mkdir -p /home/daytona/workspace/adhd-ppt && ls /home/daytona/workspace/adhd-ppt…

~/adhd-ppt/adhd.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE";
pres.title = "ADHD: A Comprehensive Guide";
pres.author = "Orris Medical";

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// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════════════════════════
{
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  sl.addText("ADHD", {
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  sl.addText("Attention-Deficit / Hyperactivity Disorder", {
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  sl.addText("A Comprehensive Clinical Guide", {
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  sl.addText("Sources: Kaplan & Sadock | Maudsley Prescribing Guidelines | Harriet Lane Handbook | Goodman & Gilman", {
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// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 2 — TABLE OF CONTENTS
// ═══════════════════════════════════════════════════════════════════════════════
{
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  addHeader(sl, "Contents", "What we will cover");

  const sections = [
    ["01", "Epidemiology", "Prevalence, sex ratio, global data"],
    ["02", "Etiology", "Genetics, environmental risk factors"],
    ["03", "Neurobiology", "Brain circuits, dopamine & NE"],
    ["04", "Diagnostic Criteria", "DSM-5 framework, specifiers"],
    ["05", "Comorbidity", "ODD, anxiety, mood, SUD, ASD"],
    ["06", "Clinical Features (Age-wise)", "Infancy → adulthood"],
    ["07", "Course & Prognosis", "Remission, persistence, outcomes"],
    ["08", "Pharmacological Rx – Children", "Stimulants, non-stimulants"],
    ["09", "Pharmacological Rx – Adults", "Evidence, cautions"],
    ["10", "Non-Pharmacological Rx", "Behavioral, psychosocial, school"],
  ];

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}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 3 — EPIDEMIOLOGY
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Epidemiology", "How common is ADHD?");

  // Big stat badges
  addBadge(sl, 0.35, 1.25, "5–9%", "Children", "worldwide");
  addBadge(sl, 2.05, 1.25, "5–7%", "Adolescents", "persist");
  addBadge(sl, 3.75, 1.25, "~2.5–5%", "Adults", "lifetime");
  addBadge(sl, 5.45, 1.25, "2–3:1", "M:F ratio", "children");
  addBadge(sl, 7.15, 1.25, "~50%", "Persist to", "adulthood");
  addBadge(sl, 8.85, 1.25, "9.4%", "US school-age", "(NSCH 2016)");

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  addCard(sl, 0.3, 3.15, 5.9, 3.8, "Global & Regional Trends", [
    "World pooled prevalence ~5.29% (Polanczyk 2007 meta-analysis, >100,000 patients)",
    "DSM-IV full criteria prevalence 5.9–7.1% (Willicutt 2012 meta-analysis)",
    "Rates rising: likely reflects increased awareness and better access to care",
    "Prevalence varies by diagnostic criteria (ICD vs DSM) and assessment method",
    "Lower rates in some Asian countries; higher in Western/North American samples",
    "6–9% of children and adolescents worldwide (Kaplan & Sadock CTP)",
  ], C.teal, C.white);

  addCard(sl, 6.5, 3.15, 5.9, 3.8, "Sex, Age & Persistence", [
    "Boys diagnosed 2–3× more than girls in clinical samples",
    "Girls often present with inattentive type → later/underdiagnosis",
    "Symptoms first recognized in toddlers; rarely before age 4",
    "Inattention often becomes prominent at age 8–9 years (school entry)",
    "60–85% persist symptoms into adolescence",
    "~60% remain symptomatic into adulthood",
    "First-time adult diagnosis compatible with DSM-5 and ICD-11",
  ], C.teal, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 4 — ETIOLOGY
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Etiology", "Genetic, neurobiological & environmental factors");

  addCard(sl, 0.3, 1.25, 4.0, 5.6, "Genetic Factors", [
    "Heritability ~76% (family, twin, adoption studies)",
    "Strongest genetic contribution of any childhood psychiatric disorder",
    "Multiple susceptibility genes involved — polygenic architecture",
    "Genes encoding dopamine (DRD4, DRD5, DAT1) and serotonin (5-HTT) receptors implicated",
    "GWAS identifies first genome-wide significant loci (PGC/EAGLE 2019)",
    "Candidate genes involved in catecholamine metabolism and signaling",
    "First-degree relatives 2–8× higher risk",
    "Concordance: MZ twins ~70–80%, DZ twins ~30–40%",
  ], C.orange, C.white);

  addCard(sl, 4.5, 1.25, 4.0, 5.6, "Environmental / Prenatal Risk Factors", [
    "Prenatal tobacco exposure (smoking during pregnancy) — 2–3× risk increase",
    "Prenatal alcohol exposure → fetal alcohol syndrome overlap",
    "Lead exposure (even low-level) strongly associated",
    "Prematurity and low birth weight",
    "Perinatal hypoxia / birth complications",
    "Maternal stress during pregnancy",
    "Nutritional deficiencies (omega-3 fatty acids, zinc, iron)",
    "Encephalitis lethargica post-influenza pandemic (1919–1920) — historical link",
    "Severe early institutionalized deprivation",
  ], C.orange, C.white);

