The Choking Game: Physician Perspectives

WHAT’S KNOWN ON THIS SUBJECT: Reports in the popular AUTHORS: Julie L. McClave, MD,a Patricia J. Russell, MD,b media and case reports have described the choking game activity Anne Lyren, MD, MSc,c,d Mary Ann O’Riordan, MS,e and and its consequences. The incidence of the activity has been Nancy E. Bass, MDf described. aSchool of Medicine, and dDepartment of Bioethics, Case Western Reserve University, Cleveland, Ohio; bMultiCare Health WHAT THIS STUDY ADDS: We report on physician awareness of System, Tacoma, Washington; and Divisions of cGeneral Academic Pediatrics, ePediatric Pharmacology and Critical Care, the choking game and opinions on including discussion of its and fChild Neurology, Department of Pediatrics, Rainbow Babies dangers in anticipatory guidance for adolescents. and Children’s Hospital, Cleveland, Ohio KEY WORDS choking game, asphyxia, anticipatory guidance, adolescents, injury prevention ABBREVIATIONS abstract AAP—American Academy of Pediatrics AEA—autoerotic asphyxia OBJECTIVE: The goal was to assess awareness of the choking game This work was presented at the American Academy of Pediatrics among physicians who care for adolescents and to explore their opin- National Conference; October 13, 2008; Boston, MA. ions regarding its inclusion in anticipatory guidance. www.pediatrics.org/cgi/doi/10.1542/peds.2009-1287 METHODS: We surveyed 865 pediatricians and family practitioners. doi:10.1542/peds.2009-1287 The survey was designed to assess physicians’ awareness of the chok- Accepted for publication Jul 28, 2009 ing game and its warning signs, the suspected prevalence of patients’ Address correspondence to Julie L. McClave, MD, Rainbow participation in the activity, and the willingness of physicians to include Babies and Children’s Hospital Case Medical Center, Department the choking game in adolescent anticipatory guidance. Information on of Pediatrics, 11100 Euclid Ave, RB&C RM 838, Cleveland, OH the general use of anticipatory guidance also was collected. 44106-6002. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). RESULTS: The survey was completed by 163 physicians (response rate: 21.8%). One-hundred eleven (68.1%) had heard of the choking game, 68 Copyright © 2009 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have of them (61.3%) through sources in the popular media. General pedia- no financial relationships relevant to this article to disclose. tricians were significantly more likely to report being aware of the choking game than were family practitioners or pediatric subspecial- ists (P ϭ .004). Of physicians who were aware of the choking game, 75.7% identified Ն1 warning sign and 52.3% identified Ն3. Only 7.6% of physicians who were aware of the choking game reported that they cared for a patient they suspected was participating in the activity, and 2 (1.9%) reported that they include the choking game in anticipatory guidance for adolescents. However, 64.9% of all respondents agreed that the choking game should be included in anticipatory guidance. CONCLUSIONS: Close to one third of physicians surveyed were un- aware of the choking game, a potentially life-threatening activity prac- ticed by adolescents. Despite acknowledging that the choking game should be included in adolescent anticipatory guidance, few physicians reported actually discussing it. To provide better care for their adoles- cent patients, pediatricians and family practitioners should be knowl- edgable about risky behaviors encountered by their patients, including the choking game, and provide timely guidance about its dangers. Pediatrics 2010;125:82–87

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Thrill-seeking or risk-taking behavior choking game have shown nonfatal in- ipatory guidance.13 Therefore, this among adolescents has long contrib- juries such as seizures, headaches, study aims to assess the knowledge of uted to morbidity and death in this age fractures, and brain injury ranging this game among pediatricians and group.1 Reports in the popular media from subtle cognitive impairment to family practitioners who care for ado- have brought increased attention to a persistent vegetative state.9,10 The full lescents and to explore their opinions dangerous activity among adolescents extent of the injuries and deaths regarding inclusion of the dangers of known as the “choking game,” among caused by the choking game is likely the choking game in anticipatory guid- other names.2 In this activity, partici- underrepresented