Effectiveness of Cannabidiol Oil for Pediatric Anxiety and Insomnia as Part of Posttraumatic Stress Disorder: A Case Report Assistant Clinical Professor of Psychiatry at the University of CBD is everywhere. From corner stores and bars to medical marijuana dispensaries, it’s being offered for its reputed ability to relieve pain and make people feel better. Parents are giving CBD to kids to combat anxiety and other problems. But there are risks, and little research to support it.
Effectiveness of Cannabidiol Oil for Pediatric Anxiety and Insomnia as Part of Posttraumatic Stress Disorder: A Case Report
Assistant Clinical Professor of Psychiatry at the University of Colorado School of Medicine in Fort Collins. E-mail: [email protected]
Naturopathic Physician at the Wholeness Center in Fort Collins, CO. E-mail: [email protected]
Anxiety and sleep disorders are often the result of posttraumatic stress disorder and can contribute to an impaired ability to focus and to demonstration of oppositional behaviors.
These symptoms were present in our patient, a ten-year-old girl who was sexually abused and had minimal parental supervision as a young child under the age of five. Pharmaceutical medications provided partial relief, but results were not long-lasting, and there were major side effects. A trial of cannabidiol oil resulted in a maintained decrease in anxiety and a steady improvement in the quality and quantity of the patient’s sleep.
Cannabidiol oil, an increasingly popular treatment of anxiety and sleep issues, has been documented as being an effective alternative to pharmaceutical medications. This case study provides clinical data that support the use of cannabidiol oil as a safe treatment for reducing anxiety and improving sleep in a young girl with posttraumatic stress disorder.
Cannabidiol (CBD) oil is a naturally occurring constituent of industrial hemp and marijuana, which are collectively called cannabis. CBD oil is 1 of at least 85 cannabinoid compounds found in cannabis and is popular for its medicinal benefits. After tetrahydrocannabinol (THC), CBD oil is the second-most-abundant component of cannabis. Other names for CBD oil include CBD-rich hemp oil, hemp-derived CBD oil, or CBD-rich cannabis oil. Considered to be generally safe, CBD has been used medicinally for decades. However, CBD is not medical marijuana and should be distinguished from high-CBD strains of medical marijuana, which do contain THC, such as “Charlotte’s Web.”
The most abundant compound in cannabis, THC is also a cannabinoid. The THC component induces the psychoactive effect, “high.” A cannabis plant has different amounts of CBD and THC depending on the strain and thus provides different recreational or medicinal effects. The cannabinoid profile of industrial hemp or medical marijuana is ideal for people looking for the medical benefits of CBD without the “high” of the THC.
The mechanism of action of CBD is multifold.1–3 Two cannabinoid receptors are known to exist in the human body: CB1 and CB2 receptors. The CB1 receptors are located mainly in the brain and modulate neurotransmitter release in a manner that prevents excessive neuronal activity (thus calming and decreasing anxiety), as well as reduces pain, reduces inflammation, regulates movement and posture control, and regulates sensory perception, memory, and cognitive function. a 2 An endogenous ligand, anandamide, which occurs naturally in our bodies, binds to the CB1 receptors through the G-protein coupling system. CBD has an indirect effect on the CB1 receptors by stopping the enzymatic breakdown of anandamide, allowing it to stay in the system longer and provide medical benefits.4 CBD has a mild effect on the CB2 receptors, which are located in the periphery in lymphoid tissue. CBD helps to mediate the release of cytokines from the immune cells in a manner that helps to reduce inflammation and pain.2
