A Comprehensive Report on All-Terrain Vehicles and Youth: Continuing Challenges for Injury Prevention

An all-terrain vehicle (ATV) is a motorized vehicle with 3 or more low-pressure off-road vehicle tires, a straddle seat, and handlebars with a throttle and hand brakes. The earliest models were 3-wheeled, but a 1988 settlement between the US Consumer Product Safety Commission (CPSC) and ATV manufacturers included banning further production of 3-wheelers because of significant safety concerns.¹  The predominant models of ATVs since that time have been 4-wheeled vehicles.

ATVs are specifically designed for off-road use only, with a high clearance and narrow track to facilitate riding over rough terrain and between obstacles. These features, however, create a relatively high center of gravity with associated instability. Their low-pressure, knobby-treaded tires are designed to “grab” off-road surfaces and provide traction. In addition, unlike vehicles designed for roadway use, most ATVs have a solid rear axle or locked rear differential that requires a wider turning radius. These design features contribute to a high propensity for loss of control, most often resulting in a rollover.

To help counterbalance this tendency, operators are required to engage in “active riding.”²  Briefly, active riding involves operators shifting their weight to maintain a stable center of gravity and prevent loss of control. Other aspects of active riding include adjusting grip and footing to counteract destabilizing forces on the vehicle and absorbing shocks with the arms and legs. Because of the complexity of off-road terrains, the operator must also maintain situational awareness at all times and be able to rapidly judge and respond to terrain changes.

Before 1998, most adult ATVs had engine sizes ranging from 90 mL to 350 mL and weights of around 150 to 300 pounds. Since then, engine sizes and vehicle weights have increased dramatically. Current adult models have engine sizes up to 1000 mL and weights over 800 pounds. Many models can achieve speeds over 70 mph. Sales information is limited, but the estimated number of ATVs in use in the United States increased from fewer than 4 million in 1999 to more than 10 million in 2008,²  and ∼12% of all Americans 30 to 49 years of age own an ATV.³ 

Age recommendations for youth models were originally related to engine size. Until 2009, vehicles for children 6 to 11 years of age had engine sizes of <70 mL and those for ages 12 to 15 years were ≤90 mL. Current recommendations are based on maximum restricted (fully engaged speed limiter) and maximum unrestricted (no speed limiter engagement) speeds. For Y6+ models (recommended for children 6 years of age and older), these speeds are 10 and 15 mph, respectively. For other youth models, the parameters are: Y10+ and Y12+, 15 mph and 30 mph; and Y14+, 20 mph and 38 mph. Many youth models still have engine sizes similar to the pre-2009 standards, but some newer models have larger engine sizes. As with previous recommendations, no motorized ATV models are manufactured for children younger than 6 years of age.

CPSC data from 1982 to 2015 demonstrate that ATV crashes have killed more than 3000 children younger than 16 years of age and resulted in emergency department (ED) visits for nearly a million more.^4,5  Over the last several decades, children 15 years of age and younger have constituted approximately one-fifth of deaths and one-third of ED visits from ATV crashes.⁵  More children die each year on ATVs than in bicycle crashes,⁶  and it is currently estimated that every hour in the United States, ∼ 4 pediatric patients are seen in an ED for an ATV-related injury.⁵ 

With respect to pediatric injury severity, a nationwide study found that the hospitalization rate was 30% higher for youth injured in ATV crashes compared with adults 18 to 44 years of age.⁷  In a similar study, children in ATV crashes were 7 times more likely to be hospitalized compared with the pediatric trauma population as a whole, and twice as likely as youth in motor vehicle collisions.⁸  Results from a large number of epidemiologic studies for individual states, as well as for US trauma center populations, can be found in a recent review article.⁹ 

Outside the United States, the majority of research on ATVs (called quad bikes in many countries) has been performed in Canada, the United Kingdom, Australia, and New Zealand. The proportions of children who were victims of fatal and nonfatal crashes in these countries have been similar to those in the United States.^10–16 

In the United States, ATVs are mostly used for recreation, and riding for fun is the source of most ATV-related deaths and injuries.^2,17,18  A study of pediatric crash victims found 96% were riding recreationally at the time of their crash.¹⁷  In addition, a US survey study²  found that 6% of respondents reported racing as 1 of their recreational ATV uses, and Canadian pediatricians¹⁹  reported that 3.6% of their pediatric patients were injured in organized racing events. Two case series from West Virginia²⁰  and Ireland²¹  have reported high morbidity from racing-related injuries.

