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pres.author = "Paediatric Residency Programme";
pres.title = "Adoption in Paediatrics – Resident Seminar";
pres.subject = "Medical, Developmental & Legal Aspects of Adoption";

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// ── AGENDA / OVERVIEW ────────────────────────────────────────────────────────
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    { num: "1", title: "Foundations of Adoption", sub: "Definitions · epidemiology · types of adoption · legal framework" },
    { num: "2", title: "Medical Assessment", sub: "Initial health evaluation · screening · infectious disease · growth" },
    { num: "3", title: "Developmental & Behavioural Issues", sub: "Attachment · developmental delays · mental health · AAP guidelines" },
    { num: "4", title: "Legal & Ethical Framework", sub: "Consent · confidentiality · international adoption · kinship care" },
    { num: "5", title: "Clinical Cases", sub: "Three case scenarios for discussion" },
    { num: "6", title: "Take-Home Points & Resources", sub: "Summary · guidelines · referral pathways" },
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// ═══════════════════════════════════════════════════════════════════════════
//   BUILD SLIDES
// ═══════════════════════════════════════════════════════════════════════════

// ── TITLE ───────────────────────────────────────────────────────────────────
titleSlide(pres,
  "Adoption in Paediatrics",
  "Medical Assessment · Developmental & Behavioural Issues · Legal & Ethical Framework"
);

// ── AGENDA ──────────────────────────────────────────────────────────────────
agendaSlide(pres);

// ════════════════════════════════════════════════════════════
//  SECTION 1 – FOUNDATIONS
// ════════════════════════════════════════════════════════════
sectionDivider(pres, "1", "Foundations of Adoption", "History · Epidemiology · Types · Definitions");

contentSlide(pres, "What Is Adoption? – Definitions", [
  "Adoption: permanent legal transfer of parental rights & responsibilities from birth parents to adoptive parents",
  "Foster care: temporary out-of-home placement – NOT adoption; goal is family reunification when safe",
  "Kinship care: placement with relatives/known adults; may become kinship adoption",
  "Open vs closed adoption:",
  { text: "Closed: sealed records, no contact with birth family" },
  { text: "Open: varying levels of contact (letters → meetings) with birth family" },
  { text: "Semi-open: mediated contact via agency" },
  "~2.5–3.5% of the US population is adopted (Kaplan & Sadock, 2022)",
  "~66,000 children adopted annually through child welfare systems in the US",
  "~122,000 children in foster care awaiting adoption at any given time",
]);

contentSlide(pres, "Types of Adoption", [
  "Domestic infant adoption: voluntary relinquishment shortly after birth; largely private agency",
  "Foster-to-adopt: child placed in foster care → adoption if reunification fails; most common public route",
  "International (intercountry) adoption:",
  { text: "Governed by Hague Convention (86 signatory countries)" },
  { text: "Numbers have declined significantly since ~2005 due to policy shifts" },
  { text: "Special medical and screening requirements on arrival" },
  "Kinship adoption: grandparent, aunt/uncle, or family friend formally adopts",
  "Stepparent adoption: most common single type of adoption in the US",
  "Embryo adoption: genetic donors ≠ gestational/social parents – unique identity issues",
  "Transracial adoption: child of one race adopted by parents of another – cultural identity support needed",
]);

contentSlide(pres, "Legal Milestones in Adoption", [
  "1851 – Massachusetts Adoption of Children Act: first US law requiring judicial oversight & best-interest standard",
  "1994 – Multiethnic Placement Act (MEPA): prohibited race-based delays in placement",
  "1996 – Interethnic Adoption Provisions: strengthened MEPA",
  "1997 – Adoption and Safe Families Act (ASFA): timelines for permanency; 15/22 months rule",
  "2000 – Child Citizenship Act: automatic citizenship for internationally adopted children",
  "2008 – Fostering Connections Act: kinship navigator programs; extended care to age 21",
  "2018 – Family First Prevention Services Act: prevention services before removal; reduces congregate care",
  "Hague Adoption Convention: international framework for ethical intercountry adoption (US acceded 2008)",
  "Indian Child Welfare Act (ICWA) 1978: special protections for placement of Native American children",
]);

twoColSlide(pres,
  "Open vs Closed Adoption – Current Evidence",
  "Open Adoption – Benefits",
  [
    "Adoptive parents report higher comfort level with process",
    "Greater empathy toward birth family",
    "Adopted children report less worry about birth family safety",
    "Predictable contact structure reduces anxiety",
    "Trust builds over time; fear of reunification decreases",
    "Better management of birth parent mental health disclosure",
  ],
  "Closed Adoption – Historical Rationale",
  [
    "Privacy and avoidance of social stigma of illegitimacy",
    "Concern for adoptee identity confusion",
    "Fear adoptive parents feel less legitimate",
    "Concern birth mother cannot grieve and move on",
    "Most evidence now favours some degree of openness",
    "Sealed records still present in many jurisdictions",
  ],
  C.navy, "1E6B7A"
);

// ════════════════════════════════════════════════════════════
//  SECTION 2 – MEDICAL ASSESSMENT
// ════════════════════════════════════════════════════════════
sectionDivider(pres, "2", "Medical Assessment of the Adopted Child", "Initial evaluation · Screening · Growth · Infectious disease");

contentSlide(pres, "The Pre-Adoption Medical Review", [
  "Families should see a paediatrician BEFORE travel for international adoption",
  "Review all available records (variable quality; often incomplete)",
  "Advise family on recommended vaccinations for travel country",
  "Protect family & community: pertussis, influenza boosters",
  "Protect child from family exposures: hepatitis A screening",
  "Discuss realistic expectations regarding available health information",
  "US Dept. of State exam ≠ comprehensive: limited to immigration communicable disease screening only",
  "Refer family to AAP Adoption Medicine Clinics if complex medical history is disclosed",
  "Source: Red Book 2021, AAP / Kaplan & Sadock Comprehensive Psychiatry 2022",
]);

tableSlide(pres,
  "Mandatory Screening on Arrival – Internationally Adopted Children",
  ["System / Condition", "Screening Test", "Rationale"],
  [
    ["HIV infection", "HIV Ag/Ab combination assay (4th gen)", "Prevalence varies by country; risk factors include institutional care"],
    ["Hepatitis B", "HBsAg, anti-HBs, anti-HBc", "Inconsistent birth dose & perinatal screening in many countries"],
    ["Hepatitis C", "Anti-HCV antibody", "Risk from institutional exposures, medical procedures"],
    ["Syphilis (congenital/acquired)", "RPR or VDRL + confirmatory treponemal test", "High prevalence in some source countries; may be latent"],
    ["Tuberculosis", "IGRA (preferred ≥2 yrs) or TST", "TB endemic in many source countries; BCG may give false+ TST"],
    ["Intestinal parasites", "3× stool O&P + Giardia/Cryptosporidium EIA", "Prevalence in institutional settings; often asymptomatic"],
    ["Lead", "Blood lead level", "Lead exposure common in many countries; cognitive risk"],
    ["Complete blood count", "CBC with differential", "Anaemia, eosinophilia (parasites), haematological disorders"],
    ["Thyroid function", "TSH", "Iodine deficiency common; affects cognitive development"],
    ["Iron studies", "Ferritin, serum iron, TIBC", "Iron deficiency anaemia very common"],
    ["Vision & hearing", "Ophthalmology + audiology referral", "Missed in country of origin; critical for development"],
    ["Developmental screen", "ASQ, BAYLEY, or Griffiths (age-appropriate)", "Delays common especially from institutional care"],
  ]
);

contentSlide(pres, "Growth Assessment in Adopted Children", [
  "Growth charts: use WHO (0–2 yrs) then CDC (>2 yrs); note prior malnutrition",
  "Catch-up growth: most children show significant catch-up within 1–2 years in a nutritious, stimulating environment",
  "Stunting (height-for-age <−2 SD): longer the institutionalisation → more severe",
  "Weight-for-height may normalise faster than linear growth",
  "Head circumference: microcephaly or failure to grow may indicate prenatal alcohol exposure (FAS)",
  "Bone age X-ray (non-dominant hand): helps estimate true age when records are absent",
  "Skin-fold thickness: nutritional reserve assessment",
  "Growth hormone axis: secondary GH deficiency from psychosocial deprivation – reversible with adequate care",
  "Meta-analysis (Leroy et al., Adv Nutr 2025): adoption or foster placement associated with significant catch-up in linear growth vs. continued institutionalisation",
]);

contentSlide(pres, "Special Screening Considerations", [
  "Fetal Alcohol Spectrum Disorder (FASD):",
  { text: "Suspect if: microcephaly, smooth philtrum, thin upper lip, short palpebral fissures, growth restriction" },
  { text: "FASD affects ~1–5% internationally adopted children; under-diagnosed" },
  { text: "Requires multidisciplinary neurodevelopmental assessment" },
  "Prenatal drug exposure: screen urine/hair toxicology if suspected; obtain birth history",
  "Sexually transmitted infections: consider if history of abuse or commercial exploitation",
  "Dental exam: often neglected; dental caries, enamel defects common",
  "Neurodevelopmental review: developmental paediatrician referral within first 3–6 months",
  "Mental health baseline: depression/anxiety screening in older adoptees; ACEs assessment",
  "Immunisation review:",
  { text: "Accept documented schedules that conform to US/UK schedule (month + year recorded)" },
  { text: "If uncertain: re-immunise OR check serological titres for MMR, hepatitis B, varicella" },
]);

