Commentary: Mask mandates in schools do more harm than good

Now that children ages 5 and older have access to vaccines, as do the adults in their lives, we must move away from politicized mask debates and shift towards exploration of short and long-term gains. This includes thoughtful consideration of unintended side effects of mandated mask wearing. Schools, along with public transportation, remain the most restrictive environments in our country. The 2022 playbook can and should look very different from that of 2020 and 2021. Given that COVID will soon become endemic, for how long, and at what cost, will we keep mask mandates for children in place?

In an essay published last week in The Atlantic, Smelkinson, et. al. provide a compilation of studies that fail to demonstrate masking in schools slows the transmission of Covid. Context for masking matters, but unfortunately, we’ve failed to answer fundamental questions on what interventions actually work to slow viral transmission.

Whether it’s 2 weeks, 6 feet, 10 days, 3 feet, 5 days, testing out of quarantine/ isolation —there are zero randomized control trials and all but two for masking (none of which are in kids). When you have not adequately tested these hypotheses you get insufficient evidence with tremendous uncertainty, polarizing opinions and faith based policies. In March of 2020 with so much uncertainty we aptly applied medicine’s precautionary principle as we locked down, wore masks, and socially distanced ourselves to “flatten the curve.” But as we approach year three of the pandemic and the fog begins to lift, the burden of proof falls on those who continue to impose life altering restrictions on kids –prove to us these interventions do more good than harm.

All public health organizations around the world align on their pro-vaccine messaging. Not so much on masking children in schools. The US CDC recommends masks for kids starting at age 2, while the World Health Organization, UNICEF and the European CDC has advised this only selectively for kids less than 12 and much of Western Europe never masked kids in school throughout the pandemic. Why the discrepancy? These global organizations analyzed the same confounded data and executed an entirely different policy on masking school-aged kids that was value based. Science and data cannot make value judgements –humans do.

For the majority of parents of healthy kids, COVID’s risk approximates many other risks we never think to question (in many cases with far less risk). Here is CDC data on hospitalization rates. The hospitalization rate for a vaccinated adult is the same as an unvaccinated teenager (4.4 vs. 5.4 per 100,000). The hospitalization rate for a vaccinated teenager is 4 in 1 million. In a pre-vaccine analysis from Germany, summarized here – a child infected with Covid —with or without preexisting conditions —there is an 8 in 100,000 chance of going to the intensive care unit. The risk of death is 3 in 1 million, with no deaths reported in the over-5 age group. Covid has lower annual mortality risk to children than motor vehicle accidents, influenza and perhaps, most importantly for the 5 to 14-year-olds, suicide.

What are the arguments for lifting mask mandates? Experts express concerns that mask mandates impede children’s development on multiple fronts, including speech/language, social emotional engagement, learning and mental health. One important note - lifting mask mandates does not mean children cannot wear masks. It means children and their parents can analyze the pros and cons, risks and benefits of children going into a third year of forced mask wearing. This includes exploring the impact mask wearing has on a child’s social emotional development and mental health.

What are the social emotional impacts of mask wearing? Mask wearing interferes with social development, including a child’s ability to identify emotions and connect with peers and educators. Particularly for younger children, mask wearing interferes with intellectual development and the ability to speak, read and learn in general. The bottom half of the face specifically is crucial for evaluation and development of nonverbal communication.

Children, especially young children, rely heavily on non-verbal communication and facial expression interpretation. However, this is not an innate skill but rather something that develops over time across thousands and thousands of live, human interactions. According to University of Toronto psychologist, Dr. Kang Lee, it takes children the first fourteen years of their life to interpret facial expressions on par with adults.

From a neurological perspective, forced mask wearing interrupts natural peer connection and therefore oxytocin levels in the brain. This impact is heightened when “mask mandate culture” becomes punitive, as is the case in many schools; teachers giving frequent warnings to children not wearing their mask properly, eating lunch in silence or at physical distance from peers, lifting masks up and down between bites. Draconian mask culture also heightens anxiety for many children and has led some to experience germ and virus phobia. This setting leads to increased cortisol and adrenaline (aka “stress hormones”), exacerbating and reinforcing anxiety. Mandated masking in schools, particularly when done in draconian, punitive manners, puts children into a heightened state of alert and readiness in a setting where they also should feel calm and secure.

