Autism spectrum disorder (ASD), is a developmental disability affecting social interaction, communication and behaviour. It is a worldwide phenomenon affecting 1 in 160 children. With ASD diagnoses tripling over the last 15 years, the burden on society is growing exponentially. Parents often find themselves with limited treatment options which may not significantly help their loved ones. In recent years, a number of parents have turned to medical cannabis as a relatively side effect-free alternative. Thankfully, science is now catching up, with several studies linking abnormalities in the endocannabinoid system to some key ASD traits, as well as some promising research suggesting cannabis may be a safe, effective treatment for autism.
The Endocannabinoid System
Discovered when scientists were investigating how compounds in the cannabis plant affect the body, the endocannabinoid system (ECS) is a complex network of fatty ligands called endocannabinoids (primarily anandamide and 2-AG, but also related endogenous compounds, arachidonic acid (AA), N-palmitoylethanolamine (PEA), and N-oleoylethanolamine (OEA)), their receptors (CB1 and CB2), and the enzymes responsible for their formation and degradation (FAAH and MAGL).
The ECS is involved in all biological function. Indeed, in the paper “Neuromodulatory functions of the endocannabinoid system,” the ECS has been termed “one of the key regulatory mechanisms in the brain controlling multiple events such as mood, pain perception, learning and memory.”
Thus we can think of the ECS as the conductor of our biological orchestra, keeping all the sections playing in harmony. But what happens if this master regulator is out of balance? Could a dysregulated endocannabinoid system play some part in the development of autism?
Indeed, a gene expression study on postmortem brains of subjects with autism found they shared reduced CB1 receptor expression. CB1 receptors are abundant throughout the central nervous system. Another study analysing the levels of the main endocannabinoids and their related endogenous compounds in 93 children with ASD found the subjects had lower levels of Anandamide (AEA), N-palmitoylethanolamine (PEA), and N-oleoylethanolamine (OEA), suggesting some kind of endocannabinoid deficiency may contribute to autism.
Other ECS abnormalities noted include alterations in the levels of the enzymes responsible for breaking down 2-AG, as well as a lack of anandamide discovered in the hippocampus area of the brain causing a deficit in social play behaviour; both in rodent models of autism.
Some of these studies do have their limitations; ASD only exists in humans and animal models only go some way towards replicating the condition. Furthermore, unusual endocannabinoid activity can be evidence of the ECS merely doing its job — trying to get our brain function back into balance again. Take for instance the overexpression of CB2 receptors found in three- to nine-year-olds with autism. In this case scientists speculated that the increase in CB2 expression was merely the ECS mitigating the inflammatory state commonly associated with autism.
However, an exciting area of research lies in the possibility that manipulating the ECS may have a therapeutic effect on some autism symptoms.
Low levels of oxytocin, a neuropeptide associated with social behavior, have been associated with ASD, in particular social reward behavior. Furthermore, research shows that administering oxytocin can be an effective therapeutic approach for people with ASD with below normal levels of oxytocin. One study using a mouse model of ASD suggests the ECS may regulate oxytocin signalling and that by increasing anandamide a total reversal of any socially impaired behavior can be achieved. Could this explain why one positive effect noted by parents of autistic children given medical cannabis is their greater ability and ease at interacting socially?
Cannabis & Autism
Cannabis has been used for thousands of years for a broad range of health conditions without doctors understanding exactly how it affects the body. These days, we know that the cannabis plant comprises at least 144 compounds called cannabinoids, the most abundant being Tetrahydrocannabinol (THC) and Cannabidiol (CBD).
While much still remains to be discovered about how THC and CBD affect the body, we do know they interact with the endocannabinoid system. Like anandamide and 2-AG, THC binds with both CB1 and CB2 receptors, while CBD works more subtly, inhibiting the enzyme responsible for breaking anandamide down in the body (FAAH).
It is suggested that cannabinoids act to support the endocannabinoid system, which as we know regulates everything from sleep, appetite, mood, the immune system, and memory. This may explain the striking number of cases in which children with severe ASD have found their symptoms improved while taking medical marijuana.
This anecdotal evidence has inspired two recent retrospective studies, both coming from different teams in Israel, where currently 2,500 children and adults with ASD receive cannabinoid treatment from the national medical cannabis program.
