Self strangulation by hanging from cloth towel dispensers in Canadian schools

Online extreme challenges putting children at risk: what we know to date

INTRODUCTION

Extreme online challenges consist in taking part in challenges proposed on web and sharing the results in videos posted on social media. The use of social networks is widespread among the very young, giving easy access to potentially dangerous content with consequences on health.

EVIDENCE ACQUISITION

The aim of this literature review was to describe the most common challenges involving children and adolescents over the last 20 years. We focused on participants features (such as age, sex and psychological background) and health implications. The review included research articles and reviews published between 2000 and 2021. We used Pubmed, Scopus and Web of science as search engines.

EVIDENCE SYNTHESIS

Many types of online challenges emerged from the analysis of the literature. The most common challenges are those that lead to self-harm, which involve acts at risk of choking and challenges that potentially lead to suicide and ingestion of substances. The extreme challenge phenomenon is a public health issue that affects a vulnerable population, as it is young and susceptible to peer pressure influence. Participants often showed problematic personality traits, making them more likely to get involved in these behaviors.

CONCLUSIONS

It is necessary for parents, teachers and health workers to be aware of the spread of the online challenges, to improve prevention interventions in the age groups involved.

Temperament and character profiles of adolescent participants in the choking game

OBJECTIVE

The role of personality traits in self-asphyxial behaviors remains largely unexplored. The aim of this study was to explore temperament and character profiles of youth reporting participation in the choking game using Cloninger's biopsychosocial model of personality.

METHODS

Data were collected among French middle-school students (N=1771) aged 9-16 years (mean age=13.0, SD=1.3) and randomly selected from 13 public establishments located in different regions of France. Logistic regression models were run to identify Cloninger's temperamental and character dimensions associated with engagement in the choking game.

RESULTS

Descriptive analysis revealed that participants showed high scores of novelty-seeking (Cohen's d=0.293, p<0.001) and low levels of cooperativeness (Cohen's d=0.182, p<0.01), persistence (Cohen's d=0.182, p<0.05), and reward dependence (Cohen's d=0.241, p<0.01). However, multivariate modeling indicated that only the novelty-seeking dimension tended to slightly differentiate participants from non-participants within the global sample (OR=1.03, 95% CI: 1-1.06). When we compared girls and boys, we found a slight trend in association only in boys (OR=1.04, 95% CI: 1-1.08).

CONCLUSIONS

Our study, which contributes to the growing literature on the psychological correlates of choking activities and is the first to investigate the potential predictive role of personality traits in this risky behavior, suggests to some extent that (a) the choking game could possibly be influenced by some temperamental characteristics, and that (b) it might not have the same function according to the gender considered.

Does intentional asphyxiation by strangulation have addictive properties?

BACKGROUND AND AIMS

Intentional asphyxiation leads to cerebral hypoxia, starving the brain of oxygen and inducing hypoxic euphoria, but carries a serious risk of accidental death, especially if practised alone. This article raises the question as to whether it could usefully be regarded as having addictive properties.

METHODS AND RESULTS

A review of the literature, together with eight case study vignettes, are presented. Intentional asphyxiation can occur with or without sexual activity. Initiation often occurs in adolescence, with development in some cases of an entrenched behaviour pattern, driven by a strong euphoriant effect, without adequate safeguarding from serious harm, and being undertaken by people with comorbidities. There does not appear to be strong evidence of seeking support for cessation of the practice.

CONCLUSIONS

Intentional asphyxiation behaviours may have addictive properties, and understanding this aspect of the problem may be fruitful in guiding research and interventions aimed at addressing it.

Accidental hanging injuries in children: recognition and management

Accidental hanging is rare in childhood but is often fatal. Window blind cords pose a particular and unique risk to young children in the UK, accounting for one to two deaths annually. These accidents are frequently associated with non-adherence to the safety instructions provided by the manufacturers. Early discovery of the child and initiation of effective cardiopulmonary resuscitation at the site of the incident are likely to improve the outcome. Prolonged suspension, children who are pulseless at first contact by the emergency paramedic responder, and patients with prolonged periods of remaining in asystole before return of spontaneous circulation after starting cardiopulmonary resuscitation are unlikely to have intact neurological survival. Management in the hospital includes early airway protection by intubation, maintenance of normal oxygen saturation, normothermia, active control of clinical and sub-clinical seizures, and strict electrolyte and glucose regulation. Child safeguarding concerns should be considered when children have asphyxial injuries, and other signs of child physical abuse should be actively looked for. There is a need for stronger legislation in the UK to prevent some of these accidents, especially those relating to window blind cords.

