Michaela Gordon

How We See Changes Everything!

By Michaela Gordon, OTR/L

Contributing Author, Dr. Felicia Lew

   Since the arrival of technology, we are spending much more time sitting and looking up close at 2D environments such as phones, tablets, and televisions. A study was published in Preventative Medicine, (Varma et al., 2017) involving 12,500 people 6-84 years of age. The participants wore activity trackers to measure how long they were active and sedentary throughout their day. The outcomes indicated that 19 year olds spent as much time in a sedentary state as 60 years old individuals! The study also indicated that 25% of boys and 50% of girls ages 6-11 did not engage in the recommended amount of 1 hour of moderate to intense level of exercise per day.

If this is the case, what activities are our children and teens doing on a daily basis? How are they using their time? According to the Common Sense Media website (www.commonsensemedia.org, 2019) , a survey of 1600 children and teens revealed the average 8-12 year old spent almost 5 hours on screens per day and the average teenager spent 7.5 hours on screens per day. This number did not include additional screen use for school or to complete homework. I think this answers what children and teens are doing with their time!

As caretakers of children and teens, we must then assess what ill effects technology and media have on their health and well-being. According the Common Sense Media website, ill effects of prolonged screen time include addiction to screens, loss of focus, lower empathy and social connection, and health problems such as eye strain. The researchers indicated that parents must educate their children and teenagers about the ill effects of technology and teach them how to moderate its use.

Occupational therapy can address these present concerns. One focus area of occupational therapy is sensory integration, which is our brain’s ability to recognize, interpret and organize information obtained through our senses. Our sensory systems have an intimate relationship with each another. The systems work together to give us a sense of where we are in space and influence how we relate to our surroundings. Sensory-motor experiences are critical to brain development. Unfortunately, a child minimizes their movements, exploration, and interaction with the world when sitting for many hours in front of a screen. They deprives their brain of the rich sensory experience of the real three-dimensional world. Their view is fixed on a two-dimensional object and they are missing out on what’s around them!

What about vision and technology? The visual system is the primary sensory system being used during screen time. The increased time looking at screens has taken a toll on our eyes, both short-term and long-term. There is evidence that outdoor play reduces the incidence of near-sightedness (myopia) in children. The American Optometric Association (www.aoa.org, 2020) states that the rate of myopic school-aged children continues to rise. The AOA states that 1 in 4 parents have a child that is near-sighted and 75% of near-sighted individuals were diagnosed between the ages of 3-11. The AOA recommends that family members receive annual comprehensive eye exams. Myopia can increase the risk of retinal detachment, early cataract development, and glaucoma. Therefore, early detection is important.

Furthermore, the importance of vision in child development is multi-layered. A child may have 20/20 vision, which is considered “perfect vision”. We call this visual acuity or how clearly the child can see. What is often missed is assessing a child’s functional vision. One important area of functional vision is visual perception. Some examples of visual perception are: finding objects within a background, identifying objects based on their parts, and determining the spatial orientation of objects. Another area of visual function is eye motor skills and coordination of movement between the two eyes. A child who is unable to visually fixate in one spot or track words across a line to read is a very frustrated child. I see a variety of negative behaviors in children when visual challenges are undetected and untreated.

As an occupational therapist, I want to do my part to guide children towards healthy development. Many occupational therapists can provide assessment and treatment to address visual perceptual challenges. A therapist who is trained in sensory integrative treatments typically uses a ground-up framework by assessing how the child processes different types of sensory input. We often see that children with poor vestibular processing also have poor visual perceptual skills. Assessment of balance, postural imitation, and bilateral coordination skills gives us a sense of the child’s visual perception. We also look at reflexes like anti-gravity postures, which can also tell us how the other sensory systems are interacting with the child’s functional vision. We also look at fine motor skills and handwriting skills to gain more specific insight into the organization and precision of the visual system.

Once we have gathered the appropriate information, we treat targeted areas to improve sensory-motor functioning. Part of the therapy process involves providing a home program to promote healthy sensory function at home. The program may be a schedule of sensory-motor activities, modifying or eliminating unhealthy habits, and educating the family and child on how to develop their sensory systems for long-term success.

Occupational therapists can work with children on ocular-motor exercises (e.g. shifting eyes from one spot to another) and visual-perceptual activities (e.g object finding board games, block design games, mazes, and handwriting). We can address upper-body coordination skills to assist with improving ball skills. Occupational therapists can perform visual screenings to determine if further examination is needed by an optometrist. Occupational therapists are not licensed to work with lens prisms or color lenses unless under direct supervision of an optometrist. Visual therapies can be quite powerful on the central nervous system. When we work with the eyes, we are really working with the mind.

Occupational therapists may not be able to treat all of your child’s vision struggles so it is important to receive further assessment by a developmental optometrist if your child presents with more complicated visual challenges. Engaging in both occupational therapy and vision therapy either simultaneously or sequentially can be beneficial. Despite some overlap of therapies provided by both disciplines, an optometrist and an occupational therapist will bring their unique perspective and expertise when working with your child.

