<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Adoption and can you explain it in depth? [/INST] Adoption is a process whereby a person assumes the parenting of another, usually a child, from that persons biological or legal parent or parents. Legal adoptions permanently transfer all rights and responsibilities, along with filiation, from the biological parents to the adoptive parents.
Unlike guardianship or other systems designed for the care of the young, adoption is intended to effect a permanent change in status and as such requires societal recognition, either through legal or religious sanction. Historically, some societies have enacted specific laws governing adoption, while others used less formal means (notably contracts that specified inheritance rights and parental responsibilities without an accompanying transfer of filiation). Modern systems of adoption, arising in the 20th century, tend to be governed by comprehensive statutes and regulations.

History
Antiquity
Adoption for the well-born
While the modern form of adoption emerged in the United States, forms of the practice appeared throughout history. The Code of Hammurabi, for example, details the rights of adopters and the responsibilities of adopted individuals at length. The practice of adoption in ancient Rome is well-documented in the Codex Justinianus.Markedly different from the modern period, ancient adoption practices put emphasis on the political and economic interests of the adopter, providing a legal tool that strengthened political ties between wealthy families and created male heirs to manage estates. The use of adoption by the aristocracy is well-documented: many of Romes emperors were adopted sons. Adrogation was a kind of Roman adoption in which the person adopted consented to be adopted by another.
Infant adoption during Antiquity appears rare. Abandoned children were often picked up for slavery and composed a significant percentage of the Empires slave supply. Roman legal records indicate that foundlings were occasionally taken in by families and raised as a son or daughter. Although not normally adopted under Roman Law, the children, called alumni, were reared in an arrangement similar to guardianship, being considered the property of the father who abandoned them.Other ancient civilizations, notably India and China, used some form of adoption as well. Evidence suggests the goal of this practice was to ensure the continuity of cultural and religious practices; in contrast to the Western idea of extending family lines. In ancient India, secondary sonship, clearly denounced by the Rigveda, continued, in a limited and highly ritualistic form, so that an adopter might have the necessary funerary rites performed by a son. China had a similar idea of adoption with males adopted solely to perform the duties of ancestor worship.The practice of adopting the children of family members and close friends was common among the cultures of Polynesia including Hawaii where the custom was referred to as hānai.

Middle ages to modern period
Adoption and commoners
The nobility of the Germanic, Celtic, and Slavic cultures that dominated Europe after the decline of the Roman Empire denounced the practice of adoption. In medieval society, bloodlines were paramount; a ruling dynasty lacking a "natural-born" heir apparent was replaced, a stark contrast to Roman traditions. The evolution of European law reflects this aversion to adoption. English common law, for instance, did not permit adoption since it contradicted the customary rules of inheritance. In the same vein, Frances Napoleonic Code made adoption difficult, requiring adopters to be over the age of 50, sterile, older than the adopted person by at least 15 years, and to have fostered the adoptee for at least six years. Some adoptions continued to occur, however, but became informal, based on ad hoc contracts. For example, in the year 737, in a charter from the town of Lucca, three adoptees were made heirs to an estate. Like other contemporary arrangements, the agreement stressed the responsibility of the adopted rather than adopter, focusing on the fact that, under the contract, the adoptive father was meant to be cared for in his old age; an idea that is similar to the conceptions of adoption under Roman law.Europes cultural makeover marked a period of significant innovation for adoption. Without support from the nobility, the practice gradually shifted toward abandoned children. Abandonment levels rose with the fall of the empire and many of the foundlings were left on the doorstep of the Church. Initially, the clergy reacted by drafting rules to govern the exposing, selling, and rearing of abandoned children. The Churchs innovation, however, was the practice of oblation, whereby children were dedicated to lay life within monastic institutions and reared within a monastery. This created the first system in European history in which abandoned children did not have legal, social, or moral disadvantages. As a result, many of Europes abandoned and orphaned children became alumni of the Church, which in turn took the role of adopter. Oblation marks the beginning of a shift toward institutionalization, eventually bringing about the establishment of the foundling hospital and orphanage.As the idea of institutional care gained acceptance, formal rules appeared about how to place children into families: boys could become apprenticed to an artisan and girls might be married off under the institutions authority. Institutions informally adopted out children as well, a mechanism treated as a way to obtain cheap labor, demonstrated by the fact that when the adopted died their bodies were returned by the family to the institution for burial.This system of apprenticeship and informal adoption extended into the 19th century, today seen as a transitional phase for adoption history. Under the direction of social welfare activists, orphan asylums began to promote adoptions based on sentiment rather than work; children were placed out under agreements to provide care for them as family members instead of under contracts for apprenticeship. The growth of this model is believed to have contributed to the enactment of the first modern adoption law in 1851 by the Commonwealth of Massachusetts, unique in that it codified the ideal of the "best interests of the child". Despite its intent, though, in practice, the system operated much the same as earlier incarnations. The experience of the Boston Female Asylum (BFA) is a good example, which had up to 30% of its charges adopted out by 1888. Officials of the BFA noted that, although the asylum promoted otherwise, adoptive parents did not distinguish between indenture and adoption: "We believe," the asylum officials said, "that often, when children of a younger age are taken to be adopted, the adoption is only another name for service."

Modern period
Adopting to create a familyThe next stage of adoptions evolution fell to the emerging nation of the United States. Rapid immigration and the American Civil War resulted in unprecedented overcrowding of orphanages and foundling homes in the mid-nineteenth century. Charles Loring Brace, a Protestant minister, became appalled by the legions of homeless waifs roaming the streets of New York City. Brace considered the abandoned youth, particularly Catholics, to be the most dangerous element challenging the citys order.
His solution was outlined in The Best Method of Disposing of Our Pauper and Vagrant Children (1859), which started the Orphan Train movement. The orphan trains eventually shipped an estimated 200,000 children from the urban centers of the East to the nations rural regions. The children were generally indentured, rather than adopted, to families who took them in. As in times past, some children were raised as members of the family while others were used as farm laborers and household servants. The sheer size of the displacement—the largest migration of children in history—and the degree of exploitation that occurred, gave rise to new agencies and a series of laws that promoted adoption arrangements rather than indenture. The hallmark of the period is Minnesotas adoption law of 1917, which mandated investigation of all placements and limited record access to those involved in the adoption.During the same period, the Progressive movement swept the United States with a critical goal of ending the prevailing orphanage system. The culmination of such efforts came with the First White House Conference on the Care of Dependent Children called by President Theodore Roosevelt in 1909, where it was declared that the nuclear family represented "the highest and finest product of civilization" and was best able to serve as primary caretaker for the abandoned and orphaned. As late as 1923, only two percent of children without parental care were in adoptive homes, with the balance in foster arrangements and orphanages. Less than forty years later, nearly one-third were in adoptive homes.Nevertheless, the popularity of eugenic ideas in America put up obstacles to the growth of adoption. There were grave concerns about the genetic quality of illegitimate and indigent children, perhaps best exemplified by the influential writings of Henry H. Goddard, who protested against adopting children of unknown origin, saying,

Now it happens that some people are interested in the welfare and high development of the human race; but leaving aside those exceptional people, all fathers and mothers are interested in the welfare of their own families. The dearest thing to the parental heart is to have the children marry well and rear a noble family. How short-sighted it is then for such a family to take into its midst a child whose pedigree is absolutely unknown; or, where, if it were partially known, the probabilities are strong that it would show poor and diseased stock, and that if a marriage should take place between that individual and any member of the family the offspring would be degenerates. The period 1945 to 1974, the baby scoop era, saw rapid growth and acceptance of adoption as a means to build a family. Illegitimate births rose three-fold after World War II, as sexual mores changed. Simultaneously, the scientific community began to stress the dominance of nurture over genetics, chipping away at eugenic stigmas. In this environment, adoption became the obvious solution for both unwed people and infertile couples.Taken together, these trends resulted in a new American model for adoption. Following its Roman predecessor, Americans severed the rights of the original parents while making adopters the new parents in the eyes of the law. Two innovations were added: 1) adoption was meant to ensure the "best interests of the child", the seeds of this idea can be traced to the first American adoption law in Massachusetts, and 2) adoption became infused with secrecy, eventually resulting in the sealing of adoption and original birth records by 1945. The origin of the move toward secrecy began with Charles Loring Brace, who introduced it to prevent children from the Orphan Trains from returning to or being reclaimed by their parents. Brace feared the impact of the parents poverty, in general, and Catholic religion, in particular, on the youth. This tradition of secrecy was carried on by the later Progressive reformers when drafting of American laws.The number of adoptions in the United States peaked in 1970. It is uncertain what caused the subsequent decline. Likely contributing factors in the 1960s and 1970s include a decline in the fertility rate, associated with the introduction of the pill, the completion of legalization of artificial birth control methods, the introduction of federal funding to make family planning services available to the young and low-income, and the legalization of abortion. In addition, the years of the late 1960s and early 1970s saw a dramatic change in societys view of illegitimacy and in the legal rights of those born outside of wedlock. In response, family preservation efforts grew so that few children born out of wedlock today are adopted. Ironically, adoption is far more visible and discussed in society today, yet it is less common.The American model of adoption eventually proliferated globally. England and Wales established their first formal adoption law in 1926. The Netherlands passed its law in 1956. Sweden made adoptees full members of the family in 1959. West Germany enacted its first laws in 1977. Additionally, the Asian powers opened their orphanage systems to adoption, influenced as they were by Western ideas following colonial rule and military occupation. In France, local public institutions accredit candidates for adoption, who can then contact orphanages abroad or ask for the support of NGOs. The system does not involve fees, but gives considerable power to social workers whose decisions may restrict adoption to "standard" families (middle-age, medium to high income, heterosexual, Caucasian).Adoption is today practiced globally. The table below provides a snapshot of Western adoption rates. Adoption in the United States still occurs at rates nearly three times those of its peers even though the number of children awaiting adoption has held steady in recent years, between 100,000 and 125,000 during the period 2009 to 2018.

