Pediatric vision and digital media: A bad combination

Pediatric eye health is important in all aspects of a child’s life and development. Vision is not simply a matter of clarity; it is a functional system that ideally is flexible and efficient. It is a primary sensory input that influences a child’s learning, development, demeanor, and stamina, and is biologically unsuited to the excessive near vision demands of the digital culture in which children find themselves.

Today’s families must manage an onslaught of digital media in children’s lives, including television content, cellular phones, tablets, and computers. Digital media devices can expand communication tools, provide easy and immediate access to information, and accommodate children’s strengths and challenges. But the benefits of technology are accompanied by risks.

The current exposure to digital media has a profound effect on children. We have never had a generation of infants and toddlers with such increased near visual demands and sensory stimulation brought on by the cell phones and tablets they interact with daily. These excessive demands experienced by children of all ages result in a visual system that is fatigued and unable to operate efficiently.

Common Sense Media reported in 2021 that use of entertainment media approached 9 hours daily among teenagers (age 13-18) and 6 hours daily for tweens (age 8-12).¹ For tweens and teens, screen media use increased 17% since the start of the COVID-19 pandemic.¹ These statistics are staggering and often lead to parents feeling helpless to address their children’s screen time habits.

Excessive digital media use also may lead children to become addicted to device use, social media, and gaming. These are very real, serious consequences that are noted in the pediatric population.

In 2018 the World Health Organization added gaming disorder to the International Classification of Diseases, Eleventh Revision.² MRI studies reveal that gaming and smartphone addictions change the physical structure of the brain in a manner that parallels drug and gambling addictions.

Screen time effect on visual efficiency

As optometrists, we know that the power of the accommodative (focusing) system is age dependent. Excessive use of this system without proper visual hygiene wears down the strength and stamina of accommodation.

Today’s optometric practices give many patients diagnoses of accommodative insufficiency due to a world driven by excessive digital demands. These demands reveal significantly reduced accommodative clinical findings, including reduced, variable visual acuity and the detection of low amounts of against-the-rule astigmatism. Recognizing these clinical findings—in addition to the asthenopia, headaches, and fatigue that accompany accommodative issues—are critical to properly treating patients.

In addition to the accommodative system, we see inherent stress put on the binocular vision system, the process of two eyes working together to form a single image. Binocular vision development begins in the brain, and there are valid neurologic concerns that screen-based activity stimulates visual processing more heavily than even the sensory processing systems, thus interrupting the development of binocular vision.

In our practices, we see binocular vision dysfunction in the form of convergence excess—having an eso-posture at near—and convergence insufficiency—having significant exo-posture at near—that are influenced by the excessive screen time of today’s youth. A close viewing distance when looking at digital devices also influences the onslaught of visual symptoms.

Clinical studies reveal that the close viewing distance often accompanying the use of handheld digital devices becomes even closer with prolonged use.³ A primary chief complaint of parents bringing young children in for an eye examination is the observation of how closely the child views a cell phone or tablet. The closer the viewing distance—accompanied by excess usage—the more likely an increase in diagnoses of accommodative and binocular vision issues and the visual symptoms that accompany them.

There are several treatment options available for accommodative and binocular vision issues. Reading glasses and bifocals are prescribed to support the visual systems and aim to decrease the visual symptoms. Vision therapy is another treatment option for accommodative and binocular vision issues, aimed at improving the efficiency of all aspects of visual function.

Progression of myopia is influenced by genetic and environmental factors, but digital media use also influences progression of myopia development. Today’s emphasis on the treatment of myopia—with a goal of minimizing progression—forces an optometrist to examine the screen time habits of patients. We know there are modifiable behaviors that influence the development of myopia.

Scientific research demonstrates that increased outdoor exposure reduces the development of myopia.⁴ The exact cause of this is not fully understood, but outdoor time likely contributes to a limit of near demands and will have a more positive impact on the visual system.

A January 2021 JAMA article says, “Home confinement due to [COVID-19] appeared to be associated with a substantial myopic shift in children.”⁵ This observation demonstrates the effect of excessive screen time on the development of myopia.

