Using Masks for In-Person Service Delivery During the COVID-19 Pandemic: What to Consider

Updated on February 16, 2022

Public and School Policy on Mask Use

The Centers for Disease Control and Prevention (CDC) provides data pertaining to community masking to control the spread of infection. ASHA recommends adhering to the most current CDC guidance to inform policies for the use of masks in all public settings and schools during the COVID-19 pandemic. The CDC recommends wearing the most protective mask possible—one that fits well and is worn consistently. The CDC guidance for mask use considers factors such as age, vaccination status, medical conditions, disabilities, transmission levels, and whether you are indoors or outdoors. ASHA places a priority, first and foremost, on health and safety.

Masks and Speech and Language Development

Questions have arisen regarding a possible connection between mask use by those who interact with young children (e.g., teachers, caregivers, day care providers) and delays in speech, language, and social development. Babies and young children look at faces during social and communication interactions, so the concern about solid masks covering the face is understandable. The American Academy of Pediatrics (AAP) and ASHA (2021) collaborated on an article regarding this issue titled, “Do Masks Delay Speech and Language Development?"

As of December 6, 2021, the CDC reported that “The limited available data indicate no clear evidence that masking impairs emotional or language development in children.” The CDC also acknowledges the need for further research.

At this time, we are not aware of any studies that have directly assessed the long-term impact on speech and language development when young children interact with adults who are wearing facemasks. However, there are studies demonstrating that children can tune into different communication cues and gestures when an adult’s mouth is not visible. Typically developing children can recognize single words, identify emotions, and attend to voices when they see photos of adults wearing masks. For example, 2-year-olds can recognize single words when looking at photos of masked faces (Singh et al., 2021), with recognition better for opaque masks than for clear masks. Preschool children appear to be able to use voices (e.g., inflection, tone) to understand emotions conveyed by masked adults in photos (Schneider et al., 2021). School-age children (7–13 years) can make accurate inferences about emotions when presented with photos of masked faces (Ruba & Pollak, 2020). We also know the importance of eye gaze in language development (Cetinçelik et al., 2021).

We do not know of any studies that address the effects of masking for children with diagnosed communication disorders. We are aware of one unpublished study about the effect of masks worn by children on speech and language development. The study compared preschool classes of 3- to 4-year-old children, one in early 2020 and one a year later when masks were required for children 2 and older. Results showed no change in language production regardless of whether the children or teachers were wearing masks. A surprising finding was that “children were producing more complex speech sounds while wearing masks than without them” (Mitsven et al., 2022). This finding was the same for children with hearing loss who wear hearing aids or cochlear implants (Mitsven et al., 2022).

Regardless of mask use, some children will take longer to reach speech and language milestones—and some may need help meeting them.

Audiologists and speech-language pathologists (SLPs) can share current research findings with families, school boards, teachers, and others to make sure that policies regarding mask use in schools and for the public are informed by science—particularly data demonstrating that mask use reduces infection. ASHA’s Code of Ethics Principle I, Rule M states: “Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served.” Principle III, Rule F states “Individuals’ statements to the public shall adhere to prevailing professional norms and shall not contain misrepresentations when advertising, announcing, and promoting their professional services and products and when reporting research results.” If you are concerned about the status of your students’ social and communication skills, please see ASHA’s Pandemic-Related Social and Communication Challenges: How Audiologists and SLPs Can Help With In-Person Learning.

See the information below for additional considerations for mask use while providing in-person service delivery.

Types of Masks

The CDC identifies three types of face masks [PDF] that meet the standard of medical grade personal protective equipment (PPE):

surgical mask
N95 respirator
elastomeric half-facepiece respirator

The correct mask type varies based on the type of service you’re providing.

Service Delivery Considerations

Telepractice

As of January 13, 2022, the CDC indicates that “Students benefit from in-person learning, and safely returning to in-person instruction continues to be a priority.”

When possible and appropriate, telepractice may be necessary for audiology and speech-language pathology service providers to mitigate COVID-19 transmission risk. You may use telepractice as the sole model of service delivery or as a complement to in-person services. For example:

Although the SLP could do instrumental assessment of swallowing in person, they could also provide the dysphagia intervention via telepractice.
Although the audiologist needs to do cochlear implant candidacy evaluation and initial activation in person, they could provide follow-up programming via telepractice.

In the school setting, service delivery options may include virtual-only interactions, hybrid (virtual and in-person) services, staggered/rotated scheduling, or fully in-person sessions.

State, local school district, and CDC considerations for schools should be followed. School-based audiologists and SLPs should evaluate their own risk and that of the students they serve when making decisions about service delivery.

Across settings, providers may also use group telepractice sessions along with in-person, one-on-one services—following federal, state, district, facility, and state licensure regulations and guidance. For more information and resources on telepractice, visit ASHA’s COVID-19 telepractice page.

Choosing the Right Mask for the Service You’re Providing

Although all in-person services provided by audiologists and SLPs carry risk of COVID-19 transmission, not all procedures need the same type of precautions or PPE, according to the CDC.

When to Use an N95 or Higher-Level Respirator

N95 masks are recommended for aerosol-generating procedures (AGPs), which the CDC defines as medical procedures that are “more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing” and that result in “uncontrolled respiratory secretions.” Higher-level respirators—like elastomeric half-facepiece respirators—are also suitable, depending on your employer's guidelines.

AGPs should not be completed without the proper PPE, according to CDC guidelines. Providers should also wear N95 masks when providing services that require close physical proximity to the patient/client.