Other mechanisms of action of CBD include stimulation of vanilloid pain receptors (TRPV-1 receptor), which are known to mediate pain perception, inflammation, and body temperature.5 In addition, CBD may exert its anti-anxiety effect by activating adenosine receptors which play a significant role in cardiovascular function and cause a broad anti-inflammatory effect throughout the body.5 At high concentrations, CBD directly activates the 5-HT1A serotonin receptor, thereby conferring an antidepressant effect.6 Cannabidiol has been found to be an antagonist at the potentially new third cannabinoid receptor, GPR55, in the caudate nucleus and putamen, which if stimulated may contribute to osteoporosis.7
Since the 1940s, a considerable number of published articles have dealt with the chemistry, biochemistry, pharmacology, and clinical effects of CBD.8 The last decade has shown a notable increase in the scientific literature on CBD, owing to its identification for reducing nausea and vomiting, combating psychotic disorders, reducing inflammation, decreasing anxiety and depression, improving sleep, and increasing a sense of well-being.9–12 Findings presented at the 2015 International Cannabinoid Research Society at its 25th Annual Symposium reported the use of CBD as beneficial for kidney fibrosis and inflammation, metabolic syndrome, overweight and obesity, anorexia-cachexia syndrome, and modification of osteoarthritic and other musculoskeletal conditions.13–16
Although studies have demonstrated the calming, anti-inflammatory, and relaxing effects of CBD, clinical data from actual cases is minimal. This case study offers evidence that CBD is effective as a safe alternative treatment to traditional psychiatric medications for reducing anxiety and insomnia.17
A ten-year-old girl presented in January 2015 for a reevaluation of behaviors related to her diagnosis of posttraumatic stress disorder (PTSD) secondary to sexual abuse. Her chief issues included anxiety, insomnia, outbursts at school, suicidal ideation, and self-destructive behaviors. Her grandmother, who has permanent custody of the patient and her younger brother, accompanied her.
Our patient had been seen for an initial evaluation in January 2012 and received a diagnosis of PTSD secondary to sexual abuse on the basis of her history, clinical observations, and behaviors ( Table 1 ). Her father had died 6 months earlier in a motor vehicle accident, and our patient’s maternal grandparents became her permanent guardians. Before her father’s death, our patient had no supervision from her father and very little supervision from her mother. An 11-year-old boy had molested her when she was 3 years old. Her medical history included her mother having methadone addiction, alcoholism, bipolar disorder, and depression. Her mother used marijuana her entire pregnancy with the girl. The patient presented in January 2012 as displaying aggressive, disobedient, impulsive, and sexually inappropriate behaviors. She also demonstrated low self-esteem and anxiety and had poor sleep (restless, interrupted, and unable to sleep alone).
|January 31, 2012||New evaluation: 7.5-year-old girl. History of sexual abuse and neglect. Issues: Insomnia, sexual behaviors. Diagnosis: PTSD secondary to sexual abuse.||None||Melatonin, 1 mg/night||February 14, 2012, laboratory values: TSH, 2.46 mIU/L (reference range, 0.47–4.68 mIU/L); ferritin: 21 ng/mL (reference range, 10–150 ng/mL).
February 16, 2012, laboratory values: Vitamin D3: 39 ng/mL (reference range, 20–50 ng/mL)
|February 20, 2012||Sleeping 2–3 hours/night. Started counseling; Cooperative and good behavior at counseling session. Anxious, traumatized.||Clonidine, 0.05 mg (half tablet) at bedtime||Inositol, 3 g 3 times/d; EPA fish oil, 500 mg/d||Eye movement desensitization and reprocessing therapy recommended|
|February 22, 2012||Did not do well with clonidine because of hallucinations, so she discontinued that treatment. Behavior still very rough; sleep poor.||Started imipramine therapy, 25 mg at bedtime||March 7, 2012: ECG was normal|
|August 8, 2012 a||Good summer. In play therapy. Overall better sleep and energy with imipramine therapy. Patient’s 6-year-old brother also now in therapy.||Imipramine, 25 mg at bedtime|
