Cannabis and Cannabinoid Research

Volume 6, Number 1, 2021

ª Mary Ann Liebert, Inc.
DOI: 10.1089/can.2019.0056

Use of Cannabis in Fetal Alcohol Spectrum Disorder

Gideon Koren,1,2,* Rana Cohen,1 and Ornie Sachs2

Abstract
Background: Fetal alcohol spectrum disorder (FASD) has been recently estimated to afflict up to 5% of American
children. Most of these children exhibit different degrees of symptomatology of disruptive behaviors. Yet, there has
been very little research on the efficacy and safety of pharmacological modalities, limited mostly to stimulants for
attention deficit hyperactive disorder or second generation atypical antipsychotics for aggression. Recently, the use
of cannabinoids has been described for symptoms related to autistic spectrum disorder with apparent favorable
effects, as well as for other disruptive behaviors. The objective of our study was to follow up in a retrospective
case series the effect of cannabis in children and young adults diagnosed with FASD.
Methods: In two children and three FASD young adults with severe disruptive behavior, changes in behavior
after cannabis use were measured by the parent version of the Nisonger Child Behavior Rating Form.
Results: In all five cases, there was a highly statistical decrease in the disruptive behavior score from 18 – 1.0 be-
fore cannabis use to 6 – 2.1 after introduction of cannabis ( p = 0.0002).
Discussion: In children and young adults with FASD, cannabis, mostly cannabidiol (CBD), has been associated
with a marked and statistically significant improvement in serious disruptive behavior. These cases suggest that
the efficacy and safety of CBD should be tested in well-controlled studies.
Keywords: cannabinoids; disruptive behavior; fetal alcohol spectrum behavior

Introduction autistic spectrum disorder (ASD) with apparent favor-

Fetal alcohol spectrum disorder (FASD) has been re-
cently estimated to afflict up to 5% of American chil-
dren,1 a higher incidence than the previously quoted
1%2 and is considered the most prevalent congenital
neurobehavioral disability. With numerous theories
attempting to identify the mechanisms underlying the
neurobehavioral damage, most of these children ex-
hibit different degrees of symptomatology of disruptive
behaviors, attention deficit hyperactivity disorder
(ADHD), oppositional behavior, depression and other
neurobehavioral problems.2 Yet, there has been very
little research published on the efficacy and safety of
pharmacological modalities, limited mostly to stimu-
lants for ADHD, or second generation atypical antipsy-
chotics for aggression.3
During the past few years, in parallel to their legaliza-
tion in increasing number of countries, the use of canna-
binoids has been described for symptoms related to
able effects,4 as well as for other disruptive behaviors.5
In our FASD diagnostic clinic, we have begun to en-
counter cases of children and young adults with FASD
treated with cannabinoids, which have been initiated
by their parents for symptoms related to FASDs. A fo-
cused literature review has failed to identify any such
published cases.
The aim of this report is to describe five cases of chil-
dren and young adults treated for disruptive symptoms
related to FASD with different cannabinoids.
Methods
All five cases described here were diagnosed by us in re-
cent years as suffering from FASD. At the time of diag-
nosis, none of them received cannabinoids. In all cases,
the initiation of cannabinoid use was by the parents.
The study protocol was approved by Shamir hospital re-
search ethics committee and informed consent was given

1
Motherisk Israel Program, Shamir Hospital, Zerifin, Israel.
2
Adelson Faculty of Medicine, Ariel University, Ariel, Israel.

*Address correspondence to: Gideon Koren, MD, Motherisk Israel Program, Shamir Hospital, Zerifin 40700, Israel, E-mail: gidiup_2000@yahoo.com

