On August 4, 2021, Gov. Sisolak set his hand and caused the Great Seal of the State of Nevada to be affixed thereunto Directive 048. 

Four months later, on December 12, the state’s Pandemic Response Team (housed within the Department of Health and Human Services and overseen by the governor) issued its K-12 mask exemption guidance. No seal affixing was required for this, but it essentially says, “There shall be no exemptions,” which appears to be in direct contradiction to section 5, bullet no. 2 of Directive 048 — not to mention the document’s own title. 

Confused? So are many of us.

I invite you to pause and click on those above hyperlinks. This article will still be open in its own browser tab when you return, so take your time and be sure to read the guidance particularly closely. If you conclude, as I and some others did, that it is thoroughly nonsensical, I also invite you to continue reading what else I have to share.

Speaking for the unheard

To begin, I am not the only voice here. The state’s guidance was forwarded to me by a colleague in the K-12 system in Washoe County and (when I finally stopped grinding my teeth after reading it), I forwarded it to several other professional colleagues and friends just to make sure I was not off-base in my assessment. 

I was not.

As such, I am authoring this on behalf of about a dozen people with various professional licenses, not just from Nevada but from across the country, as well as a handful of Nevada parents. The state’s publication gave all of us heartburn for various reasons, but for flow purposes I think I will begin by noting that it appears to be co-opted from the American Academy of Pediatrics (AAP), which cites but one lonely piece of research in its assertion that student mask wearing has "proven effective" in reducing transmission. However, that study has some substantial flaws in its methodology, including that some of the schools cited were not even in session during the study period. 

That point aside, though, to use only one study — even an appropriately designed one — to inform binding policy that affects hundreds of thousands of children is incautious at best, and at worst it is reckless and foolish. Pull out that one study and the entire premise falls apart. 

Also of note, a different CDC study in 2020 was inconclusive on student masking, which only adds to the confusion and makes informed readers wonder what changed between spring and fall. To the AAP’s credit, it referenced this study, but only insofar as it relates to ventilation, not masking. But that is the rack upon which the AAP has chosen to hang its metaphorical hat. So be it.

Do no harm?

Let's presume that masking has indeed been empirically "proven" to work across school environments. Let’s also presume that the research results have been replicated multiple times and that fidelity and reliability are established in the instruments used. The only thing such research would reveal is that COVID transmission was prevented. So let’s presume that too, just for giggles.

What all that does not account for are negative outcomes associated with mask wearing itself. (I understand the AAP’s guidance flatly rejects that any such detriments even exist, but bear with me and I will explain later why that is not true, and will further explain that we cannot know it even if it was true.)

So: We have a "proven" benefit, but no one has yet "proven" the absence of harm. This is a particularly critical point in research ethics, not to mention clinical ethics, because the ethical precept of nonmaleficence (commonly known as “do no harm”) must be considered at all times. You can learn about such ethics a little more here in this video and here in this podcast. 

I contend that masking children (and the adults with whom they interact) does indeed cause, or at least exacerbates, mental health issues long bemoaned by our state's leadership and repeatedly cited annually in Mental Health America's Ranking the States report where Nevada continually ranks dead last.

The concern from a developmental perspective is that extended mask use will, over time and especially for the youngest learners, stunt emotional, psychological, and social growth. The big question here is: over how much time? Already two years have passed and no articulable goal has been declared. Given that even vaccination does not prevent transmission (nor was that ever its intent), one has to wonder what the goal is or how to measure it.

In my field, when a patient walks into my office, we start by identifying a problem. Then we choose a goal, formulate objectives to that goal, and choose interventions to achieve the objectives and goal. All of those steps should be measurable and time-limited. 

The problem in this case appears to be COVID, imprecise though that may be. Masking children is the intervention, dubious in its efficacy as it may be. 

All else is missing.

Even granting full mask efficacy, and assuming that we have precisely identified the problem, we still don't know the goal, let alone the objectives, let alone the measurements to determine whether progress is being made. Without those steps and quantifications, we are left to wonder if we are to obscure our children's faces in perpetuity. Certainly that should not be on the table for myriad reasons, right? To do so would be and already has been detrimental to kids no matter what the AAP has to say, right?

Except that we know what the AAP has to say, which is the following, from that same link:

“Fully vaccinated individuals can become infected and transmit the virus to others; therefore, universal masking is needed to protect unvaccinated and otherwise vulnerable community members.”

That sounds an awful lot like an acknowledgement of endemic COVID without a measurable goal — and a lot like children will be wearing masks forever. I have no idea how anyone can argue with a straight face that we should cover children’s faces in perpetuity. They wouldn’t do that… right?

