451. The surprising link between your child’s vision, behavior, and screen time with Dr. Meenal Agarwal

Dr. Meenal Agarwal (00:00):

If you notice that your child is not as great playing on the field or avoiding birthday parties, avoiding interactions, connections with friends, a lot of times that has to do with their spatial awareness. And again, that has to do with the parietal lobe, talking to the amygdala, which makes them then afraid. That’s our fear center of our brain or threat center. And that makes people afraid of going into birthday parties or making connections or raising their hand in class and not participating.

Dr. Sarah Bren (00:32):

When most parents think about their child’s vision, they’re thinking about things like whether they can see the board at school or their overall eye health or whether or not they may need glasses. But children’s visual systems actually play a role in so much more than we might realize, including how they focus, how they learn, and how they experience the world around them. Hi, I’m Dr. Sarah Bren, a clinical psychologist, mom of two, and the host of Securely Attached. Each week, I sit down with leading experts in psychology, neuroscience, medicine, and child development to translate complex research into practical grounded insights that help you parent with more clarity and confidence. Today, I’m joined by Dr. Meenal Agarwal, an optometrist and author of the book Stuck in a Flat World: How Screens Rewire Our Brain’s Spatial Awareness and Sense of Safety. Dr. Agarwal has spent more than two decades working with patients and exploring the relationship between vision, brain development, and the way we experience and interact with our environment.

(01:38):

In this conversation, we’re looking at vision through a much wider lens, because as Dr. Agarwal explains, having twenty twenty vision doesn’t necessarily mean that everything is functioning as well as it could be. In fact, some children who struggle with attention, reading, or even certain behavioral challenges may have underlying visual difficulties that aren’t immediately obvious to parents or teachers. We also explore how screen time may be affecting our children’s development in ways most parents have never considered. We also explore how screen time may be affecting our children’s development in ways many parents might have not even considered. Because while we hear so much about the impact of screens on attention, behavior, and mental health, there’s another piece of the puzzle that often gets overlooked. And understanding what happens when children spend more and more of their time looking at screens and less time interacting with the physical world may completely change how we think about supporting their development.

(02:36):

Plus, we also talk about some of the less obvious signs that your child might be struggling with their vision, even if they seem to see just fine. And Dr. Agarwal shares some really simple, practical things you can build into your family’s everyday routine to support your child’s eye health, brain development, and overall wellbeing. I learned so much from this conversation and I think you will too.

(03:06):

Hello, Meenal. Thank you so much for coming. It’s so great to have you here.

Dr. Meenal Agarwal (03:10):

Oh, thank you so much, Sarah, for inviting me. I’m so excited for this conversation.

Dr. Sarah Bren (03:14):

Me too. I’m hoping we get a little nerd out on the brain stuff today. It’s my secret wish. Okay. So you are an incredibly experienced doctor when it comes to vision, but you take a… I will be so pun right now, but you have a much wider lens through which you kind of look at vision, I gather. And I was really hoping we could dive in today to talk a little bit about that, your work specifically and how you are looking at vision as a doctor that specializes in this for many, many years, but from a different lens.

Dr. Meenal Agarwal (04:02):

Yeah. And that lens is the brain because embryonically, the retina, which is major tissue in our eyes that is sending all the messages to our brain was actually brain tissue. And our optic nerve is part of the central nervous system. So when we talk about vision just being the eyes, I hate that because it is part of the entire brain and that’s why we are seeing in a lot of new research that early Alzheimer’s, early Parkinson’s plaques, proteins are being found in the retina earlier than in the brain because it is embryonically brain tissue. So we as eye doctors will probably in the next 10, 20 years be able to detect that before you go get tested for it and you have cognitive symptoms. So I just want to kind of lay that out. And then we also know that up to 50% of your brain’s areas are processing vision.

(05:05):

That is a lot, 50%. So when your vision is not good or you’re visually impaired, that is directly impacting the brain to work harder. And that’s why we do see stats and studies showing that those that are visually impaired have to have a 50% higher chance of developing dementia, which is cognitive symptoms. And so we know that vision plays a big role in brain processing and we know that all of our vision is processed in the brain. So I like to think of your eye as a vessel, and I don’t want to downgrade it, but it literally is a vessel that is sending all the messages to our brain of what we can see. So when people say to me, “Oh, all I want to know is I can just see twenty twenty and then I’m never coming back to you for an eye exam for five years.” And that hurts me because the twenty twenty is such a small piece of the puzzle.

(06:07):

When we look at your central vision, which is what you’re reading on a chart, your central vision twenty twenty, that is a very small piece of our retina that is dictating that exact central vision. That’s coming from something we call the fovea in our retina, which is about five degrees. That is a very, very small portion of our retina that’s being processed in the brain. What about the rest of it? And so know that that number or your prescription in your new glasses, Sarah…

Dr. Sarah Bren (06:41):

Yeah, I’m wearing my new glasses.

Dr. Meenal Agarwal (06:44):

That’s just a very small portion of what your brain is processing. And so whether it’s my book or whether it’s me seeing patients, I talk about so much more and that’s our spatial awareness. That’s the rest of our retina. It’s processing the space around us and that’s interacting with so many other processes in our brain, including our vestibular system, our proprioceptive system, our amygdala. I could go into so many more details. There’s so much to vision than just the eye chart. And I think that’s the take home of that.

Dr. Sarah Bren (07:21):

Yeah. That hits so deeply for me for so many reasons. But as a psychologist who specializes in working with families of kids who tend to have sensitive systems, who tend to have bigger emotional reactions and more intense behavioral response, like dysregulation, a lot of what I’m interested in is what’s actually… The behaviors themselves to me are always the byproduct. I’m super uninterested in the… I mean, there’s data in there and they have a big impact, but at the core, what causes the behaviors is something from an internal something. And oftentimes what you’re talking about of like, okay, yeah, we often think about eyes and eye health and vision as being… We can relate to it in its most known functional sense. Okay, what do I see? How do I see my vision? When we think of vision, we think of, like you were saying, how good is my ability to functionally see what I’m trying to look at, consciously trying to look at.