Contemporary adoption
Forms of adoption
Contemporary adoption practices can be open or closed.

Open adoption allows identifying information to be communicated between adoptive and biological parents and, perhaps, interaction between kin and the adopted person. Open adoption can be an informal arrangement subject to termination by adoptive parents who have sole custody over the child. In some jurisdictions, the biological and adoptive parents may enter into a legally enforceable and binding agreement concerning visitation, exchange of information, or other interaction regarding the child. As of February 2009, 24 U.S. states allowed legally enforceable open adoption contract agreements to be included in the adoption finalization.
The practice of closed adoption (also called confidential or secret adoption), which has not been the norm for most of modern history, seals all identifying information, maintaining it as secret and preventing disclosure of the adoptive parents, biological kins, and adoptees identities. Nevertheless, closed adoption may allow the transmittal of non-identifying information such as medical history and religious and ethnic background. Today, as a result of safe haven laws passed by some U.S. states, secret adoption is seeing renewed influence. In so-called "safe-haven" states, infants can be left anonymously at hospitals, fire departments, or police stations within a few days of birth, a practice criticized by some adoption advocacy organizations as being retrograde and dangerous.

How adoptions originate
Adoptions can occur between related or unrelated individuals. Historically, most adoptions occurred within a family. The most recent data from the U.S. indicates that about half of adoptions are currently between related individuals. A common example of this is a "step-parent adoption", where the new partner of a parent legally adopts a child from the parents previous relationship. Intra-family adoption can also occur through surrender, as a result of parental death, or when the child cannot otherwise be cared for and a family member agrees to take over.
Adoption is not always a voluntary process. In some countries, for example in the U.K., one of the main origins of children being placed for adoption is that they have been removed from the birth home, often by a government body such as the local authority. There are a number of reasons why children are removed including abuse and neglect, which can have a lasting impact on the adoptee. Social workers in many cases will be notified of a safeguarding concern in relation to a child and will make enquiries into the childs well-being. Social workers will often seek means of keeping a child together with the birth family, for example, by providing additional support to the family before considering removal of a child. A court of law will often then make decisions regarding the childs future, for example, whether they can return to the birth family, enter into foster care or be adopted.
Infertility is the main reason parents seek to adopt children they are not related to. One study shows this accounted for 80% of unrelated infant adoptions and half of adoptions through foster care. Estimates suggest that 11–24% of Americans who cannot conceive or carry to term attempt to build a family through adoption, and that the overall rate of ever-married American women who adopt is about 1.4%. Other reasons people adopt are numerous although not well documented. These may include wanting to cement a new family following divorce or death of one parent, compassion motivated by religious or philosophical conviction, to avoid contributing to overpopulation out of the belief that it is more responsible to care for otherwise parent-less children than to reproduce, to ensure that inheritable diseases (e.g., Tay–Sachs disease) are not passed on, and health concerns relating to pregnancy and childbirth. Although there are a range of reasons, the most recent study of experiences of women who adopt suggests they are most likely to be 40–44 years of age, to be currently married, to have impaired fertility, and to be childless.Unrelated adoptions may occur through the following mechanisms:

Private domestic adoptions: under this arrangement, charities and for-profit organizations act as intermediaries, bringing together prospective adoptive parents with families who want to place a child, all parties being residents of the same country. Alternatively, prospective adoptive parents sometimes avoid intermediaries and connect with women directly, often with a written contract; this is not permitted in some jurisdictions. Private domestic adoption accounts for a significant portion of all adoptions; in the United States, for example, nearly 45% of adoptions are estimated to have been arranged privately.
Foster care adoption: this is a type of domestic adoption where a child is initially placed in public care. Many times the foster parents take on the adoption when the children become legally free. Its importance as an avenue for adoption varies by country. Of the 127,500 adoptions in the U.S. in 2000, about 51,000 or 40% were through the foster care system.
International adoption: this involves the placing of a child for adoption outside that childs country of birth. This can occur through public or private agencies. In some countries, such as Sweden, these adoptions account for the majority of cases (see above table). The U.S. example, however, indicates there is wide variation by country since adoptions from abroad account for less than 15% of its cases. More than 60,000 Russian children have been adopted in the United States since 1992, and a similar number of Chinese children were adopted from 1995 to 2005. The laws of different countries vary in their willingness to allow international adoptions. Recognizing the difficulties and challenges associated with international adoption, and in an effort to protect those involved from the corruption and exploitation which sometimes accompanies it, the Hague Conference on Private International Law developed the Hague Adoption Convention, which came into force on 1 May 1995 and has been ratified by 85 countries as of November 2011.
Embryo adoption: based on the donation of embryos remaining after one couples in vitro fertilization treatments have been completed; embryos are given to another individual or couple, followed by the placement of those embryos into the recipient womans uterus, to facilitate pregnancy and childbirth. In the United States, embryo adoption is governed by property law rather than by the court systems, in contrast to traditional adoption.
Common law adoption: this is an adoption that has not been recognized beforehand by the courts, but where a parent, without resorting to any formal legal process, leaves his or her children with a friend or relative for an extended period of time. At the end of a designated term of (voluntary) co-habitation, as witnessed by the public, the adoption is then considered binding, in some courts of law, even though not initially sanctioned by the court. The particular terms of a common-law adoption are defined by each legal jurisdiction. For example, the U.S. state of California recognizes common law relationships after co-habitation of 2 years. The practice is called "private fostering" in Britain.

Disruption and dissolution
Although adoption is often described as forming a "forever" family, the relationship can be ended at any time. The legal termination of an adoption is called disruption. In U.S. terminology, adoptions are disrupted if they are ended before being finalized, and they are dissolved if the relationship is ended afterwards. It may also be called a failed adoption. After legal finalization, the disruption process is usually initiated by adoptive parents via a court petition and is analogous to divorce proceedings. It is a legal avenue unique to adoptive parents as disruption/dissolution does not apply to biological kin, although biological family members are sometimes disowned or abandoned.Ad hoc studies performed in the U.S., however, suggest that between 10 and 25 percent of adoptions through the child welfare system (e.g., excluding babies adopted from other countries or step-parents adopting their stepchildren) disrupt before they are legally finalized and from 1 to 10 percent are dissolved after legal finalization. The wide range of values reflects the paucity of information on the subject and demographic factors such as age; it is known that teenagers are more prone to having their adoptions disrupted than young children.

Adoption by same-sex couples
Joint adoption by same-sex couples is legal in 34 countries as of March 2022, and additionally in various sub-national territories. Adoption may also be in the form of step-child adoption (6 additional countries), wherein one partner in a same-sex couple adopts the child of the other. Most countries that have same-sex marriage allow joint adoption by those couples, the exceptions being Ecuador (no adoption by same-sex couples), Taiwan (step-child adoption only) and Mexico (in one third of states with same-sex marriage). A few countries with civil unions or lesser marriage rights nonetheless allow step- or joint adoption.

