Two years ago, Hayley Cunningham lost her cousin to a deadly game she'd never heard of.
Her cousin was found dead in his bedroom after accidentally choking himself, the result of an increasingly fatal practice gaining popularity among middle-school students known as the "choking game."
It involves near-strangulation that provides a brief floaty feeling and fainting. After grieving her cousin's death, Cunningham decided she wanted to educate others and maybe save a life.
"It would just be wrong to have this kind of information that others don't know," said Cunningham, 18.
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While conducting research for presentations she hoped to give at her school, Sayre, she met Dr. Hatim Omar, chief of the division of adolescent medicine at the University of Kentucky. In the last two years, three Kentucky deaths have been linked to the game, and Omar has treated eight teens for injuries connected with near-strangulation.
Perhaps more startling, Omar said, is "when I ask teens if they know someone doing it, over 50 percent say 'yes.'" The average age is 13, but the age range is usually between 9 and 16, he said.
That wasn't the case a few years ago. According to the Centers for Disease Control and Prevention, which issued its first warning about the practice in 2008, statistics are hard to collect because most of deaths related to choking involve the use of a ligature such as a belt, and they are routinely classified as suicide.
Games Adolescents Shouldn't Play, or GASP, a non-profit group dedicated to education about the choking game, notes on its Web site that there could be as many as 1,000 deaths a year in the United States.
Unlike auto-erotic asphyxiation, which involves both near-strangulation and masturbation, most young people view the choking game as a harmless diversion, said Marlene Huff, an associate professor of pediatrics at the University of Kentucky.
"This is not about sex at all," Huff said.
Instead, adolescents try to achieve a tingly or floaty feeling that comes from the oxygen supply being cut off to the brain and a euphoria created when the blood comes rushing back after near-strangulation, she said. That euphoria is caused by a chemical released by dying brain cells, and the surge in blood can cause stroke or seizures.
A single act can cause hemorrhaging in the brain that can permanently affect brain function, he said. Death can occur in as little as four minutes.
Some kids who are natural risk takers try the game, Huff said, but often, well-behaved students who make good grades view the practice as a harmless alternative to other taboo behaviors, such as using alcohol or drugs.
That's something Cunningham emphasizes in her presentation. Her cousin was easy-going, made straight As and wasn't the kind of kid who got into trouble, she said. It apparently never occurred to him that the game was anything more than a game.
When Cunningham began her research, she was shocked to find dozens of YouTube videos featuring kids laughing as friends fainted and twitched with seizures after suffering from a lack of oxygen, she said.
Omar thinks those videos might have helped spread the practice among preteens, whose brains have not matured enough to think through the consequences on their own. (A recent check of YouTube showed that most of the party videos have now been replaced by public service announcements about the dangers of the game.)
The game often begins as a group activity at slumber parties or unsupervised get-togethers, Huff said, but it is most dangerous when done alone, because there is no one to help if someone passes out.
There are signs to be on the lookout for, and Cunningham's relatives realize now that they didn't notice some of those signs. Her cousin had been complaining of headaches and was having trouble remembering things.
Cunningham and Omar have talked to doctors and social workers across the state to educate them about the practice. But Omar recommends that parents talk to their kids about the dangers of the game, too.
If a parent suspects that a child has experienced the game, he or she should take the child to see a specialist in adolescent medicine or a pediatrician well versed in the practice, allowing the child and the health professional to talk alone first, joining them later to ask questions, Huff said.
The anniversary of her cousin's death has Cunningham feeling a little uneasy, but she plans to continue her advocacy work when she goes to Furman University this fall.