Child’s Play
The deadly consequences of asphyxial “games.”
by Dr. Thomas A. Andrew, M.D., FCAP, FAAP
PARENTGUIDE News January 2006
“We thought we had it all under pretty
good control,” recalls Kelly L., who
reveals that nearly four years after the death
of her 13-year-old son, Michael, the bewilderment
remains raw. Michael’s parents had addressed,
at various times, tobacco, alcohol and drugs.
As far as anyone knows, Michael never used
these on a regular basis. What Michael’s
parents did not address, because they did
not know about it, was ‘Space Monkey,’
a choking game that killed Michael in 2001.
The family’s anguish was temporarily
compounded when I ruled his manner of death,
incorrectly, as suicide. Kelly was not quite
satisfied with the ruling after she did a
little digging into the circumstances of her
son’s inexplicable “suicidal hanging.”
As I was digesting the material she sent me,
another death occurred in a neighboring town.
Tommy, age 12, did not know Michael but he
and his little brother, Daniel, knew about
the game. In fact, after Tommy’s body
was discovered suspended by a dog leash from
a peg in his bedroom closet, Daniel offered
that Tommy had been playing the game.
What is this “game” all about?
Asphyxial games have been played by children
for generations. You may remember a version
from your own youth, involving pressure applied
to the abdomen, chest or neck by one player
until the other player becomes light-headed
or passes out. “Asphyxia” is the
technical term for the inadequate delivery
of oxygen to the brain. This is exactly what
happens when pressure is applied to the previously
described areas.
There are two critical differences between
earlier asphyxial games versus today’s
far more dangerous versions. Today’s
games often use ligatures, or ties, such as
dog leashes, belts, bungee cords and the like
to constrict the neck. And perhaps more importantly,
kids today sometimes play the game solo. Generally
between the ages of 9 and 14 years, the youngsters
who play the game find the light-headedness
produced by this activity exhilarating. Such
exhilaration bars kids from realizing that
losing consciousness during the game can also
result in lasting brain damage and death.
We are now in the age of extreme everything,
from sports to reality shows. In keeping with
that trend, these games, which go by a dizzying
array of names— such as Space Monkey,
Space Cowboy, Knockout, Blackout, Gasp, Flatlining,
Black Hole, Rising Sun— push the envelope
of risk taking to the next level. The magnitude
of the risk is clearly lost on the child lulled
into a false sense of security, perceiving
this activity as drug-free, and therefore
a perfectly safe high. Unfortunately, the
mythology of the game is passed from child
to child via the Internet. In the past, the
“choking game” spread by word
of mouth, from an older child to a younger
child and then to that child’s peers.
Now rapturous descriptions of the joys of
choking oneself to near unconsciousness are
just a click or two away. This is a difficult
situation for a parent unarmed with any knowledge
of the games and their potential consequences.
“Not my kid,” you confidently
say. “He/she is a good student, active
in sports, popular, hangs with a clean cut
crowd, wouldn’t touch drugs or alcohol.”
What you must be aware of, however, is that
you have just described what is emerging as
a relatively common profile of the children
who play these games. While there are undoubtedly
plenty of exceptions, fatal cases have commonly
involved high-energy, high-achieving, athletic
children who typically shun alcohol, drugs
and tobacco as stuff used by losers.
It may well be from a peer on their athletic
team, in their scout troop or in their youth
group that they learn about the game in the
first place. During an end-of-the-season party
for a Pop Warner Football team in the Lakes
Region of New Hampshire, a youngster sustained
a scalp laceration requiring a trip to the
emergency room. Over time, the story emerged
of a small group of players and cheerleaders
going to the basement of the home where the
party was held to play a choking game. The
injured boy passed out while another boy was
pressing on his chest, striking his head on
the edge of a table. If only the laceration
represented the most serious consequence of
such games. When playing alone with a ligature,
even one like a common necktie, loss of consciousness
means death.