(08:34):

But you just talked about all these other things that our eyes do to take in visual stimuli, encode it in the brain. The brain then takes in that information and if there’s too much, if it’s overwhelming, if it’s too stimulating, if there’s a lot of sensitivity to that kind of level of visual input, we might see dysregulation or there’s just a lot of stuff that our eyes are doing that are outside of our conscious awareness, but that matters. It has an impact to our nervous system, to our thinking, to our feeling and emoting and all that stuff. That’s what I heard in what you said.

Dr. Meenal Agarwal (09:16):

Yes. I mean, 100%. I mean, you heard that correctly. And I think that… I have a chapter in the book that is called It’s Not Behavior. And I’m not in the expertise that you are, so you’re going to probably correct me and say I’m all wrong, but I truly believe there are so many aspects to children, if we’re going to talk about children, where it isn’t behavior. There is an underlying, whether it’s the nervous system, whether it’s the visual system, whether it’s the brain, there’s an underlying issue that is hard to detect. I’m not saying it’s easy for us parents. I’ve been there, done that, and it’s not easy to be like, “Well, my child’s misbehaving because this is happening.” We don’t know sometimes, but there’s usually an underlying concern or dysregulation or recalibrating issue where now the child has to react in a certain way.

(10:10):

So fundamentally, it’s not behavior. There’s something that usually precedes that. And I think that’s what we both are probably trying to say. And for me, a lot of our visual concerns is because we are spending… It’s not about the hours on a screen, and I want to be clear. And my book is really not about that. We’re not trying to pick on screens. Screens are here to stay. I love screens. I use them. I’m using everything. And our kids will fall behind if they’re not using it. That’s the bottom line. We can keep them away from it until they’re wet, realistically eight, nine, but by 10, a lot of them are using it at school. So screens are here to stay. Let’s stop talking about how many hours are you on a screen? Kids are sick of it. We’re sick of it. Nobody wants to talk about that anymore.

(11:03):

What we want to talk about is what are our screens replacing? So that one hour that your child or you are spending on Instagram, TikTok, scrolling, what could that one hour have been doing? Could you have been navigating a neighborhood? Could you have been going for a walk? Could you have been playing a puzzle with your kids? Could you have been playing Simon Says? Could you guys just be going in the car for a drive? I don’t know, but could you guys have been doing something, playing with Play-Doh, building sensory, fine motor skills? I think that’s the key. Our time is limited. We only have 24 hours in a full day, and if one hour is being taken away being on a screen, what could that have been doing? I think that’s where we need to shift that mentality. And that’s really what I’m trying to do is because we are losing our 3D movement, 3D motion, our spatial awareness, our sense of safety, our navigational part of our brain, which is our parietal lobe.

(12:08):

That is a huge part of our brain that is in charge of navigation. We have an internal GPS, but we are outsourcing all of that to our external GPS on our phone, a blue dot. We’re just outsourcing so much of that to a screen or just sitting sedentary, having zero movement that we’re losing that part of the brain. I want to be clear, it’s not atrophying, but like a muscle that’s not exercised. If you don’t use a certain part of your brain, it gets tired or it becomes underused. There are exercises that you can do, not physical exercise, but exercises that we can do to help that side of the brain wake up or start working. And that’s what really the book is about. These are not exercises where I’m going to make someone go to physiotherapy and do exercises. These are recalibrations, I like to call it, for the brain so that we can reset our lifestyles.

(13:08):

I don’t want to blame children and parents because there’s a lot of people midlife like myself and we talk about that in the book where our story is that because of screens or because of a sedentary lifestyle or because we’re stuck in an up close world all the time working from home, whether it’s a small cubicle that we are at home all day post – COVID, we ourselves have lost a lot of those characteristics, those skills, those experiences that we had as a child, like navigating with a map. I can’t navigate with a map. I don’t know if you can, but I cannot. I can’t. I need to follow that blue dot going just somewhere familiar sometimes. I have been to my son’s basketball gym every Friday. I’ve been there and I still follow the blue dot because I forget.

Dr. Sarah Bren (13:57):

And tying this to what you… So here’s one really big board certified optometrist question because I hear all that you’re describing and I’m like, “Oh, we are on the same soapbox, my friend. We are right up next to each other. I feel you.” And I look at it from a psychological and relational and mental health lens, behavioral, whatever, all these things, regulation, as I think you probably do too, but from the optometry lens, from the lens of how the eye clearly, not just eye development that gets displaced by the screens, but the subsequent eye brain connections that aren’t getting kind of worked, so to speak, because of the screens, are you seeing the same kind of stuff?That’s the part that I think is really interesting about the eye brain connection getting kind of displaced by screens. When you were talking about the blue dot on the GPS map even, I was like, “Oh yeah, even when I’m in my car driving, which theoretically is a longer distance vision practice, I’m looking farther away, it’s not up close.

(15:24):

I’m actually not. I’m really looking at my GPS screen on my phone, which is a foot from my face. So even then, I’m missing out on an opportunity to be strengthening those longer distance eye muscles, I would imagine. Can you talk a little bit about just the eye piece and how the use it or lose it kind of if you’re not using what… I’m not articulating this very well, but I guess I’m trying to say when you have a lot of up close visual time…

Dr. Meenal Agarwal (15:55):

Yes, how it affects you.

Dr. Sarah Bren (15:57):

Yeah. What are you not getting and what does that do to your brain development?

Dr. Meenal Agarwal (16:03):

Okay. So I mean, I think there’s a lot to uncover there. I’m going to first say this. By the year 2050, 50% of the world will be nearsighted and we are on…

Dr. Sarah Bren (16:16):

Versus how much now? How much are we now?