by these accounts, ance for their adolescent patients. pants attempt to gain a “high” or eu- because many of the cases are never phoric feeling by temporarily depriv- reported or may be misclassified as METHODS ing the brain of oxygen. This is suicides.11 Subjects and Design achieved through pressure applied to A variety of warning signs suggest that Eight hundred sixty-five pediatricians the neck by another person’s hands or an adolescent may be participating in and family practitioners in northeast with belts, neckties, or other ligatures. the choking game. These signs in- Ohio were invited to participate in the Alternatively, the activity may entail clude headaches, unexplained bruis- study. These physicians were identi- one person taking a deep breath and ing around the neck, bloodshot eyes, fied through the Rainbow Babies and holding it, while a second person hugs facial petechiae, disorientation after Children’s Hospital pediatrician and that person from behind until the first being alone, ligatures tied in strange family physician database, along with person feels dizzy and passes out.3 knots or in unusual places, and wear current residents in pediatrics and Those who participate in this activity 6,7 marks on furniture. Local and state family medicine residency programs often describe an additional pleasur- agencies have issued warnings to in northeast Ohio (defined as the coun- able sensation with the rapid outflow schools and law enforcement agencies ties of Cuyahoga, Geauga, Lake, Lorain, of previously impeded deoxygenated describing these signs, in an attempt and Medina). Participants were ex- blood from the brain when pressure is to educate teachers and parents re- cluded if there was no mailing or released. garding this deadly game.12 Several e-mail address available in the data- The choking game can be played in case studies and editorials called for base or the location of practice listed groups or alone, and participants of- preventative measures by educators, in the database was not in northeast ten are between 7 and 21 years of age. physicians, and others who care for Ohio. adolescents.2–4,10 Physicians are in a This activity becomes life-threatening In December 2007, a survey was sent unique position to recognize these when the victim is alone, loses con- through either e-mail or US mail to subtle signs of self-inflicted asphyxia- sciousness, and cannot release the each participant, along with a cover ligature. Several case studies docu- tion and to provide timely guidance on letter describing the purpose of the mented death or near-death in ado- the dangers of such activity to both ad- survey. Electronic correspondence lescents, often boys, who were found olescent patients and their parents. was used whenever an e-mail address unconscious and later identified by Relatively little published literature was available; otherwise, a paper copy family or friends as having played the documents the choking game and the of the survey was sent through US choking game.3–5 Attempting to publi- extent of physician awareness and mail. An addressed, stamped, return cize the risks associated with the chok- knowledge of the activity. For physi- envelope was included in the postal ing game, advocacy groups have com- cians caring for adolescents, provid- mailing for return of the completed piled lists of parent-reported choking ing effective, timely, current anticipa- survey. E-mail–based questionnaires game–related deaths and have identi- tory guidance is an important goal of used the Survey Monkey online data fied Ͼ100 deaths per year between all patient encounters. Despite the collection system (Survey Monkey, 2005 and 2007.6,7 A recent report from emergence of the choking game as a Portland, OR). For all electronic corre- the Centers for Disease Control and serious threat to adolescent health, spondence, a reminder e-mail was Prevention used reports in the media counseling for adolescents and their sent 4 weeks after the initial contact. to estimate 82 probable choking parents regarding the dangers and The survey was closed to further re- game–related deaths from 1995 to warning signs of the choking game is sponses after 6 weeks. The study was 2007.8 Aside from the lethal dangers of not currently listed by the American approved by the University Hospitals asphyxiation, case studies of individu- Academy of Pediatrics (AAP) as a rec- Case Medical Center institutional re- als suspected of participating in the ommended topic for adolescent antic- view board.

