Impact of Education on School-aged Children s Knowledge of and Participation in "The Choking Game"

Abstract

Objectives: To better understand school-aged children’s awareness of and attitudes about the Choking Game (TCG). To determine if education can increase awareness of the risk of injury when playing TCG and to determine if education can decrease interest in TCG participation.

Design: Anonymous pre- and post-education surveys.

Setting: Two middle/high schools; one in Utah and one in California.

Subjects: 291 participants (163 in Utah, 128 in California) aged 9-18, 68% under age 15, 32% 15 and older; 65% white, 35% non-white; 52% female, 48% male.

Results: 76% of participants knew about TCG, of those 62% heard about it at school. 32% knew someone who had played, and twelve (4%) had played, usually with others. Most frequently cited as reasons for participation were curiosity, peer pressure, and competition. School was the most common location for playing. In California education significantly increased risk awareness, and significant positive attitude changes were observed regarding interest in playing TCG. Utah participants also exhibited attitude changes in the desired direction (less interest in playing TCG, would warn friends, and realized it was not safe to stop breathing), although results were not statistically significant, possibly due to previous education and four recent and highly publicized TCG deaths in the community.

Conclusion: Results indicate that interactive, standardized, and skills-based education can increase student awareness of TCG risks and decrease interest in participation. Students reported that the schools were often where they first heard about TCG and where TCG was commonly played. Educators and associated health care professionals should therefore be encouraged to provide preventative education as part of school curricula.

Keywords

Choking game, Risk of injury, Students

Introduction

“The Choking Game” (TCG) or self-asphyxial risk taking behavior 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 [1]. Loss of consciousness may occur, with potential injury from subsequent falling, and hypoxic injury, along with bloodshot eyes, visual impairments, severe headaches, altered mental status, recurrent episodes of syncope and changes in behavior. Death may also occur; nevertheless, young people do not seem to understand the dangers associated with this activity. Adolescent awareness of TCG ranges from 36% to 91%. The lifetime prevalence of engaging in TCG ranges from 3.8% to 17.1% in the United States. Often students mention their first introduction to TCG comes through friends at school [2]. Macnab et al. [3] found that 40% of children perceive no risk from participation in asphyxial games. Although prevention education programs designed to dispel the common misconception that TCG is not dangerous appear to be a likely solution [4] there are concerns among educators that education may have an adverse effect on youth even though authors have concluded that education does not increase likelihood of experimenting with or engaging risky behaviors [4,5]. Poland reported that a controversial issue in schools is how much if anything should be said to students in group settings about choking games [6]. RN Davis-Alldritt, as cited in Sutton p.3 states, “There is always the fear that, if you talk about something, it will encourage people to try it” [7]. Further compounding the problem, McClave found that one third of surveyed doctors were unaware of TCG and its warning signs, which may lead to injury misidentification and lost opportunity to provide prevention education [5]. The 2009 Oregon Healthy Teens survey of eighth- and eleventh-graders questioned lifetime prevalence and frequency of TCG participation [8]. About 6 percent of eighth-graders and 7.5 percent of eleventh-graders said they had participated in TCG, with no difference seen between males and females. This translates to approximately 5,200 eighth- and eleventh-grade students. Among those who had participated, one in five, or about 450 eighth-graders had done so more than five times. These youth are exposed to an even greater risk of injury, especially if they participate alone.

Dake et al. [9] surveyed 3,408 middle and high school students in the Midwestern states and found that, in contrast to findings in the Oregon survey, that male participation (11%) exceeded female participation (7%). High school students (11%) were more likely to participate than middle school students (5%). Another survey of 2,504 youths aged 9 to 18 conducted in Texas and Ontario found 68% had heard about the game, 45% knew somebody who played it, 6.6% had tried it, and 40% felt there was no risk associated with participating in TCG [3].

We found no prior studies that addressed either the effect of education in reducing the lack of understanding of the risks of TCG, or the impact of education on interest in participation in this activity. Although they were not studying the effect of education, McClave et al. [5] did conclude that educators and other adults who work with adolescents should educate students regarding the dangers of TCG and reiterated that no evidence exists to suggest that offering education increases the risk of engaging in risky behavior. This study was developed to explore these issues, and to better understand school-aged children’s awareness of and attitudes about TCG. Two primary study objectives were identified: the first to determine if education would increase awareness of the risk of injury when playing TCG; the second to determine if education would decrease interest in TCG participation.

This study was approved by the Institutional Review Board (IRB) of the University of California Davis, and supported by the University of California Davis Medical Center Nursing Research Mentorship Program and the National Center for Advancing Translational Sciences, National Institutes of Health.

Methods

Human subject’s approval and surveys used

A waiver of written consent was approved by the institutional review board (IRB). Pre and post-education surveys were designed by the authors and developed independent of the education program based on a literature review. Two authors reviewed the survey questions for face validity and pilot tested the survey questions with 4 adolescents. Surveys included multiple-choice questions to explore awareness of and attitudes about TCG using the eight Likert Scale statements shown in Table 1 through 3. A demographics section was included with the post-education survey to determine participant’s age, sex and race.

Table 1. Changes in disagreement from pre-to post-education Likert scale responses and difference in change between sites.

Education provided

Erik’s Cause, an independent not-for-profit organization whose mission is to bring TCG awareness into the national spotlight so parents and children understand its true dangers conducted the education at both survey locations [10]. An interactive, standardized, 45 min skills-based education program utilizing PowerPoint, video, and oral presentation methods was provided in a classroom setting during six sessions of approximately 15 to 30 students each.

