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CDC discusses “Choking Game” Study

February 14, 2008

 

OPERATOR:   PC Media Relations, please go ahead.

MODERATOR:  Good morning, today we will be providing an analysis of the findings from a study being released today in our Morbidity and Mortality Weekly Report or MMWR on “the choking game.” 

With me today is the author of the study, Robin Toblin, Ph.D.  That′s Robin, R-O-B-I-N and Toblin, T-O-B-L-I-N.  We also have medical epidemiologist Len Paulozzi, M.D.  That′s Len, L-E-N, and Paulozzi, PA-U-L-O-Z-Z-I.  Both scientists are with CDC′s National Center for Injury Prevention and Control.

Dr. Toblin will make a quick, short statement, and then we will open it up for questions.  Dr. Toblin?

ROBIN TOBLIN, PH.D, MPH, LEAD AUTHOR, CDC NATIONAL CENTER FOR INJURY AND PREVENTION CONTROL:  Good morning, we′re here today to discuss a dangerous activity called the choking game that some youth are participating in and that other youth may be aware of or someday become aware of.  The choking game involves intentionally trying to choke one′s self or someone else with one′s hand or a noose to obtain a brief euphoric state or “high.”

If the strangulation is prolonged, which is something that can happen very quickly, death or serious injury can result.  Today, I′ll be talking about the results of a study designed to lend more insight into the potential number of deaths among youth in the United States who have died playing the choking game. 

For this study, we analyzed media reports of deaths attributed to the choking game.  Media reports were used because deaths from things like the choking game are not officially recorded or reported and they are also not likely to be noted on death certificates as a cause of death. 

We found that from 1995 through 2007, media reports indicated that at least 82 youth have died as a result of this behavior.  They ranged from six to 19 years of age, with the average age being 13-years-old.  Eighty-seven percent of these deaths were among boys.

The media reports also illustrated that the choking game isn′t limited to one area of the country.  Instead, choking game-related deaths were reported in 31 states.  It′s also important to note that nearly all the youth who died were alone when they undertook this activity. 

Three or fewer choking game-related deaths per year were reported in the news media from 1995 to 2004.  However, there was a jump to 22 reports of deaths in 2005 and 35 reports in 2006.  In 2007, there was a sharp decrease with nine deaths occurring in the first 10 months. Since media reports were used, it is not known whether fewer children are undertaking this activity or whether there is less media reporting of choking game-related deaths.

Deaths were not included in this study if there was any mention of autoerotic activity or if reports were unclear as to the person′s intent. For example, if there was a question of whether the death resulted from suicide versus the choking game, the death was not included.  And, in fact, the difference between the age distribution of choking game deaths and that of suicides by hanging or suffocation suggest that these are not unrecognized suicides. 

Our analysis suggests that while the age distribution for choking game deaths appears to be greatest at 13 years of age, deaths from suicide by hanging or suffocation increased steadily with age through age 19.

Though our study focused on deaths caused by the choking game, there are also nonfatal consequences to engaging in this behavior described in the medical literature.  Children can lose consciousness and kill brain cells by depriving their brain of oxygen.  In some cases, permanent disability has resulted.  If they fall while playing the game, they are at risk for concussions and fractures.  They are also at risk for hemorrhages of the eyes.

At this point we don′t have any research on the best strategies to prevent youth from playing the choking game.  However, most of the media reports suggested that nearly all parents whose children died playing the choking game were not aware of or familiar with this activity before their child′s death.

Therefore, it is important that parents, educators and health care providers become aware of the choking game, and learn to recognize the following possible warning signs:  discussion of the game, including other names used for it, such as “pass-out game” or “space monkey;” bloodshot eyes; marks on the neck; severe headaches; disorientation after spending time alone; ropes, scarves and belts tied to bedroom furniture or doorknobs or found knotted on the floor; and the unexplained presence of dog leashes, choke collars and bungee cords.

