When Sarah Pacatte heard her son, Samuel, say "Gabe," she sensed something was wrong. She started running even before Samuel began screaming, "Mom!"

Reaching her sons’ bedroom within seconds, Pacatte entered a mother’s nightmare; Samuel was behind the limp body of Gabriel, his twin brother, attempting to prop him up under his armpits and lift him above a rope hanging around his neck. Pacatte instinctively put her fingers between the rope and Gabriel's neck. The rope, which was not tied or knotted, fell away.

Even with emergency service personnel intervention, repeated use of a defibrillator and several attempts at revival, Pacatte’s son died in her arms after being flown from their hometown of Paradise, Calif. to a Sacramento hospital. He never regained consciousness.

Investigating authorities at first questioned Gabriel’s motives, exploring any suicidal tendencies and asked if Gabriel was found with his pants pulled down or if his zipper was open.

However, Gabriel, who would have turned 14 on July 31, did not commit suicide and was not practicing autoerotic asphyxiation, which older teens may practice to increase sexual pleasure and what many authorities usually associate with accidental adolescent strangulation. He died from the “choking game.”

The game has many names, ranging from “pass-out game,” “suffocation game,” “blackout,” “funky chicken,” “space monkey,” “flatliner,” “tingling,” “suffocation roulette,” “space cowboy,” “knockout,” “gasp,” and “rising sun,” to name a few.

It can be done alone using a rope, necktie, hands or plastic bags. Or it may be practiced in groups with one person hyperventilating, then holding his or her breath while another person bear hugs them from behind.

Both practices reduce blood return to the heart, which reduces blood output from the heart. When blood output to the brain is reduced, brain oxygen is reduced and the person faints or passes out.

Kids may try it due to peer pressure, while others are chasing a legal high. The experience can lead to a mild to moderate state of euphoria lasting five to 10 seconds. It can also cause serious brain injury.

“More often than not these younger adolescents that die from accidental hanging have absolutely no sign of a sexual connection or a suicide connection,” Pacatte said. “Yet because so many first on the scene, medical personnel, coroners, educators and the communities as a whole are ignorant of this game, these deaths are often labeled inaccurately.”

In fact, UCLA Medical Center declined an interview request on the subject, explaining the decision by stating they had never heard of it and suggesting the choking game was perhaps "an urban legend."

Although recent stories from across the country and two high-profile cases in Idaho have shed light on what many call a growing trend, Pacatte remembers trying the game herself¯and not liking it¯when she was younger. She has received mail from others saying they experimented with it as well, and the game is by no means new. One woman wrote her admitting she tried it in 1939. Previously, when Pacatte caught Gabriel and Samuel choking themselves, she warned them to never to do it again. Both boys promised to stop. Samuel kept his promise.

“[The choking game] is something that has been kept quiet for far too long and a change needs to happen,” Pacatte said. “Kids are taught in public schools the risk associated with thrill-seeking behaviors such as illicit drug use and illicit sex. The choking game is the same type of behavior.”

Warning signs can include unexplained marks on the neck, short ropes, padded ropes or neckties tied in odd knots, bloodshot eyes, complaints of headaches and locks on bedroom doors. Older children may have signs of AEA, which may include pornography and/or women’s clothing.

Now Pacatte is trying to pick up the pieces of her life. Driving home from work, she often “loses it.” Rest is often put off until she knows she will fall asleep immediately, otherwise idle time is “sheer agony, with constant images of that night and the next day forever burnt in my mind.”

If it wasn’t for her three other children, the people in her life and a strong faith in God, which has been tested, Pacatte said she couldn’t go on. The day before her son’s birthday was especially hard. Samuel, she added, is not doing so well.

“These two [Samuel and Gabriel] were together from the very beginning of their existence, and to suddenly be severed from your roommate, your backup, your company when you get home from school, your sparring partner—oh what I wouldn't give to hear them going at it—your confidant, your partner in crime and mischief, your twin, your brother has got to be one of life’s cruelest punches,” Pacatte said. “Pile that on top of being 13. Samuel loves his brother, and Gabriel loved Samuel. Samuel has some rage going on, and we do not communicate very well right now.”

A few days after Gabriel’s death, school authorities at Gabriel and Samuel’s schools were reluctant to bring up the subject with rumors of suicide still in the air. After reading a local paper’s article revealing the true nature of Gabriel’s death, Tamara Conley, Gabriel’s algebra teacher, took an informal poll of the seventh grade classes on whether they had heard of the game. In each class 6-7 hands went up. When Conley went to the eighth graders, half the hands in every class went up. Pacatte was then asked if she would like to address Samuel’s classmates during a memorial tree-planting ceremony in honor of Gabriel.

“I told them that doing drugs, drinking, hurting your body are stupid choices and Gabe made a stupid choice,” Pacatte said. “I also told them they may or may not run into peer pressures and if they did, it would not be cool to buckle and go along with them for the sake of being cool.”

Fearing children may still pass the game along to others without knowledge of its neurologically damaging or fatal consequences, Pacatte hopes parents and anyone who has contact with children will listen, ask questions and educate kids on the dangers involved.

“I miss my son so much I can't breathe at times,” Pacatte said. “His death will not be in vain.”