Examples of AGP Procedures in Speech-Language Pathology

dysphagia care (instrumental and non-instrumental assessment and treatment)
instrumental assessment of voice via endoscopy, with or without stroboscopy
assessment and management of laryngectomy, including voice restoration using voice prosthesis and stoma care
assessment and treatment of  tracheostomies, with or without mechanical ventilation, including suctioning
non-invasive ventilation such as high-flow nasal oxygen and nasal cannulae

For detailed information, see ASHA Guidance to SLPs Regarding Aerosol Generating Procedures.

Examples of Possible AGP and/or Close-Proximity Procedures in Audiology

otoscopy
cerumen management
real-ear measurements
earmold impressions
dizziness and balance measurements
evoked potential testing

When to Use a Surgical Mask

Surgical masks are acceptable PPE for other services provided by audiologists and SLPs that have lower transmission risks than AGPs. “FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated,” the CDC states.

Making Sure PPE Is Available for the Patient/Client/Student and Provider

You (or your employer) will need to make sure you have adequate access to appropriate PPE (via a reliable pipeline) to meet ongoing practice needs and ensure your own safety as well as that of your patients/clients/students. Needs may evolve, depending on the types of diagnoses you come across in your practice setting and the types of services you need to provide. Clinicians are also encouraged to ensure that alternate PPE is available for clients/students to use in case the client/student and/or caregiver does not have access to required PPE during the session.

Determining Whether PPE Negatively Affects a Service

Although critical to infection control, masks may negatively affect audiology and speech- language pathology services.

As a clinician, use your clinical judgment (in compliance with requirements established by employer and/or federal, state, and local oversight bodies) to determine whether mask use is the most appropriate protocol for service delivery—or if you can or should make modifications.

If you’re modifying recommended best practices, make sure you’ve documented informed consent from the patient/client/student or caregiver.

Here are some examples of how masks can negatively affect services:

Increased difficulty in understanding speech: Masks attenuate sound by 3–12 dB and result in low-pass filtering of high-frequency sounds, making it more difficult to understand speech and some higher-pitched voices (Goldin et al., 2020). Listening to masked speech can be especially hard for people with hearing loss.
Reduced discrimination of speech signal among competing noise: For example, reduced discrimination may occur in the presence of traffic or noisy yard work like lawn mowing.
Reduced intelligibility of the wearer’s speech: Listeners may perceive speech as being muffled or lower in volume.
Loss of visual cues: Masks remove the ability to speechread and see facial expressions; both abilities augment communication.
Increased difficulty of verbal communication: Speaking and understanding language while wearing a mask can be hard for people with communication problems like aphasia and voice problems.
Reduced ability to provide appropriate cues to the patient/client/student: Masks can reduce one’s ability to provide communication cues—for example, in the case of speech sound production.
Non-compliance of mask wearing: Masks can be uncomfortable for young and school-aged children and for people who wear hearing aids or cochlear implants. Noncompliance with mask use can also be an issue for those with cognitive or sensory deficits.

Options for Modification

For non-AGPs provided to clients/students who do not have COVID-19, modifications to service delivery may include (but are not limited to) the following:

masks with clear panels
face shields when paired with masks
plexiglass or other clear barriers
physical distancing
use of voice amplifiers
use of family member/caregiver as a model or as an extension of clinician’s hands
use of videos or images for demonstration

It’s important to note that there is no documented clinical evidence on how these modifications impact effectiveness of overall infection control processes used in clinical practice.

Mask Exemptions

The CDC states that masks should be worn indoors by both fully vaccinated and unvaccinated individuals over the age of 2 years unless they have difficulty breathing, are unconscious, or are not able to put on and take off the mask on their own. The American Academy of Pediatrics (AAP) indicates that this CDC recommendation represents the majority of individuals—with a few rare exceptions.

Neither the CDC nor the AAP list communication differences or impairments as exemptions to wearing masks, although the AAP includes “developmental conditions that prohibit mask use.” Communication strategies are available to help mitigate the impact of masks (see below).

Because audiologists and SLPs do not engage in medical diagnoses and procedures, it is beyond their scope of practice to determine the medical status of an individual wearing a mask or to provide mask exemptions. The child’s local school district or state department of education may have established regulations about the appropriate professionals to determine an exemption.

A first step in addressing an exemption request may be to try to find a solution to the parent’s concern by modifying the type or fit of the mask, implementing accommodations such as strategic seating, or working to optimize visual cues. If significant limitations persist, discuss options for virtual services.

Taking Steps to Enhance Communication While Wearing Masks

Make sure you have the attention of your patient/and/student before you start talking.
Face them directly, and make sure nothing is blocking your view.
Speak slowly and slightly louder than usual, but don’t shout or exaggerate your speech.
Optimize hearing—confirm that those who use hearing aids and cochlear implants are wearing their devices or use a portable amplifier. Use your eyes, hands, and body language to add information to your speech.
Provide visual references (e.g., printouts, notes, images) to accompany communication.
Ask if they understood you—if they didn’t, rephrase it or write it down.
Ask them to repeat important information to see whether they understood what you said.
Reduce competing noise in the environment, if possible.
If you’re talking with someone new, ask the person what you can do to make communication easier for both of you.

Such measures appear to improve accuracy of word recognition and recall of speech when native and non-native English adults observe videos of speakers wearing masks (Smiljanic et al., 2021).