The "choking game" and other strangulation activities in children and adolescents - UpToDate
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Nicole J Ullrich, MD, PhD
Howard P Goodkin, MD, PhD
Amy B Middleman, MD, MPH, MS Ed
Daniel M Lindberg, MD
Marc C Patterson, MD, FRACP
Mary M Torchia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2017. | This topic last updated: Apr 07, 2017.
INTRODUCTION — Unintentional injury is the leading cause of death in children, adolescents, and young adults in the United States . Unintentional injury often results from risk-taking behavior such as alcohol or drug use. Self-induced hypoxia (eg, engaging in strangulation activities, such as "the choking game") is another risky behavior among children and adolescents that may have a fatal outcome.
The "choking game" — The "choking game" refers to self-strangulation or strangulation by another person with the hands or a ligature to produce a euphoric state caused by cerebral hypoxia  and is perhaps more accurately described as a "strangulation activity" than as a game [3,4]. Breath holding and/or compression of the abdomen or thorax are involved in some versions of the activity [5-8]. The intent is to release the pressure just before loss of consciousness; failure to do so can result in death, particularly when the activity is performed alone using ligatures [2,5,7,9].
Other names — Other names for strangulation activities include the American dream, air planing, black hole, black-out game, breath play, California choke, California high, choke out, cloud nine, dream game, fainting game, five minutes of heaven, flat lining, funky chicken, gasp game, ghost, knock-out game, natural high, pass-out game, purple dragon, purple hazing, rising sun, rush, the scarf game, sleeper hold, something dreaming game, space cowboy, space monkey, speed dreaming, suffocation roulette, and the tingling game [2,6,9-15].
Autoerotic asphyxia — Autoerotic asphyxia is a similar activity that involves choking oneself during sexual stimulation in order to heighten the sexual pleasure [9,16]. Autoerotic asphyxia may involve elaborate bindings, sophisticated escape mechanisms, sexual images, or cross-dressing [5,17]. Death may occur if loss of consciousness leads to loss of control and inability to reverse or stop the means of strangulation . Participants of autoerotic asphyxia are almost exclusively older adolescent and adult males [5,6,17].
Prevalence — Children and adolescents throughout the world engage in strangulation activities; fatal and nonfatal cases have been reported in the United States, Canada, Australia, Israel, France, England, Ireland, and Saudi Arabia [5,6,18-21]. According to some reports, children have engaged in strangulation activities for generations [5,9,11]; however, the first reference to the "choking game" in the medical literature occurred in 2000 .
There is little information about how many children and adolescents engage in strangulation activities. Engaging in such activities typically comes to light only when complications occur; however, the specific attribution of complications to strangulation activities is likely to be underreported because death certificates lack the detail necessary to distinguish death related to strangulation activities from other causes of unintentional strangulation [2,5,9].
In a 2015 systematic review of 17 cross-sectional studies, the median lifetime prevalence of participation in strangulation activities among survey respondents (predominantly 12 to 17 years of age) was 7.4 percent . Prevalence ranged geographically, ranging from 6 to 16 percent in France, 5 to 7 percent in Canada, and 4 to 17 percent in the United States. Survey respondents indicated that they first participated between the ages of 8 and 15 years.
Between 11 and 23 percent of those who participated did so without others present. Solitary participation in strangulation activities has been associated with higher rates of suicidality and poor mental health . It also increases the risk of death. (See 'Differential diagnosis' below and 'Mortality' below.)
In the United States, many states have reported a significant increase in reported cases. Whether there has been an actual change in the number of children engaging in strangulation activities over time, however, is uncertain [2,5]. Changes in the numbers of deaths related to the "choking game" reported in the media may be related to changes in the news media's level of interest, changes in "choking game" activity, and/or changes in awareness of the "choking game" by emergency and health care providers .
Predisposing factors — It is not clear what motivates children to engage in strangulation activities. Possible motivating factors include peer pressure, risk- or thrill-seeking behavior, and the possibility of a drug-free "high" [5,6]. In some cases, engaging in strangulation activities begins as a social activity but progresses to being performed alone . In others, engaging in strangulation activities may be "practicing" strangulation as a potential method of suicide.
