In this episode, we discuss:
- The difference between eyesight and vision
- How we learn vision and what factors impact vision development
- How trends in screen use are impacting vision and brain development in both children and adults
- The alarming increase of nearsightedness in children
- What vision therapy is and how you can find treatment
- Whether a diagnosis of ADHD could actually be a hidden vision problem
- Appelbaum Vision
- College of Optometrists in Vision Development
- Concussion Clear
Hey, everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. Have you ever thought about the difference between eyesight and vision? To be honest, I hadn’t before this podcast.
I talked with Dr. Bryce Appelbaum, who is a pioneer in neuro-optometry [and] passionate about unlocking life’s potential through vision. His expertise includes reorganizing the visual brain post-concussion to be able to return to normal life, remediating visual developmental delays interfering with reading and learning, and enhancing visual skills to elevate athletic performance. He also is an expert [on] the impact of screen use [by] children on the development of vision and brain development in general. There’s a strong correlation between [attention-deficit/hyperactivity disorder] (ADHD) and other behavioral disorders in children and vision, which I wasn’t aware of prior to this interview. There are some really concerning changes that have happened in trends in screen use in both children and adults that impact vision and brain development. We covered all of these in the show, and we also talked about [the] emerging field of vision therapy, which can help reverse some of those impacts. This is a must-listen for parents, anybody [who’s] dealing with eyesight or vision problems, and anyone who’s interested in the relationship between vision and brain development.
It was a fascinating show [and] I learned a lot myself. This is definitely something I’m going to be focusing on, pun intended, more in my own life and in my work with people going forward. So I hope you enjoy the show as much as I did. Let’s dive in.
Chris Kresser: Dr. Bryce Appelbaum, welcome to the show. It’s a pleasure to have you.
Bryce Appelbaum: Thank you so much for having me. Pleasure to be here.
What Is Vision and How Is It Different Than Eyesight?
Chris Kresser: Let’s jump right in and talk about the difference between eyesight and vision. I don’t know that I’ve ever thought about that, and I’m in the healthcare field. I imagine most laypeople haven’t thought about it either. Why is that so important?
Bryce Appelbaum: I would say you are not alone. The majority of eye doctors, and doctors in general, are solely focused on the pursuit of seeing 20/20. But there’s so much more to vision than just 20/20 eyesight. I like to describe eyesight as just simply the ability to see, whether that’s letters on the letter chart, or a street sign, or what the teacher writes on the board in the classroom. Vision is far more complex. Vision is entirely brain. Vision is how our brain tells our eyes to move together and focus and converge and track and process information. Essentially, [it’s] how we derive meaning from the world around us and then direct the appropriate action. Vision problems are brain problems, and [they] are treatable and avoidable and preventable. So much of healthcare simply looks at [the] intervention of eye disease and structure and eyesight, but we really need to be looking at the vision component, as well.
Chris Kresser: That’s fascinating, the relationship between the brain and vision. One thing that popped into my head as you were talking about that is the influence of things like psychedelic drugs on vision. How the brain processes the visual input that’s coming in through the retinas can be totally different when someone is taking psilocybin than it is when they’re not. That, to me, seems like an indicator of how much of a role the brain plays in processing that sensory input.
Bryce Appelbaum: It’s crazy to think, but we can literally train our brain how to process the world differently. We can train our brain how to engage periphery and be more open to what’s around us. Or the opposite, to lock in more focally or centrally. We know [that in] many situations in life where there is stress from our environment and we adapt to that stress, vision can be [the] dominant sensory system that we learn to have guide and lead [us], so [that] we can integrate what’s in front of us centrally and what’s around us peripherally simultaneously, [and] we can be really confident navigating through space.
Chris Kresser: A couple [of] other examples come to mind, and I think we’ll probably talk about one of them more when we talk about screens. I’ve read research on how looking at a two-dimensional screen affects the development of empathy [in kids], which was fascinating to me, at least when I first learned about it—that something in our visual field could affect our capacity to empathize with other human beings.
Bryce Appelbaum: From a developmental standpoint, vision is intended for us to engage with our three-dimensional world and to guide movement. So many of our children’s worlds and environments are being compromised by engaging with two-dimensional space and not developing interpersonal communication and the ability to read facial expressions and body language. There [are] very scary consequences of this new tech world that we’re all living in, which isn’t going away, in terms of how that’s influencing social development, emotional development, and, of course, vision development.
