Asphyxial Games in Children and Adolescents

1. Asphyxial Games in Children and Adolescents Thomas A. Andrew, MD Chief Medical Examiner State of New Hampshire

2. Seen, but not observed – Case 1 • 9-year-old male found by mother with thin rope looped twice about neck suspended from bedpost • Transported to emergency dept. then airlifted to trauma center intensive care unit • Comatose, ligature mark above thyroid cartilage, petechiae noted on face and eyelids • Declared brain dead 26 hours after admission

3. Seen, but not observed – Case 1 • Autopsy • ¼ inch ligature mark, sloping gently upward and left to the occipital notch • No hemorrhage of strap muscles, no injury of cartilage or hyoid bone • Florid facial petechiae, no conjunctival petechiae • Cerebral edema with flattened gyri, narrowed sulci, uncal grooving and herniation of cerebellar tonsils • Patchy, acute bronchopneumonia

4. Seen, but not observed – Case 1 • Investigation by State Police • Parents divorced, deceased and 7-year-old female sib with mother and her fiancé. • Children sent to room for jumping on couch. • Sibling describes deceased playing with the rope about his neck on this and previous occasions. • Cause of Death: Hanging • Manner of Death: Accident

5. A “straight-forward suicide” – Case 2 • 13-year-old male found in basement of home in a kneeling position with a 1” nylon dog leash around his neck • Had a minor argument with mother the previous evening, left the house, but all seemed well at bed time • No history of behavior disturbances, school failure, substance abuse or police contact

6. A “straight-forward suicide” – Case 2 • Autopsy • ¾ - 1 inch ligature mark directly over laryngeal cartilage sloping gently upward bilaterally to the occipital notch • No hemorrhage of strap muscles, no injury of cartilage or hyoid bone • Florid facial and sparse conjunctival petechiae • Superficial tongue bite

7. A “straight-forward suicide” – Case 2 • Pressure marks on knees and abrasions on feet • Blood Alcohol Concentration 24 mg/dL • Other toxicology negative • Cause of Death: Hanging • Manner of Death: Suicide

8. A “straight-forward suicide” – Case 2 Mother of deceased contacts OCME to discuss her concerns regarding the circumstances of death • She sends a packet of information to OCME including e-mails suggesting deceased’s involvement with an asphyxial game known locally as “Space Monkey.” • During review of this material . . .

9. A Lesson Learned – Case 3 • 11-year-old male found by 7-year-old sibling hanging by a nylon dog leash from a peg coat rack in his bedroom • Ligature removed, CPR started by parent and 911 called • Transported to emergency dept. where he is pronounced dead after 10 minute resuscitative effort • No history of behavior disturbances, school failure, substance abuse or police contact

10. A Lesson Learned – Case 3 • Autopsy • ¼ - ½ inch circumferential ligature mark with distinctive weave pattern directly over laryngeal cartilage and sloping sharply upward to the occipital notch • Florid facial and sparse conjunctival petechiae

11. A Lesson Learned – Case 3 • No hemorrhage of strap muscles, no injury of cartilage or hyoid bone • Superficial tongue bite • Toxicology negative for alcohol and drugs

12. A Lesson Learned – Case 3 • Additional investigative data • Deceased’s sibling discloses brother’s involvement with “Space Monkey” • Intent stated to the sibling was to increase the time in which he could remain conscious • Cause of Death: Hanging • Manner of Death: Accident

13. On further review . . . • Death certificate in preceding case amended to Manner of Death: Accident • Two old cases were pulled for review • 12-year-old male with ADHD found hanged by dog leash – Manner of Death: Suicide  unchanged • 12-year-old female found in bedroom closet hanged by dog leash – Manner of Death: Suicide amended to Undetermined

14. Summary of Cases

15. Black Hole Blackout Flatlining Funky chicken Gasp Knockout Rising Sun Space cowboy Space monkey Suffocation roulette Tingling The American Dream Game Asphyxial “Games”

16. Key generational differences . . . • Use of ligatures • Solo play

17. Cases referred or known to author

18. A proposed “profile” emerges . . . • Typical age range: 9-15 • Male:Female ~1.5:1 • More often “action-oriented”, athletic, average-to-above-average students who would ordinarily shun alcohol and drugs • Alternatively a younger adolescent with anxiety &/or depression having a desire for but limited access to alcohol &/or drugs

