Case Report

Use of Cannabinoid Oil in a Patient with ADHD

Hani F Ayyash^1,2*, Michael Ogundele³, Maissa T Dahabra^4,5, Hrizantema Dobreva¹, Bertha Calles Cartas⁶ and Fadi F Ayyash⁷

¹Mid and South Essex University Hospitals Group, Southend University Hospital NHS Foundation Trust, United Kingdom

²Scientific Committee Member, British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, United Kingdom

³Department of Community Paediatrics, Bridgewater Community Healthcare NHS Foundation Trust, United Kingdom

⁴Al Radwan Community Pharmacy, Jordan

⁵Faculty of Pharmacy, Applied Science University, Jordan

⁶Warneford NHS Psychiatric Hospital, Headington, Oxford, Oxford Health Foundation Trust, United Kingdom

⁷Queen Rania Children’s Hospital, Jordanian Royal Medical Services, Jordan

Submission:November 09, 2021; Published: April 22, 2022

*Corresponding author:Dr Hani Ayyash PhD, MMedSci, MBBS, PGDipPsych, MRCPCH, FRCPCH, Consultant Neurodevelopmental Paediatrician, Mid and South Essex University Hospitals Group, Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea, Southend-on-Sea, SS0 0RY, United Kingdom Hani Ayyash http://orcid.org/0000-0002-1005-1667

How to cite this article:Ayyash HF, Ogundele M, Dahabra MT, Dobreva H, Cartas BC, Ayyash FF. Use of Cannabinoid Oil in a Patient with ADHD. Acad J Ped Neonatol 2022; 11(3): 555868. 10.19080/AJPN.2022.11.555868

Abstract

We report on an adolescent boy who was assessed in neurodevelopmental clinic because his parents have become increasingly concerned about his behaviour and learning. He always had difficult time concentrating and his mind has a tendency to wander. ADHD diagnosis was made according to DSM-V following a comprehensive multidisciplinary assessment. Psychoeducation and use of ADHD medications was offered to parents but rejected in order to avoid any potential side effects of either stimulants or non-stimulant ADHD medications. Instead, a trial of Cannabinoid oil has been conducted by parents on their own responsibility. Changes were reported by the child, his family and teachers which included improvements of both academic and behaviour outcomes. The child insisted to continue using the cannabinoid oil despite the advice by the pediatrician’s that there was no evidence to support its use. In conclusion, there is no enough research data for the therapeutic use of cannabinoids in children and adolescents with ADHD in terms of efficacy and safety and for this reason it should not be encouraged for treatment of ADHD. Current practice, using stimulants and or non-stimulants in conjunction with psychoeducation should remain first line treatment for children with ADHD.

Keywords: ADHD; Cannabinoid oil; Cannabis; Medical cannabis; Stimulant drugs; Non-stimulant drugs; Drug misuse; Psychoeducation; Complementary therapy

Abbreviations: ADHD: Attention Deficit Hyperactivity Disorder, ASD: Autism Spectrum Disorder, CBO: Cannabinoid Oil, CYP: Children and Young People, MC: Medicinal cannabis

Introduction

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder defined by impairing levels of inattention, disorganization and or hyperactivity-impulsivity [1]. The disorder begins in childhood and often persists into adulthood and must be present in more than one setting. The prevalence of ADHD is estimated to occur at about 5% to 9% for children and adolescents and about 3% to 5% for adults [2,3]. Diagnosis of ADHD is traditionally based on subjective assessment of behaviour by clinicians and carers in different settings, but this approach is prone to biases. However,recent advances in computerised Continuous Performance Task (CPT) test as well Quantified Behaviour Test (QBTest) have greatly improved their clinical utility as objective diagnostic and monitoring aid [4,5]. ADHD is associated with negative impacts including reduced school performance and being at higher risk for developing antisocial personality disorders, which increases the chances of developing substance use disorders and being incarcerated later on [1]. large cross-sectional study involving 2811 adults, aged between 18- 74 years old showed an association between the frequent use of cannabis and the subtype of ADHD. A greater proportion of affected daily users reported meeting symptom criteria for the combined/hyperactive-impulsive subtype of ADHD rather than the inattentive type [6]. Other comorbidities such as autism [7], tics [8], and sleep problems [9] are common in children and adolescents with ADHD.

