SAD (or seasonal affective disorder) is a sub-form of major depression or bipolar, according to the Diagnostic and Statistical Manual of Mental Disorders, which most commonly occurs during the darker and colder autumn and winter months. Key identified risk factors include: a family history of the disorder, and living at northern latitudes. Specifically women, people with darker skin tones and individuals between the ages of 18 to 30 years of age are most at risk of developing the disorder. In order to have a diagnosis of SAD, the condition must be observed to improve outside of the colder seasons. Depending on the latitude, SAD has a prevalence of 1.9 – 9%. Individuals with lower levels of the metabolism regulating hormone adiponectin have also been observed to be at higher risk of developing SAD.

Nutrition and SAD

Vitamin D has been hypothesised to play a key role in SAD development due to reduced sunlight in northern latitudes during colder months. Additionally, it has been observed that there is a correlation between blood levels of Vitamin D and symptoms of depression, due to reduced levels of the neurotransmitters serotonin and dopamine. Vitamin D has also been hypothesised as being involved in circadian rhythm, which is affected by seasonal changes. However, supplementation of Vitamin D in SAD has yielded mixed results, and further studies are needed in this area.

Practical Interventions for Supporting Individuals with SAD

Due to the prevalence of Vitamin D in depressive conditions, the lack of sunlight during the winter months and the hypothesised role of Vitamin D deficiency in the development of SAD, increasing Vitamin D exposure is potentially of merit. This may be done through the following:

• Consuming foods which are natural sources of Vitamin D, such as oily fish including salmon and mackerel, egg yolks and organic milk and cheese
• Increasing exposure to sunlight in the winter months by being outside, particularly engaging in physical activities and spending time in nature 
• Supplementation of Vitamin D3. The RDA in the UK for Vitamin D is 10 micrograms (µg) or 400 IU. However, some individuals may benefit from supplementing higher levels of this vitamin, particularly if they have a higher BMI, a diagnosed mental health condition or darker skin pigmentation. Baseline levels of Vitamin D as established via blood test, calcium intake, genetics, oestrogen use, dietary fat content and composition, as well as co-existing diseases and medication use may also impact on Vitamin D requirements*.

*Note: before beginning any new supplement regimen, always consult your physician and a qualified nutrition practitioner.

Four years ago I was diagnosed with multiple sclerosis. Diet, vitamin supplementation, exercise, stress reduction and cognitive activity (also known as a brain-healthy lifestyle) have all been shown to significantly improve outcomes in MS – great news, right?! So why is it so hard to keep doing what is right?  As a clinical psychologist I’ve spent years working with people who are finding it difficult to make changes in their lives, despite knowing that ultimately there will be benefits. Below are some of things I have learned along the way and that have helped me navigate a new path towards a brain healthy lifestyle.

Have compassion for where you are at

Our health behaviours depend upon many factors, including what attitudes and ideas about health were laid down in our early life experience. I grew up in a low socioeconomic status inner-city household in the 1990s – I never owned a bike, never saw or heard of anyone “going for a run” and diet was only discussed as a thing you “went on” if you wanted to be thinner (usually before Christmas, so you could eat and drink with abandon during the festive season). Crucially, my family was time-poor, working long hours to make ends meet; active relaxation and ‘self-care’ was not on the agenda.

Unsurprisingly then, I have spent the majority of my adult life replicating what my early-life taught me – working hard, eating for convenience (rather than health) and neglecting balance. It’s easy to be judgemental and regretful about not having made smarter health choices in the past and label ourselves as lazy, reckless or not capable. However, research shows us that self-criticism reduces motivation and leaves us feeling worse, whereas showing ourselves compassion and understanding is much more likely to free us to make changes.  Whatever health and lifestyle choices you made so far, you were doing your best with the information and resources you had at the time.  If your inner voice is harsh and critical, remind them that you have done your best and will continue to do so – that’s all any of us can.

Expect changes to be challenging

Long term behaviour change is difficult to achieve and involves a series of small steps and crucially, ‘failures’. What sets apart people who successfully implement long term change is not an innate ability to stick perfectly to a plan, but the ability to pick oneself up and get back on track when the plan has not…gone to plan! Failing to stick to a healthy lifestyle plan does not mean you are “not capable”, “can’t do it” or “just not into a healthy lifestyle”- it simply means you are a human, not a robot. Try to see all setbacks as an opportunity to learn by asking yourself why it didn’t go to plan and what you can do differently to achieve your goal. 

