American Academy of Pediatrics Recommendations for the Prevention of Pediatric ATV-Related Deaths and Injuries

Shortly after their introduction in the 1970s, all-terrain vehicles (ATVs) were identified as a serious threat to the health and well-being of children and adolescents.^1,2  Since then, the human and economic costs of pediatric ATV-related deaths and injuries remain high, and the evidence of this threat has become more compelling over time. US Consumer Product Safety Commission (CPSC) data from 1982 to 2015 demonstrate that ATV crashes have killed more than 3000 children younger than 16 years of age and required emergency department visits for nearly a million more.^3,4  It is currently estimated that every hour in the United States, approximately 4 pediatric patients are seen in an emergency department for an ATV-related injury.⁴  In fact, more children die each year on ATVs than in bicycle crashes.⁵  Unfortunately, many parents and other caregivers have failed to recognize and/or acknowledge the risk and heed the warnings, putting children and teenagers at significant and unnecessary risk of serious injury and death.

American Academy of Pediatrics (AAP) recommendations for the use of ATVs and off-road vehicles by youth were published in 1987 and 2000.^6,7  These policy statements covered 2-wheeled vehicles (eg, dirt bikes) as well as ATVs with 3 and 4 wheels. Since 2000, the body of ATV injury prevention research has greatly expanded. A detailed summary of the current literature regarding children and ATVs and data supporting the recommendations that follow can be found in an accompanying technical report published in Pediatrics.⁸  Because of this expanded body of knowledge and because a number of safety issues related to ATVs differ significantly from those of 2-wheeled vehicles, the current policy statement will focus exclusively on ATVs.

Another type of off-road vehicle growing in popularity is generically called a side-by-side. The current peer-reviewed literature on side- by-sides is very limited, but other sources of information, including the CPSC, suggest that they are an emerging public health concern for all ages. Although some characteristics of side-by-sides are similar to ATVs (eg, propensity to rollover), other features are not (eg, seat belts). A specific set of recommendations for preventing pediatric side-by-side–related deaths and injuries is warranted but is beyond the scope of this policy statement.

Survey studies have found high proportions of youth riding on ATVs—75% of students 12 to 16 years of age in a statewide study⁹  and more than 95% of youth from predominantly rural populations.^10–12  Although the likelihood and frequency of riding an ATV is higher for youth who live in rural areas,⁹  ATV use and resulting crashes are not only a rural phenomenon.^9,13  US YouthStyles survey data showed that more than 1 in 5 urban youth reported having ridden on an ATV.¹⁴ 

In the United States, the primary use of ATVs is recreational, and more than 90% of pediatric crashes have occurred while riding for fun.^14–17  However, youth using ATVs for farming activities also represent an at-risk riding population.^15,18–20  In 2001, more than 850 000 ATVs were present on US farms and more than 380 000 youth on these farms had operated an ATV.¹⁸  The estimated ATV-related injury rate among younger riders was 4.3 per 1000 farm youth. In addition, there are remote areas with limited road access where ATVs may be used as a primary mode of transportation.

Decades of epidemiologic evidence support the conclusion that ATVs present a significant danger to the lives and health of children and adolescents.⁴  A number of major independent risk factors for pediatric ATV crashes have been identified.

Younger age (<16 years) and being male are independent risk factors for ATV crashes.^21–23  Moreover, males consistently represent 70% or more of all ATV crash victims.^24–31  The increased risk among younger riders, particularly young males, is likely attributable in part to their higher propensity for risk-taking behaviors.^32,33 

More than 90% of deaths and injuries among ATV riders younger than 16 years of age have occurred when they were on adult-size vehicles.²⁸  Child development research suggests that youth do not have the physical, mental, and cognitive maturity to operate ATVs safely, and this is especially true for the larger, heavier adult models. There are youth models available for children 6 years and older, and age-based recommendations are related to maximum restricted and unrestricted speeds.^15,34,35  No youth models are recommended for use by children younger than 6 years of age. Of particular note, maximum speeds of youth models (eg, 30 mph for 10 years and older) are not based on direct scientific evidence for their safety.³⁴ 

Riding on public roadways, both paved and unpaved,³⁶  is among the most dangerous of riding behaviors. This danger results from their fundamental off-road vehicle design^36–38  and because the inherent instability of ATVs may be exacerbated by roadway speeds. More than half of all pediatric ATV-related fatalities have occurred on the road, and the proportions varied with age, from 38% for children younger than 6 years of age to 72% for adolescents 16 to 17 years of age.²⁸  Pediatric ATV roadway crashes occur in both rural and urban areas.¹³ 