One may wonder why young people find this
behavior “fun.” The answer lies
in the changes in blood flow to the brain
induced by the application pressure to the
neck following the release of pressure. Pressure
closes the thin-walled veins of the neck,
trapping oxygen-poor blood in the brain. The
thicker, more muscular arteries delivering
blood to the brain are only partially clamped
down so blood is still delivered, albeit in
a significantly reduced amount. The oxygen-starved
brain creates a giddy, light-headed feeling.
When a player of the game releases the neck
pressure, a surge of oxygen-rich blood enters
the brain yielding the “rush”
sought by devotees of this practice.
The fine line, literally fractions of a second,
between being light-headed and unconscious
seems nonexistent to players, though it can
mean the difference between life and death.
Once the child is unconscious with no one
else around to release neck pressure, the
child’s own weight, even from the height
of a door knob or bed post, will fatally asphyxiate
him or her in one to five minutes.
It remains unclear just how widespread this
behavior really is. Anecdotally, cases
have been reported in the United States, Canada,
Australia, Israel, England and Ireland. On
the Emerald Isle, it is called “The
American Dream Game.” There are virtually
no statistics regarding how many children
are aware of the game, have played the game
or
are regular practitioners.
Exacerbating the problem is the misclassification
of some of these deaths as suicides.
Medical examiner and coroner’s offices,
often strapped for time, personnel and resources,
may not be able to explore in-depth what appears
to be a “straight-forward suicide,”
especially when suicide is consistently among
the top two or three ways in which pre-adolescent
and adolescent children die every year. The
emerging profile from fatal cases has been
described earlier— young (9-14 years),
active, athletic boys and girls. These games
should not be confused with auto-erotic asphyxia,
a similar but unrelated activity that typically
involves elaborate, almost ritualistic bindings,
sophisticated escape mechanisms and pornography,
and that is engaged in almost exclusively
by males ages 15-16 or older, even up to adulthood.
One thing is certain: kids know about these
games while their parents do not. At a dinner
party, I was relating my concerns about this
activity to the hostess and she said she was
“fairly certain” her 8th grader
would not know about the game. We asked her
daughter to join us and I asked Meghan to
tell her mother about Space Monkey. Needless
to say, there was a brief pall cast over the
dinner table. Fortunately, we remain friends.
Warning signs that your child may be playing
asphyxial games include bruises or abrasions
on one or both sides of the neck; consistent
wearing of clothing that covers the neck;
the presence of tiny pinpoint blood spots
called petechiae on the eyes, eyelids, face
and/or neck; frequent complaints of headaches
and a noticeable increase in alone time in
his/her room. A query of the home computer
may reveal visits to chat rooms or Web sites
concerning these games. Be suspicious of any
Web site that features any of the words used
in naming these games.
At the risk of being cliché, these
games should be a topic among the family’s
parent-child discussions. Just as you would
(or should) regarding tobacco, alcohol and
drugs, discuss asphyxial games. You may want
to open the discussion by saying you have
heard or read that there are ways that some
kids try to “get high” without
using drugs or alcohol, but that these activities
can be just as dangerous and fatal. Then let
your child educate you. A dialogue will get
your message across more effectively than
a lecture.
Admittedly, this is an uphill battle. I remain
haunted by the end of my conversation with
Kelly L. We talked about Michael, the game
and the aftermath of his death. What stunned
me was her revelation that youngsters in the
community still play the game and talk of
it openly. Their answer to those who question
the wisdom of this is, “it’s better
than using drugs” and “we do it
together so it’s safe.”
I
t’s not safe. Keep telling your kids
so— because you love them.
Dr. Thomas A. Andrew, M.D., FCAP, FAAP,
is a forensic pathologist and chief medical
examiner for the State of New Hampshire. He
is also board-certified in pediatrics and
has a special interest in the intersection
between forensic medicine and pediatrics.
You can visit his Web site at www.whitemountainforensic.com.
He has three children, ages 7, 9 and 11.
