-up; and (2) a three-wave model in which the causal chain was fully lagged. Results indicated strong support for the role of perceived descriptive norms in transmitting the effects of the Drinker's Check-Up, with consistent mediation across the majority of alcohol outcome measures for both the concurrent and fully lagged mediation models. These results suggest that web-based interventions that are effective in lowering perceived norms about the frequency and quantity of drinking may be a viable strategy for reducing alcohol consumption in military populations. The results did not support program mediation by the other targeted variables, indicating the need for future research on the effective components of alcohol interventions. The mediation models also suggest reasons why program effects were not found for some outcomes or were different across programs.
    Drug and alcohol dependence 01/2009; 100(3):248-57. · 3.60 Impact Factor
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    ABSTRACT: Previous research has shown that 8% to 10% of nonsmokers initiated smoking during their first year of military service despite a period of forced abstinence during boot camp. To our knowledge, no studies have looked at the influence of peers and role models on the initiation of smoking among U.S. Air Force personnel who recently completed boot camp. This cross-sectional study examined the role of perceived peer norms, roommate influence, role model influence, perceived norms of all active duty personnel, and depressive symptoms in the initiation and reinitiation of smoking among 2,962 Air Force technical training students. Previous nonsmokers were more likely to initiate smoking if they perceived that the majority of their classmates smoked (OR = 1.67, 95% CI[1.05-2.67]) and if they reported that their military training leader or classroom instructor used tobacco products (OR = 1.69, 95% CI[1.12-2.56]). Additionally, previous nonsmokers were more likely to initiate smoking if their roommate smoked (OR = 1.67, 95% CI[1.09-2.56]). Similar results were seen with previous smokers who perceived that the majority of their classmates smoked (OR = 1.63, 95% CI[1.03-2.58]) and if they reported that their military training leader or classroom instructor used tobacco products (OR = 1.95, 95% CI[1.29-2.94]). Our study suggests that military role models who use tobacco, peer smoking behavior, and perceived smoking norms increase the likelihood of smoking initiation among newly enlisted military personnel who have recently undergone a period of forced abstinence.
    Nicotine & Tobacco Research 11/2008; 10(10):1533-41. · 2.48 Impact Factor
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    ABSTRACT: This study estimated percentages of adolescents living with a mother or father with serious psychological distress (SPD), and examined moderation and mediation of the relationships between mother or father SPD and adolescent substance use. We analyzed data from nationally representative samples of adolescents interviewed with their mothers (n = 4734) and fathers (n = 3176) in the combined 2002 and 2003 National Surveys on Drug Use and Health (NSDUHs). An estimated 4.1% of adolescents living with their father had a father with SPD during the past year, and 11.5% of adolescents living with their mother had a mother with SPD during this time period. A positive association was found between mothers' SPD and adolescent binge drinking (OR = 1.49, 95% CI = 1.01-2.21), but no association was found between fathers' SPD and adolescent binge drinking. Mothers' SPD was associated with increased risk of binge drinking among adolescents aged 14-15 years (OR = 2.52, 95% CI = 1.38-4.60), and fathers' SPD was associated with lowered risk of binge drinking among black adolescents (OR = .08, 95% CI = .01-.79). A positive association was found between mothers' SPD and adolescent illicit drug use (OR = 1.55, 95% CI = 1.08-2.23), but no association was found between fathers' SPD and adolescent illicit drug use. Mothers' SPD was associated with increased risk of illicit drug use among female adolescents (OR = 2.14, 95% CI = 1.24-3.70) and among adolescents of white ethnicity (OR = 1.78, 95% CI = 1.19, 2.68). Parental involvement partially mediated the relationship between mothers' SPD and daughters' illicit drug use; mothers' SPD was associated with lower levels of parental involvement, which in turn were associated with an increased probability of daughters' illicit drug use. Overall, parents' SPD is associated differentially with adolescent substance use depending on the gender of parent and adolescent, adolescent age, race/ethnicity, and substance used. Parental involvement appears to be one mechanism through which mothers' SPD influences daughters' illicit drug use. Future research should further consider the interindividual effects of parents' SPD and associated parenting behaviors on adolescent risk behaviors.
    Journal of Adolescent Health 08/2008; 43(2):141-50. · 2.97 Impact Factor
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    ABSTRACT: In addition to common stressors, members of the U.S. Armed Forces experience a high level of stress unique to their status as service members. In an effort to combat stress, many military personnel report high levels of nicotine use. This study investigated the relationship between tobacco use and perceived stress among military members in all four armed services. Results indicate that those who use tobacco products specifically to reduce stress report significantly higher stress levels than those who do not use tobacco. Moreover, current users and those who both smoked and used smokeless tobacco were far more likely to report experiencing "a lot" of stress from a variety of sources than former or never users. Tobacco users also engaged more frequently in negative coping behaviors and relied less on the positive coping strategies used more often by former or never smokers. These findings are consistent with the larger body of literature suggesting that tobacco is not only an ineffective stress-reducing strategy, it also likely perpetuates a stress response in users. It is, therefore, critical that the military improve effective means of coping among nicotine-using troops.
