The Context

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Childhood is not the same everywhere. A child growing up in a rural area of a low-income country, with limited access to schooling, healthcare and opportunities, is very different from that of a child living in an urban, digitally connected and education-intensive society. The pressures, daily routines, and health risks are different. Prevalence studies mentioned in “The Reality” section highlight these differences in myopia, as one example. For that reason, an all-encompassing global view of myopia will be too broad. This section is therefore focused mainly on developed societies where formal education is the norm, internet access is commonplace, and myopia is becoming more prevalent.

When myopia is discussed in academic literature or public, the framework is usually quite narrow. How fast is it progressing, how to prevent it, or how to slow it down? As a clinician working with families, however, advice should be given with the child’s wider environment in mind: how the children spend their time, where they play, how long they study, how they sleep, and how they engage socially. This environment has changed substantially over the past generation. Children today benefit from better education, information, and communication. This new pattern of everyday life influences not only myopia but also children’s physical, emotional, and social well-being (UNICEF, 2025).

Modifiable Risk Factors for Myopia: Time Spent Outdoors and Education

Evidence consistently shows that time spent outdoors is associated with a reduced risk of developing myopia and probably helps to slow progression as well. Preventing myopia, or even delaying its onset, is vital in sequentially reducing the risk of high myopia, when vision-threatening complications can occur later in life. It is also an inexpensive intervention, and physical activity outdoors brings other health benefits, more daylight exposure, and more opportunities for play. We should therefore look at the child as a whole person rather than focusing only on the biology of the problem.   

Physicians refer to this as the biopsychosocial approach. The biological side includes vision, sleep, and general physical health. The psychological side includes stress, anxiety, and emotional resilience. The social aspect includes family life, peer relationships, and independence. These three key areas overlap constantly. A child who spends little time outdoors may also move less, sleep less well, feel more pressured at school, and have fewer opportunities for play. This does not mean that these factors cause one another, or that they cause myopia, but they often coexist as part of a childhood pattern of behaviour.

The Biological Context

Take the physical environment in which children live. In many developed countries, children spend large portions of the day indoors: in classrooms, in transport, at desks, doing homework, or relaxing inside the home. Even recreational time is sedentary and near-work heavy, such as reading a book or playing a video game. Outdoor time has become less central to children and their families, and this displacement puts children at risk of short-sightedness. Studies recommend at least 2 hours per day of outdoor activity to protect against the development of myopia (Xiong, 2017).

This pattern of sedentary routines and less outdoor time is also linked to obesity in the 6-14 age range. This association is thought to be related to more recreational screen use, low physical activity, and a poor diet. (Stiglic, 2019). The issue is important not just as an immediate risk of obesity but that it may establish long-term unhealthy behavioural patterns into young adulthood. In the US, CDC statistics show rising obesity prevalence among children from around 5% in 1971-1974 to over 20% in 2021-2023 (CDC, 2024). Another generational change to be aware of, and a public health concern.    

On the same timeline as myopia development, adequate sleep is another important biological factor for healthy child development. Insufficient sleep is associated with poorer academic performance, greater irritability, and an increased risk of behavioural difficulties (Chaput, 2016). There is fairly good evidence that many children, especially older ones, are sleeping less than those in previous generations. Evidence points to changes in the social and environmental conditions of modern childhood as the reason, rather than any biological need for less sleep. In particular, electronic device use and bedtime screen exposure are associated with later bedtimes and shorter sleep duration (Carter, 2016). Early school start times can also reduce sleep by forcing wake times that go against the natural sleep rhythms of adolescents (Owens, 2010).

The Psychological Context

If the physical environment of childhood has changed, so has the emotional one. Children growing up today face a world where stimulation and evaluation are continuous. Relationships with peers do not pause when school ends; social contact is extended by messaging, gaming, and social media. While the benefits of these spaces are to allow children to express themselves, be social and creative, they can also bring added pressure. In the US, a survey of children aged 12-17 years found that 20% of adolescents had a current, diagnosed mental or behavioural condition. From 2016 to 2023, the prevalence of diagnosed anxiety increased by 61% and depression increased by 45%. Girls were more likely to have anxiety and depression, and boys more likely to have behavioural or conduct problems (HRSA, 2024).    

Research suggests that social media is associated with anxiety, depression, and other emotional difficulties, especially in adolescents (Keles, 2020). But with whom, how, and why this affects children appear more complex. Social media is not to blame for everything, nor is it harmless. Having a digital life can be beneficial for some children but harmful for others, and it will depend on the age, temperament, and the type of content they are exposed to (UNICEF, 2025).