If parents believe their child is playing the choking game, they should speak to them about the life-threatening dangers associated with the game and seek additional help if necessary.  Risky behaviors like the choking game are public health issues that need greater recognition and ongoing commitment to prevention efforts.

We also need to continue our efforts to learn more about what children are at risk, what factors can put children at greater risk, and things that can be done to prevent youth from engaging in dangerous activities like the choking game.

We don′t have all the answers right now, but this analysis is an important step in better understanding the problem and whom it′s affecting.  In this case it appears that children as young as 11 and 12 years old are at risk, and that boys are of  particular concern.

I′ll be glad to take your questions now.  Thank you.

OPERATOR:   Thank you. And at this time if you would like to ask a question please press star followed by one on your touch-tone phone. You′ll be prompted to record your name for proper registration.

To withdraw your request, you may press star two. Once again, star one for questions.  And one moment for the first question. Thank you. Our first question comes from Helen Branswell, the Canadian Press.  Please go ahead.

HELEN BRANSWELL, THE CANADIAN PRESS:  Hi.  Thank you very much for taking my question.  I have a couple if I could.  I′m not clear why you don′t include deaths in which autoerotic asphyxiation was part of the mix.  Because aren′t these interlinked?

And my other question is, did you look for websites that kids might be visiting to see if there′s anything there that can explain the spike in 2005, and what our kids are learning about this that way?

TOBLIN:  To address your first question, autoerotic asphyxiation is really a different behavior. And there′s quite a bit of literature on it already, unlike the choking game.  But we chose to focus only on the choking game. 

And to answer your second question, we are aware that there are videos of the choking game out there, and that children may have looked at them.  But we aren′t aware if this led to the spike in 2005.

OPERATOR:   Thank you.  Our next question comes from Will Dunham, with Reuters. Please go ahead.

WILL DUNHAM, REUTERS:  Hi, this is Will Dunham in the Reuters Washington Bureau.  I′m just wondering, to what degree are you perhaps worried that the very release of the report will make more children aware of this practice and potentially encourage it?

Did that come into your thinking at all in deciding to go ahead with the report?

TOBLIN:  We chose to go ahead with the report because we think it is critical that parents, educators, and health care providers become aware of this phenomenon so they can look for the warning signs of it.

OPERATOR:   Thank you. Our next question comes from Peggy Peck, MedPage Today.  Please go ahead.

PEGGY PECK, MEDPAGE TODAY:  Yes.  Thank you for taking our questions and I would just like to follow up on the previous question.  You mentioned that you are relying upon news reports.  And this obviously will generate more news reports.  So I′m wondering if you could really address that question about the concerns of this news, the potential for this again, resulting in a spike down the road in 2008?

TOBLIN:  In the past there have been national news reports and the spike did not seem to increase one way or another because of an individual news report. And there was an increasing trend in 2005 and 2006, but any individual report on Oprah or Dr. Phil didn′t seem to have a specific effect. 

And we don′t think this will have a specific effect on increasing deaths from children dying from the choking game, but rather just might increase the awareness in the media and increase reports of such deaths.

OPERATOR:   Thank you. Our next question comes from Valerie Hoff, WXIA-TV.  Please go ahead.

VALERIE HOFF, WXIA-TV: Thank you.  You had mentioned that there had been injuries and disabilities because of this.  Do you have any idea how many?

TOBLIN:  We don′t have any idea how many because it′s unlikely that most of those would be reported in the media.  Since we relied only on the media for this data collection we don′t have any sense of how many children have been disabled by this.

OPERATOR: Thank you. Our next question comes from Janet Kornblum, USA Today. 

JANET KORNBLUM, USA TODAY:  OK. Thank you for taking my call.  How new is this?  Why now and also how do children find out about it?  Are they learning about this on their own or are they – like you said, there are YouTube videos out there?  I just wanted to get a little background on this.  Is it just that we′re paying attention to this now or is it a new phenomenon?