Parenting of adoptees
Parenting
The biological relationship between a parent and child is important, and the separation of the two has led to concerns about adoption. The traditional view of adoptive parenting received empirical support from a Princeton University study of 6,000 adoptive, step, and foster families in the United States and South Africa from 1968 to 1985; the study indicated that food expenditures in households with mothers of non-biological children (when controlled for income, household size, hours worked, age, etc.) were significantly less for adoptees, step-children, and foster children, causing the researchers to speculate that people are less interested in sustaining the genetic lines of others. This theory is supported in another more qualitative study wherein adoptive relationships marked by sameness in likes, personality, and appearance, were associated with both adult adoptees and adoptive parents report being happier with the adoption.Other studies provide evidence that adoptive relationships can form along other lines. A study evaluating the level of parental investment indicates strength in adoptive families, suggesting that parents who adopt invest more time in their children than other parents, and concludes "...adoptive parents enrich their childrens lives to compensate for the lack of biological ties and the extra challenges of adoption." Another recent study found that adoptive families invested more heavily in their adopted children, for example, by providing further education and financial support. Noting that adoptees seemed to be more likely to experience problems such as drug addiction, the study speculated that adoptive parents might invest more in adoptees not because they favor them, but because they are more likely than genetic children to need the help.Psychologists findings regarding the importance of early mother-infant bonding created some concern about whether parents who adopt older infants or toddlers after birth have missed some crucial period for the childs development. However, research on The Mental and Social Life of Babies suggested that the "parent-infant system", rather than a bond between biologically related individuals, is an evolved fit between innate behavior patterns of all human infants and equally evolved responses of human adults to those infant behaviors. Thus nature "ensures some initial flexibility with respect to the particular adults who take on the parental role."Beyond the foundational issues, the unique questions posed for adoptive parents are varied. They include how to respond to stereotypes, answering questions about heritage, and how best to maintain connections with biological kin when in an open adoption. One author suggests a common question adoptive parents have is: "Will we love the child even though he/she is not our biological child?" A specific concern for many parents is accommodating an adoptee in the classroom. Familiar lessons like "draw your family tree" or "trace your eye color back through your parents and grandparents to see where your genes come from" could be hurtful to children who were adopted and do not know this biological information. Numerous suggestions have been made to substitute new lessons, e.g., focusing on "family orchards".Adopting older children presents other parenting issues. Some children from foster care have histories of maltreatment, such as physical and psychological neglect, physical abuse, and sexual abuse, and are at risk of developing psychiatric problems. Such children are at risk of developing a disorganized attachment. Studies by Cicchetti et al. (1990, 1995) found that 80% of abused and maltreated infants in their sample exhibited disorganized attachment styles. Disorganized attachment is associated with a number of developmental problems, including dissociative symptoms, as well as depressive, anxious, and acting-out symptoms. "Attachment is an active process—it can be secure or insecure, maladaptive or productive." In the U.K., some adoptions fail because the adoptive parents do not get sufficient support to deal with difficult, traumatized children. This is a false economy as local authority care for these children is extremely expensive.Concerning developmental milestones, studies from the Colorado Adoption Project examined genetic influences on adoptee maturation, concluding that cognitive abilities of adoptees reflect those of their adoptive parents in early childhood but show little similarity by adolescence, resembling instead those of their biological parents and to the same extent as peers in non-adoptive families.Similar mechanisms appear to be at work in the physical development of adoptees. Danish and American researchers conducting studies on the genetic contribution to body mass index found correlations between an adoptees weight class and his biological parents BMI while finding no relationship with the adoptive family environment. Moreover, about one-half of inter-individual differences were due to individual non-shared influences.These differences in development appear to play out in the way young adoptees deal with major life events. In the case of parental divorce, adoptees have been found to respond differently from children who have not been adopted. While the general population experienced more behavioral problems, substance use, lower school achievement, and impaired social competence after parental divorce, the adoptee population appeared to be unaffected in terms of their outside relationships, specifically in their school or social abilities.

Effects on the original parents
Several factors affect the decision to release or raise the child. White adolescents tend to give up their babies to non-relatives, whereas black adolescents are more likely to receive support from their own community in raising the child and also in the form of informal adoption by relatives. Studies by Leynes and by Festinger and Young, Berkman, and Rehr found that, for pregnant adolescents, the decision to release the child for adoption depended on the attitude toward adoption held by the adolescents mother. Another study found that pregnant adolescents whose mothers had a higher level of education were more likely to release their babies for adoption. Research suggests that women who choose to release their babies for adoption are more likely to be younger, enrolled in school, and have lived in a two-parent household at age 10, than those who kept and raised their babies.There is limited research on the consequences of adoption for the original parents, and the findings have been mixed. One study found that those who released their babies for adoption were less comfortable with their decision than those who kept their babies. However, levels of comfort over both groups were high, and those who released their child were similar to those who kept their child in ratings of life satisfaction, relationship satisfaction, and positive future outlook for schooling, employment, finances, and marriage. Subsequent research found that adolescent mothers who chose to release their babies for adoption were more likely to experience feelings of sorrow and regret over their decision than those who kept their babies. However, these feelings decreased significantly from one year after birth to the end of the second year.More recent research found that in a sample of mothers who had released their children for adoption four to 12 years prior, every participant had frequent thoughts of their lost child. For most, thoughts were both negative and positive in that they produced both feelings of sadness and joy. Those who experienced the greatest portion of positive thoughts were those who had open, rather than closed or time-limited mediated, adoptions.In another study that compared mothers who released their children to those who raised them, mothers who released their children were more likely to delay their next pregnancy, to delay marriage, and to complete job training. However, both groups reached lower levels of education than their peers who were never pregnant. Another study found similar consequences for choosing to release a child for adoption. Adolescent mothers who released their children were more likely to reach a higher level of education and to be employed than those who kept their children. They also waited longer before having their next child. Most of the research that exists on adoption effects on the birth parents was conducted with samples of adolescents, or with women who were adolescents when carrying their babies—little data exists for birth parents from other populations. Furthermore, there is a lack of longitudinal data that may elucidate long-term social and psychological consequences for birth parents who choose to place their children for adoption.

Development of adoptees
Previous research on adoption has led to assumptions that indicate that there is a heightened risk in terms of psychological development and social relationships for adoptees. Yet, such assumptions have been clarified as flawed due to methodological failures. But more recent studies have been supportive in indicating more accurate information and results about the similarities, differences and overall lifestyles of adoptees.Evidence about the development of adoptees can be supported in newer studies. It can be said that adoptees, in some respect, tend to develop differently from the general population. This can be seen in many aspects of life, but usually can be found as a greater risk around the time of adolescence. For example, it has been found that many adoptees experience difficulty in establishing a sense of identity.

Identity
There are many ways in which the concept of identity can be defined. It is true in all cases that identity construction is an ongoing process of development, change and maintenance of identifying with the self. Research has shown that adolescence is a time of identity progression rather than regression. Ones identity tends to lack stability in the beginning years of life but gains a more stable sense in later periods of childhood and adolescence. Typically associated with a time of experimentation, there are endless factors that go into the construction of ones identity. As well as being many factors, there are many types of identities one can associate with. Some categories of identity include gender, sexuality, class, racial and religious, etc. For transracial and international adoptees, tension is generally found in the categories of racial, ethnic and national identification. Because of this, the strength and functionality of family relationships play a huge role in its development and outcome of identity construction. Transracial and transnational adoptees tend to develop feelings of a lack of acceptance because of such racial, ethnic, and cultural differences. Therefore, exposing transracial and transnational adoptees to their "cultures of origin" is important in order to better develop a sense of identity and appreciation for cultural diversity. Identity construction and reconstruction for transnational adoptees the instant they are adopted. For example, based upon specific laws and regulations of the United States, the Child Citizen Act of 2000 makes sure to grant immediate U.S. citizenship to adoptees.Identity is defined both by what one is and what one is not. Adoptees born into one family lose an identity and then borrow one from the adopting family.
The formation of identity is a complicated process and there are many factors that affect its outcome. From a perspective of looking at issues in adoption circumstances, the people involved and affected by adoption (the biological parent, the adoptive parent and the adoptee) can be known as the "triad members and state".
Adoption may threaten triad members sense of identity. Triad members often express feelings related to confused identity and identity crises because of differences between the triad relationships.
Adoption, for some, precludes a complete or integrated sense of self. Triad members may experience themselves as incomplete, deficient, or unfinished. They state that they lack feelings of well-being, integration, or solidity associated with a fully developed identity.