Dr. Meenal Agarwal (16:18):

I believe we’re close to 40. So we are on track for that and that’s just nearsighted. So that means you need a prescription for distance. And then there’s all the other people that are farsighted, presbyopic. Why is that happening? Because of the amount of near work. So I know it’s counterintuitive, but the more near work we do, the more we end up pushing ourselves into distance glasses. So we know that because of all the near work we’re doing, we are definitely needing more glasses and needing people to see better.

Dr. Sarah Bren (16:56):

Wait, can I ask a quick question just to clarify for myself, because it is confusing, right? The more I look at things up close, the more I lose my distance vision. And is that because I’m not practicing looking far away, so I’m not strengthening my distance muscles?

Dr. Meenal Agarwal (17:13):

Yes. So there’s actually an anatomical reason for that. The eyeball actually is stimulated to elongate. When you look up close, your eyeball actually, it’s called the axial length, which is the length of our eyeball, actually physically elongates by microns, I’m talking. And so because it elongates, you need a stronger prescription to focus the light further back when you’re looking far away. So there’s an anatomical reason for that. So it’s not so much…

Dr. Sarah Bren (17:40):

As we age, right? So that’s why as we get…

Dr. Meenal Agarwal (17:42):

No, no. So I mean, the more near work you do, whether you’re six or eight years old, the more near work you do, your prescription will keep going up because your eyeball’s going to continue to elongate. And if you’re 35, the same thing will happen. And that’s why we are seeing a rise in nearsightedness even in adults. There used to be a time I used to tell patients, besides needing reading glasses, I used to tell patients that your prescription will stabilize by the time you’re in your 30s. When I started practicing 20 years ago, now I don’t say that. I don’t talk about when it’s going to settle because it’s not going to settle. The bottom line is the more near work we’re doing, the more things are going to change. Sure, it will change at a slower rate because you’re older now and your eyeball is more set, but it’s still going to change and a lot more things are in play there than the external eye muscles are in play, the internal eye muscles are in play.

(18:32):

But essentially when we’re talking about myopia and the rate rising, it is because the eyeball is elongating with the more near work that we are doing, especially in children. We know the two proven factors for nearsightedness being on the rise are extended near work and lack of outdoor time. Most of the studies have come up to a general consensus that about two hours of outdoor time a day, it doesn’t have to be altogether, is the general recommendation for helping to decrease the onset or progression of nearsightedness.

Dr. Sarah Bren (19:12):

Is that because… I’m sorry, I have so many questions because I’m really curious, but is that because, because I don’t know that much about the eyes and I’m so interested in this because I love brain stuff, but why is near work, AKA more or less screen or anything you’re doing close up to your face, but typically in our world, near work is very screen-based. Why is that the opposite of outside work or outside time? Is that because of things like when you’re outside, you just are in a larger… There’s longer horizon lines or is it because of light? Is it because you’re moving your eye around because there’s more novelty to look at? What is the things that’s doing to the eye that’s helpful outside? Why is outside time the antidote?

Dr. Meenal Agarwal (20:00):

That’s a great question. So the main reason for outdoor time, it being specifically outdoor versus, I don’t know, a large tennis court where you are looking far, but is the sunlight exactly what you were saying? So that sunlight triggers specific cells in our retina called Emocrine cells that release our own dopamine. So the retina releases dopamine just like our brain does, and that dopamine actually helps to regulate your eyeball length. So in all, this is all about eyeball length. The longer your eyeball, the more you’re going to need a prescription. So whether you’re doing your work, which is a different mechanism or you’re outdoors, which is where dopamine is going to be released to help regulate your eyeball length, just your axial length, both are going to help to slow the progression and delay the onset of myopia. And those are the two proven factors. So yeah, the outside factor has more to do with the dopamine release.

Dr. Sarah Bren (20:55):

Which is coming from light.

Dr. Meenal Agarwal (20:57):

Sunlight, yeah.

Dr. Sarah Bren (20:57):

Sunlight. Yeah. Yeah. Interesting.

Dr. Meenal Agarwal (21:00):

It triggers the amicrine cells to release the dopamine. Yeah.

Dr. Sarah Bren (21:04):

Does it boost mood? Or I guess…

Dr. Meenal Agarwal (21:06):

Sorry?

Dr. Sarah Bren (21:08):

Does it affect mood? We talk about dopamine as giving us that little like, yeah, I want to do more of that.

Dr. Meenal Agarwal (21:14):

No, not really.

Dr. Sarah Bren (21:14):

Does it do that for eyeballs?

Dr. Meenal Agarwal (21:16):

Yeah. That dopamine that’s released by the amicrine cells is not really in a pathway to affect the brain dopamine release.

Dr. Sarah Bren (21:24):

It’s in a closed system. It’s changing the eye.

Dr. Meenal Agarwal (21:27):

I want to be clear about that.

Dr. Sarah Bren (21:28):

But important stuff.

Dr. Meenal Agarwal (21:29):

Whereas we do have a system where circadian rhythm does talk to the brain. So yes, I don’t want people to think the eye does not talk to the brain, but in that specific dopamine release, they are pretty separate. But when you have sunlight and your circadian rhythm kicks in, that is actual signals from the intrinsically photosensitive retinal ganglion cells in your retina that send a message to your suprachiasmatic nucleus in your brain to help regulate all the glands and the hormones and say, “Time to wake up.” So they do send those messages. Specifically the dopamine is usually a separate cycle.

Dr. Sarah Bren (22:14):

Okay. But still, the outside time is about, it’s the sunlight and we’re not getting it when we’re on screens.

Dr. Meenal Agarwal (22:21):

Or just indoors.

Dr. Sarah Bren (22:23):

In our house doing near work.

Dr. Meenal Agarwal (22:25):

Or playing tennis indoors. Yeah.

