The Choking Game: Physician Perspectives
Thrill-seeking or risk-taking behavior among adolescents has long contributed to morbidity and death in this
age group.1 Reports in the popular media have brought increased attention to a dangerous activity among adolescents known
as the "choking game," among other names. In this activity, participants attempt to gain a "high" or euphoric feeling by temporarily
depriving the brain of oxygen.
This is achieved through pressure applied to the neck by another person's hands or with belts, neckties, or
other ligatures. Alternatively, the activity may entail one person taking a deep breath and holding it, while a second person
hugs that person from behind until the first person feels dizzy and passes out.3 Those who participate in this activity often
describe an additional pleasurable sensation with the rapid outflow of previously impeded deoxygenated blood from the brain
when pressure is released.
The choking game can be played in groups or alone, and participants often are between 7 and 21 years of age.
This activity becomes life-threatening when the victim is alone, loses consciousness, and cannot release the ligature.
Several case studies documented death or near-death in adolescents,often boys, who were found unconscious and
later identified by family or friends as having played the choking game.Attempting to publicize the risks associated with
the choking game, advocacy groups have compiled lists of parent-reported choking game-related deaths and have identified 100
deaths per year between 2005 and 2007.A recent report from the Centers for Disease Control and Prevention used reports in
the media to estimate 82 probable choking game-related deaths from 1995 to 2007.8 Aside from the lethal dangers of asphyxiation,
case studies of individuals suspected of participating in the choking game have shown nonfatal injuries such as seizures,
headaches, fractures, and brain injury ranging from subtle cognitive impairment to persistent vegetative state.The full extent
of the injuries and deaths caused by the choking game is likely underrepresented by these accounts, because many of the cases
are never reported or may be misclassified as suicides.
A variety of warning signs suggest that an adolescent may be participating in the choking game. These
signs include headaches, unexplained bruising around the neck, bloodshot eyes,facial petechiae, disorientation after being
alone, ligatures tied in strange knots or in unusual places, and wear marks on furniture.Local and state agencies have issued
warnings to schools and law enforcement agencies describing these signs, in an attempt to educate teachers and parents regarding
this deadly game.
Several case studies and editorials called for preventative measures by educators, physicians, and others who
care for adolescents. Physicians are in a unique position to recognize these subtle signs of
self-inflicted asphyxiation and to provide timely guidance on the dangers of such activity to both adolescent patients and
their parents. Relatively little published literature documents the choking game and the extent of physician awareness and
knowledge of the activity. For physicians caring for adolescents, providing effective, timely, current anticipatory guidance
is an important goal of all patient encounters.
Despite the emergence of the choking game as a serious threat to adolescent health, counseling for adolescents
and their parents regarding the dangers and warning signs of the choking game is not currently listed by the American Academy
of Pediatrics (AAP) as a recommended topic for adolescent anticipatory guidance. Therefore, this study aims to assess the
knowledge of this game among pediatricians and family practitioners who care for adolescents and to explore their opinions
regarding inclusion of the dangers of the choking game in anticipatory guidance for their adolescent patients.
WHAT'S KNOWN ON THIS SUBJECT: Reports in the popular media and case reports have described the choking game
activity and its consequences. The incidence of the activity has been described.
WHAT THIS STUDY ADDS: We report on physician awareness of the choking game and opinions on including discussion
of its dangers in anticipatory guidance for adolescents.
OBJECTIVE: The goal was to assess awareness of the choking game among physicians who care for adolescents and
to explore their opinions regarding its inclusion in anticipatory guidance.
METHODS: We surveyed 865 pediatricians and family practitioners. The survey was designed to assess physicians'
awareness of the choking game and its warning signs, the suspected prevalence of patients' participation in the activity,
and the willingness of physicians to include the choking game in adolescent anticipatory guidance. Information on the general
use of anticipatory guidance also was collected.
RESULTS: The survey was completed by 163 physicians (response rate: 21.8%). One-hundred eleven (68.1%) had heard
of the choking game, 68 of them (61.3%) through sources in the popular media. General pediatricians were significantly more
likely to report being aware of the choking game than were family practitioners or pediatric subspecialists
Of physicians who were aware of the choking game, 75.7% identified warning sign and 52.3% identified. 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 unaware of the choking game, a potentially life-threatening
activity practiced 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 adolescent patients, pediatricians
and family practitioners should be knowledgable about risky behaviors encountered by their patients, including the choking
game, and provide timely guidance about its dangers.
AUTHORS: Julie L. McClave, MD,a Patricia J. Russell, MD,b
Anne Lyren, MD, MSc,c,d Mary Ann O'Riordan, MS,e and Nancy E. Bass, Mdf aSchool of
Medicine, and dDepartment of Bioethics, Case Western Reserve University,Cleveland, Ohio;
bMultiCare Health System, Tacoma, Washington; and Divisions of cGeneral
Academic Pediatrics, ePediatric Pharmacology and Critical Care, and fChild Neurology,
Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
This work was presented at the American Academy of Pediatrics National Conference; October
13, 2008; Boston, MA.75). Copyright Š 2009 by the American Academy of Pediatrics FINANCIAL
DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.