Although recreation is the primary use of ATVs, a national sampling of ATV-owning households²  and surveys of adolescents attending state 4-H²²  and FFA²³  conferences found that from 21% to 29% reported occupational use of the vehicle. Research has shown that the majority of occupational ATV fatalities occur in the agricultural sector,^24–26  and several epidemiologic studies indicate that children in rural areas and those living on farms constitute a particularly at-risk occupational ATV riding population.^27–29 

Total costs for ATV-related deaths and injuries are substantial. A report by the US General Accounting Office gave an estimated cost in 2007 of $22.3 billion (in 2009 dollars), more than doubling estimates from 1999.²  This included $17.7 billion in nonfatal injury costs and $4.6 billion in fatality costs. Given that children represent one-third of the injuries and one fifth of the deaths in 2007,³⁰  the overall total costs associated with pediatric ATV injuries and fatalities could be estimated as ∼ $6.9 billion. Thus, in addition to their high human costs, pediatric ATV crashes are a significant economic burden to society.

Surveys of children from largely rural areas have found ATV exposure rates of 97% to 100%, with 24% to 67% of these riders reporting having crashed while on an ATV.^22,23,31  Additionally, a school-based study of more than 4600 adolescents found that 75% had been on an ATV, including youth from schools with urban zip codes.³²  Fifty seven percent of these riders stated they had been in a crash. Similarly, high proportions (77%) of rural Canadian youth reported having ridden on ATVs.³³ 

All research to date, regardless of country of origin, has found that males represent the majority (67% to 91%) of pediatric ATV crash victims.^{12,19,34–39}  Moreover, even after controlling for exposure, ATV-related injuries per riding hour were several fold higher for males than for females.⁴⁰  A likely contributor to this increased rate is a greater male penchant for risk-taking behavior.^41,42 

The highest proportion of United States pediatric injuries has been among adolescents 12 to 15 years of age,^40,43,44  whereas Canadian pediatricians found the highest proportion of patients (45%) were somewhat younger, 10 to 14 years old.¹⁹  For deaths, CPSC fatality data showed that approximately one third of all US pediatric fatalities were children 11 years of age and younger.³⁶  The majority of ATV crash victims, including youth, have been white and of medium to high socioeconomic status.^45–48  Other demographic characteristics of pediatric ATV crashes can be found in a recent review.⁹ 

A number of studies have shown that ATV crash rates per unit population were higher in rural areas,^38,49,50  and adolescent students from areas designated as “isolated rural” reported higher exposure to ATVs and significantly greater frequency of ATV use compared with those in other geographic areas.³²  However, a geospatial mapping study in Iowa⁵¹  and a multicenter study in Ohio⁴⁶  both found that nearly one half of the crashes involving youth occurred in urban zip code areas.

Despite the fact that the majority of riding occurs off-road, ∼ 60% of ATV-related deaths are from crashes on public roadways, both paved and unpaved.^52,53  The proportion of fatal United States roadway crashes among youth ranged from 38% for children younger than 6 years of age to 72% for 16- to 17-year-olds.³⁶  The proportion of nonfatal pediatric crashes reported to have occurred on public roads or streets has ranged from 11% to 38%.^17,46,54,55 

Noncollision events constitute the majority of ATV crashes.^{36,38,52,53,56,57}  These crashes are predominately rollovers, but falls and ejections from the ATV are also common. For pediatric ATV-related fatalities, collisions are more common in older youth, with those 12 to 15 years of age having the highest percentage of collisions with a nonmoving object and teenagers 16 to 17 years of age having the highest percentage of collisions with another motor vehicle.³⁶  Although the likelihood of a collision with another motor vehicle is significantly higher on the road than off,^52,54  70% or more of ATV roadway crashes are not traffic-related—that is, they are a single-vehicle event.^36,52–54 

The most frequently injured body parts in ATV crashes are the extremities (31% to 60%) and the head, neck, and face region (16% to 44%).^34,58–61  More than half of all injuries are fractures and dislocations or injuries to the skin, including contusions, abrasions, and lacerations. Younger children (<6 years of age) are more likely to injure their head and face, whereas extremity injuries progressively increase with age.^8,58,43  Adolescents are more likely to be primarily ejected or in collisions that result in falling or being thrown from the vehicle.^36,38  These mechanisms could result in lower and upper extremity injuries from the use of legs and arms to break the fall from the vehicle and to protect the head and torso. Compared with snowmobiles and dirt bikes, ATV-related injuries have been found to have higher rates of open fractures, which can lead to higher morbidity and complications.⁶² 

Traumatic brain injuries are among the major causes of death and disability from ATV crashes.^{7,34,61,63–65}  Torso-related injuries, including multisystem trauma and compression asphyxia, are also a significant cause of ATV-related fatalities.^11,25,52  These crush-related injuries have increased over time, likely because of the increasing size and weight of ATVs.⁵²  Spinal trauma is not common in ATV crashes but can result in spinal cord injury and/or require neurosurgical or orthopedic intervention for spinal decompression or stabilization.^59,66,67 

The severity of pediatric ATV-related injuries has been shown to be more comparable to motor vehicle crashes than to other recreational sports activities.⁴³  In addition, ATV crashes have had a higher proportion of head injuries than motorbike crashes.^60,64  This higher rate of head injuries may be attributable, at least in part, to the lower helmet use among ATV crash victims compared with motorbike riders.