Set good goals

Good goal setting is the bedrock of many psychological interventions and research shows that it works. My top tips for good goals are

1) Set positive goals about what you want more of (I want to learn one new health recipe) rather than what you want less of (I want to stop eating junk food)

2) Set achievable short term goals that will bring quick benefits, such as sticking to a good sleep routine and regular bedtime for a week – this will set you on the right path and increase your confidence that those longer term and less visible benefits are also achievable

3) Link your goals to your values – list all the reasons why your goals are important to you – including those beyond your own health. When I stopped eating dairy for health reasons I found it really helpful to learn about the ethical and environmental benefits of doing so – whilst these were not my primary motivations, they have become increasingly important to me and serve as further important reasons to stick to my plan. 

Find your support team

It is hard to make change and it can be hard for those around us – my family still object to vegan, oil free meals 4 years down the road. Finding positive reinforcement for the healthy lifestyle you want to adopt can help you stay committed in the face of doubt and objection (whether that be from people around you or inside your own head!). Instagram is a wonderful way to connect with inspiring people who just really LOVE living a healthy lifestyle, sharing tips/recipes/exercises/mindfulness practices/motivation, as are Facebook groups and internet forums. You may also find local groups, like beginners running clubs and yoga classes.

Set yourself up for success

Compassion, goals and encouragement aside – good old practical planning and problem solving will go a long way in facilitating behavioural change. Strategies that I have found useful include –

●  Planning ahead for the week what I will eat and when I will exercise

●  Batch cooking and freezing meals

●  Cooking simple meals on busy days

●  Using a slow cooker and an air fryer for ease and speed

●  Planning exercise for the time of the day when I have most energy

●  Setting reminders in my phone to take supplements

●  Setting a bedtime reminder in my phone for 30 minutes before I want to be in bed

●  Leaving my phone out of the bedroom and my book next to my bed (I read a chapter a night for cognitive stimulation and relaxation)

I hope these tips can help you incorporate changes you want to make!

With thanks to Dr Nicky Hartigan for this article. Dr Nicky is a Clinical Psychologist and Director at HelloSelf, and has recently joined Food for the Brain’s Board of Trustees.

Mental health conditions are on the rise and the statistics speak for themselves: a record 70 million antidepressant prescriptions were handed out in 2018, and an estimated 10 million people will be in need of mental health support in the next five years. Mood can of course be dependent on external factors, but internal factors such as fluctuations in hormones, neurotransmitters and nutrient availability can also exert considerable influence. In light of this, treating the mind and body separately does not make sense. 

Our Second Brain

Far from being distant organs, the gut and brain communicate through a complex network of neural, hormonal and immune pathways and messengers, called the “gut-brain axis”. The integrity of our digestive system directly impacts the information our brain receives, and the quality of the building blocks of the brain tissue itself.  

Poor mental health may be a symptom of imbalances in the gut-brain axis. More  than 100 million nerve cells line our gastrointestinal tract, working independently of our brains. We know that the gut-brain axis is a strong communication mechanism because anxiety and mood changes are correlated with irritable bowel syndrome and functional bowel problems such as constipation, diarrhea, bloating, pain and stomach upset.

Our mood can also be impacted by poor vagal tone. The vagus nerve connects our digestive system to our brain and is the major nerve in our ‘rest and digest’ nervous system. With busy and stressful lifestyles regularly triggering our ‘fight or flight’ response, this vagus nerve may not be functioning well, which can contribute to depression and indigestion. 

Mood and Immunity

The nervous and immune systems work together, with the brain housing specialised immune cells called microglia to help fight infections and clear away damaged cells. When stress is excessive, or when the immune system sends persistent distress signals, the inflammatory response triggered by the immune system has been linked with depression.  

Much of the immune system is housed in our gut, making sense when much of our environmental risk exposure enters the body through our food. Our gut, therefore, needs to be in good shape for our immune system to be working well.  

Maintaining Balance

Our blood sugar levels also impact our mood. Our brain is an energy hungry organ, using 25% of our total energy stores and preferring glucose to carbohydrates to keep it going. If our blood glucose levels are unstable, say from a high carbohydrate diet, this can be stressful for the brain to cope with and can cause mood swings or feeling ‘hangry’.   