Adolescent Mental Health and the Choking Game

OBJECTIVES

To examine the demographic and health risk factors associated with participation in the choking game (CG), a dangerous and potentially fatal strangulation activity in which pressure is applied to the carotid artery to temporarily limit blood flow and oxygen.

METHODS

We obtained data from 2 cross-sectional studies realized respectively in 2009 and 2013 among French middle school students. The 2009 (n = 746) and 2013 (n = 1025) data sets were merged (N = 1771), and multivariate modeling was conducted to examine demographic and clinical characteristics of youth reporting a lifetime participation in the CG. The 2 studies included questions about risk-taking behaviors and substance use, and standardized assessments were used to collect conduct disorder symptoms and depressive symptoms.

RESULTS

In the merged 2009 and 2013 data set, the lifetime prevalence of CG participation was 9.7%, with no statistically significant differences between boys and girls. A multivariate logistic regression revealed that higher levels of conduct disorder symptoms (odds ratio: 2.33; P < .001) and greater rates of depressive symptoms (odds ratio: 2.18; P < .001) were both significantly associated with an increased likelihood of reporting CG participation.

CONCLUSIONS

The significant relationship between elevated levels of depressive symptoms and participation in the CG sheds new light on the function of self-asphyxial activities. However, with the finding that higher rates of conduct disorder symptoms were the most important predictor of CG participation, it is suggested that the profile and the underlying motivations of youth who engage in this activity should be reexamined.

The Choking Game on YouTube: An Update

The choking game (TCG) is an adolescent activity in which asphyxiation is used to obtain a “high,” occasionally resulting in seizures or death. A plethora of TCG information is available through YouTube, though this content has not been evaluated recently. The current study described TCG as portrayed in YouTube videos and compared views and ratings of TCG videos to unrelated videos. The TCG videos demonstrated diverse methods of asphyxiation, with a minority showing injury to the participants. TCG videos were less likely to be commented on or rated positively than non–choking game videos. TCG prevention videos differed significantly from actual TCG videos in the way they depicted the social context of TCG. Thus, TCG videos are accessible through YouTube, but the prevention materials available on YouTube are not accurate or representative. Accurate and educational online prevention materials should be created to decrease the occurrence of TCG.

[Choking games among 2nd and 3rd graders]

It is suspected that elementary school age children engage in "the choking game" or other asphyxial practices, but the prevalence is unknown.

OBJECTIVE

This study was conducted to determine the prevalence among 2nd and 3rd graders.

METHODS

Twenty-five schools in a region in Southeastern France were sampled on the following criteria: school size, rural/urban location, underprivileged neighborhood or not, and private/public school. Second and third grade classes were randomly sampled in each school. Another sample of 25 schools was selected in case a school refused to participate. A self-administered questionnaire, previously validated in two nonsampled schools, was administered in selected classes by the pediatrician leading the project.

RESULTS

A total of 1125 questionnaires were distributed and 95% were completed. The mean (SD) age of children was 8.3 (0.7) years. Forty percent of children reported they had already played choking games. Among all the declared players (n=401), the male to female ratio was 1.4; 13% of them played this game every day or several times a day (91% were male). This prevalence varied between schools (16-75%) and games and was significantly higher among children schooled in underprivileged neighborhoods. Seventy-six percent of non-players and 48% of players were aware of the potential life-threatening risk.

CONCLUSIONS

The mean prevalence in elementary school (40%) appears to be higher compared to middle and high schools (5-10%). Motivation differs in elementary school children compared to older children and teenagers. Prevention of choking games should start at elementary school and determinants leading to the continuation of such practices from elementary school to high school need to be explored.