PEDIATRICS Volume 125, Number 1, January 2010 83 Downloaded from www.aappublications.org/news by guest on September 26, 2021 Survey Instrument TABLE 1 Characteristics of Respondents Who Were Aware or Unaware of the Choking Game The survey was designed to assess Characteristic Overall Aware Unaware (N ϭ 163) (N ϭ 111) (N ϭ 52) northeast Ohio physicians’ knowledge Age, mean Ϯ SD, y 40.1 Ϯ 11.0 40.2 Ϯ 11.5 39.8 Ϯ 10.0 and awareness of the choking game. Time in practice, n (%) Questions were designed to assess Ͻ10 y 98 (60.1) 67 (60.4) 31 (59.6) their baseline knowledge of the chok- 10–19 y 29 (17.8) 18 (16.2) 11 (21.1) Ն20 y 36 (22.1) 26 (23.4) 10 (19.2) ing game and its warning signs, alter- Level of training, n (%) native names for the choking game, Resident/fellow 50 (30.7) 37 (33.3) 13 (25.0) the suspected prevalence of their pa- Faculty member/attending physician 113 (69.3) 74 (66.7) 39 (75.0) Specialty, n (%)a tients’ participation in this behavior, Family practice 48 (29.5) 28 (25.2) 20 (38.5) and the willingness of physicians to in- General pediatrics 84 (51.5) 66 (59.5) 18 (34.6) clude discussion of the choking game Pediatrics subspecialty 31 (19.0) 17 (15.3) 14 (26.9) Type of training hospital, n (%) in anticipatory guidance for adoles- Rural or community 30 (18.4) 19 (17.1) 11 (21.2) cent care. In addition, respondents Academic 133 (81.6) 92 (82.9) 41 (78.9) were asked to identify anticipatory Size of residency class, n (%) Ͻ guidance topics that they covered on a Small ( 10) 52 (31.9) 33 (29.7) 19 (36.5) Medium (10–19) 46 (28.2) 28 (25.2) 18 (34.6) regular basis with patients 8 to 18 Large (Ն20) 63 (39.9) 50 (45.1) 15 (28.9) years of age and their parents. Antici- a P ϭ .004, general pediatricians versus other specialties. patory guidance topics were identified through the published recommenda- Institute, Cary, NC). The level of signifi- Choking Game Awareness tions of the National Center for Educa- ϭ cance was set at P .05. Of the physicians surveyed, 111 (68.1% tion in Maternal and Child Health, con- [95% confidence interval: 60.5%– sistent with AAP guidelines for health RESULTS 75.9%]) reported that they had heard supervision.13 Participants also were Respondent Characteristics of the choking game. Of those who asked to report the amounts of time The survey was sent to a total of 865 knew about the choking game, 68 they typically spent on anticipatory physicians, through US mail for 265 (61.3%) reported hearing about the guidance in well-child and sick-child (30.6%) and through e-mail for 600 visits, along with their opinions on choking game through popular media, (69.4%). This total subject pool con- their ability to cover all that they either alone or in combination with an- sisted of 614 practicing physicians consider necessary to include in an- other source. Other sources in- (71.0%) and 251 residents (29.0%) in cluded professional conferences ticipatory guidance for their pa- the fields of pediatrics or family medi- tients. Finally, demographic informa- (15.3%), other professional experi- cine. Of the physicians to whom sur- ences (8.1%), literature (9.0%), pa- tion, including age, length of time in veys were sent, 31 (3.5%) had undeliv- tients (11.7%), or an experience from practice, level of training, specialty, erable addresses and 3 (0.3%) did not their personal lives (12.6%). Eight re- and size of residency class, was complete the survey because they re- spondents (7.2%) described knowl- collected. sponded that they did not care for pe- edge about the choking game from diatric patients. Of the remaining 831 Statistical Methods their own childhoods, either from par- eligible participants, 181 returned the ticipating in it themselves or through The primary outcome was awareness survey (response rate: 21.8%), 42 of the choking game. Demographic (23.2%) through US mail and 139 childhood friends. Table 1 describes characteristics are reported as fre- (76.8%) through e-mail. Eighteen re- the demographic characteristics asso- quencies and proportions, overall and spondents did not complete the entire ciated with knowledge of the choking according to outcome group. Re- survey, failing to respond to the main game. General pediatricians were sig- sponses are reported in a similar man- questions regarding the choking nificantly more likely to report being ner. The primary outcome is reported game. Those respondents were ex- aware of the choking game, compared as observed numbers and propor- cluded from data analysis, which re- with the other specialties represented tions, with 95% confidence intervals. sulted in 163 subjects. Table 1 shows (P ϭ .004) (Table 1). No other demo- Associations with the outcome were the demographic information for all graphic characteristic collected was tested by using ␹2 analysis. All analy- subjects. Respondents ranged from 26 significantly associated with aware- ses were performed with SAS 9.1 (SAS to 72 years of age. ness of the choking game.

