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Association of Adolescent Choking Game Activity With Selected Risk Behaviors
Association of Adolescent Choking Game Activity With Selected Risk Behaviors Joseph A. Dake, PhD, MPH; James H. Price, PhD, MPH; Nicole Kolm-Valdivia, MPH; Margaret Wielinski, MPH From the Department of Health and Recreation Professions, University of Toledo, Toledo, Ohio (Drs Dake and Price; Ms Kolm-Valdivia); and Hospital Council of Northwest Ohio, Toledo, Ohio (Ms Wielinski) Address correspondence to Joseph A. Dake, PhD, MPH, Department of Health and Recreation Professions, MS 119, University of Toledo, 2801 West Bancroft St, Toledo, Ohio 43606 (e-mail: [email protected]). Received for publication May 11, 2010; accepted September 28, 2010.
ABSTRACT OBJECTIVE: Previous research has recommended education
likelihood of middle school students engaging in the choking game were higher for older students, substance users, and those having lower grades. For high school students, adjusted odds ratios found that being older, substance use, and selected mental health issues (forced sex and attempted suicide) were most associated with choking activities. CONCLUSIONS: Engaging in the choking game was highly associated with abuse of substances, suggesting that youth engage in the choking game for the thrill-seeking experience of brief euphoria, a drug-related feeling. To reduce the potentially fatal consequences associated with this behavior, pediatricians should screen youths and provide anticipatory guidance for higher-risk youths and their parents.
for parents, teachers, and anticipatory guidance by pediatricians regarding participation in the so-called choking game, a potentially fatal behavior. The purpose of this study was to examine possible associations between selected demographic variables and risk behaviors with youth engagement in the choking game on the basis of secondary data analysis from a general adolescent health risk behavior survey. METHODS: Self-administered survey data from an adolescent needs assessment was used to assess choking game behavior between fall 2008 and fall 2009. The sample included 192 classrooms across 88 schools in a Midwestern state. RESULTS: Of the 3598 questionnaires distributed to middle and high school students, 3408 (95%) were returned completed. Participation rate in the choking game was 9%, with male participation (11%) greater than female participation (7%), and high school students (11%) more likely than middle school students (5%) to participate. Adjusted odds ratios found that the
KEYWORDS: adolescent behavior; choking; drug usage; injury; mental health; violence
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WHAT’S NEW
pressure is not removed from the neck in time, permanent brain injury or death can occur.6 The Centers for Disease Control and Prevention (CDC) examined newspaper stories to estimate the incidence of deaths due to the choking game between 1995 and 2007. In 2005, there were 22 deaths reported due to the choking game, 35 deaths in 2006, and 9 deaths in 2007.4 More than 86% of the deceased adolescents were boys who averaged 13.3 years old, ranging in age from 6 to 19 years. More than 95% of the deaths occurred while the adolescent was alone.4 There is limited research on the number of adolescents who participate in the choking game, but a study by Macnab and colleagues1 indicated that 6.6% of adolescents aged 9– 18 reported ever participating. In contrast to Andrew and Fallon,3 who found this behavior to be largely a solo activity, the study of Macnab and colleagues found that 94% of adolescents participated while someone else was present. A significant portion of adolescents are aware of the choking game. One study indicated that 68% of adolescents (aged 9–18) reported having heard of the choking game, and 45% knew someone who had participated in it.1
The choking game is an indicator activity for having experienced mental health and abuse issues, risky sexual behaviors, and substance use. This study indicates the need to address a wider variety of risk behaviors during anticipatory guidance. ASPHYXIAL GAMES HAVE many names, including choking game,1 suffocation roulette,2 space monkey, flatlining, tingling,3 pass-out game, scarf game,4 among many others.5 Because the term choking game appears to be used most often in the literature, we use it in this study. This activity should not be confused with a distinctly different behavior known as autoerotic asphyxia, where self-strangulation is used to increase sexual pleasure while masturbating.6 Asphyxial games involve applying pressure or constriction to the neck or chest through being strangled or selfstrangulation in order to restrict oxygen to the brain.1,4 This leads to a high or a euphoric feeling before loss of consciousness occurs, and a rush when the blood and oxygen flow back into the brain.1 If the constriction or
ACADEMIC PEDIATRICS Copyright ª 2010 by Academic Pediatric Association
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Many adolescents are not aware of the risks involved, as 40% of the adolescents reported that there were no risks in playing the game. A study of physicians’ awareness of the choking game found that 60.5% had heard of the choking game, with general pediatricians significantly more likely to be aware.7 Of the physicians who were aware of the choking game, over 61% had heard of it through popular media, whereas 24% had heard of it through professional conferences or literature. Less than 2% of the physicians reported including the choking game in their anticipatory guidance offered to adolescents.7 The studies that have been done on this topic have focused primarily on traditional epidemiological variables (eg, age, gender)1,3,4 rather than to describe adolescent behaviors in this area. It has been suggested that mental health issues such as anxiety and depression and use of drugs and alcohol for self-medication may characterize some of these students.5 Thus, the purpose of this study was to examine the relationships between choking game behavior and the aforementioned risk factors potentially associated with such activity by conducting a secondary analysis of a general adolescent health risk behavior survey.