Relative to bicycle crashes, ATV crash victims had a higher percentage with an Injury Severity Score (ISS) greater than 15 (defined as severe injury), more than twice the proportion of chest injuries, and a greater proportion of lower extremity fractures involving the tibia and fibula.⁶⁸  The higher proportion of chest injuries in ATV crashes compared with bicycles is consistent with being hit or pinned by the larger, heavier vehicle in a rollover event.

Children hospitalized after an ATV crash, as might be expected, have had greater injury severity than those treated as outpatients.^{35,44,46,56,59}  For example, children with head trauma, including concussions, brain contusions, and intracranial hemorrhage, were more likely to be hospitalized and to require transfer to rehabilitation facilities than youth without neurologic injuries.^34,44,56,59  Other more serious injuries requiring hospitalization have included fractures to the head and extremities and injuries to thoracic or abdominal internal organs.^{35,44,56,59,69}  Although many youth killed in ATV crashes are pronounced dead at the scene, up to 3.5% of hospitalized patients eventually died.^{11,44,61,70–72} 

Younger age has been identified as an independent risk factor for ATV crashes, with a 12-fold greater risk of injury compared with middle-aged adults.⁷³  Child development research suggests that most youth lack the physical maturity, including the strength, dexterity, and reflexes, needed for safe operation of ATVs (ie, active riding). Moreover, maintaining situational awareness and making the complex decisions required for active riding is cognitively challenging for adults, let alone for children and teenagers. Many parents may be unaware that their children are not developmentally ready to safely operate an ATV. Some medical, psychiatric, and behavioral issues in youth, as well as adolescents’ propensity for risk-taking behavior, add additional complexity to the problem.^41,42,74 

Survey studies indicate that almost all young ATV users are riding adult-size ATVs,^22,23,31  and consistent with this finding, more than 95% of pediatric deaths and injuries have occurred on adult-size vehicles.^{2,17,36,40,75}  Moreover, the engine size of vehicles involved in fatal pediatric ATV crashes has increased over time,³⁶  and research shows that the risk of ATV-related injury increases with greater engine size.⁴⁰  Children’s lack of physical and cognitive maturity makes operation of adult-size ATVs by youth particularly risky.

It is likely that youth models are safer than adult vehicles for youth operators. However, a CPSC study found that youth-size ATVs (engine sizes ≤90 mL) only decreased risk of injury among riders younger than 16 years of age by 18% compared with adult-size vehicles.⁴⁰  Speeds achievable with current youth models (eg, 30 mph for children as young as 10 years of age) can generate crash forces similar to jumping from a third-story window.^76,77  Moreover, researchers have argued that ATVs driven at 20 to 30 mph require skills the same as or better than those for driving an automobile.² 

There are no studies that have defined what, if any, constitutes an appropriate speed for operation by youth. One study analyzing YouTube videos of adult ATV crashes found that 86% of the rollovers occurred at ≤10 mph.⁷⁸  It is reasonable to hypothesize that youth would be at comparable or possibly higher risk at these relatively low speeds.^2,76,77  Taken together, these considerations suggest that current speed-based recommendations for youth vehicles may not reflect fundamental safety principles and may not achieve the goal of decreased risk.

In addition, youth models may not anthropometrically fit ages for which they are recommended. For example, 1 study found that 63% of subjects 12 to 15 years of age had better size fit for an adult model than for an ATV recommended for their age.⁷⁹  In another study, several youth model dimensions relevant to rider fit did not appear to reflect changes in body proportions with increasing age.⁸⁰  Moreover, as some youth models weigh from 200 to 300 pounds, it is unlikely most children could extricate themselves should they be pinned by the vehicle after a rollover.

Almost all ATVs are designed for a single rider, and riding with passengers on a single-person ATV is an independent risk factor for ATV-related crash and injury.^40,52  Passengers alter the center of gravity and can interfere with active riding, both of which increase the risk of losing control. Passengers may also distract operators from appropriately responding to terrain changes and obstacles in their path.