Influences
Family plays a vital role in identity formation. This is not only true in childhood but also in adolescence. Identity (gender/sexual/ethnic/religious/family) is still forming during adolescence and family holds a vital key to this.
The research seems to be unanimous; a stable, secure, loving, honest and supportive family in which all members feel safe to explore their identity is necessary for the formation of a sound identity. Transracial and International adoptions are some factors that play a significant role in the identity construction of adoptees. Many tensions arise from relationships built between the adoptee(s) and their family. These include being "different" from the parent(s), developing a positive racial identity, and dealing with racial/ethnic discrimination. It has been found that multicultural and transnational youth tend to identify with their parents origin of culture and ethnicity rather than their residing location, yet it is sometimes hard to balance an identity between the two because school environments tend to lack diversity and acknowledgment regarding such topics. These tensions also tend to create questions for the adoptee, as well as the family, to contemplate. Some common questions include what will happen if the family is more naïve to the ways of socially constructed life? Will tensions arise if this is the case? What if the very people that are supposed to be modeling a sound identity are in fact riddled with insecurities? Ginni Snodgrass answers these questions in the following way.
The secrecy in an adoptive family and the denial that the adoptive family is different builds dysfunction into it. "... social workers and insecure adoptive parents have structured a family relationship that is based on dishonesty, evasions and exploitation. To believe that good relationships will develop on such a foundation is psychologically unsound" (Lawrence). Secrecy erects barriers to forming a healthy identity.The research says that the dysfunction, untruths and evasiveness that can be present in adoptive families not only makes identity formation impossible, but also directly works against it. What effect on identity formation is present if the adoptee knows they are adopted but has no information about their biological parents? Silverstein and Kaplans research states that adoptees lacking medical, genetic, religious, and historical information are plagued by questions such as "Who am I?" "Why was I born?" "What is my purpose?" This lack of identity may lead adoptees, particularly in adolescent years, to seek out ways to belong in a more extreme fashion than many of their non-adopted peers. Adolescent adoptees are overrepresented among those who join sub-cultures, run away, become pregnant, or totally reject their families.Concerning developmental milestones, studies from the Colorado Adoption Project examined genetic influences on adoptee maturation, concluding that cognitive abilities of adoptees reflect those of their adoptive parents in early childhood but show little similarity by adolescence, resembling instead those of their biological parents and to the same extent as peers in non-adoptive families.Similar mechanisms appear to be at work in the physical development of adoptees. Danish and American researchers conducting studies on the genetic contribution to body mass index found correlations between an adoptees weight class and his biological parents BMI while finding no relationship with the adoptive family environment. Moreover, about one-half of inter-individual differences were due to individual non-shared influences.These differences in development appear to play out in the way young adoptees deal with major life events. In the case of parental divorce, adoptees have been found to respond differently from children who have not been adopted. While the general population experienced more behavioral problems, substance use, lower school achievement, and impaired social competence after parental divorce, the adoptee population appeared to be unaffected in terms of their outside relationships, specifically in their school or social abilities.The adoptee population does, however, seem to be more at risk for certain behavioral issues. Researchers from the University of Minnesota studied adolescents who had been adopted and found that adoptees were twice as likely as non-adopted people to develop oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD), with an 8% rate in the general population. Suicide risks were also significantly greater than the general population. Swedish researchers found both international and domestic adoptees undertook suicide at much higher rates than non-adopted peers; with international adoptees and female international adoptees, in particular, at highest risk.Nevertheless, work on adult adoptees has found that the additional risks faced by adoptees are largely confined to adolescence. Young adult adoptees were shown to be alike with adults from biological families and scored better than adults raised in alternative family types including single parent and step-families. Moreover, while adult adoptees showed more variability than their non-adopted peers on a range of psychosocial measures, adult adoptees exhibited more similarities than differences with adults who had not been adopted. There have been many cases of remediation or the reversibility of early trauma. For example, in one of the earliest studies conducted, Professor Goldfarb in England concluded that some children adjust well socially and emotionally despite their negative experiences of institutional deprivation in early childhood. Other researchers also found that prolonged institutionalization does not necessarily lead to emotional problems or character defects in all children. This suggests that there will always be some children who fare well, who are resilient, regardless of their experiences in early childhood. Furthermore, much of the research on psychological outcomes for adoptees draws from clinical populations. This suggests that conclusions such that adoptees are more likely to have behavioral problems such as ODD and ADHD may be biased. Since the proportion of adoptees that seek mental health treatment is small, psychological outcomes for adoptees compared to those for the general population are more similar than some researchers propose.

Mental health
Adopted children are more likely to experience psychological and behavioral problems than non-adopted peers. Children who were older than four at the time of their adoption experience more psychological problems than those who were younger.According to study in the UK, adopted children can have mental health problems that do not improve even four years after their adoption. Children with multiple adverse childhood experiences are more likely to have mental health problems. The study suggests that to identify and tread mental health problems early, care professionals and the adopting parents need detailed biographical information about the childs life. Another study in the UK suggests that adopted children are more likely to suffer from post-traumatic stress (PTS) than the general population. Their PTS symptoms depend on the type of adverse experiences they went through and knowledge of their history offers an option for tailored support.

Adoptees of LGBT parents
There is evidence that shows the adoptees of LGBT families and those in heterosexual families have no significant differences in development. One of the main arguments used against same-sex adoption is that a child needs a mother and a father in the home to develop properly. However, a 2013 study of predictors for psychological outcomes of adoptees showed that family type (hetero, gay, lesbian) does not affect the childs adjustment; rather the preparedness of the adoptive parent(s), and health of relationship to partner, and other contextual factors predicted later adjustment in early placed adoptees. Along with this, a 2009 study showed again that sexual orientation of parents does not affect externalizing and internalized problems, but family functioning and income can affect adjustment, especially for older adoptees.

Public perception of adoption
In Western culture, many see that the common image of a family being that of a heterosexual couple with biological children. This idea places alternative family forms outside the norm. As a consequence – research indicates – disparaging views of adoptive families exist, along with doubts concerning the strength of their family bonds.The most recent adoption attitudes survey completed by the Evan Donaldson Institute provides further evidence of this stigma. Nearly one-third of the surveyed population believed adoptees are less-well adjusted, more prone to medical issues, and predisposed to drug and alcohol problems. Additionally, 40–45% thought adoptees were more likely to have behavior problems and trouble at school. In contrast, the same study indicated adoptive parents were viewed favorably, with nearly 90% describing them as "lucky, advantaged, and unselfish".The majority of people state that their primary source of information about adoption comes from friends and family and the news media. Nevertheless, most people report the media provides them a favorable view of adoption; 72% indicated receiving positive impressions. There is, however, still substantial criticism of the medias adoption coverage. Some adoption blogs, for example, criticized Meet the Robinsons for using outdated orphanage imagery as did advocacy non-profit The Evan B. Donaldson Adoption Institute.The stigmas associated with adoption are amplified for children in foster care. Negative perceptions result in the belief that such children are so troubled it would be impossible to adopt them and create "normal" families. A 2004 report from the Pew Commission on Children in Foster Care has shown that the number of children waiting in foster care doubled since the 1980s and now remains steady at about a half-million a year."Attitude toward Adoption Questionnaire (ATAQ): this questionnaire was first developed by Abdollahzadeh, Chaloyi and Mahmoudi(2019). Preliminary Edition: This questionnaire has 23 items based on the Likert scale of 1 (totally Disagree), up to 5 (Totally Agree) being obtained after refining the items designed to construct the present tool and per-study study. The analysis of item and initial psychometric analyses indicate that there are two factors in it. Items 3-10-11-12-14-15-16-17-19-20-21 are reversed and the rest are graded positively. The results of exploratory factor analysis by main components with varimax rotation indicated two components of attitude toward adoption being named respectively cognitive as the aspects of attitude toward adoption and behavioral-emotional aspects of attitude toward adoption. These two components explained 43.25% of the variance of the total sample. Cronbachs alpha coefficient was used to measure the reliability of the questionnaire. Cronbachs alpha coefficient was 0.709 for the whole questionnaire, 0.71 for the first component, and 0.713 for the second one. In addition, there was a significant positive relationship between desired social tendencies and the cognitive aspect of attitude toward adoption as well as the behavioral -emotional aspects of attitude toward adoption (P ≤ 0.01).

Reform and reunion trends
Adoption practices have changed significantly over the course of the 20th century, with each new movement labeled, in some way, as reform. Beginning in the 1970s, efforts to improve adoption became associated with opening records and encouraging family preservation. These ideas arose from suggestions that the secrecy inherent in modern adoption may influence the process of forming an identity, create confusion regarding genealogy, and provide little in the way of medical history.
Family preservation: As concerns over illegitimacy began to decline in the early 1970s, social-welfare agencies began to emphasize that, if possible, mothers and children should be kept together. In the U.S., this was clearly illustrated by the shift in policy of the New York Foundling Home, an adoption-institution that is among the countrys oldest and one that had pioneered sealed records. It established three new principles including "to prevent placements of children...", reflecting the belief that children would be better served by staying with their biological families, a striking shift in policy that remains in force today. In addition, groups such as Origins USA (founded in 1997) started to actively speak about family preservation and the rights of mothers. The intellectual tone of these reform movements was influenced by the publishing of The Primal Wound by Nancy Verrier. "Primal wound" is described as the "devastation which the infant feels because of separation from its birth mother. It is the deep and consequential feeling of abandonment which the baby adoptee feels after the adoption and which may continue for the rest of his life."Open records: After a legal adoption in the United States, an adopted persons original birth certificate is usually amended and replaced with a new post-adoption birth certificate. The names of any birth parents listed on the original birth certificate are replaced on an amended certificate with the names of the adoptive parents, making it appear that the child was born to the adoptive parents. Beginning in the late 1930s and continuing through the 1970s, state laws allowed for the sealing of original birth certificates after an adoption and, except in some states, made the original birth certificate unavailable to the adopted person even at the age of majority.Adopted people have long sought to undo these laws so that they can obtain their own original birth certificates. Movements to unseal original birth certificates and other adoption records for adopted people proliferated in the 1970s along with increased acceptance of illegitimacy. In the United States, Jean Paton founded Orphan Voyage in 1954, and Florence Fisher founded the Adoptees Liberty Movement Association (ALMA) in 1971, calling sealed records "an affront to human dignity". While in 1975, Emma May Vilardi created the first mutual-consent registry, the International Soundex Reunion Registry (ISRR), allowing those separated by adoption to locate one another. and Lee Campbell and other birthmothers established CUB (Concerned United Birthparents). Similar ideas were taking hold globally with grass-roots organizations like Parent Finders in Canada and Jigsaw in Australia. In 1975, England and Wales opened records on moral grounds.By 1979, representatives of 32 organizations from 33 states, Canada and Mexico gathered in Washington, DC, to establish the American Adoption Congress (AAC) passing a unanimous resolution: "Open Records complete with all identifying information for all members of the adoption triad, birthparents, adoptive parents and adoptee at the adoptees age of majority (18 or 19, depending on state) or earlier if all members of the triad agree." Later years saw the evolution of more militant organizations such as Bastard Nation (founded in 1996), groups that helped overturn sealed records in Alabama, Delaware, New Hampshire, Oregon, Tennessee, and Maine. A coalition of New York and national adoptee rights activists successfully worked to overturn a restrictive 83-year-old law in 2019, and adult adopted people born in New York, as well as their descendants, today have the right to request and obtain their own original birth certificates. As of 2021, ten states in the United States recognize the right of adult adopted people to obtain their own original birth certificates, including Alabama, Alaska, Colorado, Connecticut, Kansas, Maine, New Hampshire, New York, Oregon and Rhode Island. Connecticut in 2021 became the tenth state to restore an adopted persons right to request and obtain their original birth certificates.