Prevalence and associated harm of engagement in self-asphyxial behaviours ('choking game') in young people: a systematic review

OBJECTIVE

To assess the prevalence of engagement in self-asphyxial (risk-taking) behaviour (SAB) ('choking game') and associated morbidity and mortality in children and young people up to age 20.

DESIGN

Systematic literature review.

SEARCH STRATEGY

Electronic database search of MEDLINE, Embase, PsycINFO, CINAHL, PubMed, Web of Science Core Collection, BIOSIS citation index and the Cochrane register with no language or date limits applied. References of key papers were reviewed, and experts were contacted to identify additional relevant papers.

ELIGIBILITY CRITERIA

Systematic reviews, cross-sectional, cohort and case-control studies, and case reports examining SAB with regard to individuals aged 0-20 years, without explicitly stated autoerotic, suicidal or self-harm intentions were included.

RESULTS

Thirty-six relevant studies were identified, and SAB was reported in 10 countries. In North America, France and Colombia, awareness of SAB ranged from 36% to 91% across studies/settings, and the median lifetime prevalence of engagement in SAB was 7.4%. Six studies identified the potential for SAB to be associated with engagement in other risk behaviours. Ninety-nine fatal cases were reported. Of the 24 cases described in detail, most occurred when individuals engaged in SAB alone and used a ligature.

CONCLUSIONS

The current evidence on SAB among young people is limited, and stems predominantly from North America and France. Awareness of SAB among young people is high, and engagement varies by setting. Further research is needed to understand the level of risk and harm associated with SAB, and to determine the appropriate public health response.

Deaths due to hanging among adolescents - A 10-year retrospective study

The present study was carried out to analyze various factors associated with death due to hanging among adolescents and to identify the areas of intervention for preventing such deaths. A retrospective study was carried out on 51 cases of adolescent deaths due to hanging, the autopsies of which were conducted by the Department of Forensic Medicine, Dr Shankarrao Chavan Government Medical College, Nanded, Maharashtra State (India), during the period between 1 January 2001 and 31 December 2010. In the present study, death by hanging among the adolescent age group was most commonly suicidal (96.08%) in nature, and only two (3.92%) cases of deaths due to accidental hanging were observed. Of the total number of suicidal deaths due to hanging among adolescents, the majority (80.39%) were among the older adolescent (15-19 years) age group. Rope and clothing items were commonly used ligature materials for committing suicide by hanging. Females outnumbered male victims (M:F ratio 1:1.13) among adolescents, contrary to the male preponderance observed among victims of the older age group (M:F ratio 1:0.44). Most of the suicidal deaths due to hanging (83.67%) among adolescents were observed at the victims' home. The predisposing and precipitating factors observed were domestic strife, examination-related stress, and physical and psychological illness.

The choking game: a risky behavior for youth

Nurses working with children and adolescents should be cognizant of choking games, risky acts in which pressure is applied to the neck and the airway is obstructed to achieve a high. Evidence supports that many children and adolescents do not understand the grave consequences of choking games nor do they view participation as dangerous. Parents, teachers, pediatricians, nurses, and psychiatric-mental health professionals are not always aware that children and adolescents are engaging in choking games. The purpose of this article is to describe the signs, changes over the years, consequences, and educational resources available for addressing this behavior in children and adolescents. Understanding the nomenclature of choking games, how to assess, and how to intervene when participation in this behavior is suspected are also addressed.

Accidental mechanical asphyxia of children in Germany between 2000 and 2008

Accidents constitute one of the greatest risks to children, yet there are few medical reports that discuss the subject of accidental asphyxia. However, a systematic analysis of all documented cases in Germany over the years 2000-2008 has now been conducted, aiming at identifying patterns of accidental asphyxia, deducing findings, defining avoidance measures and recommending ways of increasing product safety and taking possible precautions. The analysis is based on a detailed retrospective analysis of all 91 relevant autopsy reports from 24 different German forensic institutes. A variety of demographic and morphological data was systematically collected and analysed. In 84 of the 91 cases, the sex of the victim was reported, resulting in a total of 57 boys (68 %) and 27 girls (32 %). The age spread ranged between 1 day and 14 years, with an average of 5.9 years. Most accidents occurred in the first year of life (20 %) or between the ages of 1 and 2 years (13 %). In 46 % of cases, the cause of death was strangulation, with the majority occurring in the home environment. In 31 % of all cases, the cause of death was positional asphyxia, the majority resulting from chest compression. In 23 % of cases, the cause of death was aspiration, mainly of foreign bodies. Today, accidental asphyxiation is a rare cause of death in children in Germany. Nevertheless, the majority of cases could have been avoided. Future incidence can be reduced by implementing two major precautions: increasing product safety and educating parents of potentially fatal risks. Specific recommendations relate to children's beds, toys and food.

