Friday, March 29, 2019

Cannabinoids and Sleep. What is the data?

A working list of  published TRIALS in peer reviewed publications related to cannabinoids /  CBD and insomnia

There are no FDA approved medications for insomnia in children. 

1 trial in clonidine  for autism and one for ADHD.

While I am not advocating CBD for every child with ADHD, I am linking   ONE relevant clinical article supporting the widespread use of CLONIDINE. its hardly a rich database of clinical data. 

Dr Josh 

Cannabidiol and Sleep

Barchel D, Stolar O, De-Haan T, Ziv-Baran T, Saban N, Fuchs DO, Koren G, Berkovitch M.
Front Pharmacol. 2019 Jan 9;9:1521. doi: 10.3389/fphar.2018.01521. eCollection 2018.
Free PMC Article

Shannon S, Lewis N, Lee H, Hughes S.
Perm J. 2019;23:18-041. doi: 10.7812/TPP/18-041.

4.  2018 Aug;33(9):565-571. doi: 10.1177/0883073818773028. Epub 2018 May 16.

Medical Cannabis for Pediatric Moderate to Severe Complex Motor Disorders.


A complex motor disorder is a combination of various types of abnormal movements that are associated with impaired quality of life (QOL). Current therapeutic options are limited. We studied the efficacy, safety, and tolerability of medical cannabis in children with complex motor disorder. This pilot study was approved by the institutional ethics committee. Two products of cannabidiol (CBD) enriched 5% oil formulation of cannabis were compared: one with 0.25% δ-9-tetrahydrocannabinol (THC) 20:1 group, the other with 0.83% THC 6:1 group. Patients aged 1 to 17 years (n = 25) with complex motor disorder were enrolled. The assigned medication was administered for 5 months. Significant improvement in spasticity and dystonia, sleep difficulties, pain severity, and QOL was observed in the total study cohort, regardless of treatment assignment. Adverse effects were rare and included worsening of seizures in 2 patients, behavioral changes in 2 and somnolence in 1.


CBD; THC; cannabis; cerebral palsy; dystonia; movement disorders; spasticity
Autism and Sleep

Mazzone L, Postorino V, Siracusano M, Riccioni A, Curatolo P.
J Clin Med. 2018 May 3;7(5). pii: E102. doi: 10.3390/jcm7050102. Review.
Free PMC Article
Johnson CR, Smith T, DeMand A, Lecavalier L, Evans V, Gurka M, Swiezy N, Bearss K, Scahill L.
Sleep Med. 2018 Apr;44:61-66. doi: 10.1016/j.sleep.2018.01.008. Epub 2018 Feb 1.
Köse S, Yılmaz H, Ocakoğlu FT, Özbaran NB.
Sleep Med. 2017 Dec;40:69-77. doi: 10.1016/j.sleep.2017.09.021. Epub 2017 Oct 13.
Moore M, Evans V, Hanvey G, Johnson C.
Children (Basel). 2017 Aug 8;4(8). pii: E72. doi: 10.3390/children4080072. Review.
Free PMC Article
Souders MC, Zavodny S, Eriksen W, Sinko R, Connell J, Kerns C, Schaaf R, Pinto-Martin J.
Curr Psychiatry Rep. 2017 Jun;19(6):34. doi: 10.1007/s11920-017-0782-x. Review.
Free PMC Article
Malow BA, Katz T, Reynolds AM, Shui A, Carno M, Connolly HV, Coury D, Bennett AE.
Pediatrics. 2016 Feb;137 Suppl 2:S98-S104. doi: 10.1542/peds.2015-2851H.
Free Article
Yang Z, Matsumoto A, Nakayama K, Jimbo EF, Kojima K, Nagata K, Iwamoto S, Yamagata T.
Brain Dev. 2016 Jan;38(1):91-9. doi: 10.1016/j.braindev.2015.04.006. Epub 2015 May 6.
 2014 Apr;15(4):472-5. doi: 10.1016/j.sleep.2013.10.018. Epub 2014 Feb 7.

Use of sleep medication in children with ADHD.



Sleep problems are common in children with attention-deficit/hyperactivity disorder (ADHD), yet little is known about sleep medication use in this population. The aim of this study was to describe sleep medication use, as well as associated child and family characteristics in school-aged children with ADHD.


