Challenging Dogma

...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

Public Health’s Fixation on Teen Asphyxiation “Games” Increases Awareness But Doesn’t Solve the Problem - Thanh Mai Nguyen

Asphyxiation games are activities in which a person strangles themselves in order to deprive the brain of oxygen enough to mimic the euphoric effect common to illegal substance use. It has a few common names such as “Space Monkey,” “Fainting Game,” “Choke Trance,” “The Hanging Game,” and the “Passing-Out Game” (1). It has been exposed in various newspapers and television shows such as the Dr. Phil show and CBS’s The Early Show. Items most commonly used to wrap around the nape of one’s neck include belts, pantyhose, ropes and other such fixtures (2). The ones most likely to participate in these games are not from the low-income or minority populations. Rather, they are teenagers from middle class families who live in suburban American towns (3). They are average teenagers who are not substance abusers, are in team sports in search of an activity that has leaves no chemical trances, and do so out of “boredom.” These teens utilize the internet, public education campaigns and the information offered to learn about the activity. Most teens initiate these games in groups under peer pressure, but a number advance to playing these games alone. The danger in playing alone is that most do not know when to stop and may go too far, killing them. The number of deaths attributed to choking games that were designated suicides by medical examiners should lead public health practitioners to educate themselves and the medical community of its existence and prevalence in this population (4). These games have existed since the 1960’s and have waxed and waned in popularity, having a global reach to areas such as France and Canada.

Despite the nation’s growing interest on discussing teen asphyxiation games, there has been no attention in the media regarding intention to initiate these activities, or for effective prevention of these unintentional teen deaths. Instead, the proposed prevention efforts have focused on publicizing the dangers of this activity and on parental chaperones at teen parties. This narrow emphasis has sparked curiousness and interest in places like teen chat rooms and has fueled a greater problem.

Media attention to teen asphyxiation games have caught the attention of the target audience, but not as intended. Public health campaigns to scare teenagers from participating in these games may have instead created a forum for teenagers to share their experiences and to encourage techniques for hiding or “improving” the dangerous activity (5). Schools have shied away from the constant pressure of parents to advise students against the dangerous activity for fear that increasing exposure would lead to increased deaths and legal liabilities. Many parents have rallied for legislative changes that would protect all children, but similar to the school districts, parents have been instructed to educate their children on an individual basis. Overall, the perspective that advocates have taken is ineffective and insufficient to address the problem of teen asphyxiation games due to aspects of adolescent development in terms of social learning theory, social disorganization theory, and social norms theory, which will all be discussed.

Argument #1: Social Learning Theory
The teenage years are described as rebellious and are preoccupied with group belongingness and social acceptance (6). With Albert Bandura’s model of Social Learning theory, teenagers who have an interest in asphyxiation games are predominantly preoccupied with the social networks surrounding them and are easily swayed by peer pressure (7). During this developmental stage, being a part of the “in-crowd” is vital to forming intimate relationships and sustaining a positive perspective on one’s self image. They readily observe the behaviors promoted by others and desire to repeat them with the intention that they may achieve peer acceptance. This theory proposes that teens are engaging in a reciprocal relationship with their peers by discussing and engaging in activities such as the “choking game,” because the feedback reinforces the sense of belongingness with their peers (8).

Teenagers are likely to think that that they are not vulnerable to negative consequences of dangerous activities. They become convinced that “bad things” only happen to other people, increasing their likelihood to engage in repeat risky activities, such as smoking, sexual initiation, and substance abuse. Chat rooms are a technological advance that has become popular forums for teens to discuss personal experiences and the thrill of this dangerous activity. This exposure increases the probability of teens engaging in far riskier or multiple activities than those seen in previous studies on teenage modeling behavior. Also, the increased discussion and time spent with influential peers is likely to decrease any negative stigma that the risks entail becoming in their perspective, normative behaviors of typical teenagers. By introducing positive peer role models and supporting programs that promote teen leadership, teens may become encouraged to reciprocate esteemed behaviors and sustain positive self images.