Dr. Sarah Bren (22:27):

True. So that’s so interesting because… And when we are not getting this outdoor time, our eyeballs are lengthening, which is creating more likelihood for vision issues. But also, because we were talking before about how the vision function, holistic eyeball vision function, not just the stuff you can see in front of you twenty twenty vision, but peripheral vision, your ability to process visual sensory input also impacts nervous system functioning, regulation, emotions, behaviors, all that stuff. When you have more myopia, do you see a correlation in other issues in the system? I’m trying to think of, for example, I have definitely seen in my practice kids who are having a lot of dysregulation and they get glasses and it gets better because there was something, not because the vision was causing it, but it’s like this domino effect of the system wasn’t able to process the input, which was actually kind of distressing to activating for the system.

(23:41):

It’s working really hard. And so it kind of caused… It’s like once they got the glasses and the messages that the eyes were trying to give to the brain was clear, system calmed down a little bit, there was just a little bit less overload.

Dr. Meenal Agarwal (23:56):

I completely agree with that. So I don’t know which came first, whether it’s the focusing or attention issues or dysregulation or whether it was the need for a prescription, but I want to say the bulk of these patients are farsighted patients actually. So they actually see better at far than they do at near. And it doesn’t mean they can’t see it near. So a lot of these children can see beautifully. This is probably the scariest thing that we see in children is that parents just don’t bring them in because there was never any symptoms. Whereas with the opposite nearsighted patients, they usually can’t see the board at school. But with farsighted patients, they typically can see everything. So what’s happening is they’re looking up close and because they’re farsighted, their muscles are working harder to compensate for that farsightedness. And what happens is they get tired or faster, the muscles, the eye strain, and then your brain gives out because the brain is processing that vision.

(24:54):

So the brain decides, I’m just not going to focus. So these children typically get labeled as inattentive, lack of focus on some sort of learning spectrum, ADHD. So I do see a lot of ADHD children who, mild prescription can change their world and also increase their focus. There’s so many pieces to that. So yes, I don’t want to say that it’s 100% correlated, but there is definitely a relation to lack of vision and change in mood, focus, attention.

Dr. Sarah Bren (25:35):

Definitely something to rule out. If you have a kid who is having a lot of trouble with some of these things, not going to hurt to take them to an eye doctor and just rule that out.

Dr. Meenal Agarwal (25:42):

100%. And there are so many kids that I see where we are putting them to glasses, not because they can’t see up close, but because that mild prescription is making their eyes tired. I encourage parents just to take their kids in for a regular eye exam because you don’t know what you’re going to discover. Again, your kids are not going to say, “I can’t see up close,” because they can see up close, but the behavior is going to change and that’s going to be your indication. So not doing well at school or not… My first question is always, are they on par with grade level? So not being on par, slower to read, slower to write, mixing up letters, reading backwards at a reasonable age. Of course, a four year old might do that, but we’re eight years old and we’re doing that. We might want to look into why that’s happening.

(26:30):

I want to also go into another aspect of that, which may not have to do with farsightedness, but more with near work time in general, but not being able to play sports well. So missing the ball, not being as good of an athlete. A lot of kids age 10 to 15 are in rep sports. And so I do get a lot of parents bringing them in saying, “I want to improve their game and make them a better athlete.” And that requires increasing your reaction time and depth perception and spatial awareness. So there is another piece to that as well where if you notice that your child is not as great playing on the field or avoiding birthday parties, avoiding interactions, connections with friends, a lot of times that has to do with their spatial awareness. And again, that has to do with the parietal lobe, talking to the amygdala, which makes them then afraid.

(27:23):

That’s our fear center of our brain or threat center. And that makes people afraid of going into birthday parties or making connections or raising their hand in class and not participating. But I’m not labeling every kid like, “My kids are shy, my kids don’t want to raise their hand in class. I was like that when I was young. I’m not like that anymore.” But let a child be a child. That’s the bottom line. But if you are noticing things that you don’t feel are on par, there’s no harm in obviously taking them for an eye exam and making sure that everything’s okay.

Dr. Sarah Bren (27:57):

Got it. And so if you are doing eye exams, like you were saying, you’re looking at the prescription, your ability to read the letters on the wall, right? But spatial awareness, like proprioceptive awareness, are you checking that in an eye exam as well? And is that going to get supported with glasses or corrective eyewear? Or is that more like, “Well, let’s we need to think about eye health a little bit more holistically.” And is it just we put glasses on or is it we do other things to support those?

Dr. Meenal Agarwal (28:37):

Oh, other things. Yes. So not really glasses because glasses is that 2020 number that makes you see centrally. But when we’re talking about spatial awareness, we know that has to do with your parietal lobe. And so yes, a big piece of it is recalibrations or talking about exercises such as the 20 / 20 / 20 rule, which is while you’re doing near work, for every 20 minutes, take a 20 second break and look 20 feet away. So that’s far away. So again, every 20 minutes for 20 seconds, look 20 feet or far away. So that’s a rule we give a lot of these children to help build their spatial awareness because they’re then looking out into space rather than all the near work.

Dr. Sarah Bren (29:19):

Would you actually have a kid who maybe has a watch on that has a little timer that goes off every 20 minutes for them to help track that? Because I could see this being a really helpful little cue to get to build into kids’ just habits.

Dr. Meenal Agarwal (29:34):

So a lot of parents ask me that, and honestly, whatever works for whatever your child prefers. But my first step is always wherever they do their near work, whether that’s playing Minecraft on a computer or doing homework, place that desk near a window and you will find that your child will naturally just look out the window because they might hear a noise or they might see a tree in the background. They will naturally look out. So I would try that first because I hate being timed. I personally don’t like that. And I know my kids don’t like that, but if that works for your child, that would be your next step. But the first step is just placing it near a window where it’s more enticing to look outside because placing it near a wall is not very enticing to look at that photo on the wall.