Surveys of teenagers indicate that participation in strangulation activities may be associated with other risky behaviors (such as substance use, risky sexual activity, poor dietary behaviors, engagement in risky sports) and poor mental health (eg, suicidality) [21,23,24]. This is not surprising, since risky behaviors tend to cluster in adolescents [25-28].
Mortality — The United States Centers for Disease Control and Prevention (CDC) used media reports to estimate the incidence of ”choking game"-related deaths among children and adolescents <20 years of age between 1995 and 2007 . Cases were included only if the death was described in a news report and resulted from self-strangulation or strangulation by another person as part of an activity with elements of the "choking game" as described above. Deaths were excluded if the news story indicated that the medical examiner ruled the death a suicide or of undetermined intent or if it included any mention of autoerotic asphyxiation. (See 'Definitions' above.)
The report included the following observations:
Eighty-two probable "choking-game"-related deaths were identified; deaths occurred in 31 states with no evident geographic clustering or variation by season or day of the week.
Less than three deaths per year were reported between 1995 and 2004; 22 were reported in 2005, 35 in 2006, and nine in 2007.
The deaths occurred in children aged 6 to 19 years, with a mean and median age of 13.3 and 13 years, respectively; 87 percent of deaths occurred in boys. The age distribution of "choking game" deaths was similar to that for deaths attributed to all types of unintentional choking/suffocation  but differed from that of suicide by hanging/suffocation (figure 1).
Among deaths for which sufficient detail was reported, 96 percent occurred while the decedent was alone.
Among deaths for which sufficient detail was reported, 93 percent of parents were not aware of the "choking game" until the death of their child.
Information regarding drug use, race/ethnicity, socioeconomic status, and the role of influence by peers or the media/internet was not available.
The CDC findings are subject to limitations inherent in using news media for case findings. These include incomplete ascertainment of cases, inability to independently verify case details, attribution of deaths to causes or intents other than those recorded on the death certificate, and lack of information about nonfatal injuries . Nonetheless, the findings are supported by a series of 24 deaths attributed to asphyxial activities by medical examiners that predominantly occurred in boys between the ages of 9 and 15 years .
PATHOPHYSIOLOGY — The pathophysiologic effects of strangulation activities have not been well studied. Several mechanisms, including cerebral hypoxia and hypoperfusion, cerebral vascular engorgement, decreased cardiac output (related to increased thoracic pressure), and hypercarbia have been postulated to play a role in loss of consciousness and other clinical manifestations [6,9,11,18,30]. After loss of consciousness, when the pressure is released, there may be a secondary "high" related to the rush of blood and oxygen to the brain .
Cerebral hypoxia and hypoperfusion — Several elements of strangulation activity may result in cerebral hypoxia. These include breath holding, external limitation of chest wall expansion, and compression of the carotid arteries . Compression of the carotid sinuses further reduces cerebral oxygenation through reflex bradycardia and vasodilation .
Acute severe hypoxia can cause loss of consciousness in 10 to 20 seconds, permanent brain damage in three minutes, and death in four to five minutes . Hypoxia that is less severe can cause impaired judgment, drowsiness, dulled pain sensation, excitement, disorientation, and headache . Other symptoms and signs of hypoxia include anorexia, nausea, vomiting, tachycardia, and tachypnea; hypertension occurs when hypoxia is severe.
The effects of arrest of cerebral circulation were evaluated in a study that was performed before the Belmont Report (which outlines ethical principles and guidelines for the protection of human subjects) . Complete arrest of cerebral circulation for 5 to 10 seconds resulted in a rapidly reversible loss of consciousness and convulsive syncope that was preceded by an aura of visual blurring and constriction. Upon recovery of consciousness, many of the subjects were described as excited, euphoric, and "having a foolish smile on their faces."
EEG correlates — Cerebral hypoperfusion and hypoxia are associated with initial slowing of the background on electroencephalogram (EEG), followed by high-amplitude delta activity . Loss of consciousness, with flattening of the EEG background, occurs if hypoperfusion and hypoxia persist .
Presentation — Children and adolescents who engage in strangulation activities usually do not come to medical attention unless they have suffered a complication of asphyxia, the most serious of which are neurologic injury (eg, coma, seizures, stroke, brain damage) and death [2,18]. The risk of death and neurologic injury are increased when strangulation activity is performed alone and when ligatures are used [2,5,7]. (See "Evaluation of stupor and coma in children" and "Treatment and prognosis of coma in children".)
