Q. Recently I heard about a child who had died while playing a game called Black-Out, and that a pediatrician had been found dead as a result of a similar type of activity. What is it and how does it affect the brain?

A. This is not a game (in spite of the name). It is a highly dangerous and potentially life-threatening activity used to alter one’s state of consciousness. It has been practiced worldwide for generations and has been passed down in playgrounds, summer camps, neighborhoods, and probably via online chat-rooms these days. In almost any group of adults, one can find someone who played this game in some form or another during childhood. It is known by a plethora of other labels including Choking Game, Fainting Game, Dream Game, Pass-out Game, Flat liner, Suffocation Roulette, California Choke, Space Cowboy, Space Monkey, and Purple Dragon to name just a few. 

The goal is to achieve a euphoric state by stopping the flow of oxygen-containing blood to the brain. Individuals who engage in this type of activity are typically juvenile males, but juvenile females and adults of both genders have also been involved. The activity has been responsible for hundreds of juvenile deaths, and likely for many others that were listed as "suicides" although no suicide note was left. Even if they survive, people are probably killing brain cells each time they engage in this activity. The damage is also likely to be permanent and cumulative. Neurological disabilities (among survivors) are typically in the juvenile male cohort.

Sometimes children choke each other until the person being choked passes out. The pressure on the arteries is then released and blood flow to the brain resumes causing a "rush" as consciousness returns. There are variations of this activity which involve hyper-ventilating until the participant loses consciousness. The variation in blood pressure may also cause strokes, seizures, and retinal damage.

Sadly enough, most victims are not children in trouble. Rather they tend to be well-liked, active, intelligent, stable youngsters who wanted nothing to do with drugs or alcohol. This was an activity they felt was safe. In addition, they don’t realize that a child choking another child who is injured or who dies, could be indicted and prosecuted for his/her part in the injury or death—not a pretty picture.

It is never safe. This activity is dangerous enough in groups. The danger becomes even greater when a ligature is used and the activity is performed alone. If the individual loses consciousness and there is no one there to immediately release the pressure, he is unable to help himself. Most of the children who have died from this were alone.

Children have no clue about the physiological principles involved and need to be told by the adults in their lives how dangerous this is. Also, most children have no concept of their own mortality. They truly believe nothing can hurt them. Children may not fully understand the outcomes from playing this deadly game, but as they do it more they may become addicted to the rush/experience. As they grow older they continue to do this and it can progress into something even more dangerous. Unfortunately, it is not only children whose brains have been damaged or destroyed by this activity but also adults. Some have used it in an attempt to increase sensations associated with sexual activity (e.g., in combination with masturbation).

The attractions of the activity are myriad. It may be done as a dare, it can induce a brief sense of euphoria, it is reported to enhance erotic feelings, it may be amusing to some to watch others losing consciousness or behaving erratically, the prospect of an altered state of consciousness may be attractive, and participants may appear “cool” because it may be viewed as risky. It is also free, legal, and can appear innocuous to those who don’t understand the mechanism involved.

Warning signs may include:

• Any suspicious mark on the side of the neck, sometimes hidden by means of a turtleneck, scarf, or permanently turned-up collar 
• Changes in personality, such as becoming overly aggressive or agitated 
• Any type of strap, rope, or belt lying about near the child without any reason (questions about such objects are often eluded) 
• Headaches, loss of concentration, a flushed face 
• Bloodshot eyes or any other noticeable signs of stress on the eyes 
• A thud in the bedroom or against a wall indicating a fall 
• Questions or comments about the effects, sensations, or dangers of strangulation

The only antidote I know of is to talk about this activity and its consequences openly and with everyone—children (starting in elementary grades), parents, and teachers. Young people need to be told by the trusted adults in their lives how dangerous this really is. That information needs to be part of curricula addressing other risky behaviors (e.g., alcohol, street drugs).

You can find additional information at the following website. http://www.deadlygameschildrenplay.com