Teens who participate the "choking game" alone are at higher risk of suicidal thoughts than teens who participate in a group setting, found research released online today in Pediatrics.

Also known as knock out, space monkey, flatling or the fainting game, the choking game involves placing pressure using the hands or fingers, or an object such as a belt or tie to the carotid artery to temporarily limit blood flow and oxygen. The goal is to achieve a euphoric feeling once the flow of oxygen and blood is restored to the brain. The game puts teens at great risk for injury or death, particularly if they participate alone.

Researchers examined data from the 2011 and 2013 Oregon Healthy Teens Survey. They compared responses from teens who reported engaging in the choking game in group settings with those who participated alone. They found that among nearly 21,000 8th grade students in the study, 3.7 percent had participated in the choking game, and 18 percent of those participated alone. Adjusting for gender and geography, respondents who participated in the choking game alone had nearly five times the odds of having contemplated suicide compared to those who reported participating in a group. They also were more likely to report poor mental health.

The data from the study is limited since it only surveyed 8th grade teens and not older teens, and cannot be applied to other states or populations due to how the data was analyzed by the researchers. However, they point out health care providers may want to incorporate the discussing the risks of the choking game as part of a teen wellness visit.

We connected with one of the study's authors Sarah Knipper, MSW, a school health epidemiologist in the Oregon Public Health Division of the Oregon Health Authority, to talk about what parents can learn from the study.

The data is from Oregon, how widespread do you think playing the "choking game" is in the country?

Yes, our study only looks at 8th graders in Oregon. To our knowledge, Oregon is the only state that does statewide public health surveillance on the choking game. A handful of other studies have looked at national samples and have gotten estimates of anywhere from 5-11 percent lifetime participation. But it would be great to see other states do some surveillance on this topic with their young people to see whether there are any state or regional variations.

Is this something parents should specifically discuss with teens or would it better in a context of speaking about risky behaviors in general?

We don't have any research on exactly the best way to prevent choking game participation. We know from other studies that many kids don't understand how dangerous this activity is. So we do recommend that parents talk to their kids about it using simple factual words. They can ask their kids if they know what it is, if they know anyone who has done it or if they've done it themselves, and make sure they know that it is not safe and someone could get really hurt even if they are doing it with a group of friends. They should stop and tell a safe adult such as a parent or teacher.

What are some behavioral warning signs for parents that their teen might be participating in something like this?

It can be really hard to identify kids who are participating – there may not be any overt signs. However, here are a few things that parents could look for:

Physical signs:

  • Bloodshot eyes;
  • Unexplained marks on the neck;
  • Small red dots around the face, eyelids or lining of the eyelids or eyes;
  • Frequent, severe headaches;

Behavioral signs:

  • Disorientation after spending time alone
  • Mention of the activity or its aliases (e.g., Pass-Out Game, Fainting Game, Blackout)

Environmental signs:

  • Unexplained presence of dog leashes, choke collars, bungee cords, ropes, scarves or belts tied to bedroom furniture or doorknobs or found knotted on the floor

Where is a good place to start when parents believe their teen needs help?

A lot of kids who participate in the choking game, particularly alone, also have depression and/or use alcohol or drugs. We recommend that concerned parents or other adults reach out to a mental health provider or ask their child's primary care provider about getting their youth screened and referred for services if appropriate.

Lastly, we encourage parents to remember that taking risks is a healthy and normal part of being a teenager, and to support their kids in activities such as sports, the arts, learning a language, and rock climbing.

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