Off-road vehicle use by children and adolescents: Strategies to prevent injury

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Outcomes of ORV use for children and adolescents

Off-road vehicles (ORVs) are designed for use in rough terrain. As a category of motorized vehicle, they include all-terrain vehicles (ATVs) and side-by-sides (SxSs), which are increasingly popular and comprise both utility terrain vehicles (UTVs) and recreational off-highway vehicles (ROVs) (Figure 1)^[1][2].  

Figure 1. Common ORV model characteristics

Source: Wayne Daub, General Manager, Canadian Quad Council.

Children and adolescents use ORVs primarily for recreation in Canada, but 43% of adolescent riders also report occupational ORV use in agricultural settings^[3]. Compared with other provinces in Canada, youth in the Northwest Territories, Yukon, and Nunavut report higher ORV use (76.2% versus 52.1%), which likely reflects the unique transportation needs in remote areas^[4]. Indigenous peoples are highly represented in Northern communities, and ORVs are used as necessary transportation for cultural and land-based activities such as fishing and hunting^[5]-[7].

Regardless of the purpose of use, ORVs are strongly associated with severe injuries in children and adolescents, who comprise an estimated 12% to 15% of ATV riders but 27% to 35% of related fatalities^[8]. ATVs have been available longer than SxSs, and data specific to ATVs are identified as such in this statement. However, SxSs are involved in a significant proportion (>50%) of incidents where severe injuries or fatalities occur in riders younger than 16 years of age^[1]. Patterns of injury related to SxSs are not as well characterized as ATV injuries but appear to be equally severe^[1]. Rates of ORV-related hospitalizations and deaths in children and youth (0 to 19 years old) have stabilized in the last decade in Canada^[9]. However, morbidity and mortality peaked in 2020-2021, which likely reflects the dramatic rise in ORV sales and use during the pandemic lockdown^[9][10]. Between 2012 and 2022, 6452 children and adolescents were hospitalized (an average of 537 cases per year) and 230 died (an average of 20 deaths per year) due to ORV injuries^[9]. Although 54% of fatalities occurred in adolescents 15 to 19 years of age, 37 children younger than 9 years of age died, including 10 identified as drivers at time of injury^[9].

Leading causes of death and disability in paediatric ATV crashes include traumatic brain injury, spinal cord injury, and multisystem crush-related trauma, the latter directly correlating with increasing vehicle size^[11]-[17]. ATV fatalities in older adolescents are related primarily to rollovers^[18], while vehicle ejection is more common among younger children because they are frequently positioned as passengers^[11][17][19]. Boys are more likely to use and be injured from ORVs than girls in all provinces and territories^[11][17][20]. Youth 16 to 20 years of age are at higher risk of ATV-related spinal cord injuries, severe trauma, and death than younger people, highlighting the need for public health messaging and safety interventions also targeting young adults^[21].

The positive benefits of ORV use for child and youth well-being have not been thoroughly studied, but several are reported by users. Benefits include necessary transportation in rural or remote communities, where vehicle and road access may be prohibitively expensive and difficult, enhanced social opportunities and quality time outdoors, and the development of physical skills such as hand-eye coordination, spatial awareness, balance, and core strength^[22]. While such benefits are considerable, they are not specific to ORVs, and could be attained through other, less hazardous outdoor activities.

ORV-related injuries are usually much more severe than those sustained while pursuing other recreational outdoor activities. For example, ATV injuries are three times more likely to require hospitalization or intensive care than bicycle-related injuries (30.8% versus 9.6%)^[23], and involve disproportionately higher rates of open fractures, surgery, hospitalization, and complications compared with injuries caused by snowmobiles or dirt bikes^[17][24]. The severity of ORV-related injuries is more comparable to injuries sustained during motor vehicle crashes than to common childhood recreational injuries^[23]. After taking the much greater daily exposure of children and adolescents (0 to 19 years) to automobiles into account, ORV injuries caused a proportionately higher number of deaths (at 230) in the decade 2012 to 2022 than automobiles in the same period (at 755)^[9]. Motorcycle injuries caused 99 deaths in the same age group and time frame^[9]. The disproportionate harm caused by ORV use in children and adolescents does not favour their use when considering overall health and well-being.