TOBLIN:  There have been activities like this in the past, but what is new now is that children are playing alone and that they′re using ligatures.  And those are risk factors that make them more likely to die from this activity.

And then could you repeat your second question?

KORNBLUM: Where are they picking this up – on their own, or are they watching TV, or are they watching YouTube, talking to each other?  How is this happening?

TOBLIN:  They′re learning it, as we understand it, through peers.  The peers pass it on to one another and they learn it from each other at school, at summer camp, at a party.  Just as a note, I used the word “ligature.”  To explain what that is, that is a noose.  So that might be a belt, or a scarf, or a T-shirt, a bungee cord.

OPERATOR:   Thank you. Our next question comes from Miriam Falco, CNN.

MIRIAM FALCO, CNN: Hi, thanks for taking the questions.  Beyond just this press conference and hoping that there′s more media coverage about this, what more can be done to get better statistics beyond just what media reports exist out there?  And what concrete steps are you taking so that parents, teachers, and physicians or whomever else are more aware of this?

TOBLIN: This report is a first attempt to measure the magnitude of this problem and possible next steps might include a question about this game on a behavior survey given to the teen population. Such surveys could identify characteristics of children associated with playing the game. And we are aware of other researchers who have conducted such surveys. 

In addition, we will continue to use media reports to track choking game fatalitie, and try to confirm that the numbers have declined.  And also, we’ll be looking in to see if there are other systems in the future that might be able to reliably report on the choking game.

OPERATOR: Thank you. Our next question comes from Denise Gellene, Los Angeles Times.  Please go ahead.

DENISE GELLENE, LOS ANGELES TIMES:  Hi. Can you put this number in any kind of context or perspective?  For example, how many suicides do you have a year in this age group?

TOBLIN:  In the years 1999 to 2005, we know there were 5,101 suicides from hanging or suffocation. And this is 82 over a 12-year period.  So it is a relatively small number. However, there may be under-reporting and there may be cases we’re not picking up because of the method of using media reports.

OPERATOR:   Thank you. Reed Cooley, Congressional Quarterly, please go ahead.

REED COOLEY, CONGRESSIONAL QUARTERLY: Hi, I’m sorry I had withdrawn my question. It’s already been answered.

OPERATOR:   OK, we’ll move on to the next question. Danell Elucia (ph), please go ahead. MSNBC.com.

DANELL ELUCIA (ph), MSNBC.COM:  Hi, thanks for taking my question.  The parents who have been concerned with this problem for years say the most important thing that could be done would be to get an ICD-10 code added to the mortality database to specifically track this.  Have you talked about that at all?  Is that likely?

TOBLIN:  ICD codes are added as new conditions are recognized, but not every type of disease or injury has its own code.  The World Health Organization determines when new codes are warranted.

OPERATOR:  Thank you. Jordan Light, New York Daily News, your line is open.

JORDAN LIGHT, NEW YORK DAILY NEWS:  Hi, can you just talk a little bit more about the origin of this game.  You mentioned that it’s not new.  Do we know where it started and when?  Can you talk a little bit about why the shift towards kid playing this alone?

TOBLIN:  Asphyxial games, as they are sometimes referred to, have been played by youth for generations, but it is unclear, as of right now from the media reports, why this shift has occurred to playing alone and using ligatures. 

OPERATOR:   Thank you.  We have a follow-up from Valerie Hoff, WXIA-TV.

VALERIE HOFF, WXIA-TV:  Thank you very much.  You had mentioned about the 5000 suicides, or the 5,101 suicides from 1999 to 2005.  What is the likelihood that some of those may have actually been people playing the choking game who did not mean to kill themselves?

TOBLIN:  It is possible that some of the suicides were unintentional choking games.  However, if you look at the graph in our paper, it shows that really the distribution is quite different between choking game deaths and suicide deaths.  Suicide by hanging increases every year as a child ages, and we stopped at 19, which was the peak.  Whereas, with the choking game, the peak is at age 13 and declines after that. 