  addCard(sl, 8.7, 1.25, 3.9, 5.6, "Psychosocial & Other Factors", [
    "Chaotic family environment / poor parenting not causative but worsens course",
    "Adverse childhood experiences (ACEs) can mimic or exacerbate ADHD",
    "Food additives (artificial colors) → modest effect in sensitive individuals",
    "Sugar intake — evidence does not support causal role",
    "Excessive screen time — correlational, not established as cause",
    "Head injury may unmask or precipitate ADHD symptoms",
    "ADHD is NOT caused by poor parenting alone — biologic basis is primary",
    "Interaction: genetic vulnerability × environmental triggers",
  ], C.orange, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 5 — NEUROBIOLOGY
// ═══════════════════════════════════════════════════════════════════════════════
{
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  addHeader(sl, "Neurobiology", "Brain circuits, neurotransmitters, and structural changes");

  addCard(sl, 0.3, 1.25, 4.0, 5.7, "Key Brain Regions", [
    "Prefrontal Cortex (PFC): Most implicated — regulates executive function, attention, inhibition",
    "High dopamine utilization in PFC — dysfunction = core ADHD deficit",
    "Caudate nucleus & striatum: reward processing, motor inhibition",
    "Anterior cingulate cortex: response inhibition, error monitoring",
    "Cerebellum: timing and motor coordination deficits",
    "Fronto-striato-cerebellar circuits: overall delay in maturation (~3 years lag)",
    "Total brain volume ~3–4% smaller in children with ADHD (reversible with treatment)",
    "Right hemisphere preferentially involved vs. left in controls",
  ], C.teal, C.white);

  addCard(sl, 4.5, 1.25, 4.0, 5.7, "Neurotransmitter Dysregulation", [
    "DOPAMINE: Insufficient DA signaling in PFC → deficits in attention, working memory, motivation",
    "NOREPINEPHRINE: Deficient NE modulation in PFC → impaired signal-to-noise ratio",
    "DA & NE reuptake/synthesis genes (DAT1, DRD4, DβH) implicated",
    "Serotonin: secondary role — mood regulation, impulsivity",
    "Inverted-U curve: optimal DA/NE levels needed for PFC function; both excess and deficit impair performance",
    "Stimulants act by blocking DA/NE reuptake (MPH) or promoting DA/NE release (AMP)",
    "NE α2A receptors in PFC: target for guanfacine and clonidine",
  ], C.teal, C.white);

  addCard(sl, 8.7, 1.25, 3.9, 5.7, "Neuroimaging & Cognitive Models", [
    "fMRI: Reduced activation in frontal-striatal circuits during cognitive tasks",
    "Structural MRI: Cortical thinning, reduced grey matter in frontal/parietal regions",
    "qEEG: Increased theta/beta ratio used as biomarker",
    "Inhibitory control model (Barkley): ADHD = primary deficit in behavioral inhibition",
    "Dual-pathway model: Cool executive (prefrontal) + Hot emotional (limbic) pathways",
    "Delay aversion model: Hypersensitivity to delay → preference for immediate reward",
    "Executive function impairments: working memory, response inhibition, cognitive flexibility",
    "Default mode network (DMN) fails to deactivate → mind-wandering during tasks",
  ], C.teal, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 6 — DIAGNOSTIC CRITERIA (DSM-5)
// ═══════════════════════════════════════════════════════════════════════════════
{
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  sl.background = { color: C.offWhite };
  addHeader(sl, "Diagnostic Criteria — DSM-5", "5 Core Requirements + Symptom Domains");

  // 5 core criteria boxes across top
  const crits = [
    ["Age of Onset", "Several symptoms present\nbefore age 12 years"],
    ["Duration", "Symptoms present for\n≥6 months"],
    ["Symptom Count", "≥6 symptoms (children)\n≥5 symptoms (≥17 yrs/adults)"],
    ["Pervasiveness", "Symptoms in ≥2 settings\n(home, school, work)"],
    ["Exclusion", "Not explained by another\nmental/medical disorder"],
  ];
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  // Inattention column
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    "Often fails to give close attention to details / careless mistakes",
    "Often has difficulty sustaining attention in tasks or play",
    "Often does not seem to listen when spoken to directly",
    "Often does not follow through on instructions / fails to finish",
    "Often has difficulty organizing tasks and activities",
    "Often avoids tasks requiring sustained mental effort",
    "Often loses things necessary for tasks (keys, pencils, materials)",
    "Often easily distracted by extraneous stimuli",
    "Often forgetful in daily activities",
  ], C.teal, C.white);

  // Hyperactivity/Impulsivity column
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    "Often fidgets with or taps hands/feet, or squirms in seat",
    "Often leaves seat when expected to remain seated",
    "Often runs/climbs in inappropriate situations (adults: restlessness)",
    "Often unable to play or engage in leisure activities quietly",
    "Often 'on the go' as if 'driven by a motor'",
    "Often talks excessively",
    "Often blurts out answers before questions completed",
    "Often has difficulty waiting their turn",
    "Often interrupts or intrudes on others",
  ], C.orange, C.white);