FACTORS INFLUENCING ORV-RELATED CRASHES AND INJURIES

Aside from gender^[17][25], several other factors influence paediatric ORV-related crashes and injuries, and they are addressed below to better inform clinical counselling and public policy. Speed, nighttime riding, lack of protective equipment (i.e., a government-certified helmet, eye protection, and clothing and footwear for operators and passengers), and substance use are well established risk factors for crashes and injuries in adults^[17][21][25]. Ethanol and cannabinoid consumption combined with ORV use was self-reported by 10% to 21% of adolescents in one Canadian study^[26], and testing for these substances respectively was positive in 5.0% and 6.8% in another recent study of ATV-related trauma cases^[27]. Adult supervision may help ensure that young riders adhere to safe riding practices, but even conscientious oversight cannot prevent a crash and subsequent injuries when a child or youth loses control of an ORV.

Disparities in rates of ORV-related trauma among Canadian children and adolescents, especially in rural areas and socially disadvantaged populations, are primarily linked to substance use and lack of helmet use^[4][26][28]. Ontario data have also shown an inverse U-shaped relationship between material deprivation and ORV-related injuries, suggesting that increased risk for injury likely relates to ORV exposure and use rather than social inequities per se^[4][26].

Physical attributes and developmental skill levels

ORV use requires riding skills, terrain awareness, and operational knowledge to control the vehicle, all exercised while anticipating environmental risks and responding appropriately to potential hazards. Staying alert and responding appropriately to sudden changes in terrain involves ‘active riding’, which requires precise hand-eye coordination, physical strength, balance, spatial awareness, and constant attention^[11][17][22]. These developmental skills and the cognitive maturity to link actions to consequences—specifically, the implications of unsafe behaviours for self and others and the relationships between distance, speed, and braking—tend to develop in most adolescents between 14 and 16 years of age^[29][30]. Studies to determine when ORV drivers are likely to acquire such developmental skills are needed. The current literature suggests that being younger than 16 years of age is an independent risk factor for loss of control causing crashes^[11][31], especially when driving an adult-sized vehicle^[17][20].

Carrying or being a passenger

Most ATVs are designated for single riders and have labels affixed warning against the dangers of carrying passengers. Yet riding with or as a passenger remains a common practice among youth and was recently reported by >90% of paediatric respondents in separate surveys^[17][32]. ATV stability is impacted by carrying passengers, both behind and in front of the driver, which predisposes to rollovers and forward flips^[19]. Passengers are often children under the age of 11, predominantly female^[9][22][32], and have higher odds of being injured during crashes or rollovers than drivers^[22]. Between 2012 and 2022, children and adolescents riding as passengers accounted for 19% of hospitalizations and 28.3% of fatalities related to ORV injuries in Canada^[9]. Even when riding with adult operators (often a family member) as opposed to other children or adolescents, the risk of death for passengers younger than age 6 increased sixfold (3.56 to 21)^[11][17][19]. The likelihood of injury and crashing compounds with the number of riders on a vehicle, especially when they are not wearing a helmet. Children and adolescents as passengers are particularly vulnerable when drivers are untrained, ignore safety behaviours, or are impaired^{[22][26][27][33]}.

Helmet use

Helmets help protect against moderate to severe traumatic brain injury^[17]. Children and adolescents not wearing a helmet have a fivefold higher risk of sustaining severe head or neck injuries^[20][34]. Despite their proven protective effects, the use of helmets among paediatric ORV-related crash victims is known to be relatively low (<40%), even in jurisdictions with helmet legislation^[11][32]. This risk factor contrasts with >80% helmet usage documented in youth riding dirt bikes^[11][17][35]. A significant change in socially normative behaviour through education and promotion is required to secure this injury prevention strategy.  