Cyberbullying is another growing concern for children and adolescents. A WHO study reported that among 11-, 13-, and 15-year-olds across 44 countries, the proportion reporting that they had been cyberbullied increased to 15% for boys and 16% for girls (from 12% and 13% respectively) from 2018 to 2022 (WHO, 2024). Unlike older forms of bullying, cyberbullying can follow a child home beyond school hours, spread rapidly, and reach a wide audience. The chance of exclusion, humiliation, or conflict no longer depends on face-to-face encounters. Evidence suggests that cyberbullying victimization is associated with higher risks of depression, anxiety, and self-harm (Li, 2024).

The Social Context

Ages 6 to 14 are an important stage of social development because children start becoming more independent, more self-aware, and more influenced by the world outside their family. During these years, friendships become more important, and they begin comparing themselves with others, which moulds their confidence and identity. Early adolescence is also challenging because of puberty and changing social pressures, affecting how they feel and behave (Eccles, 1999).

Children of this generation face different social challenges as more of their friendships and social lives happen through screens rather than in person. There is some evidence that they are more susceptible to loneliness, comparison, and social exclusion compared to children in the past (Zoellner, 2025). The more time children spend on their devices indoors, the fewer opportunities they will have for outdoor play, which is where they often build social skills through conversation and unstructured play with others (Tremblay, 2015). Increased outdoor time therefore not only reduces the risk of developing myopia but also supports healthier social development.

The Broader View

Understanding the rising epidemic of myopia requires appreciation of the environment where children are growing up; often spending less time outdoors, more time indoors, and in near-focused settings. Those same environments also influence mobility, sleep, stress, mood, play, and social development. Modern families are raising children in conditions that are difficult to balance. Educational demands are high, digital life is necessary, and safety concerns are real. Against this background, recommendations regarding the correct amount of outdoor time and other routines like screen time should be practical and flexible, but the value should not be underestimated.

Public health does not always have to rely on a single dramatic finding, but several moderate lines of evidence pointing in the same direction can be just as powerful. Protecting childhood has always been a shared responsibility among parents, educators, healthcare professionals, and policymakers, and collective action will shape not only children’s health and development now but also their well-being and outcomes later in life.

The Shared Approach in Practice

The evidence gathered across the biological, psychological, and social contexts of childhood has been laid out. This is not about anti-tech or anti-education. Children do better with more time outdoors, less sustained close-up work, and adequate sleep. What follows are therefore recommendations on how this might be achieved and should be tailored to the individual child.

For Parents and Caregivers

1. A child’s first eye examination should ideally take place before starting school, and annually thereafter. When one or both parents are myopic, earlier and more frequent review is sensible.

2. Children should try to be outdoors for an average of two hours per day. This does not have to be a structured activity; simply being outside in daylight appears to be beneficial. If the time on school days is difficult, longer periods at weekends can still be helpful.

3. Reading, writing, and drawing are all valuable activities, but regular breaks should be taken if possible. The widely cited 20-20-20 rule - a 20-second break looking at least 20 feet away after every 20 minutes of near work - is a memorable guide, but it is the general habit of regularly interrupting close-up activity that is important. Holding reading material at least 30 cm away and in good lighting is good practice.

4. Handheld devices are not inherently harmful, but the way they are typically used — close to the eyes, for sustained periods, often at the expense of outdoor time and sleep — aligns with several known risk factors for myopia. If families decide to allow smartphones, then the conversation turns to how they are used: when, for how long, at what distance, and in place of what other activities. Handheld gaming devices can be docked and played on TV screens, sitting further away. Schoolwork can be done on PC monitors or even projected on the TV.

5. It is important to remember that most myopic children DO NOT go on to develop sight-threatening complications. The aim of myopia control is to keep the final degree of myopia as low as possible and is achievable with appropriate treatment and lifestyle measures.

For Educators and Schools

1. Evidence from school-based studies in East Asia shows that adding 40-80 minutes of outdoor time a day can reduce the incidence of myopia. Closing classrooms during break time, outdoor physical education, and holding a lesson a day outdoors can all contribute. Maximizing natural light in classrooms may also help.

2. In the classrooms, ensuring desks are sized to pupils, bright ambient lighting, and correcting reading and writing posture at desks will benefit. For digital learning, larger screens viewed at the proper distance are better than handheld devices. Large screens or boards used at the front of the classroom are preferable.

3. Schools across several countries are reviewing personal smartphone use during the school day, recognising its educational and social implications. From a myopia standpoint, break times spent outdoors looking into the distance are more protective than time spent on handheld devices indoors. For schools that allow pupils to bring phones onto the premises, storing them in lockers at the start of the day is likely to be more effective than leaving them in bags.