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TABLE 2 Physician Awareness of Alternative TABLE 3 Physician Awareness of Warning Signs of the Choking Game Names for the Choking Game Recognizable Warning Signs Awareness Among Alternative Names Awareness Among Those Aware of Choking Those Aware of Choking Game (N ϭ 111), n (%) N ϭ n Game ( 111), (%) Strange bruising or red marks around neck 78 (70.3) AEA 74 (66.7) Bloodshot eyes and/or petechiae on face 64 (57.7) Pass-out game 51 (46.0) Ligatures (bed sheets, belts, tee shirts, ties, or ropes) tied in 46 (41.4) Fainting game 48 (43.2) strange knots and/or found in unusual places Black out 38 (35.1) Internet history of Web sites or chat rooms mentioning asphyxiation 35 (31.5) 5 min of heaven 27 (24.3) or choking game Rush 20 (18.0) Curiosity about asphyxiation (ie, “how’s it feel” or “what happens if”) 34 (30.6) Knock-out game 17 (15.3) Disorientation and/or grogginess after being alone 25 (22.5) Natural high 16 (14.4) Unusual demands for privacy 25 (22.5) Suffocation roulette 9 (8.1) Locked or blocked bedroom/bathroom doors 25 (22.5) Space monkey 5 (4.5) Frequent, often-severe headaches 21 (19.9) Funky chicken 4 (3.6) Changes in attitude (overly aggressive) 16 (14.4) Speed dreaming 4 (3.6) Wear marks on furniture (eg, bunk beds or closet rods) 16 (14.4) Tingling game 4 (3.6) Purple dragon 2 (1.8) alternative names and physician patient they suspected had partici- awareness of each. pated in the activity. Only 2 respon- Respondents also were asked to iden- Physicians who were aware of the dents, that is, 1.9% of those who knew tify the names of similar asphyxial ac- choking game identified a median of 3 about the choking game, reported that tivities among adolescents. The most warning signs (range: 0–11 signs) of a they included the choking game in an- commonly identified activity was auto- patient’s involvement in this activity. ticipatory guidance offered to their ad- erotic asphyxia (AEA), with 62.0% of all The most common signs were bruising olescent patients; however, 64.9% of physicians surveyed reporting knowl- around the neck (70.3%), bloodshot eyes all respondents agreed that the chok- edge of AEA. AEA is the practice of using and/or petechiae on the face (46.0%), ing game should be included in antici- strangulation to enhance the pleasure and ligatures tied in strange knots patory guidance. Most physicians of sexual stimulation. Several reports and/or found in unusual places (42.2%). (84.8%) were not concerned that dis- have acknowledged the difference Three fourths of physicians who re- cussing the choking game with their between AEA and the choking game ported that they were aware of the chok- adolescent patients would prompt the and other asphyxial activities among ing game were able to identify Ն1 warn- patients to participate in it. youths, stating that AEA, although sim- ing sign; 52.3% were able to identify Ն3. ilar, should be considered a separate Table 3 describes the warning signs of Anticipatory Guidance entity because its participants are al- participation in the choking game and Table 4 shows responses to anticipa- most exclusively adult and the choking physician awareness of each. tory guidance questions. The majority game does not necessarily include Of physicians who were aware of the of physicians surveyed (70.6%) re- masturbation.11 Because of this, AEA choking game, 7.6% had cared for a ported spending Ͼ2 minutes on antic- was excluded from the analysis of al- ternative names for the choking game. TABLE 4 Time Spent on Anticipatory Guidance The median number of alternative names identified by physicians aware n (%) of the choking game was 2 (range: Overall Aware of Unaware of Choking Game Choking Game 0–10 names). The most frequently Time spent on anticipatory guidance at well-child visitsa identified alternative names were “pass- None 7 (4.3) 4 (3.6) 3 (5.8) out game” (46.0%), “fainting game” Ͻ1 min 7 (4.3) 5 (4.5) 2 (3.9) (43.2%), and “black out” (35.1%). Of 1–2 min 34 (20.9) 15 (13.5) 19 (36.5) Ͼ2 min 115 (70.6) 87 (78.4) 28 (53.9) those who reported that they were Time spent on anticipatory guidance at sick-child visits aware of the choking game, 71.2% None 32 (19.6) 20 (18.0) 12 (23.1) were able to identify Ն1 other name Ͻ1 min 56 (34.4) 33 (29.7) 23 (44.2) 1–2 min 54 (33.1) 42 (37.8) 12 (23.1) for asphyxial activity among adoles- Ͼ2 min 21 (12.9) 16 (14.4) 5 (9.6) cents and 53.2% were able to identify Inadequate time to cover anticipatory guidance topics 147 (90.2) 103 (92.8) 44 (84.6) Ն2 alternative names. Table 2 shows a P ϭ .002, Ͼ2 minutes vs Ͻ2 minutes.

