"'Choking Game' Awareness and Participation Among 8th Graders

Errata: MMWR Vol. 59, No. 1
Weekly
January 22, 2010 / 59(02);49


In the report, "'Choking Game' Awareness and Participation Among 8th Graders --- Oregon, 2008," on page 5, errors occurred in the ordering of the reference list. The list should read as follows:

References
1. Katz KA, Toblin RL. Language matters: unintentional strangulation, strangulation activity, and the "choking game." Arch Pediatr Adolesc Med 2009;163:93--4.
2. Andrew TA, Fallon KK. Asphyxial games in children and adolescents. Am J Forensic Med Pathol 2007;28:303--7.
3. Urkin J, Merrick J. The choking game or suffocation roulette in adolescence. Int J Adolesc Med Health 2006;18:207--8.
4. CDC. Unintentional strangulation deaths from the "choking game" among youths aged 6--19 years---United States, 1995--2007. MMWR 2008;57:141--4.
5. Ullrich NJ, Bergin AM, Goodkin HP. "The choking game": self-induced hypoxia presenting as recurrent seizurelike events. Epilepsy Behav 2008;12:486--8
6. Shlamovitz GZ, Assia A, Ben-Sira L, et al. "Suffocation roulette": a case of recurrent syncope in an adolescent boy. Ann Emerg Med 2003;41:223--6.
7. Le D, Macnab AJ. Self strangulation by hanging from cloth towel dispensers in Canadian schools. Inj Prev 2001;7:231--3.
8. Senanayake MP, Chandraratne K, de Silva T, et al. The "choking game": self-strangulation with a belt and clothes rack. Ceylon Med J 2006;51:120.
9. Macnab A, Deevska M, Gagnon G, et al. Asphyxial game or "the choking game": a potentially fatal risk behaviour. Inj Prev 2009;15:45--9.
10. McClave JL, Russell PJ, Lyren A, O'Riordan MA, Bass NE. The choking game: physician perspectives. Pediatrics 2010;125:82--7 [E-pub ahead of print December 14, 2009].

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"Choking Game" Awareness and Participation Among 8th Graders --- Oregon, 2008
Please note: An erratum has been published for this article. To view the erratum, please click here.

Weekly
January 15, 2010 / 59(01);1-5


The "choking game" is an activity in which persons strangulate themselves to achieve euphoria through brief hypoxia (1). It is differentiated from autoerotic asphyxiation (2,3). The activity can cause long-term disability and death among youths (4). In 2008, CDC reported 82 deaths attributed to the choking game and other strangulation activities during the period 1995--2007; most victims were adolescent males aged 11--16 years (4). To assess the awareness and prevalence of this behavior among 8th graders in Oregon, the Oregon Public Health Division added a question to the 2008 Oregon Healthy Teens survey concerning familiarity with and participation in this activity. This report describes the results of that survey, which indicated that 36.2% of 8th-grade respondents had heard of the choking game, 30.4% had heard of someone participating, and 5.7% had participated themselves. Youths in rural areas were significantly more likely (6.7%) to have participated than youths in urban areas (4.9%). Choking game participation was higher among 8th graders who reported mental health risk factors (4.0%), substance use (7.9%), or both (15.8%), compared with those who reported neither (1.7%). Public health surveillance of these strangulation activities among youths should be expanded to better quantify the risks and understand the motives and circumstances surrounding participation. Parents, educators, counselors, and others who work with youths should be aware of strangulation activities and their serious health effects; they should watch for signs of participation in strangulation activities, especially among youths with suspected substance use or mental health risk factors.