Wrong. The CDC alluded to as much on January 12. 

Yikes.

Hold that thought for now, and let's get back to the state’s problematic guidance and our bellyache about it. 

Foul language

One major complaint is that it hijacks and inappropriately leverages clinical rehabilitative behavioral therapy language, that being the technique of desensitization. This technique is to be used only by highly skilled practitioners who have undergone rigorous education, training, and supervised experience in its implementation. Desensitization is used for treatment and growth, usually for overcoming specific phobias, OCD symptoms and sometimes PTSD. It should not be used to conform children to mask-wearing against their will.

Utilization of this therapeutic technique simply to gain obedience seems to indicate prima facie that the AAP knows full well that children are averse to wearing masks and, therefore, must be trained like animals in order to wear them. That the AAP would recommend such a tactic knowing in advance that kids would resist is unconscionable and should raise any practitioner’s ethical hackles. That Nevada DHHS would endorse it… well, that lacks critical thinking and reflects an abject failure to consult other professionals.

In that same bullet, as well as later in the document, the guidance says that all children should wear a mask "unless physical, developmental, or behavioral impairments make wearing a mask unsafe." 

Doing harm

My argument, along with several hundred other practitioners across the globe whose research and writings I consume regularly, is that mask-wearing does cause physical, developmental, and behavioral impairments.

It is literally THE reason that those of us who work with children decry the K-12 masking. We do not want to deal with the negative outcomes down the road in two, five, or eight years when developmental delays will be obviously diagnosable. We are advocating to cease child masking now. I invite you to read my tweet thread for the laundry list of reasons as to why, all of which are rooted in decades of research, volumes upon volumes of which is available via a few keystrokes in Google. 

(Contrarily, one cannot Google volumes upon volumes of empirical literature substantiating the practice of masking to prevent COVID transmission.)

Yet this guidance from the state — and the AAP itself, apparently — tries to tell us that developmental concerns are "rare," and positions itself as the sole authority on what constitutes an exemptive condition. It eschews all other non-pediatrician practitioners while hinting at revoking clinician autonomy to make that determination with their patients. 

The list of “specific conditions” even includes a complete revocation of anxiety as a valid medical reason — which is professionally offensive to me (and others) and flirts with eroding practice authority under state law, including parts or all of multiple NRS chapters including, without limitation; 622, 629, 630, 632, 633, 641, 641A, 641B, along with their associated regulatory chapters in NAC.

Usually, guidance like this supports an order, such as Directive 048. For the state’s executive branch to mandate masks in K-12 settings is one thing, but to issue guidance that undercuts licensees’ ability to treat as they see fit is… something else. It seems to run afoul of the legislative branch's will and intent. 

I invite you to picture the following scenario: Imagine that I have a 7th grade patient whom I have diagnosed with anxiety, the apparent origins of which seem to be (a) the requirement to wear a mask while healthy, and (b) having to get tested regularly in order to participate in school basketball, resulting in her experiencing constant feelings of fear of being held out of basketball, which (c) is a protective factor against her anxiety. 

The state’s guidance reads as though it usurps my ability to recommend that, as part of her treatment plan, she be granted a mask exemption.

Alternatively, of course, she could go on an Individualized Education Program (also known as an IEP) or a 504 plan, both of which involve far more resources than necessary and are utterly ridiculous for a case of anxiety, the roots of which are easily identified and the path to recovery not needing a federal-level accommodation. If you’re curious, this page does a good job explaining the differences between the two interventions.

I would be remiss here not to mention that children (or adults) who come from abusive or neglectful backgrounds, including those who have been sexually assaulted — and possibly even had their mouths covered during the assault — have also apparently been discounted from consideration. The state document literally reads "anxiety is not a medical reason..." and then points the parents back to the pediatrician, irrespective of other state-licensed professionals' involvement with the child. 

Translated: "We don't care how you're suffering or why, just conform. Wear a mask. Do not deviate. Dissent will not be tolerated.”

To ice this cake completely, nothing in the state’s "specific conditions" list is actually exempted, save for the Communication Difficulties bullet, in which case a face shield is recommended. The problem with that, however, is that it contradicts the AAP's own guidance on another page wherein it states that for masks to stop COVID transmission they "should fit over the mouth and nose and fit snugly along the side of the face without any gaps." But if the goal for mask wearing is to prevent transmission, a face shield cannot rightly be used because it is not a sealed mask without gaps. Again, what’s the goal here?

This kind of inconsistency is driving people mad. I know because parents tell me as much while waving these documents in my face. From at least six feet away, of course.