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  sl.addText(
    "SPECIFIERS:  Combined Presentation (meets both)  |  Predominantly Inattentive  |  Predominantly Hyperactive-Impulsive  |  Severity: Mild / Moderate / Severe",
    { x: 0.42, y: 7.02, w: 11.9, h: 0.45, fontSize: 10, color: C.tealLt, fontFace: "Calibri" }
  );
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 7 — COMORBIDITY
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Comorbidity", "Co-occurring disorders are the rule, not the exception");

  const comorbids = [
    ["Oppositional Defiant Disorder (ODD)", "54–84%", "Most common comorbidity; defiance, argumentativeness, hostile mood"],
    ["Conduct Disorder (CD)", "20–40%", "More serious rule-breaking; predicts adult antisocial behavior"],
    ["Anxiety Disorders", "Up to 33%", "GAD, separation anxiety, social anxiety — can complicate treatment"],
    ["Depressive Disorders", "Up to 33%", "MDD, dysthymia; treatment of ADHD often improves mood symptoms"],
    ["Learning Disorders", "~25%", "Reading, math, written expression disorders; independent of IQ"],
    ["Autism Spectrum Disorder", "30–50% of ASD", "DSM-5 now allows dual diagnosis; shared executive function deficits"],
    ["Sleep Disorders", "~50%", "Delayed sleep phase, restless legs; worsens ADHD severity"],
    ["Tic Disorders / Tourette's", "~10–20%", "Stimulants may exacerbate; consider non-stimulants"],
    ["Substance Use Disorders", "Adolescent risk ↑", "Mediated largely by comorbid CD; treated ADHD has lower SUD risk"],
    ["Bipolar Disorder", "Differentiate carefully", "Episodic course, grandiosity, decreased sleep distinguish BP from ADHD"],
  ];

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    sl.addText(note, { x: x + 1.28, y: y + 0.5, w: 4.75, h: 0.5,
      fontSize: 9.5, color: C.grey, fontFace: "Calibri", italic: true });
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}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 8 — CLINICAL FEATURES: INFANCY & PRESCHOOL
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Clinical Features — Infancy & Preschool (0–5 years)", "Early signs often missed or attributed to temperament");

  addCard(sl, 0.3, 1.25, 5.9, 5.7, "Infancy (0–2 years)", [
    "Excessive activity in the crib, poor sleep, cries a great deal",
    "Difficult to settle, high-need infant temperament",
    "Feeding difficulties, colic-like behavior",
    "Reduced sleep duration, frequent night waking",
    "Not reliably recognized as ADHD at this stage",
    "ADHD can have its onset in infancy but is rarely diagnosed this early",
  ], C.tealMid, C.white);

  addCard(sl, 6.5, 1.25, 5.9, 5.7, "Preschool (2–5 years)", [
    "Excessive gross motor activity — constant running, climbing",
    "Cannot sit still even briefly; inability to participate in group activities",
    "Frequent temper tantrums; emotional dysregulation",
    "Difficulty following simple instructions",
    "High rates of accidental injury due to impulsivity",
    "Destructive behavior — difficulty with cause-and-effect reasoning",
    "Peer difficulties begin — intrusive, rough-and-tumble play style",
    "Disruptive in preschool / daycare settings",
    "Diagnosis valid from age 4 with appropriate criteria; hyperactivity normal before age 4",
    "Behavioral interventions (parent training) are FIRST-LINE in preschoolers",
  ], C.tealMid, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 9 — CLINICAL FEATURES: SCHOOL AGE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Clinical Features — School Age (6–12 years)", "Peak referral period — academic demands unmask deficits");

  addCard(sl, 0.3, 1.25, 4.0, 5.7, "Attention & Academic", [
    "Inattention becomes prominent at age 8–9 when tasks require sustained effort",
    "Careless mistakes; rushes through work without checking",
    "Rapidly shifts attention — cannot sustain focus in routine or repetitive tasks",
    "Poor organization of homework, materials, schedule",
    "Difficulty starting tasks; procrastination",
    "Academic underachievement despite adequate intelligence",
    "Sluggish cognitive tempo (SCT): daydreaming, mental fogginess, confusion in inattentive type",
    "Loses school materials repeatedly",
  ], C.navy, C.white);

  addCard(sl, 4.5, 1.25, 4.0, 5.7, "Hyperactivity & Impulsivity", [
    "Fidgets, squirms, leaves seat in class",
    "Yells out answers, cannot wait turn",
    "Interrupts others; intrusive in games",
    "Engages in dangerous activities without thought of consequence",
    "Physical fights due to impulsive reactions",
    "Gross motor hyperactivity begins to decrease through this period",
    "Inner restlessness may persist even when visible activity decreases",
    "Activity may normalize in very engaging environments (video games, 1-on-1 settings)",
  ], C.navy, C.white);

  addCard(sl, 8.7, 1.25, 3.9, 5.7, "Social & Emotional", [
    "Peer rejection — peers identify ADHD children as intrusive, bossy, insensitive",
    "Difficulty accurately interpreting non-verbal social cues",
    "Trouble cooperating, following rules in games",
    "Poor time management; unreliable sense of time",
    "Temper outbursts, mood lability, emotional reactivity",
    "Low frustration tolerance",
    "Low self-esteem due to repeated academic and social failures",
    "Executive function deficits: poor working memory, planning, response inhibition",
  ], C.navy, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 10 — CLINICAL FEATURES: ADOLESCENTS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Clinical Features — Adolescence (13–17 years)", "Hyperactivity fades; inattention and impulsivity persist");