The first study coming out of the lab of Raphael Mechoulam, was based on the experiences of 188 ASD patients between 2015-2017. They were given medical cannabis with a ratio of 30% CBD to 1.5% THC. A cannabidiol rich treatment was the obvious choice as the non-intoxicating cannabinoid has already been found to have anti-anxiety and anti-seizure effects, while being well tolerated and safe in children.
After six months of medical marijuana treatment, 30.1% of subjects noted a significant improvement in their condition, 53.7% moderate, and 6.4% a slight improvement. Additionally, quality of life markers such as the ability to shower and dress independently with no difficulty also doubled and 84% of ASD subjects who also had epilepsy reported a “disappearance of symptoms.”
Thus, the authors concluded cannabis treatment is a “well tolerated safe and effective option to relieve symptoms associated with ASD.”
The second study published soon after in March 2019 assessed 60 children with ASD who were given CBD-rich cannabis as an adjunct treatment over 7-13 months. Considerable improvement in behaviour problems was noted in 61% of subjects, 39% improvement in anxiety and 47% in communication difficulties. Most children were taking other medication alongside the cannabis, with 33% taking a lower dosage and 24% stopping their medication altogether by the end of the study.
Despite the positive results and relatively few side effects, the author Dr Adi Aran suggests a cautious approach to prescribing cannabis for ASD as the study had no control group and used a wide variety of strains and strengths of cannabis. Dr Aran has gone on to conduct a stage 2 clinical trial, the results of which are awaiting publication.
A further stage 2 clinical trial is currently being conducted using the purified CBD drug Epidiolex in children and adolescents with ASD, while another compares the administration of CBD and another cannabinoid, CBDV, in men with autism.
In an age of evidence-based medicine, until the data is published from these clinical trials, most ASD patients around the world will not be able to access medical cannabis for their condition.
Indeed, right now, only Israel and some American States (Delaware, Georgia, Minnesota, Missouri, Pennsylvania, South Carolina, and Utah) list autism (ASD) as a qualifying condition for their medical cannabis programs.
This is of course is frustrating for the thousands of parents and people of all ages with ASD, but until we have more evidence about the efficacy, safety and dosing of medical cannabis for autism, it is inadvisable to administer cannabis without the supervision of an experienced medical professional.
People with autism and their families are in dire need of effective therapies, and perhaps cannabis can play a role in their treatment. More studies are certainly needed, and have been lacking due to the regulatory environment of cannabis up until now.
Autism Spectrum Disorder (ASD) is a developmental disorder that includes impairments in social interaction, as well as developmental impairments with language and communication skills. It additionally will often manifest itself as repetitive behavior.
As a complex neurobehavioral condition, an autism diagnosis covers a large range of symptoms; however, it has been researched that ASD is about four times more common among boys than among girls. Studies have also identified individuals with ASD (with an average prevalence of between one and two percent) across Asia, Europe, and North America.
Researchers classify autism spectrum disorders into four categories:
- Asperger’s syndrome: Since it is in on the milder end of the autism spectrum, people with Asperger’s should be able to handle their daily lives on their own, even though having a hard time being social.
- Pervasive developmental disorder (PDD-NOS): If it is not specified otherwise, this disorder applies to anyone who has a more severe form of Autism than Asperger’s syndrome, but doesn’t show signs of actual autism.
- Autistic disorder: This older term to describe the disorder includes all the same types of symptoms as the previous two, but at a more intense level.
- Childhood disintegrative disorder: This is used to diagnose children who are developing normally, until they begin to lose social and mental skills between the ages of 2 and 4. In addition, children suffering from this disorder tend to have more seizures. This is the rarest, and most difficult part of the autism spectrum.
Although showing similar behaviors to autism, Rett syndrome is no longer considered as another classification for ASD. The reason is that according to research, Rett is caused by a genetic mutation that has no relation to what causes ASD.
Everyone experiences ASD differently, and symptoms may also differ from one individual to another. However, children with autism are known to suffer from sensory problems, meaning, they are highly sensitive to touch, texture and sound. Children with autism often seem to ignore being spoken to, and they tend to be visibly agitated by even softer sounds.
People on the autism spectrum also tend to have difficulty regulating their emotions; they may yell, laugh, or cry for seemingly no reason, and show aggressive behavior when feeling stressed.
Although ASD occurs at all intelligence levels, one of its characteristics is uneven cognitive abilities or skills. Children with autism typically do well on tasks that require immediate memory or visual but show less skill when it comes to symbolic or abstract thinking. Also, nonverbal skills tend to be stronger than verbal ones.