The presence of passengers has been found to increase the likelihood of certain crash mechanisms, namely backward rollovers, rollovers on sloped terrain, collisions with motor vehicles, and falls or ejections of riders to the rear.⁸¹  Predictably, rear ejections were more often associated with head injuries, because it is more difficult to protect one’s head with an outstretched hand when ejected to the rear versus to the side. Despite widespread warnings, riding with or as a passenger is an exceedingly common practice among youth and is reported by as many as >90% of pediatric survey respondents.^22,23,31,32 

Research has shown that a significant proportion of crash victims (15% to 40%) were passengers at the time of their injury or death.^{34–37,59,65,68,82}  In addition, when including operators with passengers, CPSC fatality data showed that nearly half (46%) of youth fatalities involved multiple riders on the ATV at the time of the crash.³⁶ 

Overall, younger children and females are more likely to be a passenger on an ATV compared with older youth and males.^40,52  With respect to operator and passenger age, a study of fatal pediatric crashes found that older youth were primarily riding with peers, whereas those younger than 12 years of age were more frequently riding with adult-aged operators.³⁶  Additionally, a case study focusing on the relationship between the operator and the passenger found that all pediatric passenger fatalities involved ATVs operated by a family member.⁸³ 

There are a few adult ATV models that have an integrated, raised seat for a passenger as part of their design. These are commonly referred to as 2-up models. To our knowledge, the safety and stability of these multirider ATVs has not been tested by independent sources.

Another factor contributing to the risk of ATV crashes and severity of injuries is higher speed. Essentially all adult ATV models have maximum speeds of at least 45 mph, and many models can exceed 70 mph. Fundamental characteristics of ATV dynamics and physical forces suggest that higher speeds would increase the likelihood of losing control and that greater vehicle weight combined with higher speed would result in more serious injury and a higher risk of death.^{2,65,69,84,85}  In the few studies including speed as a variable, those from West Virginia and Ontario reported excessive speed was a characteristic in 10% and 60% of fatal crashes, respectively.^12,86 

ATVs are designed for off-road use only, and riding these vehicles on public roadways is one of the most significant risk factors for serious injury and death.^36,52–54  This problem is an issue on both paved and unpaved roadways.⁵³  ATV manufacturers, regulatory agencies, and consumer protection groups have all strongly stated that ATVs should not be driven on public roads.^87,88  Despite these warnings, the vast majority of adolescents surveyed reported having ridden on public roads (up to 81%).^22,23,32 

One third of all injuries in a statewide database and more than half of all United States deaths involving ATVs have occurred on public roads.^52,54  The percentage of roadway fatalities among youth increased with increasing age, with nearly three quarters of victims 16 to 17 years of age killed in roadway crashes.³⁶  Other studies have found about one-fifth of nonfatal pediatric injuries occurred on public roads and streets.^17,46,54,55 

Roadway crashes are much more likely to involve a collision with another motor vehicle compared with crashes off-road. However, more than two-thirds of roadway fatalities and an even greater percentage of roadway injuries are not related to traffic (ie, not a collision with another vehicle).^52,54  Thus, low-traffic roads still represent an increased likelihood of death and injury relative to off-road terrain, and the off-road design of ATVs is often a major factor in crashes.

Design features contributing to the increased risk on roadways include the vehicle’s relatively high center of gravity, off-road vehicle tires, and lack of rear differential.⁵³  Unlike roadway tires that have shallow treads and are designed to continually grip and release the roadway surface, ATV tires are designed for traction on off-road terrains and can unevenly and unpredictably grab the roadway, resulting in rapid destabilization. The response of the vehicle’s low-pressure tires and relatively soft suspension to uneven roadway surfaces, such as ruts and bumps, can also lead to loss of control. Moreover, roadway vehicles have an open rear differential so that the outside wheels can turn faster than the inside wheels, allowing for a smaller turning radius. Most ATVs have a solid rear axle or a locked rear differential, and operators may easily misjudge the speed and/or turning radius needed to successfully negotiate a roadway curve or turn. All of these features contribute to an increased risk of loss of control and rollover, especially at the higher speeds commonly used on the road.

Helmets have been shown to reduce the likelihood of ATV-related deaths from head injury by ∼ 40% and nonfatal brain injuries by 60% or more.^{52,54,89–91}  Additionally, injured youth wearing helmets had lower Injury Severity Score and shorter hospital length of stay compared with unhelmeted riders.^46,68  Hospital and ICU admissions, and their associated costs, were similarly lower when ATV victims had fewer head injuries.^68,90,92,93 

ATV helmet use has generally been higher for children than for adults, but overall use remains relatively low. Although more than half of youth survey respondents stated they had worn a helmet at times when riding ATVs, a much smaller proportion reported they were always helmeted (17% to 30%).^22,23,32  Survey studies of youth and of parents have identified attitudes that may influence decisions regarding pediatric helmet use.^94,95  Currently, little or no information is available regarding the use of other personal protective equipment, including eye protection, protective clothing, and chest protectors. Moreover, although use of personal protective equipment is generally required for organized ATV racing events, their effectiveness in these and other settings has not been well studied.