METHODS PARTICIPANTS Students in middle school grades (6–8) and high school grades (9–12) representing 145 schools from 8 Midwestern counties were the potential sampling frame. Schools from each of the 8 counties were stratified by grade level. Subsequently, a random sample of schools within each of the aforementioned grade levels was selected to participate. School administrators from each school identified an appropriate general education (eg, English, math, social studies) classroom to participate in the study. This resulted in a sample of 3598 students from 192 classrooms across 88 different schools. Parental notification was conducted informing them of the assessment and the process for exempting their child from participation. A total of 172 parents (5%) requested that their child be excluded from the assessment. This process was approved by the school administration and an external institutional review board of the local hospital council. INSTRUMENT DEVELOPMENT The instrument was developed through a joint effort between community leaders, school superintendents, local community health agencies, and university professors to help establish content validity. Most items on the instrument were derived from the CDC’s Youth Risk Behavior Surveillance System (YRBSS) questions focusing on 6 priority health risk behaviors.8 As indicated by the CDC, “local agencies that conduct a YRBSS can add or delete questions to meet their policy or programmatic needs.”9 Items analyzed for this study were worded exactly the same across the various county surveillance instruments. The dependent variable (engaging in the choking game)
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was assessed through the survey item, “Have you ever played the choking game (pass-out game, space monkey, dream game)?” (yes/no). Demographic and background variables assessed in this study included gender, age, race, grade level, who they live with, and grades received in school. Risk behaviors assessed included participation in a variety of substance use behaviors (tobacco, alcohol, marijuana, inhalants, prescription drugs); number of sex partners; and mental health and abuse issues (being abused by a boyfriend/girlfriend or an adult, forced sexual intercourse, self-injury behavior, depression, suicide contemplation, and suicide attempts). The instrument was pilot tested with 23 students to assess comprehension to ensure internal validity of responses. Feedback from the students indicated that the survey was easy to read and understand. PROCEDURE The local hospital council, which was in charge of collecting the data, distributed and collected the assessment instruments from the students. Students were requested to place no identifying marks on the questionnaire to keep the data anonymous. These techniques helped ensure validity of student responses. Data from all schools were aggregated to reduce the likelihood of identification of specific schools. DATA ANALYSIS Data were analyzed by SPSS version 14.0 (SPSS, Chicago, IL). Initial analyses used the c2 test to examine significant differences between descriptive variables and the 2 age categories (middle/high school). Additionally, analyses examined unadjusted odds ratios with 95% confidence intervals to examine the strength of the relationships between each variable and choking behavior. Adjusted odds ratios (AORs) controlling for demographic variables were calculated by means of variables with statistically significant unadjusted odds ratios.10 Missing responses from students were investigated and found that no more than 2.3% of any predictor variable was missing and only 1.1% of the responses for the choking game variable were missing. Thus listwise deletion was used rather than replacing missing data with imputed values.10
RESULTS DEMOGRAPHIC AND BACKGROUND CHARACTERISTICS Of the 1450 questionnaires distributed to middle school students and the 2148 questionnaires distributed to high school students, 1365 (94%) and 2043 (95%) were returned completed, respectively. Nonparticipants were students excluded at parental request or students who did not complete the questionnaires. The majority of both middle school and high school students were white (80% and 85%, respectively) and lived with both parents (60% and 59%, respectively). The students were relatively equally divided by gender, and a plurality were academically superior (made mostly As)
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(Table 1). The overall participation rate in the choking game was 9%. The prevalence of the activity doubled from middle school (5%) to high school (11%). MIDDLE SCHOOL STUDENT PARTICIPATION IN THE CHOKING GAME An examination of the prevalence of choking activity in the middle school years (12–15 years of age) indicates that it was significantly more likely to be found in students with the following attributes: older (25% for 15 years of age), lived in a non-2-parent family (9%), and received lower grades (Ds and Fs) (17%). Additionally, choking game activity was significantly higher in students who reported the following risks: violence by others (15%–22%), mental health issues (12%–30%), and substance use behaviors (21%–37%) (Table 2). Previous research has shown that selected demographic characteristics (eg, gender and age) affect the prevalence of choking game participation. Thus, to control for these potential confounding effects on other demographic variables and risk behaviors, adjusted odds ratios with 95% confidence intervals were calculated controlling for the 5 demographic variables (Table 3). A total of 15 variables were significantly associated with an increased risk of participating in the choking game (Table 3). The variables most significantly associated with participating in the choking game by middle school students were as follows: being older (15 years of age) (AOR ¼ 25.3), used marijuana in the past 30 days (AOR ¼ 19.9), smoked Table 1. Demographic and Background Characteristics of Adolescent Respondents* Item Gender Female Male Race† White African American Hispanic Other/mixed race Age (y) #12 13 14 15 16 17 $18 Living arrangements† Both parents Parent and stepparent Non-2-parent family Grades in school† Mostly As Mostly Bs Mostly Cs Mostly Ds and Fs
Middle School, n (%)
High School, n (%)
714 (53) 636 (47)
966 (48) 1061 (52)
921 (80) 53 (5) 91 (8) 94 (8)
1536 (85) 90 (5) 108 (6) 74 (4)
613 (45) 488 (36) 230 (17) 32 (2) . . .
. . 213 (10) 502 (25) 526 (26) 543 (27) 258 (13)
736 (60) 214 (17) 280 (23)
1074 (59) 282 (15) 471 (26)
306 (44) 239 (35) 116 (17) 31 (5)
468 (39) 427 (36) 224 (19) 71 (6)
*N ¼ 1365 middle school (grades 6–8) students and 2043 high school (grades 9–12) students. †One or more counties did not ask this question.
1þ cigarettes in the past 30 days (AOR ¼ 14.9), and binge drank in the past 30 days (AOR ¼ 12.2). HIGH SCHOOL STUDENTS PARTICIPATION IN THE CHOKING GAME High school students (14–18 years of age) who engaged in the choking game shared many characteristics with middle school students. These participants were more likely to be males (14%), of mixed race (27%), from families with a stepparent (17%), and students receiving lower grades (Ds and Fs) (27%) (Table 2). In regard to behavioral associations, the following were associated with higher prevalence of choking game behavior: having 4 or more sexual partners (22%); violence by others (22%–33%), mental health issues (16%–30%), and substances use behaviors (18%–29%). An examination of adjusted odds ratios, again adjusting for demographic variables, found 23 variables to be significantly related to high school students engaging in choking game activity (Table 3). The variables and their relative impacts on choking activity were as follows: age (compared with the youngest middle school age) (AOR ¼ 7.0–9.6), ever been forced to have sexual intercourse (AOR ¼ 4.5), ever used inhalants to get high (AOR ¼ 3.4), attempted suicide in the past year (AOR ¼ 3.2), and binge drank in the past 30 days (AOR ¼ 3.0).
DISCUSSION Our study found a significant relationship between choking game involvement and violence by others, mental health issues, and substance use behaviors. In addition, our research found a higher percentage of students (9%) engaging in choking game behavior compared with Ramowski and colleagues11 (6%) and Macnab and colleagues1 (7%). This is not surprising because these studies had a younger average age sample than our study. Also, the studies used different wordings to their items to elicit the information from their samples, which may also explain differences in prevalence rates among the studies. Additionally, our study confirms earlier studies that identified male subjects being more likely than female subjects to engage in the behavior.1,3 We found that the proportion of youths engaging in the choking game doubled for both sexes from middle school to high school. Unique to middle school students, students older than their class peers were more likely to engage in the choking game. This follows other research that has shown a relationship between being older for grade level and engaging in other risk behaviors.12,13 We also found, as did Andrew and Fallon,3 that average and belowaverage academic grades were associated with increased participation in the choking game. This finding associated with grades is in keeping with other research that has found poor grades to be associated with a wide variety of health risk behaviors.14 In our cohort, there was an important association between use of a variety of drugs and participation in the choking game. This finding is in contrast to the finding
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Table 2. Student Demographic and Risk Behaviors Associated With Participation in the Choking Game Variable Gender Female Male Race* White African American Hispanic Other/mixed race Age #12 13 14 15 16 17 $18 Living arrangements* Both parents Parent and stepparent Non-2-parent family Grades in school* Mostly As Mostly Bs Mostly Cs Mostly Ds and Fs Hit, slapped, physically hurt by boyfriend or girlfriend in past year? Yes No Hit, slapped, physically hurt by adult in past year?* Yes No Ever purposely hurt self (cutting, burning, etc) Yes No Felt sad/hopeless for 2þ weeks in past year Yes No Contemplated suicide in past year* Yes No Attempted suicide in past year Yes No Ever been forced to have sexual intercourse Yes No No. of sex partners 0 1 2–3 4 or more Smoked 1þ cigarettes in the past 30 days Yes No Drank alcohol in past 30 days Yes No Binge drank (5þ) in past 30 days* Yes No Used marijuana in past 30 days Yes No
Total No.