Reunion
Estimates for the extent of search behavior by adoptees have proven elusive; studies show significant variation. In part, the problem stems from the small adoptee population which makes random surveying difficult, if not impossible.
Nevertheless, some indication of the level of search interest by adoptees can be gleaned from the case of England and Wales which opened adoptees birth records in 1975. The U.K. Office for National Statistics has projected that 33% of all adoptees would eventually request a copy of their original birth records, exceeding original forecasts made in 1975 when it was believed that only a small fraction of the adoptee population would request their records. The projection is known to underestimate the true search rate, however, since many adoptees of the era get their birth records by other means.The research literature states adoptees give four reasons for desiring reunion: 1) they wish for a more complete genealogy, 2) they are curious about events leading to their conception, birth, and relinquishment, 3) they hope to pass on information to their children, and 4) they have a need for a detailed biological background, including medical information. It is speculated by adoption researchers, however, that the reasons given are incomplete: although such information could be communicated by a third-party, interviews with adoptees, who sought reunion, found they expressed a need to actually meet biological relations.It appears the desire for reunion is linked to the adoptees interaction with and acceptance within the community. Internally focused theories suggest some adoptees possess ambiguities in their sense of self, impairing their ability to present a consistent identity. Reunion helps resolve the lack of self-knowledge.Externally focused theories, in contrast, suggest that reunion is a way for adoptees to overcome social stigma. First proposed by Goffman, the theory has four parts: 1) adoptees perceive the absence of biological ties as distinguishing their adoptive family from others, 2) this understanding is strengthened by experiences where non-adoptees suggest adoptive ties are weaker than blood ties, 3) together, these factors engender, in some adoptees, a sense of social exclusion, and 4) these adoptees react by searching for a blood tie that reinforces their membership in the community. The externally focused rationale for reunion suggests adoptees may be well adjusted and happy within their adoptive families, but will search as an attempt to resolve experiences of social stigma.Some adoptees reject the idea of reunion. It is unclear, though, what differentiates adoptees who search from those who do not. One paper summarizes the research, stating, "...attempts to draw distinctions between the searcher and non-searcher are no more conclusive or generalizable than attempts to substantiate ... differences between adoptees and nonadoptees."In sum, reunions can bring a variety of issues for adoptees and parents. Nevertheless, most reunion results appear to be positive. In the largest study to date (based on the responses of 1,007 adoptees and relinquishing parents), 90% responded that reunion was a beneficial experience. This does not, however, imply ongoing relationships were formed between adoptee and parent nor that this was the goal.

Controversial adoption practices
Reform and family preservation efforts have also been strongly associated with the perceived misuse of adoption. In some cases, parents rights have been terminated when their ethnic or socio-economic group has been deemed unfit by society. Some of these practices were generally accepted but have later been considered abusive; others were uncontroversially reprehensible.
Forced adoption based on ethnicity occurred during World War II. In German-occupied Poland, it is estimated that 200,000 Polish children with purportedly Aryan traits were removed from their families and given to German or Austrian couples, and only 25,000 returned to their families after the war.The Stolen Generation of Aboriginal people in Australia were affected by similar policies, as were Native Americans in the United States and First Nations of Canada.These practices have become significant social and political issues in recent years, and in many cases the policies have changed. The United States, for example, now has the 1978 Indian Child Welfare Act, which allows the tribe and family of a Native American child to be involved in adoption decisions, with preference being given to adoption within the childs tribe.From the 1950s through the 1970s, a period called the baby scoop era, adoption practices that involved coercion were directed against unwed mothers, as described for the U.S. in The Girls Who Went Away.
More recently the military dictatorship in Argentina from 1976 to 1983 is known to have given hundreds of babies born to women captives who were then murdered to be brought up by military families.In Spain under Francisco Francos 1939–75 dictatorship the newborns of some left-wing opponents of the regime, or unmarried or poor couples, were removed from their mothers and adopted. New mothers were frequently told their babies had died suddenly after birth and the hospital had taken care of their burials, when in fact they were given or sold to another family. It is believed that up to 300,000 babies were involved. These system—which allegedly involved doctors, nurses, nuns and priests—outlived Francos death in 1975 and carried on as an illegal baby trafficking network until 1987 when a new law regulating adoption was introduced.On January 29, 2010, a group of ten American Baptist missionaries from Idaho attempted to cross the Haiti–Dominican Republic border with 33 Haitian children. The group, known as the New Life Childrens Refuge, did not have proper authorization for transporting the children and were arrested on kidnapping charges. After the process for the adoption of 400 children by families in the US and the Netherlands was expedited, Unicef and SOS Children urged an immediate halt to adoptions from Haiti. Jasmine Whitbread, chief executive of Save the Children said: "The vast majority of the children currently on their own still have family members alive who will be desperate to be reunited with them and will be able to care for them with the right support. Taking children out of the country would permanently separate thousands of children from their families—a separation that would compound the acute trauma they are already suffering and inflict long-term damage on their chances of recovery."

Rehoming in the United States
With the increase in adoption rates over the many decades, the United States has been faced with a new morally questionable practice: rehoming. This is the act of caregivers posting an advertisement when they do not feel the child should be in their care any longer. Investigation of the childs new housing situation is not required in this practice, and this has created an underground market, one where child traffickers can thrive. There is a lack of regulation surrounding this practice and current legislation contradicts each other, making this harder to combat.
When a parent adopts a child, they may not have been aware that the child has special needs and thus, are not equipped to help this child. The child may act out or not fit in with the family so the family turns to rehoming. Rehoming is not adoption and because of that, the government does not have to be notified and adoption agencies are not involved. Thus, re-homing is a prime target for child and sex traffickers. There are laws set in place to protect children through adoption processes and against sex trafficking, but there are barely any laws regarding rehoming. The courts authorize this practice because the U.S. state law may allow a parent, legal guardian or relative within the second degree to place out or board out a child. However, while the U.S. federal bill Preventing Sex Trafficking and Strengthening Families Act would require the family to make rational decisions and prioritize the health of the child, the Interstate Compact on the Placement of Children contradicts this. This states that the family only has to make sure children are placed in adequate care only when the re-homing process is done across state lines. There is no mention of maintaining the childrens safety when rehoming within the same state.
The laws surrounding rehoming are basically non-existent which puts adopted children at the risk of unequipped parents and all other types of dysfunctional homes. This second-chance adoption, as some parents see it, has led to negative effects that failed adoptions have on children as they go through the process of readapting to a new home environment again. With the statute that allows second-degree legal guardians to put their adopted child in the care of someone else, and the rising of re-homing websites and ads on social media, the rehoming process highly exposes children to underground markets and other trafficking prospects. In that regard, laws and statutes concerning adoption and rehoming should be re-evaluated to ensure the full protection of adopted children.
In 2018, the Uniform Law Commission formed a committee to study the rehoming issue, which is also known more formerly as "unregulated transfer of adopted children". The committee indicated that it will draft a uniform or model law to prohibit the unregulated transfer of all adopted children.

Adoption terminology
The language of adoption is changing and evolving, and since the 1970s has been a controversial issue tied closely to adoption reform efforts. The controversy arises over the use of terms which, while designed to be more appealing or less offensive to some persons affected by adoption, may simultaneously cause offense or insult to others. This controversy illustrates the problems in adoption, as well as the fact that coining new words and phrases to describe ancient social practices will not necessarily alter the feelings and experiences of those affected by them. Two of the contrasting sets of terms are commonly referred to as "positive adoption language" (PAL) (sometimes called "respectful adoption language" (RAL)), and "honest adoption language" (HAL).

Positive adoptive language (PAL)
In the 1970s, as adoption search and support organizations developed, there were challenges to the language in common use at the time. As books like Adoption Triangle by Sorosky, Pannor and Baran were published, and support groups formed like CUB (Concerned United Birthparents), a major shift from "natural parent" to "birthparent" occurred. Along with the change in times and social attitudes came additional examination of the language used in adoption.
Social workers and other professionals in the field of adoption began changing terms of use to reflect what was being expressed by the parties involved. In 1979, Marietta Spencer wrote "The Terminology of Adoption" for The Child Welfare League of America (CWLA), which was the basis for her later work "Constructive Adoption Terminology". This influenced Pat Johnstons "Positive Adoption Language" (PAL) and "Respectful Adoption Language" (RAL). The terms contained in "Positive Adoption Language" include the terms "birth mother" (to replace the terms "natural mother" and "real mother"), and "placing" (to replace the term "surrender"). These kinds of recommendations encouraged people to be more aware of their use of adoption terminology.