Safety training

ATV safety training courses and programs for children and adolescents are known to increase safety knowledge and behaviours, including helmet use, not riding with or as a passenger, and staying away from public roads^[3][17]. However, the impact of ATV safety training in preventing crashes and injuries among children and adolescents has been insufficiently studied^[22][36]. Current training rates for this age group are low, with <5% having completed a certified training course with hands-on experience in one recent study^[3]. Safety training must become a priority for researchers and policy-makers.

Riding environment

ORVs are designed for off-road use, on dirt trails, in forested areas and other natural terrains, and specifically not for roads with asphalt or compacted surfaces, including highways. Yet despite frequent warnings against public road use from ORV manufacturers and consumer protection groups, 80% of surveyed youth (11 to 16 years of age) reported riding on public roadways in one study^[37]. Riding on paved or unpaved public roads is one of the strongest risk factors for severe or fatal ATV-related injuries^[38]. Studies have shown that nearly three-quarters of 16- and 17-year-olds killed on ATVs were in ‘on road’ crashes^[11][17], more than two-thirds of which were caused by loss of control and not by colliding with another vehicle^[17][39]. Off-road tires create a higher centre of gravity when riding and are not designed for compacted road surfaces, which can lead to unpredictable or uneven road contact and greater risk for rapid loss of control, regardless of speed or driver ability^[15]. Nighttime riding on paved roads is a particularly hazardous combination^[33][39][40]. 

ORV size and engineering features

ATVs have features such as longer seats that enable active riding^[22], but when a child or adolescent operates an adult-sized vehicle, such features are immediately compromised, predisposing to loss of control and crashes^{[1][9][11][17]}. Age-based ‘youth models’ (some designed for riders as young as 6 years old) are marketed as offering appropriate rider-to-vehicle ’fit’, along with speed limit control and engine size restrictions^[22]. Also, manufacturing standards require that all youth models carry warning labels stating a specific age limit for operators, the necessity for mandatory supervision, and that vehicle operation by children under the designated age limit increases “risk of severe injury or death”^[41]. However, anthropomorphic (rider-to-vehicle) fit has been observed to better predict appropriate vehicle transition than age. One study demonstrated that taller 12- to 15-year-old adolescents were at higher risk for crashing on youth model ATVs than on adult vehicles^[42]. Even older adolescents (i.e., 16-year-olds) often do not experience appropriate rider-vehicle fit, and current ATV design specifications for fit require updating^[30].

The speed limits currently applied to youth models (16 to 32 km/h with potential to override) have not been adequately studied for safety. Restricted ATV engine sizes (≤90 cc; 250 to 425 lbs) were shown to decrease injury rates in youth <16 years old by 18% in one study compared with adult-sized vehicles (600 to 700 lbs)^[17][31]. However, rollovers were still observed at low speeds, and the question of appropriate operating speeds for young adolescents remains unanswered^[17][41]. Study data pertaining to fit, size, and speed persistently challenge both age-based criteria for transitioning to adult-sized ATVs and the safety of endorsing youth models. For SxSs, the use of restraints (i.e., seatbelts) is essential to prevent ejection during a collision^[22]. Structural crush protection devices may help prevent severe injuries during rollovers and are recommended or mandated for occupational ORV use in several countries^[42][44]. However, research has also shown such devices to be injury risk factors, and further testing is needed to establish their safety^[22][43][44].

Legislation and enforcement

The literature has repeatedly demonstrated the need for both evidence-based legislation and strong accompanying enforcement to protect children and adolescents from severe ORV-related injuries^[1][22]. For example, Nova Scotia revised their Off-Highway Vehicles Act to limit ATV use to adolescents over 14 years old, in conjunction with an educational campaign, in 2004. An initial 50% decrease in youth (<16 years old) emergency room (ER) visits and admissions subsequently rebounded within 5 years to pre-intervention levels^[45]. In Quebec, despite ATV legislation introduced in 1996 and reinforced in 2006 and 2009, ATV hospitalization rates among children and youth (0 to 18 years) did not change between 1998 and 2010^[46]. A review of this study period found that 45% of participants were underage to be operating an ATV, and 31% were not wearing a helmet^[46].

