Center for Injury Research and Prevention

The Choking Game- Assessing the Risks

November 29, 2016

The choking game is described as an activity where the participant applies pressure to the carotid artery with fingers or a tie to temporarily stop blood flow and then releases the pressure and restores blood and oxygen flow to the brain, resulting in a euphoric sensation. When performed alone, the risk of death increases- in fact, more than 95 percent of deaths from the choking game occurred when the participant was alone.

However, it is difficult to know just how frequently youth engage in this behavior. Some studies suggest a lifetime prevalence of between 5 to 10 percent  among youths, but deaths due to the choking game may be misclassified as suicides or accidental deaths, which adds to the challenge of accurate measurement. Other studies suggest that certain youths may be at higher risk for participating, including those who engage in substance use, poor mental health, violence, early onset sexual activity, and a thrill-seeking personality.

Given the low awareness of the risks of the choking game among parents and providers (a previous study suggests up to one-third of pediatricians and family physicians are unaware of the game), and knowing that most of the deaths occur when youths engage in the activity while alone, this recent study published in Pediatrics sought to compare characteristics of youth who reported participating in the choking game while alone versus in a group.

This study analyzed data from the Oregon Healthy Teens survey, which includes questions about the prevalence and mode of participation in the choking game for 8th graders from all Oregon public secondary schools.

Over 19,000 students answered the question about participation in the choking game in 2011 and 2013. Of the 93 percent of students who answered the question on choking game participation:

  • 3.8 percent responded that they had participated in the choking game in 2011 (relatively unchanged at 3.7 percent in 2013).
  • In 2011, 22.7 percent of students reported hearing of someone else participating in the choking game (17.2 percent in 2013).
  • Of the 727 students who reported participation in the choking game in 2011 and 2013, 17.6 percent reported engaging in the activity while alone.
  • After adjusting for geographic location and gender, solitary participation in the choking game was significantly associated with suicidal ideation (“considered suicide in the past 12 months”) and “fair or poor mental health status”.

The study authors are careful to mention that the participation in the choking game itself may not necessarily be a suicidal attempt, but rather a way to decrease psychological pain or distress. The questions about the choking game on the survey were not tested for reliability or validity, and the generalizability of the study is limited given that it was performed in Oregon only.

Despite the limitations, however, this study does make me think about how to adjust my own practice. My takeaways:

  • A teen who participates in the activity (especially alone) may be experiencing poor mental health and may require screening for suicidal ideation.
  • A teen who is known to be at risk for suicidal thoughts should be counseled that participating in the activity alone is associated with a much higher mortality rate. Engaging while alone means that there is no one to stop the strangulation, especially since there is a higher risk for loss of consciousness.
  • We clinicians need to be more aware of these dangerous fads. Read here for tips on keeping social media dialogue open with our teens. 

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