Blood sugar swings can also make us feel fatigued and have a detrimental impact on an important protein, BDNF (brain-derived neurotrophic factor) essential for the survival and growth of brain cells. BDNF helps our brain cells communicate and promotes the calming neurotransmitter GABA, levels of which may be low in anxiety sufferers. It also supports how our body makes energy,  and therefore if levels of BDNF are low, we are more likely to feel fatigued, listless and at risk of experiencing mental ill health. 

Top Tip

Keeping our gut healthy with a Mediterranean style diet, abundant in fibre-rich fruit and vegetables, oily Omega-3 rich fish, and wholegrains enriched with B-vitamins, translates into increased brain health, in turn improving our mood and mental health. 

With thanks to Julie Pichler at Vagus Wellbeing for this article. Julie is a registered Nutritional Therapist and delivers our Workplace Wellbeing programme, offering educational and empowering webinars. Julie’s specialism is the gut-brain connection and how food impacts our mood and brain health.

Find out more about our webinars here and how they can support your employees’ mental wellbeing.

Vitamin D deficiency is more common in patients with schizophrenia. This is due to factors such as social isolation, lack of movement, smoking, spending less time outside, malnutrition, and disruption of vitamin D synthesis by antipsychotic drugs.

The study looked into the relationship between sunlight exposure and positive, negative, and cognitive symptoms. 52 patients were invited to take part and 40 completed the study.

Patients had their serum 25OHD levels measured in order to understand their current vitamin D level in the blood.

The following clinical assessment scales were used pre and post replacement of Vitamin D:

SANS – scale for the assessment of negative symptoms
SAPS – Scale for the Assessment of Positive Symptoms
WCST-CV- Wisconsin Card Sorting Test used to evaluate executive function

Vitamin D deficiency was found in 65.4% of the patients with vitamin D values below the normal limit.

Various levels of oral vitamin D was given once a week for eight weeks to the patients according to their initial levels. Vitamin D levels were measured again eight weeks after the initiation of the treatment. Additionally, patients whose serum vitamin D level could not reach > 30 ng/mL within the eight weeks were given additional doses until the optimal level was reached.

Results showed that the mean SANS score was statistically significantly lower after replacement of vitamin D and the total attention score was also significantly improved. The study therefore concluded that addressing vitamin D deficiency in schizophrenic patients (together with antipsychotic treatment) can improve the total attention span and positive and negative symptoms in schizophrenia.

The abstract can be accessed here.

Neriman A, Hakan Y, Ozge U. The psychotropic effect of vitamin D supplementation on schizophrenia symptoms. BMC psychiatry. 2021 Dec;21(1):1-0.

This paper investigated iron deficiency and schizophrenia. Previous research finding that iron deficiency may alter dopaminergic transmission, this study was conducted to identify whether low blood iron levels could be related to severity of schizophrenia symptoms. This study was conducted on 121 patients during their first episode of schizophrenia disorder. Symptoms were measured using the positive and negative syndrome scale (PANSS), and iron deficiency was defined as a serum ferritin less than 20ng/ml. The study found patients with iron deficiency were significantly more likely to have more prominent negative symptoms, and patients with more negative symptoms had significantly lower serum ferritin (iron) levels than their counterparts. This study highlights a possibility for further investigation as to whether iron supplementation could be used as an intervention.

The abstract can be accessed here

Kim SW, Stewart R, Park WY, Jhon M, Lee JY, Kim SY, Kim JM, Amminger P, Chung YC, Yoon JS. Latent iron deficiency as a marker of negative symptoms in patients with first-episode schizophrenia spectrum disorder. Nutrients. 2018 Nov;10(11):1707

This study investigated omega 3 and schizophrenia. Specifically, the study explored the effect of omega-3 supplementation in symptom severity in schizophrenic patients over a long period of time, as previous studies have had mixed findings when interventions lasted 10-12 weeks.  A randomized placebo-controlled trial was conducted over 26 weeks to study whether omega-3 fatty acids would have an effect on symptom severity in first episode schizophrenic patients. 71 patients were assigned either a placebo of olive oil or 2.2g/day of omega-3 supplement. Severity of symptoms were measured using the positive and negative syndrome scale (PANNSS). A 50% improvement in symptom severity was recorded more frequently in the omega-3 group compared to the placebo group. Significant improvements were found in depressive symptoms, the level of functioning and clinical global impression when patients were supplemented. These findings suggest that a 6-month intervention of omega-3 supplementation may be able to decrease symptom severity in first episode schizophrenia patients.

