By Morgan Wharton
Updated January 2013
Destructive behaviors typically practiced by adolescents and teenagers are also being adopted by children at an increasingly young age. Specifically, teens and children are choosing to harm themselves through cutting, biting, and asphyxiation techniques like the “choking game,” despite the many potential risks and consequences.
Non-suicidal self-injury (NSSI) is a dangerous behavior of children and teenagers who harm themselves without intending to commit suicide. The most common form of self-injury is cutting; other forms include self-inflicted burns, bites, hair-pulling, and hitting. Overall, 15-25% of teenagers have reported non-suicidal cutting behavior. In addition to teenagers, self-harm has been reported in 8% of third graders (ages 8 and 9).1 One study surveyed one hundred and ninety-six patients under the age of 6 who were referred for neurodevelopmental evaluations at a pediatric clinic. Thirty-two percent of the children surveyed had harmed themselves within the past month. The frequency of self-harm varied from less than once per month, to more than once per hour; 1 to 6 times per week was the most frequently reported interval of self-harm. Girls are at a much higher risk of cutting behaviors, up to three times as high as that of young boys.1
Teens with a parent who died of cancer are much more likely to deliberately injure themselves than adolescents whose parents haven’t died, especially if they are girls. A study published in 2012 found that 29% of teenage girls who had lost a parent to cancer harmed themselves after their parent’s death, compared with 15% of girls who hadn’t experienced that trauma. (Only 10% of boys whose parents had died practiced self-injury as compared with 7% of boys who hadn’t lost a parent to cancer).
The Choking Game
The choking game, which also has many nicknames including “Space Monkey” and the “Pass Out Game” consists of restricting blood flow to the brain by squeezing or applying pressure to the neck.4,, Once the pressure is released and the blood and oxygen reenter the brain, the individual experiences a high. This activity can be self-inflicted using a belt, rope, or scarf, or another individual can manually apply pressure.6 Between 5 and 10 percent of the U.S. population has participated in the choking game; males and females practice these choking techniques at equal rates.6,7
The choking game had been labeled the “good kids’ drug” because most of the publicized deaths from the game occurred in high-achieving children.2,6 However, studies have indicated that this game is actually more common among children who use alcohol, tobacco, and other drugs, and who engage in sexual activity.6 In middle school, the kids most likely to play the choking game are those who use controlled substances and get failing grades. In high school, the teens most likely to engage in this risky behavior are the ones who use substances, have attempted suicide, or have experienced sexual assault.4 Females who responded on a survey that they had poor nutrition and males who responded that they had been exposed to violence were also more likely to participate in the choking game.6
What’s at Stake?
It is crucial to spot NSSI, including participation in the choking game, and work to stop the behaviors. Each activity has potentially serious consequences, including death. According to the Centers for Disease Control and Prevention (CDC), children can lose consciousness from the choking game within seconds and can damage their brain and central nervous system after just three minutes., The choking game caused at least 82 deaths of youth ages 6 to 19 between 1995 and 2007.6,7 These deaths were calculated solely from media reports of choking-game related deaths, so the actual number is believed to be much higher, possibly as high as 444 deaths.6,
Kids who have a history of NSSIbehaviors are at higher risk for attempting suicide and for carrying it out successfully. Additionally,NSSI behaviors are associated with increased rates of eating disorders and the use of alcohol, tobacco and other drugs, all of which can have a devastating effect on health in the course of a lifetime.2 The choking game is considered a gateway activity, meaning that kids start with it and move on to more dangerous and risky activities, including drug use and sexual activity.7
How to Prevent Self-Harm and Asphyxiation Behaviors in Children and Identify Them Once Children Have Started
Parents, caretakers and physicians can take several steps to prevent and identifyNSSIand self-choking.
Parents and other caregivers (including teachers) should be on the look-out for evidence of self-harm on a child or teen’s skin. Sixty-nine percent of people who engage in self-harm do so by two or more methods, including cutting, burning, biting, and stabbing. Multiple types of wounds, combined with symptoms of depression, strongly suggest self-injury.10
Physicians can also play an important role in spotting self-injury through physical examinations and attention to reports of pain that may be the result of self-inflicted injuries. Because children and teenagers are more likely to report instances of self-harm to family and friends than physicians, communication between all parties is a necessary and integral part of identifying NSSIbehavior.10
Physical evidence is the best way to determine if children or teens have been playing the choking game. A lot of little purple spots, usually on the neck or eyelids, called petechiae indicate hemorrhaging caused by the choking game.6 Other physical signs of choking include neck lacerations, unexplained headaches, and disorientation or confusion after time spent alone.7 Ninety-four percent of youth who partake in the choking game participate with friends, so if you see these warning signs in your son or daughter’s friends, you should be concerned that perhaps your child is also engaging in this behavior.4
Unfortunately, many doctors and pediatricians are not aware of how widespread these practices are or how to tell if kids are involved in them. Less than 2% of doctors discuss the dangers of the choking game with children before it starts.4 Nearly 1/3 of doctors who responded to a survey were unfamiliar with the choking game and its warning signs. Of those who acknowledged an awareness of the choking game, almost 1/4 could not identify a single warning sign, and only 53% could identify three or more. Doctors who interact with children should be aware of asphyxiation behaviors, warning signs, and consequences in order to educate patients and spot the signs before children get hurt or start engaging in even riskier behavior. In addition to educating themselves and patients, doctors and other health professionals should educate school officials and other adults who are in frequent contact with children and teenagers.4
When discussing the dangers of self-induced choking with youth, it helps to refer to it as a “strangulation activity” rather than a “game.” It’s fine to call it what the kids call it at the outset to make sure they understand what you are talking about but then the language needs to become less conversational to drive home how serious an issue this is and just how harmful these practices can be.5,6
Monitoring the internet and, specifically, the YouTube activity of your children can alert you to their interest in these practices. YouTube contains more than five thousand videos of self-injury and self-harm. Based on the one hundred most viewed videos involving some form of self-harming, 80% were available with no viewer restrictions, and 28% showed a live act of self-harm. Although some of the videos contained neutral content, others seemed to promote self-injury by describing novel ways of harming oneself, as well as alternative methods to conceal that harm. YouTube is an important and influential source of information for youth, and adolescents who engage in self-harm are more likely to use social networking, such as YouTube, than adolescents who do not practice NSSI.