Case Report

The parents of a 14 years old boy took him to the general practitioner because they have become increasingly concerned about his behaviour and learning not only at home but also in school. The doctor decides more information is required before any treatment is indicated. No other previous medical history was reported. His parents and teachers indicate that he is restless and often requires reminders to stay on task. He is described as constantly presenting with difficulty listening and following instructions. He indicates that he always had difficult time concentrating in the class and his mind has a tendency to wonder. He always has difficulty settling to sleep and he sometimes wakes up at night. At this point the GP decided to refer him to the Child Development Centre for assessment as the possibility of him having ADHD was raised. Full medical and developmental assessment was performed by neurodevelopmental paediatrician and showed him to be a bright and articulate boy with normal physical examination. The ADHD screening tools such as Connors Questionnaires as well as SNAP Questionnaires from home and school indicated high scores for ADHD symptoms and showed consistency across both setting. ADHD diagnosis was made according to DSM-V criteria. The diagnosis of ADHD and its course of treatment to include psycho-education and ADHD medications was explained to parents. Parents were not keen using the ADHD medications in order to avoid any potential side effects. Teachers implemented support within the school setting in order to improve his ability to manage instructions, ask for help when he needs it. Since his diagnosis, a trial of Cannabinoid oil which was bought over the counter has been conducted by parents as there was no improvement in his concentration and hyperactive behaviour. When reviewed in clinic he stated that the cannabinoid oil helps to calm his mind and to decrease the restlessness of his thoughts. The child and his parents insisted to continue using the cannabinoid oil despite the advice by the Paediatric team that there was no strong evidence and or research to support its use.

Discussion

Management of ADHD patients, including medication treatment and psychoeducation [10], requires pro-active service development, engagement of commissioning and service managers for addressing primary and secondary care involvement in order to optimise patients care and have a comprehensive individual care plan for ADHD patients [11,12]. In a recent observational cohort survey in the UK, it was identified that families of children with ADHD are using a wide variety of main and non-main treatments, which are both publicly and privately funded to help with ADHD management. Nearly 70% of those surveyed, reported using pharmaceutical medications, 74% had participated in a parenting class and 45% reported use of non-mainstream treatment. The most popular non-mainstream treatments used were nutrition, homoeopathy, massage, and cranial osteopathy. Out of 175 families surveyed, only one child with ADHD symptoms were managed using cannabidiol [13].

Researching medicinal cannabis and/or cannabinoid oil in neurodevelopmental disorders, specifically ADHD, is undoubtedly controversial. There is only one controlled study on cannabisbased medication in adults with ADHD. Researchers reported reduced hyperactivity/impulsivity symptoms as well as improved emotional ability [14]. In a cross-sectional study on adult ADHD patients who were licensed for medical cannabis use, it was revealed that the high consumption of medicinal cannabis was associated with ADHD medication reduction and improved ADHD Self Rating Scores [15]. An observational descriptive study, with an average age 10 years old found that there was an improvement in the symptoms of social communication and many co-morbid mental disorders in patients with ASD including symptoms of ADHD. Behaviour disorders, motor deficits, autonomy deficits, communication and social interaction, cognitive deficits, sleep disorders and seizures, with mild adverse effects such as sleepiness, irritability, diarrhoea, conjunctival hyperaemia and increased body temperature were reported [16].

A longitudinal study in New Zealand children showed a clear dose-dependent association between ADHD symptoms at 25 years of age and cannabinoid abuse. This association was found to be mediated through abuse of other substances, including Ectasy (MDMA) and methamphetamines, suggesting the possible existence of a causal chain process in which cannabis use led to increased rates of other forms of drug use, with these being associated with increased symptoms of adult ADHD [17]. In a series of clinical cases with 30 treatment- resistant adults with ADHD, it was found that MC was helpful for a variety of symptoms, including improved concentration and sleep as well reduced impulsivity [18]. On the other hand, there have been several case reports on the use of Cannabinoids in patients with ADHD. Hupli described the therapeutic use of cannabinoids for a 33 years old male with a combined- type adult ADHD who reported relief of the patient’s ADHD symptoms with reduced hyperactivity as well as improved focus and impulse control. Before using cannabinoids, the patient was tried for several years on several medications including Ritalin but with poor results [19]. In a single case study of a cannabis use on 28 adult male with ADHD while off stimulants, it was also reported that the consumption of cannabis had a positive impact on performance, behaviour and mental state of the subject. However, on blood testing, very high concentrations of cannabinoids were found in view of the patient smoking cannabis instead of taking the prescribed dronabinol [20].

In conclusion, from our current study, the evidence does not support the use of cannabinoids in the management of children with ADHD. There was only one double blind randomised controlled study which was conducted in adults with small number of participants and the results can’t be generalised to children and adolescents. There have been limited single-case reports in adults with ADHD and evidence of self-medication reporting variable extent of symptom control. In general, there is no enough research data for the therapeutic use of cannabinoids in children and adolescents with ADHD in terms of efficacy and safety and for this reason it should not be recommended for treatment of ADHD.

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