Asphyxial Games in Children and Adolescents Thomas A

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

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

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

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

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

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

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

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. ”

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

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

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

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

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

Summary of Cases Cas Age Se e x Psychiatr Previo School us Proble ic Attemp ms Diagnosi t s Precipitati Manner ng Event of Death 1 9 M N N N Y? A 2 13 M N N N Y? S A 3 11 M N N A 4 12 M Y N S 5 12 F N N N Y? S

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

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

Cases referred or known to author Case Age Sex Psych Dx Prev. Att. School Precip. Prob. MOD 1 13 F N N N Y U 2 13 M N N N Y A 3 14 M ? N N N ? 4 10 M ? N ? ? ? 5 15 F N N A 6 12 M Y N Y Y S 7 14 M N N S 8 12 M N N S 9 12 M N N S 10 14 F ? ? S 11 14 M Y ? Y Y? S 12 10 M N N A 13 15 F N N A 14 14 F Y N S 15 17 M N N S

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

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)

Research of note – theteenbrain. com

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

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

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

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

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

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

Making the tough call Suicide? 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

Making the tough call Suicide? 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

Risk Factors • “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

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

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%)

The Media Reacts. . .

Ireland The Irish Examiner – International News

England

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.

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