Chris Kresser: I want to come back to that because I’m hugely concerned about this. It’s a frequent topic on my podcast. And by “this” I mean our relationship with screens as a species, but particularly the impact of screens on kids and childhood development.
Another example that popped into my mind are those puzzles you look at in different ways and see different things, depending on how you look at them. Even when you soften your gaze versus when you focus on a particular point. I imagine that is exactly what you’re talking about, with how the brain affects that visual input and how we can train ourselves to see things differently based on our gaze and how we hold our gaze.
Bryce Appelbaum: A hundred percent. Another parallel would be the old Magic Eye books, where there’s two ways to allow that depth to pop out. We can soften our gaze, like you shared, and engage in [the] periphery and diverge our eyes, almost looking through the page. Then we notice that when both eyes are working together and the brain’s turning on that sensory input and filtering it and processing it appropriately, the three-dimensional image pops out. Or vice versa, [by] looking hard and close and converging our eyes, an alternate effect can occur. What’s pretty cool is when you learn how to have a good rapport with space and learn how to control those systems at will, you can make a Magic Eye have the image pop out and the background goes backwards. Or, if you look at it the opposite way, the opposite occurs, and the background pops forward and [the] image goes backwards.
On a daily basis with my specialty [in] vision therapy, we’re typically working with individuals who have problems, whether it’s developmental delays visually [that are] impacting reading and learning and academics, or rewiring the brain post-concussion after the visual centers [are] no longer communicating with the postural and body centers like they should, or eye turns, or lazy eyes. I’m sure we can talk at length [about] any of these areas. But we can learn how to have better eye coordination, and better eye coordination teaches us how to have better eye–brain–body integration, which is important for sports and driving and just navigating through life in a safe and confident manner.
Factors That Affect Eyesight and Vision
Chris Kresser: Let’s talk about some of the factors that affect both eyesight and vision. I imagine there’s some similarities and also some differences. I think most people would probably assume whether you need reading glasses or you’re nearsighted or farsighted is largely genetic. I’m curious what the research says, in terms of the role of genetics versus other environmental factors like nutrient status. That’s a big part of my work, and most people think nutrient deficiency is something that’s limited to the developing world. Of course, that’s absolutely incorrect. There are a lot of people in the industrialized world who are suffering from mild to moderate nutrient deficiencies, [which] could affect things like eyesight. So I’m curious [about] what the research shows there.
Bryce Appelbaum: Absolutely. So, vision in general is a learned system. When every child is born, we can’t converge, track, or focus our eyes, depth perception is not in place, and we see in black and white. Then, through our life experiences and developing the ability to use both sides of our body and get the reciprocal body coordination from crawling and then walking, we develop the ability to use our eyes together, and we develop the ability for our visual system to emerge. That’s something that’s either learned well or not learned as well as it could be, and that’s when some intervention is needed. More so than ever, these days, kids are being introduced to technology and screens earlier and earlier and being asked to read at earlier and earlier ages, often before they’re visually ready.
Chris, you know better than anybody [that] when our systems are under stress, we either adapt or we avoid. The majority of vision problems are [either] maladaptions or not having the visual foundation in place to meet the demands of our world, based [on] what’s being asked of us in our world we’re not visually ready for. For developing prescriptions and developing the ability to see, eyesight-wise, we know that there [are] two main components: genetics and environment. Obviously, we can’t control genetics. But from an environment[al] standpoint, visual systems can be taught, they can be enhanced, [and] they can be remediated to be able to guide and lead in the appropriate fashion. We now know [that] myopia, for instance, which is nearsightedness, [is] a new pandemic in countries that value education and technology. We know that a child born today to two parents, neither of which [is] nearsighted, has a one in four chance of becoming nearsighted. If one of them is nearsighted and the other is not, there’s a one in three chance. And if both parents are nearsighted, [there’s] a one in two chance.
We know that is mainly from the environmental standpoint and the fact that so many of us are not getting the [ultraviolet] (UV) exposure and the sunlight that we need outdoors, which is so crucial to so many aspects of development, but specifically brain and vision development. We know that being exposed to blue light and artificial light from screens at a very high frequency and magnitude can disrupt circadian rhythms and can be a driving force behind metabolic disorders and even cancers. So, I think you bring up a very interesting point. Nutrition plays a huge role, [and] environment plays a huge role. In countries where there is malnutrition, there’s a much higher likelihood of structural vision problems, but often, those countries don’t have access to the technology that we have in countries that don’t have as many of those concerns. So it’s definitely a balance back and forth between what’s occurring. We know, at least with the macula, which is the sweet spot of our retina [and] the back layers of our eye that allow us to see clearly in that 20/20 zone, there are so many supplements and nutrients that can significantly improve the quality of that area.