|January 21, 2015||Returned for evaluation and treatment after 3 years. Suicidal ideation; cut self on leg; defiant and stubborn. Had psychotherapy 3 years straight twice a month. Sleeps with brother; can’t sleep alone.||Off all medications for past 18 months||Melatonin, 5 mg; St John’s wort, 450 mg twice/d; magnesium, 300 mg/d; diphenhydramine, 25 mg/night|
|February 16, 2015||Hard to manage. Has outbursts at school.||Magnesium and St John’s wort: stopped treatment; EPA fish oil, 750 mg/d; diphenhydramine, 25 mg/night||February 11, 2015: Normal cortisol and DHEA levels|
|March 16, 2015||Better overall. Started animal-assisted therapy.||EPA fish oil, 750 mg/d; diphenhydramine, 25 mg/night||Started a regimen of CBD oil, 25 mg (1 capsule)/d at 6 pm|
|April 14, 2015||Sleeping better with CBD treatment. Getting biofeedback. Has stomachaches. Mood is more at ease.||EPA fish oil, 750 mg/d; diphenhydramine, 25 mg/night||CBD oil, 25 mg (1 capsule)/d at 6 pm|
|May 26, 2015||“Ghosts” waking patient up at night.||EPA fish oil, 750 mg/d||CBD oil, 25 mg (1 capsule)/d at 6 pm|
|July 22, 2015||Sleeping better; able to sleep in own room 3–4 nights/wk.||EPA fish oil, 750 mg/d||CBD liquid, 12 mg (in 4 sublingual sprays)/night; 12 mg more (in 4 sublingual sprays) during the day as needed for anxiety, typically 3 or 4 times/wk|
|August 24, 2015||Sleeping well. Handling school well.||EPA fish oil, 750 mg/d||CBD oil, 25 mg (1 capsule)/night; CBD liquid, 6–12 mg (in 2–4 sublingual sprays) as needed for anxiety, typically 2 or 3 times/wk|
CBD = cannabidiol; DHEA = dehydroepiandrosterone; ECG = electrocardiogram; EPA = eicosapentaenoic acid; PTSD = posttraumatic stress disorder; TSH = thyroid stimulating hormone.
Workup during 2012 included laboratory studies, which ruled out a thyroid dysfunction and an iron or vitamin D deficiency. The patient was started on a regimen of 1 mg/night of melatonin, which helped her sleep duration. Three grams of inositol 3 times a day and 500 mg/d of eicosapentaenoic fish oil were also helpful in reducing her anxiety. A trial of clonidine was implemented, which resulted in hallucinations and thus was discontinued. The patient was switched to a regimen of 25 mg of imipramine at bedtime to decrease her anxiety, which appeared to be helpful. Counseling sessions were started. The patient continued psychotherapy for 3 years, but she was not seen again in our clinic until the return visit in January 2015, when she was not receiving any of her medications and supplements.
At the patient’s return in January 2015, she demonstrated the same prominent symptoms as at her initial presentation. At that time, the initial treatment included the following supplements and medications to assist with her sleep and anxiety: melatonin, 5 mg/night; magnesium, 300 mg/d; and diphenhydramine (Benadryl), 25 mg/night. Our patient demonstrated slight gains but was still having outbursts at school and was reportedly difficult to manage at home. In addition, her underlying anxiety continued.
Cannabidiol oil was explored as a potential additional treatment to help her insomnia and anxiety, but we deferred for two months while we waited for a response from other interventions. The grandmother preferred reducing the pharmacologic load given her granddaughter’s failure to respond long term to psychiatric medications.
In March 2015, CBD oil was recommended as a potential additional treatment to help her insomnia and anxiety, and her grandmother provided full informed consent. Our patient was administered the Sleep Disturbance Scale for Children18 and the Screen for Anxiety Related Disorders (SCARED)19 before taking the CBD oil and each month afterward for the next 5 months. Test scores on the Sleep Disturbance Scale for Children and Screen for Anxiety Related Disorders demonstrated an improvement ( Table 2 ).
Patient’s clinical progress in sleep and anxiety
|Date of visit||Sleep scale score a||SCARED score b|
|March 16, 2015||59||34|
|May 25, 2015||42||24|
|July 22, 2015||41||19|
|August 24, 2015||37||16|
|September 22, 2015||38||18|
a A score of more than 50 is considered indicative of a sleep disorder on the Sleep Disturbance Scale for Children.