The abstract can be viewed by clicking here

Pawełczyk T, Grancow-Grabka M, Kotlicka-Antczak M, Trafalska E, Pawełczyk A. A randomized controlled study of the efficacy of six-month supplementation with concentrated fish oil rich in omega-3 polyunsaturated fatty acids in first episode schizophrenia. J Psychiatr Res. 2016 Feb;73:34-44.

This study explored antipsychotics, omega 3 and schizophrenia. The review compiled previous studies surrounding treatment of schizophrenia using omega-3 and looked at what pathways in the brain are impacted by an omega-3 supplementation. After compiling information on omega-3 and anti-psychotic drugs it was found that the drugs used to treat schizophrenia and omega-3 supplementation impact on dopamine and glutamate transmission, oxidative stress, inflammation, myelination, and neurotransmission pathways in a similar way. Through evaluation of multiple clinical studies on omega-3 supplementation it was concluded that omega-3 has been linked to improved symptoms in those experiencing a schizophrenic episode. This research suggests that omega-3 supplementation may be an important consideration in schizophrenia. 

To view the abstract, click here

Shared Biological Pathways between Antipsychotics and Omega-3 Fatty Acids: A Key Feature for Schizophrenia Preventive Treatment? Int J Mol Sci. 2021 Jun 26;22(13):6881

When in balance, stress can be helpful. It keeps us motivated, helps us get out of the bed in the morning, and can serve as a warning sign that we need to make some lifestyle changes. Prolonged stress, on the other hand, can have serious consequences for our wellbeing, not least because of its impact on our eating habits and nutritional needs.

Chronic stress increases the body’s metabolic needs, which may result in increased uptake and excretion of nutrients. Chronic stress can therefore increase nutrient requirements, and also exacerbate deficiencies that already exist. 

Furthermore, during periods of prolonged stress, our food choices may alter, causing increased consumption of sugar and processed foods. One reason for this may be reduced time and energy to prepare meals, leading to increased reliance on processed foods and ready meals. 

Another possible reason is that during periods of stress we actually have an in-built preference for higher fat and sugar foods. Theoretically, this mechanism may have been beneficial to early humans during stressful periods such as food scarcity, since fat provides significant calories and sugar affords a quick release of glucose, and therefore energy. However, in modern times, stress can last for significant periods of time, due to work, relationships, financial pressures and other stressors and so can literally tip the scales in the wrong direction.

Moreover, food availability is more abundant: there is an ever growing array of processed foods, microwave meals, as well as high sugar and fat snacks cheaply and readily available. 

Caffeine, from coffee and energy drinks, is also readily available, and often employed as a coping mechanism for stress and stress-related exhaustion. High consumption of caffeine causes blood glucose levels to fluctuate, through increasing cortisol levels and dysregulating insulinotropic polypeptide and GLP-1, which are both involved in regulating appetite control and insulin levels. 

The impact of prolonged stress, therefore, may be weight gain and blood glucose dysregulation, heightening the risk of the development of chronic diseases related to obesity, such as type II diabetes. 

Using Nutrition to Build Resilience

Nutrition can be used as a means of supporting the body during times of stress, increasing resilience, building strength and re-equipping the body with nutrients that may become depleted during periods of chronic stress. 

Research has indicated that magnesium and vitamin B6 may support individuals experiencing stress. A study by Pouteau et al. (2018) indicated that combined supplementation helped to alleviate stress levels in subjects who were experiencing extreme stress. 

A further study by Jahangard et al. (2019) indicated that individuals who were administered omega-3 fatty acids demonstrated reduced markers of psychological and physiological burnout, including decreased cortisol levels, compared with controls. 

Here are some practical ideas for increasing your consumption of these nutrients: 

• Consume green leafy vegetables, nuts and cacao, which are all rich in magnesium
• Take a bath with Epsom salts to increase magnesium levels transdermally 
• Up your vitamin B6 intake with turkey, chickpeas and salmon. Salmon – along with other oily fish – is also a great source of omega 3 fatty acids. Enjoying turkey and salmon with homemade hummus and a colourful salad would be an excellent way of increasing vitamin B6 and omega-3 fatty acids

We hope you find these tips useful. However, if you’re experiencing frequent panic attacks, chronic anxiety and depression, it may be worth seeking some personalised support with an integrative mental health practitioner that can also advise you on your diet. 

