I was working in the emergency room last week when a 9-year-old boy came in with difficulty breathing.
While nurses got his vital signs, I asked his mother the usual questions in a pediatric history: When did it start? Has this ever happened before? Any fever? I recorded the answers.
He had asthma as a kid but hadn't been sick in several years. He was fine when he went to school this morning. Besides the trouble breathing, there were no other problems. On physical exam, outside of the wheezing in his lungs, I at first didn't notice anything unusual. Then on closer inspection I saw a tiny line of broken blood vessels on the front of his neck, a rosy red string, like a bruise.
I asked the boy and his mother: Any fighting? Any necklaces getting caught on things? No and no. Then I asked the boy, both in front of his mother and later, with her out of the room: Have you been playing the "choking game"?
Ten or maybe even five years ago, I wouldn't have even known to ask that question. And maybe as a parent, neither would you. But now we all need to know to ask the question. We all need to know: What is the choking game?
The choking game consists of strangulation, either self-strangulation or strangulation by another person, for the purposes of achieving a brief state of euphoria — a "high." This state is brought about by a temporary lack of oxygen to the brain. Individuals who participate in this potentially deadly game are typically under 20 years of age and may be as young as 9.
The "game" is known by many other names including suffocation roulette, space monkey, airplaning, California high, cloud nine, funky chicken, choke out, and others. Hands may be used to perpetrate the strangulation but other ligatures such as belts, T-shirts, scarves, shoelaces and bed linens can also be used. When the strangulation is prolonged, death or severe or permanent neurological injury can occur. This may include short-term memory loss, seizures, hemorrhages in the eyes and stroke.
The problem with getting a handle on how frequently this occurs is that there are no public health agencies currently collecting data on the phenomenon. Death certificates that simply describe the death as strangulation may not be able to distinguish death due to the choking game from death by suicide.
In a February 2008 report, the Centers for Disease Control and Prevention attempted to estimate the number of deaths from the choking game that occurred among youth from 1995 to 2007. Due to the above limitations, they relied on Internet searches of news media reports as well as reports on two choking game awareness Web sites.
The CDC concluded that 82 deaths in 31 states were likely a result of the choking game and 86.6 percent of the deaths occurred in boys. The mean age of the children who died was 13.3 years. Importantly, most of the deaths occurred while the child was alone. Also, none of the parents of any of these children was aware of the choking game until after the death of their child.
So just how prevalent is the practice? Again, it's hard to say. Every two years, high schools and middle schools across the nation administer the Youth Risk Behavior Surveillance System. It's a questionnaire developed by the CDC to monitor high-risk behaviors in students. It includes questions about drugs, alcohol and sexual activity. In 2006, a county in Ohio included its own question about the choking game in the survey. The survey found that 11 percent of the children 12 to 18 years old, and 19 percent of the kids ages 17 to 18, reported playing the "game" at least once.
We should all be able to recognize the warning signs that may indicate experimentation with the choking game, including bloodshot eyes, pinpoint bruising around the eyes or face, marks on the neck and frequent or severe headaches.
Suspicious paraphernalia such as ropes, scarves or belts tied to furniture or found knotted on the floor should alert parents to the possibility of involvement. A sudden or unusual need for privacy such as locked bedroom doors as well as disorientation after spending time alone are also red flags.
As with any risky behavior, open conversation with kids is the key to shared information in both directions. Dinner table discussions can help children share concerns they may have about themselves or their friends while affording parents the opportunity to teach kids about its dangers.
The point is educating ourselves and our children about the dangers of the choking game — the first step toward reducing its morbidity and mortality. As for my little boy in the ER, he turned out to have a simple asthma attack, brought on by hanging out in his sister's room with a cat and her cigarette smoke.
He denied knowledge of or participation in the choking game, but now at least he and his mom both know about this potentially deadly "game."
Dr. Carolyn Roy-Bornstein is a board certified pediatrician with Merrimack Valley Child and Adolescent Health and Merrimack Valley Hospital. Her office is at Merrimack Health Center, 62 Brown St,. adjacent to the hospital. She can be reached at 978-521-8108. Parents are invited to e-mail questions for future columns to CRoy.MVCAH@comcast.net.