Middle School Participation, n (%)
High School Participation, n (%)
1680 1697
32 (5) 42 (7)
81 (9)** 142 (14)**
2458 143 199 168
49 (5) 5 (10) 8 (9) 6 (6)
157 (10)** 9 (10)** 19 (18)** 20 (27)**
613 488 443 534 526 544 258 1811 496 751
16 (3)** 29 (6)** 23 (10)** 8 (25)** . . . 30 (4)** 13 (6)** 25 (9)**
. . 20 (10) 51 (10) 55 (11) 70 (13) 28 (11) 98 (9)** 48 (17)** 66 (14)**
775 666 340 102
9 (3)** 11 (5)** 12 (11)** 5 (17)**
37 (8)** 45 (11)** 44 (20)** 19 (27)**
208 3165
10 (22)** 64 (5)**
42 (26)** 182 (10)**
294 2343
20 (15)** 42 (5)**
35 (22)** 152 (11)**
812 2520
37 (12)** 38 (4)**
103 (21)** 118 (8)**
726 2648
38 (16)** 36 (3)**
78 (16)** 145 (10)**
311 2670
27 (23)** 43 (4)**
48 (25)** 148 (9)**
167 3215
20 (30)** 55 (4)**
29 (30)** 192 (10)**
160 3214
8 (19)** 67 (5)**
38 (33)** 185 (10)**
2333 406 329 217
51 (5)** 7 (16)** 7 (23)** 7 (30)**
76 (6)** 49 (14)** 57 (20)** 41 (22)**
467 2921
22 (33)** 53 (4)**
95 (24)** 126 (8)**
934 2448
34 (21)** 40 (3)**
136 (18)** 87 (7)**
526 2461
17 (27)** 52 (5)**
96 (21)** 101 (8) **
356 3034
13 (37)** 61 (5)**
82 (26)** 141 (8)** (Continued )
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Table 2. (Continued ) Variable Ever used inhalants to get high Yes No Ever used medications without a prescription to get high Yes No
Total No.
Middle School Participation, n (%)
High School Participation, n (%)
282 3105
12 (14)** 62 (5)**
57 (29)** 167 (9)**
327 3064
11 (26)** 63 (5)**
73 (26)** 151 (9)**
*Not all counties asked all items. **P < .01. N ¼ 1365 for middle school and 2043 for high school.
by Andrew and Fallon,3 who found students who participated in the choking game appeared to avoid alcohol and other drugs. We believe our data are more representative of student behavior because we examined over 3400 students and Andrew and Fallon3 drew their conclusions
from two dozen case studies, all of which resulted in death. Although warning signs and consequences of engaging in the choking game are known, a search for a particular cause may be futile because there are relationships among a wide variety of potential causes.
Table 3. Odds Ratios for Risk Behaviors Associated With Participation in the Choking Game* Middle School Item Gender Female Male Race White African American Hispanic Other/mixed race Age #12 13 14 15 16 17 $18 Living arrangements Both parents Parent and stepparent Non-2-parent family Grades in school Mostly As Mostly Bs Mostly Cs Mostly Ds and Fs Hit, slapped, physically hurt by boyfriend or girlfriend in past year? No Yes Hit, slapped, physically hurt by adult in past year? No Yes Ever purposely hurt self (cutting, burning, etc) No Yes Felt sad/hopeless for 2þ weeks in past year No Yes Contemplated suicide in past year No Yes
High School
Unadjusted OR (95% CI)
Adjusted OR† (95% CI)
Unadjusted OR (95% CI)
Adjusted OR† (95% CI)
1.00 1.51 (0.94–2.42)
1.00 1.66 (0.74–3.76)
1.00 1.67 (1.26–2.23)
1.00 1.66 (1.13–2.45)
1.00 1.87 (0.71–4.90) 1.71 (0.78–3.74) 1.20 (0.50–2.87)
1.00 1.83 (0.46–7.18) 1.39 (0.38–5.12) 0.46 (0.06–3.63)
1.00 0.98 (0.48–1.99) 1.94 (1.15–3.28) 3.22 (1.88–5.52)
1.00 0.48 (0.18–1.26) 1.12 (0.58–2.14) 2.69 (1.26–5.75)
1.00 2.34 (1.25–4.35) 4.19 (2.17–8.09) 12.27 (4.79–31.47) . . .
1.00 3.89 (1.21–12.49) 3.66 (0.96–13.95) 25.25 (4.50–144.77) . . .