// ════════════════════════════════════════════════════════════
//  SECTION 3 – DEVELOPMENTAL & BEHAVIOURAL
// ════════════════════════════════════════════════════════════
sectionDivider(pres, "3", "Developmental & Behavioural Issues", "Attachment · ACEs · Mental health · Intervention");

contentSlide(pres, "Adversity Before Adoption – Key Concepts", [
  "Adverse Childhood Experiences (ACEs): abuse, neglect, parental mental illness, substance use, poverty",
  "Institutionalisation effects:",
  { text: "Cognitive delays proportional to duration of institutional care" },
  { text: "Language delays: most common developmental finding" },
  { text: "Sensory-seeking or self-stimulatory behaviour (adaptive in institution → maladaptive at home)" },
  "Toxic stress: persistent activation of stress response → structural brain changes (HPA axis dysregulation)",
  "Parental neglect & inability to provide care: most common current reason for removal",
  "Historical causes: parental death/illness, poverty → today: drug/alcohol abuse, domestic violence",
  "50–60% of children in foster care meet criteria for at least one psychiatric disorder (systematic review data)",
  "Adopted children generally show better outcomes than those remaining in foster care",
]);

contentSlide(pres, "Attachment Theory & Reactive Attachment Disorder", [
  "Bowlby's attachment theory: secure base needed for exploration and healthy development",
  "Secure attachment develops from consistent, responsive caregiving in the first 3 years",
  "Disrupted attachment: multiple caregivers, emotional unavailability, trauma, neglect",
  "Reactive Attachment Disorder (RAD) – DSM-5 Criteria:",
  { text: "Inhibited type: emotionally withdrawn, minimal social engagement, positive affect, irritability" },
  { text: "Disinhibited type (DSED): indiscriminate social engagement; approaches unfamiliar adults freely" },
  { text: "Must have experienced social neglect as a necessary (not sufficient) cause" },
  { text: "Onset before age 5; not explained by ASD" },
  "Prevalence: RAD in ~1.5–2% adopted children; DSED more common post-institutionalisation",
  "Key clinical distinction: DSED ≠ ADHD (not impulsive in non-social domains)",
  "Treatment: relationship-focused parenting, dyadic therapy, NOT coercive 'rebirthing' therapies",
]);

contentSlide(pres, "Developmental Delays in Adopted Children", [
  "Language delay: almost universal from institutionalised care; bilingual children may lag further initially",
  "Cognitive development:",
  { text: "IQ typically lower in internationally adopted vs. domestic peers initially" },
  { text: "Significant recovery possible with early, enriched educational environment" },
  "Motor delay: global in severely deprived infants; physiotherapy usually effective",
  "Social-emotional development:",
  { text: "Difficulties reading emotions in others → missed social cues → peer relationship problems" },
  { text: "Emotional dysregulation common; may present as aggression or mood swings" },
  "Sensory processing difficulties: tactile sensitivity, food texture issues, sound hypersensitivity",
  "School readiness: many need Individual Education Plans (IEPs); early referral to educational psychology",
  "Neurodevelopmental diagnoses to consider: ADHD, ASD, intellectual disability, DCD, learning disorders",
  "Referral timeline: complete developmental assessment by 6 months post-adoption",
]);

contentSlide(pres, "Mental Health in Adopted Children", [
  "Overall mental health: better than children remaining in care; not equivalent to non-adopted peers",
  "Internalising disorders: depression, anxiety, somatic complaints – particularly in internationally adopted adolescents",
  "Externalising disorders: ADHD, conduct disorder, oppositional defiant disorder",
  "Identity development challenges:",
  { text: "Transracially adopted adolescents may face racial identity struggles and discrimination" },
  { text: "Search for birth family is normal developmental task – not pathological" },
  { text: "Need for information about birth heritage should be proactively supported" },
  "Trauma & PTSD:",
  { text: "Complex/developmental trauma: not always meeting full PTSD criteria but pervasive effects" },
  { text: "Trauma-informed care (TIC) framework should guide all interactions" },
  "Psychotropic medication: disproportionately high in foster care – requires careful oversight",
  "Meta-analysis (Askeland et al., 2017): higher rates of anxiety and depression in internationally adopted adolescents",
]);

twoColSlide(pres,
  "Behavioural Presentations – Red Flags vs. Normal Adjustment",
  "Expected Adjustment Behaviours",
  [
    "Regression (bed-wetting, thumb sucking) in first months",
    "Clinginess or separation anxiety",
    "Grief and mourning for previous relationships",
    "Testing of new caregivers (normal attachment behaviour)",
    "Food hoarding or over-eating (learned survival behaviour)",
    "Language switch difficulties (international)",
    "Most resolve within 6–12 months with consistent care",
  ],
  "Red Flags Needing Assessment",
  [
    "Persistent indiscriminate affection with strangers (DSED)",
    "No response to comfort when distressed after 6+ months",
    "Severe self-injurious behaviour",
    "Persistent violent tantrums beyond age-appropriate",
    "Complete social withdrawal or mutism",
    "Regression lasting >12 months",
    "Disclosure of abuse or sexual behaviour concerns",
  ],
  "2A4A6A", C.teal
);

contentSlide(pres, "The AAP Approach – Comprehensive Health Evaluation", [
  "AAP Clinical Report (Jones et al., Pediatrics 2019): gold standard for newly adopted children",
  "Visit 1 (within 2 weeks of placement): urgent medical concerns, initial relationship building",
  "Complete evaluation within 1 month:",
  { text: "Full medical history (from records + adoptive family + child if able)" },
  { text: "Physical exam including growth parameters, dysmorphic features, skin, dentition" },
  { text: "Development: formal screening tool (ASQ-3, PEDS)" },
  { text: "Behavioural/emotional screen (CBCL, SDQ for age ≥4)" },
  { text: "Vision, hearing, dentistry referrals" },
  { text: "All indicated laboratory & infectious disease screening" },
  "Ongoing: annual visits + as needed; trauma-informed approach throughout",
  "AAP Council on Foster Care, Adoption, and Kinship Care: key resource for protocols",
  "Paediatric adoption medicine clinics: specialist resource for complex presentations",
]);

// ════════════════════════════════════════════════════════════
//  SECTION 4 – LEGAL & ETHICAL
// ════════════════════════════════════════════════════════════
sectionDivider(pres, "4", "Legal & Ethical Framework", "Consent · Confidentiality · International adoption · Child safeguarding");

contentSlide(pres, "Legal Framework – Domestic Adoption", [
  "Best interests of the child: primary legal standard in all jurisdictions",
  "Parental rights termination (TPR): court order required before adoption can proceed",
  "Consent to adoption:",
  { text: "Birth mother: minimum waiting period after birth (24–72 hrs in most US states) before consent valid" },
  { text: "Birth father: putative father registries vary by state; unknown father has limited protections" },
  { text: "Child: older children (typically ≥12–14 yrs) must consent in many jurisdictions" },
  "Home study: mandatory assessment of prospective adoptive family (background checks, interviews, home inspection)",
  "Interstate Compact on the Placement of Children (ICPC): governs cross-state placements",
  "Adoption finalisation: court hearing; usually 6–12 months post-placement",
  "Post-adoption: child has full inheritance rights; original birth certificate may be sealed",
  "Indian Child Welfare Act (ICWA): tribal court involvement required; placement preferences (Native family first)",
]);

contentSlide(pres, "International Adoption – Hague Convention", [
  "Hague Convention on Intercountry Adoption (1993): protects against child trafficking, sale, abduction",
  "86+ signatory countries; US acceded 2008",
  "Key Hague requirements:",
  { text: "Child genuinely orphaned or relinquished with full informed consent" },
  { text: "Domestic adoption options exhausted first (subsidiarity principle)" },
  { text: "Accredited adoption service providers (ASPs) only" },
  { text: "Immigration visa (IR-3 or IR-4) required for US entry" },
  "Non-Hague countries: different rules; more risk; due diligence critical",
  "Medical exam pre-departure: US Dept. of State physician – communicable disease + mental health screen only",
  "Child Citizenship Act 2000: child automatically becomes US citizen upon IR-3 visa issuance",
  "Common source countries (currently): Colombia, South Korea, India, Philippines, China (declining)",
  "Prohibited: Guatemala, Cambodia, Nepal (trafficking concerns); Russia (political moratorium)",
]);

