How can I teach my son to cooperate with wearing a face mask?

As the country further re-opens during the COVID-19 pandemic, I would like my son with autism to be able to visit some places he used to enjoy. However, I know that face masks are now required, and he is resistant to wearing one. How can I teach my son to cooperate with wearing a face mask?

Answered by Erin Richard White, PhD, BCBA-D
Alpine Learning Group

Mother helps a child with autism with wearing a face mask In response to the COVID-19 pandemic and the recommendations of the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention, 2020), it has suddenly become a relevant goal for many individuals with autism to learn to cooperate with wearing a face mask to help minimize exposure and prevent the spread of the virus.

While this is a new skill for us to teach, the field of applied behavior analysis has a number of evidence-based procedures that you can draw upon to teach this skill. These procedures have been used to teach cooperation with other feared or unpleasant stimuli such as cooperating with doctor visits (Gillis et al., 2009), dental appointments (Allen et al., 1992), haircuts (Schumacher & Rapp, 2011), and blood draws (Shabani & Fisher, 2006). These techniques have also been used to teach cooperation with wearing eyeglasses (DeLeon et al., 2008), prostheses (Richling et al., 2011), and medical alert bracelets (Cook et al., 2015).

Selecting a Mask

Presumably, your son does not want to wear a mask because he finds something about it aversive. Therefore, try to make the mask as pleasant as possible. There are a variety of masks available, and after trying out different options, you may find that your son is less resistant to certain ones. Options include those that connect to the head using elastic loops around the ears; others that either use ties or elastic to wrap around the back of the head; and various fabric options. They are available in different fabrics and patterns. Having your son select his own masks may be helpful. Washing the mask in a pleasant-smelling detergent or fabric softener may also make the mask more pleasing.

Many people find masks cause discomfort to their ears, but there are options available to ease the pressure put on the ears. Selecting a mask that secures around the back of the head will eliminate any pressure to the ears. If your son chooses to wear one with ear loops, there are several products that allow the mask to be attached to the product, rather than the wearer’s ears. One of these is called “ear savers,” which are pieces of plastic or cloth that you attach the mask’s ear loops to. Another option is buying or making a hat or headband that has buttons sewn near one’s ears. There are also masks available with adjustable ear loops, to allow for a customized and comfortable fit.

If your son wears glasses, the condensation that builds up on his lenses may make the mask more unpleasant. Anti-fogging wipes and solutions can stop condensation from forming on lenses (check to ensure that these products are compatible with any specialty coatings on his lenses). There are also masks specifically designed for people who wear glasses. Finally, if your son wears his glasses a little lower on his nose, it will create more space between his face and his lenses, giving his breath more room to escape.

Developing a “Cooperates with Wearing a Mask” Skill Acquisition Program

What is unique at this time is that schools are still largely closed for in-person instruction. Thus, parents have become teachers, hopefully with the consultation of their child’s teacher or behavior analyst. This can be a big undertaking, but when you are ready to begin, follow these steps:

Decide how to measure your son’s progress. One simple way is to score each opportunity as correct or incorrect and then summarize the data across the day. For example, if he cooperates with wearing it for 3 min during 7 out of 10 trials, his percentage for the day would be 70%. Then, decide when you will determine a step is mastered. If you have a BCBA with whom you work, consult them regarding an appropriate criterion.
Begin by running a baseline session to determine how long your son can cooperate with wearing his mask and what step you will begin teaching. For example, baseline may indicate that he will wear the mask for 1.5 min, so you can begin teaching with step 3 on the sample teaching steps below.
At the start of each trial, have your son select a reward he can earn for wearing the mask for the duration requested. Eventually, going out in public to a favorite location will be a natural reinforcer. Until that time, another motivator would likely be needed to promote cooperation. Once he demonstrates mastery of the skill, your rewards may need to be faded based on what is acceptable/available in the final setting where your son demonstrates the skill. To do this, you could have him wear it several times successfully before earning his reward or by reducing the size of the reward (e.g., reducing internet access from 5 min to 3 min, then 1 min, and then eliminating it and just providing praise).
If your son cooperates with wearing the mask for the target duration as requested, praise his enthusiastically (e.g., “Super job! You wore your mask the whole time!) and offer him the reward he selected.
Do not move on to the next teaching step until the previous one is mastered. As he progresses through steps, your goal will be to increase the demand gradually so that he will remain relaxed and calm.
If your son does not cooperate, simply restart the trial. It is important to avoid ending a session when your son removes the mask. If he is unsuccessful after 2 tries, go back to a previous step so that you can end on a positive note. Take a look at the additional strategies below for ones that you can incorporate into your teaching to increase your son’s success. Also, look for signs of agitation before you start a teaching session and if you see them, wait until he has a more positive affect before starting a trial.
To promote generalization, vary the masks you use, where your son wears the mask (e.g., kitchen, front porch, bedroom) and, if possible, who is asking him to wear the mask.
As your teaching progresses, you can also incorporate other skills related to wearing a mask and caring for one properly including following the instructions to put on, take off, and adjust his mask; and learning to put it in his hamper when he’s finished wearing it (or garbage if it is disposable).