74
CANNABIS IN FASD
by the parents for use of anonymous data. The diagno-
sis of FASD was based on the internationally accepted
criteria.6 Disruptive symptomatology was ranked by
the parent version of the Nisonger Child Behavior Rating
Form, a visual analog scale for disruptive symptoms.7
Changes in disruptive symptoms before versus after
cannabis use were quantified by Student’s t-test for
paired data.
Cases
Case 1
The case is a 5-year 4-month-old boy with FASD whose
behavior has been characterized by aggressiveness to-
ward kindergarten peers and, numerous daily tantrum
attacks resulting in damage to toys and furniture. His
FASD was characterized by global cognitive delay,
ADHD, and conduct disorder. He has been reported
to have taken parcels and toys belonging to other chil-
dren and used to disappear regularly.
Over the 2 years since the initiation of two oil drops
containing cannabidiol (CBD) (20%) with traces of tet-
rahydrocannabinol (THC, 0.2%), there has been a dra-
matic change in his behavior: his tantrum attacks have
been reduced to once a day or less and his aggressiveness
toward other children has disappeared. He asks permis-
sion before taking things belonging to other people,
communicates his feelings more clearly. And his disap-
pearances have decreased substantially. During the CBD
exposure, he did not receive any antipsychotic drug.
Case 2
The case is a 12-year-old boy diagnosed with FASD char-
acterized by learning disability and conduct disorder; he
displayed severe restlessness, aggressive behavior, and
impulsivity despite treatment with methylphenidate
and risperidone. The initiation of three morning drops
of CBD oil (15% CBD and 1% of THC) has led to a
marked reduction in aggressiveness, restlessness, and im-
pulsivity, and has allowed to cancel the plan to increase
the dose of risperidone.
Case 3
The case is a 19-year-old young man diagnosed with
FASD characterized by global cognitive delay, ADHD,
and conduct disorder. He exhibited severe bouts of ag-
gressive behavior, impulsivity, and inability to control
his behavior. Two years of smoking cannabis (THC)
twice daily (0.5 g per cigarette) has been associated with
a marked decrease in his anger levels, calming his anger
attacks and allowing him to think in a balanced way.
75
Case 4
The case is a 20-year-old young woman with FASD,
characterized by learning disability, cognitive delay,
and conduct disorder. She exhibited high levels of ag-
gression and impulsivity, inability to concentrate and
listen, and numerous episodes of disappearance. Pre-
vious use of risperidone was associated with severe dys-
phoria and vegetative behavior. Over the 5-month use
of 1 g daily preparation of flowers containing CBD,
there has been a dramatic decrease in aggressiveness
and impulsivity, and she has not disappeared over
the whole of 5 months. After several weeks the dose
could be reduced to 0.5 g/day with similar favorable ef-
fects. According to her mother, her ability to listen and
retain information increased substantially.
Case 5
The case is a 20-year-old young man with FASD charac-
terized by global cognitive delay, ADHD, and conduct
disorder. He exhibited extreme restlessness and aggres-
sion, affecting his ability to think rationally, to focus or
maintain a steady line of rational activities. Two years
of twice daily use of smoked CBD (0.5 + 0.5 g) has allowed
him to be much more restful and focused, to execute
tasks, to think and solve issues, and ‘‘to count to 10 before
I respond to things.’’ According to his mother, with the
CBD he is capable of maintaining rational thinking.
In none of these five cases did the parents report on
adverse effects, nor did they detect tolerance over time.
Statistical analysis
There was a highly statistical decrease in the disruptive
behavior score from (mean – SD) 18 – 1.0 before cannabis
use to 6 – 2.1 after introduction of cannabis ( p = 0.0002).
Discussion
Many children and adults diagnosed with FASD suffer
from symptoms stemming from disruptive behavior,
characterized by agitation, aggression, restlessness, im-
pulsivity, and related symptoms.2 These typically inter-
rupt substantially with their ability to interact with
peers and adults, maintain tasks, sitting in class or
hold a job, with numerous other difficulties.
Because a high percentage of children with FASD ex-
hibit symptoms of ADHD, they often receive stimulants
that may favorably improve their hyperactivity, inatten-
tion, and impulsivity. However, not rarely, the stimulants
increase agitation, impulsivity, and related symptoms.3
The symptomatic aggressive child with FASD often re-
ceives a second generation antipsychotic drug, with
76
risperidone being the most widely used.3 However, the
common adverse effects in achieving calm in these
cases are sedation, apathy, and loss of cognitive ability
among other adverse behavioral reactions, in addition
to excessive weight gain and the metabolic syndrome.
Over the past few years, a slowly growing body of re-
search has aimed at examining the potential role of can-
nabinoids in treating different pediatric conditions. In
general, the attempt has been to avoid the habit forming
THC in favor of the generally nonaddictive CBD.8
Although the best evidence to date related to CBD use
for specific forms of epilepsy, several studies have
shown its apparent efficacy for symptoms of ASD.4,5
We have recently shown that based on parents’ reports,
CBD improved symptoms of aggression and restlessness
in the majority of children with ASD. In parallel, it also
improved their sleep and ability to communicate.4
The five cases presented here are, to the best of our
knowledge, the first reports of the use of cannabinoids
for symptoms of FASD. The initiation of their use was
by highly concerned parents who felt that existing ther-
apeutic options have not addressed the severity and se-
riousness of the children’s symptoms of disruptive
behavior. As such, this is not a controlled study from
any aspect: the different cannabinoids used, the differing
routes of administration, and the wide range of ages
should be acknowledged. However, these cases may in-
form clinical researchers how to design a proper study
with cannabis for children with FASD. A common de-
nominator of all five cases has been the nature of symp-
toms, including restlessness, aggression, agitation, and
impulsivity, and the very high score on the Nisonger dis-
ruptive behavior scale. This allows to begin evaluating
the cannabinoid efficacy for these symptoms, which is
quite similar to what we and others have encountered
in children with ASD.4,5 It is apparent that these five
children and young adult did not experience serious ad-
verse drug reactions.
Before a properly powered prospective study is initi-
ated, one must consider potential adverse effects of
cannabis on children’s brain development. Several re-
cent studies have suggested that the recreational use
of cannabis is associated with adverse effects on differ-
ent brain functions among adolescents.9,10
These cases suggest that the efficacy and safety of CBD
should be tested in well-controlled studies. Adding them
to the very restricted armamentarium of pharmacological
solutions for disruptive behavior may be very meaningful,
KOREN ET AL.
especially because second generation antipsychotic drugs
carry high risk of adverse central nervous system effects,
in addition to serious weight gain and complex metabolic
changes. Future studies should select a single source of
cannabis with accurate evidence of content, a randomized
controlled design, either against placebo or a standard
psychoactive drug, and objective measures of improve-
ment and short- and long-term adverse effects.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this study.
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Cite this article as: Koren G, Cohen R, Sachs O (2021) Use of cannabis
in fetal alcohol spectrum disorder, Cannabis and Cannabinoid
Research 6:1, 74–76, DOI: 10.1089/can.2019.0056.
Abbreviations Used
ADHD ¼ attention deficit hyperactive disorder
ASD ¼ autistic spectrum disorder
CBD ¼ cannabidiol
FASD ¼ fetal alcohol spectrum disorder
THC ¼ tetrahydrocannabinol