Please head to our ‘Seeking Help’ page for more information on organisations and networks you can reach out to. 

The summer holidays can be a great time to get kids into the kitchen and kick-start long-term healthy eating habits. We’ve picked three easy recipes that you can have fun recreating at home with the little ones. Our Head of Nutrition, Alice, also shares her thoughts on their brain-boosting properties. Post your best creations on Instagram and tag us @foodforthebrainfoundation.

Sweet Potato Quiche

Ingredients:

4 sweet potatoes, peeled and sliced into thin rounds (the rounds should be thin enough to bend easily)

5 eggs, beaten

2 cups fresh spinach

10 slices of sundried tomato, chopped

1 red onion, sliced

1 garlic clove, minced

2 tbsp fresh chives

Olive oil

Method:

Preheat your oven to 200°C. Arrange the potato slices in a pie dish in a circular pattern to form a “crust” for the quiche. Drizzle the sweet potatoes with olive oil and season to taste. Place in the oven and bake for 15 to 20 minutes.

Warm some olive oil in a skillet over a medium heat and add the garlic and onion. Cook until the onion and garlic are soft and fragrant, around 5 minutes.

Add in the spinach. Sauté until wilted, 2 to 3 minutes, and set aside to cool down. When the sweet potatoes are done, lower the oven heat to 375 F.

In a bowl, combine the beaten eggs with the spinach mixture, sundried tomato and chives.

Pour over the sweet potato crust, and place in the oven. Bake for 30 to 35 minutes, or until the eggs are set; serve warm.

Alice adds: Sweet potatoes, spinach and red onion are a rich source of antioxidants, which may help to support brain health by reducing the effects of oxidative stress on the brain. Eggs are great for increasing protein and are also a good source of vitamins B6 and B12, folate and choline, which are essential for keeping tiny brains energised throughout the day, as well as supporting a biochemical process called methylation, which is vital for mental and neurological wellbeing. 

Chocolate Crunchies

Ingredients:

100g good quality dark chocolate, broken into rough chunks

2 tbsp tahini or unsalted hazelnut butter (from health-food stores)

2 tsp ground cinnamon

50g oats

50g mixed unsalted nuts, roughly chopped

50g desiccated coconut

50g pumpkin seeds

A good tbsp of ground or cracked flaxseeds (linseeds)

Method:

Melt the chocolate then stir in the tahini. Place ten paper cake cases on a baking sheet. Mix in the dry ingredients until evenly coated then spoon into the cake cases and chill until set.

Alice adds: Kids love chocolate and the above recipe is a luxurious chocolate fix, which also packs a nutritional punch. Pumpkin seeds are a good source of zinc, which is important for increasing levels of GABA and modulating dopamine and adrenaline. Cacao is a rich source of magnesium, which similarly to zinc also works to reduce excitability of neurons, as well as reducing levels of oxidative stress in the brain. Flaxseeds are a source of dietary fibre and also contain ALA, a vegan source of omega 3 fatty acids, which are essential for brain health.

Big Baked Beans

Ingredients:

1 tbsp olive oil

2 red onions, peeled and finely chopped

2 x 400g cans butter beans, rinsed and drained

2 x 400g cans chopped tomatoes

A little salt, or 1 tsp Marigold Reduced Salt Vegetable Bouillon powder

Freshly ground black pepper

Method:

Heat the oil in a saucepan and sauté the onions for 2 minutes to soften. Stir in the remaining ingredients and simmer for 2 minutes, then taste to check the seasoning. Serve on wholemeal or rye toast. Tip: You can also purée the mixture before adding the beans to make a smooth sauce like the canned versions.

Alice adds: These baked beans contain no added sugar and are low in salt. Consuming high levels of sugar and refined foods has been indicated to increase hyperactivity and neurocognitive deficits in some studies. Swapping store cupboard staples such as baked beans for low sugar and low salt alternatives, or making your own using the recipe above, is a great way of reducing sugar and salt intake whilst keeping little tummies happy. 

