Campbell et al12 reported that 38% of male riders and 18% of female riders rode ‘a lot’. This pattern of increased exposure among young males may help explain their increased prevalence of ATV related injury and death. 3 ,4 ,13 ,14Inconsistent helmet use by young ATV riders is a long standing, well documented problem. 10–12 ,14–19 For example, more than half of riders aged 8–18 years in three rural states reported never or almost never wearing a helmet. 11 ,16 ,17 We found that the most frequent riders had the lowest consistent helmet use, with 8 of 10 youth who rode at least six times during the past year not always wearing a helmet. Helmet non use among youth is of particular concern because young ATV riders have a greater likelihood of crashing than adults5 ,18 and the likelihood of dying or sustaining a serious non fatal traumatic brain injury in an ATV crash is substantially higher among unhelmeted ATV riders. 18–21 Although in 2012 31 US states had a helmet requirement for ATV riders, these regulations include various qualifiers such as when and by whom helmets must be worn, and exceptions for age requirements if a child is supervised by an adult, riding on private property, or has a safety certificate. 22 Effectiveness studies of such state imposed regulations in reducing injuries and deaths among young riders have produced equivocal results. 13 ,20 ,23–25 Enforcement of these regulations is limited in part because many states’ laws pertain only to the use of ATVs on public lands, and according to a 2008 ATV owners’ survey obtained by the US Government Accountability Office, nearly 80% of ATV riding among riders of all ages occurs on private property. 26 Further evaluation of the effectiveness of ATV helmet regulations and enforcement strategies is needed. 27This study has limitations.

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