Provisions related to training and education were a part of the 10-Year Consent Decree between the CPSC and ATV manufacturers and were shown to improve operator behavior and to reduce the risks of a crash.⁹⁶  Similarly, other studies have shown children who had received safety training had fewer crashes than those who had not,²²  and training of adolescents was associated with safer riding behaviors, including a significantly greater likelihood of wearing a helmet.²³ 

Since expiration of the Consent Decree in 1998, studies have found that only 15% to 26% of youth ATV riders reported receiving formal safety education or training, and as low as 1% to 5% of adolescents reported completing an ATV certification course with hands-on training.^{18,22,23,31,97}  The majority of riders have indicated they were self-taught or had received minimal instruction from a relative or another adolescent.^98,99 

Although there appears to be widespread lack of interest and participation in training,^23,99  the majority of youth in a survey study indicated that they knew safe use of an ATV should include taking a hands-on riding course.¹⁰⁰  Similarly, adolescents in focus groups recognized a responsibility to be educated and stated they would be accepting of ATV training requirements.^98,100 

Few studies have examined the supervisory practices of parents whose children ride ATVs or the impact of providing supervision. Manufacturers recommend that children younger than 16 years of age should not ride on adult-size ATVs and should have direct adult supervision while operating youth models. Even when directly present, parents have very limited ability to prevent a crash and subsequent injury once a child loses control of an ATV. However, adult supervision is the only way to effectively monitor and enforce safe riding practices by youth to decrease the probability or severity of a crash and injury.

Surveys of youth at agricultural fairs found that the proportion riding with adult supervision significantly decreased with age, from 54% for those 10 to 12 years of age to only 24% for those 16 to 17 years of age.³¹  Another survey study of predominately rural youth found that only 45% of respondents reported they always rode with adult supervision.²²  In both studies, youth reporting no supervision were more likely to report having been in a crash. Similarly, a multi-institutional study of pediatric patients injured in ATV crashes found that more than half had been unsupervised at the time of their crash.¹⁷  Unfortunately, research has also shown that having had an unsupervised child injured in an ATV crash did not improve parental supervisory practices.⁶⁸ 

Alcohol plays a significant role in many ATV crashes involving adults and increases the likelihood of injury.^{73,92,101–103}  Although much less common in pediatric crashes overall, one-fifth of the deaths among victims 16 and 17 years of age who were drivers of the ATV involved alcohol.³⁶  Recreational drugs and some prescription and over-the-counter medications are also likely to increase the risk for ATV crash but are poorly studied. Driving an ATV at night decreases the likelihood of seeing terrain changes and other hazards that might lead to loss of control or collisions. Nighttime crashes were found to be more frequent among adults than youth, but the proportion of pediatric ATV crashes occurring after dark has been nearly one-fifth in some studies.^17,104 

The greatest challenges for ATV injury prevention continue to be limited resources, barriers to changing human attitudes and behavior, limited industry adoption of improved safety standards in vehicle design, and lack of or limited state safety laws and their enforcement. Because the challenges are multifactorial, so too must be the injury prevention efforts.⁹⁸  These efforts must be based on the 3 pillars of injury prevention: education, engineering, and enforcement of evidence-based safety laws.

Education is considered an essential component in decreasing ATV-related injuries and deaths.^{45,61,98,105–107}  However, knowledge about safe riding behaviors, manufacturer recommendations, and ATV safety laws often appears to be absent or limited.^{22,23,108–111}  Training and educational efforts to reach beginning riders at a younger age could increase their knowledge and awareness and might instill attitudes that would lead to safer choices. In fact, after receiving ATV safety education, adolescents who were less frequent riders were the most likely to state they would use the knowledge provided.¹⁰⁹  Thus, youth may be more accepting of safety messages before ingrained habits are established.