. . 3.86 (1.96–7.59) 4.21 (2.37–7.48) 4.35 (2.46–7.70) 5.57 (3.19–9.71) 4.54 (2.41–8.55)
. . 7.00 (2.12–23.10) 9.56 (3.28–27.84) 8.71 (2.95–25.74) 9.60 (3.35–27.48) 9.14 (2.94–28.40)
1.00 1.43 (0.67–3.08) 1.81 (0.97–3.93)
1.00 0.77 (0.23–2.54) 1.30 (0.52–3.24)
1.00 1.95 (1.36–2.78) 1.83 (1.33–2.51)
1.00 1.72 (1.04–2.85) 1.30 (0.83–2.05)
1.00 1.13 (0.41–3.08) 2.66 (0.98–7.21) 4.50 (1.22–16.62)
1.00 1.11 (0.36–3.42) 2.82 (0.97–8.23) 6.90 (1.67–28.51)
1.00 1.53 (0.98–2.38) 3.30 (2.09–5.20) 5.08 (2.28–9.28)
1.00 1.03 (0.62–1.69) 1.79 (1.05–3.05) 2.02 (0.92–4.44)
1.00 4.80 (2.03–11.33)
1.00 3.84 (1.12–13.17)
1.00 3.78 (2.61–5.48)
1.00 2.54 (1.49–4.31)
1.00 3.40 (1.77–6.52)
1.00 2.72 (1.06–6.99)
1.00 2.41 (1.64–3.54)
1.00 1.45 (0.80–2.62)
1.00 3.03 (1.77–5.20)
1.00 4.03 (1.77–9.17)
1.00 3.21 (2.44–4.21)
1.00 2.77 (1.85–4.14)
1.00 4.79 (2.77–8.31)
1.00 4.73 (1.99–11.26)
1.00 2.21 (1.66–2.93)
1.00 1.54 (1.01–2.37)
1.00 6.00 (3.31–10.88)
1.00 6.89 (2.39–19.85)
1.00 3.66 (2.58–5.20)
1.00 1.65 (0.91–2.97) (Continued )
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Table 3. (Continued ) Middle School Item Attempted suicide in past year No Yes Ever been forced to have sexual intercourse No Yes No. of sex partners 0 1 2–3 $4 Smoked 1þ cigarettes in the past 30 days No Yes Drank alcohol in past 30 days No Yes Binge drank (5þ) in past 30 days No Yes Used marijuana in past 30 days No Yes Ever used inhalants to get high No Yes Ever used medications without a prescription to get high No Yes
High School
Unadjusted OR (95% CI)
Adjusted OR† (95% CI)
Unadjusted OR (95% CI)
Adjusted OR† (95% CI)
1.00 10.61 (5.32–21.16)
1.00 6.77 (2.44–18.74)
1.00 3.95 (2.58–6.06)
1.00 3.16 (1.59–6.28)
1.00 3.26 (1.35–7.83)
1.00 6.43 (1.76–23.46)
1.00 5.12 (3.42–7.67)
1.00 4.46 (2.47–8.03)
1.00 3.45 (1.43–8.35) 7.89 (3.00–20.74) 9.21 (3.42–24.77)
1.00 3.02 (0.78–11.69) 3.73 (0.67–20.78) 1.95 (0.19–19.96)
1.00 2.78 (1.92–4.02) 4.13 (2.89–5.91) 4.72 (3.15–7.08)
1.00 2.48 (1.49–4.14) 2.84 (1.71–4.73) 2.63 (1.42–4.85)
1.00 9.03 (4.73–17.22)
1.00 14.89 (5.64–39.31)
1.00 4.65 (3.50–6.20)
1.00 2.65 (1.74–4.05)
1.00 6.24 (3.59–10.86)
1.00 8.05 (3.42–8.93)
1.00 3.72 (2.83–4.89)
1.00 2.54 (1.72–3.73)
1.00 6.40 (3.22–12.75)
1.00 12.19 (3.73–39.83)
1.00 3.97 (2.96–5.32)
1.00 2.97 (1.91–4.61)
1.00 9.93 (4.48–22.01)
1.00 19.87 (6.54–60.39)
1.00 4.72 (3.50–6.36)
1.00 2.86 (1.87–4.36)
1.00 3.56 (1.72–7.37)
1.00 1.21 (0.26–5.62)
1.00 4.15 (2.97–5.79)
1.00 3.37 (2.10–5.42)
1.00 6.85 (3.14–14.97)
1.00 8.38 (2.37–29.59)
1.00 4.37 (3.21–5.95)
1.00 2.67 (1.72–4.13)
*OR ¼ odds ratio; 95% CI ¼ 95% confidence interval. †Adjusted ORs for demographic items were adjusted for all other demographic variables. All behavior items were adjusted for all of the demographic variables.
There are a number of potential limitations to the current study. First, the external validity of the findings may be limited because of the geographic scope of the study, which was limited to one Midwestern state. Thus, generalization of our findings to other populations should not be made until further research on other populations confirms the generalizability of our findings. Second, some of the adolescents may have overreported or underreported some risk behaviors on the basis of their perceptions of whether engaging in the behaviors was socially desirable. However, our findings had a number of parallels to other studies on adolescent choking behaviors that may indicate that this problem was limited. Third, assessment of choking game activity was by a single item on the questionnaire. This only permitted analyses regarding involvement in choking game behavior and not additional aspects, such as whether the student was alone or why he or she engaged in the behavior. Finally, our data are cross-sectional and do not permit cause-and-effect relationships to be ascertained. In keeping with the suggestions of prior authors, health care providers should be aware of signs and symptoms of choking game behaviors that may be seen in a clinical setting.4,6 Furthermore, health care providers should also increase their likelihood of identifying these high-risk
youth by querying parents of their patients regarding ligatures found around the house, the child’s unusual need for privacy, or any mention of the choking game. Because of the potentially fatal consequences associated with choking game behavior, health care professionals need to provide anticipatory guidance for all adolescents. Most parents of adolescents who died as a result of the choking game reported being unaware that the game even existed.4 Adolescents and their parents should be educated on the dangers of the choking game. Clinicians could volunteer their time to engage in local school in-service activities to educate teachers and other adults who work with youths regarding the warning signs and the dangers of choking game behaviors. Further research to better delineate the nature of the choking game activity is encouraged. Studies need to be conducted to better understand why students choose to engage in the choking game and to find effective methods of primary prevention.5
REFERENCES 1. Macnab AJ, Deevska M, Gagnon F, et al. Asphyxial games or “the choking game”: a potentially fatal risk behaviour. Inj Prev. 2009; 15:45–49.
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2. Shlamovitz GZ, Assia A, Ben-Sira L, Rachmel A. “Suffocation roulette”: A case of recurrent syncope in an adolescent boy. Ann Emerg Med. 2003;41:223–226. 3. Andrew TA, Fallon KK. Asphyxial games in children and adolescents. Am J Forensic Med Pathol. 2007;28:303–307. 4. Centers for Disease Control and Prevention. Unintentional strangulation deaths from the “choking game” among youths aged 6–19 years, United States, 1995–2007. MMWR Morb Mortal Wkly Rep. 2008;57: 141–144. 5. Andrew TA, Macnab A, Russell P. Update on the “choking game”. J Pediatr. 2009;155:777–780. 6. Urkin J. The choking game or suffocation roulette in adolescence [editorial]. Int J Adolesc Med Health. 2006;18:207–208. 7. McClave JL, Russell PJ, Lyren A, et al. The choking game: physician perspectives. Pediatrics. 2010;125:82–88. 8. Centers for Disease Control and Prevention. 2007 youth risk behavior survey. Available at: http://www.cdc.gov/HealthyYouth/yrbs/brief. htm. Accessed March 18, 2010.
ACADEMIC PEDIATRICS 9. Centers for Disease Control and Prevention. YRBSS frequently asked questions. Available at: http://www.cdc.gov/HealthyYouth/yrbs/faq. htm. Accessed March 18, 2010. 10. Field A. Discovering Statistics Using SPSS. 2nd ed. Thousand Oaks, Calif: Sage; 2009. 11. Ramowski SK, Nystrom RJ, Chaumeton NR, et al. “Choking game” awareness and participation among 8th graders—Oregon, 2008. MMWR Morb Mortal Wkly Rep. 2010;59:1–5. 12. Byrd RS, Weitzman M, Doniger AS. Increased drug use among old-for-grade adolescents. Arch Pediatr Adolesc Med. 1996;150: 470–476. 13. Malek MK, Chang BH, Davis TC. Fighting and weapon-carrying among seventh-grade students in Massachusetts and Louisiana. J Adolesc Health. 1998;23:94–102. 14. Centers for Disease Control and Prevention. Student health and academic achievement. Available at: http://www.cdc.gov/Healthy Youth/health_and_academics/index.htm. Accessed March 18, 2010.