In 2010, the state of Massachusetts enacted comprehensive legislation conforming to nearly all recommendations made by the American Academy of Pediatrics and other professional organizations, including restricting ORV use to operators 14 years and older, and creating a multisectoral committee to assist with legislation and enforcement^[1]. A comparison of ORV-related injury rates before and after implementation demonstrated a significant (33% to 50%) decline in ER visits and hospitalizations in children younger than 14 years, and authors advocated for increasing minimum operator age from 14 to 16 years to better protect 14- and 15-year-olds from preventable serious harm^[1]. When state-level legislation focused solely on driver education or helmet-wearing, success in reducing paediatric ORV-related injury rates was more variable^[1][17]. Nevertheless, when comparing helmet use between states with and without legislation, paediatric helmet laws correlate with higher usage and fewer ATV-related head injuries^[11][17].

TRANSLATING EVIDENCE INTO ACTION

The ‘E’s of injury prevention include engineering, enforcement, education, and equity. Despite strong evidence for the need to address strategies concurrently, present ORV-related regulations and programming in Canada fall far short of requirements. Each province and territory has jurisdiction over ORV use and safety, similar to the automobile sector. Provincial/ territorial laws governing minimum operating age, driver safety training, helmet use, designated areas for operation, supervision, and licensing and vehicle registration vary despite multiple calls for harmonization to facilitate public adoption^{[41][47]-[49]}. Recent legislative amendments have even run counter to the evidence by increasing public roadway use to facilitate access to trails separated by public roads^{[4][17][33][50]}.

Moreover, the lack of regulation and safety engineering for ORVs compared with automobiles is concerning, especially considering the disproportionate number and severity of ORV injuries in children and adolescents. Graduated driver licensing (GDL) programs for car and motorcycle drivers are established, enforced, and based in part on evidence for risky or reckless driving behaviours among young drivers of any motorized vehicle, which should include ORVs^[51]. GDL programs for ORV use could enhance the safety of children and adolescents in Canada, comparable to the 2.5-fold drop in motor vehicle fatalities in youth 15 to 19 years old over the last decade^[9].

Federally, the Transport Motor Vehicle Safety Regulations Act includes only two articles pertaining to ORVs—on lighting systems and vehicle identification numbers—compared with dozens of safety standards for other motor vehicle types^[52]. Health Canada, which oversees the Canada Consumer Product Safety Act, has the authority to prohibit products that do not comply with regulations or that pose a “danger to human health or safety”. Yet they do not report on incidents involving ATV youth models despite significant associated paediatric injuries and these models being marketed for use by children^[53]. Currently, only voluntary industry standards for ORV design and regulation exist, developed and adopted by Moto Canada (formerly the Canadian Off-Highway Vehicle Distributors Council [COHV])^[4][44][54]. Engineering safety standards ‘by design’ is expected practice in the automotive industry, with proven effects toward reducing motor vehicle crashes and injury severity^[44]. Comparable industry focus and regulatory oversight are required to improve the safety of all young ORV operators and passengers^[44].

Implementing evidence-based enforcement and engineering laws is the most effective way to prevent paediatric ORV-related injuries. However, individual-level actions are also needed to improve ORV safety, and health care providers have a role to play in promoting and counselling precautions with young people and families. Whatever the purpose of ORV use by children and youth—for recreation, transport, or work—their crash risks and injury profiles are similar^[5][55][56]. Figure 2 shows how strategies can interact to improve safety, even for children and youth in remote areas or agricultural sectors. The disproportionate risk of severe injury and death faced by children and adolescents riding ORVs can be significantly reduced by taking a multisectoral, evidence-based approach^[58][59].

Recommendations

For industry:

1. Improve vehicle design and engineering safety features, as in the automotive industry, to reduce crash risks and address the large margin for driver error.
2. Discontinue ORV models for children and adolescents under 16 years of age until safety modifications have been implemented, tested, standardized, and proven to be effective in all Canadian settings.

