CBD-enriched cannabis for autism spectrum disorder: an experience of a single center in Turkey and reviews of the literature
Introduction: Autism spectrum disorder is a neurodevelopmental disorder characterized by deficits in communication, social interaction, restricted interest, and repetitive behaviors. Although more cases are being diagnosed, no drugs are approved to treat the core symptoms or cognitive and behavioral problems associated with autism. Therefore, there is an urgent need to develop an effective and safe treatment.
Objective: In this study, we aim to share our 2-year experience with CBD-enriched cannabis treatment in autism and review the latest studies.
Materials and methods: The study included 33 (27 males, six females) children diagnosed with autism spectrum disorder who were followed up between January 2018 and August 2020. The mean age was 7.7 ± 5.5 years. The average daily dosage of cannabidiol (CBD) was 0.7 mg/kg/day (0.3-2 mg/kg/day). The median duration of treatment was 6.5 months (3-28 months). The preparations used in this study contained full-spectrum CBD and trace elements tetrahydrocannabinol (THC) of less than 3%.
Results: The outcomes were evaluated before and after treatment based on clinical interviews. At each follow-up visit, parents were asked to evaluate the effectiveness of the CBD-enriched cannabis treatment. According to the parents’ reports, no change in daily life activity was reported in 6 (19.35%) patients. The main improvements of the treatment were as follows: a decrease in behavioral problems was reported in 10 patients (32.2%), an increase in expressive language was reported in 7 patients (22.5%), improved cognition was reported in 4 patients (12,9%), an increase in social interaction was reported in 3 patients (9.6%), and a decrease in stereotypes was reported in 1 patient (3.2%). The parents reported improvement in cognition among patients who adhered to CBD-enriched cannabis treatment for over two years. The antipsychotic drug could be stopped only in one patient who showed mild ASD symptoms. No change could be made in other drug use and doses. Additionally, this study includes an extensive review of the literature regarding CBD treatment in autism spectrum disorder. According to recent studies, the average dose of CBD was 3.8±2.6 mg/kg/day. The ratio of CBD to THC in the used preparations was 20:1. The most significant improvements were seen in the behavioral problems reported in 20-70% of the patients.
Conclusion: Using lower doses of CBD and trace THC seems to be promising in managing behavioral problems associated with autism. In addition, this treatment could be effective in managing the core symptoms and cognitive functions. No significant side effects were seen at the low doses of CBD-enriched cannabis when compared to other studies.
Keywords: Autism spectrum disorder; Cannabidiol; Cannabis.
CBD for Autism Spectrum Disorder
Autism spectrum disorder (ASD), more often simply referred to as autism, includes a broad range of conditions that are characterized primarily by challenges in basic social skills, repetitive behaviors as well as speech and nonverbal communication.
Autism does not consist of one type, but instead has many subs-types and lie on a spectrum that is most influenced by a combination of genetic and environmental factors. Because of this, each person with autism has a distinct set of strengths and challenges. How different autism sufferers learn, think and problem-solve can range from highly skilled to severely challenged with some people requiring a significant amount of support in their daily lives, while others may live entirely independently, or requiring little support.
There are several factors that influence the development of autism. For instance, ASD is often accompanied by sensory sensitivities and medical issues such as gastrointestinal (GI) disorders, seizures or sleep disorders, as well as mental health challenges such as anxiety, depression and attention issues. These concomitant symptoms and diseases can aggravate the symptoms of autism or interfere with treatment.
Signs and symptoms of ASD usually appear around the age of two or three, however some associated developmental delays can present as early as 18 months of age. Research shows that the earlier the intervention and treatment of ASD, the more positive outcomes can be expected later in life for those suffering from it.
Autism Spectrum Disorder Types
The three types of autism spectrum disorders are:
Autistic disorder: The most severe type, this is sometimes referred to as “classic” autism. People with autistic disorder have significant language delays, social and communication challenges, and unusual behaviors and interests.