  addCard(sl, 0.3, 1.25, 6.0, 5.7, "How Symptoms Change", [
    "Gross motor hyperactivity markedly decreases — 'driven by a motor' becomes inner restlessness",
    "Distractibility is usually the LAST symptom to remit",
    "Inattentive symptoms often increase in importance as academic demands escalate",
    "Impulsivity persists — risky decision-making, sensation-seeking",
    "Executive function deficits become more apparent (planning exams, assignments)",
    "Time management problems cause academic failure despite intelligence",
    "Forgetfulness: missed deadlines, lost belongings, broken commitments",
    "DSM-5: Only 5 symptoms required (instead of 6) for ≥17 years",
  ], C.teal, C.white);

  addCard(sl, 6.6, 1.25, 6.0, 5.7, "Risks & Psychosocial Impact", [
    "Academic underachievement → dropout risk increases",
    "Onset of conduct disorder and antisocial behavior",
    "Driving: significantly higher rates of accidents, violations, license suspensions",
    "Substance use initiation — cigarettes, alcohol, cannabis",
    "SUD risk is largely mediated by co-occurring conduct disorder",
    "Social difficulties continue: rejection sensitivity, poor peer relationships",
    "Emotional dysregulation and mood lability",
    "Self-harm and suicidal ideation risk elevated in those with comorbid depression",
    "Evaluation: symptom history from childhood informants required",
  ], C.teal, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 11 — CLINICAL FEATURES: ADULTS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Clinical Features — Adults (18+ years)", "Often diagnosed late; significant functional impairment");

  addCard(sl, 0.3, 1.25, 4.0, 5.7, "Core Symptoms in Adults", [
    "Inattention predominates: poor focus, forgetfulness, disorganization",
    "Restlessness replaces childhood hyperactivity",
    "Impulsivity: snap decisions, speaking without thinking, risk-taking",
    "Chronic procrastination, difficulty initiating and completing tasks",
    "Poor time management, frequently late",
    "Difficulty sustaining attention in meetings, reading",
    "Loses items (phone, keys, documents) repeatedly",
    "Hyperfocus: paradoxical intense focus on highly engaging tasks",
  ], C.orange, C.white);

  addCard(sl, 4.5, 1.25, 4.0, 5.7, "Functional Domains Affected", [
    "Occupational: frequent job changes, underperformance, underemployment",
    "Relationships: conflict due to forgetfulness, impulsivity, emotional dysregulation",
    "Finances: impulsive spending, missed bills, disorganized finances",
    "Driving: higher accident rates persist into adulthood",
    "Parenting: difficulty managing household and children consistently",
    "Health behaviors: irregular sleep, poor diet, exercise avoidance",
    "Higher rates of unintended pregnancy, STIs",
    "Lower educational attainment as a group",
  ], C.orange, C.white);

  addCard(sl, 8.7, 1.25, 3.9, 5.7, "Diagnosis in Adults", [
    "First-time adult ADHD diagnosis compatible with DSM-5 & ICD-11",
    "Must establish childhood onset (before age 12)",
    "Use validated interviews: DIVA-5 (based on DSM-5 criteria)",
    "Collateral history from childhood informants (parents, school records)",
    "Rule out: bipolar disorder (psychosis must be excluded before starting stimulants), anxiety, depression, sleep disorders, substance use",
    "Self-report scales: ASRS, Conners Adult Rating Scale",
    "Neurocognitive testing as adjunct (not standalone diagnostic)",
    "≥5 symptoms in either domain required for adult diagnosis",
  ], C.orange, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 12 — COURSE & PROGNOSIS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Course & Prognosis", "A lifelong condition for many — outcomes vary widely");

  // Timeline flow
  const stages = [
    { label: "Preschool", text: "Hyperactivity\nhigh; impulsivity\ndominates" },
    { label: "School Age", text: "Inattention\nbecomes central;\nacademic failure" },
    { label: "Adolescence", text: "Hyperactivity\ndeclines; risks:\nCD, SUD, accidents" },
    { label: "Adulthood", text: "~60% persist;\noccupational &\nrelationship impact" },
    { label: "Mid-life", text: "Symptoms often\nstabilize; self-\nmanagement improves" },
  ];
  stages.forEach((s, i) => {
    const x = 0.3 + i * 2.55;
    sl.addShape(pres.ShapeType.roundRect, { x, y: 1.3, w: 2.35, h: 1.5, rectRadius: 0.1,
      fill: { color: C.navy }, line: { color: C.tealMid, width: 1.5 } });
    sl.addText(s.label, { x, y: 1.36, w: 2.35, h: 0.4, align: "center",
      fontSize: 12, bold: true, color: C.gold, fontFace: "Calibri" });
    sl.addText(s.text, { x, y: 1.78, w: 2.35, h: 0.9, align: "center",
      fontSize: 9.5, color: C.white, fontFace: "Calibri" });
    if (i < 4) {
      sl.addShape(pres.ShapeType.rect, { x: x + 2.36, y: 1.95, w: 0.18, h: 0.18,
        fill: { color: C.tealMid } });
    }
  });

  addCard(sl, 0.3, 3.0, 5.9, 4.0, "Predictors of Persistence & Poor Outcome", [
    "Family history of ADHD",
    "Comorbid conduct disorder — strongest predictor of poor outcome",
    "Comorbid anxiety, depression",
    "Adverse life events / chaotic family environment",
    "Absence or delay of treatment",
    "Overactivity is first symptom to remit; distractibility is last",
    "Remission usually between ages 12–20 when it occurs",
  ], C.teal, C.white);

  addCard(sl, 6.5, 3.0, 5.9, 4.0, "Long-term Outcomes", [
    "~40% show remission at puberty or early adulthood",
    "~60% have persistent symptoms — partial remission most common",
    "Vulnerability to: antisocial behavior, substance use disorders, mood disorders",
    "Learning problems often continue throughout life",
    "Employment: early employment similar to peers with comparable education",
    "Those with persistent symptoms: more accident-prone, impulsive",
    "Social functioning: key determinant of long-term quality of life",
    "Early treatment improves outcomes; reduces SUD and CD risk",
  ], C.teal, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 13 — PHARMACOLOGICAL Rx: CHILDREN (Overview)
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Pharmacological Treatment — Children & Adolescents", "Evidence-based algorithm; stimulants are first-line");