SCARED = Screen for Anxiety Related Disorders.
A trial of CBD supplements (25 mg) was then initiated at bedtime, and 6 mg to 12 mg of CBD sublingual spray was administered during the day as needed for anxiety. A gradual increase in sleep quality and quantity and a decrease in her anxiety were noted. After 5 months, the patient was sleeping in her own room most nights and handling the new school year with no difficulties. No side effects were observed from taking the CBD oil.
Studies repeatedly recognize the prevalence of an anxiety-provoked sleep disorder after a traumatic experience.20 Our patient was definitely experiencing this phenomenon, which was aggravated by daily stressful activities.
The main finding from this case study is that CBD oil can be an effective compound to reduce anxiety and insomnia secondary to PTSD. A review of the literature suggests some benefits from the use of CBD because of its anxiolytic and sleep-inducing effects.9 Animal studies support use of this treatment and report that “CBD may block anxiety-induced [rapid eye movement] sleep alteration via its anxiolytic effect on the brain.”21
The strength of this particular case is that our patient was receiving no pharmaceutical medications (other than nonprescription diphenhydramine) but only nutritional supplements and the CBD oil to control her symptoms. Her scores on the sleep scale and the anxiety scale consistently and steadily decreased during a period of 5 months (see Table 2 ). She was ultimately able to sleep through the night most nights in her own room, was less anxious at school and home, and displayed appropriate behaviors. The patient’s grandmother (her caregiver) reported: “My granddaughter’s behaviors are definitely better being on the CBD. Her anxiety is not gone, but it is not as intense and she is much easier to be around. She now sleeps in her own room most of the time, which has never happened before.”
Further study will need to be conducted to determine the permanency of our patient’s positive behaviors and how long she will need to continue taking the CBD oil. We do not have a reasonable foundation to recommend dosing from the scientific literature. However, in our experience, this supplement given 12 mg to 25 mg once daily appears to provide relief of key symptoms with minimal side effects. Our patient did not voice any complaints or discomfort from the use of CBD. We routinely asked about headache, fatigue, and change in appetite or agitation in addition to conducting a routine psychiatric evaluation. Although CBD is considered generally safe,17 the long-term effects are yet to be studied.
The ultimate goal is to gradually taper her off the use of CBD oil and transition our patient into lifelong coping strategies such as yoga, meditation, and various other therapeutic activities.
Marijuana and Medicine
Scientific data indicate the potential therapeutic value of cannabinoid drugs, primarily [tetrahydrocannabinol], for pain relief, control of nausea and vomiting, and appetite stimulation; smoked marijuana, however, is a crude [tetrahydrocannabinol] delivery system that also delivers harmful substances.
— Joy JE, Watson SJ Jr, Benson JA Jr. Marijuana and medicine: Assessing the science base. Washington, DC: National Academies Press; 1999.
CannaVest Corp, San Diego, CA, which had no involvement in the case study or distribution of the product, provided the CBD oil that was administered to the patient. No financial support was provided.
Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.
a GW Pharmaceuticals is the founder of the Cannabinoid Research Institute, directed by Philip Robson, MD. Further research articles listed.
The author(s) have no conflicts of interest to disclose.
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CBD: What Parents Need to Know
Parents are giving it to kids to combat anxiety and other problems. But there are risks, and little research to support it.
What You’ll Learn
- Is CBD safe for kids?
- What are the risks of giving kids CBD?
- Can CBD help kids who have mental health disorders?
- Quick Read
- Full Article
- What do we know about CBD?
- Concerns about CBD
- Is CBD safe?
- CBD oil for anxiety
- CBD and autism
- Research boom
These days, you can find CBD everywhere. Some people believe that it can treat everything from chronic pain and cancer to anxiety and ADHD. But is it safe for kids?
CBD is still pretty new, so there’s very little research about its safety or how well it works, especially for children. So far, there’s only one marijuana-derived medication that has been approved by the Food and Drug Administration. It’s called Epidiolex, and it’s used to treat a rare form of epilepsy in patients who are at least two years old.