The Oregon Healthy Teens survey, an annual population-based anonymous survey* of 8th and 11th graders† designed to monitor and measure adolescent health and well-being, is based on the CDC's Youth Risk Behavior Survey (YRBS) and includes questions on physical and mental health, sexual activity, substance use, physical activity/nutrition, and community characteristics. In 2008, all 647 Oregon public middle and high schools were part of the sampling frame, which was stratified into eight regions. Schools were sampled randomly from within each region, with a total of 114 schools being sampled. The data were weighted to achieve a statewide representative sample. Weighting was based on the probability of school and student selection, and a post-stratification adjustment for county participation. Schools use an active notification/passive consent model with parents, who may decline their child's participation. In 2008, the survey contained a total of 188 questions, which were designed to be completed in the course of a class period. Overall, 77.0% of sampled schools agreed to administer the survey, and 83.7% of the 8th graders in those schools participated. In 2008, a single question about the choking game was added to the 8th-grade survey. Students were asked whether they had ever heard of the choking game, had heard of someone participating, had helped someone participate, or had ever participated in the choking game themselves.§

All analyses were conducted using statistical software to accommodate the survey design and weighting appropriately. The strength of association between variables was analyzed using a chi-square test with Rao-Scott corrections, and all reported p-values are based on corrected Rao-Scott chi-square results.

The 2008 survey included 10,642 respondents. Of these, 7,757 (73%) answered the choking game question. The mean age of respondents to this question was 13.7 years (standard deviation = 0.5). Those who did not answer this question were more likely to be male and nonwhite and more likely to report higher levels of sexual activity, substance use, and mental health risk factors. Among the respondents, 36.2% had heard of the choking game, and 30.4% had heard of someone participating in it. Additionally, 2.6% had helped someone participate, and 5.7% had ever participated themselves.

A similar percentage of females reported participating compared with males (5.3% versus 6.1%, p = 0.13). Hispanic (7.7%) and American Indian/Alaska Native (7.6%) youths had the highest participation rates, followed by white (5.4%), black (4.5%), Native Hawaiian (3.4%), and Asian (2.8%) youths.¶ Youths living in rural areas had a significantly higher participation rate than those in urban areas (6.7% rural versus 4.9% urban, p = 0.01) (Table).

Youths who participated in the choking game were significantly more likely to also report other unhealthy behaviors and mental health risk factors. In particular, youths who had used substances** and also reported mental health risk factors†† had the highest participation rate (15.8%) and were approximately nine times more likely to participate in the choking game than those without either risk factor. Among those who reported substance use only and no mental health risk factors, the participation rate was 7.9%, and among those reporting mental health risk factors only but no substance use, the participation rate was 4.0%. The participation rates among all these groups were substantially higher than the rate among students who reported neither substance use nor mental health risk factors (1.7%) (Table).

Reported by

SK Ramowski, MSW, RJ Nystrom, MA, NR Chaumeton, PhD, KD Rosenberg, MD, Public Health Div, Oregon Dept of Human Svcs. J Gilchrist, MD, Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC.

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Unintentional Strangulation Deaths from the "Choking Game" Among Youths Aged 6--19 Years --- United States, 1995--2007

The "choking game" is defined as self-strangulation or strangulation by another person with the hands or a noose to achieve a brief euphoric state caused by cerebral hypoxia. Participants in this activity typically are youths (1). Serious neurologic injury or death can result if strangulation is prolonged. In recent years, news media reports have described numerous deaths among youths attributed to the choking game. Because no traditional public health dataset collects mortality data on this practice, CDC used news media reports to estimate the incidence of deaths from the choking game. This report describes the results of that analysis, which identified 82 probable choking-game deaths among youths aged 6--19 years, during 1995--2007. Seventy-one (86.6%) of the decedents were male, and the mean age was 13.3 years. Parents, educators, and health-care providers should become familiar with warning signs that youths are playing the choking game (2).

Death certificates lack the detail necessary to distinguish choking-game deaths from other unintentional strangulation deaths. Therefore, CDC identified probable choking-game deaths from 1) a LexisNexis* search in November 2007 of newspaper reports since the 1970s and 2) reports on two choking-game--awareness websites,† which were created in 2005 and 2006. Deaths of children listed on the two websites but not matched by LexisNexis newspaper reports were included in the assessment only if subsequent Internet searches located news media reports (e.g., from television stations) of the incidents confirming that the deaths met the case definition. For consistency, case characteristics were obtained only from news media reports.

