It is so difficult to give advice as to what haircut should be done when you cannot fully see the face of the customer. The coronavirus pandemic and aerosols: does COVID-19 transmit via expiratory particles? It helps pupils and teachers to modify their behavior in order to align with social communication and behavioral norms. In addition to the considerations already discussed, the following general remark should be considered: Face masks serve the additional benefit of reminding everybody who is present at school pupils, teachers, administrative and supporting staff of the lingering presence of the pandemic and of the appropriate behaviors that are highly important for keeping everybody safe. Initially regarded as some form of flu with symptoms such as fever and cough, it has been found to be much more severe, affecting not only the lungs but also the liver, heart, kidneys, and brain, with symptoms such as anosmia [12] and cognitive dysfunction due to defects of neuro-axonal integrity (even in mild to moderate cases; [1]). In fact, evidence from eye movement studies during gazing at a face suggests that the eye is the facial feature that is attended to first and longest during face processing, as they appear to be most informative in communication. In their view, specific behaviors cause us to experience emotions (and not vice versa), as exemplified in the following statement: You are not crying because you are sad, but you are sad because you are crying. As mask-wearing has become a normality in many societies, the magnitude with which covering our faces affects our social interactions and ability to recognize and identify other people becomes ever more clear. The It may be for this reason, that many people do not like the wearing masks at all in the first place. Before 4The reason for this misguiding advice became clear over time: There were too few masks. The Secret of Our Success. Rivett L., Sridhar S., Sparkes D. Screening of healthcare workers for SARS-CoV-2 highlights the role of asymptomatic carriage in COVID-19 transmission. When infected people re-breathe air in the mask, their virus load increases. Fontana Press; London UK: 1872. Even infants below one year of age are able to comprehend facial expressions as social cues representing the feelings of other people before they are one year old. Health 2020, publ. Mathematics anxiety: separating the math from the anxiety. Reynolds G.D., Roth K.C. Given that school closures already have come to an end, or will have to end eventually, the question of wearing face masks at schools during the next phase of the pandemic is heavily discussed, particularly, where new cases pop up in spots of waxing and waning infections, or in some states, in the form of additional waves of infection (as for example currently in Israel, Australia and Croatia). A psychotherapist wrote me an email, noting that socially complicated and challenging inpatients in psychotherapy are very difficult to treat, as dissociative states and tensions are much harder to detect early enough so that appropriate interventions can be performed. Duguid J.P. In daily life, human observers are extremely proficient in recognizing faces, discriminating between them and using them to derive a vast range of information, be it about static features like age, gender or identity, or changeable features like gaze direction, lip movements or emotional states (see second next section). Wearing a face mask may give a false sense of security and may make people less compliant with other infection control measures. This matter should be discussed urgently, since it globally affects more than 1.5 billion students, teachers, and school staff directly, and, in addition, their families indirectly. Still Confused About Masks? Given that the real smile involves the upper and the lower half of the face, with the upper half providing the distinctive frowning that renders a smile a true smile, there is a lot of room for misunderstanding: Face masks block the smile and allow only the frowning to be communicated which may actually be worse than no smile at all! From birth to about 8 months, babies look at their mother's mouth in order to pars the stream of sound into meaningful units (phonemes) in order to learn their mother tongue. Whereas some studies indicate that children are less likely to infect others [20], [50], some studies find children to be infectious [72]. Because we cannot see the lower half of the face when someone is wearing a mask, our ability to understand people is reduced considerably. Gtzinger F., Santiago-Garca B., Noguera-Julin A., Lanaspa M., Lancella L., etal., on behalf of