ABSTRACT OBJECTIVE: Previous research has recommended education
likelihood of middle school students engaging in the choking game were higher for older students, substance users, and those having lower grades. For high school students, adjusted odds ratios found that being older, substance use, and selected mental health issues (forced sex and attempted suicide) were most associated with choking activities. CONCLUSIONS: Engaging in the choking game was highly associated with abuse of substances, suggesting that youth engage in the choking game for the thrill-seeking experience of brief euphoria, a drug-related feeling. To reduce the potentially fatal consequences associated with this behavior, pediatricians should screen youths and provide anticipatory guidance for higher-risk youths and their parents.
for parents, teachers, and anticipatory guidance by pediatricians regarding participation in the so-called choking game, a potentially fatal behavior. The purpose of this study was to examine possible associations between selected demographic variables and risk behaviors with youth engagement in the choking game on the basis of secondary data analysis from a general adolescent health risk behavior survey. METHODS: Self-administered survey data from an adolescent needs assessment was used to assess choking game behavior between fall 2008 and fall 2009. The sample included 192 classrooms across 88 schools in a Midwestern state. RESULTS: Of the 3598 questionnaires distributed to middle and high school students, 3408 (95%) were returned completed. Participation rate in the choking game was 9%, with male participation (11%) greater than female participation (7%), and high school students (11%) more likely than middle school students (5%) to participate. Adjusted odds ratios found that the
KEYWORDS: adolescent behavior; choking; drug usage; injury; mental health; violence
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WHAT’S NEW
pressure is not removed from the neck in time, permanent brain injury or death can occur.6 The Centers for Disease Control and Prevention (CDC) examined newspaper stories to estimate the incidence of deaths due to the choking game between 1995 and 2007. In 2005, there were 22 deaths reported due to the choking game, 35 deaths in 2006, and 9 deaths in 2007.4 More than 86% of the deceased adolescents were boys who averaged 13.3 years old, ranging in age from 6 to 19 years. More than 95% of the deaths occurred while the adolescent was alone.4 There is limited research on the number of adolescents who participate in the choking game, but a study by Macnab and colleagues1 indicated that 6.6% of adolescents aged 9– 18 reported ever participating. In contrast to Andrew and Fallon,3 who found this behavior to be largely a solo activity, the study of Macnab and colleagues found that 94% of adolescents participated while someone else was present. A significant portion of adolescents are aware of the choking game. One study indicated that 68% of adolescents (aged 9–18) reported having heard of the choking game, and 45% knew someone who had participated in it.1
The choking game is an indicator activity for having experienced mental health and abuse issues, risky sexual behaviors, and substance use. This study indicates the need to address a wider variety of risk behaviors during anticipatory guidance. ASPHYXIAL GAMES HAVE many names, including choking game,1 suffocation roulette,2 space monkey, flatlining, tingling,3 pass-out game, scarf game,4 among many others.5 Because the term choking game appears to be used most often in the literature, we use it in this study. This activity should not be confused with a distinctly different behavior known as autoerotic asphyxia, where self-strangulation is used to increase sexual pleasure while masturbating.6 Asphyxial games involve applying pressure or constriction to the neck or chest through being strangled or selfstrangulation in order to restrict oxygen to the brain.1,4 This leads to a high or a euphoric feeling before loss of consciousness occurs, and a rush when the blood and oxygen flow back into the brain.1 If the constriction or
ACADEMIC PEDIATRICS Copyright ª 2010 by Academic Pediatric Association
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Many adolescents are not aware of the risks involved, as 40% of the adolescents reported that there were no risks in playing the game. A study of physicians’ awareness of the choking game found that 60.5% had heard of the choking game, with general pediatricians significantly more likely to be aware.7 Of the physicians who were aware of the choking game, over 61% had heard of it through popular media, whereas 24% had heard of it through professional conferences or literature. Less than 2% of the physicians reported including the choking game in their anticipatory guidance offered to adolescents.7 The studies that have been done on this topic have focused primarily on traditional epidemiological variables (eg, age, gender)1,3,4 rather than to describe adolescent behaviors in this area. It has been suggested that mental health issues such as anxiety and depression and use of drugs and alcohol for self-medication may characterize some of these students.5 Thus, the purpose of this study was to examine the relationships between choking game behavior and the aforementioned risk factors potentially associated with such activity by conducting a secondary analysis of a general adolescent health risk behavior survey.