Health risks of Oregon eighth-grade participants in the "choking game": results from a population-based survey

OBJECTIVE

To examine the risk behaviors associated with participation in the "choking game" by eighth-graders in Oregon.

METHODS

We obtained data from the 2009 Oregon Healthy Teens survey, a cross-sectional weighted survey of 5348 eighth-graders that questioned lifetime prevalence and frequency of choking game participation. The survey also included questions about physical and mental health, gambling, sexual activity, nutrition, physical activity/body image, exposure to violence, and substance use.

RESULTS

Lifetime prevalence of choking game participation was 6.1% for Oregon eighth-graders, with no differences between males and females. Of the eighth-grade choking game participants, 64% had engaged in the activity more than once and 26.6% >5 times. Among males, black youth were more likely to participate than white youth. Among both females and males, Pacific Islander youth were much more likely to participate than white youth. Multivariate logistic regression revealed that sexual activity and substance use were significantly associated with choking game participation for both males and females.

CONCLUSIONS

At >6%, the prevalence of choking game participation among Oregon youth is consistent with previous findings. However, we found that most of those who participate will put themselves at risk more than once. Participants also have other associated health risk behaviors. The comprehensive adolescent well visit, as recommended by the American Academy of Pediatrics, is a good opportunity for providers to conduct a health behavior risk assessment and, if appropriate, discuss the dangers of engaging in this activity.

Prevention of the Choking Game: parent perspectives

Background:

Many preadolescents and adolescents have been reported to take part in forced asphyxiation as a means of creating a feeling of being high without taking drugs. This activity goes by different names, including the Choking Game, Blackout, and Space Monkey. The limited epidemiological data suggest that about 6-11% of adolescents report having engaged in this behavior.

Methods:

This study surveyed a predominantly Caucasian cohort of parents regarding their knowledge of the choking game and its associated risks, as well as their attitudes toward possible prevention efforts.

Results:

Three quarters of parents responding reported being familiar with the choking game but considerably fewer (20%) reported having talked to their children about this activity. Ninety-six percent of parents reported knowing that unintentional death was a potential risk and ninety percent believe information about this activity should be included in school health curricula.

Conclusion:

Parents of adolescents in the United States appear to be quite knowledgeable about the Choking Game and its potential risks and are overwhelmingly supportive of prevention measures. The parents surveyed understood the importance of preventing children from engaging in the Choking Game, but may need specific help in how to talk to their children about it. Further work is needed to confirm that the proportion of parents identified as aware of this risk taking behavior is consistent across other populations and to urgently identify effective prevention efforts that can be integrated into existing health curricula.

Polydrug use and attempted suicide among Hispanic adolescents in Puerto Rico

This study was aimed at examining the relationship between suicidal attempts, polydrug use, and depression in adolescents. A sample of 691 adolescents and their parents were interviewed. Subjects who met the criteria for depression and those who used alcohol were significantly more likely to be suicidal attempters (OR = 6.8, p < 0.001; OR = 7.5, p < 0.001). Polydrug users were significantly more likely to attempt suicide (OR = 8.8, p = 0.032). Adolescents with mothers who met the criteria for depression were more likely to report suicide attempts (OR = 2.4, p = 0.069). Health professionals need to screen for polydrug use and depression to prevent future suicidal behaviors.

The choking game and YouTube: a dangerous combination

PURPOSE

To study postings of partial asphyxiation by adolescents on YouTube and to increase awareness of this dangerous activity as well as the value of YouTube as a research tool.