Because CBD is so new, there also aren’t a lot of rules about what can and cannot be included in CBD products. So, there’s a huge variety in the quality of products. You may even find different amounts of CBD in different packages of the same product.
Since there isn’t a lot of research about CBD, doctors say there are some risks with using CBD for kids. For example, CBD products may contain things other than CBD, and those things could be harmful. Plus, we don’t yet know if CBD works well with other medications or how much you should give your child.
Although a few studies have found that CBD oil might work for anxiety, they only looked at healthy people who were put in situations that made them anxious. There are no studies yet on people with chronic anxiety. Researchers are also exploring CBD for kids with autism spectrum disorder. The results are good so far, but more research needs to be done before we can know if it’s safe and effective.
CBD is everywhere. From corner stores and bars to medical marijuana dispensaries, it’s being offered for its reputed ability to relieve pain and make people feel better.
Though CBD — full name cannabidiol — is extracted from marijuana or hemp, it doesn’t contain THC, the chemical in marijuana that has psychoactive effects, so it doesn’t make you feel high.
Available in the form of vaping, oils, lotions, cocktails, coffee, gummies — you name it — CBD has been touted as a treatment for complaints as far-reaching as chronic pain, cancer, migraines, anxiety and ADHD. You know it’s gone mainstream when even Consumer Reports has issued guides on how to shop for CBD and tips for safe CBD use.
Not only are adults experimenting with CBD for whatever is bothering them, increasingly parents are turning to CBD to help their kids focus, sleep, calm down and more.
But popular use of CBD is blowing up with very little research into its safety or its efficacy, especially in children. The first and only marijuana-derived drug approved by the Food and Drug Administration, Epidiolex, is used to treat a rare, severe form of epilepsy in patients two years of age and older. And since cannabis is in the early stages of legalization and regulation, there is a huge variety in the quality and dosage of products — risks associated with using products that have not been vetted by the FDA.
What do we know about CBD?
For millennia, hemp plants have been used for medicinal purposes around the world. In 1851 marijuana was classified by the United States Pharmocopeia as a viable medical compound used to treat conditions like epilepsy, migraines and pain. But since marijuana and cannabis-related products were made illegal in the US in 1970, there has been a dearth of research about either marijuana or CBD. Its classification as a Schedule 1 drug made it nearly impossible to get federal funding to study cannabis.
“The biggest problem is there’s a lot that we still need to know, especially in kids,” says Paul Mitrani, MD, a clinical psychiatrist at the Child Mind Institute. “In regards to treating mental health disorders in children and adolescents, there’s a lack of evidence to support its use.”
Dr. Mitrani, who is a pediatrician and child and adolescent psychiatrist, says it’s an area worthy of investigation but recommends that parents wait until further research is done before giving a child CBD.
Concerns about CBD
While anecdotal evidence of the benefits of CBD is common, there are risks associated with using these products, especially in children. Some of the concerns:
- Products are unreliable in delivering a consistent amount of CBD. They could have less, or more, than advertised, and most do not offer independent verification of active contents. Analysis of products for sale show that many do not have the amount of CBD that they advertise. “So you can’t depend on the quality of what you’re getting,” notes Dr. Mitrani.
- How much is absorbed? Very little is known about how much CBD is actually delivered to the brain in a given product. Various delivery systems — vaping, taking it orally, eating it in baked goods, etc. — have different rates of delivery. Even the oils that the CBD is dissolved in can result in varying effects. “Effects can vary a lot based on the delivery system used and the amount people are exposed to can be inconsistent,” Dr. Mitrani says.
- Products may contain things other than CBD, and they could be harmful. Lab testing — which provides information about CBD levels, THC levels (if any), and contaminants in the product — isn’t mandatory for CBD products in every state. Without a CoA (Certificate of Analysis) it’s that much harder to verify the safety of the product. Bootleg CBD may be connected to recent lung illnesses and deaths that have been attributed to vaping. The CDC and the American Medical Association recommend avoiding vaping entirely while the cause of these illnesses is determined.