METHODS PARTICIPANTS Students in middle school grades (6–8) and high school grades (9–12) representing 145 schools from 8 Midwestern counties were the potential sampling frame. Schools from each of the 8 counties were stratified by grade level. Subsequently, a random sample of schools within each of the aforementioned grade levels was selected to participate. School administrators from each school identified an appropriate general education (eg, English, math, social studies) classroom to participate in the study. This resulted in a sample of 3598 students from 192 classrooms across 88 different schools. Parental notification was conducted informing them of the assessment and the process for exempting their child from participation. A total of 172 parents (5%) requested that their child be excluded from the assessment. This process was approved by the school administration and an external institutional review board of the local hospital council. INSTRUMENT DEVELOPMENT The instrument was developed through a joint effort between community leaders, school superintendents, local community health agencies, and university professors to help establish content validity. Most items on the instrument were derived from the CDC’s Youth Risk Behavior Surveillance System (YRBSS) questions focusing on 6 priority health risk behaviors.8 As indicated by the CDC, “local agencies that conduct a YRBSS can add or delete questions to meet their policy or programmatic needs.”9 Items analyzed for this study were worded exactly the same across the various county surveillance instruments. The dependent variable (engaging in the choking game)
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was assessed through the survey item, “Have you ever played the choking game (pass-out game, space monkey, dream game)?” (yes/no). Demographic and background variables assessed in this study included gender, age, race, grade level, who they live with, and grades received in school. Risk behaviors assessed included participation in a variety of substance use behaviors (tobacco, alcohol, marijuana, inhalants, prescription drugs); number of sex partners; and mental health and abuse issues (being abused by a boyfriend/girlfriend or an adult, forced sexual intercourse, self-injury behavior, depression, suicide contemplation, and suicide attempts). The instrument was pilot tested with 23 students to assess comprehension to ensure internal validity of responses. Feedback from the students indicated that the survey was easy to read and understand. PROCEDURE The local hospital council, which was in charge of collecting the data, distributed and collected the assessment instruments from the students. Students were requested to place no identifying marks on the questionnaire to keep the data anonymous. These techniques helped ensure validity of student responses. Data from all schools were aggregated to reduce the likelihood of identification of specific schools. DATA ANALYSIS Data were analyzed by SPSS version 14.0 (SPSS, Chicago, IL). Initial analyses used the c2 test to examine significant differences between descriptive variables and the 2 age categories (middle/high school). Additionally, analyses examined unadjusted odds ratios with 95% confidence intervals to examine the strength of the relationships between each variable and choking behavior. Adjusted odds ratios (AORs) controlling for demographic variables were calculated by means of variables with statistically significant unadjusted odds ratios.10 Missing responses from students were investigated and found that no more than 2.3% of any predictor variable was missing and only 1.1% of the responses for the choking game variable were missing. Thus listwise deletion was used rather than replacing missing data with imputed values.10
RESULTS DEMOGRAPHIC AND BACKGROUND CHARACTERISTICS Of the 1450 questionnaires distributed to middle school students and the 2148 questionnaires distributed to high school students, 1365 (94%) and 2043 (95%) were returned completed, respectively. Nonparticipants were students excluded at parental request or students who did not complete the questionnaires. The majority of both middle school and high school students were white (80% and 85%, respectively) and lived with both parents (60% and 59%, respectively). The students were relatively equally divided by gender, and a plurality were academically superior (made mostly As)
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(Table 1). The overall participation rate in the choking game was 9%. The prevalence of the activity doubled from middle school (5%) to high school (11%). MIDDLE SCHOOL STUDENT PARTICIPATION IN THE CHOKING GAME An examination of the prevalence of choking activity in the middle school years (12–15 years of age) indicates that it was significantly more likely to be found in students with the following attributes: older (25% for 15 years of age), lived in a non-2-parent family (9%), and received lower grades (Ds and Fs) (17%). Additionally, choking game activity was significantly higher in students who reported the following risks: violence by others (15%–22%), mental health issues (12%–30%), and substance use behaviors (21%–37%) (Table 2). Previous research has shown that selected demographic characteristics (eg, gender and age) affect the prevalence of choking game participation. Thus, to control for these potential confounding effects on other demographic variables and risk behaviors, adjusted odds ratios with 95% confidence intervals were calculated controlling for the 5 demographic variables (Table 3). A total of 15 variables were significantly associated with an increased risk of participating in the choking game (Table 3). The variables most significantly associated with participating in the choking game by middle school students were as follows: being older (15 years of age) (AOR ¼ 25.3), used marijuana in the past 30 days (AOR ¼ 19.9), smoked Table 1. Demographic and Background Characteristics of Adolescent Respondents* Item Gender Female Male Race† White African American Hispanic Other/mixed race Age (y) #12 13 14 15 16 17 $18 Living arrangements† Both parents Parent and stepparent Non-2-parent family Grades in school† Mostly As Mostly Bs Mostly Cs Mostly Ds and Fs
Middle School, n (%)
High School, n (%)
714 (53) 636 (47)
966 (48) 1061 (52)
921 (80) 53 (5) 91 (8) 94 (8)
1536 (85) 90 (5) 108 (6) 74 (4)
613 (45) 488 (36) 230 (17) 32 (2) . . .
. . 213 (10) 502 (25) 526 (26) 543 (27) 258 (13)
736 (60) 214 (17) 280 (23)
1074 (59) 282 (15) 471 (26)
306 (44) 239 (35) 116 (17) 31 (5)
468 (39) 427 (36) 224 (19) 71 (6)
*N ¼ 1365 middle school (grades 6–8) students and 2043 high school (grades 9–12) students. †One or more counties did not ask this question.
1þ cigarettes in the past 30 days (AOR ¼ 14.9), and binge drank in the past 30 days (AOR ¼ 12.2). HIGH SCHOOL STUDENTS PARTICIPATION IN THE CHOKING GAME High school students (14–18 years of age) who engaged in the choking game shared many characteristics with middle school students. These participants were more likely to be males (14%), of mixed race (27%), from families with a stepparent (17%), and students receiving lower grades (Ds and Fs) (27%) (Table 2). In regard to behavioral associations, the following were associated with higher prevalence of choking game behavior: having 4 or more sexual partners (22%); violence by others (22%–33%), mental health issues (16%–30%), and substances use behaviors (18%–29%). An examination of adjusted odds ratios, again adjusting for demographic variables, found 23 variables to be significantly related to high school students engaging in choking game activity (Table 3). The variables and their relative impacts on choking activity were as follows: age (compared with the youngest middle school age) (AOR ¼ 7.0–9.6), ever been forced to have sexual intercourse (AOR ¼ 4.5), ever used inhalants to get high (AOR ¼ 3.4), attempted suicide in the past year (AOR ¼ 3.2), and binge drank in the past 30 days (AOR ¼ 3.0).
DISCUSSION Our study found a significant relationship between choking game involvement and violence by others, mental health issues, and substance use behaviors. In addition, our research found a higher percentage of students (9%) engaging in choking game behavior compared with Ramowski and colleagues11 (6%) and Macnab and colleagues1 (7%). This is not surprising because these studies had a younger average age sample than our study. Also, the studies used different wordings to their items to elicit the information from their samples, which may also explain differences in prevalence rates among the studies. Additionally, our study confirms earlier studies that identified male subjects being more likely than female subjects to engage in the behavior.1,3 We found that the proportion of youths engaging in the choking game doubled for both sexes from middle school to high school. Unique to middle school students, students older than their class peers were more likely to engage in the choking game. This follows other research that has shown a relationship between being older for grade level and engaging in other risk behaviors.12,13 We also found, as did Andrew and Fallon,3 that average and belowaverage academic grades were associated with increased participation in the choking game. This finding associated with grades is in keeping with other research that has found poor grades to be associated with a wide variety of health risk behaviors.14 In our cohort, there was an important association between use of a variety of drugs and participation in the choking game. This finding is in contrast to the finding
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Table 2. Student Demographic and Risk Behaviors Associated With Participation in the Choking Game Variable Gender Female Male Race* White African American Hispanic Other/mixed race Age #12 13 14 15 16 17 $18 Living arrangements* Both parents Parent and stepparent Non-2-parent family Grades in school* Mostly As Mostly Bs Mostly Cs Mostly Ds and Fs Hit, slapped, physically hurt by boyfriend or girlfriend in past year? Yes No Hit, slapped, physically hurt by adult in past year?* Yes No Ever purposely hurt self (cutting, burning, etc) Yes No Felt sad/hopeless for 2þ weeks in past year Yes No Contemplated suicide in past year* Yes No Attempted suicide in past year Yes No Ever been forced to have sexual intercourse Yes No No. of sex partners 0 1 2–3 4 or more Smoked 1þ cigarettes in the past 30 days Yes No Drank alcohol in past 30 days Yes No Binge drank (5þ) in past 30 days* Yes No Used marijuana in past 30 days Yes No
Total No.