the ptbnet COVID-19 Study Group (2020) COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study. Careers, Department of Psychiatry, University of Ulm, Leimgrubenweg 12-14, D-89075 Ulm, Germany. sharing sensitive information, make sure youre on a federal The size and the duration of air-carriage of respiratory droplets and droplet-nuclei. Constants across cultures in the face and emotion. Young People Are Infecting Older Family Members in Shared Homes. Davies N.G., Klepac P., Liu Y., Prem K., Jit M., Eggo R.M. Face masks (surgical type) reduced infection risk by 85%. Asadi S., Bouvier N., Wexler A.S., Ristenpart W.D. Moreover, a fraction of carbon dioxide previously exhaled is inhaled at each respiratory cycle. In addition, the existence of a face mask may reduce the motivation of the wearer to produce facial expressions in the first place. Enea V., Iancu S. Processing emotional body expressions: state-of-the-art. Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. Bilingualism modulates infants selective attention to the mouth of a talking face. Leung N.H.L., Chu D.K.W., Shiu E.Y.C., Chan K.H., McDevitt J.J., Hau B.J.P., Yen H.L., Li Y., Ip D.K.M., Peiris J.S.M., Seto W.H., Leung G.M., Milton D.K., Cowling B.J. Diamond A., Lee K. Interventions shown to aid executive function development in children 4 to 12 years old. Face masks block emotional signaling between teacher and learner. In addition, the verdict on children as regarding their role in infecting other people is not yet in. However, in order to decrease the spread to the virus, along with other measures of physical distancing and economic lockdowns, school closures were implemented during March 2020 affecting more than 1.5 billion students (children and adolescents) around the globe [73]. A face masks protects the person wearing it and the person with whom he or she talks. Both types of face masks led to significant differences in temperature and humidity in the microclimates between face masks and skin. An experimental study on the physical effects of wearing either a surgical or an N95/FFP-2 face mask was performed with 5 healthy male and 5 healthy female subjects, who performed intermittent exercise on a treadmill while wearing the protective facemasks in a climate chamber controlled at an air temperature of 25C and a relative humidity of 70%. Scheller E., Bchel C., Gamer M. Diagnostic features of emotional expressions are processed preferentially. The virus can remain airborne for many hours in classrooms. Learn more Szablewski C.M., Chang K.T., Brown M.M., Chu V.T., Yousaf A.R. The protection of teachers, educators,carers and parents and the general hygiene rules do not conflict withthis. Pandemic. So using a mask amounts to doing a favor to others and oneself. This pandemic has been a moving target as regards our knowledge about it.3 Face masks impair face recognition and face identification. Here's the Science Behind How Face Masks Prevent Coronavirus. No masking maximizes exposure, whereas universal masking results in the least exposure ([65], p. 1423, Science Magazine, with permission). Gunnery S.D., Ruben M.A. PMC legacy view The author did not receive funding for this article. Accessibility (because of the long-term psychological, physiological, educational and even economic burden [3], that societies put on their most vulnerable members; [15]). By now, the role of experience in the process of perceptual narrowing in face processing has demonstrated enhanced behavioral and neural responsiveness to (1) mother over stranger, (2) female over male, (3) own-race over other-race, and (4) native over non-native faces. How individual face parts contribute to successful emotion recognition. In two other studies, one from two surveys of 2812 and 2343 inhabitants of the small town of V near Padua in Italy, and another from 1032 healthcare workers (including frontline patient-facing staff such as doctors, nurses and physiotherapists) in the UK, similar findings have been reported [42]. In a society within which the large majority of people wear masks, there is a lot of room for mutual emotional misinterpretation and therefore misunderstanding. The general headmaster of the elementary and basic schools (up to grade 10) in Ulm told me that there was a lot of discussion as regards wearing face masks at schools, when the corona-pandemic was roaming through Germany by the middle of March 2020. On top of this innate preference, the role of social experience in face processing and recognition becomes ever more salient, as research with infants has shown using such different measures as behavioral data, eye-tracking data, and