Certain foods like dark green, leafy vegetables that have lots of lutein and zeaxanthin are phenomenal for that area. Antioxidants and vitamins like A, C, [and] E can decrease the risk of diseases forming down the road, like macular degeneration or cataracts. And omega-3s are phenomenal for overall brain health, but especially eye health, as well. Specifically, the outer layer, the tear film, which can be more viscous and protective for so many of us. From a nutrition standpoint, there is so much that we can all be doing to maximize our brain’s ability to use our eyes efficiently.
Chris Kresser: Yeah, and even just those essential nutrients that you mentioned, I think the latest statistics suggest 89 percent [of people] don’t get enough vitamin E and 67 percent don’t get enough vitamin A, and that’s in the [United States], one of the richest, most developed countries in the world. I think vitamin C’s close, just below 50 percent. To me, that’s low-hanging fruit that people can leverage to improve their vision and their eyesight.
The Impact of Screens on Vision
Chris Kresser: Let’s get back to some other causes. I think this would be a good segue to talk about screens and how screens impact vision in both kids and adults, because we’re talking about factors that affect the development of vision. Like you said, that’s largely a learned capacity. When infants are born, that hasn’t developed. What are the implications of the dramatic increase in screen use [by] kids from a developmental perspective, since that is an anomaly from a historical perspective? There’s never been a time in human evolutionary history where kids have had the level of exposure to two-dimensional screens that they have now. What impact is that having on the development of vision?
Bryce Appelbaum: When we were kids, Chris, our parents had to drag us in from being outside. We would not want to be inside and not want to be around the table. We’d want to be playing sports and climbing in the woods. Now, parents are dragging their kids outside after being stuck indoors in low light for way longer than we should.
We spoke about the cognitive, emotional, [and] social implications. There’s more software in education now than ever, at earlier ages. Apps are made to be addictive [and] to create an environment where we want to come back for more. [They] allow for that neurotransmitter dopamine to be excitatory and be released and make us feel good and want to come back. But light levels have a large influence on vision [and] on prescription development. We know myopia, nearsightedness, is induced from excessive near-visual stress. We’re now seeing myopia increase at an alarming rate, in terms of magnitude as well as frequency. Even high levels of myopia. We can’t change the genetics, but we can change the environment. There are so many things we can be doing to minimize these negative impacts. There’s also clear warning signs, both in terms of performance and physical signs when screens are presenting too much [of a] challenge for us to be able to interpret or make sense of. Headaches, eyestrain, resistance to learning, early blurry vision far away, screens going into and out of focus, reading problems, [and] postural adaptations like tilting our heads or turning our heads or leaning forward to get closer to the screen, because our focusing system is not functioning the way [it] should, especially as the print gets smaller. That can be a clear sign [from] a child, when they would rather be read to or avoid reading because they don’t have the system in place to extract meaning from those words. From a myopia standpoint, from a structural standpoint, we know structure and function are very much intimately related. We also know that so much can be done to help make that visual stress less of an issue for us moving forward.
Chris Kresser: Let’s unpack the impact a little bit more. It seems to me there are several characteristics [of] the way that kids and adults use screens that stand out. One is just the physical nature of staring at something that’s two-dimensional [and] that’s anywhere from a few inches to a couple of feet in front of your face. Our generation grew up watching TV, but the difference [is that], in most cases, the TV was 10 feet away or more. You [were] sitting on a couch. It seems to me that even that alone has a different impact. So there’s just the viewing distance and the mechanics of that. Then there’s the nature of what’s happening with [the] eyes and tracking movements that will be different depending on what they’re doing with the screen, like a video game or something where there’s constant motion and eye tracking going in different directions in a rapid way that wouldn’t happen very often in a natural environment without screens. And then you mentioned the small type and having to focus in on a very small thing, [which] you wouldn’t typically do. Is there research [showing] differential consequences or impacts of those different things? Or does it all sort of blend together in the research at this point?