Based on your son’s skill set, there are additional strategies you should consider incorporating into your teaching:

Provide a signal to your son for how long he’ll need to wear the mask. You can use a timer, give him an appointment, or write in his daily schedule when he’ll put the mask on a take it off (e.g., put on mask, do laundry, do a puzzle, take off mask).
Model wearing the mask yourself. Provide photos of his favorite people or characters also wearing their masks.
Provide choice to your son as to which masks you will buy and which mask he will wear each time he needs to put one on.
As the sessions increase in length, have your son do something fun while wearing his mask (e.g., playing a favorite board game, reading a book).
Use written rules and pictures to help your son learn why we are wearing masks and when he might need to wear one, as well as other information regarding important skills for preventing the spread of COVID-19, such as washing his hands properly, avoiding touching his face, and social distancing. You can make customized materials or find ones online by searching “COVID-19 social stories.”

Sample Teaching Steps

1. Cooperates with putting on a mask

a. For a mask with ear loops:

i. Holds mask up to face

ii. Holds mask up to face and wears 1 ear loop

iii. Wears mask with both ear loops

b. For a tie-back mask:

i. Wears mask with 1 string tied loosely

ii. Wears mask with 2 strings tied loosely

iii. Wears mask with strings tied tighter

iv. Wears mask with strings tied snuggly

c. For any mask:

i. Wears mask covering chin

ii. Wears mask covering bottom lip

iii. Wears mask covering both lips

iv. Wears mask covering nose

2. Cooperates with wearing a mask for 1 min

3. Cooperates with wearing a mask for 2 min

4. Cooperates with wearing a mask for 3 min

5. Cooperates with wearing a mask for 4 min

6. Cooperates with wearing a mask for 5 min

7. Cooperates with wearing a mask for 10 min

8. Cooperates with wearing a mask for 15 min

9. Cooperates with wearing a mask for 20 min

10. Continue to increase until you reach the terminal goal

The actual progression of steps will vary based on the progress your son makes. Perhaps increasing by 1 min at a time will be too challenging for his, and you will only increase by 15 sec at each step. On the other hand, you may be able to collapse steps if the duration of your son’s toleration increases rapidly.

Teaching your son to cooperate with wearing masks might be challenging, especially when you may not have as much help from his school as usual. However, as noted above, teaching people with autism to cooperate with other unpleasant stimuli has been researched in the past, and these previous findings provide strategies that will, hopefully, guide you in teaching your son this newly relevant skill. If you would like to hear more in-depth information on this topic and view video examples of teaching techniques, a related webinar is available online at https://www.alpinelearninggroup.org/media-center/video-library.php.

References

Allen, K. D., Lobien, T., Allen, S., & Stanley, R. T., (1992). Dentist-implemented contingent escape for management of disruptive child behavior. Journal of Applied Behavior Analysis, 25(3), 629-636. https://doi.org/10.1901/jaba.1992.25-629

Centers for Disease Control and Prevention (2020). About cloth facial coverings. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html

Cook, J. L., Rapp, J. T., & Schulze, K. A. (2015). Differential negative reinforcement of other behavior to increase wearing of a medical bracelet. Journal of Applied Behavior Analysis, 48(4), 901-906. https://doi.org/10.1002/jaba.228

DeLeon, I. G., Hagopian, L. P., Rodriguez-Catter, V., Bowman, L. G., Long, E. S., & Boelter, E. W. (2008). Increasing wearing of prescription glasses in individuals with mental retardation. Journal of Applied Behavior Analysis, 41(1), 137-142. https://doi.org/10.1901/jaba.2008.41-137

Gillis, J. M., Hammond Natof, T., Lockshin, S. B., & Romanczyk, R. G. (2009). Fear of routine physical exams in children with autism spectrum disorders: Prevalence and intervention effectiveness. Focus on Autism and Other Developmental Disabilities, 24(3), 156-168. https://doi.org/10.1177/1088357609338477

Richling, S. M., Rapp, J. T., Carroll, R. A., Smith, J. N., Nystedt, A., & Siewert, B. (2011). Using noncontingent reinforcement to increase compliance with wearing prescription prostheses. Journal of Applied Behavior Analysis, 44(2), 375-379. https://doi.org/10.1901/jaba.2011.44-375

Schumacher, B. I., & Rapp, J. T. (2011). Increasing compliance with haircuts in a child with autism. Behavioral Interventions, 26(1), 67-75. https://doi.org/10.1002/bin.321

Shabani, D. B., & Fisher, W. W. (2006). Stimulus fading and differential reinforcement for the treatment of needle phobia in a youth with autism. Journal of Applied Behavior Analysis, 39(4), 449-452. https://doi.org/10.1901/jaba.2006.30-05

Citation for this article:

White, E. R. (2020). Clinical Corner: How can I teach my son to cooperate with wearing a face mask? Science in Autism Treatment, 17(8).

Other ASAT articles that may be of interest:

Related Media Watch letters:

ASAT Responds to Spectrum News 1 “Face Masks Create New Challenges for People with Autism or Sensory Disorders”

ASAT Responds to News12 New Jersey “Flemington Man with Autism Makes Hundreds of Masks to Donate to Area Hospitals”

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