contentSlide(pres, "Confidentiality & Medical Records", [
  "Adopted children's medical records: often incomplete, inaccurate, or absent",
  "Disclosure to adoptive parents:",
  { text: "All known medical/genetic information MUST be disclosed before adoption" },
  { text: "Non-disclosure of known conditions is grounds for annulment in some jurisdictions" },
  "Genetic information: Kaplan & Sadock note adoption as setting where genetic disorders may emerge",
  { text: "Family history of hereditary conditions: should inform screening/surveillance" },
  { text: "Consider genetic counselling if birth family history of single-gene disorder, chromosomal condition, or hereditary cancer" },
  "Access to original birth certificates:",
  { text: "Varies by state: 8 states have complete open access; others require petition" },
  { text: "DNA testing (direct-to-consumer) has transformed birth family search" },
  "Confidentiality in clinical care: adoptees have full rights to their own records at age of majority",
  "Clinician role: support identity search as healthy developmental process, not pathology",
]);

twoColSlide(pres,
  "Ethical Issues in Adoption",
  "Ethical Principles",
  [
    "Child's best interest overrides adult desires",
    "Non-maleficence: avoid unnecessary medical testing/labelling",
    "Respect for birth parent autonomy & informed consent",
    "Justice: equitable access to adoption services regardless of race, sexuality, religion",
    "Cultural preservation: transracial adoption + cultural identity support",
    "Subsidiarity: domestic placement before international adoption",
  ],
  "Common Ethical Dilemmas",
  [
    "Should known HIV status of birth parent be disclosed pre-adoption?",
    "Medical experimentation in foster care populations",
    "'Medical special needs' labelling: stigmatising vs. enabling resources",
    "LGBTQ+ prospective adopters: discrimination in some agencies",
    "Intercountry adoption vs. in-country poverty alleviation",
    "Pressure on vulnerable birth mothers to relinquish",
  ],
  "2A3A5A", "8B4513"
);

contentSlide(pres, "Child Safeguarding in the Adoption Context", [
  "Mandatory reporting: adoption professionals and healthcare workers are mandated reporters",
  "Pre-adoption: paediatrician may be first to identify abuse/neglect in foster/institutional setting",
  "Post-adoption abuse: rare but documented; newly placed children may be at elevated risk",
  "Indicators of abuse in newly adopted children:",
  { text: "Unexplained injuries, fearfulness, sexualised behaviour, dissociation" },
  { text: "Prior abuse may be unrecognised due to communication barriers (language, trust)" },
  "Child protection referral: when in doubt, refer; threshold is lower in this population",
  "Commercial Sexual Exploitation of Children (CSEC): risk for internationally adopted children from certain countries",
  "Inter-agency communication: paediatrician ↔ social worker ↔ mental health ↔ school is essential",
  "Documentation: meticulous records of all findings; photographs of physical findings with consent",
]);

// ════════════════════════════════════════════════════════════
//  SECTION 5 – CLINICAL CASES
// ════════════════════════════════════════════════════════════
sectionDivider(pres, "5", "Clinical Cases", "Three case scenarios for discussion");

caseSlide(pres, 1,
  "Mei Lin is a 3-year-old girl adopted from China 2 months ago. Her adoptive parents report she eats voraciously, hoards food in her room, and has frequent tantrums lasting 30–45 minutes. She does not speak English yet and rarely makes eye contact with either parent. She seems happy with strangers and will climb onto any adult's lap. On examination: weight 10th centile, height <3rd centile. Head circumference 2nd centile. Mild smooth philtrum and thin upper lip noted.",
  [
    "What screening investigations would you order at this visit?",
    "What developmental concerns does this presentation raise? What formal tools would you use?",
    "How would you counsel the parents about the food hoarding and indiscriminate affection behaviours?",
    "What is your differential for the dysmorphic facial features? How does this change your management?",
  ]
);

caseSlide(pres, 2,
  "Jaylen is a 7-year-old boy who has been in foster care for 4 years after removal due to parental methamphetamine use and neglect. He is referred to your clinic by his foster carer who reports he is being expelled from school for aggression toward peers and teachers. He has a diagnosis of ADHD and is on methylphenidate 10mg BD. His foster carer also mentions he is seeing 3 different specialists and taking 4 medications total.",
  [
    "How do you approach the polypharmacy issue in a foster care child?",
    "What trauma-informed assessment would you perform?",
    "What is your differential for his school behaviour? What is the role of FASD in this case?",
    "What advocacy role does the paediatrician have in this child's educational and placement needs?",
  ]
);

caseSlide(pres, 3,
  "The Chen family are prospective adoptive parents who come to see you before travel to collect their 18-month-old son from an orphanage in Eastern Europe. They bring a translated medical summary indicating he was born at 34 weeks, had a head ultrasound 'with small changes' at day 3, and received 'standard immunisations'. The birth mother's history is unknown. They ask what you would advise them to do before travel, what to watch for on arrival, and what tests he will need.",
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    "What additional information would you try to obtain before they travel?",
    "Design a post-arrival screening plan based on AAP/Red Book recommendations.",
    "What does 'small changes on head ultrasound' potentially represent? How does this inform neurodevelopmental monitoring?",
  ]
);

// ════════════════════════════════════════════════════════════
//  SECTION 6 – SUMMARY
// ════════════════════════════════════════════════════════════
sectionDivider(pres, "6", "Take-Home Points & Resources", "Summary · Guidelines · Referral pathways");

contentSlide(pres, "Key Take-Home Points", [
  "Adopted children represent a vulnerable population with complex medical, developmental, and psychosocial needs",
  "Every newly adopted child needs a comprehensive health evaluation within the first month (AAP standard)",
  "International adoptees require systematic infectious disease, growth, and developmental screening",
  "Early adversity and institutionalisation have measurable effects on brain development – but significant recovery is possible",
  "Reactive Attachment Disorder and DSED are specific diagnoses with specific criteria; don't over-label behaviour",
  "Trauma-informed care is not optional – it is the standard of care for this population",
  "Polypharmacy in foster/adopted children must be actively monitored and minimised",
  "Legal and ethical framework: always centre the best interests of the child",
  "The paediatrician is an advocate, not just a clinician – liaise with social work, education, mental health",
  "Support the adoptee's search for identity and birth heritage as a healthy developmental process",
]);

tableSlide(pres,
  "Key Guidelines & Resources",
  ["Resource", "Organisation", "Year", "Access"],
  [
    ["Comprehensive Health Evaluation of the Newly Adopted Child", "AAP (Jones et al.)", "2019", "Pediatrics 143(5)"],
    ["Health Care Issues for Children in Foster & Kinship Care", "AAP Council on Foster Care", "2015", "Pediatrics 136(4):e1142"],
    ["Red Book: Internationally Adopted Children (Section 2)", "AAP Committee on Infectious Diseases", "2021", "AAP Red Book Online"],
    ["Practice Parameter: Youth in Child Welfare System", "AACAP CQI (Lee et al.)", "2015", "JAACAP 54(6):502"],
    ["Hague Adoption Convention", "Hague Conference", "1993/2008", "hcch.net"],
    ["FASD Diagnostic Guidelines", "Canadian Diagnostic Guide", "2015", "cmaj.ca"],
    ["Fostering Connections / Family First Act Summary", "Child Welfare Information Gateway", "2018", "childwelfare.gov"],
    ["Trauma-Informed Care in Pediatric Settings", "NCTSN", "Ongoing", "nctsn.org"],
    ["Adoption and Genetic Disorders", "Emery's Medical Genetics 17e", "2022", "Kaplan & Sadock Ch 54.1"],
    ["Developmental Outcomes – Foster & Adopted Children (Mini-Review)", "Frontiers in Public Health", "2025", "PMC12894384"],
  ]
);

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// ── WRITE ────────────────────────────────────────────────────────────────────
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  .then(() => console.log("DONE: Adoption_Seminar_Paediatrics.pptx"))
  .catch(err => { console.error("ERROR:", err); process.exit(1); });

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pres.author = "Paediatric Residency Programme";
pres.title = "Adoption in Paediatrics – Resident Seminar (45 Slides)";
pres.subject = "Medical, Developmental & Legal Aspects of Adoption";