Most education and public awareness programs for ATV safety have been part of broader injury prevention efforts. For example, Farm Safety Day Camps include an ATV safety component.^112–114  One of these programs followed participants at 3-month and 1-year intervals and found that acquired knowledge was maintained and there was an improvement in self-reported safety behaviors (eg, increased helmet use, less passenger riding) relative to precamp testing.¹¹⁵ 

The National Children’s Center for Rural and Agricultural Health and Safety has developed guidelines to assist parents in assigning developmentally appropriate farm jobs to their children 7 to 16 years of age, including safe occupational ATV use (www.cultivatesafety.org).¹¹⁶  A randomized controlled trial comparing farms with and without training on these guidelines found that intervention farms were less likely to violate minimum age guidelines on using ATVs (operators should be 16 years of age or older).¹¹⁷  Another program used an ATV safety poster to increase youth and public safety awareness and engage agribusinesses in ATV injury prevention.¹¹⁸ 

An ATV education module video was incorporated into a state’s hunter safety education course, and surveys of more than 1300 participants measured significant increases in ATV knowledge related to appropriate helmet usage, not carrying passengers, and the importance of hands-on training.¹⁰⁰  A set of educational materials was also developed by the same group, but the toolkit’s efficacy has not yet been tested. A video-based program for parents also showed that this strategy could be used to increase parental awareness of the dangers of ATVs to their child.¹¹⁹ 

Among youth-targeted programs that have focused exclusively on ATV injury prevention is the 4-H ATV safety program.¹²⁰  Although an earlier 4-H publication is no longer available online or in print, it noted self–reported improvements in safety behaviors at follow-up, including increased helmet use from 19% to 32%. Analysis of results for the first 4600 participants in the school-based Safety Tips for ATV Riders (STARs) program, primarily targeting youth 12 to 16 years of age, demonstrated increases in short-term ATV safety knowledge, with approximately half of participants stating that they were likely or very likely to use the safety information that was presented.¹⁰⁹  A high school-based program showed a similar increase in ATV safety knowledge but reported only limited effects on safer riding practices 12 to 24 weeks after the intervention.¹²¹ 

Development, dissemination, and rigorous evaluation of ATV safety education programs targeting youth is an important area for future injury prevention efforts. Moreover, future research areas should include assessing long-term knowledge retention and the impact of education on changes in riding behaviors and subsequent crash and injury. More programming for adult audiences, including parents and guardians, the general public, providers of emergency medical services, policy makers, and law enforcement would also be helpful.

Anticipatory guidance is a mainstay of well-child checkups and routine adolescent medical examinations. Some of the best evidence for successful counseling-based interventions for child health and development are related to injury prevention.^122–126  Pediatricians and other primary care providers are in a unique position to educate and offer ATV safety advice to patients and their families. Identifying patients at risk for injuries is a key aspect of injury prevention. The high priority of ATV safety counseling by pediatricians and other primary care providers is supported by the high exposure rates of some populations of children to ATVs, the high risk of crashes, and the seriousness of the related injuries.

More than 70% of Alabama pediatricians in a survey study stated it was important to educate families on ATV use, but less than half did.¹²⁷  Moreover, those who provided anticipatory guidance often shared information that did not follow the ATV policy recommendations of the American Academy of Pediatrics (AAP). Forty-two percent of Canadian pediatricians reported they never discussed ATV safety with their patients.¹⁹  The majority of Iowa primary care providers in a survey study also believed that ATV injury prevention anticipatory guidance was important to provide, but fewer than 12% provided this guidance to at least 25% of their pediatric patients.¹⁰⁸  The most common barriers cited by these providers were that ATV safety counseling was not an existing part of their well-visit routine and that they did not have enough time to provide additional counseling. Studies have shown that providers are less likely to perceive barriers when they attach greater importance to addressing safety hazards with patients and their families.

With respect to knowledge, Iowa health care providers had low knowledge scores regarding ATV safety and related laws, and the majority believed they did not have adequate knowledge to provide anticipatory guidance on this topic.¹⁰⁸  Research has demonstrated a correlation between lack of knowledge and the provision of less injury prevention counseling.^128,129  Thus, pediatricians and other primary care providers, as well as trainees, would benefit from ATV injury prevention education provided through easily accessible venues, including AAP conferences. Training boosts confidence and can help develop more effective counseling behaviors.^130,131  Lack of resources was also a stated barrier to providing ATV safety anticipatory guidance. The development of safety handouts and online resources related to ATVs would overcome this barrier. In addition, ATV safety could be incorporated into The Injury Prevention Program (TIPP) of the AAP. Equipped with adequate knowledge and readily available resources, pediatricians and other providers could play a significant role in advocating for ATV safety.

Engineering safety into the vehicle would be the most effective method of ATV injury prevention. In this respect, the industry could make additional efforts to decrease the vehicle’s high propensity for rollovers. Promoting evidence-based safety-related design changes and standards set to ensure compliance across the industry are key targets for advocacy and regulatory action.