The presenting complaints of children with less severe episodes of hypoxia whose findings ultimately are attributed to self-induced hypoxia may include [2,6,9,18]:
Recurrent confusional episodes and seizure-like events. (See "Nonepileptic paroxysmal disorders in children".)
Syncope or recurrent syncope, possibly associated with head trauma or other injuries. (See "Causes of syncope in children and adolescents" and "Emergent evaluation of syncope in children and adolescents".)
Paroxysmal episodes of altered awareness.
Acute vision changes or visual loss, resulting from Valsalva retinopathy (hemorrhagic retinopathy related to a sudden increase in intrathoracic pressure), characterized by intraretinal and subretinal hemorrhage over the macula [8,34].
Warning signs — Potential warning signs that an adolescent might be engaging in strangulation activities include [2,9,10,13,14]:
Mention of the "choking game" (by this or other names) (see 'Other names' above)
Curiosity about asphyxiation (eg, how it feels)
Unexplained bruising or red marks on the neck
Wearing high-necked shirts, even in warm weather
Bloodshot eyes or pinpoint bruising around the eyes
Petechiae on the face, especially the eyelids or conjunctiva
Frequent, severe headaches
Disorientation after spending time alone
Unusual need for privacy
Increased and uncharacteristic irritability or hostility
The unexplained presence of dog leashes, choke collars, bungee cords, etc
Ropes, scarves, and belts tied to bedroom furniture or doorknobs, or found knotted on the floor or in unusual places
Wear marks on bedposts and closet rods
Internet history of websites or chat rooms mentioning asphyxiation or the "choking game"
EVALUATION — When considering strangulation activities as the precipitant of asphyxia-related complications (eg, loss of consciousness), it is critical to take a careful history [5,6]. It may be necessary to interview siblings, friends, and other associates of the patient. The parents often are unaware of their child's participation in strangulation activities until medical intervention becomes necessary.
Video-electroencephalogram (EEG) monitoring was useful in a case in which the patient presented with recurrent seizure-like events . During monitoring, the patient was observed to hold his breath and use his hands to compress his carotid arteries. Within five seconds, this behavior was followed by EEG changes consisting of bursts of generalized polymorphic delta-theta slowing that resolved when the patient returned to a normal breathing pattern.
In cases of death, evaluation of the death scene may provide subtle clues to the mechanism of injury . With the permission of the caregivers, examination of journals, diaries, and computers also may provide important information.
DIFFERENTIAL DIAGNOSIS — The differential diagnosis for children who present with complications related to strangulation activities may include syncope, traumatic asphyxia (intentional or unintentional), seizures, brain tumor, cardiac dysrhythmia, substance use, and suicidality (eg, "practicing" strangulation as a potential suicide method). (See "Causes of syncope in children and adolescents" and "Emergent evaluation of syncope in children and adolescents".)
MANAGEMENT — The management of children and adolescents who engage in strangulation activities depends upon the method of presentation. Acute management for those who are found unconscious may require aggressive resuscitation and treatment of postanoxic brain injury; with such measures, full recovery may be possible [35-40]. Initial treatment is focused on ensuring cerebral oxygenation and lowering increased intracranial pressure . A good response to initial resuscitation is an important prognostic factor for eventual recovery . Stabilization of children with critical injuries is discussed separately. (See "Classification of trauma in children" and "Severe traumatic brain injury in children: Initial evaluation and management" and "Treatment and prognosis of coma in children".)
Psychiatric consultation generally is warranted for children and adolescents who survive near-hanging injuries . Neuropsychiatric evaluation is necessary to assess for possible residual sequelae .
Referral to a mental health provider is also warranted for children and adolescents who engage in solitary strangulation activities and those who appear to be using the activity as a means of self-medication.
Children and adolescents who engage in strangulation activities should be screened for depression and suicidality. Some of them actually may be "rehearsing" for suicide (ie, practicing the method to become more comfortable with using it to kill themselves). (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Screening' and "Suicidal ideation and behavior in children and adolescents: Evaluation and management", section on 'Screening for suicidal ideation'.)
PREVENTION — Until there is better information regarding the epidemiology of strangulation activities (eg, prevalence, risk factors, protective factors), prevention efforts must focus on increasing public awareness of such activities and the very real risk of death when children and adolescents engage in such activities [2,5,23,41].