For those who say that mask wearing actually reduces anxiety in some children, this is flawed logic. Lifting mask mandates does not limit anyone’s ability to wear a mask, and the CDC has now indicated that N95 masks provide protection for the self and others. This means wearing an N95 mask around a mixed group of masked and unmasked individuals offers significant protection to the mask wearer. But here is the larger concern with the “masks reduce anxiety” rhetoric; children undoubtedly have developed anxiety about COVID, germs and physical closeness with others. How could they not have? Avoidance is not a treatment strategy for anxiety. In fact, avoidance makes anxiety worse. At some point, those with COVID anxiety will need to practice exposure, with support from adults, as this is the most evidenced based intervention for anxiety.

Children are required to spend hours a day wearing masks without strong evidence that it protects them or anyone else from severe risk. We now know that the risk of a bad outcome from Covid for both vaccinated and unvaccinated children, is extremely low. Similarly, we recognize that there is a risk, by sending children into school buildings, that the building could catch on fire. This is why schools must comply with fire codes and conduct fire drills. We don’t, however, send children to school in fire retardant fabric and have them carry smoke extinguishers. Doing so would harm their mental health in exchange for reducing the risk of a fire at school from extremely low to slightly lower. In short - beyond fire codes and fire drills, we’re at diminishing returns.

Many children still haven’t recovered from the impact of isolation. Less than 10% of all mental health providers are able to accept new patients. This figure is likely much lower among providers working with children and adolescents. During school closures children experienced isolation and extreme levels of depression and self-harm. This year, mental health providers working with children are seeing heightened presentations of anxiety, OCD, sleep difficulty, disordered eating and social anxiety. While a correlation cannot be drawn directly to mask wearing, we do know that humans are wired for connection and function most optimally when experiencing social connection. In short, a return to normalcy in school will undoubtedly facilitate healing and recovery: “More restrictive policies increase fear & falsely convey that schools are unsafe. This increases harm to student mental health, which can have major detrimental effects.” - Dr. Scott Balsitis, Lead Author, Children, Covid and The Urgency of Normal Toolkit.

The mental health care system was underfunctioning prior to COVID and we now know that forced school closures contributed to a mental health crisis nationally, particularly for children and adolescents. Last month, The American Academy of Pediatrics, Academy of Child and Adolescent Psychiatry and Children’s Hospital Association declared a state of emergency specific to youth mental health. Furthermore research has shown these impacts are more significant for children of color and children of lower socioeconomic stability. ER utilization, Emergency Room Boarding and access to care remain at crisis levels. The statistics are alarming; between 2019 and 2021 ER visits for suicide attempts jumped 51% for girls between 12 and 17 years of age. Mental health matters. Calls from mental health professionals to resume in person learning went largely unresponded to, all while children sat in Emergency Rooms awaiting access to treatment.

While it is too early to know the short and long-term psychological impacts of mask wearing on children, policies that continue to place a higher premium on physical health over social, emotional and mental health sends a clear message. We do not yet value mental health as equal or even part of physical and overall health.

For how long and at what cost can we have children bear the burden of preventing a virus that by and large doesn’t pose a severe threat to them or vaccinated adults in their lives? Given that the CDC now reports that cloth masks do not provide significant reduction in transmission, continued mask mandates in schools is akin to theater; the children forced into a performance for the benefit of an audience.

Daniel Kim, DO, FCCP, of Stratham, is a pulmonologist and critical care physician at The Manchester VA Medical Center, Exeter Hospital, and Concord Hospital - Laconia. He serves as a physician member on the Critical Care Air Transport Team with the 157th Medical Group in the NH Air National Guard. The views expressed here are his own and do not represent the views of these organizations.

Jessica Lyons MS, LMFT (Brown University, University of New Hampshire) is a psychotherapist in private practice in Exeter, NH, Co-Founder of Aloft Integrated Wellness LLC in Exeter, NH and Stratham, NH and Adjunct Professor - The Graduate School, University of New Hampshire Department of Human Development and Family Studies. The views expressed here are her own and do not represent the views of these organizations.

This article originally appeared on Portsmouth Herald: Commentary: Mask mandates in schools do more harm than good