4. Children who start formal reading earlier show higher rates of myopia. Adolescents who have early start times for school have less time for sleep. Adjustments to school curriculum and structure may therefore have biological benefits.

For Policymakers

1. Myopia is a condition that can respond to modifiable environmental factors. It carries a long-term risk of vision-threatening complications. This can become an economic burden through lost productivity and treatment required for pathological myopia. There are current examples of successful policy implementation. The Taiwanese Tian-Tian 120 program introduced 120 minutes of daily outdoor time in schools, resulting in a measurable reduction in myopia among primary school children (Wu, 2020).

2. School-based vision screening, subsidised treatment for myopia control, public education campaigns, and outdoor initiatives can all be beneficial to children’s well-being during the sensitive ages of 6-14.

3. There appears to be an ongoing debate regarding the need to protect minors from early exposure to the internet. The same window (ages 6–14) during which myopia develops most rapidly is also when handheld screen use is becoming more common, making this a reasonable area for guidance alongside mental health considerations. As noted earlier, policy shifts may not have to wait for definitive causal proof when several lines of evidence pointing in the same direction are just as persuasive.

   Next: The Response‍ ‍

References

Carter, B., Rees, P., Hale, L., Bhattacharjee, D., & Paradkar, M. S. (2016). Association between portable screen-based media device access or use and sleep outcomes: A systematic review and meta-analysis. JAMA Pediatrics, 170(12), 1202–1208.

CDC. (2024). Prevalence of overweight, obesity, and severe obesity among children and adolescents ages 2–19 years: United States, 1963–1965 through August 2021–August 2023. National Center for Health Statistics.

Chaput, J.-P., Gray, C. E., Poitras, V. J., Carson, V., Gruber, R., Olds, T., Weiss, S. K., Kestler, M., Tremblay, M. S., & Gorber, S. C. (2016). Systematic review of the relationships between sleep duration and health indicators in school-aged children and youth. Applied Physiology, Nutrition, and Metabolism, 41(6 Suppl. 3), S266–S282.

Eccles, J. S. (1999). The development of children ages 6 to 14. The Future of Children, 9(2), 30–44.

HRSA, Health Resources and Services Administration. (2024). Adolescent mental and behavioral health, 2023 (National Survey of Children’s Health data brief). US Department of Health and Human Services.

Keles, B., McCrae, N., & Grealish, A. (2020). A systematic review: The influence of social media on depression, anxiety and psychological distress in adolescents. International Journal of Adolescence and Youth, 25(1), 79–93.

Li C, Wang P, Martin-Moratinos M, Bella-Fernández M, Blasco-Fontecilla H. Traditional bullying and cyberbullying in the digital age and its associated mental health problems in children and adolescents: a meta-analysis. Eur Child Adolesc Psychiatry. 2024 Sep;33(9):2895-2909.

Owens, J. A., Belon, K., & Moss, P. (2010). Impact of delaying school start time on adolescent sleep, mood, and behavior. Archives of Pediatrics & Adolescent Medicine, 164(7), 608–614.

Stiglic, N., & Viner, R. M. (2019). Effects of screentime on the health and well-being of children and adolescents: A systematic review of reviews. BMJ Open, 9(1), e023191.

Tremblay, M. S., Gray, C., Babcock, S., Barnes, J., Bradstreet, C. C., Carr, D., et al. (2015). Position statement on active outdoor play. International Journal of Environmental Research and Public Health, 12(6), 6475–6505.   

UNICEF Innocenti – Global Office of Research and Foresight, Childhood in a Digital World: Screen time, skills and mental health, UNICEF Innocenti, Florence, June 2025.

World Health Organization. (2024, March 27). One in six school-aged children experiences cyberbullying.

Wu PC, Chen CT, Chang LC, Niu YZ, Chen ML, Liao LL, Rose K, Morgan IG. Increased Time Outdoors Is Followed by Reversal of the Long-Term Trend to Reduced Visual Acuity in Taiwan Primary School Students. Ophthalmology. 2020 Nov;127(11):1462-1469.

Xiong, S., Sankaridurg, P., Naduvilath, T., Zang, J., Zou, H., Zhu, J., Lv, M., He, X., & Xu, X. (2017). Time spent in outdoor activities in relation to myopia prevention and control: A meta-analysis and systematic review. Acta Ophthalmologica, 95(6), 551–566.

Zoellner, F., Erhart, M., Schütz, R., Napp, A., Devine, J., Reiss, F., Ravens-Sieberer, U., & Kaman, A. (2025). Two decades of loneliness among children and adolescents: longitudinal trends, risks and resources – Results from the German BELLA and COPSY studies. European Child & Adolescent Psychiatry, 34, 3629 - 3641.