  // Hierarchy diagram
  sl.addShape(pres.ShapeType.roundRect, { x: 3.8, y: 1.25, w: 5.0, h: 0.75, rectRadius: 0.12,
    fill: { color: C.tealMid }, line: { color: C.tealMid, width: 0 } });
  sl.addText("1st LINE: Methylphenidate (MPH)", { x: 3.8, y: 1.32, w: 5.0, h: 0.55,
    align: "center", fontSize: 13, bold: true, color: C.white, fontFace: "Calibri" });

  sl.addShape(pres.ShapeType.rect, { x: 6.25, y: 2.0, w: 0.12, h: 0.3, fill: { color: C.tealMid } });

  sl.addShape(pres.ShapeType.roundRect, { x: 2.8, y: 2.3, w: 7.0, h: 0.7, rectRadius: 0.1,
    fill: { color: C.navy }, line: { color: C.tealMid, width: 1 } });
  sl.addText("2nd LINE: Lisdexamfetamine / Dexamfetamine", { x: 2.8, y: 2.37, w: 7.0, h: 0.5,
    align: "center", fontSize: 12, bold: true, color: C.gold, fontFace: "Calibri" });

  sl.addShape(pres.ShapeType.rect, { x: 6.25, y: 3.0, w: 0.12, h: 0.3, fill: { color: C.grey } });

  sl.addShape(pres.ShapeType.roundRect, { x: 1.5, y: 3.3, w: 9.6, h: 0.7, rectRadius: 0.1,
    fill: { color: C.light }, line: { color: C.grey, width: 1 } });
  sl.addText("Non-Stimulants: Atomoxetine | Guanfacine XR | Clonidine XR | Viloxazine", { x: 1.5, y: 3.37, w: 9.6, h: 0.5,
    align: "center", fontSize: 11.5, color: C.dark, fontFace: "Calibri" });

  addCard(sl, 0.3, 4.2, 6.1, 2.85, "Key Prescribing Principles", [
    "Drug treatment only part of an overall treatment plan",
    "Environmental modifications + parent training FIRST",
    "Adequate MPH trial: >0.8 mg/kg/day; AMP: >0.5 mg/kg/day",
    "Extended-release (ER) formulations preferred: once daily, better adherence, less diversion",
    "Booster dose of IR stimulant in afternoon may be needed for evening coverage",
    "Annual review of medication; consider drug holidays",
    "Monitor: BP, HR, weight, height, appetite, sleep, tics",
  ], C.teal, C.white);

  addCard(sl, 6.7, 4.2, 5.9, 2.85, "Response Rates", [
    "65–75% of stimulant-treated youth respond",
    "MPH and AMP: similar overall response rates",
    "Lisdexamfetamine: network meta-analyses suggest greater efficacy vs. MPH",
    "Atomoxetine: less effective than stimulants; onset 4–6 weeks",
    "If one stimulant fails → try different class (MPH → AMP or vice versa)",
    "Non-stimulants especially useful: tics, anxiety, abuse potential, stimulant failure",
    "2nd-generation antipsychotics NOT recommended for ADHD",
  ], C.teal, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 14 — STIMULANT MEDICATIONS DETAILS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Stimulant Medications — Details", "Methylphenidate & Amphetamine formulations");

  addCard(sl, 0.3, 1.25, 6.0, 5.8, "Methylphenidate (MPH) — Class I", [
    "MECHANISM: Blocks dopamine and norepinephrine reuptake transporters (DAT, NET)",
    "Short-acting (IR): Ritalin, Focalin — duration 3–5 hours, TID dosing",
    "Intermediate: Ritalin SR, Methylin ER — 8 hours",
    "Long-acting: Concerta (OROS, IR22%/ER78%) — 10–12 hrs",
    "Aptensio XR: IR40%/ER60%; Quillivant XR: suspension form",
    "Daytrana: transdermal patch — 9 hrs after removal",
    "Jornay PM: taken at night, releases next morning",
    "COTEMPLA XR-ODT: orally disintegrating tablet — 6–17 years",
    "Azstarys: serdexmethylphenidate prodrug (Ser-d-MPH) 70% / d-MPH 30%",
    "Side effects: insomnia, appetite suppression, ↑BP/HR, growth deceleration, headache",
    "Long-term: associated with lower height and weight — monitor growth",
  ], C.navy, C.white);

