All-terrain vehicle injuries in children – It's time for advocacy

The release of the Canadian Paediatric Society position statement on its recommendations for all-terrain vehicle (ATV) use in Canada (pages 337–340) serves as a reminder of the concern the medical and injury-prevention community have regarding the continual increase in the number of injuries associated with ATV use. Even over the past five years, a period when voluntary standards, education and some legislative efforts should have offered solutions to this problem, studies continue to show increasing risks of injury to children operating ATVs, both recreationally and on the farm (1–10). According to the American Consumer Product and Safety Commission (CPSC), not only are absolute numbers increasing among all ages, but the rates of injuries per driving hour and per driver have jumped significantly from 1997 to 2001 (10). While 18-year-old to 25-year-old operators have the highest probability of sustaining an injury, the next highest is for those aged 12 to 16 years, whose risk almost doubled over this time period (10). Taking away the effect of alcohol, which plays a larger role in ATV-related injuries sustained by young adults, it is likely that the true risk may actually be highest for the younger age range (1,11). Expectedly, comparable escalations in injuries have occurred in Canada (12–14). A recent report from the Canadian Institute of Health Information revealed a 50% increase in ATV-related hospitalizations from 1996/1997 to 2000/2001, with 36% occurring in children and youth (13). This is clearly a red flag not to be ignored. The reality is that ATVs are getting bigger and faster, as are the industry and sales. Unfortunately, preventive policy development has not kept pace (15,16). Throughout the history of policy development around ATVs, ‘red flags’ have been waved regarding their inherent risks, particularly to children and youth. The 1998 consent decrees (17,18), referred to by Dr Warda (pages 337–340), addressed concerns over the increasing numbers of ATV-related injuries at that time. In it, the American government stated that ATVs “…are unique and complex, requiring a high degree of skill and constant attentiveness for safe operation” (17,18). The final decree included age related recommendations whereby ATVs with engines over 90 cc may only be used by drivers 16 years of age and older. Despite stated concerns about the high proportion of injuries in children under the age of 16 years, and the fact that no evidence had been presented demonstrating a significant safety advantage of smaller-sized vehicles, the operation of ATVs with 70 cc to 90 cc engine sizes by those aged 12 years and older was still permitted (17–19). In 1998, an ‘ATV Action Plan’ (19) was developed by the major manufacturers, which continued to recommend the marketing and sale of youth-sized vehicles (70 cc to 90 cc) to youth aged 12 to 15 years old. Pursuant to this, the CPSC commended the plan and indicated its active participation in monitoring it, despite expressing continued concern over the risk of injury to children younger than 16 years, which they cited as 2.5 to 4.5 times that of drivers over the age of 16 (20). The assumption was made that as the majority of childhood injuries occur to children operating adult-sized machines, smaller ones must be safer. However, in reality, up to the late 1990's, and even today, sales and therefore use of youth-sized ATVs were only a small fraction of that of adult-sized vehicles (1). More notably, current evidence refutes claims of the enhanced safety of smaller vehicles (1,10). Therefore, it is alarming that yet smaller ATVs have been developed and are marketed for even younger children, aged six to 11 years (21). These, and their larger counterparts, must follow standards outlined by the American National Standards Institute and the Special Vehicle Institute of America (22). But the industry developing these standards and the CPSC may not be in accord on these smaller vehicles, as there are no published discussions between these two bodies regarding their safety. Recent testing of youth-sized ATVs has reportedly been done by the CPSC, but the results are not yet available and until they are, claims of increased safety cannot be substantiated (23). Where is the evidence behind permitting youth to drive ATVs, but restricting them to smaller machines? The CPSC estimates that the risk of injury per driving hour for a driver less than 16 is reduced by only 18% when driving a less than 90 cc engine machine compared with operating a vehicle over 200 cc (10). However, the risk on a smaller vehicle is still almost twice that of an older driver on a larger machine. In fact, the risk of injury to a driver less than 16 years old operating a smaller machine is five times higher than the risk to an older driver on the same sized machine. Age alone plays a large role in the risk of injury. So what does the industry say? Although promoted as ‘safe’ for children if driven properly, to ensure their ‘safe use’, the manuals accompanying all youth model ATVs must state, “AN ATV IS NOT A TOY AND CAN BE HAZARDOUS TO OPERATE. An ATV handles differently from other vehicles including motorcycles and cars. A collision or rollover