Bryce Appelbaum: Absolutely. The larger the screen, the farther away, the better. With these close screens, it’s a shorter working distance, which means the inside and outside muscles of our eyes that control making something clear and single and keeping it that way are stimulated in ways that they would not be when we’re looking beyond arm’s length and our eyes are in their natural resting position. What that means is the need to focus and then converge our eyes doesn’t exist when we’re watching screens far away. With computers and with more near-sedentary types of technology, it’s a greater impact in terms of the direct light that’s being presented. There’s glare. There’s a lack of tactile feedback and hand-eye coordination that comes with learning more of a distance-related task. The eye movements you mentioned—evolutionarily, our tracking system was meant to gaze on the horizon. Now we’re having to make these very careful integral eye movements with a small artificial plane up close. We know [that] on screens, compared to just reading on paper, we skim and scan much more quickly when reading digitally versus in print.
There’s even a tremendous problem with dryness that’s emerged from all this screen use, where we know that the blink rate decreases dramatically on screens versus in real life. The average person blinks anywhere from 15 to 20 times a minute. Depending on the studies you read, we know that it’s about a third of that when we’re on the screen, meaning we’re literally locked in, zoned out, [and] not making those automatic eye movements and blinking movements. Dry eye syndrome and computer vision syndrome are creating the scenario where even our tear film, that windshield of our car, is no longer clear to see through, and that can exacerbate a lot of other problems, as well.
Chris Kresser: I think I’ve heard of injuries in gamers from not blinking for an excessive period of time. Am I making that up? It seems like I’ve read that.
Bryce Appelbaum: You are not making that up. There’s significant dry eye. I’ve heard stories of gamers being so in a trance, so locked in focally, that World War III could be going on around them and they would have no idea. The need to use the restroom and to eat and to just get up becomes a daunting task when you’re stuck in that focal central processing, which from a brain standpoint, is really making the ground less aware because you’re so locked in on the figure.
Increasing Prevalence of Nearsightedness
Chris Kresser: So is this also what’s behind the increase in nearsightedness in children? First of all, is there an increase in nearsightedness? I know you see a lot of media articles, but I have plenty of experience with not trusting the headlines that I see in the media about these sorts of things. So, first of all, is there actually an increase in nearsightedness that’s been documented by research? And then, second, is that because of this excessive myopic focus on small text on the screen?
Bryce Appelbaum: There’s a dramatic increase. It’s predicted that by 2050, 50 percent of the population in the [United States] will be nearsighted.
Chris Kresser: Wow. What is it now, just for comparison?
Bryce Appelbaum: I would have to look at the exact number, but I would imagine probably in the teens.
Chris Kresser: Yeah, nowhere near 50; I know that.
Bryce Appelbaum: Nowhere near that. And we have studies, post-Covid, now. In 2021, a study came out with children ages six to eight who clearly showed an increase in myopia through the Covid lockdown. There was a Dutch study where teenagers had an increased level of myopia correlated with using screens for more than 20 minutes a day without taking breaks. Although this isn’t really anything new in my field, Covid was different because many of us were locked inside. The visual stress that’s being presented for most of us [who] don’t have the tools in place [to deal with it], we adapt or we avoid. And if you think about eyesight just as a symptom, the symptom is distance blur. The problem is near-visual stress. Whether that’s a focusing system, the internal muscles responsible for clarity [have] difficulty sustaining focus or maintaining flexibility, [or] the muscles themselves become taught and locked in. The blur in the distance is a symptom of that near-functional problem.
So many doctors treat the symptom, and in many cases you have to treat the symptom. That’s, “Here’s new, stronger glasses.” Very often, that can become your new normal. You then adapt to that lens, [and] you need something stronger to maintain that same clarity. We go down this vicious cycle. At some point in life, for many people, their [prescription for] glasses changes. And people wonder, “Well, why is that?” There’s all these old wives’ tales about why that happens. But anatomically, our bodies stop changing in terms of structure when we’re done growing. Yet, the eyes can often elongate and change shape, based [on] the need to lock into that focusing system. We can think about the focusing system as an old-school camera, which many of the younger listeners probably have no idea what that even means. The manual focus that you’re literally turning is shifting how in front of you [something is] on the z-axis, [and] how you can allow something to be clear there. But when we’re stuck at one distance, autofocus stops working, and then that becomes, again, your new normal. Very often, the “prescription” for distance is a different prescription than what should be prescribed for near, because for near, the demands are different.