Middle School Participation, n (%)
High School Participation, n (%)
1680 1697
32 (5) 42 (7)
81 (9)** 142 (14)**
2458 143 199 168
49 (5) 5 (10) 8 (9) 6 (6)
157 (10)** 9 (10)** 19 (18)** 20 (27)**
613 488 443 534 526 544 258 1811 496 751
16 (3)** 29 (6)** 23 (10)** 8 (25)** . . . 30 (4)** 13 (6)** 25 (9)**
. . 20 (10) 51 (10) 55 (11) 70 (13) 28 (11) 98 (9)** 48 (17)** 66 (14)**
775 666 340 102
9 (3)** 11 (5)** 12 (11)** 5 (17)**
37 (8)** 45 (11)** 44 (20)** 19 (27)**
208 3165
10 (22)** 64 (5)**
42 (26)** 182 (10)**
294 2343
20 (15)** 42 (5)**
35 (22)** 152 (11)**
812 2520
37 (12)** 38 (4)**
103 (21)** 118 (8)**
726 2648
38 (16)** 36 (3)**
78 (16)** 145 (10)**
311 2670
27 (23)** 43 (4)**
48 (25)** 148 (9)**
167 3215
20 (30)** 55 (4)**
29 (30)** 192 (10)**
160 3214
8 (19)** 67 (5)**
38 (33)** 185 (10)**
2333 406 329 217
51 (5)** 7 (16)** 7 (23)** 7 (30)**
76 (6)** 49 (14)** 57 (20)** 41 (22)**
467 2921
22 (33)** 53 (4)**
95 (24)** 126 (8)**
934 2448
34 (21)** 40 (3)**
136 (18)** 87 (7)**
526 2461
17 (27)** 52 (5)**
96 (21)** 101 (8) **
356 3034
13 (37)** 61 (5)**
82 (26)** 141 (8)** (Continued )
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Table 2. (Continued ) Variable Ever used inhalants to get high Yes No Ever used medications without a prescription to get high Yes No
Total No.
Middle School Participation, n (%)
High School Participation, n (%)
282 3105
12 (14)** 62 (5)**
57 (29)** 167 (9)**
327 3064
11 (26)** 63 (5)**
73 (26)** 151 (9)**
*Not all counties asked all items. **P < .01. N ¼ 1365 for middle school and 2043 for high school.
by Andrew and Fallon,3 who found students who participated in the choking game appeared to avoid alcohol and other drugs. We believe our data are more representative of student behavior because we examined over 3400 students and Andrew and Fallon3 drew their conclusions
from two dozen case studies, all of which resulted in death. Although warning signs and consequences of engaging in the choking game are known, a search for a particular cause may be futile because there are relationships among a wide variety of potential causes.
Table 3. Odds Ratios for Risk Behaviors Associated With Participation in the Choking Game* Middle School Item Gender Female Male Race White African American Hispanic Other/mixed race Age #12 13 14 15 16 17 $18 Living arrangements Both parents Parent and stepparent Non-2-parent family Grades in school Mostly As Mostly Bs Mostly Cs Mostly Ds and Fs Hit, slapped, physically hurt by boyfriend or girlfriend in past year? No Yes Hit, slapped, physically hurt by adult in past year? No Yes Ever purposely hurt self (cutting, burning, etc) No Yes Felt sad/hopeless for 2þ weeks in past year No Yes Contemplated suicide in past year No Yes
High School
Unadjusted OR (95% CI)
Adjusted OR† (95% CI)
Unadjusted OR (95% CI)
Adjusted OR† (95% CI)
1.00 1.51 (0.94–2.42)
1.00 1.66 (0.74–3.76)
1.00 1.67 (1.26–2.23)
1.00 1.66 (1.13–2.45)
1.00 1.87 (0.71–4.90) 1.71 (0.78–3.74) 1.20 (0.50–2.87)
1.00 1.83 (0.46–7.18) 1.39 (0.38–5.12) 0.46 (0.06–3.63)
1.00 0.98 (0.48–1.99) 1.94 (1.15–3.28) 3.22 (1.88–5.52)
1.00 0.48 (0.18–1.26) 1.12 (0.58–2.14) 2.69 (1.26–5.75)
1.00 2.34 (1.25–4.35) 4.19 (2.17–8.09) 12.27 (4.79–31.47) . . .
1.00 3.89 (1.21–12.49) 3.66 (0.96–13.95) 25.25 (4.50–144.77) . . .