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  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:0.18, h:5.625, fill:{color:C.amber} });
  s.addText("Questions & Discussion", { x:0.5, y:1.2, w:9, h:1.1, fontSize:36, bold:true, color:C.white, fontFace:"Calibri", align:"center" });
  s.addText(
    "\"The best interests of the child are of paramount importance\"\n\u2014 UN Convention on the Rights of the Child, Article 3",
    { x:1, y:2.5, w:8, h:1.2, fontSize:16, italic:true, color:C.amber, fontFace:"Calibri", align:"center", wrap:true }
  );
  s.addText(
    "Sources: Kaplan & Sadock Comprehensive Psychiatry (2022)  \u00B7  AAP Red Book (2021)  \u00B7  AACAP Practice Parameters (2015)\nAAP Clinical Report: Newly Adopted Child (2019)  \u00B7  Emery\u2019s Medical Genetics (2022)  \u00B7  Front. Public Health (2025)",
    { x:0.5, y:4.7, w:9, h:0.6, fontSize:9, color:C.midGray, fontFace:"Calibri", align:"center" }
  );
}

// ══════════════════════════════════════════════════════
//  SLIDE COUNTER  (for reference only)
// ══════════════════════════════════════════════════════
// Target: 45 slides total
// 1  – Title
// 2  – Agenda
// 3  – Section 1 divider
// 4  – Definitions
// 5  – Types of Adoption
// 6  – Epidemiology stats
// 7  – Legal Milestones Timeline
// 8  – Open vs Closed
// 9  – Section 2 divider
// 10 – Pre-Adoption Medical Review
// 11 – Mandatory Screening Table
// 12 – Infectious Disease Detail
// 13 – Growth Assessment
// 14 – FASD – Diagnosis & Features
// 15 – Immunisation Review
// 16 – Section 3 divider
// 17 – Adversity Before Adoption
// 18 – Toxic Stress & Brain Development
// 19 – Attachment Theory & RAD
// 20 – RAD vs DSED Comparison
// 21 – Developmental Delays
// 22 – Language & Cognitive Development
// 23 – Mental Health in Adopted Children
// 24 – Identity Development in Adolescence
// 25 – Red Flags vs Adjustment (Two-col)
// 26 – AAP Comprehensive Health Evaluation
// 27 – Section 4 divider
// 28 – Domestic Legal Framework
// 29 – International Adoption & Hague Convention
// 30 – Confidentiality & Records
// 31 – Ethical Issues
// 32 – Child Safeguarding
// 33 – Section 5 divider
// 34 – Foster Care – History & Policy
// 35 – Foster Care Outcomes Data (Stats)
// 36 – Placement Stability & Disruption
// 37 – Kinship Care
// 38 – Ageing Out of Foster Care
// 39 – BIPOC Children in Foster Care
// 40 – Section 6 divider
// 41 – Case 1 (Infant, FAS features)
// 42 – Case 2 (School-age foster, polypharmacy)
// 43 – Case 3 (Pre-adoption counselling)
// 44 – Case 4 (Adolescent identity)
// 45 – Case 5 + Resources / Closing

// ═══════════════════════════════════════════════════
// BUILD
// ═══════════════════════════════════════════════════

// SLIDE 1 – Title
titleSlide(
  "Adoption in Paediatrics",
  "Medical Assessment · Developmental & Behavioural Issues · Legal & Ethical Framework · Foster Care"
);

// SLIDE 2 – Agenda
agendaSlide();

// ─────────────────────────────────────────────────────
// SECTION 1 – FOUNDATIONS
// ─────────────────────────────────────────────────────

// SLIDE 3
sectionDivider("1", "Foundations of Adoption", "History · Epidemiology · Types · Definitions");

// SLIDE 4
contentSlide("Definitions & Core Concepts", [
  "Adoption: permanent legal transfer of all parental rights & responsibilities to the adoptive parent(s)",
  "Foster care: temporary out-of-home placement – goal is family reunification when safe; NOT adoption",
  "Kinship care: placement with relatives or known adults; may progress to kinship adoption",
  "Open adoption: varying contact with birth family (letters, visits, calls)",
  { text: "Predefined structure for contact reduces anxiety for child and both families" },
  { text: "Research shows higher adoptive-parent comfort and greater empathy toward birth family" },
  "Closed (confidential) adoption: sealed records, no contact – increasingly rare",
  "Semi-open: agency-mediated indirect contact (letters/photos only)",
  "Transracial adoption: child of one racial/ethnic background placed with parents of another",
  "Embryo adoption: genetic donors differ from gestational and social parents – unique identity issues",
]);

// SLIDE 5
contentSlide("Types of Adoption", [
  "Domestic infant adoption: voluntary relinquishment soon after birth; largely private agency",
  "Foster-to-adopt: child placed in foster care → parental rights terminated → adoption; most common public route",
  "International (intercountry) adoption:",
  { text: "Governed by the Hague Convention (86+ signatory countries)" },
  { text: "Significant decline since ~2005 due to geopolitical shifts and child-trafficking concerns" },
  { text: "Special medical screening requirements on US/UK arrival" },
  "Kinship adoption: grandparent, aunt/uncle, or known family friend formally adopts",
  "Stepparent adoption: most common single type in the US; child acquires stepparent's legal parentage",
  "Special needs adoption: children with physical, cognitive, or emotional disabilities; state subsidies available",
  "LGBTQ+ adoption: legal in all 50 US states since 2015 (Obergefell); some agency-level discrimination remains",
  "Private independent adoption: attorney-facilitated; no agency involvement; higher ethical risk",
]);

// SLIDE 6 – Epidemiology stats
statSlide("Adoption by the Numbers", [
  { value: "2.5–3.5%", label: "of US population is adopted", color: C.teal },
  { value: "66,000+", label: "children adopted annually through US child welfare", color: C.navy },
  { value: "122,000", label: "children in foster care awaiting adoption", color: C.orange },
  { value: "424,000", label: "children in formal foster care at any time", color: "2A7A4B" },
  { value: "673,000", label: "children served by child welfare systems per year", color: C.purple },
  { value: "50-60%", label: "of children in foster care meet criteria for ≥1 psychiatric disorder", color: "8B4513" },
]);

// SLIDE 7
contentSlide("Legal Milestones in Adoption", [
  "1851 – Massachusetts Adoption of Children Act: first US law requiring judicial oversight & best-interest standard",
  "1935 – Title IV, Social Security Act: first federal child welfare funding (excluded minority families until Civil Rights era)",
  "1974 – Child Abuse Prevention & Treatment Act (CAPTA): funds prevention, investigation, treatment of maltreatment",
  "1980 – Adoption Assistance & Child Welfare Act: prevention of removal; 6-month review mandate; permanency planning",
  "1994 – Multiethnic Placement Act (MEPA): prohibited race-based delays in placement decisions",
  "1997 – Adoption & Safe Families Act (ASFA): 15/22-month rule → TPR and permanency hearing timelines",
  "2000 – Child Citizenship Act: automatic US citizenship for internationally adopted children on IR-3 visa",
  "2008 – Fostering Connections Act: kinship care supports; extended foster care to age 21",
  "2018 – Family First Prevention Services Act: prevention-first; limits congregate care; evidence-based services",
  "1978 – Indian Child Welfare Act (ICWA): tribal court involvement; placement preference hierarchy for Native children",
]);

// SLIDE 8
twoColSlide(
  "Open vs Closed Adoption – Evidence Summary",
  "Open Adoption – Evidence-based Benefits",
  [
    "Higher adoptive-parent comfort with the process",
    "Greater empathy toward birth family",
    "Children report less worry about birth parent safety",
    "Trust builds; fear of reunification reduces over time",
    "Helps child manage birth parent mental health disclosures",
    "Predictable contact structure lowers anxiety",
    "Agreed-upon boundaries give adoptive parents control",
    "Better long-term psychosocial identity outcomes",
  ],
  "Closed Adoption – Historical Rationale",
  [
    "Protect privacy; avoid stigma of illegitimacy",
    "Prevent adoptee identity confusion",
    "Adoptive parents feel fully legitimate",
    "Birth mother can grieve and move on",
    "Note: most evidence NOW favours some openness",
    "Sealed records still exist in many jurisdictions",
    "DNA testing (23andMe, AncestryDNA) has effectively ended true 'closed' adoption",
    "Open records laws expanding: 8 US states now fully open",
  ],
  C.navy, "1E6B7A"
);

// ─────────────────────────────────────────────────────
// SECTION 2 – MEDICAL ASSESSMENT
// ─────────────────────────────────────────────────────

// SLIDE 9
sectionDivider("2", "Medical Assessment of the Adopted Child", "Initial evaluation · Screening · Growth · Infectious disease");

// SLIDE 10
contentSlide("Pre-Adoption Medical Review", [
  "Families should see a paediatrician BEFORE travel to collect a child internationally",
  "Review all available records – quality is variable; often incomplete or inaccurate",
  "Advise family on pre-travel vaccinations for destination country",
  "Protect family & community: pertussis and influenza boosters for all household contacts",
  "Protect child from family exposures: hepatitis A screening for family members",
  "US Department of State pre-departure exam: NOT comprehensive",
  { text: "Limited to immigration communicable disease screening only" },
  { text: "Examines for serious physical/mental disorders preventing visa issuance" },
  { text: "Does NOT constitute a comprehensive paediatric assessment" },
  "Refer to AAP Adoption Medicine Clinics for complex pre-disclosed medical histories",
  "Schedule post-arrival appointment within 2 weeks of placement (AAP recommendation)",
  "Source: AAP Red Book 2021; AAP Clinical Report on Newly Adopted Child (2019)",
]);