I’m a big believer that the ideal prescription for anybody should be the weakest lens possible that is the most balanced [and] allows us to meet the demands of life. If we’re seeing HD clarity at every single distance, very often, that’s locking that focusing system in too centrally, and that’s when adaptation occurs. So I promote 20/happy rather than 20/20, where we want to be able to meet the visual demands of life, [and] obviously, be legal to drive based [on] state regulations, but you don’t always have to see the hairs on every single person’s face at every distance. The key is finding the right prescription for the right person that allows them to meet their activities of daily living appropriately.
Chris Kresser: Well, I can speak personally. You can see I have these reading glasses on now, which I didn’t need until maybe four months ago. It was pretty sudden in my case. And what I’ve noticed is how much worse my near-distance vision is since I started wearing these glasses. It’s pretty dramatic and it feels notable.
Dr. Bryce Appelbaum is on a mission to change the way the world views vision. He believes there is more to vision than just 20/20 eyesight and is dedicated to unlocking life’s potential through vision. #chriskresser #visiontherapy #vision
Bryce Appelbaum: People joke and say you blow out the candles on your 40th, 42nd birthday, or like you, had a bad dream and you wake up and all of a sudden, your arms aren’t long enough and you can’t make something clear in front of you. There are anatomical changes to the structure inside of our eye that occur as we age, where the focusing system and the lens become more rigid and less flexible. Just like any muscle in our body, if we stop using them, we lose voluntary control over them. I [work with] plenty of patients who do active work every day, or more intensive work with office space vision therapy, to prolong the need for reading glasses. If we’re intentional behind that and we’re exercising the systems in the way that we could or should, we can at least delay the onset of the symptoms. But very often, getting that first pair of glasses acts as a crutch. Then that becomes your new normal, and then you’re taking off the glasses and it seems like what you were doing before is not even possible. Yet again, we often go down that vicious cycle of reaching for more and more and more, kind of like medications, just increasing the dosage. If we can be intentional, we can slow down that change. We can even reverse it, in many cases, if we develop the right rapport with the different muscle systems.
Chris Kresser: Yeah, I just try to wear them less at this point and spend some time looking at things, even if I can’t see them perfectly well, just lingering a little bit to see if they come into focus. I have no idea if that’s helpful or not.
Let’s talk about vision therapy because I think this is a good segue to that. What can people do? As a Functional Medicine clinician, I’m always keenly focused on cause and effect. Obviously, it goes without saying that one of the things people can do is not do the things that are causing the problem in the first place. For kids and screens, that’s a whole other conversation of how to manage that, and we’ve had many shows and guests on that topic. But speaking more specifically about what they can do from a vision therapy perspective, let’s talk a little bit about that.
Vision Therapy and How You Can Seek Treatment
Bryce Appelbaum: Most people are probably wondering, “I’ve never heard about vision therapy. What even is vision therapy?” I describe vision therapy as physical therapy for the brain through the eyes. It’s essentially rewiring the software of one’s brain to change how they’re taking in the world around them and processing visual information. It requires extra training and extra desire and extra knowledge from the doctor. You don’t have to be board certified in vision therapy to offer vision therapy, but I would argue the level of care is dramatically different when you are. Vision therapy has been around for a long time, but I would say in the last five to seven years, [it] has become almost mainstream in many cities because of the wonderful benefits we’re noticing with rewiring the brain post-concussion to establish better integration and synergy between the different postural systems, visual systems, vestibular systems, and much of what gets disrupted from concussion and head injury. And we can talk about that, as well, maybe later. But from a vision therapy standpoint, it’s an individualized program, where you’re ideally working with doctors or under the supervision of doctors to arrange the conditions appropriately to raise your awareness [of] what your visual system is doing, so that you can self-regulate, self-monitor, and figure out how to eliminate these maladaptations to make it so that the visual system and the brain are operating the way in which the brain is wired.
Often, we see [that], if it’s hard for the eyes to work together, an adaptation that occurs where there’s almost a rivalry or competition over sensory input, where the brain picks one eye and ignores the other eye, or focuses the eyes at different planes, or converges behind the target because it’s [too] hard to converge on the target. These spatial mismatches occur, which allow for double vision and movement of images and all the symptoms, but also depth perception. Depth perception is something that can be taught [at any age]. The brain can be rewired by equalizing the skills between both eyes so that the visual centers in the back of the brain, the visual cortex, can respond to that information appropriately. But I would say, really solid vision therapy is treatment that integrates cognition and balance and movement and vestibular input as early as the patient allows. Essentially, from the beginning. Ideally, it’s office therapy with home reinforcement, where the new learning takes place in [an] office under the guidance of a doctor, and then the reinforcement is to establish muscle memory and make the learning more habitual.