PEDIATRICS Volume 125, Number 1, January 2010 85 Downloaded from www.aappublications.org/news by guest on September 26, 2021 ipatory guidance at well-child visits. by patients who participate in this riers to discussing the choking game However, physicians who reported activity. may be fear of offending patients or that they were aware of the choking Few physicians reported that they had their parents or fear of prompting pa- game were significantly more likely to cared for a patient whom they sus- tients to participate in asphyxial activ- describe spending Ͼ2 minutes on an- pected had participated in the choking ity. Thomas et al16 examined anticipa- ticipatory guidance than were those game. This perceived incidence is tory guidance on topics such as sexual who were not aware of the activity grossly inconsistent with data avail- normalcy and sexual abuse preven- (78.4% vs 53.9%; P ϭ .002). In compar- able from surveys of adolescents dis- tion, which currently are recom- ison, only 12.9% of all physicians re- closing their participation. A survey of mended by the AAP as topics of discus- ported spending Ͼ2 minutes on antic- adolescents in Williams County, Ohio, sion, and 98% of surveyed parents ipatory guidance during sick-child reported that 11% of adolescents ad- thought that their doctor should dis- visits, with no significant difference be- mitted to having played the choking cuss Ն1 topic related to normal sexu- tween those who were aware of the game.14 A more-recent survey of mid- ality with their child. No evidence exists choking game and those who were not. dle school and high school students in to suggest that discussing other risky Finally, 90.2% of all physicians sur- Texas and Ontario showed that 68% of behaviors, such as smoking, alcohol veyed thought there is not enough time children had heard of the choking use, drug use, and sexuality, with ado- in typical well-child visits to cover all of game, 45% knew someone who had lescents prompts them to participate the recommended anticipatory guid- played it, and 6.6% had tried it them- in those activities. In addition, with the ance topics. selves.15 This inconsistency between availability of the Internet and its fre- Of the 62 anticipatory guidance topics physicians’ perceptions and adoles- quent use by adolescents, information listed in the survey, the most com- cents’ self-reports suggests that this on the choking game already is avail- monly reported topics covered for pa- behavior is occurring much more of- able to adolescents; indeed, videos tients 8 to 18 of age were smoking/ ten than physicians appreciate. demonstrating how to engage in the chewing tobacco (87.7%), healthy, Pediatricians and family practitioners activity can be found on popular Web well-balanced diet (87.7%), school per- play a central role in the health of ad- sites. It is likely that many adolescent formance (87.1%), adequate physical olescents who seek care for illnesses, patients know about the choking game activity (85.9%), and alcohol use as well as routine care and prepartici- but do not understand how risky the (86.5%). Of the 62 topics, 56 topics pation physical examinations. These behavior is. (82.3%) had a nominally higher fre- interactions allow physicians the Anticipatory guidance represents a quency among physicians who re- unique opportunity to screen adoles- critical opportunity to enhance adoles- ported that they were aware of the cents for high-risk behaviors and to