This fall, many students lucky enough to have in-person schools are returning with required all-day face masks. In one sense, if children have face-to-face school, we should count our blessings, not complain about details. However, decisions about how to reopen often drive whether and when we open, and our nationwide expectation of continuous masking for all students, especially young ones, merits scrutiny. Mandatory all-day masks for children, never piloted at scale here or evaluated for developmental impact, should be reevaluated by states, districts, and schools.
This practice has the potential for substantial adverse effects with debatable public health benefits. To make an ethical decision, we must consider two key questions: Are universal masks for schoolchildren likely to limit coronavirus spread significantly? And (an underexplored question) could they adversely affect children?
It appears asymptomatic adults and, especially, children do not seem to have a substantial role in coronavirus spread. Experts have pointed out asymptomatic spread, while possible, seems uncommon in childcare settings, useful proxies for schools, particularly for younger grades. Despite sensationalized headlines on children's viral load, multiple reviews and contact-tracing studies have failed to find instances of children infecting teachers and a German well-publicized survey (where most states do not require student masks) hypothesized that keeping schools open slowed transmission. One recent Norwegian study estimated that, with low community transmission, 200,000 people would need to wear facemasks to prevent one new infection per week; even with the elevated transmission, the number is 70,000. These figures suggest that if Philadelphia or Washington, DC, respectively, opened their public schools, having every student wear a mask would prevent one infection (not one hospitalization or death) per week. While other studies postulate greater benefits from masks for healthy people, they are not conducted on children and typically assume high asymptomatic transmission, a finding less relevant for pediatric populations. Further, children are unlikely to wear masks with the degree of compliance found in adult studies, leading to reduced benefits.
We must also consider potential adverse outcomes; children at low risk for COVID-19 complications and transmission are also less likely to have effective coping strategies, and their brains are still developing. Thus, the debate over students wearing masks in school all day is fundamentally different from the debate over masks for adults running errands at CVS. Pediatric mask-wearing has been found to have discernible effects on fear, anxiety, and language development. The author of one review on the topic recommended limiting the populations of children required to wear masks, the duration of mask-wearing, and the settings in which masks were required — advice that most states and schools have disregarded. In one survey of Polish young adults wearing masks due to COVID-19, 97 percent perceived inconvenience or adverse effects; 35 percent of those reported difficulty breathing. Mask-wearing at longer durations can impact thermoregulation and thermal stress. A recent German study found masks to have a "negative impact on cardiopulmonary capacity...and quality of life" and recommended these effects be balanced against potential reductions in viral transmission. It's important to remember when we consider children that adverse effects are not merely "inconveniences" but, by increasing anxiety and physical stress, can materially impact their short and long-term health, well-being, and potential for school success.
Mask-wearing can be especially challenging for students with disabilities, including sensory processing disorder, Autism Spectrum Disorder, and mental health or intellectual disabilities. The World Health Organization states that mask-wearing should "not be mandatory" for children "of any age" who have "developmental disorders, disabilities or... health conditions".
Covering children's faces has the potential to impede verbal and nonverbal communication and, by extension, language development, and social skills — among the very things we send children to school to learn. It is near-impossible to imagine effective phonics instruction with everyone masked, especially for a phonetic (not pictographic) language such as English, which has a highly irregular system.
Federal guidelines (as well as those of the WHO) acknowledge nuance in this topic, but many states and districts have yet to catch up. The White House re-entry policy encourages masks where distancing cannot be maintained — in school settings, and this might include hallways and busses. Revised CDC guidelines state masks can be "considered," but not necessarily "recommended," if six-foot distancing is possible indoors. These guidelines are welcome steps in the right direction, balancing children's well-being with their relatively low likelihood of transmission.
In most districts, officials can't even purchase cleaning products unless they have been evaluated and approved for safety. We should hold ourselves to that same standard, at a minimum, when imposing a mandatory non-pharmaceutical intervention on all children. Children themselves are not likely to benefit significantly from mandatory masking; many discussions focus on the benefit to adults. But this is backwards. Civilized societies do not inflict likely harm on children for an uncertain benefit to adults. Particularly (but not exclusively) in areas with low community transmission, we must consider the ethics behind requiring thousands of children to mask up all day to prevent, potentially, a handful of new cases where high-risk individuals have already opted out.
In times of crisis, children look to adults to model courage and wisdom. Concerning masks in school, school decision-makers need to begin demonstrating both qualities.
Patricia Rice Doran, Ed.D., is an associate professor of Special Education at Towson University, with expertise in school accommodations and health planning for children with neuroimmune disorders. Her views are her own and do not represent her institution.