  addCard(sl, 6.6, 1.25, 5.9, 5.8, "Amphetamines — Class II", [
    "MECHANISM: Reverses DAT/NET (releases DA/NE) + blocks reuptake",
    "Dextroamphetamine (IR): 4–6 hrs; Dexedrine Spansule (ER): 8–10 hrs",
    "Mixed amphetamine salts (MAS): Adderall (IR 6–8 hrs), Adderall XR (10–12 hrs)",
    "Lisdexamfetamine (LDX, Vyvanse): prodrug activated in RBCs → gradual release",
    "LDX duration: 12–14 hrs; low abuse potential; first-line option especially in adults",
    "Mydayis (triple-bead AMP): up to 16 hours for adults",
    "Dyanavel XR: suspension form; Evekeo ODT: oral dissolving tablet",
    "Side effects: appetite suppression, insomnia, ↑HR/BP, weight loss, dry mouth",
    "Greater abuse/diversion risk for IR formulations; LDX reduces this",
    "Contraindications: structural cardiac disease, hypertension, glaucoma, concurrent MAOI",
    "Black box: potential for abuse and dependence (Schedule II controlled substances)",
  ], C.navy, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 15 — NON-STIMULANT MEDICATIONS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Non-Stimulant Medications", "For stimulant failures, comorbidities, or abuse concerns");

  const drugs = [
    {
      name: "Atomoxetine (Strattera)",
      cat: "NE Reuptake Inhibitor",
      bullets: [
        "MOA: Selective NE reuptake inhibitor (non-controlled)",
        "Onset: 4–6 weeks for full effect; taken once or twice daily",
        "Approved: ≥6 years (children) and adults",
        "Efficacy: Less effective than stimulants in head-to-head studies",
        "BBW: Suicidal thinking in children/adolescents — monitor closely",
        "Also monitor: liver function (rare hepatotoxicity)",
        "Advantages: no diversion risk, can treat comorbid anxiety",
        "SE: appetite decrease, nausea, fatigue, sexual dysfunction in adults",
      ]
    },
    {
      name: "Guanfacine XR (Intuniv)",
      cat: "α2A Adrenergic Agonist",
      bullets: [
        "MOA: Selective α2A receptor agonist — modulates PFC NE signaling",
        "Licensed for children/adolescents in UK and USA",
        "Efficacy broadly comparable to atomoxetine; superior to clonidine for ADHD",
        "Can be used as monotherapy or adjunct to stimulants",
        "Particularly useful for tics, oppositional behavior, aggression",
        "SE: sedation, bradycardia, hypotension, rebound hypertension on abrupt D/C",
        "Children started on guanfacine should continue into adulthood",
      ]
    },
    {
      name: "Clonidine XR (Kapvay)",
      cat: "α2 Adrenergic Agonist",
      bullets: [
        "MOA: Non-selective α2 agonist; older drug, more SE than guanfacine",
        "Extended-release widely used in USA (not licensed in many countries)",
        "Useful adjunct for sleep problems, tics, and aggression",
        "RCT evidence supports efficacy as monotherapy in children",
        "SE: Sedation, hypotension, dry mouth, rebound hypertension",
        "Must be tapered on discontinuation",
      ]
    },
    {
      name: "Viloxazine (Qelbree)",
      cat: "NE Reuptake Inhibitor",
      bullets: [
        "MOA: Selective NE reuptake inhibitor (newer agent)",
        "FDA approved 2021 for children ≥6 years and adults",
        "Once-daily extended-release capsule; non-scheduled",
        "Evidence from multiple RCTs; meta-analyses confirm efficacy",
        "SE: somnolence, decreased appetite, nausea, irritability",
        "BBW: suicidal ideation (class warning similar to atomoxetine)",
      ]
    },
  ];

  drugs.forEach((d, i) => {
    const col = i % 2, row = Math.floor(i / 2);
    const x = 0.3 + col * 6.35, y = 1.28 + row * 3.1;
    sl.addShape(pres.ShapeType.roundRect, { x, y, w: 6.15, h: 2.95,
      rectRadius: 0.1, fill: { color: C.white }, line: { color: C.tealMid, width: 1.5 } });
    sl.addShape(pres.ShapeType.roundRect, { x, y, w: 6.15, h: 0.55,
      rectRadius: 0.1, fill: { color: C.teal }, line: { color: C.teal, width: 0 } });
    sl.addText(d.name, { x: x + 0.12, y: y + 0.06, w: 3.8, h: 0.4,
      fontSize: 12, bold: true, color: C.white, fontFace: "Calibri" });
    sl.addText(d.cat, { x: x + 3.9, y: y + 0.08, w: 2.1, h: 0.36,
      fontSize: 9.5, italic: true, color: C.tealLt, fontFace: "Calibri", align: "right" });
    const items = d.bullets.map((b, j) => ({
      text: b,
      options: { bullet: { code: "2022" }, fontSize: 9.5, color: C.dark, fontFace: "Calibri",
                 breakLine: j < d.bullets.length - 1 }
    }));
    sl.addText(items, { x: x + 0.1, y: y + 0.6, w: 5.95, h: 2.25, valign: "top" });
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 16 — PHARMACOLOGICAL Rx: ADULTS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Pharmacological Treatment — Adults", "Evolving evidence, cardiovascular considerations, tailored approach");