The first ATVs introduced were 3-wheeled vehicles that were found to be particularly unstable. This led to a ban of their manufacture in 1988,¹  but not to their recall. Because of this, there are still 3-wheeled ATVs in use and ongoing deaths and injuries associated with them. The only way to prevent this is to make all existing 3-wheelers inoperable and remove them from the secondary market.

The locked differential found in most ATVs provides significant benefits when traveling over off-road terrain where the traction under each wheel may differ significantly. However, this delivery of unequal torque with equal tire rotational speed can create difficult and unpredictable handling, particularly when negotiating a curve or making a turn. Improved safety of ATVs might be achieved if all vehicles had an open differential that could be selectively locked by the operator or locked automatically when the driving situation required it (ie, variable traction from wheel to wheel). An unlocked differential would likely result in fewer ATV rollovers, the most common crash mechanism.

Studies suggest that standardizing seat design, specifically seat length and placement, is another potential approach to promoting safer use of ATVs and reducing crashes. In an image-based study of adult models,¹³²  ATV seat length and the distance from the front of the seat to the handlebars varied considerably.¹³³  The shortest seat length measured was 21 inches and the longest was 37 inches. Focus group studies indicate that youth see longer seats as inviting for additional riders,⁹⁸  and it seems likely that this is true for adults as well. Thus, design standards with shorter seat lengths may reduce the likelihood of multiple riders on the ATV.

In these studies, the back of adult ATV seats was most often located at or just beyond the rear axle that is below it, especially on models with a rear rack.¹³³  Models with seats that extend beyond this may inappropriately allow or encourage a passenger behind the driver. In addition, the distance of the front of the seat to the handlebars ranged from 3 to 16.5 inches. Adult ATVs with seat fronts positioned closer to the handlebars could allow young children to sit close enough to reach the handlebars and controls to operate the vehicle, and/or allow adults to place a child in front of them.

Design standards that would address this problem would include those designating a minimum distance (farther being better) from seat front to handlebars, and the shortest seat length consistent with adult operation and active riding requirements. Additional studies are needed to determine optimal seat design.

Significant questions about the safety of youth-size ATVs exist. One question is regarding the apparent lack of proper anthropometric fit of youth to the dimensions of the ATVs recommended for their age range, a problem often mentioned by parents and 1 identified in research studies.⁷⁹  Basic rider-vehicle dynamics suggest that a significant mismatch between the operator’s physical features and the vehicle’s dimensions reduce their ability to maintain vehicle control. Youth ATVs that fit children younger than the recommended ages likely encourage inappropriate vehicle use. Fit parameters for youth have been adopted by safety advocacy programs, such as the National 4-H Council, based on recommendations by the ATV Safety Institute.¹³⁴  Standardized designs that reflect these anthropometric parameters could be mandated and the seats designed with lengths that would discourage multiple riders.

Another safety consideration for youth ATVs is speed. Of note, current youth models have maximum restricted and unrestricted speeds that are not based on direct scientific evidence of their safety.¹³⁵  Moreover, child development research strongly suggests that they do not have the physical, mental, and cognitive maturity or the good judgment needed to operate at these maximum speeds (ie, 15 mph for children 6 years and older, 30 mph for children 10 years and older). Lower speed limit standards for youth models are imperative, unless the industry can provide compelling evidence that the speeds at which they can presently travel are safe for the ages recommended.

Moreover, maximum restricted speeds are controlled by speed limiters, most commonly a throttle limiting screw that can easily be adjusted by children with a screwdriver. Ideally, tamper-proof speed governors, code-protected and/or programmable, would be a standard feature of both youth and adult-size ATVs. Parents and others could then reliably set the maximum speed of vehicles driven by youth, including older teenagers operating adult-size vehicles.

Many youth models weigh 200 pounds or more, making self-extrication extremely difficult for many children after a rollover and increasing the likelihood of crush-related injuries.⁵²  Greater weights could also increase the forces potentially transmitted to a young rider during a crash, resulting in more severe injuries. Further research by manufacturers and others is needed to determine how the weights of youth ATVs may be decreased while maintaining structural integrity.

The size, weight, and speed of ATVs have increased dramatically over time, and these changes have likely contributed to the risk of death and serious injury, including crush-related injuries like compression asphyxia and multiorgan trauma. Nonindustry ATV research and development has produced at least 2 types of crush protection devices (CPDs).^136,137  These devices are designed to reduce the likelihood of crush-related injuries by (1) restricting backward and sideways rollovers to 90 degrees at low to moderate speeds on flat to moderately sloped terrain, and/or (2) providing a protective space for riders not able to clear the ATV in event of a complete rollover. Support for their efficacy under these conditions comes from earlier simulator studies by Australian researchers^138,139  and a recently reported study commissioned by the CPSC.¹⁴⁰ 

CPDs are not the same as rollover protective devices, nor are seat belts used with them. Current evidence supports the conclusion that CPDs are protective under the conditions for which they are designed (eg, travel speeds <30 mph).^{138,139,141,142}  Although it is possible that CPDs could cause an injury in an unusual circumstance just as seat belts do in motor vehicles, to our knowledge, there are currently no reports of serious CPD-associated injuries.