Moreover, the list itself and its lack of exemptions demonstrates a staggering lack of awareness of individualized care by issuing a blanket summary. Making a definitive statement that no conditions exist in any field, anywhere, across 11 different medical disciplines, is the height of hubristic sanctimony from the AAP and, by extension, the State of Nevada as well.

Proof, please

Of course, no research is cited to support the state’s position because we don't even have reliable research supporting mask efficacy, let alone studies to determine that no conditions whatsoever exist across all of pediatric medicine that would exempt a child from wearing a mask. 

How do we know this? 

Because conducting such research would require parental consent and voluntary participation in a randomized control trial involving purposely masking children who have these medical conditions solely to determine if greater harm would befall them. And that would never, ever be approved by any institutional review board anywhere because it runs so far afoul of all clinical and research ethics. 

Succinctly put, that entire section in the state’s guidance is an intentionally deceitful lie. And Nevada’s Executive Branch endorsed it.

One last point. The same "desensitization" language I previously condemned is utilized again in the Developmental Pediatrics section, where we are told that kids with autism, behavioral issues, and intellectual disabilities just need to be conditioned into compliance, like some kind of cruel Skinner Box. 

Imagine taking a child with an intellectual disability or autism and repeatedly forcing him to wear the mask despite his multiple muted cries of protestation. Everyone to whom I forwarded the guidance was stunned that AAP would repeat the same heartless suggestion — and that the state of Nevada would sign off on it. I mean truly stunned. Enraged, even. 

And so, I write this article.

But wait, there’s hope!

For nearly seven years my agency has performed outpatient counseling for all demographics, including school-based care, across all of Northern Nevada. I have been working with families for 13 years professionally and with children broadly for 26 years. Student distress (anecdotally) is at an unprecedented high and suicidal ideation (empirically) is skyrocketing. It's really, really bad and getting worse in the last semester.

Not one to complain without offering a solution, I will posit one: Repeal Directive 048. 

Or, at least, eliminate the K-12 masking requirement.

Yes, it will require an explanation, and maybe even an apology about how “It was a good idea at the time but we now know it doesn't do anything.” Yes, the governor might have to eat crow when he issues that explanation. Yes, he will catch flak from the always-masker crowd, certain supporters, and maybe even some staff. In fact, I expect that last one to happen to me just for penning this.

But we have to stop making things worse. If infection numbers were down and kids were suffering, maybe it would be a different discussion. But numbers are not down and kids are suffering more than ever. At this juncture we have to offer help where we can, which is at least to alleviate mental anguish and not mortgage our future. After all, we have tried the current method for nearly five months now to no avail but, in fact, to greater detriment.

While many reasons exist for kids' unprecedented misery, many are not within our control. Clearly within our control, however, is at least one measure that will relieve tens of thousands of children and their parents, and that is to ditch the K-12 mask mandate.

Also, the state needs to just scrap this particular guidance piece. It's not guidance; it’s a pronouncement. And it comes off as unprofessional and tone deaf. If its intent was to substantiate 048, then issuing it four months after the directive was issued comes off as desperately insistent.

In conclusion

Some of you may be wondering why I chose this route rather than taking my concerns straight to the state’s pandemic response people. Because I would rather confront these things directly, I did reach out.

Unfortunately, I was very diplomatically told to take a hike and, in all probability, that occurred without my letter (this very missive) even being read. That is a totally inappropriate response when something of this magnitude is at stake, so now I am taking it to you, the people, in order that my professional opinion might be acknowledged instead of being totally discarded by uninterested parties. 

Children’s mental health crises are not new to Nevada. Intensifying this problem by requiring something that child development professionals know, based on seven decades of research will create more future woes, is intolerable. Unidimensional decision making rarely benefits anyone so I am bringing a different perspective to the discussion. You can decide whether my position holds water or not.

Sadly, I knew all of this a long time ago and I did not speak up. Maybe if I had, parental choice would not have been revoked by executive fiat and children would not be ideating suicide at rates that are setting records at our pediatric ERs. Who knows. 

So, like Dr. Prasad, I also apologize. But now you have different information and you are free to do as you wish with it, including to tell me to take a hike as the state did. For the sake of your children though, I ask that you don’t. They will thank you later, I promise.

Jake Wiskerchen is a Marriage and Family Therapist and National Certified Counselor. He founded and owns Zephyr Wellness, an outpatient counseling agency, and from 2017-19 he chaired the State Board of Examiners for Marriage and Family Therapists (MFTs) and Clinical Professional Counselors (CPCs). Presently he serves on the boards for Walk the Talk America and Pinecrest Academy of Northern Nevada and hosts two mental health podcasts.