Honest adoption language (HAL)
"Honest Adoption Language" refers to a set of terms that proponents say reflect the point of view that: (1) family relationships (social, emotional, psychological or physical) that existed prior to the legal adoption often continue past this point or endure in some form despite long periods of separation, and that (2) mothers who have "voluntarily surrendered" children to adoption (as opposed to involuntary terminations through court-authorized child-welfare proceedings) seldom view it as a choice that was freely made, but instead describe scenarios of powerlessness, lack of resources, and overall lack of choice. It also reflects the point of view that the term "birth mother" is derogatory in implying that the woman has ceased being a mother after the physical act of giving birth. Proponents of HAL liken this to the mother being treated as a "breeder" or "incubator". Terms included in HAL include terms that were used before PAL, including "natural mother", "first mother", and "surrendered for adoption".

Inclusive adoption language
There are supporters of various lists, developed over many decades, and there are persons who find them lacking, created to support an agenda, or furthering division. All terminology can be used to demean or diminish, uplift or embrace. In addressing the linguistic problem of naming, Edna Andrews says that using "inclusive" and "neutral" language is based upon the concept that "language represents thought, and may even control thought."Advocates of inclusive language defend it as inoffensive-language usage whose goal is multi-fold:

The rights, opportunities, and freedoms of certain people are restricted because they are reduced to stereotypes.
Stereotyping is mostly implicit, unconscious, and facilitated by the availability of pejorative labels and terms.
Rendering the labels and terms socially unacceptable, people then must consciously think about how they describe someone unlike themselves.
When labeling is a conscious activity, the described persons individual merits become apparent, rather than his or her stereotype.A common problem is that terms chosen by an identity group, as acceptable descriptors of themselves, can be used in negative ways by detractors. This compromises the integrity of the language and turns what was intended to be positive into negative or vice versa, thus often devaluing acceptability, meaning and use.
Language at its best honors the self-referencing choices of the persons involved, uses inclusive terms and phrases, and is sensitive to the feelings of the primary parties. Language evolves with social attitudes and experiences.

Cultural variations
Attitudes and laws regarding adoption vary greatly. Whereas all cultures make arrangements whereby children whose birth parents are unavailable to rear them can be brought up by others, not all cultures have the concept of adoption, that is treating unrelated children as equivalent to biological children of the adoptive parents. Under Islamic Law, for example, adopted children must keep their original surname to be identified with blood relations, and, traditionally, women wear a hijab in the presence of males in their adoptive households. In Egypt, these cultural distinctions have led to making adoption illegal opting instead for a system of foster care.

Homecoming Day
In some countries, such as the United States, "Homecoming Day" is the day when an adoptee is officially united with their new adoptive family.

See also
References
Barbara Melosh, the American Way of Adoption page 10

Further reading
Argent, Hedi. Related by Adoption: a handbook for grandparents and other relatives (2014)
Askeland, Lori. Children and Youth in Adoption, Orphanages, and Foster Care: A Historical Handbook and Guide (2005) excerpt and text search
Carp, E. Wayne, ed. Adoption in America: Historical Perspectives (2002)
Carp, E. Wayne. Family Matters: Secrecy and Disclosure in the History of Adoption (2000)
Carp, E. Wayne. Jean Paton and the Struggle to Reform American Adoption (University of Michigan Press; 2014) 422 pages; Scholarly biography of an activist (1908–2002) who led the struggle for open adoption records
Conn, Peter. Adoption: A Brief Social and Cultural History (2013) excerpt and text search
Eskin, Michael. The Wisdom of Parenthood: An Essay (New York: Upper West Side Philosophers, Inc. 2013)
Fessler, Ann. The Girls Who Went Away: The Hidden History of Women Who Surrendered Children for Adoption in the Decades Before Roe v </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Myositis ossificans and can you explain it in depth? [/INST] Myositis ossificans comprises two syndromes characterized by heterotopic ossification (calcification) of muscle. The World Health Organization, 2020, has grouped myositis ossificans together with fibro-osseous pseudotumor of digits as a single specific entity in the category of fibroblastic and myofibroblastic tumors.

Classification
In the first, and by far most common type, nonhereditary myositis ossificans (commonly referred to simply as "myositis ossificans", as in the remainder of this article), calcifications occur at the site of injured muscle, most commonly in the arms or in the quadriceps of the thighs.
The term myositis ossificans traumatica is sometimes used when the condition is due to trauma. Also myositis ossificans circumscripta is another  synonym of myositis ossificans traumatica refers to the new extraosseous bone that appears after trauma.
The second condition, myositis ossificans progressiva (also referred to as fibrodysplasia ossificans progressiva) is an inherited affliction, autosomal dominant pattern, in which the ossification can occur without injury, and typically grows in a predictable pattern. Although this disorder can be passed to offspring by those afflicted with FOP, it is also classified as nonhereditary, as it is most often attributed to a spontaneous genetic mutation upon conception.Most (i.e. 80%) ossifications arise in the thigh or arm, and are caused by a premature return to activity after an injury. Other sites include intercostal spaces, erector spinae, pectoralis muscles, glutei, and the chest. On planar x-ray, hazy densities are sometimes noted approximately one month after injury, while the denser opacities eventually seen may not be apparent until two months have passed.

Pathophysiology
The exact mechanism of myositis ossificans is not clear. Inappropriate response of stem cells in the bone against the injury or inflammation causes inappropriate differentiation of fibroblasts into osteogenic cells. When a skeletal muscle is injured, inflammatory cytokines (Bone morphogenetic protein 2, Bone morphogenetic protein 4, and Transforming growth factor) are released. These cytokines stimulate the endothelial cells of the blood vessels to transform into mesenchymal stem cells. These mesenchymal stem cells then differentiate into chondrocytes, and osteoblasts, resulting in bone formation in soft tissues.The process of myositis ossificans can be divided into three stages: early, intermediate, and mature. The early phase occurs in the first four weeks of injury with inflammatory phase of bone formation. This is followed by intermediate phase of bone formation (four to eight weeks following injury) where calcification started to occur and is visible on X-rays. During the maturation phase, mature bone started to form. As the maturation continues, the bone will consolidate in the coming months and subsequently bone regression occurs.

Diagnosis
Sonographic diagnosis
Calcification is typically depicted 2 weeks earlier by ultrasound (US) when compared to radiographs. The lesion develops in two distinct stages with different presentations at US. In the early stage, termed immature, it  depicts a non-specific soft tissue mass that ranges from a hypoechoic area with an outer sheet-like hyperechoic peripheral rim to a highly echogenic area with variable shadowing. In the late stage, termed mature, myositis ossificans is depicted as an elongated calcific deposit that is aligned with the long-axis of the muscle, exhibits acoustic shadowing, and has no soft tissue mass associated. US may suggest the diagnosis at early stage, but imaging features need to evolve with successive maturation of the lesion and formation of the characteristic late stage changes before they become pathognomonic.The differential diagnosis includes many tumoral and nontumoral pathologies. A main concern is to differentiate early myositis ossificans from malignant soft-tissue tumors, and the latter is suggested by a fast-growing process. If clinical or sonographic findings are dubious and extraosseous sarcoma is suspected, biopsy should be performed. At histology, detection of the typical zonal phenomenon is diagnostic of myositis ossificans, though microscopic findings may be misleading during the early stage.

Radiologic  diagnosis
The radiological features of myositis ossificans are ‘faint soft tissue calcification within 2–6 weeks, (may have well-defined
bony margins by 8 weeks) separated from periosteum by lucent zone and on CT, the characteristic feature is peripheral ossification’.

Management
Since myositis ossificians is more common in those with bleeding disorders, the formation of bone in soft tissue is thought to be associated with haematoma formation </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Sadness and can you explain it in depth? [/INST] Sadness is an emotional pain associated with, or characterized by, feelings of disadvantage, loss, despair, grief, helplessness, disappointment and sorrow. An individual experiencing sadness may become quiet or lethargic, and withdraw themselves from others. An example of severe sadness is depression, a mood which can be brought on by major depressive disorder or persistent depressive disorder. Crying can be an indication of sadness.Sadness is one of the six basic emotions described by Paul Ekman, along with happiness, anger, surprise, fear, and disgust.: 271–4

Childhood
Sadness is a common experience in childhood. Sometimes, sadness can lead to depression. Some families may have a (conscious or unconscious) rule that sadness is "not allowed", but Robin Skynner has suggested that this may cause problems, arguing that with sadness "screened off", people can become shallow and manic.: 33, 36  Pediatrician T. Berry Brazelton suggests that acknowledging sadness can make it easier for families to address more serious emotional problems.: 46, 48 Sadness is part of the normal process of the child separating from an early symbiosis with the mother and becoming more independent. Every time a child separates a little more, he or she will have to cope with a small loss. If the mother cannot allow the minor distress involved, the child may never learn how to deal with sadness by themselves.: 158–9  Brazelton argues that too much cheering a child up devalues the emotion of sadness for them;: 52  and Selma Fraiberg suggests that it is important to respect a childs right to experience a loss fully and deeply.Margaret Mahler also saw the ability to feel sadness as an emotional achievement, as opposed for example to warding it off through restless hyperactivity. D. W. Winnicott similarly saw in sad crying the psychological root of valuable musical experiences in later life.