Asperger syndrome: This is a milder type of autism spectrum disorder. While people with Asperger’s don’t struggle intellectually, they do have difficulty with social interaction.
Pervasive developmental disorder: This type of autism describes individuals who meet some, but not all, of the criteria for the other subtypes.
Symptoms of Autism Spectrum Disorder
While symptoms vary across the autism spectrum, two common indicators of ASD include:
Social communication challenges
- Social withdrawal
- Unusual reactions in social settings
- Inappropriate social interactions
- A lack of empathy
- A lack of understanding social cues
- Not engaging with play with peers
- Problems with two-way conversations
- An abnormal tone of voice
- The avoidance of eye contact or poor eye contact
- Deficits in language comprehension
- A delay in learning to speak
- Flat or monotonous speech patterns
Restricted, repetitive behavior
- Abnormal body posturing or facial expressions
- Intense focus on one topic
- A preoccupation with specific topics
- Repetitive movements
- Self-abusive behaviors that result in injury and/or self-harm
Other autism symptoms and signs can also include:
- Learning disabilities
- Repeating words or phrases out of context
- Using odd words or phrases
- Sleep disturbances
- Gastrointestinal (GI) disorders such as Irritable Bowel Syndrome and Chron’s disease
Autism Spectrum Disorder Medications and Treatments
Although doctors haven’t identified a cure for autism, there are treatment options that can aid people with ASD in their everyday life that can include a combination of medicines and behavioral interventions.
There are no medications that can cure ASD, but can help manage problems with aggression, irritability, behavioral reactivity, self-injury and repetitive behaviors. Certain medications may also help reduce high energy levels and hyperactivity, aid with focus, reduce the symptoms of anxiety and depression or manage seizure activity.
The core interventions for helping people with ASD are aimed at managing the core challenges of behavior and social interactions, for which several treatments have proven to be helpful. The include:
- Behavior and Communication Approaches including Applied Behavioral Analysis (ABA) like Discrete Trial Training (DTT) and Early Intensive Behavioral Intervention (EIBI) which build positive behaviors and reduce unwanted behaviors, Occupational Therapy, Social Skills Training, Speech Therapy and assistive technologies such as communication boards and electronic tablets
- Dietary Approaches are aimed primarily at improving biomedical markers, although some parents feel that dietary changes make a difference in how their child acts or feels. Dietary treatments are based on the idea that food allergies or lack of vitamins and minerals can aggravate symptoms of ASD with changes including the removal of certain foods and using vitamin or mineral supplements.
- Complementary and Alternative Medicine (CAM) can help relieve the symptoms of ASD. CAM treatments for ASD include chelation (a treatment to remove heavy metals such as lead from the body), biologicals (for example, secretin), or mind-body medicine. However, many of these treatments have not been studied for effectiveness.
CBD and Autism Spectrum Disorder
Research and Scientific Evidence
There is an increasing interest in the use of cannabinoids as a treatment for mental health and neurodevelopmental disorders. This has also given rise to an increase in investigations into the effectiveness of Cannabidiol (CBD) for the treatment and management of ASD symptoms, especially those related to behavior, with many researchers concluding that it has the potential to help those suffering from autism.
Cannabidiol Based Medical Cannabis in Children with Autism- a Retrospective Feasibility Study
Researchers published the results of a 2018 retrospective study in Neurology . Their objective was to assess the efficacy, tolerability and safety of CBD as an adjuvant therapy for refractory behavioral difficulties in children suffering from ASD.
They administered oral CBD and tetrahydrocannabinol (THC) at a ratio of 20:1 (a similar ratio as that of hemp-derived full-spectrum CBD oils) to sixty children with confirmed diagnoses of ASD. The dosage was increased to effect a maximum dose of 10mg/kg per day. Efficacy and tolerability were assessed using various questionnaires including a modified Liverpool Adverse Events Profile, the Caregiver Global Impression of Change (CGIC) scale, the Home Situations Questionnaire–Autism Spectrum Disorder (HSQ-ASD) and the Autism Parenting Stress Index (APSI).