One suggested intervention involves changing the language that is used to describe and refer to the activity, preferring "strangulation activity" to "playing the choking game" . "Playing the choking game" downplays the risk of complications and death, whereas "strangulation activity" reinforces the message that this is a life-threatening activity. Children and adolescents may be more careful about engaging in a strangulation activity than they would be about playing a game.
We recommend that children and adolescents receive education regarding the dangers of strangulation activities, emphasizing that there is no way to safeguard against serious complications or death. The effectiveness of educational interventions to prevent or reduce participation in strangulation activities has not been well studied. However, counseling interventions have been demonstrated to prevent or reduce other behaviors with health risks (eg, tobacco use during pregnancy, risky sexual behavior) [42-44]. Limited observational data suggest that education through the school system and from parents and peers can increase awareness of strangulation activities and decrease interest in participation [45,46]. In one survey, parents were the most respected source of information for preadolescents, and the victim and/or victim's family was the most respected source of information for older adolescents .
A framework for identifying health risks in adolescents and working with the adolescent to develop a management plan is presented separately. (See "Guidelines for adolescent preventive services", section on 'Strategy for provision of adolescent preventive services'.)
Improved mortality surveillance, with proper attribution of deaths to strangulation activities rather than suicide or unintentional hanging, may help to identify interventions aimed at reducing or eliminating participation in strangulation activity and strangulation activity-related deaths .
Resources — Websites devoted to increasing awareness of strangulation activities include:
The Centers for Disease Control and Prevention's The "Choking Game": CDC's Findings on a Risky Youth Behavior
Games Adolescents Shouldn't Play
SUMMARY AND RECOMMENDATIONS
The "choking game" is defined as self-strangulation or strangulation by another person to produce a euphoric state by reducing cerebral oxygenation. Failure to release pressure before loss of consciousness can result in serious neurologic injury or death, particularly when strangulation activity is performed alone. (See 'The "choking game"' above.)
Deaths resulting from strangulation activities are most common in teenage boys (median age 13 years) who engage in the activity alone. (See 'Epidemiology' above.)
Loss of consciousness may occur within seconds of strangulation, and death may occur within minutes. (See 'Cerebral hypoxia and hypoperfusion' above.)
Presenting complaints of children with less severe episodes of hypoxia whose findings ultimately are attributed to self-induced hypoxia may include confusional episodes, seizure-like events, syncope, paroxysmal episodes of altered awareness, acute visual loss, and neurologic injury. (See 'Presentation' above.)
When considering strangulation activities as the precipitant of asphyxia-related complications, it is critical to take a careful history; it may be necessary to interview siblings, friends, and other associates of the patient. Video-electroencephalographic monitoring may be useful in patients with paroxysmal episodes. (See 'Evaluation' above.)
Children and adolescents who are found unconscious may require aggressive resuscitation and treatment of postanoxic brain injury. With such measures, full recovery may be possible. (See 'Management' above.)
Referral to a mental health provider is warranted for children who engage in strangulation activities. (See 'Management' above.)
We encourage clinicians to educate children and adolescents about the dangers of strangulation activities. The education should stress that there is no way to safeguard against serious complications or death. (See 'Prevention' above.)
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Contributor Disclosures: Nicole J Ullrich, MD, PhD Nothing to disclose. Howard P Goodkin, MD, PhD Consultant/Advisory Boards: Sage Therapeutics [refractory status epilepticus (clinical standardization group)]. Amy B Middleman, MD, MPH, MS Ed Nothing to disclose. Daniel M Lindberg, MD Nothing to disclose. Marc C Patterson, MD, FRACP Grant/Research/Clinical Trial Support: Vtesse [Niemann-Pick C (Cyclodextrin)]. Consultant/Advisory Boards: Actelion [Niemann-Pick C (Miglustat)]; Agios [CGD]; Alexion [General lysosomal diseases, lysosomal acid lipase deficiency (Sebelipase alfa)]; Amicus [Fabry, Gaucher, Pompe (Migalastat)]; Novartis [MS]; Shire [MLD]. Other Financial Interest: Sage [Honorarium as Editor-in-Chief of Journal of Child Neurology and Child Neurology Open]. Mary M Torchia, MD Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.