neuroscience data mainly from event related potentials (ERP), functional magnetic resonance imaging (fMRI), and near infrared spectroscopy (NIRS). Features of faces (such as the size and form of the nose, the color of the eyes etc.) Teachers willing to learn and engage, will find workarounds even around the blocking by face masks. Kanat M., Heinrichs M., Mader I., Tebartz van Elst L., Domes G. Oxytocin modulates amygdala reactivity to masked fearful eyes. As soon as babies are born, they show a preference for looking at human faces above anything else, and they will even stare at a rudimentary drawing of a face if it is shown to them. The school's specific situation must also inform any decision regarding face mask use. The new PMC design is here! ) that wearing face masks is one of the most effective preventive measures people can take to protect themselves and others from becoming infected with the virus [65]. In a study of 158 health care workers during the Covid-19 pandemic, the most common side effect of prolonged face mask use was bilateral headache, reported by about 80% of the participants [58]. Since emotions are a major driver of group cohesion, the decreased emotionality, and decreased positive emotionality in particular, may interfere with smooth classroom action. Peltola M.J., Leppnen J.M., Mki S., Hietanen J.K. In sum, recognition of, and response to, the outward emotional displays of one's peers faces is a critical and necessary component of social interaction in schools. Wearing masks is comparatively cheap and easy to implement and supervise. When these emotional displays are inhibited by face masks, our ability to communicate effectively with one another is reduced and we are primarily left with mimicking negative (frown) emotions. At the same time, wearing masks may have physical side effects. [Pandemie. Since such expressions serve the purpose of communication, the realization of wearing a communications-blocking device will reduce efforts to facially express emotions. In addition to these problems of physical health, three more problems of using face masks have to be addressed: Impaired face recognition and identification, impaired communication, and blocked emotional signaling. If applied to the use of face masks in school settings, these results suggest that happiness and disgust are less likely to be recognized, whereas fear and sadness may be recognized with a higher probability. Face masks may further cause perioral dermatitis with rashes and redness, i.e., an infection of the skin around the mouth because of saliva, sweat, and moist vapor between the mask and the skin. A natural experiment published on June 16th 2020 used the different timing (between April 8 and May 15) of state policies mandating public or community use of face masks or covers in 15 US states plus DC in mitigating covid-19 spread [52]. Of particular relevance for schools may be the experiences with face masks in hospitals, including psychiatric hospitals, such as the clinic which I am heading. Lazzarino A.I., Steptoe A., Hamer M., Michie S. Covid-19: important potential side effects of wearing face masks that we should bear in mind. There is additional epidemiological evidence for the effectiveness of wearing face masks regarding the spread of the new coronavirus: In Hongkong, 96% of the populations used face mask, and the incidence of new cases in March was 129 per million inhabitants, whereas in Spain, Italy, and Germany, where at the time no face masks were used, the incidence was 2983 (Italy), 2251 (Spain), and 1242 (Germany) per million [31]. Pons F., Bosch L., Lewkowicz D.J. Face masks reduce airborne transmission of the SARS-CoV-2 virus. Speaking through a face mask may dampen higher frequencies and therefore may impair verbal communication. We are forced to rely only on language and gesture, which limits the extent to which we can interpret nuance, with some input from interpreting eye movements, which are still visible above the mask. This may provide a breeding ground for bacteria. Hoehl S., Striano T. Neural processing of eye gaze and threat-related emotional facial expressions in infancy. Health Affairs, published online ahead of print June 16th, 2020 (. 1. 