Sleep medication use was ascertained using a prospective parent-completed seven-night sleep and medication log. Exposure variables included socio-demographic characteristics, total sleep problem severity (Children's Sleep Habits Questionnaire), ADHD severity and subtype (ADHD Rating Scale IV), ADHD medication use, internalising and externalising co-morbidities (Anxiety Disorders Interview Schedule for Children/Parent version IV) and parent mental health (Depression Anxiety Stress Scale).


Two hundred and fifty-seven children with ADHD participated and of these 57 (22%) were taking sleep medication (melatonin 14% and clonidine 9%). Sleep medication use was associated with combined-type ADHD and ADHD medication use. The presence of co-occurring internalising and externalising co-morbidities was also associated with sleep medication use in ad hoc analyses.


Sleep medication use is common in children with ADHD and is associated with combined-type ADHD and use of ADHD medication. Further research is needed on the broad functional benefits and long-term safety of sleep medication in this population.


Attention deficit hyperactivity disorder; Child; Medication therapy management; Melatonin; SleepSleep initiation and maintenance disorders

Sunday, March 17, 2019

Vayarin, Vayarin Plus, Vayacog - Vaya ConDios! No More Medical Food for ADHD !

Vayarin Vayacog and VayaPlus are not available in the USA anymore. 

I have emailed my unhappiness with this sudden news. I find it beyond callous to drop people (especially children) without alternatives.

I have no idea what can replace these products! I will start looking. 

Dr. Josh

IFF (@iff) owns Frutarom that owns Enzymotec that owns Vayarin.

Mr. Yehudai owns Frutarom.Vayarin Frutarom owner link

Dr. Josh

Friday, March 08, 2019

Autism & Cannabidiol Treatment Trial - What is the evidence?

Interesting - 53 kids & 68% improved in self-injury !

Oral Cannabidiol Use in Children With Autism Spectrum Disorder to Treat Related Symptoms and Co-morbidities.

Barchel D, et al. Front Pharmacol. 2018.


OBJECTIVE: Children with autism spectrum disorder (ASD) commonly exhibit comorbid symptoms such as aggression, hyperactivity and anxiety. Several studies are being conducted worldwide on cannabidiol use in ASD; however, these studies are still ongoing, and data on the effects of its use is very limited. In this study we aimed to report the experience of parents who administer, under supervision, oral cannabinoids to their children with ASD.

METHODSAfter obtaining a license from the Israeli Ministry of Health, parents of children with ASD were instructed by a nurse practitioner how to administer oral drops of cannabidiol oil. Information on co-morbid symptoms and safety was prospectively recorded biweekly during follow-up interviews. An independent group of specialists analyzed these data for changes in ASD symptoms and drug safety.

RESULTS: 53 children at a median age of 11 (4-22) year received cannabidiol for a median duration of 66 days

Self-injury and rage attacks (n = 34) improved in 67.6% and worsened in 8.8%. 
Hyperactivity symptoms (n = 38) improved in 68.4%, did not change in 28.9% and worsened in 2.6%. Sleep problems (n = 21) improved in 71.4% and worsened in 4.7%. 
Anxiety (n = 17) improved in 47.1% and worsened in 23.5%. 
Adverse effects, mostly somnolence and change in appetite were mild
CONCLUSION: Parents' reports suggest that cannabidiol may improve ASD comorbidity symptoms;

 however, the long-term effects should be evaluated in large scale studies.

Tuesday, March 05, 2019

PANDAS PANS Strep and REM Sleep Disorder

Fascinating. REM sleep disorder seen in 87% of patients with PANS. PSG may be helpful in PANDAS / PANS. Note this is a case series. -JR

" RBD has been reported to occur only rarely in children. However, in this consecutive case series of 15 children with PANS, we observed 4 children (27%) met RBD criteria and noted evidence of REM sleep motor disinhibition in 8 others (53%). Only two patients (13%) had a normal PSG, and PANS symptoms had remitted for one of those children."