- CBD may be safe itself, but it may interact with other medications a child is taking, that are also metabolized in the liver.
- If it’s used for sleep, Dr. Mitrani worries that while it may potentially help with sleep, “your child may become tolerant to it and possibly experience worsening sleep problems if stopped.”
- Since CBD use — especially for kids — is a still so new, few people are familiar with dosing for children, so determining how much to give your child would be tricky. Clinical doses versus what you might find at a coffeehouse could vary dramatically.
- The legality of cannabis products and CBD is still murky. CBD derived from hemp is federally legal, while CBD derived from marijuana plants is subject to the legal status in each state — and remains federally illegal. Meanwhile, the FDA issued a statement making clear that products that contain CBD — even if they are derived from legal, commercial hemp — cannot claim to have therapeutic benefits or be sold as dietary supplements unless they have been approved by the FDA for that use.
Is CBD safe?
Last year the World Health Organization, acknowledging the explosion in “unsanctioned” medical uses of CBD, reviewed the evidence for its safety and effectiveness. The WHO report concluded that “CBD is generally well tolerated with a good safety profile.” Any adverse effects could be a result of interactions between CBD and a patient’s existing medications, the WHO noted.
The report found no indication of potential abuse or dependence. “To date there is no evidence of recreational use of CBD or any public health-related problems associated with the use of pure CBD.”
As for effectiveness, the WHO noted that several clinical trials had shown effectiveness for epilepsy, adding: “There is also preliminary evidence that CBD may be a useful treatment for a number of other medical conditions.”
CBD oil for anxiety
In 2015 a group of researchers led by Esther Blessing, PhD, of New York University, investigated the potential of CBD for treating anxiety. In a review of 49 studies, they found promising results and the need for more study.
The “preclinical” evidence (ie from animal studies) “conclusively demonstrates CBD’s efficacy in reducing anxiety behaviors relevant to multiple disorders,” Dr. Blessing wrote. Those include generalized anxiety disorder, PTSD, panic disorder, social anxiety disorder and OCD.
The review notes that the promising preclinical results are also supported by human experimental findings, which also suggest “minimal sedative effects, and an excellent safety profile.” But these findings are based on putting healthy subjects in anxiety-producing situations and measuring the impact of CBD on the anxiety response. Further studies are required to establish treatment with CBD would have similar effects for those who struggle with chronic anxiety, as well as what the impact of extended CBD use may be.
“Overall, current evidence indicates CBD has considerable potential as a treatment for multiple anxiety disorders,” Dr. Blessing concludes, “with need for further study of chronic and therapeutic effects in relevant clinical populations.”
CBD and autism
A group of Israeli researchers have been exploring the use of CBD to reduce problem behaviors in children on the autism spectrum. A feasibility study involving 60 children found substantial improvement in behavioral outbreaks, anxiety and communication problems, as well as stress levels reported by parents.
The researchers, led by Adi Aran, MD, director of the pediatric neurology unit at Shaare Tzedek Medical Center, went on to do a double-blind, randomized, placebo-controlled trial with 150 participants with autism. In this trial, just completed but not yet analyzed, patients were treated CBD for three months.
In the US, research has been given a boost by changing guidelines and laws. In 2015 the DEA eased some of the regulatory requirements that have made CBD, as a Schedule 1 substance, difficult to study. “Because CBD contains less than 1 percent THC and has shown some potential medicinal value, there is great interest in studying it for medical applications,” the DEA said in announcing the change.
And in approving the first CBD-based drug, Epidiolex, last year the FDA expressed enthusiasm for the research boom that is sure to come, paired with stern words for the flood of marketers of products claiming unsubstantiated health benefits.
“We’ll continue to support rigorous scientific research on the potential medical uses of marijuana-derived products and work with product developers who are interested in bringing patients safe and effective, high quality products,” the FDA pledged. “But, at the same time, we are prepared to take action when we see the illegal marketing of CBD-containing products with serious, unproven medical claims.”