// SLIDE 11
tableSlide(
  "Mandatory Screening – Internationally Adopted Children (AAP/Red Book)",
  ["System / Condition", "Recommended Test(s)", "Rationale"],
  [
    ["HIV (1 & 2)", "4th-generation Ag/Ab combination assay", "Prevalence varies by country; institutional exposure risk"],
    ["Hepatitis B", "HBsAg, anti-HBs, anti-HBc (total)", "Inconsistent perinatal screening & birth-dose vaccination"],
    ["Hepatitis C", "Anti-HCV antibody", "Medical procedure exposure; institutional risk"],
    ["Syphilis", "RPR/VDRL + confirmatory treponemal test", "High prevalence in source countries; may be latent/congenital"],
    ["Tuberculosis", "IGRA (preferred ≥2 yrs); TST if IGRA unavailable", "TB endemic; BCG may cause false-positive TST"],
    ["Intestinal parasites", "3× stool O&P + Giardia/Cryptosporidium EIA", "Very common in institutional settings; often asymptomatic"],
    ["Lead", "Whole-blood lead level", "Lead exposure common; neurotoxic; cognitive risk"],
    ["Anaemia / CBC", "FBC with differential, iron studies, ferritin", "Iron deficiency anaemia extremely common"],
    ["Thyroid", "TSH (free T4 if abnormal)", "Iodine deficiency common; affects cognitive development"],
    ["Developmental screen", "ASQ-3 / Bayley / Griffiths (age-appropriate)", "Delays common; baseline essential"],
    ["Vision & hearing", "Ophthalmology + audiology referral", "Frequently missed in country of origin"],
    ["Dental", "Dental exam within 6 months", "Dental caries and enamel defects very common"],
  ]
);

// SLIDE 12
contentSlide("Infectious Disease – Key Considerations", [
  "Hepatitis B: most important blood-borne infection in internationally adopted children",
  { text: "HBsAg-positive child: refer to paediatric gastroenterology/hepatology; household contacts need vaccination" },
  { text: "Anti-HBs alone without anti-HBc: likely vaccine-induced; may need booster" },
  "Tuberculosis:",
  { text: "IGRA preferred over TST in BCG-vaccinated children aged ≥2 years (avoids false positives)" },
  { text: "TST ≥10 mm or positive IGRA: chest X-ray; treat latent TB per guidelines even if asymptomatic" },
  "Intestinal parasites: treat empirically with albendazole if stool O&P is negative but origin is high-prevalence country",
  "Malaria: consider if origin is malaria-endemic country AND child has fever within 3 months of arrival",
  "Chagas disease (T. cruzi): consider serology if origin is Latin America",
  "HIV: re-test at 3 months if high-risk origin (window period); disclose status to adoptive family",
  "All household contacts: check immunisation status and update; pertussis and influenza particularly important",
]);

// SLIDE 13
contentSlide("Growth Assessment", [
  "Use WHO charts (0–2 yrs) then CDC charts (>2 yrs); note pre-adoption malnutrition context",
  "Catch-up growth: most children show significant recovery within 1–2 years in a nurturing home",
  { text: "Meta-analysis (Leroy et al., Adv Nutr 2025): significant catch-up in linear growth with adoption vs. continued institutionalisation" },
  "Stunting (height-for-age <-2 SD): duration of institutionalisation is the strongest predictor",
  "Weight normalises faster than linear growth; head circumference slowest to recover",
  "Head circumference <2nd centile: consider FASD, congenital infection, genetic syndrome",
  "Bone age X-ray (non-dominant wrist): estimates true age when records are unreliable or absent",
  "Secondary psychosocial growth hormone deficiency:",
  { text: "Emotional deprivation suppresses GH pulsatility → linear growth failure" },
  { text: "Fully reversible with adequate care and emotional stimulation; GH replacement rarely needed" },
  "Nutritional assessment: 24-hour dietary recall, skin-fold thickness, micronutrient screening (Vit D, zinc, B12)",
  "Obesity risk: post-institutional children may over-eat due to food insecurity → monitor weight trajectory",
]);

// SLIDE 14
contentSlide("Fetal Alcohol Spectrum Disorder (FASD)", [
  "FASD: umbrella term covering FAS, partial FAS (pFAS), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD)",
  "Estimated prevalence in internationally adopted children: 1–5%; higher in Eastern European adoptees",
  "FAS requires ALL of: prenatal alcohol exposure + facial features + growth deficiency + CNS abnormalities",
  "Facial features (≥2 required for FAS/pFAS):",
  { text: "Short palpebral fissures (≤10th centile)" },
  { text: "Smooth philtrum (rank 4–5 on Lip-Philtrum Guide)" },
  { text: "Thin vermilion border of upper lip (rank 4–5)" },
  "Growth: height or weight ≤10th centile (pre- or postnatal)",
  "CNS: head circumference ≤10th centile; structural brain abnormalities; recurrent non-febrile seizures",
  "Neurobehavioral impairment (ARND): IQ ≥1.5 SD below mean OR specific domain deficits (executive function, memory, attention, language)",
  "ARND: no facial features required; neurobehavioural impairment is sufficient with documented prenatal exposure",
  "Management: multidisciplinary team; IEP support; stimulant medications for ADHD features; caregiver coaching",
  "Source: Kaplan & Sadock 2022; Hoyme et al. Diagnostic Criteria; Langman's Embryology",
]);

// SLIDE 15
contentSlide("Immunisation Review for Adopted Children", [
  "Accept written records with month + year of administration that conform to US/UK schedule",
  "If records are absent, undated, or doses appear outside recommended age ranges:",
  { text: "Option 1: Re-immunise from the beginning (safe; no evidence of harm from extra doses)" },
  { text: "Option 2: Check serological titres for MMR, Hepatitis B, Varicella – act on results" },
  "BCG scar: evidence of BCG vaccination; note for TB interpretation (does NOT confer reliable TB protection)",
  "Hepatitis A: check serology; internationally adopted children from endemic regions may be immune",
  "Common gaps found: 2nd MMR dose, 4th DTaP, Hib, PCV13, Varicella",
  "Catch-up schedule: follow CDC/AAP accelerated catch-up tables; minimum intervals apply",
  "Travel vaccines for family: Hepatitis A + B, Typhoid, Yellow Fever (if applicable), Rabies pre-exposure (selected)",
  "COVID-19 vaccination: catch-up per current CDC schedule if not completed",
  "Document all immunisations given in your clinic in a single consolidated record for the family",
]);

// ─────────────────────────────────────────────────────
// SECTION 3 – DEVELOPMENTAL & BEHAVIOURAL
// ─────────────────────────────────────────────────────

// SLIDE 16
sectionDivider("3", "Developmental & Behavioural Issues", "Attachment · ACEs · Delays · Mental health · Intervention");

// SLIDE 17
contentSlide("Adversity Before Adoption – Key Concepts", [
  "Adverse Childhood Experiences (ACEs): abuse (physical, emotional, sexual), neglect, parental substance use, domestic violence, parental mental illness, poverty, incarceration",
  "Dose-response relationship: number of ACEs correlates with health outcomes (CDC-Kaiser study)",
  "Institutionalisation effects are well-documented:",
  { text: "Global developmental delays proportional to duration in institutional care" },
  { text: "Language delay: most universal finding in post-institutional children" },
  { text: "Stereotypies and self-stimulatory behaviours (adaptive in institution → maladaptive at home)" },
  "Most common current reasons for removal: parental drug/alcohol abuse, neglect, inability to provide care",
  "Historical causes (pre-1980s): poverty, parental death/incapacitating illness",
  "Trauma types: single-incident (Type I) vs. complex/developmental (Type II): multiple, chronic, interpersonal",
  "Complex trauma in young children: pervasive effects on self-regulation, cognition, and relationships",
  "50–60% of children in foster care meet criteria for ≥1 psychiatric disorder (systematic review data, 2024)",
]);

// SLIDE 18
contentSlide("Toxic Stress & Brain Development", [
  "Toxic stress: prolonged activation of the stress response system without adequate adult buffering",
  "HPA axis dysregulation: abnormal cortisol patterns – hyper- or hypo-responsiveness; persists into adulthood",
  "Structural brain effects:",
  { text: "Smaller hippocampal volume: impairs learning, memory, emotional regulation" },
  { text: "Prefrontal cortex: reduced grey matter density → executive function deficits" },
  { text: "Amygdala hyperreactivity: exaggerated fear response; hypervigilance" },
  "Sensitive periods: first 1,000 days most critical (conception to age 2); effects greatest in early life adversity",
  "Epigenetic changes: methylation patterns altered by early adversity → gene expression changes",
  "Protective factors that buffer toxic stress:",
  { text: "Consistent, sensitive caregiver (even one is sufficient)" },
  { text: "Stable, predictable routines" },
  { text: "Access to play, language-rich environment, adequate nutrition" },
  "Neuroplasticity: significant recovery possible even after severe early adversity when placed in nurturing home",
  "Implication for clinical practice: trauma-informed care is mandatory, not optional",
]);