There are lots of programs out there, as well, that can be helpful for some at improving symptoms [by] a certain percentage. I have a recent program launch called ScreenFit, which does a really nice job as a visual wellness program to train and rehabilitate the visual skills and abilities necessary to support these high visual demands of screen usage and teach you how to eliminate some of the challenges that we experience on a daily basis. Absolutely, individualized care one-on-one is the gold standard, and that should never change. But we are now seeing occupational therapy and physical therapy and lots of other doctors adopting vision therapy-like exercises with tracking and cross-midline types of activities. So much of the world takes place on the z-axis, which requires eye coordination and convergence and divergence and all those other areas we spoke about.
Chris Kresser: Let’s talk about those two different options. If someone wants to find a vision therapist in their area, is that the term that they would use? Would [they] just Google “vision therapy”? You’re in Maryland, so if someone’s near you, they can come to see you. But if they’re somewhere else, could they Google “vision therapy,” plus the name of where they are? Would that do it? Or are there different names of that therapy in different places?
Bryce Appelbaum: There’s a few different names for what vision therapy is. Sometimes you’ll see neuro-optometric vision therapy, sometimes you’ll see vision training, [and] sometimes you’ll see vision therapy. I would say the best place to go to is COVD.org. That’s the College of Optometrists in Vision Development, [which is] the international organization that board certifies doctors in vision therapy and rehabilitation. There’s a wonderful “locate a doctor” section where you can type in your address, your zip code, your state, your country, and adjust the search radius, and it can tell you the closest doctors within that radius. If the letters F-C-O-V-D are after the doctor’s name, that means they’re a fellow of the College of Optometrists in Vision Development, or essentially that they’re board certified in vision therapy and rehabilitation. Again, you don’t have to be board certified to offer vision therapy and to help people, but I would argue the level of care and understanding is different with those doctors who are. So that’s a great place to look.
Another great resource is visionhelp.com. That’s an organization I’m a part of, as well, that has about 10 practices around the country. All of us are thought leaders in this area, with goals of just raising awareness. [It’s a] great resource for all the research, literature, videos on how vision impacts learning [and] sports, and eye turns and lazy eyes, and autism and [attention-deficit disorder] (ADD) and ADHD, which so often gets misdiagnosed based [on] slapping labels on behaviors that can come from so many vision problems.
So I think definitely, ask your primary care doctor about vision therapy. But again, not all doctors are in agreement because the research and literature to support vision therapy that has been groundbreaking is from the last decade or so. Although there has been research for a long time, many doctors [were] taught in school decades ago that certain things didn’t work or weren’t effective. But I would say, we should all be keeping up to date with the latest literature and research and doing the best to stay aware of this so that we can help our patients as best as possible. I think the head injury world is becoming incredibly receptive [to] vision therapy. Vision therapy is the missing piece for so many people to return to [learning], return to life, and get back to [their] previous level of function after a concussion or head injury [occurs].
Chris Kresser: And how about the ScreenFit program? Can you tell us a little bit more about that?
Bryce Appelbaum: Absolutely. You can find [the ScreenFit program] at www.screenfit.com. This is a program that empowers you with the tools to support healthy visual habits and efficient use of the eyes together as a coordinated team. Our beta tests had individuals across the board, age-wise. [The youngest was] six and our oldest was in her 80s. I relate it to almost like a workout program that does sit-ups and push-ups and air squats and has the right sequencing and is more bodyweight-type stuff. This is a program where you don’t need any equipment. It’s all designed to be done from a phone, tablet, or computer. The screen that we’re already on way more than we should be. It’s a daily workout, about 10 to 15 minutes a day, programmed for six weeks. There’s two different phases of it. The first phase works on the foundational visual skills. Activities like, “Follow this ball across the screen as it’s making a unique pattern,” to “Here’s a way to constrict focus. Look close for X amount of seconds, and then look far for X amount of seconds as you’re holding a pencil at a certain distance.”
The second phase, which is much more of an integration phase, works a lot more on eye coordination and eye teaming and the vestibular impact of staring at screens and what that can do, in terms of our sedentary. It’s a great program, and what’s really exciting is we’ve had some tremendous interest from very large organizations, [both] as corporate wellness programs [and] from insurance companies recognizing that, “Oh, wow, if prescriptions aren’t changing every year, or if we’re able to offer this as a certain option for certain people, [there’s an] impact on overall health and lack of medication to treat symptoms and lack of increasing prescription based [on] the adaptations that are occurring.” It’s a pretty exciting thing we’ve been working on for several years and [is] finally out within the last couple of months.