Dr. Sarah Bren (30:16):

Yeah. There’s nothing else drawing their attention away from the screen.

Dr. Meenal Agarwal (30:20):

Yeah. So I think most of it is those exercises. But back to your question about how to test for it. So we cater it for each person. Everybody is different. And so we’re not doing all of this in every eye exam, but when there are complaints of not wanting to go into crowds or following a GPS all the time or missing the ball, then we are doing reaction time testing, depth perception testing, siccades and pursuit testing, fixation testing, binocular vision testing, visual field testing. So it’s catered to each kid individually and it really depends on what they want out of the eye exam and what they’re trying to improve on. And of course, this is all not done in one eye exam. There are follow-ups, but I think the initial exam is just to understand, get the basics, which is the twenty twenty vision, get the general depth, get the general binocular vision assessment.

(31:12):

And then when we see issues or parents feel there are issues, then we’ll dive into a second appointment where we are doing things. But I think so much of our body is intertwined. People would never imagine that not wanting to go to a birthday party or hang out with friends could be a spatial awareness issue, which essentially starts from being a vision issue of not processing enough space through your parietal lobe.

Dr. Sarah Bren (31:38):

That is so interesting. And so, okay, I definitely want to ask you questions about what we can do as a parent for ourselves and for our kids to kind of strengthen those parietal visual connection and also spatial awareness, depth perception, all that stuff. But before, I’m curious, if you’re a parent listening to this, you’re like, oh my God, I didn’t even know that this is what an optometrist could… I didn’t know to ever ask about this. If you are considering taking your kid to the eye doctor after listening to this episode, what kind of questions do you encourage parents to even ask? If you hadn’t ever thought about the function of going to the eye doctor being beyond just what’s my vision prescription, what would you encourage parents to be thinking about in terms of what their kid is and isn’t? What would be relevant information to share with an optometrist and questions to ask to deepen that exam and the outcome?

Dr. Meenal Agarwal (32:45):

Yeah. I mean, I love that question because so many parents come to me and I’m sitting there asking them all the questions like, “So how’s your child doing in school? So are they hanging out with friends?” And parents look at me like I’m a weirdo, but I’m genuinely not trying to weird them out. I think that is a big piece of it. I never think it’s bad to relay too much information. And I know time slots are limited and I get all of that. So pick your few things that really bug you. For example, learning is a big piece. 80% of learning is visual. If you can’t see it, you ain’t processing it. It’s the bottom line. So that’s a big piece. I want to know everything that’s happening in school in terms of learning. Are they reading? Are they writing letters backwards? What’s happening?

(33:33):

Are they on par with grade level? And lack of attention and daydreaming, that’s another one. They’re daydreaming while looking at the board. They daydream and look out to the window. So we want to know those things. The piece of learning is very important. Please tell us. And then the second piece I think that I love when parents do tag on is the social aspect piece. They’re really shy. They don’t really talking to people.This person is a gymnast, but we’re really trying to work on their balance beam or whatever it is. I like to know those kind of things. I have a kid who I believe is probably 11 now and we pride into so many things and parents never wanted to tell me that he’s a rep baseball player. And at that time I think he was trying to make it onto the rep team.

(34:23):

I want to know that because if I know that, then this child in particular was a plus three in one eye and zero in the other eye and he was fine functioning without glasses because the plus three eye was just doing all the work. But that will kill his depth perception. He is not catching the ball for the life of him. And I will tell you that, it’s going to kill his gait.

Dr. Sarah Bren (34:43):

Interesting.

Dr. Meenal Agarwal (34:43):

And so that changes my prescribing ability and what I want to do. So if I had not gotten out of them that he was a pro baseball player or trying to try out for rep, then I would have maybe not given him the plus three or maybe given him a lower prescription or whatever the situation was.

Dr. Sarah Bren (35:00):

So it’s a really dynamic.

Dr. Meenal Agarwal (35:02):

Yeah. And now what we did was I gave him a plus three, but we now have put him into contact. So because he was having depth issues with the glasses being so different, it’s called anisometropia where one eye is a different prescription, very different from the other eye. You can get image size differences. So you’ll go wonky, you’ll feel dizzy, nauseous, all that. So we ended up fitting him in a contact with the plus three roughly prescription. And his game improved dramatically. Of course, we did vision therapy exercise as well, training his depth and all of that stuff. But I mean, I think that it’s never too much to say whatever you want to say about a child’s life. I like to know. I mean, I don’t know, maybe I’m nosy, whatever it is, but I like to know about your life because that changes it.

(35:47):

If you tell me that your child hates glasses… I’m going to back that up. If I prescribe your child with glasses and you tell me next year that your child hates glasses because you were embarrassed to tell me that whole year, then I’ve lost a whole year of correcting your child’s vision. Possibly they didn’t do as well in school. I would rather you tell me from the get-go that my child is very worried about their false lash extensions and doesn’t like that it touches the glasses. So what are our options? Just like when I go to my dentist, I say, “I’m not flossing every day. It’s the bottom line. You can tell me today to floss every day. It’s not happening. So now what do we do? Are there other options? What can I do?” Be honest, tell us what it is. And at the same token, I encourage women to talk about menopause.

(36:39):

Are you in perimenopause? I don’t know why so many women hesitate to tell me. I mean, obviously I don’t want to interject because I feel like it offends some women when I talk about menopause, but I do want to ask them after 35, are you experiencing any perimeter menopause symptoms? Because one of the top symptoms is dry eye syndrome and that is when listed as one of the top for women. It can also cause fluctuating vision, meibomian gland dysfunction, change the curvature of your cornea. And now there are studies saying that it can cause early glaucoma. So there are reasons we’re asking these questions and we want to know. So I feel like patients will go to a GP and reveal everything and more, but they’ll go to their dentist, their eye doctor, their physiotherapist, their chiro and reveal nothing.

