After finding a picture of her son engaging in a dangerous activity known as "the choking game", Michele Mansfield kept her eyes open for additional warning signs that her son was putting his life at risk.
But ultimately, her diligence could not save her son's life.
"No one ever talked about it," said Mansfield of Phoenix, adding that at the time her son Nick Serna likely engaged in the practice -- from 2004 to 2005 -- there was little information available on the deadly game.
"Sometimes he would be in his room, and he would come out kind of dazed and confused," she said. "I would check his eyes for redness, but I never checked his pupil size. You do not always see redness unless they do it for a long, extended period of time."
On Jan. 29, 2005, Mansfield's suspicions were confirmed.
"We called him for dinner and he didn't come," she recalled. "I had been in the room 15 minutes earlier."
Nick had strangled himself using an ace bandage tied to his bed. Mansfield believes that her son had no intention of killing himself, but that a strip of Velcro had caused the bandage to remain around his neck even after he released it.
"He was blue, and it was awful."
Now, new research suggests that doctors, as well as parents, may be less aware than they should be of the warning signs that a child is engaging in this dangerous practice.
The report, titled "The Choking Game: Physician Perspectives," will be published in the January issue of the journal Pediatrics. It details the results of a survey issued to 163 pediatricians, in which nearly a third of the doctors -- 32 percent -- had never even heard of the choking game. A quarter of those who responded could not identify a single physical warning sign of a child's participation in the game, such as bruising around the neck, headaches and bloodshot eyes.
Choking Game Is a Deadly Pastime
The choking game is an activity usually practiced by children and adolescents, either alone or in groups. Sometimes the "players" choke each other; other times they use improvised nooses to accomplish the goal of the activity -- depriving the brain of needed oxygen -- which leads to possible loss of consciousness and a temporary high.
Mansfield said the report confirmed to her something which she had long suspected.
"Doctors don't look for this in kids because it's not something that's talked about; it's not common knowledge," she said. "I don't think doctors are very educated about it."
Mansfield said that after this realization, she began to talk to doctors about the practice in the first year after her son died.
"Even when I want out there and started talking about it, most of them were skeptical," she said. "Some of them listened to me, but some of them blew me off."
Judith Myers-Walls, an associate professor and extension specialist of Child Development and Family Studies at Purdue University in West Lafayette, Ind., agreed that doctors should know more about the practice.
"I can tell you that I came in contact with this more than 30 years ago when I was a houseparent with 'pre-delinquent' teens," she said. "One of the teens fell and had a knot on his head. He said it was because he was standing on something and fell, but we discovered he was playing with anoxia -- it wasn't called the choking game then.
"It is important to recognize that there are some teens who are always looking for a way to find a 'high,' and approaches like this are cheap and do not involve possession of illegal substances," Myers-Walls said. "So they are hard to control, and they may seem safer and more harmless to the kids."
Choking Game Warning Signs
Some doctors were not particularly surprised by the findings -- especially since detecting the warning signs of teh activity may be difficult during a brief appointment.
"I know that the choking game exists, but with the limited time allowed for health visits, it's hard to cover all high risk behaviors," said American Academy of Pediatrics spokeswoman Dr. Alanna Levine. "That being said, it is important to touch on the subject and perhaps research such as this study will remind pediatricians to add it to the conversations."
She added that doctors and parents should not wait for warning signs to appear before discussing the dangers of the choking game with kids.
In recent years, more research has been devoted to learning more about this dangerous game. In a February 2008 article, researchers with the U.S. Centers for Disease Control and Prevention reported that the choking game had led to the death of at least 82 children and adolescents since 1995.
According to the CDC report, most of those who died were between the ages of 11 and 16. Boys are more likely to die from the choking game than girls, and nearly all who died were playing alone when they died.
The CDC suggests that doctors and parents should be on the lookout for the following warning signs that a child may be engaging in the choking game:
Discussion of the game or its aliases
Marks on the neck
Wearing high-necked shirts, even in warm weather
Frequent, severe headaches
Disorientation after spending time alone
Increased and uncharacteristic irritability or hostility
Ropes, scarves, and belts tied to bedroom furniture or doorknobs or found knotted on the floor
The unexplained presence of dog leashes, choke collars, bungee cords, etc.
Petechiae (pinpoint bleeding spots) under the skin of the face, especially the eyelids, or the conjunctiva (the lining of the eyelids and eyes)
Mansfield said she hopes more doctors will take these warning signs to heart so more children can be protected.
"I wish that doctors would be educated about this," she said. "They need to be, because it could save a child's life."