Social behavior difficulties
Children with autism generally will not look at, or listen to, people speaking to them. Eye contact is rare, and even when established it is very inconsistent.
These children additionally have difficulty managing the back and forth nature of a conversation. They can be seen making facial expressions that do not match the conversation, and sometimes will move in slightly erratic ways that seem to be out of context. Further, autistic people will sometimes speak in an unusual tone of voice, and they have significant difficulty understanding someone else’s behavior or point of view.
People with ASD are known for having repetitive or restrictive behaviors, such as repeating words or phrases (echolalia). They may show a lasting interest in a topic, a fact, or the moving of a specific object. Alternatively, they might have an extreme reaction to a slight change in their daily routine.
The cause of ASD is still being researched. However, studies have found several correlations that may indicate on the triggers to autistic behavior:
- Heredity: Parents who have an autistic child have a 2-18% chance of having a second autistic child.
- Age of Parents: The parent’s ages when having a child have a direct correlation to autism; the older the parents, the higher the risk.
- Twins: Research has been done showing that if one identical twin has ASD, the likelihood the other will be affected rises to 36-95%. For fraternal twins, the odds drop to 0-31%.
- Genetics: Autism has been seen to occur more in individuals with certain genetic or chromosomal conditions. 1 out of 10 autistic children is diagnosed with Down Syndrome or another genetic, chromosomal, disorder.
- Environmental factors: Possible contributors to autism include certain foods, as well as infectious diseases, pesticides, alcohol, smoking, and illicit drugs
- Birth defects: A relatively small percentage of children who were born premature, or had lower birth weights, were at a greater risk of having ASD. This risk factor is still being researched.
There is no blood test or any medical test that can diagnose ASD with certainty. However, physicians can use medical tests to rule out other causes for symptoms that resemble autistic behavior.
Doctors can now diagnose autism in babies. An autistic behavior may be diagnosed if the infant doesn’t respond to a smile by the age of six months, if he doesn’t gesture (by pointing or waving) by the age of 14 months, he doesn’t say a word by the age of 16 months and so on.
For children, diagnosis methodology includes a general physical exam and a neurological exam, as well as lab tests and genetic testing. The purpose of the full screening is to determine the cause of the developmental problems and to identify possible co-existing conditions.
Another cause to rule out before diagnosing ASD is hearing problems that may explain social and language delays. Hearing impairment is tested in a formal audiological assessment. Here, physicians look for other sound sensitivities or hearing problems which can co-occur with autism.
Other possible tests include lead screening (to rule out lead poisoning, that can cause similar symptoms), speech and language evaluation, cognitive testing, adaptive functioning assessment, and sensory-motor evaluation. In the meantime, developmental specialists will observe the child while playing or interacting with others to look for unusual behavior associated with ASD.
The method for diagnosing ASD in adults is still in development. For now, clinicians primarily diagnose adults through a series of in-person observations and interactions, while ruling out any possible underlying physical illness that might be held accountable for irregular behaviors. Although patients are no longer children, the clinician may ask to contact their parents to uncover memories and lifelong behavior patterns. If it turns out the patient didn’t show symptoms of ASD as a child, it is impossible that he or she would be evaluated for some mental health or affective disorder.
Autism is comorbid with other conditions, such as epilepsy. According to the National Institute of Neurological Disorders and Stroke (NINDS), 20-30% of individuals with ASD develop epilepsy by the time they reach childhood.
Other than medical problems, people with autism might also suffer problems in their daily lives as a result of their social behavior. Some of those consequences might include problems at school, employment problems, social isolation, and victimizations as a result of bullying.
There is no cure for autism, but early diagnosis and intervention, as well as behavior modification, can improve the quality of life. Training and support may be the assistance a child with autism needs to go to school like any other child and become a high-functioning adult.
Although there is no medical treatment to weaken the symptoms of autism, doctors sometimes prescribe medications for patients who display related symptoms, such as depression, anxiety or seizures.
Some autistic individuals benefit from alternative therapies, including diet changes, meditation and a procedure called “chelation,” in which heavy metals are removed from the blood. The effect of these treatments is not scientifically proven, and chelation is even considered dangerous.
Because managing children with autism is considered stressful, parents are recommended to get help. In addition to consulting with governmental and non-profit organizations, parents may benefit from a support system or a support group, and some free time to maintain the relationship with their spouse.