can occur quickly, even during routine maneuvers such as turning and driving on hills or over obstacles, if you fail to take proper precautions,” A warning label is also affixed directly to all ATVs stating, “Improper use of ATVs can result in SEVERE INJURY or DEATH,” (24). Are these safety warnings or more red flags? Why should driving motorized vehicles even be promoted as a recreational activity for youth? In the context of an epidemic of childhood obesity, promoting ‘nonactive’ recreation that requires little energy expenditure runs counter not only to the principles of injury prevention, but to the principles of health promotion (25). Why not allow children to operate ATVs, but just impose limits on how and where, as is done by many jurisdictions in North America? The reason is that this appears to have little effect, if any. Upperman et al (4) failed to show any statistically significant reduction of paediatric ATV-related injuries in states with some legislation limiting their use compared with those with no safety legislation (26). Similar rates and characteristics of paediatric injuries and deaths were shown by Keenan and Bratton (2) when comparing a state with helmet and mandatory youth training legislation with a state lacking these policies. As the data has shown, despite the legislative and policy efforts of the past two decades, paediatric injury rates and risks have continued to increase. In the case of large powerful motorized vehicles requiring significant skill, judgment and control, simply mandating safer operation practices by children is nonsensical as well as ineffective. Is it reasonable, then, to simply prohibit the use of ATVs by those under the age of 16? Motorized vehicles on the highways are certainly under strict age regulations, and with the advent of graduated driver licensing programs, these restrictions are getting even tougher (27). Health Canada has just banned the sale of baby walkers, recognizing that infants and toddlers “do not have the necessary skills, reflexes or cognitive abilities to safely make use of these products” (28). Yet, the number of baby walker injuries requiring hospitalization is only a fraction of the number of youths killed or hospitalized from ATV-related injuries (28–31). The answer to the question should be clear. Some may argue that such policy and legislation is paternalistic, abrogating the right to do what one wants (32). After all, if children are no longer allowed to drive ATVs, why not ban cycling, since far more children are injured riding bicycles than ATVs (33)? The reason is the degree of risk. Hargarten (34) demonstrated that “per vehicle”, ATV-related injuries were six times more likely to result in hospitalization and 12 times more likely to result in a fatality compared with bicycles. Similarly, higher rates of hospitalization and use of intensive health care resources for ATV-related injuries as compared with bicycles, have been found in other centres and nationally (6,14). Many prevention initiatives have been promoted by health care workers concerned with injuries affecting children and youth (30,35). The advantage that we, as professionals, may have in guiding policy development is that our standard practice is to make evidence-based decisions. Here, the evidence is undeniably clear – ATVs pose a significant risk to anyone who uses them, although the risk can be mitigated by responsible use. The risk, however, is substantially higher in children due to cognitive underdevelopment and/or risk-taking or impulsive behaviours. Additionally, smaller machines have not demonstrated themselves to be safer. Should we wait for further injury data, or do we simply use reason and just say “no?” Unpalatable as it may seem to some, we have laws that are justified as promoting health and safety such as graduated licensing, seat belt and helmet legislation (36). Enforced legislation has been shown to reduce injuries beyond that which education and training can do (29,37). And in the case of legislation involving children, paternalism is accepted as a moral rationale to limit behaviours, even by its strictest opponents (32). However, without strong evidence and rational arguments by advocates for safety, the views of those opposed, who may have competing interests, may be heard more clearly by policy makers. Advocacy by physicians, nurses, paramedics and other allied health care workers in the prevention of childhood injuries is essential. The red flags and the need for stronger policies around the use of ATVs by children and youth can no longer be ignored. The Canadian Paediatric Society should be commended in adhering to these principles and joining numerous other health and safety organizations with similar positions on ATV nonuse by children and youth (40–42). Indeed, those working in the health care of children are poised to be strong advocates for youth as we learn, teach and spend our careers making evidence-based decisions (43). Whether we are physicians or physiotherapists, we should not underestimate the influence we can have with those who develop policy. Advocacy and articulating the evidence are part of our professional role in society; complacency and indifference are not.

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