Neuroanatomy
A large amount of research has been conducted on the neuroscience of sadness. According to the American Journal of Psychiatry, sadness has been found to be associated with "increases in bilateral activity within the vicinity of the middle and posterior temporal cortex, lateral cerebellum, cerebellar vermis, midbrain, putamen, and caudate." Jose V. Pardo has his M.D and Ph.D and leads a research program in cognitive neuroscience. Using positron emission tomography (PET) Pardo and his colleagues were able to provoke sadness among seven normal men and women by asking them to think about sad things. They observed increased brain activity in the bilateral inferior and orbitofrontal cortex. In a study that induced sadness in subjects by showing emotional film clips, the feeling was correlated with significant increases in regional brain activity, especially in the prefrontal cortex, in the region called Brodmanns area 9, and the thalamus. A significant increase in activity was also observed in the bilateral anterior temporal structures.

Coping mechanisms
People deal with sadness in different ways, and it is an important emotion because it helps to motivate people to deal with their situation. Some coping mechanisms include: getting social support and/or spending time with a pet, creating a list, or engaging in some activity to express sadness. Some individuals, when feeling sad, may exclude themselves from a social setting, so as to take the time to recover from the feeling.While being one of the moods people most want to shake, sadness can sometimes be perpetuated by the very coping strategies chosen, such as ruminating, "drowning ones sorrows", or permanently isolating oneself.: 69–70  As alternative ways of coping with sadness to the above, cognitive behavioral therapy suggests instead either challenging ones negative thoughts, or scheduling some positive event as a distraction.: 72 Being attentive to, and patient with, ones sadness may also be a way for people to learn through solitude; while emotional support to help people stay with their sadness can be further helpful.: 164  Such an approach is fueled by the underlying belief that loss (when felt wholeheartedly) can lead to a new sense of aliveness, and to a re-engagement with the outside world.

Pupil empathy
Pupil size may be an indicator of sadness. A sad facial expression with small pupils is judged to be more intensely sad as the pupil size decreases. A persons own pupil size also mirrors this and becomes smaller when viewing sad faces with small pupils </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Presbyopia and can you explain it in depth? [/INST] Presbyopia is physiological insufficiency of accommodation associated with the aging of the eye that results in progressively worsening ability to focus clearly on close objects. Also known as age-related farsightedness (or age-related long sight in the UK), it affects many adults over the age of 40. A common sign of presbyopia is difficulty reading small print which results in having to hold reading material farther away.  Other symptoms associated can be headaches and eyestrain. Different people will have different degrees of problems. Other types of refractive errors may exist at the same time as presbyopia.  This condition is similar to hypermetropia or far-sightedness which starts in childhood and exhibits similar symptoms of blur in the vision for close objects.
Presbyopia is a typical part of the aging process. It occurs due to age related changes in the lens (decreased elasticity and increased hardness) and ciliary muscle (decreased strength and ability to move the lens), causing the eye to focus right behind rather than on the retina when looking at close objects. It is a type of refractive error along with nearsightedness, farsightedness, and astigmatism. Diagnosis is by an eye examination.Presbyopia can be corrected using glasses, contact lenses, multifocal intraocular lenses, or LASIK (presbyLASIK) surgery. The most common treatment is glass correction using appropriate convex lens. Glasses used to correct presbyopia may be simple reading glasses, bifocals, trifocals, or progressive lens.People over 40 are at risk for developing presbyopia and all people become affected to some degree. Around 25% of people (1.8 billion globally) are currently affected.

Signs and symptoms
The first symptoms most people notice are difficulty reading fine print, particularly in low light conditions, eyestrain when reading for long periods, blurring of near objects or temporarily blurred vision when changing the viewing distance. Many extreme presbyopes complain that their arms have become "too short" to hold reading material at a comfortable distance.Presbyopia, like other focal imperfections, becomes less noticeable in bright sunlight when the pupil becomes smaller. As with any lens, increasing the focal ratio of the lens increases depth of field by reducing the level of blur of out-of-focus objects (compare the effect of aperture on depth of field in photography).
The onset of presbyopia varies among those with certain professions and those with miotic pupils. In particular, farmers and homemakers seek correction later, whereas service workers and construction workers seek correction earlier. Scuba divers with interest in underwater photography may notice presbyopic changes while diving before they recognize the symptoms in their normal routines due to the near focus in low light conditions.

Interaction with myopia
People with low near-sightedness can read comfortably without eyeglasses or contact lenses even after age forty, but higher myopes might require two pairs of glasses (one for distance, one for near), bifocal, or progressive lenses. However, their myopia does not disappear and the long-distance visual challenges remain. Myopes considering refractive surgery are advised that surgically correcting their nearsightedness may be a disadvantage after age forty, when the eyes become presbyopic and lose their ability to accommodate or change focus, because they will then need to use glasses for reading. Myopes with low astigmatism find near vision better, though not perfect, without glasses or contact lenses when presbyopia sets in, but the more astigmatism, the poorer the uncorrected near vision.A surgical technique offered is to create a "reading eye" and a "distance vision eye", a technique commonly used in contact lens practice, known as monovision. Monovision can be created with contact lenses, so candidates for this procedure can determine if they are prepared to have their corneas reshaped by surgery to cause this effect permanently.

Mechanism
The cause of presbyopia is lens hardening by decreasing levels of α-crystallin, a process which may be sped up by higher temperatures. It results in a near point greater than 25 cm (or equivalently, less than 4 diopters).
In optics, the closest point at which an object can be brought into focus by the eye is called the eyes near point. A standard near point distance of 25 cm is typically assumed in the design of optical instruments, and in characterizing optical devices such as magnifying glasses.There is some confusion over how the focusing mechanism of the eye works. In the 1977 book, Eye and Brain, for example, the lens is said to be suspended by a membrane, the zonula, which holds it under tension. The tension is released, by contraction of the ciliary muscle, to allow the lens to become more round, for close vision. This implies the ciliary muscle, which is outside the zonula, must be circumferential, contracting like a sphincter, to slacken the tension of the zonula pulling outwards on the lens. This is consistent with the fact that our eyes seem to be in the relaxed state when focusing at infinity, and also explains why no amount of effort seems to enable a myopic person to see farther away.
The ability to focus on near objects declines throughout life, from an accommodation of about 20 dioptres (ability to focus at 50 mm away) in a child, to 10 dioptres at age 25 (100 mm), and levels off at 0.5 to 1 dioptre at age 60 (ability to focus down to 1–2 meters only). The expected, maximum, and minimum amplitudes of accommodation in diopters (D) for a corrected patient of a given age can be estimated using Hofstetters formulas: expected amplitude (D) = 18.5 - 0.3 × (age in years), maximum amplitude (D) = 25 - 0.4 × (age in years), minimum amplitude (D) = 15 - 0.25 × (age in years).

Diagnosis
Treatment
In the visual system, images captured by the eye are translated into electric signals that are transmitted to the brain where they are interpreted </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Childhood arthritis and can you explain it in depth? [/INST] Childhood arthritis (also known as juvenile arthritis, JRA, Juvenile Idiopathic Disease or Arthritis, or Stills Disease) is any form of chronic arthritis or chronic arthritis-related conditions which affects individuals under the age of 16. Most types are autoimmune disorders.

Signs and symptoms
Several types of childhood arthritis exist, the most common being juvenile idiopathic arthritis (JIA), also known as juvenile rheumatoid arthritis (JRA) or juvenile chronic arthritis (JCA).  Other types of childhood arthritis include juvenile myositis, juvenile lupus, juvenile scleroderma, vasculitis, and fibromyalgia.JRA again can be divided into three main forms: The classification is based upon symptoms, number of joints involved and the presence of certain antibodies in the blood.
Polyarticular arthritis is the first type of arthritis, which affects about 30–40% of children with arthritis and is more common in girls than boys. Typically five or more joints are affected (usually smaller joints such as the hands and feet but many also affect the hips, neck, shoulders and jaw).
Oligoarticular (aka pauciarticular) arthritis can be early or late onset and is the second type of arthritis, affecting about 50% of children with juvenile arthritis. This type affects fewer than four joints (usually the large joints such as knees, ankles or wrists) and may cause eye inflammation in girls with positive anti-nuclear antibodies (ANA). Girls younger than eight are more likely to develop this type of arthritis.
Systemic disease is the least common form, with 10–20% of children (boys and girls equally) being affected with limited movement, swelling and pain in at least one joint </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Hypoxemia and can you explain it in depth? [/INST] Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, and often causes hypoxia as the blood is not supplying enough oxygen to the tissues of the body.

Definition
Hypoxemia refers to the low level of oxygen in blood, and the more general term hypoxia is an abnormally low oxygen content in any tissue or organ, or the body as a whole. Hypoxemia can cause hypoxia (hypoxemic hypoxia), but hypoxia can also occur via other mechanisms, such as anemia.Hypoxemia is usually defined in terms of reduced partial pressure of oxygen (mm Hg) in arterial blood, but also in terms of reduced content of oxygen (ml oxygen per dl blood) or percentage saturation of hemoglobin (the oxygen-binding protein within red blood cells) with oxygen, which is either found singly or in combination.While there is general agreement that an arterial blood gas measurement which shows that the partial pressure of oxygen is lower than normal constitutes hypoxemia, there is less agreement concerning whether the oxygen content of blood is relevant in determining hypoxemia. This definition would include oxygen carried by hemoglobin. The oxygen content of blood is thus sometimes viewed as a measure of tissue delivery rather than hypoxemia.Just as extreme hypoxia can be called anoxia, extreme hypoxemia can be called anoxemia.

