Increasing Face Mask Wearing in Autistic Individuals Using Behavior Analytic Interventions: A Systematic Review and Meta-analysis
Graded exposure paired with differential reinforcement reliably increases mask wearing in autistic clients across settings.
01Research in Context
What this study did
Cowell et al. (2023) hunted for every single-case study that taught autistic kids to wear a face mask. They found seven papers. All used tiny steps plus treats or praise.
The team pooled the results to see how well the package works. They only included studies that measured mask-on time with real data.
What they found
Every study showed big jumps in mask wearing after the tiny-steps-plus-reinforcement plan. Kids went from zero tolerance to keeping the mask on for full sessions.
The gains held across home, clinic, and school. Still, the authors warn that study quality varies, so keep your eyes open for flaws.
How this fits with other research
MShawler et al. (2021) is one of the seven studies inside this review. Their resetting DRO schedule got six autistic children to 30 minutes of passive mask wearing with no escape extinction. Cowell’s bigger picture says the same tactic keeps working when you zoom out.
Pui Cai et al. (2024) looked at dental visits, not masks. Their review found only small, shaky gains in cooperation. Cowell’s mask data look stronger, but both teams used graded exposure. The difference: mask studies used tighter single-case designs, while dental papers mixed many methods.
Lam et al. (2025) reviewed oral-hygiene trials in autism and also saw only weak effects. Taken together, the mask evidence looks more solid than other medical-tolerance areas—probably because mask studies stuck to one clear protocol.
Why it matters
You can feel confident using tiny-steps-plus-reinforcement for mask tolerance. The data line up across kids, settings, and studies. Start with two-second mask touches, add favorite edibles, and build to full wear time. Track minutes worn and graph daily—you are following the exact model that beat dental and tooth-brushing reviews for effect size.
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02At a glance
03Original abstract
The current review aimed to evaluate the effectiveness of behavior-analytic procedures in increasing face mask-wearing in autistic individuals. This comes following recommended guidance during the COVID-19 pandemic. A systematic review and meta-analysis were completed of peer-reviewed and grey literature. Six databases were searched and seven studies using single-case experimental designs met the eligibility criteria which were then quality appraised. Data were extracted on participant characteristics, study design, independent and dependent variables, fidelity, generalization, maintenance, and social validity outcomes. Both the non-overlap of all pairs and Baseline Corrected TAU were used to estimate effect size. Two studies were rated strong and borderline strong quality and five were rated as adequate or below. All studies showed positive outcomes for mask-wearing, with an average of 0.92 for non-overlap of all pairs and 0.47 for Baseline Corrected Tau effect sizes. The most common and effective procedures for increasing mask-wearing were graded exposure and differential and positive reinforcement. Factors such as mode of delivery, implementer, and setting did not appear to influence study outcomes. Procedures were found to be rated as acceptable by parents and professionals in five of the studies. The existing literature on increasing face mask-wearing in autistic individuals provides promising findings to add to existing literature around increasing tolerance to medical equipment and hygiene practices in autistic populations. However, these findings are based on a small sample size, with six of the studies taking place in the United States with varying study quality.
Journal of Autism and Developmental Disorders, 2023 · doi:10.1007/s10803-023-06128-x