cent health, although the wide array of choking game, compared with those provide education to patients and their topics a physician might cover during who were not aware of this activity. parents. No physician can diagnose or these brief opportunities is daunting. counsel a patient about a behavior of As our survey showed, most physi- DISCUSSION which he or she is not aware. Many of cians think that the time available dur- This study demonstrated that a major- the physicians in this survey were not ing a well-child visit is inadequate for ity of physicians caring for adoles- aware of the choking game or its impli- discussion of all that is recommended. cents were aware of the choking game, cations. Reliable accurate information However, physicians who care for ado- but this knowledge did not translate needs to be developed for physicians, lescents are in a unique position to into counseling of patients regarding to allow them to counsel adolescents raise awareness, to detect warning the risks of the activity. Although most and their parents adequately. The AAP signs, and to educate adolescents and of the physicians surveyed agreed that currently does not recommend inclu- their parents about this dangerous be- the choking game should be included sion of the choking game in anticipa- havior before it is too late. Among par- as a topic of discussion with their ado- tory guidance, and physicians have lit- ents of youths who died as a result of lescent patients, very few reported ac- tle opportunity to learn about this choking game–related activity, the tually discussing it. Apart from super- deadly behavior. most common recollection is that they ficial knowledge provided by sources As demonstrated in this survey, even were unaware that the choking game in the popular media, many physicians physicians who are aware of the chok- existed and they would have recog- surveyed could not identify the major ing game fail to communicate its dan- nized the warning signs in their child if warning signs that may be displayed gers to adolescent patients. Some bar- they had known what to look for.17 A

86 MCCLAVE et al Downloaded from www.aappublications.org/news by guest on September 26, 2021 ARTICLES brief targeted conversation with ado- ing the awareness of emergency phy- CONCLUSIONS lescents and their parents about the sicians, because this group of provid- The choking game is a dangerous ac- choking game may put this activity on ers is likely to encounter patients tivity that is popular among adoles- parents’ “radar” and help prevent chil- injured through participation in the ac- cents; however, some physicians dren from playing this deadly game. All tivity. Additional information on knowl- caring for adolescents seem to be un- pediatric providers, including emer- edge of the choking game among ado- aware of the choking game and are un- gency medicine physicians, pediatric lescents and their parents would be able to identify important warning neurologists, and other specialists, valuable. Although recent studies signs of participation in the activity. should be aware of this activity and, showed that up to 7% of adolescents The AAP places importance on provid- when appropriate, be prepared to dis- admit to participating in the choking ing timely anticipatory guidance to cuss it with their patients. game,15,18 further investigation of inju- children and adolescents. On the basis This survey was primarily descriptive ries resulting from this activity may be of this study, we think that the choking in nature, as dictated by the survey de- worthwhile. Future studies also could game should be included in this dis- sign. This limits the results to observa- explore methods for raising aware- cussion. Moreover, pediatricians and tions of the opinions expressed by ness of the choking game among ado- family practitioners should be pro- those who responded to the survey. lescents, their parents, and the physi- vided with reliable accurate informa- This might have biased our sample, be- cians who care for