Signs and symptoms
In an acute context, hypoxemia can cause symptoms such as those in respiratory distress. These include breathlessness, an increased rate of breathing, use of the chest and abdominal muscles to breathe, and lip pursing.: 642 Chronic hypoxemia may be compensated or uncompensated. The compensation may cause symptoms to be overlooked initially, however, further disease or a stress such as any increase in oxygen demand may finally unmask the existing hypoxemia. In a compensated state, blood vessels supplying less-ventilated areas of the lung may selectively contract, to redirect the blood to areas of the lungs which are better ventilated. However, in a chronic context, and if the lungs are not well ventilated generally, this mechanism can result in pulmonary hypertension, overloading the right ventricle of the heart and causing cor pulmonale and right sided heart failure. Polycythemia can also occur. In children, chronic hypoxemia may manifest as delayed growth, neurological development and motor development and decreased sleep quality with frequent sleep arousals.Other symptoms of hypoxemia may include cyanosis, digital clubbing, and symptoms that may relate to the cause of the hypoxemia, including cough and hemoptysis.: 642 Serious hypoxemia typically occurs when the partial pressure of oxygen in blood is less than 60 mmHg (8.0 kPa), the beginning of the steep portion of the oxygen–hemoglobin dissociation curve, where a small decrease in the partial pressure of oxygen results in a large decrease in the oxygen content of the blood. Severe hypoxia can lead to respiratory failure

Causes
Hypoxemia refers to insufficient oxygen in the blood. Thus any cause that influences the rate or volume of air entering the lungs (ventilation) or any cause that influences the transfer of air from the lungs to the blood may cause hypoxemia. As well as these respiratory causes, cardiovascular causes such as shunts may also result in hypoxemia.
Hypoxemia is caused by five categories of etiologies: hypoventilation, ventilation/perfusion mismatch, right-to-left shunt, diffusion impairment, and low PO2. Low PO2 and hypoventilation are associated with a normal alveolar–arterial gradient (A-a gradient) whereas the other categories are associated with an increased A-a gradient. : 229

Ventilation
If the alveolar ventilation is low, there will not be enough oxygen delivered to the alveoli for the bodys use. This can cause hypoxemia even if the lungs are normal, as the cause is in the brainstems control of ventilation or in the bodys inability to breathe effectively.

Respiratory drive
Respiration is controlled by centers in the medulla, which influence the rate of breathing and the depth of each breath. This is influenced by the blood level of carbon dioxide, as determined by central and peripheral chemoreceptors located in the central nervous system and carotid and aortic bodies, respectively. Hypoxia occurs when the breathing center doesnt function correctly or when the signal is not appropriate:

Strokes, epilepsy and cervical neck fractures can all damage the medullary respiratory centres that generates rhythmic impulses and transmit them along the phrenic nerve to the diaphragm, the muscle that is responsible for breathing.
A decreased respiratory drive can also be the result of metabolic alkalosis, a state of decreased carbon dioxide in the blood
Central sleep apnea. During sleep, the breathing centers of the brain can pause their activity, leading to prolonged periods of apnea with potentially serious consequences.
Hyperventilation followed by prolonged breath-holding. This hyperventilation, attempted by some swimmers, reduces the amount of carbon dioxide in the lungs. This reduces the urge to breathe. However, it also means that falling blood oxygen levels are not sensed, and can result in hypoxemia.

Physical states
A variety of conditions that physically limit airflow can lead to hypoxemia.

Suffocation, including temporary interruption or cessation of breathing as in obstructive sleep apnea, or bedclothes may interfere with breathing in infants, a putative cause of SIDS.
Structural deformities of the chest, such as scoliosis and kyphosis, which can restrict breathing and lead to hypoxia.
Muscle weakness, which may limit the ability of the diaphragm, the primary muscle for drawing new air into lungs, to function. This may be a result of a congenital disease, such as motor neuron disease, or an acquired condition, such as fatigue in severe cases of COPD.

Environmental oxygen
In conditions where the proportion of oxygen in the air is low, or when the partial pressure of oxygen has decreased, less oxygen is present in the alveoli of the lungs. The alveolar oxygen is transferred to hemoglobin, a carrier protein inside red blood cells, with an efficiency that decreases with the partial pressure of oxygen in the air.

Altitude. The external partial pressure of oxygen decreases with altitude, for example in areas of high altitude or when flying. This decrease results in decreased carriage of oxygen by hemoglobin. This is particularly seen as a cause of cerebral hypoxia and mountain sickness in climbers of Mount Everest and other peaks of extreme altitude. For example, at the peak of Mount Everest, the partial pressure of oxygen is just 43 mmHg, whereas at sea level the partial pressure is 150 mmHg. For this reason, cabin pressure in aircraft is maintained at 5,000 to 6,000 feet (1500 to 1800 m).
Diving. Hypoxia in diving can result from sudden surfacing. The partial pressures of gases increases when diving by one ATM every ten metres. This means that a partial pressure of oxygen sufficient to maintain good carriage by hemoglobin is possible at depth, even if it is insufficient at the surface. A diver that remains underwater will slowly consume their oxygen, and when surfacing, the partial pressure of oxygen may be insufficient (shallow water blackout). This may manifest at depth as deep water blackout.
Suffocation. Decreased concentration of oxygen in inspired air caused by reduced replacement of oxygen in the breathing mix.
Anaesthetics. Low partial pressure of oxygen in the lungs when switching from inhaled anesthesia to atmospheric air, due to the Fink effect, or diffusion hypoxia.
Air depleted of oxygen has also proven fatal.  In the past, anesthesia machines have malfunctioned, delivering low-oxygen gas mixtures to patients.  Additionally, oxygen in a confined space can be consumed if carbon dioxide scrubbers are used without sufficient attention to supplementing the oxygen which has been consumed.

Perfusion
Ventilation-perfusion mismatch
This refers to a disruption in the ventilation/perfusion equilibrium. Oxygen entering the lungs typically diffuses across the alveolar-capillary membrane into blood. However this equilibration does not occur when the alveolus is insufficiently ventilated, and as a consequence the blood exiting that alveolus is relatively hypoxemic.  When such blood is added to blood from well ventilated alveoli, the mix has a lower oxygen partial pressure than the alveolar air, and so the A-a difference develops. Examples of states that can cause a ventilation-perfusion mismatch include:

Exercise. Whilst modest activity and exercise improves ventilation-perfusion matching, hypoxemia may develop during intense exercise as a result of preexisting lung diseases. During exercise, almost half of the hypoxemia is due to diffusion limitations (again, on average).
Aging. An increasingly poor match between ventilation and perfusion is seen with age, as well as a decreased ability to compensate for hypoxic states. : 646
Diseases that affect the pulmonary interstitium can also result in hypoxia, by affecting the ability of oxygen to diffuse into arteries. An example of these diseases is pulmonary fibrosis, where even at rest a fifth of the hypoxemia is due to diffusion limitations (on average).
Diseases that result in acute or chronic respiratory distress can result in hypoxia. These diseases can be acute in onset (such as obstruction by inhaling something or a pulmonary embolus) or chronic (such as chronic obstructive pulmonary disease).
Cirrhosis can be complicated by refractory hypoxemia due to high rates of blood flow through the lung, resulting in ventilation-perfusion mismatch.
Fat embolism syndrome, in which fat droplets are deposited in the pulmonary capillary bed.

Shunting
Shunting refers to blood that bypasses the pulmonary circulation, meaning that the blood does not receive oxygen from the alveoli. In general, a shunt may be within the heart or lungs, and cannot be corrected by administering oxygen alone. Shunting may occur in normal states:

Anatomic shunting, occurring via the bronchial circulation, which provides blood to the tissues of the lung. Shunting also occurs by the smallest cardiac veins, which empty directly into the left ventricle.
Physiological shunts, occur due to the effect of gravity. The highest concentration of blood in the pulmonary circulation occurs in the bases of the pulmonary tree compared to the highest pressure of gas in the apexes of the lungs. Alveoli may not be ventilated in shallow breathing.Shunting may also occur in disease states:

Acute respiratory distress syndrome (ARDS). Alveolar collapse, which can increase the amount of physiological shunting, may be managed through a combination of increasing oxygenation as well as positive pressure to recruit collapsed alveoli.
Pathological shunts such as patent ductus arteriosus, patent foramen ovale, and atrial septal defects or ventricular septal defects. These states are when blood from the right side of the heart moves straight to the left side, without first passing through the lungs. This is known as a right-to-left shunt, which is often congenital in origin.

Exercise
Exercise-induced arterial hypoxemia occurs during exercise when a trained individual exhibits an arterial oxygen saturation below 93%. It occurs in fit, healthy individuals of varying ages and genders. Adaptations due to training include an increased cardiac output from cardiac hypertrophy, improved venous return, and metabolic vasodilation of muscles, and an increased VO2 max </s>