Data showed that, following treatment, behavioral outbreaks improved significantly in 61% of patients, anxiety and communication problems improved in 39% and 47% of patients respectively, and disruptive behaviors were improved on average by 29%. In addition, parents reported a reduction in stress. They concluded that this preliminary study provides so much support for the feasibility of CBD as a promising treatment option for refractory behavioral problems in children with ASD, that they have launched a large, double-blind, placebo-controlled cross-over trial with 120 participants.
Oral Cannabidiol Use in Children With Autism Spectrum Disorder to Treat Related Symptoms and Co-morbidities
Reporting on the experiences of parents regarding the effects of oral CBD on co-morbidities such as aggression, hyperactivity and anxiety in their children with ASD, clinicians published their results in Frontiers of Pharmacology in 2019.
In this study, parents of children with autism were instructed to administer a full-spectrum CBD oil with a CBD:THC ratio of 20:1 at a concentration of 30%. The recommended daily dose of CBD was 16 mg/kg (maximum daily dose 600 mg), and for THC- daily dose of 0.8 mg/kg (maximum daily dose of 40 mg) for at least 30 days. The following four ASD co-morbidity symptoms were evaluated: hyperactivity symptoms, sleep problems, self-injury and anxiety using various measures and parental reports.
After objective analysis by an independent group of specialists including a pediatric neurologist specialized in ASD, clinical pharmacologists and pharmacists, results showed that CBD has the potential to improve ASD co-morbidity symptoms significantly. Their study found that, of the 53 children that received CBD for a median of 66 days, self-injury and rage attacks improved by 67.6% in 34 patients, hyperactivity symptoms by 68.4% in 38 children, sleep problems by 71.4% in 21 children and anxiety improved by 47.1% in 17 patients.
The effect of cannabidiol (CBD) on low-frequency activity and functional connectivity in the brain of adults with and without autism spectrum disorder (ASD)
In another 2019 study published in the Journal of Psychopharmacology, this time in adults, scientists investigated the effect of CBD on low-frequency activity and functional connectivity in the brain of individuals with and without ASD.
To investigate this notion, a task-free fMRI was acquired in 17 healthy men and 17 men with ASD. Testing took place following the double-blind oral administration of 600 mg CBD or matched placebo in random order. The fractional amplitude of low-frequency fluctuations (fALFF) in brain activity was measured across the whole brain. In the even of CBD significantly altering fALFF, they also tested if functional connectivity of those regions were also affected by CBD.
Their results showed that results regarding the effects of CBD were primarily driven by the ASD group, showing significantly increased fALFF and functional connectivity in, as well as between cortical regions that are consistently implicated in autism. The researchers concluded that patients with ASD respond differently to CBD, with the implication that it may affect the complex behaviors these regions modulate.
In addition to the scientific evidence indicating that CBD shows potential for relieving many symptoms of autism as well as those of co-morbidities, anecdotal evidence also shows that CBD may help manage ASD symptoms in some patients. Any search of Facebook groups or Google return 100s, if not 1,000s of results, with many people claiming CBD has helped them, or their child. In addition, online parenting and autism resources are also indicating that there is an upsurge in interest from people interested in using CBD for ASD.
The many properties of CBD has the potential to provide beneficial actions for relieving various aspects, symptoms and co-morbidities in patients with autism. As discussed, CBD may play an important role by, in particular alleviating symptoms of both refractory and disruptive behavioral problems, as well as psychological issues such as anxiety and sleep problems, potentially by changing the cerebral functioning of the brain areas implicated in ASD. However, research is still in its infancy, so it is important to always consult a medical practitioner before using CBD for ASD. Your treating physician or medical specialist can monitor dosage, symptom severity and other clinical parameters including drug interactions and contraindications.
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