Sampling procedure

Convenience sampling was used to choose the schools. The Cedar City School in Utah was selected because Erik’s cause had a scheduled education event occurring at that location. The Cedar City students were attending a voluntary Friday-Saturday leadership conference offered to all area public junior and senior high students by Leaders for Life, a regional not-for-profit organization whose mission is to provide a unique opportunity for youth/students to escape the cycle of destructive behavior through education [11]. Rocklin Academy Charter School was selected because it is a Charter School and the California based sample represented a different population than the public, Utah based Cedar City School. Rocklin junior and senior high students were participating in a weeklong “Hero Week” during regular school hours. Participants at both sites were 9 to 18 years of age, had parental consent to receive the education, were physically and mentally capable of completing the survey, and were willing to participate in the study. Students were instructed that participation was voluntary, that they should not put their name on the surveys, and that all results would remain anonymous. Surveys were distributed to 163 participants in Cedar City, Utah on March 28, 2014, and 128 students in Rocklin, California on September 15, 2014. All students who attended these two events voluntarily agreed to complete surveys.

Data collection

The pre-education survey was administered immediately prior to each education session. The post-education survey remained in sealed envelopes at the student’s desk during the session so that the surveys could not be viewed during the program. Two study authors were present during the entire process to monitor compliance. The post-education survey was administered immediately following each education session. Study data were collected and managed using REDCap (Research Electronic Data Capture) [12]. REDCap is a secure, web-based application designed to support data capture for research studies.

Data analysis

Age was dichotomized as ‘under 15’ and ‘15 and older’ to avoid problems with chi square approximations and with logistic regression associated with low numbers of students within the age categories. Race was dichotomized as ‘white’ and ‘non-white’ because of the small numbers of individuals in racial and ethnic categories other than white. To measure the effect of education on student attitudes, each student’s post-education responses to the eight Likert scale statements were subtracted from their pre-education responses. The Likert scale was coded from 0 to 4, where 0 indicated ‘strongly disagree’ and 4 indicated ‘strongly agree’. The resulting variable had a possible range of -4 to 4, and represents the degree of disagreement with the statement – a positive value indicates an increase in disagreement, and a negative value indicates a decrease in disagreement. This variable will be referred to as ‘change in attitude’ hereafter. A significant p-value (<0.05) indicates that the change is significantly different from 0.

Differences between the two sites in age, race, and sex distribution were tested using Fisher’s exact test. Significant differences in the demographic variables would imply that the attitude variables (change in Likert scale responses to the eight statements) would need to be analyzed separately for the two sites to avoid confounding. A multifactor ANOVA was fit for each statement, controlling simultaneously for site, age, sex and race. However, due to the discrete nature of the response variable, violations of the normal assumption were evident; and given the large sample sizes required for non-normal, multivariable models, these models were deemed inappropriate and results are not shown.

Differences in the proportion of students who had previously heard of TCG associated with site, age, sex, and race were tested using Fisher’s exact test. Changes in attitude due to education (significantly different from zero) were tested using the Wilcoxon signed rank test. Differences in change in attitude associated with site, sex, age, race, and previous knowledge were tested using the Wilcoxon rank sum test. All analyses were performed using SAS^® software version 9.4 (SAS Institute, Cary, NC).

Results

Multiple choice pre-education survey questions

Participants were allowed to select more than one answer for all multiple choice questions. A large proportion (76%) were aware of activities that included either getting dizzy or passing out with a majority (91.9% Cedar City; 59.8% Rocklin) being familiar with the term “Choking Game” (Figure 1). Hereafter all pass-out activity names will be referred to as TCG. Of those participants aware of TCG, “at school” (62%) and “friends” (49%) were reported as the top two sources of information (Figure 2). 32% of the participants knew someone who had played TCG. Twelve students (4%) had played, usually with others (94%). Locations for playing TCG were reported as school (50%), home (33%), friend’s home (22%), and other (17%). Most frequently cited as reasons for participation were peer pressure or dare, curiosity, and competition (Figure 3).

Figure 1: Awareness of pass-out activity names.

Figure 2: How students heard about pass-out?

Figure 3: Why students participated in TCG?

Likert scale survey results

In assessing changes in student attitudes a Likert Scale survey was used. The results of the change in attitude analyses are presented in Table 1 through 3. For all data a significant p-value (<0.05) indicates that the change is significantly different from 0.

Change in student attitude within and between sites

As indicated in (Table 1) for statements 3, 6 and 8 in Cedar City, and for all statements in Rocklin, the data provide significant evidence that education changed participant attitudes in the expected positive direction. In Cedar City for statement 3 students concluded they would say no if invited to participate. For statement 6, Cedar City students agreed that playing can be addictive and for statement 8, students agreed playing TCG is not safer than using alcohol. For statements 1, 4 and 5 in Cedar City the attitude changes were in the expected direction, but were not statistically significant. Although not statistically significant after the education session Cedar City students agreed they were less interested in playing TCG (statement 1), would warn friends about the dangers of playing (statement 4) and realized it was not safe to stop breathing (statement 5). The Cedar City average change for statement 7 was not in the expected direction, but was not statistically significant. Students concluded they were still likely to play TCG although their responses were not statistically significant.

The right-most column in Table 1 compares the mean change in attitude between the two sites. Except for statement 6 (playing can be addictive) there were statistically significant differences between the Cedar City and Rocklin results, with Rocklin student attitudes demonstrating a greater mean change.

Prior knowledge

Across both sites 76% of students had previously heard of the choking game (89% at Cedar City, 59% at Rocklin). Table 2 compares the impact of education on those students with prior knowledge compared to those without prior knowledge of TCG. Responses to statements 1 (I am interested in playing TCG) and 2 (TCG is dangerous) indicated that those without prior knowledge had statistically significantly larger attitude changes than those with prior knowledge.