Dr. Sarah Bren (37:34):

I’m so excited right now because I’m like, this is pulling to me, you’re pulling back the veil of how interconnected vision is to all these other things. And I think we historically have been kind of like our medical model has created very siloed specialties that feel like they, one, don’t talk to one another, but also a lot of people don’t know what an optometrist can do other than give me glasses to read better or whatever. I think there’s also just this public service announcement of what does an optometrist do and what can you use them for? And understanding that it’s such a much more, because you know, because you’re in it, you know it’s a really holistic practice. But I think that the consumer of the medical service might not totally get this and I’m learning. I’m so excited that you’re pulling back the veil a little bit.

Dr. Meenal Agarwal (38:39):

Yeah. And I want to actually, I know that wasn’t a question, but I’m going to answer that question.

Dr. Sarah Bren (38:43):

Do it. There should be a question.

Dr. Meenal Agarwal (38:45):

To be clear, an optometrist is an eye doctor who is there to help you see clearly, comfortably and help diagnose diseases. So we are assessing your binocular vision, diagnosing diseases. We are doing it all. But the point that you need surgery, so you need surgical intervention, most of us in most provinces and states may not be certified to do that and depending on your state as well. And we may need to refer out to an ophthalmologist for that. But up to the diagnosis and the treatment, even with drops or whatever, that’s all done by us. You don’t need to go to the ophthalmologist. We are trained in four years. We only talk about eyes in our four years of schooling. So that’s a lot of years of just knowing about the eye. So tell your optometrist everything you need to and leverage that because sometimes we are able to write medical notes to the GPs and say, “Hey, I think you need to look into this.” For example, I just saw a lady who is 37 and she’s been my long-term patient.

(39:51):

And this year I noticed on her dilated retinal exam that she had a hemorrhage near her optic nerve, which sometimes can be indicative of glaucoma, but she’s very young for that. So we can also be indicative of a vascular condition. So I just sent her, even though she’s seen her family doctor for a routine checkup, I just sent her family doctor a report saying I request a vascular workup, which could be an ECG. It could be so many things. Obviously a basic blood pressure check, but lots of things. And she’s now having that done and likely we might catch something early that she has. So there are so many avenues that we are… There’s so much to say. We are the only people that can see your blood vessels in a routine exam. There is no other healthcare field where you can see blood vessels.

(40:43):

So a lot of times we are catching a systemic disease earlier than others. For example, high blood pressure, diabetes, MS, autoimmune conditions, a stroke, heart conditions. There are so many things. I don’t even remember half of them.

Dr. Sarah Bren (41:01):

I’m like, windows are the eyes to the soul. And it’s like maybe they’re also the windows to the entire medical, your physical medical health.

Dr. Meenal Agarwal (41:09):

And I think we’re starting to see that more and more in studies. There are so many studies coming out of a brain health, heart health being seen in the eyes four years before certain conditions are developing. And so the biggest take home would be when you go to see your optometrist, just make sure you’re getting a comprehensive eye exam. And that’s the key word, comprehensive, because I think so many of us go to eye doctors or places where it’s a glasses shop and it’s just about glasses and it’s just many of us do have glasses areas for convenience, but you can’t just have a prescription check that is not an eye exam. That is like a three minute part of our eye exam. Sure, we care if you can see, that’s a big piece of it, but what about the health of your eye? So a comprehensive eye exam usually includes a vision check, all the other pieces to vision depth, binocular vision, and then also your health check, which is your retinal health, the blood vessels, diseases, that kind of piece. So a comprehensive eye exam is a key word that you ask for when booking an eye exam.

Dr. Sarah Bren (42:16):

Got it. And you can book that with an optometrist or an ophthalmologist. And how often? No, no?

Dr. Meenal Agarwal (42:22):

Well, sorry. You can book that with an optometrist. Ophthalmologists usually are there for surgical purposes. I think also in the states, most states, they’re mainly doing surgery. I think there’s a very few that would do comprehensive eye exams or accept.

Dr. Sarah Bren (42:34):

Got it. So this is for optometrists.

Dr. Meenal Agarwal (42:36):

You got it because that’s your first line of getting into now I need something else. Yeah.

Dr. Sarah Bren (42:41):

Great. And how often do we want to have comprehensive eye exams?

Dr. Meenal Agarwal (42:46):

Annually.

Dr. Sarah Bren (42:47):

Annually. And how often do you recommend going in for follow-ups?

Dr. Meenal Agarwal (42:52):

Well, I think that would be dependent on what the problem is. If there is a problem, majority of my patients don’t have a problem, so we see them once a year. And I would start at six months of age. So six months is our start. We do not need children to read us letters. We can test everything with nonverbal kids as well. So you don’t have to… I have many patients who are nonverbal, for whatever reason, don’t choose to speak, have ADHD and don’t want to focus. There are so many ways that we can test it. We can do an entire exam with handheld equipment. We don’t need them sitting up anywhere. But just look for the person that’s comfortable with that because sometimes some people in all professions are not comfortable with certain demographics or not able to accommodate that, right? So you just want to make sure, yes, okay, if you’re in a wheelchair, is it wheelchair accessible?

(43:40):

If you have a child that has ADHD, maybe that doctor is not the best one for you. So you might want to just mention that in the phone. I don’t think it’s harmful to say these things on the phone to the person that’s booking the appointment. I think it’s a good heads up.

Dr. Sarah Bren (43:54):

Yeah. And I think in listening to this episode and people are understanding it a little bit more from a more complex, more nuanced way, recognizing like, yeah, that is really relevant. It is really relevant. And so finding someone who is comfortable working with kids, who is comfortable working with kids with neurodiverse presentations or whatever, I think is worth actually talking about because it’s relevant to the vision exam.