// SLIDE 19
contentSlide("Attachment Theory & Its Clinical Relevance", [
  "Bowlby: children are biologically primed to seek proximity to a caregiver (attachment figure) under threat",
  "Ainsworth: Strange Situation Procedure identified 4 attachment patterns:",
  { text: "Secure (Type B): uses caregiver as safe base; distressed at separation; quickly comforted" },
  { text: "Insecure-avoidant (Type A): minimises attachment behaviour; appears independent" },
  { text: "Insecure-ambivalent/resistant (Type C): maximises attachment; difficult to soothe" },
  { text: "Disorganised (Type D): no coherent strategy; most strongly associated with abuse/neglect" },
  "Disorganised attachment is the strongest attachment predictor of later psychopathology",
  "Internal working models: mental representations of self and others formed from early attachment experiences",
  "Clinical implications:",
  { text: "Children may test new caregivers ('does this adult really mean it?')" },
  { text: "Therapeutic response: predictable, warm, non-reactive parenting" },
  { text: "Avoid punitive or coercive approaches in children with attachment difficulties" },
  "Source: Kaplan & Sadock 2022, Chapter 54.1",
]);

// SLIDE 20
twoColSlide(
  "Reactive Attachment Disorder (RAD) vs. DSED – DSM-5",
  "Reactive Attachment Disorder (RAD)",
  [
    "Inhibited/emotionally withdrawn pattern",
    "Rarely seeks or responds to comfort",
    "Minimal social and emotional responsiveness",
    "Positive affect markedly limited",
    "Irritability, sadness, fearfulness even without threat",
    "Must have history of severe social neglect",
    "Onset before age 5 (must show by age 9 months)",
    "Not better explained by ASD or intellectual disability",
    "Treatment: relationship-focused parenting; dyadic therapy",
  ],
  "Disinhibited Social Engagement Disorder (DSED)",
  [
    "Disinhibited, overfamiliar pattern",
    "Reduced reticence with unfamiliar adults",
    "Overly familiar verbal or physical behaviour",
    "Diminished checking back with caregiver in unfamiliar settings",
    "Willingness to go off with strangers",
    "May persist even after attachment security established",
    "More common after institutional care",
    "May co-occur with ADHD but is NOT ADHD",
    "Treatment: caregiver coaching; consistent routines; patience",
  ],
  "2A3D5A", C.teal
);

// SLIDE 21
contentSlide("Developmental Delays – Assessment & Management", [
  "Language delay: almost universal after institutional care; bilingual exposure may cause additional initial lag",
  { text: "Screen with ASQ-3 (Communication domain) at every visit; refer speech therapy early (don't wait)" },
  "Cognitive development: IQ typically lower in post-institutionalised vs. domestic peers initially",
  { text: "Significant IQ recovery possible with enriched, stimulating home and educational environment" },
  "Gross motor delay: global in severely deprived infants; physiotherapy usually effective within months",
  "Fine motor and sensory processing: tactile sensitivity, food texture issues, sound hypersensitivity common",
  "Social-emotional development:",
  { text: "Difficulty reading others' emotions → missed social cues → peer relationship problems" },
  { text: "Emotional dysregulation: aggressive outbursts or withdrawal; not 'naughtiness' – it is dysregulation" },
  "Formal developmental assessment by developmental paediatrician: within 6 months of placement (AAP)",
  "Educational psychology referral: most post-institutional children benefit from IEP or equivalent plan",
  "Neurodevelopmental differential: ADHD, ASD, intellectual disability, DCD, specific learning disorders",
  "Watchful waiting is NOT appropriate – early intervention yields the greatest benefit (neuroplasticity window)",
]);

// SLIDE 22
contentSlide("Language & Cognitive Development in Adopted Children", [
  "Language is the most sensitive marker of institutionalisation effects",
  "International adoptees face dual challenge: first language attrition + second language acquisition",
  "First language attrition: rapid within first 3–6 months in new environment (especially children <3 yrs)",
  "Second language acquisition: most children achieve conversational fluency within 1–2 years",
  { text: "Academic language (CALP) takes 5–7 years – much longer than social language" },
  { text: "Teachers may misjudge child as having resolved language issues when academic gap persists" },
  "Bilingual testing: use language-independent tests (non-verbal IQ, Leiter, WNV) during transition period",
  "Reading difficulties: common even after oral language recovers; phonological processing deficits",
  "Executive function deficits (working memory, inhibitory control, cognitive flexibility): very common",
  { text: "Often more impaired than IQ scores suggest" },
  { text: "Directly interferes with classroom learning independent of cognitive ability" },
  "School-based support: speech-language pathology + educational psychology collaboration is key",
  "Parental coaching: language-rich home environment; reading aloud; avoiding screen overuse",
]);

// SLIDE 23
contentSlide("Mental Health in Adopted Children", [
  "Adopted children show better mental health than children remaining in foster care",
  "However, rates of psychiatric disorder remain higher than non-adopted peers",
  "Internalising disorders: depression, anxiety, somatic complaints; particularly common in internationally adopted adolescents",
  { text: "Meta-analysis (Askeland et al., JAACAP 2017): significantly elevated rates of anxiety and depression" },
  "Externalising disorders: ADHD (most common), conduct disorder, oppositional defiant disorder",
  { text: "ADHD prevalence 2–3× higher in adopted vs. non-adopted populations" },
  "Post-traumatic presentations: hypervigilance, startle response, flashbacks, sleep disturbances, dissociation",
  "Complex/developmental trauma: pervasive effects not always meeting full DSM PTSD criteria",
  "Suicide risk: elevated in adopted adolescents – enquire directly; do not assume protective factors are sufficient",
  "Psychosis: slightly elevated lifetime risk in internationally adopted individuals (reasons unclear)",
  "Substance use: higher rates in former foster youth; monitor in adolescence",
  "Psychotropic medication: disproportionately high in foster care; requires careful oversight and regular review",
]);

// SLIDE 24
contentSlide("Identity Development in Adopted Adolescents", [
  "Erikson: adolescence = identity vs. role confusion; all adolescents face this; adopted teens face it with additional layers",
  "Adoptee identity tasks:",
  { text: "Integration of adoption story into self-narrative" },
  { text: "Making meaning of birth parent relinquishment ('why was I given up?')" },
  { text: "Managing curiosity about birth heritage, medical history, genetics" },
  "Search for birth family: NORMAL developmental task – do not pathologise; support proactively",
  "DNA testing: increasingly common; paediatrician should prepare family for unexpected discoveries (half-siblings, misattributed paternity)",
  "Transracial adoptees:",
  { text: "Face racial identity development AND adoptee identity simultaneously" },
  { text: "May experience racial discrimination that adoptive parents do not fully understand" },
  { text: "Benefit from cultural connections, same-race mentors, heritage camp participation" },
  "International adoptees: cultural identity loss; grief about origin country language and culture",
  "Disclosure of adoption: evidence strongly supports early, age-appropriate, honest disclosure",
  { text: "Children told before age 5 have better psychological adjustment than those told later" },
  "Clinician role: normalise identity questions; refer to adoption-competent therapists if distress is significant",
]);

// SLIDE 25
twoColSlide(
  "Behavioural Presentations – Red Flags vs. Expected Adjustment",
  "Expected Adjustment (First 6–12 Months)",
  [
    "Regression (bed-wetting, thumb sucking)",
    "Clinginess and separation anxiety",
    "Grief and mourning for previous relationships",
    "Testing caregiver boundaries (normal attachment behaviour)",
    "Food hoarding or over-eating",
    "Difficulty with transitions and change in routine",
    "Language-related frustration behaviours",
    "Night terrors, nightmares",
    "Most resolve with consistent, nurturing care",
  ],
  "Red Flags – Refer for Assessment",
  [
    "Persistent indiscriminate affection with all strangers",
    "No response to comfort after 6+ months",
    "Severe self-injurious behaviour",
    "Violent tantrums beyond expected developmental range",
    "Complete social withdrawal or selective mutism",
    "Regression lasting beyond 12 months",
    "Sexualised behaviour inconsistent with age",
    "Dissociative episodes",
    "Expressed wish to die or suicidal ideation",
  ],
  "2A4A6A", "8B2020"
);