Nearly all ATVs are designed for a single rider. Riding with or as a passenger increases the risk of crashing.^21,23,39  Passengers shift the center of gravity and can interfere with both the physical (eg, shifting of weight) and cognitive (eg, awareness of the terrain) aspects of safe vehicle operation. Research studies have determined that 15% to 40% of children injured in nonfatal ATV crashes were passengers,^27,29,40  and passenger victims constituted 25% of all pediatric ATV-related fatalities in the CPSC database.²⁸  Operators on ATVs with passengers are also at increased risk, and 46% of all pediatric ATV-related deaths were passengers or operators with passengers.²⁸ 

Studies have found that helmet use among pediatric crash victims is relatively low (25% or less).^28,41,42  The exception to these findings was a study showing that following passage of an ATV helmet law covering youth younger than 12 years of age, half of the pediatric crash victims in this age range were wearing helmets at the time of the crash.⁴³  Overall, helmets can reduce the likelihood of an ATV-related fatal head injury by about 40% and a nonfatal brain injury by 60% or more.^{28,37,38,44–46} 

There are a number of contributors to pediatric ATV crash risk that have been less well studied. These include inadequate adult supervision,^11,12,16,28  lack of training,^10–12,47  speed,^24,48,49  alcohol use,²⁸  and nighttime riding.^16,50 

High proportions of youth in survey studies report engaging in unsafe riding behaviors.^9–12,14  One-half to 92% of youth reported having ridden with multiple riders, and 42% to 81% indicated they had ridden on public roads. In 2 studies, 46% and 53% responded that they had ridden an ATV after dark.^11,12  Whereas relatively high proportions reported they sometimes wore a helmet, 30% or less indicated they always or almost always rode helmeted.^9,10,12  More frequent riders and riders from rural areas were less likely to report being helmeted.^9,14  When the number of risky behaviors (multiple riders, riding on the road, riding unhelmeted) for each student in a statewide study was determined, 60% reported engaging in all 3 and only 2% had engaged in none.⁹ 

Studies have identified the major crash mechanisms and injury patterns for youth riding ATVs.⁵¹  These mechanisms and patterns vary by pediatric age group,^28,52  but overall injury severity is high.

The most common crash mechanism is a noncollision event—predominantly rollovers.^{28,30,37,38,53–55}  Although motor vehicle collisions are significantly more likely on roadways than off-road, more than 70% of ATV roadway crashes are single-vehicle events.^37,38  Collisions are more likely among youth than among adults,⁵⁶  and fatality victims 12 to 17 years of age had a higher proportion of both collisions with motor vehicles (26% vs 15%) and other collision events (34% vs 25%) compared with those younger than 12 years of age.²⁸  The higher proportion of motor vehicle collisions among older youth may be attributable to more riding on the road relative to their younger cohort.

Research illustrates a relatively high morbidity and mortality among pediatric ATV crash victims. For example, United States hospitalization rates (2000–2004) were 30% higher for youth as compared with victims 18 to 44 years of age.⁵⁷  Additionally, pediatric ATV crash victims were 7 times more likely to be hospitalized than the overall pediatric population and twice as likely as pediatric patients in motor vehicle crashes.⁵⁸  Injuries from roadway crashes are generally more severe than those off-road.^36,38 

Injury patterns among children younger than 16 years of age showed that the youngest victims (<6 years of age) had higher proportions of head, face, and neck injuries, whereas older youth more commonly suffered extremity injuries.⁵²  Traumatic brain injury is among the leading causes of death and disability in pediatric ATV crashes,^15,28,56,59  and the likelihood and severity of head injuries are higher in roadway crashes than in those off-road.³⁸  The severity of head injury also increases as the vehicle engine size and power increase.⁶⁰ 

Multisystem injury attributable to crush-related trauma is also a major cause of pediatric ATV-related death and serious injury. Compression-related asphyxia resulting from victims being trapped with the vehicle over their chest or neck has increased over time.³⁸  The increase in this type of injury is consistent with the larger engine size of ATVs involved in fatal pediatric crashes.²⁸ 

Passengers affect both the mechanisms and types of injuries. For example, passengers increase the likelihood of backward rollovers and falls or ejections to the rear⁶¹  and decrease the likelihood of self-ejection. These, in turn, may reduce riders’ ability to break their fall and protect their head and could help explain the higher rates of brain injury in crashes with multiple riders.⁶¹  The lower likelihood of passengers and operators with passengers to be helmeted relative to operators riding alone may also contribute to the increased likelihood of brain injury in multi-rider crashes.³⁷ 

On the basis of the robust and growing body of peer-reviewed evidence,⁸  the AAP updates its earlier recommendations^6,7  with the ongoing goal of decreasing pediatric deaths and injuries related to the use of 3- and 4-wheeled ATVs:

1. The recommendation of the AAP remains that no child younger than 16 years of age should operate or ride as a passenger on an ATV. This is the consensus-based best practice for preventing pediatric ATV-related deaths and injuries.