them. These tion about the dangers of the choking cause the respondents might not be methods might include incorporation game, to pass on to their adolescent representative of the group at large. In of the choking game into residency patients and their parents. addition, external validity is limited by curricula and physician continuing ed- ACKNOWLEDGMENTS the small sample size from a relatively ucation, preparation of an informa- We gratefully acknowledge Brian Ber- small geographic area. tional pamphlet describing this deadly man, MD, M. Deborah Lonzer, MD, and Future research may study national game for parents, or inclusion of the Janet Ink, for their assistance in sur- awareness of the choking game choking game in recommended antici- vey distribution, and all of the physi- among physicians, as well as examin- patory guidance for adolescents. cians who participated in the survey. REFERENCES

1. Eaton DK, Kann L, Kinchen S, et al. Youth risk tics in the United States. Available at: 13. Green M, Palfrey J, eds. Bright Futures: behavior surveillance: United States, 2005. www.thedbfoundation.com/Choking_ Guidelines for Health Supervision of Infants, J Sch Health. 2006;76(7):353–372 Game_Statistics.html. Accessed January 25, Children, and Adolescents. 2nd ed, rev ed. 2. Urkin J, Merrick J. The choking game or suf- 2008 Arlington, VA: National Center for Education focation roulette in adolescence. Int J Ado- 8. Centers for Disease Control and Prevention. in Maternal and Child Health; 2002 lesc Med Health. 2006;18(2):207–208 Unintentional strangulation deaths from 14. Williams County Partnerships for Success. 3. Shlamovitz GZ, Assia A, Ben-Sira L, Rachmel the “choking game” among youths aged Williams County Youth Health Risk Behav- 6–19 years: United States, 1995–2007. A. “Suffocation roulette”: a case of recur- ioral Survey, Fall 2006. Bryon, OH: Williams MMWR Morb Mortal Wkly Rep. 2008;57(6): rent syncope in an adolescent boy. Ann County Partnerships for Success; 2007:23 141–144 Emerg Med. 2003;41(2):223–226 15. Macnab AJ, Deevska M, Gagnon F, Cannon 9. Gicquel JJ, Bouhamida K, Dighiero P. Oph- 4. Le D, Macnab AJ. Self strangulation by hang- WG, Andrew T. Asphyxial games or “the thalmological complications of the asphyx- ing from cloth towel dispensers in Canadian choking game”: a potentially fatal risk be- iophilic “scarf game” in a 12-year-old child schools. Inj Prev. 2001;7(3):231–233 haviour. Inj Prev. 2009;15(1):45–49 [in French]. J Fr Ophtalmol. 2004;27(10): 5. Senanayake MP, Chandraratne KA, de Silva 1153–1155 16. Thomas D, Flaherty E, Binns H. Parent expec- tations and comfort with discussion of nor- TU, Weerasuriya DC. The “choking game”: 10. Ullrich NJ, Bergin AM, Goodkin HP. “The self-strangulation with a belt and clothes choking game”: self-induced hypoxia pre- mal childhood sexuality and sexual abuse rack. Ceylon Med J. 2006;51(3):120 senting as recurrent seizurelike events. Ep- prevention during office visits. Ambul Pedi- 6. GASP: Games Adolescents Shouldn’t Play. ilepsy Behav. 2008;12(3):486–488 atr. 2004;4(3):232–236 Ј Choking game community support. Statis- 11. Andrew TA, Fallon KK. Asphyxial games in 17. Corre G. Ceci N est Pas un Jeu [This Is Not a tics: By Year, Country. Available at: children and adolescents. Am J Forensic Game; in French and English]. Paris, France; www.deadlygameschildrenplay.com/ Med Pathol. 2007;28(4):303–307 APEAS with sanofi aventis; 2007 stats-statistics.asp. Accessed January 25, 12. Ohio Resource Network for Safe and Drug 18. Adlaf EM, Paglia-Boak A, Beitchman JH, 2008 Free Schools and Communities. The choking Wolfe D. The Mental Health and Well-Being of 7. Dylan Blake Foundation. Adolescent risky game. Available at: www.ebasedprevention. Ontario Students, 1991–2007: Detailed OS- behaviors: “the choking game” (adolescent org/oewn/choking-game. Accessed May 18, DUHS Findings. Toronto, Canada: Centre for asphyxiation activity). Choking Game Statis- 2007 Addiction and Mental Health; 2007

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