7This is why plastic surgeons have proposed to use botox, which can be injected around the orbicularis occuli muscle to prevent wrinkles around the eyes (no crow's feet and no frowning), as a means to prevent mask-induced false social signaling [57]. Accordingly, once you no longer produce a smile, you are less happy. During the time of school-closures (from about the middle of March into April and/or May 2020) it became clear that face masks covering mouth and nose in closed public spaces (public transportation, stores, restaurants etc.) For effective verbal communication, covering the mouth with cloth has two detrimental consequences: First, the auditory signal is impaired, as faces masks may dampen sound amplitude, and especially may absorb frequency bands used in speech. Wearing Face Masks Is The new Normal: Know These Tips and Tricks to Avoid Common Side Effects. I implemented the general use of face masks for all staff and patients on March 16th 2020, and it soon became clear that they interfere with practicing psychiatry: The decreased emotional observability made the job harder to do. Physical distancing, face masks, and eye protection for prevention of Covid-19. By now, schools plan for the fall on a global scale. HHS Vulnerability Disclosure, Help The louder someone speaks the more droplets and aerosols are produced. In severely ill patients, the virus causes a two-pronged attack by a dysfunctional immune system (cytokine storm) and blood clotting system (multi-organ thrombosis; [33], [66]), causing strokes with chronic neurological deficits [60], [70]. However, covering the lower half of the face reduces the ability to communicate, interpret, and mimic the expressions of those with whom we interact. Masks and testing are necessary to combat asymptomatic spread in aerosols and droplets. As the emotions of the viewer also follow his expressions, his or her emotions will be blunted as a result. A new coronavirus, SARS-CoV-2, has caused a global pandemic of the disease Covid-19, with as of July 31st almost 300.000 new cases within a single day, more than 17 million confirmed infections, and more than 670.000 deaths [16]. All of this happens primarily outside of conscious awareness, and hence, is hard to be consciously controlled or even corrected. What The World May Learn From Jena; Original Title In German. It is a medical truism that everything that has effects also has side effects. The authors summarize their perspective with a highly convincing drawing, which is reproduced in Fig. Elsevier Public Health Emergency Collection, http://www.uni-ulm.de/klinik/psychiatrie3/index.html, https://www.ucsf.edu/news/2020/06/417906/still-confused-about-masks-heres-science-behind-how-face-masks-prevent, https://theconversation.com/face-masks-what-the-spanish-flu-can-teach-us-about-making-them-compulsory-137648, https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6, https://www.newscientist.com/article/2238473-you-could-be-spreading-the-coronavirus-without-realising-youve-got, https://www.nature.com/articles/s41591-020-0843-2.pdf), https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00818?cookieSet=1, https://download.uni-mainz.de/presse/03_wiwi_corona_masken_paper_zusammenfassung.pdf, https://en.unesco.org/covid19/educationresponse. Cohn S. The Conversation; 2020. Ameres M., Brandstetter S., Tonchev A.A., Kabesch M., Leppert D., Kuhle J., Wellmann S. Association of neuronal injury blood marker neurofilament light chain with mild-to-moderate COVID-19. [15], p. 241], who cite an open letter published in June 2020, signed by more than 1500 members of the United Kingdom's Royal College of Paediatrics and Child Health (RCPCH). Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV-2). Fontana Press; London UK: 1999. Eibl-Eibesfeld I. Mnchen; Piper: 1975. Lyons I.M., Beilock S.L. smile, involves both the mouth (the zygomatic major muscle raises the corners of the mouth) and the eyes (the orbicularis oculi muscle raises the cheeks, forms crow's feet around the eyes, and causes the eyebrows to move closer as in frowning). The Expression of the Emotions in Man and Animals. 2This quote is taken from Couzin-Frankel etal. Received 2020 Aug 6; Accepted 2020 Aug 6. Measurements now show that intense coughs and sneezes that propel larger droplets more than 20 feet can also create thousands of aerosols that can travel even further. Accordingly, it has been shown, that emotions which are perceived in faces have an effect on the style, faces are processed in the first place: A face that is perceived to have a negative emotion is processed in a less holistic manner than a face displaying a positive emotion [17]. 