2. The AAP recognizes the following safety practices for ATV operators. These rules are based on the most serious risk factors for pediatric ATV-related deaths and injuries. All available evidence indicates that parents and other adults who fail to enforce these safety rules with children are placing them at significant and unnecessary danger of injury.

   • Never operate an ATV on a public roadway.

   • Never cross a public roadway unless permitted by law and supervised by an adult 18 years of age or older.

   • Never carry or ride as a passenger on a single-rider ATV (all youth models and the majority of adult models).

   • Only operate ATVs that are the right size for the operator—ie, that meet anthropometric fit criteria and meet manufacturer age recommendations for the rider.

   • Always wear a Department of Transportation-compliant helmet.

   • Never ride at night (ie, after dusk and until dawn).

   • Never operate an ATV under the influence of alcohol, illicit drugs, or substances or medications that physically or cognitively impair the ability to maintain vehicle control.

3. The AAP acknowledges that some families may have special circumstances—for example, living in remote communities—for which transportation to work and school as well as other essential nonrecreational activities may require the use of ATVs by youth younger than 16 years of age. In these cases, parents should follow as closely as possible all general and age-specific safety rules to reduce the chances of harm to the children in their care.

4. Age-based studies of pediatric ATV-related deaths and injuries have determined that there are differential impacts of risk factors by age. Based on these studies, the following practices should be applied to further mitigate these risks.

   Children younger than 6 years of age:

   • Caregivers should never allow children in this age range to operate an ATV because of their extremely limited physical, mental, and cognitive maturity. Note that there are no ATVs recommended for this age group.

   • Allowing these children to operate an ATV under any circumstances should be considered a particularly irresponsible and dangerous choice.

   • Caregivers should never carry or allow these children to ride as passengers on any ATV.

   Children 6 to 11 years of age:

   • Although there are youth models designated for children in this age range, the safety of these vehicles is unknown, and the limitations in the physical and cognitive abilities of these children are significant.

   • Parents should seriously consider these factors and not allow 6- to 11-year-olds on ATVs.

   Children 12 to 15 years of age:

   • Despite some children in this age range potentially meeting anthropometric fit criteria for adult ATVs, 98% of deaths and injuries among youth 12 to 15 years of age occur on adult vehicles, suggesting that proper fit is not sufficient for safe operation of adult vehicles by these youth.

   • Thus, children in this age range should be restricted to youth models.

   • Moreover, all children, including those 12 to 15 years of age, should be directly supervised by an adult (but not as a rider on the same vehicle) to ensure they practice the safest riding behaviors.

5. Parents and other adults are highly encouraged to ensure that these additional safety recommendations are followed:

   • Have youth complete formal ATV safety training, preferably with a hands-on component, before riding ATVs. Potential sources of formal training can be found at ATVsafety.org or by calling 800-887-2887.

   • Make sure youth wear other protective gear in addition to a helmet, including a face shield or goggles, long sleeves, long pants, over-the-ankle boots, and gloves. Consider use of a chest protector and more durable gear if aggressive riding at higher speeds is planned (eg, ATV motocross racing).

   • Ensure reasonable speed for noncompetitive riding by setting and enforcing speed limiter settings on youth models.

   • Mount an orange safety flag on the youth-size ATV so that it is at least 5 feet off the ground and use reflectors and lights to increase visibility of the vehicle to others.

   • Determine that their child knows and understands the rules of ATV safety.

   • Use appropriate disciplinary actions to promote consistent practice of these rules.

6. Parents in households that do not own an ATV should never assume that their child does not have access to these vehicles. If they do not want their child on an ATV, they should make their child, all relevant adults, and other children aware of this fact.

7. Although teenagers 16 years of age and older may operate an adult-size ATV and may no longer require direct adult supervision, the other previously mentioned safety rules and recommendations still pertain, including never riding as or carrying passengers and always wearing a Department of Transportation-approved helmet. In addition:

   • Although some jurisdictions may allow those 16 years of age and older with a driver’s license to drive on public roadways, for safety reasons this should be avoided unless absolutely necessary.

   • If operating an ATV on the road, all laws and regulations related to that operation as well as all other traffic safety laws should be obeyed, including refraining from operating the ATV under the influence of alcohol or drugs.

   • Even if allowed by law for older teenagers, nighttime riding is also best avoided.

8. The manufacture of 3-wheeled ATVs was banned in 1988; however, evidence shows that these vehicles continue to kill and injure riders, including youth.²¹  Thus, the AAP recommends:

   • All owners stop using 3-wheeled ATVs and render them inoperable.