Rapid Eye Movement Sleep Abnormalities in Children with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS)


Current Knowledge/Study Rationale: REM sleep behavior disorder (RBD) has been demonstrated across all ages, but has been reported to occur only rarely in childhood. Among adults, RBD is associated with neurodegenerative conditions; its significance in pediatric patient populations is unknown. Demonstrating abnormalities of sleep architecture in children with PANS may provide additional insights into the etiopathogenesis of the neuropsychiatric syndrome.
Study Impact: This case series reports on sleep-related motor disturbances among children with PANS, particularly in the REM state. Pediatric RBD is likely not generated by the same mechanisms that often predict the onset of a neurodegenerative disorder among adults, and may instead be a useful marker of transient central nervous system disturbance in select cohorts.


Monday, March 04, 2019

Indica vs. Sativa - Are they different? Not consistently.

I often hear claims that there is a consistent CHEMICAL difference between indica vs sativa. That is, there are terpenes that have different psychoactive effects.

While particular products in certain areas, may be different in CHEMOTYPE (terpenes, essential oils etc.) . It appears that there i NO consistent chemical difference.

Webinar from U of Vt.

Monique McHenry, PhD is a botanist with a background in plant diversity and evolution. She is the co-director of the cannabis pharmacology course at the University of Vermont Medical School. She is also Co-Founder of the Phytoscience Institute, a plant-based pharmaceutical research center. Dr. McHenry completed her BA and MSc at the University of Colorado, and her PhD at the University of Vermont.

Sunday, March 03, 2019

Autism & Sleep and ADD Anxiety Behavior Elopement Social Skills

There is #NoZZZinAutism ! 

 2018 May 3;7(5). pii: E102. doi: 10.3390/jcm7050102.

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Object name is jcm-07-00102-g001.jpgThe Relationship between Sleep Problems, Neurobiological Alterations, Core Symptoms of Autism Spectrum Disorder, and Psychiatric Comorbidities.


Children with Autism Spectrum Disorder (ASD) are at an increased risk for sleep disturbances, and studies indicate that between 50 and 80% of children with ASD experience sleep problems. These problems increase parental stress and adversely affect family quality of life. Studies have also suggested that sleep disturbances may increase behavioral problems in this clinical population. Although understanding the causes of sleep disorders in ASD is a clinical priority, the causal relationship between these two conditions remains unclear. Given the complex nature of ASD, the etiology of sleep problems in this clinical population is probably multi-factorial. In this overview, we discuss in detail three possible etiological explanations of sleep problems in ASD that can all contribute to the high rate of these symptoms in ASD. Specifically, we examine how neurobiological alterations, genetic mutations, and disrupted sleep architecture can cause sleep problems in individuals with ASD. We also discuss how sleep problems may be a direct result of core symptoms of ASD. Finally, a detailed examination of the relationship between sleep problems and associated clinical features and psychiatric comorbidities in individuals with ASD is described.

Insomnia and Autism How and Why ?

Why is the assessment of sleep important in children with autism?

Assessment of Sleep in Children with Autism Spectrum Disorder

Paul R. Carney, Academic Editor and James D. Geyer, Academic Editor
The importance of properly assessing children with ASD for sleep disorders cannot be overstated, as inadequate sleep can have detrimental effects on memory, attention, cognition, daytime behavior, and even language acquisition [,,,,].

 Additional reports suggest that chronic sleep disturbance increases the risk of physical health problems, including changes in cardiovascular, immune, endocrine, nervous system function, and, for children with ASD in particular, increased weight status and poorer overall health-related quality of life [,,,]. 

Furthermore, chronic sleep disturbances experienced by children with ASD are less likely to remit with age, and continue even into adulthood [,,]. T

herefore, early identification and intervention may help to offset some of the potentially detrimental effects that may occur secondary to prolonged sleep inadequacy.

Saturday, March 02, 2019

Epilepsy Autism Cannabis - My professional experience

 I am performing a quality assurance review of my epilepsy practice.  As a pediatric epilepsy specialist I treat many patients who suffer from refractory epilepsy.  That is, they continue to have seizures despite adequate trials of two anticonvulsants.   Refractory epilepsy is a disabling condition that strikes approximately 20% of people with epilepsy. 