6It is named after Pan American World Airways (an airline that no longer exists), whose flight attendants were trained to always smile at their passengers. When strangers meet, who speak two different languages which they do not mutually understand, they can still interpret facial expressions such as smiles and frowns with ease and thereby communicate. Dimberg U., Thunberg M., Elmehed K. Unconscious facial reacions to emotional facial expressions. So why not use wearing face masks as a simple tool for social behavior training? The Washington Post; 2020. In fact, this is why burglars and thieves wear them. Development of attention to faces during the first 3 years: influences of stimulus type. The .gov means its official. A hairdresser from another city sent me an email, once the lockdown was over such that he was able to restart his business: Yesterday I had two new customers, and I must say that I just had to ask them to go outside so we could remove our masks briefly. Perceptions of Duchenne and non-Duchenne smiles: a meta-analysis. One of the richest and most powerful tools in human communication is the face, from which observers can quickly and easily make a number of inferences about identity, gender, sex, age, race, ethnicity, sexual orientation, physical health, attractiveness, emotional state, personality traits, pain or physical pleasure, deception, and even social status [38]. Atcherson S.R., Mendel L.L., Baltimore W.J., Patro C., Lee S., Pousson M., Spann M.J. In some schools, physical distancing was implemented, with or without masks. During the height of the pandemic in Germany, little was known about such basics as how infectious are children/adolescents?, how effective are face masks really?, how contagious is the virus or are things the same indoors and outdoors? This has changed. Not seeing the bottom half of the face makes it particularly difficult to recognize a mask-wearer's positive emotions pleasure, joy, happiness, amusement, sociability, and friendliness as they are basically communicated by a smiling mouth. Anfinrud P., Stadnytskyi V., Bax C.E., Bax A. Visualizing speech-generated oral fluid droplets with laser light scattering. Wmann L. Folgekosten ausbleibenden Lernens: was wir ber die Corona-bedingten Schulschlieungen aus der Forschung lernen knnen. But even in schools for the mentally retarded and behaviorally challenged students, face masks were implemented and worn by teachers and students. This measure could contribute greatly to controlling the COVID-19 pandemic, with the benefit greatest in conjunction with other non-pharmaceutical interventions [such as physical distancing] that reduce community transmission ([26], p. 305). Compared to adults, children are less likely to fall ill, and if so, their illness is usually mild [34]. So the decreases in facial emotion communication can be compensated to some degree. Curby K.M., Johnson K.J., Tyson A. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. It is known for more than 70 years that the act of speaking generates oral fluid droplets that vary widely in size, from clearly visible to invisibly small aerosols [24], [55]. Some teachers as well as other headmasters voiced concerns that they could not imagine teaching with face masks. Asadi S., Wexler A.S., Cappa C.D., Barreda S., Bouvier N.M., Ristenpart W.D. School openings across the globe suggest ways to keep the coronavirus at bay, despite outbreaks. In fact, the most basic form of communication between humans is by facial expressions. Bombari D., Schmid P.C., Schmid Mast M., Birri S., Mast F.W., Lobmaier J.S. Mimicking and sharing emotions: a re-examination of the link between facial mimicry and emotional contagion. Pascalis O., Scott L.S., Kelly D.J., Shannon R.W., Nicholson E., Coleman M., Nelson C.A. At the same time, emotional mimicry and thereby emotional contagion [59] is interrupted by the mask as well, i.e., the social phenomenon that we are involuntarily copying the facial expression of other people with whom we communicate. A student looking at the critical face of a teacher thereby becomes less creative, and thereby less able to solve math problems, which increases the likelihood of math anxiety to develop [51]. In 2017 researchers from the University of Bielefeld published results from an experimental study of emotion recognition, which clearly demonstrated the importance of the eyes and mouth in the perception of emotions from faces. Therefore, face masks impair mainly our positive social interactions and our ability to understand, and empathize with, one another. Within 30min after removal of the face mask, the pain resolved spontaneously. Moreover, according to the embodied emotions hypothesis first proposed by William James more than one hundred years ago, not physically displaying emotions reduces their experience. In contrast, dishonest smiles, which are also called fake smiles, Botox smiles, Pan Am smiles6 Bethesda, MD 20894, Web Policies In particular, the subjects identified fear and sadness largely by focusing on the eyes whereas disgust and happiness were more successfully identified when subjects focused on the mouth region [74]. This news led, even in small-town American newspapers, to statements such that using face masks against influenza is like using barbed wire fences to shut out flies [14]. 