The Link Between Vision Issues and ADHD
Chris Kresser: That is exciting. I’m definitely going to recommend this as a resource because like I said, I’m really concerned about the impact of screens on kids’ vision. You mentioned something in passing that I want to go back to, because ADD and ADHD are epidemic among kids at this point. You mentioned a link between vision issues and ADHD. I’d love to hear more about that.
Bryce Appelbaum: Sure. So there is not a blood test for ADD or ADHD. Very often, ADD or ADHD is not a biochemical imbalance in the brain. It is a cluster of symptoms that can come from many different areas. But there’s a very intimate link between visual attention and overall cognitive attention. I did a progress [evaluation] for a young man yesterday that we’re working with who is on a 50-milligram extended-release ADD medication, and a 20-milligram add-on at the end of the day. When I first met him, he had significant visual developmental delays. He had trouble focusing his eyes. [He] hadn’t even learned how to use that system. He had a convergence insufficiency, meaning he was aligning his eyes as if where he was looking up close was significantly farther back. It was so hard for him to maintain eye focus that, of course, his brain focus was then also compromised. The medical world, which likes to assign labels to behaviors, looked at his challenges of difficulty focusing his eyes and not remembering what he was reading and being distracted by what’s in the periphery when he’s in a classroom and trying to read, and decided [to] take a more structural approach, because that’s all they knew. And his medication level has dramatically increased year after year after year.
I’ve been working with him for three months. He’s no longer taking the add-on pill at the end of the day, and he had leftover 10-milligram extended-release pills from when he was much younger that he started taking, not with my guidance. They said his overall attention has improved dramatically for the last few weeks, and their plan is to wean him off all medications. It’s unfortunate because vision is not everything, but it is a very large piece to the puzzle. I do not think that ADD or ADHD, or even dyslexia for that matter, can be an accurate diagnosis without these hidden functional vision problems being ruled out first. I give screenings to doctors on what types of simple tests can be done to see if there is a potential for a functional vision problem. We can take a pen or pencil and bring it across [the] midline and track that image. There should be no head movements; it should be all eye movements. We should be able to have smooth, effortless eye movements across our midline and take that same pencil and bring it at arm’s length and then bring it down [the] midline toward your nose. It should be effortless all the way in, where you’re seeing one image all the way in. If either of those situations is not occurring, that is a clear sign in a 30-second, very delicate test that vision is potentially interfering with the brain’s ability to sustain focus.
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Chris Kresser: If a parent wanted to take their child in for that kind of exam, would that be done in a typical vision exam? Or would they have to ask for those specifically?
Bryce Appelbaum: They absolutely should be done in typical vision exams, but they are not. Especially with healthcare these days, so many eye doctors are packing patients in like sardines, and you’re not even spending much time with the doctors and it’s all automated. We live in a three-dimensional world. The learning and the measurements need to take place in three-dimensional space. So I think specifically asking to be tested for convergence insufficiency, any doctor can do that, or should be able to do that. Or for a tracking problem. I think the interpretation of those results and what that means obviously would leave [something] to be desired, but I think that’s something that, if you know what to look for, it’s pretty glaring and hard not to miss. A child, in particular, who loves to be read to but really dislikes reading on their own or is distracted in the classroom with desk work, where they’re really listening to what the teacher is presenting rather than being able to take it in with their eyes, they’re relying on a different sensory system because the input is so confusing visually. Those are clear signs that there’s likely [a] vision problem.
Or a child who is smart in everything but school. I think there’s so much being asked of us from a sustained, near-concentration task standpoint, that very often, if performance and behaviors are inconsistent, I think that’s a great sign that something is interfering and not allowing that person to achieve at their potential.
Chris Kresser: So fascinating. I’ve really learned a lot, and I think this is one of those things that is not even on the radar for most people. It’s so profoundly important for so many different reasons that we’ve discussed, and how vision affects that bidirectional relationship where our brain development affects vision, but our vision affects our brain and how we essentially relate to the world around us.
Bryce Appelbaum: Research says that one in 10 kids has a vision problem significant enough to impact learning. And that statistic is from a while ago, so that number, in my opinion, is probably two to three times that right now. Convergence insufficiency. Depending on what you read, anywhere from around 20 percent of kids have this problem, and there’s a very intimate link between convergence insufficiency and difficulty focusing. These problems like myopia are increasing at an alarming rate, just based [on] what we’re asking our kids to do at earlier and earlier ages before they’re visually ready or have the development in place to support those tasks.