    Military medicine 04/2008; 173(3):271-7. · 0.77 Impact Factor
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    ABSTRACT: The detrimental health effects of tobacco use have long been documented and accepted. Recent research has begun to explore the financial strain that tobacco places on those who use it (e.g. Mokdad, A.H., Marks, J.S., Stroup, D.F., Gerberding, J.L., 2004. Actual causes of death in the United States, 2000. J. Am. Med. Assoc. 291, 1239-1245). The issue of this financial burden is particularly salient for young enlisted in the military who often struggle with financial issues and who continue to use tobacco at relatively high rates. Using the 2002 Department of Defense Survey of Health Related Behaviors among Military Personnel, the current study examines the percentage of income young military members spend on tobacco given varying levels of consumption. In addition, a representative sample of junior enlisted (E1-E4) from all four military branches were surveyed about their tobacco use and their experiences of financial strain and experienced stress from financial problems. Adjusted logistic models demonstrated that smokers reported substantially higher amounts of both financial strain and stress from financial problems then those who did not smoke. This study suggests there is a relationship between financial stress and tobacco use among junior military members.
    Preventive Medicine 01/2008; 45(6):460-3. · 3.50 Impact Factor
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    Jason Williams, David P Mackinnon
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    ABSTRACT: Recent advances in testing mediation have found that certain resampling methods and tests based on the mathematical distribution of 2 normal random variables substantially outperform the traditional z test. However, these studies have primarily focused only on models with a single mediator and 2 component paths. To address this limitation, a simulation was conducted to evaluate these alternative methods in a more complex path model with multiple mediators and indirect paths with 2 and 3 paths. Methods for testing contrasts of 2 effects were evaluated also. The simulation included 1 exogenous independent variable, 3 mediators and 2 outcomes and varied sample size, number of paths in the mediated effects, test used to evaluate effects, effect sizes for each path, and the value of the contrast. Confidence intervals were used to evaluate the power and Type I error rate of each method, and were examined for coverage and bias. The bias-corrected bootstrap had the least biased confidence intervals, greatest power to detect nonzero effects and contrasts, and the most accurate overall Type I error. All tests had less power to detect 3-path effects and more inaccurate Type I error compared to 2-path effects. Confidence intervals were biased for mediated effects, as found in previous studies. Results for contrasts did not vary greatly by test, although resampling approaches had somewhat greater power and might be preferable because of ease of use and flexibility.
    Structural Equation Modeling A Multidisciplinary Journal 01/2008; 15(1):23-51. · 4.24 Impact Factor
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    ABSTRACT: To assess the effects of random drug and alcohol testing (DAT) among high school athletes. This was a 2-year prospective randomized controlled study of a single cohort among five intervention high schools with a DAT policy and six schools with a deferred policy, serially assessed by voluntary, confidential questionnaires. DAT school athletes were at risk for random testing during the full academic year. Positive test results were reported to parents or guardians, with mandatory counseling. Indices of illicit drug use, with and without alcohol use, were assessed at the beginning and end of each school year for the past month and prior year. Potential mediating variables were evaluated. Student-athletes from intervention and control schools did not differ in past 1-month use of illicit drug or a combination of drug and alcohol use at any of the four follow-up periods. At the end of the initial school year and after 2 full school years, student-athletes at DAT schools reported less drug use during the past year (p < .01) compared to athletes at the deferred policy schools. Combining past year drug and alcohol use together, student-athletes at DAT schools reported less use at the second and third follow-up assessments (p < .05). Paradoxically, DAT athletes across all assessments reported less athletic competence (p < .001), less belief authorities were opposed to drug use (p < .01), and indicated greater risk-taking (p < .05). At the final assessment, DAT athletes believed less in testing benefits (p < .05) and less that testing was a reason not to use drugs (p < .01). No DAT deterrent effects were evident for past month use during any of four follow-up periods. Prior-year drug use was reduced in two of four follow-up self-reports, and a combination of drug and alcohol use was reduced at two assessments as well. Overall, drug testing was accompanied by an increase in some risk factors for future substance use. More research is needed before DAT is considered an effective deterrent for school-based athletes.
    Journal of Adolescent Health 11/2007; 41(5):421-9. · 2.97 Impact Factor

Publication Stats

1k Citations
49.05 Total Impact Points


  • 2008–2014
    • RTI International
      • Division of Behavioral Health and Criminal Justice Research
      Durham, North Carolina, United States
    • Kansas City University of Medicine and Biosciences
      Kansas City, Missouri, United States
    • University of Missouri - Kansas City
      • Department of Psychology
      Kansas City, MO, United States
    • United States Air Force
      New York City, New York, United States
  • 2007–2008
    • Research Triangle Park Laboratories, Inc.
      Raleigh, North Carolina, United States
    • Oregon Health and Science University
      • Department of Medicine
      Portland, OR, United States
  • 2004
    • Arizona State University
      • Department of Psychology
      Mesa, AZ, United States