Argument #2: Stigma Theory/Social Disorganization Theory
Peer influences on teenagers can have both negative and positive effects. People live in groups and the dynamics of a person’s status within a group can influence their choices and behavior. In the case of teen asphyxiation games, teens engage in these activities to avoid being a non-cooperative member from the dominant group. Stigma or disorganization theory can then be used to explain why they engage in these activities at higher rates than their counterparts. The thrill of engaging in an “off limits” group activity that carries a negative stigma undermines their unstable formation of family and societal values (9). The activity then is labeled as inappropriate by authority figures and promotes their status and reputation within the group. In addition, it serves as a mode for identity formation among their social networks in which the behavior serves a functional value.

When their peers are discussing and trying out a game in common areas such as the schoolyard or mall parking lots, then it becomes less taboo and more enticing by way of public demonstration. Once a teenager participates in repeated “choking games” and is exposed to aspects of the game on a regular basis, then the game becomes less restrictive in a sense, and becomes acceptable. Each attempt reinforces for the teen the immediate gratification, and that there is no harm or direct consequence to their involvement. The stigmatized activity becomes acceptable not just by their peers, but more importantly to the individual themselves, to the point that there is little hesitation to repeat the act and to encourage others of its harmless effects.

If public health campaigns would reframe the adolescent years from rebellious, and confrontational with parental and authority figures, to times of endeavors at identity formation and mature thinking, teens would be better able to defend themselves against activities such as the “choking game.” Many coercive public health campaigns illustrate teens as unknowledgeable, passive, and reckless decision makers in their intentions and behaviors. Repeated images of teens engaging in socially condemned activities categorize teens as immature and turn them off from the public health message. Public health campaigns directed at teens should be promote group influences as normative socialization events that serve as learning experiences to increase individual self esteem and boost confidence in decision-making.

Argument #3: Social Norms Theory
The basis of Social Norms theory is that teens overestimate the involvement of their peers in high risk activities. Teens incorrectly perceive other’s behaviors and beliefs as different from their own when they are not (10). Teenagers tend to be pompous and over exaggerate their narratives, to gain prestige and admiration from their social networks. They are likely to revere peer involvement in high risk activities such as asphyxiation games and feel like everyone has tried it. With the availability of the internet and photo editing software, teens are able to mimic and post asphyxiation poses on blogs for personal recognition and to incite discussion amongst their peers, namely those they view as important. Even those who fail to achieve peer acceptance in their immediate environments may become global “stars” on internet chat rooms, where most information is exchanged regarding how to conduct, heighten, and modify the “high” that comes from these games. With a global following of people from different locations, ages and education levels, these teenagers are not far from achieving the instant gratification that the asphyxiation games provide.

Educational public health campaigns so far have focused on scare tactics and have been ineffective in decreasing adolescent initiation in these activities. Instead, campaigns should utilize components of Social Norms theory to change misperceptions of groups, their intention to engage in unhealthy behaviors, and ultimately individual behavior. This theory focuses on the importance of peer influences and suggests that changing group perceptions will lead individuals to resort back to previous familial and societal values that promoted self esteem and self efficacy (11).

Successful Interventions: So what options do we have?
The Gatehouse Project in Australia suggests increasing a teenager’s connectedness with school and social networks in order to foster greater educational achievements (12). This program utilizes Stigma theory on teen’s exposure to socialization activities, to decrease interpersonal conflicts at school and to increase connectedness with school environments. Bond et al., found that students who felt connected to a social network but not to school were more likely to engage in substance abuse and alcohol. With the intervention, Bond et al. found higher rates of graduation and less illegal substance usage. Greater connectedness with school and feelings of achievement also encouraged teenagers to create positive friendships with other students and to have decreased mental illness symptoms, leading to better achievement in the classroom.