YouTube has also been found to contribute to normalizing the choking game, making it seem like a fun activity that most teens try at some point.9,12 A study found 65 videos of the choking game on YouTube, showing children and teenagers participating in the choking game both alone and in pairs. Frequently, the participants remarked on the pleasurable sensations experienced after regaining consciousness.9 These “testimonials” may encourage more youth to try the choking game. Some have proposed that YouTube should create an automatic response, providing links to hotlines and other resources along with the link, similar to what Google provides for suicide-related searches.12
The Bottom Line
Parents and other adults who play an important role in the life of a child or teen should be on the look-out for and know how to identify signs of self-injury and participation in the choking game. Parents, caretakers, and physicians can all take an active role in the identification and prevention of these behaviors through increased vigilance and speaking with your child or teen before they engage in these behaviors. If your child is playing the choking game or self-harming, be sure to discuss the serious consequences and risks of the behaviors. In the case of the choking game, it is best to notify school personnel because classmates are likely playing the game as well. Parents should also closely monitor your child’s future interactions with friends for signs of the choking game.4 Keep scarves, belts, ropes and other materials that could be used for the choking game away and sharp objects that could be used for self-injury away from your child. Finally, children and teenagers who self-injury or engage in the choking game should also see a physician and a mental health professional to address bodily harm and possible depression or other psychiatric disorders.10
 Smith, M. Study shows even little kids can be cutters. MedPage Today. 2012
 Brausch, AM, Decker, KM, Hadley, AG. Risk of suicidal ideation in adolescents with both self-asphyxial risk-taking behavior and non-suicidal self-injury. Suicide and Life-Threatening Behavior. 2011; 41: 424-434.
 MacLean, JWE, Tervo, RC, Hoch, J, Tervo, M, Symons, FJ. Self-injury among a cohort of young children at risk for intellectual and developmental disabilities. Journal of Pediatrics. 2010; 157: 979-983.
 Grenklo, TB, Kreicbergs, U, Hauksdóttir, A, et al. Self-injury in teenagers who lost a parent to cancer: A nationwide, population-based, long-term follow-up. Archives of Pediatrics & Adolescent Medicine. 2012; ():1-8. doi:10.1001/jamapediatrics.2013.430.
 Katz, KA, Toblin, RL. Language matters: Unintentional strangulation, strangulation activity, and the “choking game”. Archives of Pediatrics & Adolescent Medicine. 2009; 163: 93-94.
 Ramowski, SK, Nystrom, RJ, Rosenberg, KD, Gilchrist, J, Chaumeton, NR. Health risks of Oregon eighth-grade participants in the “choking game” Results from a population-based survey. Pediatrics. 2012; 129: 846-851.
 HealthDay. Young risk-takers drawn to dangerous ‘choking game’. Available at: http://consumer.healthday.com/Article.asp?AID=663736. Accessibility verifiedJanuary 16, 2013.
 Centers for Disease Control and Prevention. Research update the choking game: CDC’s findings on a risky youth behavior. Available at: http://www.cdc.gov/homeandrecreationalsafety/Choking/choking_game.html. Accessibility verifiedJanuary 16, 2013.
 Linkletter, M, Gordon, K, Dooley, J. The choking game and YouTube: A dangerous combination. Clinical Pediatrics. 2010; 49: 274-279.
 Kerr, PL, Muehlenkamp, JJ, Turner, JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. Journal of the American Board of Family Medicine. 2010; 23: 240-259.
 McClave, JL, Russell, PJ, Lyren, A, O’Riordan, MA, Bass, NE. The choking game: Physician perspectives. Pediatrics. 2010; 125: 82-87.
 Lewis, SP, Heath, NL, St. Denis, JM, Noble, R. The scope of nonsuicidal self-injury on YouTube. Pediatrics. 2011; 127: 552-557.