   • All owners refrain from selling these vehicles to other consumers on the secondary market.

   • Manufacturers, through their dealers, provide incentives to remove 3-wheelers from the market, such as a generous discount for trading them in at dealerships.

   • If dealers have or receive a used 3-wheeled ATV as a trade-in, they should be made inoperable and properly discarded.

9. The experiences of ATV injury prevention advocates strongly suggest that general public awareness of the significant dangers that ATVs pose to youth is limited. The AAP recommends that manufacturers, regulatory agencies, and public health institutions increase their efforts to educate stakeholders and the public regarding the hazards of ATVs to children and teenagers.

10. Primary care providers should identify families who own ATVs and determine whether patients have had or may have potential exposure to ATVs. If so, anticipatory guidance about ATV safety should be provided based on AAP safety recommendations.

11. The AAP should work with racing organizations, such as the ATV Motocross National Championship series and Grand National Cross-Country series, to encourage them to discontinue competition by riders younger than 6 years of age as there are no vehicles manufactured for this age group, and to ensure that all recommended safety rules are followed for riders of all ages.

12. Evidence suggests that off-road vehicle parks and trails and organized riding events can be safer riding experiences for all family members.^62,63  The AAP recommends support for these dedicated recreational riding settings as a safer alternative to other off-road riding.

13. The AAP recommends that design modifications to make youth and adult ATVs safer be independently tested and, if found effective, be required as standard design. These would include ATVs with:

    • Rollover-protection structures and restraint devices (ie, seat belts or harnesses). Such vehicles should include design features that prevent operation or significantly limit speed if the restraint device is not in use.

    • Crush protection devices.

    • Headlights that automatically turn on when the vehicle is started to improve visibility.

    • Tamper-proof speed governors or limiters.

    • Seat designs that decrease the likelihood of passengers on ATVs—for example, optimal seat length adjustment or placement, and/or vehicle noperability if passengers are present.

    • Youth ATV design changes that would lower maximum speeds and improve stability and anthropometric fit.

14. A prompt and effective emergency medical response can reduce the long-term medical consequences following a crash. The AAP recommends that emergency medical services providers be provided training about the specific challenges of off-road vehicle crash rescue and the common injury patterns that occur. Emergency medical services agencies should consider obtaining off-road rescue vehicles for remote crashes and training operators in their safe use.

15. Pediatricians and other stakeholders should advocate for legislative changes that promote ATV safety. State, county, and local laws and ordinances that encourage unsafe riding behaviors, such as allowing recreational ATV riding on public roadways, should be repealed. In addition, the following evidence-based ATV safety legislation should be passed and enforced in all states.

A. Laws that:

• Require ATV safety training, including a hands-on component, and age-appropriate operator licensing for youth.

• Require a safety flag to increase vehicle visibility.

• Require visible display of a vehicle license number to aid in enforcement.

• Require use of an approved helmet when on an ATV.

B. Laws that:

• Prohibit use of adult-size ATVs by youth younger than 16 years of age.

• Prohibit operation of any ATV, including youth-size models, if the child or teenager is below a specified age, ideally younger than 16 years of age, but minimally younger than 12 years of age.

• Prohibit passengers on ATVs designed for a single rider.

• Prohibit use of ATVs on public streets and roads except for occupational purposes by licensed operators 16 years of age and older.

• Prohibit operation of ATVs while under the influence of drugs or alcohol.

Charles A. Jennissen, MD, FAAP Gerene M. Denning, PhD Mary E. Aitken, MD, MPH, FAAP

Benjamin Hoffman, MD, FAAP, Chairperson Phyllis F. Agran, MD, MPH, FAAP Michael Hirsh, MD, FAAP Brian Johnston, MD, MPH, FAAP Sadiqa Kendi, MD, FAAP Lois K. Lee, MD, MPH, FAAP Kathy Monroe, MD, FAAP Judy Schaechter, MD, MBA, FAAP Milton Tenenbein, MD, FAAP Mark R. Zonfrillo, MD, MSCE, FAAP Kyran Quinlan, MD, MPH, FAAP, Immediate Past Chairperson

Jonathan D. Midgett, PhD – Consumer Product Safety Commission Bethany Miller, MSW, MEd – Health Resources and Services Administration Judith Qualters, PhD – Centers for Disease Control and Prevention Alexander W. (Sandy) Sinclair – National Highway Traffic Safety Administration Suzanne Beno, MD – Canadian Paediatric Society

Bonnie Kozial

AAP

American Academy of Pediatrics

ATV

all-terrain vehicle

CPSC

US Consumer Product Safety Commission