Dr. Meenal Agarwal (44:19):

Yeah.

Dr. Sarah Bren (44:26):

One of the things I talk about so often on this podcast is how important it is to look beyond our children’s behavior and really try to understand what’s going on underneath it. Because when a child is struggling, there can be so many different factors at play, whether it’s their sensory needs, their emotional development, their relationships, or even something we might not immediately think to consider, like their visual system. We want to make sure we’re looking beneath the hood rather than just focusing on the behaviors we’re seeing on the surface. And that’s exactly the approach we take at my practice, Upshur Bren Psychology Group. Our team works with children, parents, and families to get a better understanding of what’s going on, identify where additional support might be helpful, and develop an individualized approach with the support that makes the most sense for you. Sometimes that means working directly with the child through individual therapy. Sometimes it means a comprehensive psychological evaluation to better understand what might be contributing to their struggles. And sometimes the best place to start is with parent coaching, where we can help you develop practical strategies that fit your family’s needs. Whether you’re navigating a specific challenge or you’ve just had that feeling that something isn’t quite right, you don’t have to figure it all out on your own.

(45:43):

You can visit upshurbren.com to learn more about our services and schedule a free 30 minute consultation call with a member of our care team. That’s U-P-S-H-U-R-B-R-E-N.com. Or you can click the link in the episode description. Okay, let’s get back to my conversation with Dr. Meenal Agarwal.

(46:09):

So we’ve been talking about things that as parents, if we want to go get an eye exam for ourselves, a comprehensive vision exam for ourselves and our kids, you’re going to give us a much better sense of what’s going on, what things need to get touched, if any. What can parents do at home when we’re now realizing, okay, eye health and eye functioning is, it’s not a silo. It’s very much part of a very holistic system that probably does inform regulation, emotional and behavioral regulation, among lots of other things. What can we do at home to counteract the screen time stuff, but also just strengthen eye health, support it?

Dr. Meenal Agarwal (47:03):

Okay. So I think there’s two pieces to that. So for eye health, it goes along with the body, movement, exercise, not being sedentary, eating healthy. So for us, lutein and zeaxanthin are two pigments that are found in green leafy colored. It doesn’t have to be only green, but colored vegetables. So broccolis, red peppers, green peppers, kale, that kind of food. So those are great foods for our health as well. Less processed food, staying hydrated. I think that’s kind of the eye health is the same as the systemic health because it’s the window to the body. So that piece matches the eye health part of it. The second part of it is what can we do at home and for our kids? So I’m a very tired parent. When I’m done my work day, I would like to sit and watch TV. I do not want to talk. I do not want to play. But there are ways that you can do this with your children while sitting. For example, if you’re sitting and you don’t want to move, you can play Simon Says where you just involve talking. Simon Says, touch your nose. Simon Says, touch your… You are building their vestibular system, their movement, their hand-eye coordination. There’s so many things in play with Simon says. If you’re in a car and you really don’t want to entertain your kids, but you also don’t want to give them a screen, play ice by, let them play I Spy with the three kids or two kids and spot that thing that’s red, and then follow that car.

(48:42):

Follow that car. Tell us where you think that car’s going, who’s in that car, and where’s the family going and building imagination? So you can do things where you’re not moving because I don’t want to move sometimes, but the three things I want parents to build into their life and their kids’ life, movement, play and space.

Dr. Sarah Bren (49:04):

Okay.

Dr. Meenal Agarwal (49:06):

By space, I mean navigating space, whether it’s being outdoors, whether it’s navigating without a GPS, just remembering directions, whether it means a scavenger hunt, whatever you want, climbing a rock structure, space. Be out in space. Space is important or look at space even if you’re on a screen, but start looking at the space around you. Movement is self-explanatory. And play involves whether it’s Lego, whether it’s puzzles, whether it’s building an obstacle course at home, some sort of play. Even for parents, play could be doing a puzzle with your kids. I just finished a thousand piece basketball puzzle with my son because he loves basketball, but we do it every night because otherwise he’s 10 and he’s going to be playing Roblox. That’s the bottom line. So if I didn’t put that puzzle out and I didn’t actually actively, although I like to sit, but I realized I actually like doing this kind of fun. And every night I was almost going by myself.

Dr. Sarah Bren (50:05):

There’s some accompaniment from you to help scaffold that. If there’s a puzzle sitting on a table, your kid may or may not be drawn to it. If there’s a puzzle sitting at a table and you are sitting there playing pieces together, you know that’s going to be an allure. You don’t even have to be like, “Come do the puzzle with me. Just start doing the puzzle.” Nine times out of 10, your kids are going to walk up to you and be like, “Can I help? What are you doing?” Where our attention goes, their energy flows.

Dr. Meenal Agarwal (50:35):

And they model our behavior, right? And I think that’s key. Kids are so delicate. And I always say, and I learned this from one of my son’s teachers, that all children are kind, loving and good people. They are children. They’re all just learning it at their own pace and in their own experiences. So I think when I label my son as misbehaved because he’s not listening to me, it’s not because he’s a bad kid. It’s because there’s something dysregulating there and I just need to change it or shift the environment. But saying no, get off Roblox, get off talking to your friends on your computer, that’s not going to work. I need to lure him into something else. And that’s the way you do it, right? I’m always like, I have that puzzle actually right in front of the computer. So it’s like I start doing it, but we just finished it.

(51:27):

And honestly, now I’m thinking, what should I do next? Should I get another puzzle? Should I get something else? So as parents, I do feel like the world has put us in a place where we need to navigate that for them because it’s not readily available in our time. I just went out in the backyard and played with all the neighbors. That’s not happening anymore. So how are we going to navigate that for them? And I think that’s the struggle. So let’s bring back the old games, let’s bring back those things, the old habits and start letting them see in a 3D world rather than an AI fake, flat curated world.

