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 82 MCCLAVE et al Downloaded from www.aappublications.org/news by guest on September 26, 2021 ARTICLES 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