// SLIDE 26
contentSlide("AAP Comprehensive Health Evaluation – Protocol", [
  "AAP Clinical Report (Jones et al., Pediatrics 2019): gold standard for newly adopted children",
  "Visit 1 – within 2 weeks of placement:",
  { text: "Urgent medical issues; initial relationship building; reassure and orient family" },
  { text: "Begin infectious disease screening; check for immediately actionable concerns" },
  "Complete evaluation – within 1 month:",
  { text: "Full medical history (records + adoptive family + child if age-appropriate)" },
  { text: "Complete physical exam: growth, dysmorphic features, skin, eyes, ears, dentition, genitalia" },
  { text: "Formal developmental screening: ASQ-3 (all domains) or PEDS" },
  { text: "Behavioural/emotional screen: CBCL (1.5–5 yr or 6–18 yr), SDQ (age ≥4)" },
  { text: "Vision (Lea symbols/Cardiff cards) and hearing (pure-tone audiometry if >3 yrs)" },
  { text: "All indicated laboratory and infectious disease screening" },
  "Follow-up: 1 month, 3 months, 6 months post-adoption, then annually",
  "Developmental paediatrics referral: within 6 months for all post-institutional adoptees",
  "Trauma-informed approach throughout: avoid exposing, re-traumatising examinations without trust-building",
]);

// ─────────────────────────────────────────────────────
// SECTION 4 – LEGAL & ETHICAL
// ─────────────────────────────────────────────────────

// SLIDE 27
sectionDivider("4", "Legal & Ethical Framework", "Consent · Confidentiality · Hague Convention · Safeguarding");

// SLIDE 28
contentSlide("Domestic Legal Framework", [
  "Best interests of the child: primary legal standard in all jurisdictions (UN CRC Article 3; all US state laws)",
  "Parental rights termination (TPR): court order required; grounds include abuse, neglect, abandonment, long-term incapacity",
  "Consent to adoption:",
  { text: "Birth mother: minimum waiting period (24–72 hrs post-birth in most US states) before consent is valid" },
  { text: "Birth father: putative father registries vary by state; legal protections limited for unknown fathers" },
  { text: "Child: most US states require consent for children aged ≥12–14 years" },
  "Home study: mandatory pre-placement assessment (background checks, interviews, home inspection, financial review)",
  "Interstate Compact on Placement of Children (ICPC): governs every cross-state placement; both states must approve",
  "Post-placement supervisory visits: social worker visits typically required for 6–12 months before finalisation",
  "Adoption finalisation: court hearing; child receives new birth certificate; full inheritance rights",
  "Indian Child Welfare Act (ICWA 1978): tribal court involvement required; placement preference hierarchy (tribal family first)",
  "Re-adoption: recommended after international adoption to obtain US birth certificate; protects citizenship",
]);

// SLIDE 29
contentSlide("International Adoption & the Hague Convention", [
  "Hague Convention on Intercountry Adoption (HCCH, 1993): protects against child trafficking, sale, and abduction",
  "86+ signatory countries; United States acceded in 2008",
  "Core Hague principles:",
  { text: "Subsidiarity: domestic placement options must be exhausted before international adoption" },
  { text: "Child genuinely orphaned or relinquished with full, informed, unpressured consent" },
  { text: "Accredited Adoption Service Providers (ASPs) only; strict financial controls" },
  { text: "Central Authority in each country oversees the process" },
  "Non-Hague countries: different legal frameworks; higher ethical risk; due diligence critical",
  "US immigration visas:",
  { text: "IR-3: both adoptive parents saw child before adoption – automatic US citizenship on entry" },
  { text: "IR-4: adoption completed in US after child arrives – re-adoption required" },
  "Currently active sending countries: Colombia, South Korea, India, Philippines, China (declining)",
  "Prohibited/suspended: Guatemala, Cambodia, Nepal (trafficking); Russia (political moratorium since 2012)",
  "Medical exam pre-departure (US Dept. of State designated physician): communicable disease + visa screen only; NOT comprehensive",
]);

// SLIDE 30
contentSlide("Confidentiality & Medical Records in Adoption", [
  "Adopted children's medical records: often incomplete, inaccurate, or entirely absent",
  "Pre-adoption disclosure obligations:",
  { text: "All KNOWN medical, genetic, and psychosocial information MUST be disclosed to prospective adoptive parents" },
  { text: "Non-disclosure of known conditions: grounds for reversal of adoption in some jurisdictions" },
  "Genetic information:",
  { text: "Kaplan & Sadock (2022): adoption is a common setting where genetic disorders first present clinically" },
  { text: "Known hereditary conditions in birth family must be disclosed; genetic counselling offered" },
  { text: "Direct-to-consumer DNA testing has transformed the landscape of birth family discovery" },
  "Access to original birth certificates:",
  { text: "Varies by US state: 8 states have complete open access; others require petition or court order" },
  { text: "UK: adopted adults (age ≥18) have a statutory right to original birth certificate" },
  "Adoptee rights to their own records at age of majority: full rights; clinicians should support access",
  "Clinician role: document all findings meticulously; support identity search as healthy development",
  "Confidentiality within the clinical consultation: same rules as any paediatric patient; evolving Gillick competence",
]);

// SLIDE 31
twoColSlide(
  "Ethical Issues in Adoption",
  "Guiding Ethical Principles",
  [
    "Best interests of child override adult desires (non-negotiable)",
    "Non-maleficence: avoid over-testing, labelling, stigmatising",
    "Autonomy: respect birth parent's informed consent to relinquish",
    "Justice: equitable access regardless of race, sexuality, religion, income",
    "Cultural preservation: transracial adoption must include cultural identity support",
    "Subsidiarity: domestic placement always preferred over international",
    "Transparency: honest disclosure of all known information",
  ],
  "Common Ethical Dilemmas in Practice",
  [
    "Must known HIV+ birth parent status be disclosed pre-adoption?",
    "Medical experimentation/research in foster care populations",
    "'Special needs' labelling: stigmatising vs. enabling resources?",
    "LGBTQ+ prospective adopters: discrimination in faith-based agencies",
    "International adoption vs. addressing in-country poverty & inequality",
    "Pressure on vulnerable birth mothers to relinquish",
    "Embryo donation: should genetic siblings be told of each other?",
  ],
  "2A3A5A", "7A3010"
);

// SLIDE 32
contentSlide("Child Safeguarding in the Adoption Context", [
  "All healthcare workers in contact with children are mandated reporters – no exceptions",
  "Pre-adoption: paediatrician may be first professional to identify abuse or neglect in an institutional setting",
  "Post-adoption abuse: rare but documented; newly placed children may not disclose due to language barriers or fear",
  "Physical indicators in newly adopted children:",
  { text: "Unexplained bruising, burns, fractures in unusual locations → skeletal survey; safeguarding referral" },
  { text: "Scarring inconsistent with reported history" },
  "Behavioural indicators:",
  { text: "Sexualised behaviour, dissociation, fearfulness, aggression" },
  { text: "Prior abuse may be unrecognised due to communication barriers (language, developmental level)" },
  "Commercial Sexual Exploitation of Children (CSEC): risk in children from certain international contexts",
  "Child protection referral: when in doubt, refer; threshold is lower in this population",
  "Inter-agency working: paediatrician ↔ social worker ↔ mental health ↔ school ↔ police (if indicated)",
  "Documentation: meticulous clinical notes; body-map diagrams; photographs of physical findings with consent",
  "Never delay safeguarding action due to concerns about family rapport or 'false alarm' stigma",
]);

// ─────────────────────────────────────────────────────
// SECTION 5 – FOSTER CARE IN DEPTH
// ─────────────────────────────────────────────────────

// SLIDE 33
sectionDivider("5", "Foster Care in Depth", "Outcomes · Kinship care · Placement stability · Ageing out");

// SLIDE 34
contentSlide("Foster Care – History & Policy Overview", [
  "19th century: orphanages replaced child labour; 1909 White House Conference endorsed foster care over institutions",
  "Social Security Act 1935, Title IV: first federal funding for child welfare; initially excluded minority families",
  "1980 – Adoption Assistance & Child Welfare Act: prevention of removal; 6-month reviews; reunification as goal",
  "1994 – MEPA: prohibited race-based delays; recruited diverse foster/adoptive families",
  "1997 – Adoption & Safe Families Act (ASFA): 15/22-month rule; faster permanency decision-making",
  "~57% of children removed from home are eventually reunified with family of origin",
  "Significant proportion of reunified children re-enter care: reunification not always the best outcome",
  "Reasons for non-reunification: ongoing substance abuse (most common), persistent neglect, domestic violence",
  "2008 – Fostering Connections Act: kinship care support; extended care to age 21 (optional for states)",
  "2018 – Family First Prevention Services Act: prevention-first; limits group/congregate care",
  "Current system serves ~673,000 children/year with ~424,000 in care at any given moment (US data)",
]);