3Historically, this was also the case one hundred years ago, after the French bacteriologist Charles Nicolle discovered that the agent that caused influenza was much smaller than any known bacterium in October 1918, i.e. National Library of Medicine With this method, it was possible to discern which of the 48 parts of the face contributed to what extend to the observer's recognition of the facial expression being revealed. But second to the eyes are the regions of mouth and nose, when it comes to attending facial features. Those phenomena increase breathing frequency and deepness, and they may worsen the burden of covid-19 if infected people wearing masks spread more contaminated air. But within seconds of absence, its importance is realized. Moreover, given the diversity of educational settings in terms of country, culture and learners as well as teachers age, different considerations may weight in differently in any balanced decision as regards the use of face masks in classrooms. Respiratory virus shedding in exhaled breath and efficacy of face masks. Just as in psychotherapy, where learning to talk about emotions (and not just having them) is an important mechanism of coping with emotional distress, students and teachers can learn this and the pandemic is a good reason to do so. These should be weighed against the alternatives, i.e., school closures (with the enormous burden on the children and their parents) and school re-openings without masks (with their increased risk of new infections). The mouth region on a face conveys information that is crucial for smiling, i.e., a positive emotion, which can work as social glue and facilitates positive social cognition and action [69]. A recent study on the cardiovascular effects of face masks (surgical or N95/FFP-2) in young healthy male subjects on a bike-ergometer showed a 2 percent decrease in maximum power (not significant) for the surgical mask and a 5 percent decrease of maximal power (p<0,01) for the N95/FFP-2 mask [32]. Itchy rashes may be caused by irritant dermatitis, caused by the mask and/or the attached rubber strings rubbing the skin of nose and ears [63]. I write this paper on an island in the German state of Mecklenburg-Vorpommern, on which at the time of writing there were zero cases. We know from our experience with sensory handicapped people, that they learn to compensate by sharpening their remaining senses. UNESCO (2020) Education: From Disruption to Recovery. Lavezzo E., Franchin E., Ciavarella C. Suppression of a SARS-CoV-2 outbreak in the Italian municipality of V, Lawton G. (2020) You Could Be Spreading The Coronavirus Without Realising You've Got It. Wegrzyn M., Vogt M., Kireclioglu B., Schneider J., Kissler J. Mapping the emotional face. In the Italian study, 42,5% of confirmed SARS-CoV-2 infections were asymptomatic, and in the British study, 60% had no or only very light symptoms. Everybody can be infectious while not knowing it [43]. The authors comment: Infectious aerosol particles can be released during breathing and speaking by asymptomatic infected individuals. Wearing face masks may cause glasses to fog and thereby cause anything from discomfort to accidents. They must do so responsibly. Because speech transmission is impaired by mask-wearing, there is a risk of misunderstanding when face masks are used widely in schools. Second, the visual signal from the lips is completely obstructed. MacIntyre C.R., Wang Q. Finally, the spread of the pandemic is modified by the number of currently infected cases. No data was collected for this opinion paper. Emergence of enhanced attention to fearful faces between 5 and 7 months of age. As Prather and coworkers note in their highly informative perspective, published in Science magazine online on May 27th 2020: [] calculations predict that in still air, a 100-m droplet will settle to the ground from 8 feet in 4.6s, whereas a 1-m aerosol particle will take 12.4h [to settle down]. The authors presented single faces of two different individuals expressing Ekman's six basic emotions (as well as a seventh neutral face expression) behind a 68 grid of 48 white tiles that were sequentially (in random order) uncovered to 94 student subjects, with subjects instructed to stop the uncovering as soon as they recognize the emotion of the face and name it correctly.
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