For the federal government:

1. Legislate and enforce a regulatory framework and safety standards for ORVs comparable to those governing the automotive industry.
2. Collaborate with provincial/territorial authorities, hospitals, and other data sources that monitor and report on ORV incidents, injuries, and related safety statistics, especially for youth ORV models, and share this data publicly.
3. Fund and support a “Canadian Off-Road Vehicle Advisory Committee”of cross-sectoral experts to track and evaluate ORV-related studies in Canada and elsewhere, and make evidence-informed recommendations to government, industry, and public policy-makers.
4. Support research initiatives investigating paediatric ORV injury prevention.

For provincial/territorial governments:

1. For more equitable injury prevention, co-develop ORV training programs with Indigenous communities to ensure their ways of knowing and experienced realities are fully considered. 
2. Legislate and enforce ORV use as for automobiles, across jurisdictions and applying both to public and private land. Such legislation should include:

a. Mandatory registration, licensing, with enforcement provisions.

b. A minimum operator age of 16 years for all ORV sizes and models.

c. Restricting the number of passengers for which an ORV is designed and passenger age to 12 years and older, with enforcement.  

d. A graduated driver licensing system to follow successful completion of an approved training course with both theoretical and skill-based components.

e. Collaborating with ministries of transportation to strictly limit ORV use on public roadways, with enforcement.

f. Mandating protective gear, including government-certified helmets for operators and passengers.

g. A ‘zero tolerance’ policy on impaired driving.

h. Raising public awareness of ORV risks and safety messaging with focus on equity and child- /adolescent-specific precautions.

3. Adjust ORV regulations to reflect essential transport needs (i.e., in rural and remote communities and for Indigenous hunting and fishing), or agricultural work. Policy focus in these settings should be on restricting recreational use, safety training, and individual precautions.

For paediatric health care providers:

1. Educate families about the significant risks for severe injury and death associated with ORV use by children and adolescents, even when these vehicles are youth models or operated with adult supervision.

2. Engage with young riders and families who are likely to use ORVs for essential transport (e.g., in remote areas or the agricultural sector) and/or recreation to counsel on safer practices and harm reduction (Figure 2). Emphasize:

• Avoiding paved and compacted roads,
• Riding as a passenger only on vehicles manufactured to carry passengers, and making sure all vehicle-equipped safety equipment is being properly used, and
• Wearing a helmet and protective gear at all times.

3. Recommend reputable ORV safety training and education programs.

Figure 2. ORV-related injury prevention strategies based on their (1) Impacts in preventing severe injuries, and (2) Feasibility in adoption at the present time.​​​

Resources

Parachute: All-terrain vehicles
Canadian ATV Safety Institute

Canadian Agricultural Safety Association (CASA)
ATV Safety and Gear 
CASA also provides resources to help parents select safer agricultural work for children and adolescents aged 7 to 16 years old.

Canada Safety Council
ATV Rider Training

Acknowledgements

The authors wish to thank Wayne Daub, Dr. Kathy Belton, and Dr. Natalie Yanchar for their expert reviews, and Andre Champagne for providing national epidemiologic data. This statement was reviewed by the Adolescent Health, Community Paediatrics, and First Nations, Inuit and Métis Health Committees of the Canadian Paediatric Society, and by the CPS Paediatric Emergency Medicine Section Executive. It was also reviewed by members of Parachute Canada.

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CANADIAN PAEDIATRIC SOCIETY INJURY PREVENTION COMMITTEE (2023-2024)

Members: Suzanne Beno MD (Chair), Hema Patel MD (Board Representative), Daniel Rosenfield MD, Dominic Allain MD, Kristian Goulet MD, Emilie Beaulieu MD MPH, Maaz Mirza MD (Resident Member)
Liaisons: Pamela Fuselli  MSc (Parachute - Leaders in Injury Prevention), Andre Champagne (Public Health Agency of Canada), April Kam MD (CPS Paediatric Emergency Medicine Section)
Principal authors: Suzanne Beno MD, Kristian Goulet MD, Pamela Fuselli MSc, Emilie Beaulieu MD, MSc

Funding
There is no funding to declare.

Potential Conflict of Interest
Dr. Goulet reported that he is on an advisory board and has been reimbursed by drug companies for presentations about head injuries. No other disclosures were reported.

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.