A case was defined as a death, described in a news report, resulting from self-strangulation or strangulation by another person as part of an activity with elements of the choking game (also known as the "blackout game," "pass-out game," "scarf game," "space monkey," and by other names). Deaths were excluded if reports included any mention of autoerotic asphyxiation, a practice of choking oneself during sexual stimulation that is usually engaged in by teen-aged or adult males (1). Deaths also were excluded if reports noted that the medical examiner ruled the death was a suicide or of undetermined intent coupled with no mention of elements of the choking game, or if the age of the decedent was missing from news reports. Cases were restricted to youths aged <20 years who were residents of the United States. Following are two examples of cases of choking-game deaths.

Case 1. In February 2006, an adolescent boy aged 13 years came home from school in a good mood and had dinner with his family. He then went to his bedroom to do his homework. Approximately 1 hour later, his mother went to check on him and discovered him slumped in a corner with a belt around his neck. His face was blue. The mother began cardiopulmonary resuscitation while one of the other children called an ambulance. The boy died at a local hospital 1 hour later. No suicide note was found. The county medical examiner ruled that the death resulted from accidental asphyxiation by hanging. In the weeks following his death, multiple teens told the director of a local counseling agency that the choking game had been played at local parties.

Case 2. In April 2005, an adolescent girl aged 13 years was found dead, hanging from a belt and shoelace made into a noose on the door of her bedroom closet, after her brother went to her room to see why she had not come down for breakfast. No suicide note was found. The medical examiner determined that the teen had died at 9:30 p.m. the previous night. After the teen's death, the family learned that the girl had confided in a cousin that she recently had played the choking game in the locker room at school and that a group of girls at her school had been suspended for playing the choking game.

The LexisNexis search and follow-up Internet searches for confirmatory news reports on deaths from the two choking-game websites produced 106 deaths that referred to the choking game. A total of 24 of the deaths were excluded: 20 because news reports either provided no evidence of the choking game or because the medical examiner ruled the death was of undetermined intent, three because the death circumstances had autoerotic elements, and one because no age of the decedent was reported. Among the remaining 82 deaths, 49 (59.8%) were identified via LexisNexis, and 72 (87.8%) were collected from the choking-game websites. LexisNexis was the sole source for 10 (12.2%) of the deaths, and the websites were the sole initial source for 33 (40.2%) of the deaths; 39 (47.6%) deaths were identified by both sources. The median period between the date of death and the news media report was 33.5 days (range: 2 days--6 years).

The earliest choking-game death was identified as occurring in 1995. Three or fewer deaths occurred annually during 1995--2004; however, 22 deaths occurred in 2005, 35 in 2006, and nine in 2007. Seventy-one (86.6%) of the 82 decedents were male, and the age range of decedents was 6--19 years, with a mean age of 13.3 years (standard deviation = 2.1) and a median age of 13 years. Age distribution of the 82 choking-game decedents during 1995--2007 differed from that of the 5,101 youths aged 6--19 years whose deaths were attributed to suicide by hanging/suffocation during 1999--2005§ (Figure).

Among the 70 deaths for which sufficient detail was reported, 67 (95.7%) occurred while the decedent was alone. Among the 42 deaths for which sufficient detail was reported, 39 (92.9%) parents of decedents said they were not aware of the choking game until the death of their child.

Choking-game deaths occurred in 31 states; no geographic clustering was evident. Deaths did not vary significantly by season or by day of the week. No information regarding decedent drug use, race/ethnicity, or socioeconomic status was available.

Reported by: P Russell, MD, MultiCare Health System, Tacoma, Washington. L Paulozzi, MD, J Gilchrist, MD, Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control; R Toblin, PhD, EIS Officer, CDC.

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