Since last year I have been a member of the state of Texas Compassionate Use Program. As such I have recommended low THC cannabis for my patients with the State of Texas Compassionate use program.   This program the state of Texas authorizes dispensaries to sell patients with epilepsy an oil containing 100 mg of Cannabadiol per ml and no more than .5% tetrahydrocannabinol. 

 I have over 60 of my patients in the registry.  The effects on epilepsy are similar to other publications and I will bring those forward any future posting. 

 Because there are current legislative considerations regarding the use of this product in autism, I want to post my observations which have not yet been published. 

I am performing a de-identified retrospective review based on parent/patient report. 

There is a need for more literature about the risks and benefits about this treatment especially focussing on autism. 

Insomnia and aggression are major problems for people with autism and their families. Their are no medications that are FDA approved for insomnia in children. There are two medications approved for behavioral problems in autism. These agents frequently fail. 

I have data on a subgroup of these patients who have co-morbid autism. The N is 11.


Sleep Improvement 
  • 9% - No Improvement
  • 27.2% - No or slight Improvement
  • 73% - 25-100% Improvement. 

  •  54% have a 25 -100% improvement.
Texas low-THC cannabis appears to improve sleep and aggression in autism

Of all the kids with epilepsy 54% had their quality of life at least much improved. 

Of kids with epilepsy and autism 58% had their quality of life at least much improved

Side effects were minimal and I will share this data in future posts.  


CBD with under .5% THC appears to have a positive effect on sleep in children with refractory epilepsy and autism.

CBD with under .5% THC appears to have a positive effect on reducing aggression in children with refractory epilepsy and autism.

Certainly thee are weaknesses in a retrospective, descriptive report. 

Further, I have not controlled for success of epilepsy treatment. Is the sleep improvement due to restoration of circadian rhythms with successful treatment? Is the sleep improvement due to medication interactions?

Yet, this data should be public to inform public debate. 

Insomnia impairs development. Treatment of insomnia improves social function and behavior in children with autism.

Insomnia is a family crushing problem in kids with autism.  The US Army published data on the effects of chronic insomnia on behavior.  How can a family sleep well with a child wandering the house? They do not. 

There are no medications FDA-approved for insomnia in children.  The anti-psychotic medications used off-label for insomnia cause significant side effects such as morbid obesity.  Some antihistamines may provoke seizures. Antidepressants are often used off label. Melatonin is frequently prescribed and fails in this setting. 

Using CBD for insomnia in children with autism would be a "compassionate use" if ever there was one. 

Dr. Rotenberg 

Brain Injury Awareness Month-March 2019

As a board certified brain injury specialist and child/adolescent neurologist I am convinced that a brain injury is still an under recognized neurologic problems.

Some facts:

  • Concussion  is mild brain injury.

  • In younger children, the effects of brain injury are much more serious. 
  • Mild brain injury can have effects that last longer than three weeks. 
  • Brain injury is a qualifying condition for special education. If your child is having school problems and has a history of brain injury, consider if they are related. 
  • Symptoms of brain injury can be neurologic, psychological, cognitive, and physical.
  • Most brain injuries occur from accidents and not sports. 
  • Boys and girls are often different in injury pattern and symptom pattern. 
  • In sports where the rules are the same  for boys and for  girls (not American football) girls have more concussions. 
  • “Brain rest”  sounds good but is impossible to measure and has very little data to support this recommendation. 

In my practice, I pay attention to individualized treatment  to speed recovery: activity, monitoring sleep, optimizing the school requirements,  nutrition and sometimes ... medication. 

Friday, March 01, 2019

DHA reduces serum markers of concussive injury in NFL players

Moe data on DHA and brain injury. - JR

Effect of Docosahexaenoic Acid on a Biomarker of Head Trauma in American Football


 This study provides novel data specific to the optimal dose of DHA for plasma and biomarker changes in American football athletes. Further, the data presented herein demonstrate that a season of American football is associated with some level of subconcussive injury, which results in a measurable increase in a marker of axonal damage. 

Most importantly, we report for the first time that supplemental DHA, irrespective of dose, may likely attenuate elevations in serum NFL coincident with those times in which an increased number and magnitude of head impacts typically occurs in American football athletes.

Article here