Of note, current evidence and experience are not sufficient to fully define the limits of existing CPDs in terms of their protective effects and safety or to recommend one CPD design over another. Design standards are needed that would address the serious problem of ATV crush-related injuries in both adult and youth models.

There is an adult and youth ATV model available with a rollover protective structure and seat belt called the Polaris Ace. Independent testing of the safety of these vehicles to verify their safety benefits has not been performed. If the added safety features were found to be effective, the manufacturers and the CPSC could consider requiring them on all youth models. In addition, technologies that track vehicle location, detect crashes, and alert others via satellite that a crash has occurred could be developed and incorporated into youth and adult ATVs. These technologies have proven valuable for identifying crashes in off-road, particularly remote, locations.¹⁴³ 

States vary considerably in their number and type of ATV safety laws.¹⁴⁴  Studies comparing fatality rates among all US states suggest that more laws overall can reduce deaths, including pediatric fatalities.^145,146  Similarly, minimum age laws have seen some success at reducing injuries among the target age range,^147,148  and a 2-state comparison found that a pediatric helmet law could increase helmet use and decrease head injuries.⁵⁵  In addition, a 2017 study in a state with an ATV helmet law found that 49% of pediatric patients in ATV crashes had been wearing a helmet,¹⁴⁹  a proportion considerably higher than that found in most studies.

Few states require ATV safety training,¹⁴⁴  and most youth receive little or no formal education.^{18,22,23,31,89,97–99}  Moreover, although overall injuries were not evaluated, 1 study found no association between the presence of state training requirements and decreased ATV mortality. However, even when states do mandate training, most only do so if the adolescent is riding on public (not private) lands, and this likely limits their effectiveness.

Enforcement is key to the effectiveness of safety legislation. Indeed, a review of states with ATV-related legislation found that those associated with better enforcement had greater impact.¹⁵⁰  Other evidence for the importance of enforcement is provided by studies showing that all-rider motorcycle helmet laws (more easily enforceable) are quite effective, whereas youth-only helmet laws (markedly more difficult to enforce) are much less so.^151,152  Moreover, dedicated ATV riding parks and trails where rules are enforced appear to provide a safer riding environment than other locations.^153,154  Finally, given the high proportion of ATV roadway deaths and injuries, the National Highway Traffic Safety Administration and other federal and state regulatory agencies could also take a more active role in identifying measures to decrease off-road vehicle driving on public roadways, including that by children.

The large body of available evidence continues to strongly support the safety recommendation of the AAP that no child or adolescent younger than 16 years of age ride on an ATV. See the accompanying AAP policy statement on ATVs.¹⁵⁵  This recommendation is based on the physical and cognitive immaturity of youth younger than 16 years of age, which is mismatched with the physical size of and active riding skills required for ATVs. However, because youth are being allowed to ride these vehicles, vigorous and widespread injury prevention efforts are needed. Efforts will require multiple strategies, including education, engineering, and well-enforced ATV safety laws. Moreover, parents and other adults who choose to ignore the AAP recommendation are responsible for following recommended vehicle age restrictions and ensuring all other ATV safety rules are adhered to through direct supervision of the youth in their care. Health care providers and injury prevention specialists can use anticipatory guidance and other methods to educate families regarding ATV safety, to help effect behavioral changes, and to support the passage and enforcement of promising safety legislation. Ongoing evaluation of the impact of educational efforts and of safety legislation is also needed. ATV manufacturers can rapidly adopt technology and design changes that will improve the safety of their vehicles and decrease unsafe use. Federal and other agencies responsible for product safety can help develop and enforce design standards. Only through strong and sustained efforts will we significantly decrease pediatric ATV-related deaths and injuries, along with their associated human and economic costs.

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

The authors would like to thank Lois Lee, MD, for reviewing the manuscript before submission. We would also like to thank the University of Iowa Carver College of Medicine Department of Emergency Medicine and the University of Arkansas for Medical Sciences Department of Pediatrics for their support of the authors in the writing of this manuscript.

AAP

American Academy of Pediatrics

ATV

all-terrain vehicle

CPD

crush protection device

CPSC

US Consumer Product Safety Commission

ED

emergency department