Chris Kresser: Right. And then there’s the added impact of Covid over the past few years, where screen time increased by 1.5-fold in most kids, because they were at home [rather than] at school. Even [since] they’ve gone back to school, that additional screen time [hasn’t] stayed at quite the same level, but it hasn’t dropped [back] down to pre-Covid levels [either]. So we don’t even know yet what the implications of that additional increase will be.
Bryce Appelbaum: And so many schools by me are pivoting, where they did the virtual learning and everyone got used to being on tablets and screens at home, and now tablets are commonplace in the classroom. I did a tour of a school last week and kindergarteners [were] on tablets in the dark.
Chris Kresser: That’s absolutely crazy. It’s a huge experiment that we’re performing. It’s almost like switching the food that we serve kids, which is already atrocious in schools, to some kind of weird mixture of things, without any research validating whether that’s a good idea. It’s always struck me that, in both public and private schools, so much of what happens is not based on any evidence at all. It’s just decisions that are made by administrators or teachers, based on prevailing trends or whatever is driving it. In some cases, like, “Oh, let’s start doing assignments on Google Classroom because that’s easier for the teachers.” That means kids in elementary school are interacting with the tablet or computer to do their homework instead of a printed out worksheet [like] we had when we were growing up. And if you’re just looking at it from an efficiency perspective, that makes a lot of sense. It makes it more efficient; it makes it easier for teachers to have everything in one place. But nobody’s thinking about these issues that you’re talking about like how will that affect vision? How will that affect brain development? How will that affect social development? How will that affect kids’ capacity for empathy? How will it affect their physical health? There’s all these repetitive stress injuries associated with excessive screen use [like] tech neck, [which you get] because you’re leaning over and looking at your phone or the computer for so long. It just seems really haphazard to me.
Bryce Appelbaum: You’re seeing this generation of kids who, [and] I’m sure you see this in interviews, as well, can’t even hold a conversation because they’re used to communicating via the written word, versus maintaining eye contact. Any change in eye movement is a change in attention, whether it’s voluntary or involuntary. If we have trouble controlling our eye movements, we’re going to have trouble controlling our attention. So often, eye contact is a faulty integration of that central and peripheral visual processing, where it’s almost like we can look everywhere [except] lock in at somebody’s eyes, because our brain is imbalanced in this disequilibrium [and] unable to not look at what’s around us. It’s scary from a health standpoint, from a nutrition standpoint, [and] from a circadian rhythm standpoint, but also down the road knowing that men and women are changing and how we interact with each other is changing. I think we’re going to look back on this time and recognize that the increase in screen usage and computer usage, which is wonderful for so many things in life, also has really shifted how we’re interacting with one another.
Chris Kresser: Absolutely. So if you could share again the link to ScreenFit, so people who want to [can] get started and work on this right away, and [also] where people can learn more about your work. Then maybe a couple of the links for people who want one-on-one [and] want to find a clinician in their local area to work with directly. That would be super helpful.
Bryce Appelbaum: Absolutely. ScreenFit you can find on www.screenfit.com. The international organization that board certifies doctors in vision therapy and rehabilitation [is] COVD.org. A great resource for education and awareness [is] visionhelp.com. Then for me, you can find me at concussionclear.com. That’s a way to work with us. We see a lot of people come from out of state or out of [the] country for intensive boot camps. My practice is in Bethesda and Annapolis, Maryland, two locations, and it’s Appelbaum Vision. You can find us at Appelbaumvision.com. And then myself, I’m on Instagram @DrBryceAppelbaum, but we spell Appelbaum very uniquely, because we like to make things difficult for people. It’s E-L, not L-E.
Chris Kresser: All right. Well, thank you, Bryce. It’s been really illuminating to learn more about this. Like I said, I think it’s one of [those] issues that’s not getting nearly enough attention. So I’m really grateful for the work that you’re doing, and [I] really enjoyed the conversation.
Bryce Appelbaum: I appreciate you caring so much and using your ability to cast a very large net on the population and the world to raise awareness, because when we all know better, we can all do better.
Chris Kresser: Absolutely, 100 percent. Thanks for listening, everyone. [I] hope you got a lot out of this. Keep sending your questions to ChrisKresser.com/podcastquestion. We’ll see you next time.
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