METHODS

Videos were searched on YouTube using many terms for recreational partial asphyxiation. Data were gathered on the participants and on the occurrence of hypoxic seizure.

RESULTS

Sixty-five videos of the asphyxiation game were identified. Most (90%) participants were male. A variety of techniques were used. Hypoxic seizures were witnessed in 55% of videos, but occurred in 88% of videos that employed the "sleeper hold" technique. The videos were collectively viewed 173550 times on YouTube.

CONCLUSIONS

YouTube has enabled millions of young people to watch videos of the "choking game" and other dangerous activities. Seeing videos may normalize the behavior among adolescents. Increased awareness of this activity may prevent some youths from participating and potentially harming themselves or others.

The choking game: physician perspectives

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 (P = .004). Of physicians who were aware of the choking game, 75.7% identified >or=1 warning sign and 52.3% identified >or=3. 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 knowledgeable about risky behaviors encountered by their patients, including the choking game, and provide timely guidance about its dangers.

Extensive petechiae in attempted self-strangulation

A 29-year-old Korean man reported to have been robbed, bound, and gagged by a stranger in his apartment. Clinical findings included extensive petechiae to his face and tramline patterned abrasions and ligature furrows to his neck and face as well as his wrists. Initially, no other leads in the investigation existed and a robbery was assumed to have taken place. The man eventually confessed to fabricating the story and to having self-induced the ligature marks by subluxating his jaw at the temporomandibular joint and hooking the rope closest to the back of his neck on the corner of table. The man demonstrated this unsuspected ability to law enforcement officers. As a motive for his unconventional behavior, he confessed to engaging in autoaggressive behavior as punishment for "losing face" after his ex-girlfriend terminated her pregnancy. This case demonstrates that petechiae due to neck compression also may occur in the living and are due to vascular compression and not lethal hypoxia.

Unintentional strangulation deaths from the "choking game" among youths aged 6-19 years - United States, 1995-2007

The "choking game" is defined as self-strangulation or strangulation by another person with the hands or a noose to achieve a brief euphoric state caused by cerebral hypoxia. Participants in this activity typically are youths (Andrew & Fallon, 2007). Serious neurologic injury or death can result from engaging in this activity. Recent news media reports have described numerous deaths among youths attributed to the choking game. Because no traditional public health dataset collects data on this practice, CDC used news media reports to estimate the incidence of deaths from the choking game. This report describes the results of that analysis, which identified 82 probable choking-game deaths among youths aged 6-19 years during 1995-2007. Seventy-one (86.6%) of the decedents were male, and the mean age was 13.3 years. Parents, educators, and health-care providers should become familiar with warning signs that youths are playing the choking game (Urkin & Merrick, 2006). Impact of industry: By learning about the risk factors for and warning signs of the choking game, parents, educators, and health-care providers may be able to identify youth at risk for playing the game and prevent future deaths.

"The choking game": self-induced hypoxia presenting as recurrent seizurelike events

Risk-taking behavior resulting in accidental injury is common in adolescence. Self-induced hypoxia as a means of self-stimulation, sometimes referred to as "the choking game," has recently become more widely recognized, particularly with a series of well-publicized deaths in teenagers and with wider visibility on national news and Internet sites. We report a case of self-induced hypoxia via carotid compression and breath holding that presented as recurrent confusional episodes and seizurelike events. Video/EEG monitoring was a useful tool in elucidating the neurological effects of the "game," which may result in prolonged neurological injury or life-threatening outcome.

The psychological autopsy: solving the mysteries of death

The psychological autopsy is an important assessment tool used to identify aspects of a person's life that explain any lingering mystery that shrouds their death. In addition to answering questions of the past, the psychological autopsy has significant implications for the future. Statistics obtained from mortality data affect the course of health care research, the flow of resources, and ultimately public health policy. From a public health perspective, the misclassification of suicides as accidents or deaths from natural causes can negatively affect research funding and policy development related to suicide prevention efforts, making a standardized and accurate procedure imperative. Although the psychological autopsy was developed initially as a tool to assist the coroner in clarifying the cause of death, this procedure has transcended the confines of forensic science and has applications in the many arenas of litigation and public health policy.