// SLIDE 35 – Stats
statSlide("Foster Care Outcomes – Key Data", [
  { value: "86%", label: "employed part/full-time by age 21 after ageing out", color: C.teal },
  { value: "69%", label: "achieved HS diploma or GED", color: C.green },
  { value: "33%", label: "experienced incarceration by age 17", color: C.red },
  { value: "27%", label: "experienced homelessness by age 21", color: C.orange },
  { value: "50%", label: "experience at least one placement disruption in a 12-month period", color: C.navy },
  { value: "45%", label: "are classified as 'resilient' at age 21 (employment + education + avoidance of high-risk outcomes)", color: C.purple },
]);

// SLIDE 36
contentSlide("Placement Stability & Disruption", [
  "Placement instability: major driver of poor mental health outcomes in foster care",
  "50% of children in foster care experience ≥1 placement disruption in a 12-month period",
  "Child-level risk factors for disruption:",
  { text: "Older age at placement, mental health diagnosis, conduct disorder, sexual/gender minority identity" },
  { text: "Prior physical or sexual abuse (higher risk than neglect alone)" },
  "Caregiver-level protective factors:",
  { text: "Warm, child-centred approach; prior training in special needs care" },
  { text: "Lower caregiver stress in the 6 months before placement" },
  "System-level factors:",
  { text: "High caseworker turnover → increased disruption risk" },
  { text: "Guardianship/adoption subsidies and graduate-level social work staff → improved stability" },
  "Kinship placements: less likely to be disrupted than non-kinship; possible reasons:",
  { text: "Pre-existing relationships; fewer children in placement; identity/cultural continuity" },
  "Evidence-based interventions: Attachment and Biobehavioral Catch-up (ABC); TBRI (Trust-Based Relational Intervention); PCIT",
  "Multiple disruptions: cumulative harm to child and caregiver; system accountability required",
]);

// SLIDE 37
contentSlide("Kinship Care – Benefits, Challenges & Evidence", [
  "Definition: formal or informal placement with relatives (grandparents, aunts/uncles) or close family friends",
  "Supported by: ASFA 1997, Fostering Connections 2008 – preference for kinship placement mandated",
  "Theoretical advantages:",
  { text: "Preservation of child's cultural, racial, religious identity" },
  { text: "Pre-existing attachment relationship – easier attachment re-establishment" },
  { text: "Greater placement stability; access to extended family network" },
  { text: "Sibling preservation more likely in kinship placements" },
  "Evidence: kinship children show greater mental health stability and fewer behavioural problems vs. non-kinship foster care",
  "Challenges:",
  { text: "Kinship carers: more likely to be older, single, with health limitations, lower SES, less educated" },
  { text: "Frequently grandmothers who parented the birth parent – may replicate some risk factors" },
  { text: "Lower reimbursement rates than non-kinship foster care in most states" },
  { text: "Child welfare workers report difficulty supervising; carers may not enforce contact restrictions" },
  "Kinship adoption: most stable permanent outcome for children who cannot be reunified with birth parents",
]);

// SLIDE 38
contentSlide("Ageing Out of Foster Care", [
  "Definition: young people who remain in foster care until reaching age of majority (18–21 depending on state)",
  "~26,000 young people age out of US foster care annually",
  "Federal support: Independent Living Initiative (1986); Chafee Foster Care Independence Act (1999); John H. Chafee provisions extended care to age 21 for participating states",
  "National Youth in Transition Database (NYTD): longitudinal outcomes at age 17, 19, 21",
  "Outcome subgroups at age 21:",
  { text: "Resilient (45%): employed, educated, avoiding high-risk outcomes" },
  { text: "Parents on public assistance (~17%): early parenthood; limited workforce participation" },
  { text: "Troubled and struggling (18%): homelessness, substance use, unemployment, incarceration" },
  { text: "Incarcerated (15%): highest arrest/substance use rates; predominantly male" },
  "Key vulnerabilities on exit from care:",
  { text: "No adult safety net; average American is not financially independent until age 26" },
  { text: "Housing insecurity (27% homeless by age 21)" },
  { text: "Mental health needs go unmet; loss of Medicaid in some states" },
  "Paediatrician role: transition planning from age 14; connect to adult services; health-care transition toolkit",
]);

// SLIDE 39
contentSlide("BIPOC Children in the Child Welfare System", [
  "Racial disproportionality: Black and Indigenous children are significantly over-represented in foster care",
  "African American children: remain in foster care longer; experience more placement changes than White children",
  { text: "Studies show they are underrepresented in mental health institutions and overrepresented in punitive settings" },
  "Indigenous children (ICWA context):",
  { text: "Native American children removed from families at rates 2.7× higher than White children" },
  { text: "ICWA (1978): enacted after widespread forced removal of Native children from communities" },
  { text: "Placement preference: (1) extended family, (2) tribal member, (3) other Native family, (4) non-Native" },
  "Structural drivers: poverty, systemic racism in CPS reporting and investigation, implicit bias in caseworker decisions",
  "MEPA (1994) prohibited race-matching delays but also complicates culturally-matched placement",
  "Mental health disparities: BIPOC children less likely to receive mental health services; more likely to receive punitive responses",
  "Paediatrician advocacy role:",
  { text: "Recognise and counter implicit bias in clinical encounters" },
  { text: "Advocate for culturally responsive care and racially informed placement decisions" },
  { text: "Engage community-based organisations and cultural liaisons" },
]);

// ─────────────────────────────────────────────────────
// SECTION 6 – CLINICAL CASES
// ─────────────────────────────────────────────────────

// SLIDE 40
sectionDivider("6", "Clinical Cases", "Five discussion scenarios for the seminar");

// SLIDE 41
caseSlide(1,
  "Mei Lin, 3-year-old girl adopted from China 2 months ago. Adoptive parents report voracious eating, food hoarding in her room, and tantrums lasting 30–45 minutes. She does not speak English and rarely makes eye contact with either parent. She will climb onto any adult's lap without hesitation. Exam: weight 10th centile, height <3rd centile, OFC 2nd centile. Smooth philtrum, thin upper lip, and short palpebral fissures noted.",
  [
    "What screening investigations would you order at this visit? (infectious disease + developmental)",
    "The facial features concern you – what diagnostic process do you initiate? What multidisciplinary team is needed?",
    "How do you explain food hoarding and indiscriminate affection to the parents? What is the RAD/DSED differential here?",
    "She is not speaking English at all – is this expected? What language assessments are appropriate?",
  ]
);

// SLIDE 42
caseSlide(2,
  "Jaylen, 7-year-old boy in foster care for 4 years after removal due to parental methamphetamine use and neglect. Referred for school expulsion risk due to aggression. He has a diagnosis of ADHD on methylphenidate 10mg BD. Foster carer reports he is seeing 3 specialists and taking 4 medications total (methylphenidate, risperidone, clonidine, sertraline). Last mental health review was 11 months ago.",
  [
    "How do you approach polypharmacy in a foster care child? What is your first step?",
    "ADHD vs. FASD vs. trauma response vs. complex PTSD – how do you differentiate in this child?",
    "Jaylen has had 3 foster placements in the past year. How does this influence his school behaviour?",
    "What is the paediatrician's advocacy role in his educational plan, court reports, and foster carer support?",
  ]
);

// SLIDE 43
caseSlide(3,
  "The Nguyen family are prospective adoptive parents preparing to travel to collect their 18-month-old son Minh from an orphanage in Eastern Europe. Translated medical summary: born at 34/40, head ultrasound 'with small changes' at day 3 of life, received 'standard immunisations'. Birth mother history: alcohol use in pregnancy noted. No other birth family medical history available.",
  [
    "What pre-travel health advice and vaccinations do you give the Nguyen family?",
    "What information would you try to obtain before they travel? (imaging reports, immunisation records, birth mother history)",
    "Design a post-arrival screening plan based on AAP/Red Book recommendations for Minh.",
    "'Small changes on head ultrasound' – what are the most likely findings? How does this inform your neurodevelopmental monitoring plan?",
  ]
);

// SLIDE 44
caseSlide(4,
  "Amara, 15-year-old girl, adopted transracially from Ethiopia at age 2 by a White British family. Referred by GP for low mood, school refusal, and self-harm (superficial cutting). At interview she says she feels 'like she doesn't belong anywhere' – she looks different from her family, doesn't know her birth family, and her classmates make racist comments. She has started researching Ethiopian culture and wants to contact her birth family.",
  [
    "What is your psychiatric/psychological assessment approach? What diagnoses are you considering?",
    "How does transracial adoptee identity development complicate her presentation?",
    "Her adoptive parents say 'we raised her colourblind – race was never an issue'. How do you respond?",
    "She wants to search for her birth family. How do you advise her and her parents? Is this therapeutic or destabilising?",
  ]
);

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    "Kaplan & Sadock Comprehensive Psychiatry 2022 – Chapter 54.1",
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