Promoting face covering through positive reinforcement


A study examines if promoting positive behaviors including masking leads to improved face covering in children with autism spectrum disorder and/or attention-deficit/hyperactivity disorder.

With more schools moving to in-person education and not all children able to receive the COVID-19 vaccine, the use of effective mitigation strategies remains important to prevent the spread of COVID-19 in children. Because asymptomatic cases of the disease are common in those aged 18 years and younger, wearing masks is an important way to prevent spread. However, many have questioned the ability for students to mask effectively, especially children with autism spectrum disorder (ASD) and/or attention-deficit/hyperactivity disorder (ADHD). A research letter in JAMA Network Open looked at whether promoting positive behavior including masking could improve the use in children with ASD or ADHD.1

Investigators looked at the face covering behavior in 104 children aged 5 to 13 years who had participated in a summer treatment program at the University of Washington Autism Center during July 2020. Each child attended a 4-week day camp on weekdays for 6 hours a day. Groups of 10 children were watched by 6 to 7 graduate and undergraduate students and they participated in a variety of activities such as group discussions, sports, board games, snack and lunch, and recess, which were all held outside. Children were given tokens for certain behaviors like helping and following activity rules. A masking bonus was given to a child who properly wore a face covering over the nose and mouth for most of the interval. Tokens were redeemed at the end of each day for small prizes.

The average age of the participants was 8.9 years; 81% were male; 86% attended a public school; and 68% had an individualized education plan. Diagnoses in the group included ASD, 28 (27%); ADHD, 37 (36%); ASD and ADHD, 29 (28%); and none, 11 (10%). In the first 3 weeks, face covering compliance was recorded during 30,539 total intervals (range, 175-331 per child), with an average of 24.47 intervals per day per child. In this first period, 89 children wore their face covering for at least 75% of all observable intervals and this include snack and lunch time, when face covering was not expected. A significant link was found between age and prevalence of wearing a face covering, with covering being found in 2682 of 4411 intervals (61%) among children aged 7 years and 1147 of 1248 intervals (92%) among children aged 12 years (P = .01).

The investigators concluded that the school-aged children at the camp, many who have ASD and/or ADHD, were able to wear a face covering when doing a variety of activities. These findings are consistent with other findings, but the inclusion of children with greater special education needs indicates that masking can comfortably be done by a variety of children.


1. Aaronson B, Glick S, Kirk C, et al. Assessment of feasibility of face covering in school-aged children with autism spectrum disorders and attention-deficit/hyperactivity disorder. JAMA Netw Open. 2021;4(5):e2110281. doi:10.1001/jamanetworkopen.2021.10281

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