One example of positive leadership and community connectedness for teens supported by the National Center for Cultural Competence (NCCC) is the Parent Support Network of Rhode Island’s Youth Speaking Out (13). It was created with the input, feedback, and interests from high risk youths to juvenile delinquency. This program encourages components of both Social Learning and Social Norms theory, which enables youth to design activities based on their individual interests, abilities, and needs. It promotes youth involvement in society and fosters healthy relationships with community members. Through leadership, civic service, and self-exploration activities, teens learn a sense of self worth and self esteem in an arena to advocate for themselves. Teens are provided with the ability to make choices, a social group which fosters individualization as well as belongingness, and to be accountable for their decisions. The connectedness formed is shown to decrease their involvement in the juvenile justice system and delinquent activities. It also fosters healthy emotional peer relationships in structured settings.

In order to understand how the public health community is to combat teen asphyxiation games, we need to focus on the framing of public awareness campaigns that strengthen teens’ abilities, and not their failures or immature misconceptions. From ten to sixteen years of age, it is very important for parents to be active participants in discussing risks just like smoking, sex, and alcohol. Parents need to advocate for their children by screening news and information disseminated to their children through the internet, television, or phone. Parents need to censor their children from movies and television shows that portray death as a painless or reversible. A public education component that addresses teen intention to initiate “choking games” should also be established because this problem extends beyond teenagers and their friends. A committee of advocates with focused objectives can correctly educate and empower parents to prevent the problem of teenage asphyxiation games. Educating teenagers by changing group perceptions is more desired than on an individual basis.

By supporting their decision-making skills, public health campaigns may be able to increase the negative perception for this problem before it becomes normalized. The shaping of a child’s understanding around risky behaviors that lead to death begins early on. It is understandable that not every family has the means to combat short lived teen activities. Public health needs to arm teenagers with skills that emphasize self esteem and competency in mastering their identity within a social framework. Educators and health care providers also need the skills to correctly identify high risk teenagers, to prevent participation in risky behaviors with dire consequences that will impact more that teens themselves.

1. Perlstein S. New Asphyxial Game Erroneously Seen as Safe. Pediatric News 2003; 37: 22.
2. Associated Press. Idaho Boy Dies While Playing Choking Game. Fox News. 2005 July 13.,2933,162379,00.html.
3. Kunkle, F. Teen’s Death in ‘Choking Game’ Focuses Attention on Dangerous Practice: Longtime Practice Cast into Spotlight by Md. Teen’s Death. The Washington Post. 2006 April 2.
4. Associated Press. 2005.
5. Perlstein S. 2003.
6. Gilmore M, Hawkins J, Catalano R, Day L, Moore M, Abbott R. Structure of Problem Behaviors in Preadolescence. Journal of Consulting and Clinical Psychology. 1991; 59: 499-506.
7. DeFluer M and Ball-Rokeach S. Theories of Mass Communication. (5th Ed.) New York: Longman Inc. 1989; 208-227.
8. Bandura A & Walters R. Social Learning and Personality Development. New York: Holt, Rinehart & Winston; 1963.
9. Wikipedia contributors. Social Disorganization Theory. Wikipedia. 2007 February 26.
10. Berkowitz A. An Overview of the Social Norms Approach (pp. 193-194). In: Lederman L, Stewart L, editors. Changing the Culture of College Drinking. New Jersey: Hampton Press, Inc.; 2005.
11. Berkowitz A. The Social Norms Approach: Theory, Research, and Annotated Bibliography. New York; 2004.
12. Bond L. Social and School Connectedness in Early Secondary School as Predictors of Late Teenage Substance Use, Mental Health, and Academic Outcomes. Journal of Adolescent Health 2007; 40: 9-18.
13. National Center for Cultural Competence. Engaging Youth to Create Positive Change: Parent Support Network of Rhode Island. Washington DC: Center for Child and Human Development.

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