  addCard(sl, 0.3, 1.25, 6.0, 5.8, "First-Line & Evidence", [
    "Lisdexamfetamine (LDX) OR Methylphenidate MR: both first-line choices (NICE/Maudsley)",
    "Amphetamines preferred in adults per evidence: larger effect sizes vs. MPH",
    "Evidence largely from short-term RCTs (<52 weeks); long-term data limited",
    "Strength of evidence for adult ADHD medications rated 'low' to 'very low' (Maudsley)",
    "Modified-release (MR) formulations preferred: less diversion risk, smoother effect",
    "Atomoxetine: appropriate if stimulant contraindicated, not tolerated, or misuse risk",
    "Stimulant response may lessen over time in some patients",
    "Annual review mandatory; consider medication-off days and dose reduction trials",
    "Cardiovascular monitoring: BP, HR at each visit — dose-related risk noted (2024 study)",
    "Caution: bipolar/psychosis diagnosis — stimulants may worsen psychosis",
    "LDX: also effective in adults with co-occurring amphetamine/methamphetamine use disorder",
  ], C.navy, C.white);

  addCard(sl, 6.6, 1.25, 5.9, 5.8, "Special Populations & Considerations", [
    "ELDERLY: No licensed indication; assess carefully; use lowest effective dose; high cardiovascular risk",
    "PREGNANCY: Stimulants generally avoided; risks include preterm birth, LBW; decision shared with patient (see Maudsley ADHD in pregnancy guidelines)",
    "BIPOLAR COMORBIDITY: Mood stabilizer first; stimulant may be added cautiously with psychiatrist",
    "SUBSTANCE USE DISORDER: LDX or atomoxetine preferred (lower abuse potential); MPH MR acceptable; avoid IR short-acting stimulants",
    "ANXIETY COMORBIDITY: Atomoxetine or guanfacine often preferred; stimulants may worsen anxiety",
    "SLEEP DISORDER: Evening stimulant avoidance; melatonin adjunct; address sleep hygiene",
    "AUTISM SPECTRUM: Lower stimulant response rates; higher SE rates; start low, go slow",
    "CARDIOVASCULAR DISEASE: Avoid stimulants if uncontrolled hypertension, arrhythmias, structural cardiac disease; cardiologist input",
    "DIVERSION CONCERNS: Always prescribe MR formulations; random urine drug screens if needed",
  ], C.navy, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 17 — NON-PHARMACOLOGICAL: CHILDREN
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Non-Pharmacological Treatment — Children & Adolescents", "Foundational; always initiated; often sufficient alone in mild ADHD");

  addCard(sl, 0.3, 1.25, 4.0, 5.7, "Behavioral Interventions", [
    "Parent Training in Behavior Management (PTBM): FIRST-LINE for preschoolers; improves parental skills",
    "Behavioral Classroom Interventions: structured routines, token economy, daily report cards",
    "Behavioral therapy (child-directed): reward systems, contingency management",
    "Organizational skills training (OST): homework folders, checklists, time-management tools",
    "Social skills training (SST): teaches perspective-taking, cooperative play, conflict resolution",
    "Summer Treatment Programs (STP): intensive, multi-modal behavioral intervention",
    "PCIT (Parent-Child Interaction Therapy): for preschoolers with ODD comorbidity",
  ], C.teal, C.white);

  addCard(sl, 4.5, 1.25, 4.0, 5.7, "School & Educational Support", [
    "504 Plan / IEP (Individualized Education Plan): formal school accommodations",
    "Extended test time, preferential seating, reduced distraction environment",
    "Chunked assignments, clear and brief instructions",
    "Frequent breaks; movement opportunities between tasks",
    "Positive behavior reinforcement by teachers",
    "Liaison between clinician, parents, and school essential",
    "Academic tutoring for co-occurring learning disorders",
    "Regular teacher feedback via structured rating scales (Vanderbilt)",
  ], C.teal, C.white);

  addCard(sl, 8.7, 1.25, 3.9, 5.7, "Complementary Approaches", [
    "Neurofeedback (EEG biofeedback): some RCT evidence; not yet standard of care",
    "Mindfulness-based interventions: reduces inattention and emotional dysregulation",
    "Exercise / physical activity: consistent evidence for acute cognitive improvement",
    "Omega-3 fatty acid supplementation: modest effect; safe adjunct",
    "Sleep hygiene interventions: critical — sleep deprivation worsens ADHD severity",
    "Dietary interventions (Feingold diet, elimination diet): limited evidence; consider in individual cases",
    "Working memory training (Cogmed): improves WM but limited generalization",
    "Avoid: bioresonance, homeopathy, megavitamins — no evidence",
  ], C.teal, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 18 — NON-PHARMACOLOGICAL: ADULTS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Non-Pharmacological Treatment — Adults", "CBT and coaching address core functional deficits");

  addCard(sl, 0.3, 1.25, 5.9, 5.7, "Psychotherapeutic Approaches", [
    "CBT for ADHD (adults): specifically adapted — skills training, cognitive restructuring",
    "Targets: procrastination, disorganization, emotional dysregulation, low self-esteem",
    "Group CBT: peer support + skill building; evidence-based format",
    "Dialectical Behavior Therapy (DBT) skills: emotional regulation, distress tolerance",
    "Acceptance and Commitment Therapy (ACT): values-based living, psychological flexibility",
    "Metacognitive Therapy: targeting maladaptive beliefs about attention",
    "ADHD coaching: goal-setting, accountability, time management — not a substitute for therapy",
    "Psychoeducation: essential for all patients and families; reduces stigma, improves adherence",
  ], C.orange, C.white);