The COVID-19 pandemic has brought much disruption, fear and anxiety, and this is particularly true amongst children and teens who have been affected by school closures, physical distancing and new routines. It is no surprise, then, that many children have been feeling more anxious or exhibiting signs of anxiety, and that related conditions such as OCD, social anxiety and disordered eating appear to be on the rise. Witnessing this in a child can be very worrying and stressful for parents.

At Food for the Brain, we’re passionate about sharing the science and nutritional strategies that promote good brain health and mental wellbeing at every life stage. Nurturing healthy brains in children is particularly important given the growing body of evidence connecting diet and mental health. 

Diet and Mental Health

We all know that diet plays a huge part in our health, but recently we have started to understand more about its connection to mental health. Unhealthy dietary patterns have been associated with poorer mental health in children and adolescents. Furthermore, a 2017 paper published in Public Health Nutrition found the UK to have the most ‘ultra-processed’ diet in Europe, as measured by family food purchases. British children were found to be eating “exceptionally high” proportions of ultra-processed foods*, which is likely to be contributing to health problems.

Specific Nutrients for Mental Health

The brain is the most energy-hungry organ in the body, stealing roughly 25% of the body’s energy requirements. In addition, there are specific nutrients that play a role in mental wellbeing. Ensuring good levels of these nutrients can support your child’s brain and mental health. 

Zinc

Zinc is a mineral found in higher concentrations in seafood, organ meat, chickpeas, lentils and pumpkin seeds – not foods that tend to be loved by children. Zinc can also be found in other foods such as the dark meat of chicken, yogurt, almonds and peas, but it may be harder to obtain the amounts children need from these sources.

Zinc is believed to interact with an important anti-anxiety brain chemical called GABA. GABA is the body’s main inhibitory neurotransmitter, meaning that it prevents excitatory neurotransmitters like dopamine and noradrenaline from over-stimulating the brain. This relaxes us and promotes feelings of calm, as well as helping to slow down our heart rate and breathing. In those who are deficient in GABA, feelings of anxiety and stress can be common symptoms.

Although zinc has not been as well researched as other nutrients, it has been connected in research to both ‘mood disorders’ and depression. Zinc supplementation may even reduce anger and lessen depression.

If your child does not eat seafood, chickpeas or chicken, you could encourage them to eat extra almonds, cashews and pumpkin seeds, to make up for any potential shortfalls. You could try making things like energy balls with nuts and seeds, adding raisins or dried apricots, which are also high in iron. 

Vitamin B6

B6 is really important for our mental wellbeing because the body uses it to make brain chemicals like GABA and serotonin, which make us feel calm, focussed and happy.

This vitamin is found in a wide range of foods such as meat, fish, chickpeas, vegetables and wholegrains. However, if your child’s diet mostly comprises refined, white foods such as bread and pasta, they may be losing out on important sources of this vitamin. Wholegrains and wholefoods should be the focus, keeping refined white flour to a minimum to help achieve good B6 levels. 

Iron

According to the World Health Organization, iron deficiency is the most prevalent nutritional deficiency. Iron deficiency in children is known to affect behaviour and learning, and has also been associated with increased anxiety and social problems. 

The best sources of iron are red meat, seafood and the dark meat of chicken. Plant foods also contain a lot of iron, such as beans, lentils, kale, cabbage and broccoli. Eggs and dairy contain iron in smaller amounts and may be a good source if your child will not eat plant or meat sources. An emphasis on green vegetables, however, is always recommended for overall good health.

What if my child doesn’t like these foods?

The biggest challenge for parents tends to be picky eaters, and time restraints. A picky eater may exclude whole food groups, such as animal protein or plant foods such as beans or greens. This may cause children to struggle to get the nutrition they need for good mental health.

Top Tips: It’s not easy coaxing a fussy child to eat something they don’t like, but disguising the food within something they do like can be a good trick. For example, making a well seasoned vegan burger using chickpeas. Or a creamy soup, sneaking in mixed vegetables, then blending until smooth for children who don’t like lumps. Shredding onion and celery into tomato sauce also disguises them well. Follow us on social media for additional tips this month on preparing meals for picky eaters.

* This report by The Soil Association provides useful information on ultra-processed foods and how to spot them.

With thanks to our volunteer, Linda Albinsson at Thrive Kids Clinic, for this article.