Screen time effect on child development

Beyond influencing a child’s visual system, digital media also has a significant impact on the overall development of our pediatric population. We know that early exposure to digital media negatively affects a child’s intellectual, social, and emotional development. Elevated digital media use more specifically results in decreased cognition and language skills. Further, the way children use digital media has a strong correlation with their mental health.

Quality of sleep

An area to examine is the influence of technology on quality of sleep among youth. In the Journal of Clinical Sleep Medicine, it was noted that “Adolescents’ bad sleep quality was consistently associated with the mobile phone use and number of devices in the bedroom, while in preadolescents, with Internet use and turning-off time.”⁶

Children and teens with devices in the bedroom experience decreased sleep duration, increased daytime drowsiness, and poorer academic performance. Poor sleep habits align with additional issues in the realm of mental health.

Unhealthy online habits result in elevated incidences of anxiety, depression, and hyperactivity diagnoses. Structural changes in the brain related to cognitive control and emotional regulation are associated with a digital media addiction.⁷ Neurologic changes noted with digital media addictions correlate clinically with the patterns of substance behavior dependence.

The path of excessive and unhealthy digital media use may lead to mental health challenges and addiction in our adolescent population. This is a path that every family wants to avoid.

Setting boundaries

The best way to achieve balance in one’s family regarding digital media use is to develop rules and boundaries. Each family can strive to create a system that works for them.

Digital media use can be classified into 3 categories, known as the “3 C’s of media.” They are as follows:

» Consumption: taking in media in a passive manner

» Creation: active engagement and development of skills

» Communication: using media to connect with another person

A well-balanced approach to digital media limits consumption and communication to 1 to 2 hours daily. However, it is understood that schools rely heavily on digital devices in their educational models, and this does contribute to stress on the visual system and impact on development.

Parents must focus on what they can control and create a home environment that supports the benefits of technology and balances screen time in a manner that has a positive effect on all aspects of their child’s life.

As Catherine Steiner-Adair, EdD, author of The Big Disconnect: Protecting Childhood and Family Relationships in the Digital Age, says: “Parenting in the digital age challenges in ways the human brain—AND heart—can hardly process fast enough. We do not want to surrender ourselves unquestioningly to adapt to technology.”⁸

References

1. Two years into the pandemic, media use has increased 17% among tweens and teens. Common Sense Media. March 23, 2022. Accessed August 12, 2022. https://www.commonsensemedia.org/press-releases/two-years-into-the-pandemic-media-use-has-increased-17-among-tweens-and-teens

2. Inclusion of “gaming disorder” in ICD-11. World Health Organization. September 14, 2018. Accessed August 12, 2022. https://www.who.int/news/item/14-09-2018-inclusion-of-gaming-disorder-in-icd-11

3. Long J, Cheung R, Duong S, Paynter R, Asper L. Viewing distance and eyestrain symptoms with prolonged viewing of smartphones. Clin Exp Optom. 2017;100(2):133-137. doi:10.1111/cxo.12453

4. Lingham G, Mackey DA, Lucas R, Yazar S. How does spending time outdoors protect against myopia? A review. Br J Ophthalmol. 2020;104(5):593-599. doi:10.1136/bjophthalmol-2019-314675

5. Wang J, Li Y, Musch DC, et al. Progression of myopia in school-aged children after COVID-19 home confinement. JAMA Ophthalmol. 2021;139(3):293-300. doi:10.1001/jamaophthalmol.2020.6239

6. Bruni O, Sette S, Fontanesi L, Baiocco R, Laghi F, Baumgartner E. Technology use and sleep quality in preadolescence and adolescence. J Clin Sleep Med. 2015;11(12):1433-1441. doi:10.5664/jcsm.5282

7. Lissak G. Adverse physiological and psychological effects of screen time on children and adolescents: literature review and case study. Environ Res. 2018;164:149-157. doi:10.1016/j.envres.2018.01.015

8. Steiner-Adair C, Barker T. The Big Disconnect: Protecting Childhood and Family Relationships in the Digital Age. New York etc.: Harper; 2014.