. . 3.86 (1.96–7.59) 4.21 (2.37–7.48) 4.35 (2.46–7.70) 5.57 (3.19–9.71) 4.54 (2.41–8.55)
. . 7.00 (2.12–23.10) 9.56 (3.28–27.84) 8.71 (2.95–25.74) 9.60 (3.35–27.48) 9.14 (2.94–28.40)
1.00 1.43 (0.67–3.08) 1.81 (0.97–3.93)
1.00 0.77 (0.23–2.54) 1.30 (0.52–3.24)
1.00 1.95 (1.36–2.78) 1.83 (1.33–2.51)
1.00 1.72 (1.04–2.85) 1.30 (0.83–2.05)
1.00 1.13 (0.41–3.08) 2.66 (0.98–7.21) 4.50 (1.22–16.62)
1.00 1.11 (0.36–3.42) 2.82 (0.97–8.23) 6.90 (1.67–28.51)
1.00 1.53 (0.98–2.38) 3.30 (2.09–5.20) 5.08 (2.28–9.28)
1.00 1.03 (0.62–1.69) 1.79 (1.05–3.05) 2.02 (0.92–4.44)
1.00 4.80 (2.03–11.33)
1.00 3.84 (1.12–13.17)
1.00 3.78 (2.61–5.48)
1.00 2.54 (1.49–4.31)
1.00 3.40 (1.77–6.52)
1.00 2.72 (1.06–6.99)
1.00 2.41 (1.64–3.54)
1.00 1.45 (0.80–2.62)
1.00 3.03 (1.77–5.20)
1.00 4.03 (1.77–9.17)
1.00 3.21 (2.44–4.21)
1.00 2.77 (1.85–4.14)
1.00 4.79 (2.77–8.31)
1.00 4.73 (1.99–11.26)
1.00 2.21 (1.66–2.93)
1.00 1.54 (1.01–2.37)
1.00 6.00 (3.31–10.88)
1.00 6.89 (2.39–19.85)
1.00 3.66 (2.58–5.20)
1.00 1.65 (0.91–2.97) (Continued )
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Table 3. (Continued ) Middle School Item Attempted suicide in past year No Yes Ever been forced to have sexual intercourse No Yes No. of sex partners 0 1 2–3 $4 Smoked 1þ cigarettes in the past 30 days No Yes Drank alcohol in past 30 days No Yes Binge drank (5þ) in past 30 days No Yes Used marijuana in past 30 days No Yes Ever used inhalants to get high No Yes Ever used medications without a prescription to get high No Yes
High School
Unadjusted OR (95% CI)
Adjusted OR† (95% CI)
Unadjusted OR (95% CI)
Adjusted OR† (95% CI)
1.00 10.61 (5.32–21.16)
1.00 6.77 (2.44–18.74)
1.00 3.95 (2.58–6.06)
1.00 3.16 (1.59–6.28)
1.00 3.26 (1.35–7.83)
1.00 6.43 (1.76–23.46)
1.00 5.12 (3.42–7.67)
1.00 4.46 (2.47–8.03)
1.00 3.45 (1.43–8.35) 7.89 (3.00–20.74) 9.21 (3.42–24.77)
1.00 3.02 (0.78–11.69) 3.73 (0.67–20.78) 1.95 (0.19–19.96)
1.00 2.78 (1.92–4.02) 4.13 (2.89–5.91) 4.72 (3.15–7.08)
1.00 2.48 (1.49–4.14) 2.84 (1.71–4.73) 2.63 (1.42–4.85)
1.00 9.03 (4.73–17.22)
1.00 14.89 (5.64–39.31)
1.00 4.65 (3.50–6.20)
1.00 2.65 (1.74–4.05)
1.00 6.24 (3.59–10.86)
1.00 8.05 (3.42–8.93)
1.00 3.72 (2.83–4.89)
1.00 2.54 (1.72–3.73)
1.00 6.40 (3.22–12.75)
1.00 12.19 (3.73–39.83)
1.00 3.97 (2.96–5.32)
1.00 2.97 (1.91–4.61)
1.00 9.93 (4.48–22.01)
1.00 19.87 (6.54–60.39)
1.00 4.72 (3.50–6.36)
1.00 2.86 (1.87–4.36)
1.00 3.56 (1.72–7.37)
1.00 1.21 (0.26–5.62)
1.00 4.15 (2.97–5.79)
1.00 3.37 (2.10–5.42)
1.00 6.85 (3.14–14.97)
1.00 8.38 (2.37–29.59)
1.00 4.37 (3.21–5.95)
1.00 2.67 (1.72–4.13)
*OR ¼ odds ratio; 95% CI ¼ 95% confidence interval. †Adjusted ORs for demographic items were adjusted for all other demographic variables. All behavior items were adjusted for all of the demographic variables.
There are a number of potential limitations to the current study. First, the external validity of the findings may be limited because of the geographic scope of the study, which was limited to one Midwestern state. Thus, generalization of our findings to other populations should not be made until further research on other populations confirms the generalizability of our findings. Second, some of the adolescents may have overreported or underreported some risk behaviors on the basis of their perceptions of whether engaging in the behaviors was socially desirable. However, our findings had a number of parallels to other studies on adolescent choking behaviors that may indicate that this problem was limited. Third, assessment of choking game activity was by a single item on the questionnaire. This only permitted analyses regarding involvement in choking game behavior and not additional aspects, such as whether the student was alone or why he or she engaged in the behavior. Finally, our data are cross-sectional and do not permit cause-and-effect relationships to be ascertained. In keeping with the suggestions of prior authors, health care providers should be aware of signs and symptoms of choking game behaviors that may be seen in a clinical setting.4,6 Furthermore, health care providers should also increase their likelihood of identifying these high-risk
youth by querying parents of their patients regarding ligatures found around the house, the child’s unusual need for privacy, or any mention of the choking game. Because of the potentially fatal consequences associated with choking game behavior, health care professionals need to provide anticipatory guidance for all adolescents. Most parents of adolescents who died as a result of the choking game reported being unaware that the game even existed.4 Adolescents and their parents should be educated on the dangers of the choking game. Clinicians could volunteer their time to engage in local school in-service activities to educate teachers and other adults who work with youths regarding the warning signs and the dangers of choking game behaviors. Further research to better delineate the nature of the choking game activity is encouraged. Studies need to be conducted to better understand why students choose to engage in the choking game and to find effective methods of primary prevention.5
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2. Shlamovitz GZ, Assia A, Ben-Sira L, Rachmel A. “Suffocation roulette”: A case of recurrent syncope in an adolescent boy. Ann Emerg Med. 2003;41:223–226. 3. Andrew TA, Fallon KK. Asphyxial games in children and adolescents. Am J Forensic Med Pathol. 2007;28:303–307. 4. Centers for Disease Control and Prevention. Unintentional strangulation deaths from the “choking game” among youths aged 6–19 years, United States, 1995–2007. MMWR Morb Mortal Wkly Rep. 2008;57: 141–144. 5. Andrew TA, Macnab A, Russell P. Update on the “choking game”. J Pediatr. 2009;155:777–780. 6. Urkin J. The choking game or suffocation roulette in adolescence [editorial]. Int J Adolesc Med Health. 2006;18:207–208. 7. McClave JL, Russell PJ, Lyren A, et al. The choking game: physician perspectives. Pediatrics. 2010;125:82–88. 8. Centers for Disease Control and Prevention. 2007 youth risk behavior survey. Available at: http://www.cdc.gov/HealthyYouth/yrbs/brief. htm. Accessed March 18, 2010.
ACADEMIC PEDIATRICS 9. Centers for Disease Control and Prevention. YRBSS frequently asked questions. Available at: http://www.cdc.gov/HealthyYouth/yrbs/faq. htm. Accessed March 18, 2010. 10. Field A. Discovering Statistics Using SPSS. 2nd ed. Thousand Oaks, Calif: Sage; 2009. 11. Ramowski SK, Nystrom RJ, Chaumeton NR, et al. “Choking game” awareness and participation among 8th graders—Oregon, 2008. MMWR Morb Mortal Wkly Rep. 2010;59:1–5. 12. Byrd RS, Weitzman M, Doniger AS. Increased drug use among old-for-grade adolescents. Arch Pediatr Adolesc Med. 1996;150: 470–476. 13. Malek MK, Chang BH, Davis TC. Fighting and weapon-carrying among seventh-grade students in Massachusetts and Louisiana. J Adolesc Health. 1998;23:94–102. 14. Centers for Disease Control and Prevention. Student health and academic achievement. Available at: http://www.cdc.gov/Healthy Youth/health_and_academics/index.htm. Accessed March 18, 2010.