19. What is in the literature? • Perrot, LJ, et al., Asphyxiation by hanging in two young Hispanic children – homicide, suicide or accidental deaths? AJFMP 6(4): 284-288, 1985 • Clarke, MA, et al., Asphyxial deaths due to hanging in children. JFS 38(2): 344-352, 1993 • Cooke, CT, et al., Death by hanging in Western Australia. Pathology 27:268-272, 1995 • Le D, Macnab AJ, Self-strangulation by hanging from cloth towel dispensers in Canadian schools. Injury Prevention 7:231-233, 2001. • Makwana N, et al., Two cases of near asphyxiation in children using non-releasing plastic garden ties. Emerg Med J 18:229-231, 2001. • Denton, JS, Fatal accidental hanging from a lanyard key chain in a 10-year-old boy. JFS 47(6):1345-1346, 2002 • Gicquel JJ, et al., Ophthamological complications of the asphyxiophilic “scarf game” in a 12-year-old child. J Fr Ophthalmol 27(10):1153-1155, 2004 (In French)

20. Research of note – theteenbrain.com

21. The Obvious Conundrum Youth Suicide • Suicidal violence is annually the second or third most common cause of death in the same age group • Scene and autopsy findings do not appreciably differ • Thorough investigation is the key to accurate certification

22. Youth Suicide in New Hampshire • Over 80% of youth suicides are male • Firearms account for as many youth suicides as hanging, overdoses and all other methods combined • Hanging predominates in 11-15 age group and females in general • Roughly 15% have made a previous attempt • 20% were known to have told others of suicidal ideation

23. Youth Suicide in New Hampshire • 51% had depressive symptoms • Nearly 40% had been referred for counseling or therapy • Depression is the most common diagnosis • 90% are medicated • 30% have had inpatient psychiatric admissions • Nearly 40% were taking prescribed medication, with 5% on five different drugs at the time of death

24. Youth Suicide in New Hampshire • Post-mortem toxicology has rarely detected the presence of illegal drugs • 11% with BAC 0.03 – 0.41 • 7% positive for illicit drugs • Nearly 30% had told others of an intent to commit suicide (3:1 male predominance) • Approximately 60% lived with both parents • Over 60% of events were at victim’s residence (including all females)

25. Youth Suicide in New Hampshire • Nearly 25% (nearly all males) were known to be experiencing social/educational difficulties • Roughly 20% (nearly all males) were known to have legal difficulties • Overall, 64% had ongoing stressors, 33% were immediate

26. Making the tough callSuicide? Accident? Undetermined? • Gathering data • Previous attempts • Family history of suicide • Recent “exposure” to suicide • Substance abuse/mental health history • Sexual orientation

27. Making the tough callSuicide? Accident? Undetermined? • Death scene and autopsy findings • Lethality of method • Trappings of ritualistic behavior • “Operational Criteria” • Rosenberg, ML, et al. “Operational Criteria for the Determination of Suicide,” J For Sci. 33(6); 11/98: 1445-1456 • Jobes, DA, et al. “Empirical Criteria for the Determination of Suicide Manner of Death,” J For Sci. 36(1); 1/91: 244-256

28. Making the tough callSuicide? Accident? Undetermined? • Application of “standard” criteria to adolescents? • Risk takers • Russian roulette • Asphyxial “games” • Substance abuse - How much is too much? • The question of intent • “Weighted” criteria • Swedo, SE et al. “Can Adolescent Suicide Attempters Be Distinguished From At-Risk Adolescents? Peds. 88(3); 9/91: 620-628

29. “Specific” Previous attempts Mood disorder Substance abuse (particularly in males) Males older than 16, living alone History of physical or sexual abuse “Less specific” Recent dramatic personality change Psychosocial stressor Writing, thinking or talking about death or dying Altered mental status Risk Factors

30. Other Risk Factors • Repeated aggression or delinquency • Chronic medical disorder • IQ below 70 • Poor parental relationships • Academic failure or drop-out • Pregnancy in females • Separation/divorce/single parent • Frequent family moves • Parental substance abuse, mental illness or criminality • Witness to extreme conflict &/or violence

31. 2003 YRBS Data • Percentage of HS students who seriously considered suicide and made a plan • Maine 24.7%, NH 28%, US 27.9% • Attempted suicide • Maine 9% (females 12.1%, males 5.3%) • NH 7.7% (females 11.4%, males 3.9%) • US 8.5% (females 11.3%, males 5.9%)

32. The Media Reacts . . .

44. Ireland The Irish Examiner – International News

45. England

46. Conclusions • The games are not new, but the terms of engagement have changed • Suicidal violence remains a leading cause of death in young adolescents, but some cases may be misclassified • Death scenes and autopsy findings involving asphyxial games do not appreciably differ.

47. Recommendations • Investigators must ask the right questions of the right people to expose the possible role of such games in hanging deaths • Clues, albeit subtle, at death scene may suggest unintentional outcome of asphyxial activity • Do not neglect diaries, journals and computers if given access • When encountering such cases, engage local resources e.g. public health/injury prevention, pediatric society, youth suicide coalitions to raise public awareness