Developmental optometrist Dr. Felicia Lew has kindly offered more insight into her work as a vision therapist. She gives us further insight into what a parent would expect from vision therapy.

Dr. Lew, what is the difference between a developmental optometrist and an ophthalmologist?

Good question, as there seems to be some confusion about this. First, the similarities. Both optometrists and ophthalmologist evaluate and treat eye conditions that do not require surgery. These include infections, glaucoma, and removal of foreign bodies. Both optometrists and ophthalmologists also administer comprehensive eye exams.

Second, the difference – surgery. Ophthalmologists operate. Optometrists do not. Ophthalmologists undergo extensive surgical training, and usually specialize in particular types of eye surgery. The most common form of pediatric eye surgery is to correct misalignment of the eyes. This is done by cutting the muscles surrounding the eyes and then repositioning them. Optometrists spend all their time in graduate school learning about the eyes and vision system, as well as related subjects such as optics, pharmacology, and neurology. Optometrists’ training also emphasizes optical correction, which allows them to help patients correct their vision without surgery with devices such as glasses and contacts.

Developmental optometrists are a sub-group of optometrists who take a more holistic approach to vision care known as “vision therapy.” They obtain a doctorate degree in optometry and then pursue further training through organizations such as the College of Vision Development and the Optometric Extension Program. Most developmental optometrists begin their careers as traditional optometrists. But then they realize that vision care is much more than helping patients see 20/20 and making sure patients do not have eye disease.

A traditional optometrist usually spends 30 minutes or less with a patient for a comprehensive eye exam. A developmental optometrist, however, may spend several hours with a patient, spread over several appointments, to complete a comprehensive eye exam, a developmental eye exam, and a functional vision evaluation. In my practice, I watch a child’s eyes and look to evaluate issues such as (1) whether the eyes work together as a team, (2) blinking, (3) reading difficulty, and (4) sensitivity to sensory stimuli. I also evaluate head and body posture, balance, and interactions with surroundings. I thoroughly assess eye movement and alignment with the aid of computerized tracking equipment which utilizes sensors to detect and record eye position. I also evaluate visual perception and processing areas such as visual memory, visual closure, directionality, visual figure-ground discrimination, and writing skills.

Following such a comprehensive evaluation, a developmental optometrist will create a treatment plan that does not include surgery or drugs. The goal of vision therapy is to rewire the connections between the eyes and the brain more efficiently. This leads to improvements in the patient’s life which can include a safer and more stable visual world, interest and engagement in surroundings, enjoyment of reading, faster completion of schoolwork, and cosmetic and functional alignment of the eyes.

Developmental optometry’s less traditional approach has gained much attention in recent years. World renowned institutions such as the Mayo Clinic and Harvard’s Boston Children’s Hospital have been implementing programs in developmental optometry and vision therapy.

And this just makes sense. In his book Brain Rules, developmental molecular biologist John Medina explains that vision “trumps all the other senses,” occupying more space in the brain than the other senses combined. Given its importance to overall health and wellness, we need to address all the complexities of the visual system when fostering learning and development in children.

What type of specialized therapies do you perform to improve visual perception?


My toolbox is overflowing. In addition to prescribing glasses and contact lenses in the traditional sense, I can use lenses, prisms and filters to modify sensory perception. For example, I can place lenses in front of the eyes to enable a patient to more accurately identify sounds and locate where the sound came from. I also use a lot unique gadgets and gizmos for vision training which keep a child visually challenged – and having fun at the same time.

Both in-office and home therapy incorporate games and activities which give feedback to a child to make them more aware of how their eyes and brain work together. Many activities integrate the other sensory systems so a child can make connections between the senses to better understand their surroundings. When appropriate, I use computer programs like virtual reality games to provide controlled increases in complexity and difficulty to improve visual skills.

When do you think it is appropriate for a child to work with both you and an occupational therapist?


Good question – and difficult to answer because each child is unique. I will recommend seeing an occupational therapist or other professional if the concerns that need to be addressed are beyond my scope of practice. I find collaboration with occupational therapists and practitioners of other disciplines invaluable to a holistic approach.

Do you recommend vision therapy before occupational therapy or vice versa?

     The general rule is that a child with developmental concerns should have a developmental eye and vision evaluation in addition to evaluations with other professionals to identify whether the areas which need improvement are primarily related to vision. If so, I would probably recommend vision therapy first.

However, I see many children after they have seen an occupational therapist. I appreciate this, because it means that they already have done work in areas related to vision development such as primitive reflexes. This primes them for what I do. Often, occupational therapists will refer a child to me if they think there should be more emphasis on the visual system.

If you could pick one habit to change in order to improve a child’s visual health, what would it be?


Ah, an easy one — less screen time and more real-life play, especially outdoors. Playing in free space is so important for healthy development.

That being said, some newer studies indicate that computer games can aid the development of vision skills. Also, exposure to blue light – which digital screens emit – boosts memory, alertness and cognitive function, but too much can cause eyestrain, poor sleep and possibly macular degeneration.

So, a moderate amount of screen time is OK. But focus on playing outside.