  addCard(sl, 6.5, 1.25, 5.9, 5.7, "Lifestyle, Occupational & Digital Tools", [
    "Exercise: aerobic activity (30 min, 3–5×/week) significantly improves attention, mood, executive function",
    "Sleep optimization: consistent schedule, avoid screen light before bed, treat comorbid sleep disorders",
    "Mindfulness practice: reduces mind-wandering, improves present-moment awareness",
    "Environmental modifications: structured workspace, reduce distractions, use of external cues",
    "Digital tools: calendar apps, reminder systems, Pomodoro technique (timed work blocks)",
    "Occupational therapy assessment for workplace accommodations",
    "Vocational counseling: identify strengths; job environments suited to ADHD",
    "Support groups (CHADD, ADDISS): peer support and advocacy",
    "Couples/family therapy when relationships significantly impacted",
  ], C.orange, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 19 — TREATMENT SUMMARY BY AGE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.background = { color: C.offWhite };
  addHeader(sl, "Treatment Summary by Age Group", "Integrated, stepped-care approach");

  const rows = [
    ["Age Group", "First-Line Non-Pharm", "First-Line Pharm", "Key Cautions", C.navy, C.white, true],
    ["Preschool\n(3–5 yrs)", "Parent training (PTBM)\nBehavioral therapy", "MPH (if severe impairment\n& PTBM failed)", "Not routinely recommended\nbefore age 5", C.tealMid, C.white, false],
    ["School Age\n(6–12 yrs)", "PTBM + Classroom\nbehavioral interventions\n+ Social skills training", "MPH extended-release\n1st line; AMP/LDX 2nd;\nAtomoxetine/Guanfacine\nnon-stimulant options", "Monitor growth (HT/WT)\nBP, HR, sleep, appetite", C.teal, C.white, false],
    ["Adolescents\n(13–17 yrs)", "CBT-adapted, school\naccommodations, OST,\nPsychoeducation", "MR stimulants preferred;\n≥5 symptoms required;\nConsider comorbidity", "Risk of SUD, driving\nimpairment; consent\nfor treatment", C.teal, C.white, false],
    ["Adults\n(18+ yrs)", "CBT for ADHD, coaching,\nexercise, mindfulness,\nenvironmental mods", "LDX or MPH-MR 1st line;\nAtomoxetine alternative;\nViloxazine option", "CVD monitoring;\npregancy/bipolar\nconsiderations", C.navy, C.white, false],
  ];

  const colWidths = [1.7, 3.4, 3.6, 3.4];
  const colX = [0.3, 2.0, 5.4, 9.0];
  const rowH = 1.12;
  const startY = 1.22;

  rows.forEach((row, ri) => {
    const [c0, c1, c2, c3, bg, fg, isHeader] = row;
    const y = startY + ri * rowH;
    colX.forEach((x, ci) => {
      const text = [c0, c1, c2, c3][ci];
      const cellBg = isHeader ? C.navy : (ri % 2 === 0 ? bg : C.white);
      const cellFg = isHeader ? C.white : (ri % 2 === 0 ? fg : C.dark);
      sl.addShape(pres.ShapeType.rect, { x, y, w: colWidths[ci], h: rowH,
        fill: { color: cellBg }, line: { color: C.tealMid, width: 0.8 } });
      sl.addText(text, { x: x + 0.08, y: y + 0.04, w: colWidths[ci] - 0.16, h: rowH - 0.08,
        fontSize: isHeader ? 11.5 : 9.5, bold: isHeader,
        color: isHeader ? C.gold : cellFg, fontFace: "Calibri",
        valign: "middle", wrap: true });
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
//  SLIDE 20 — KEY TAKEAWAYS & REFERENCES
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    "ADHD affects ~5–9% of children and persists into adulthood in ~60%; it is a neurobiological, highly heritable disorder.",
    "Core neurobiology: dopamine/norepinephrine dysregulation in prefrontal-striatal circuits → deficits in attention, inhibition, and executive function.",
    "DSM-5 requires ≥6 symptoms (≥5 in ≥17 yrs), onset before age 12, ≥2 settings, and exclusion of other causes.",
    "Comorbidity is the rule: ODD (54–84%), anxiety (33%), depression (33%), learning disorders (25%), ASD, SUD.",
    "Clinical presentation is age-dependent: hyperactivity dominates early; inattention and executive dysfunction dominate in adolescence and adulthood.",
    "PRESCHOOL: Parent training (PTBM) is first-line; medication reserved for severe cases.",
    "SCHOOL AGE: Extended-release MPH is first-line pharmacotherapy; combined behavioral + pharmacological approaches optimal.",
    "ADULTS: LDX or MPH-MR first line; cardiovascular monitoring mandatory; CBT addresses functional deficits beyond medication.",
    "Non-pharmacological interventions (CBT, parent training, exercise, sleep, school accommodations) are essential at all ages.",
    "Treatment is long-term; annual review, growth monitoring, and tailored plans are essential for optimal outcomes.",
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    "Sources: Kaplan & Sadock's CTP  ·  Kaplan & Sadock's Synopsis of Psychiatry  ·  Maudsley Prescribing Guidelines in Psychiatry (15e)  ·  Harriet Lane Handbook (23e)  ·  Goodman & Gilman's Pharmacological Basis of Therapeutics",
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