So they really seem to be a different phenomena.

OPERATOR:   Thank you.  Denise Gellene, Los Angeles Times, your line is open.

DENISE GELLENE, LOS ANGELES TIMES:  Yes, I was wondering if there’s any formula that you apply to numbers, such as the ones you’ve collected for this game, to try to determine what the actual number might be in the population?  Do you have a sort of rule of thumb for that, or some sort of estimate for that?

TOBLIN:  We don’t have any estimates.  This is really the first attempt at a national study to look at this phenomenon, and to see how many cases there are.  And without a better source for reliable numbers, we can’t say what the national data would be.

OPERATOR:   Thank you.  Once again, as a reminder, if you would like to as a question, please press star one.  Our next question comes from Miriam Falco, CNN.  Please go ahead.

MIRIAM FALCO, CNN:  Hi, going back to what I asked you before.  And going back to what you just answered earlier about how it is up to the World Health Organization to make a new definition of what′s the cause of death, if I got that right.  How long does it take for something like this to happen?  What if this isn′t as prevalent in other countries?  Then we never get proper statistics, and you only rely on media reports? 

It just doesn′t seem very reliable.  And in this day and age where information proliferates much faster via TV and via the Internet, what is being done now, or what could be done now, to better get the message out to more people because these reports have been around, as your own paper says? 

Since 1995 at least 82 children have died.  There’s probably many more because kids are doing this and not doing it with other people around them, so what concrete measures are being taken instead of ‘maybe there’ll a survey question in the future’?

LEN PAULOZZI, MD, MPH, MEDICAL EPIDEMIOLOGIST, CDC NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL:  This is Dr. Len Paulozzi.  I thought I might help answer that question.  The World Health Organization revises the International Classification of Diseases about every ten years.  They are in the process of developing the 11th edition now, and we can discuss with the National Center for Health Statistics the issue of a specific code for the choking game, and the agencies from each country meet to discuss the suggestions for changes in the ICD. 

There are some cases that have been reported in other countries, according to some of the websites we have looked at, so there may be interest in other countries as well and in better tallying these deaths.

OPERATOR:   Thank you.  Our next question comes from Tom Watkins, CNN.

MODERATOR: This will be our last question.

TOM WATKINS, CNN:  OK. Did you talk to any of the survivors, and if so, did you get any sense for their motivations and can you describe in more detail the long-term disability that you mentioned?

TOBLIN:  We have spoken significantly to one of the parents of the victims who is one of our co-authors, Patricia Russell, a family practice physician in Tacoma. She is one of our co-authors and she lost a son to the choking game.  We have spoken to her, and she is in touch with many parents of victims of the choking game.  And as far as we know, the only thing that we’ve heard from children is that they hoped to get a ‘cool’ and ‘dreamy feeling’, as they have described it.

And to answer your question about non-fatal consequences, they can have concussions and fractures from falling down.  They can have hemorrhages of the eyes.  They can wind up with neurological disability that would lead them to have comas or potentially seizures for the rest of their lives.

MODERATOR:  New York Daily News just came in.  I’ll reframe that and we’ll just take one more question.

OPERATOR:   Thank you.  We’ll take our last question from Jordan Light, New York Daily News.  Please go ahead.

LIGHT:  Hi.  I was just looking at the MMWR.  I don’t think I see a list of the states where deaths have been reported.  Do you have that?

TOBLIN:  I don’t have that with me, but there were 31 states, and it was very widespread from Alaska to Maine, California to Florida.

OPERATOR:   Thank you.  We have no further questions at this time.

TOBLIN:  Thank you very much for speaking with us today.

MODERATOR:  Thank you.

OPERATOR: Thank you and this does conclude today’s conference call.  We thank you for your participation, and you may now disconnect your lines.

END

####

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