Dr. Sarah Bren (52:03):

Right. Because it’s not good for their vision, but it’s also not good for their brains. Absolutely. We don’t have to be guilty about that. That’s why I like what you’re saying is it’s not… And we’ve said this before, I think on the podcast a lot when we talk about screen episodes is thinking about not what I focus on is this sort of negative, like there’s too much of the screen, we need to take the screen away versus shifting our attention to the positive, the what do I want more of? What do I want to put my attention on and orient to that feels good and try to increase bringing more of that in. It will naturally displace some of the screens. And that’s I think an easier place to start. You get less resistance from your kid. It feels better. It’s much more fun to say, “Ooh, what puzzle might my family be interested in or what game or what thing or whatever?” Think about how that makes you feel.

(53:07):

It activates a little bit of curiosity, excitement, fun, playfulness, what connectedness, creativity versus if I think, “Oh, I got to get rid of these screens. They’re so bad.” And then I’m focused on that and I feel stressed, negative, panicky, guilty, ashamed, whatever, hopeless, overwhelmed, all the things. But it’s like we’re answering the same question, just which side of the coin are you going to focus your attention on? It’s a lot easier. It’s just better, feels better.

Dr. Meenal Agarwal (53:43):

Yeah, absolutely. I mean, we all feel that mom guilt. I think that’s, I don’t know, ingrained in us. And too often that we’ve felt like, “Oh, your child’s under two. They shouldn’t be on a screen. Okay, get over it.” And I get upset at those things too because I’m like, “Hey, well, try being a mom with three kids where your two-year-old is screaming at a restaurant. You are going to give them a screen.That’s the bottom line. So you just want that 10 minutes of peace. Nothing’s happening to their brain in 10 minutes. I’ve done it. We’ve all done it. Nothing’s happening to that brain in 10 minutes. So do what you need to for your own sanity, your own peace. But I think let’s look at the broader picture. If your child is on a screen for an hour, let’s maybe shift them after half an hour, interject, take them to the bathroom.

(54:27):

I don’t know. Build that spatial awareness or that movement in between if we can to help kind of break it up. And I think that’s key. So don’t beat yourself up if you’ve given your child a screen for two hours on an airplane because we’ve all been mom shamed on an airplane. That’s my biggest pet peeve, but do your thing, but think about it more.

Dr. Sarah Bren (54:48):

Yes. Oh, thank you. This is so, so rich. I learned so much. I’m really excited about this. And I think there’s a lot of really good, very doable, practical strategies that you gave. And I highly recommend, if this is exciting, this book, I’m very excited. So Stuck in a Flat World: How Screens Rewire Our Brains, Spatial Awareness and Sense of Safety. Go get that book. Everyone should be reading this. You need to be thinking about not just… It’s a different story about screens. It’s about eyes and health and everything. So I’m excited. Also, my personal takeaway from this as a therapist, and I know we have a lot of therapists that listen to this podcast, is we need to build into our… Because when we do a comprehensive psychological evaluation when we’re starting with a new family, I’m going to make sure I’m checking about eyes and have they been to an eye doctor and can we rule out? I think I need to make sure that that gets part of my intake process actually.

(55:55):

Yeah. I mean, 100%, because it’s a big part of the attention, the ADHD and those kids. And I want to add, Sarah, it’s funny because my book actually does not talk about the eyes as an eye doctor. We talk about the brain a little bit more because essentially it is the brain processing it, but we talk a lot about midlife, empathy, the rise of introversion. Most of my book is about that and why this is all happening as a society, the loss of milestones in children, why children are fearing driving now. 25% of teens now cite fear as the primary reason for not driving in our time we jumped at our licenses. So there’s so many things that I think parents, women, and of course children even, give the book to your teenager because there’s so many things that they’ll relate to like, oh, no wonder I’m not dating.

(56:48):

No wonder there’s manipulation chapters, why people are being manipulated more, how that’s happening in the brain. And of course, all of it stems from vision, but essentially it’s the brain that’s processing that part of it and how the different areas talk. So of course we back it up with science, why we are fearing things more, why we are introverted, why does empathy sit in the parietal lobe? And because that’s not being calibrated, the stats on empathy are crazy when you read studies and stats on the lack of empathy and where we’re headed. So there’s just so much to it that I do want people to think it’s not only about screens, it is about why all of this is happening in our brains, in our lives and my personal stories and my patient stories of what I’ve gone through in midlife, what my patients have gone through in midlife, not necessarily about the eyes, but about their lack of catching a ball, their lack of socializing, lack of going to birthday parties.

(57:43):

I just think there’s a piece of it for everyone in there and I hope it changes lives that that was my only ask of the book really.

(57:53):

I believe it will. And if people want to get in touch with you, they want to read your book, they want to know more about the work that you’re doing, how can they connect with you? Where can we send them?

Dr. Meenal Agarwal (58:03):

The easiest place would be Instagram. I’m active on there @dr.meenalagarwall. And then of course you can buy my book on any platform and my website is drmeenalagarwal.com, so you can also reach me there. But yeah, reach out. I love to hear when people will say to me, “Oh, you posted that post and actually my child went through that.” So let me know. It really helps us when we build our next stories or we can share that with other people as well.

Dr. Sarah Bren (58:31):

Amazing. We’ll link to that in the show notes too so people can easily connect and thank you. I learned so much.

Dr. Meenal Agarwal (58:36):

Thank you so much, Sarah. Thank you for the conversation.

Dr. Sarah Bren (58:45):

If you enjoyed listening to this conversation, I want to hear from you. Share your thoughts and your feedback with me by scrolling down to the ratings and review section on your Apple Podcasts app or whatever app you’re listening on, and let me know what you think of this episode or the show in general. Your support means the absolute world to me and just a simple tap of five stars can make a real impact in how the show gets reached by parents everywhere. So thank you so much for listening and don’t be a stranger.