Is Cannabis Legalization Eliciting Abusive Behaviors in Parents? A Case Report

Abstract

The interest in cannabis, cannabis-based compounds, and treatments is rapidly growing along with the legalization of marijuana in many countries and widespread use of cannabis derivatives in medical products. A growing body of literature is warning about possible unintentional intoxication in children because of unregulated and unsupervised use of cannabinoids by parents; to our knowledge, very rarely have parental self-prescription and self-administration to their children (affected by neurologic or other disorders or no disorders at all) been reported. We report a 4-year-old child, suffering from an anti-N-methyl-D-aspartate receptor encephalitis, who was found unpredictably positive for cannabis and other illicit substances after drug testing was performed in order to investigate the child's treatment-resistant behavioral disturbances. Toxicologic analyses were also extended to the child's parents, who finally disclosed that they had deliberately administered a cannabis-derived product (cannabidiol extract) as a home remedy for managing their child's behavior. Careless with regard to the possible adverse effects and certain that the product was legal, they presumed there was no need for them to inform the physicians in charge of treating the child of this practice.

Introduction

The interest in cannabis, cannabis-related compounds, and cannabis-based drugs is rapidly growing, as is the legalization of marijuana in many states, countries and, the widespread use of cannabis derivatives in medical products. Clinical studies^1,2 have emphasized the beneficial effects of cannabis-derived products in a wide variety of pediatric pathologic conditions, ranging from incurable malignancies to neurologic or neuropsychiatric disorders to dermatologic diseases. However, the quality of evidence is strong only for the treatment of chemotherapy-induced nausea and vomiting and epilepsy.³ Conversely, the support for the use of cannabis products for other common pediatric disorders, including spasticity, neuropathic pain, autism spectrum disorder, Tourette's disorder, and posttraumatic stress disorder, is not well grounded.^4–6

The lack of well-developed randomized controlled trials accounts for the fact that many indications for medical cannabis, as approved in adults, are not recommended in children. The main concern with conducting such studies in children is the fear of psychoactive effects and neuronal damage on a short- and long-term basis, as suggested by observational studies^7,8 on recreational marijuana use in adolescents.

The absence of authorized products for the pediatric population and the abundance of unregulated products could be even more harmful and facilitate improper parental behaviors.

For these reasons, although recognizing cannabinoids as an option in children with life-limiting or severely debilitating conditions and for whom current therapies are inadequate, the American Academy of Pediatrics has opposed the legalization of marijuana for medical use outside the regulatory process of the US Food and Drug Administration (FDA).⁹ To date, medical cannabis prescriptions in children are restricted to very few conditions.

The growing popularity of cannabis products, which more and more countries are legalizing, may lead a few parents to use unregulated and unsupervised cannabinoid extracts for home-treating their children who are suffering from mild symptoms (e.g., sleeplessness, irritability) as well as severe neurologic conditions or symptoms.¹⁰

We present a case in which the parent deliberately administered cannabis-derived products for the purpose of modulating child behavior and emotions.

Case Report

A 4-year-old child suffering from an anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis was found unpredictably positive for cannabis and other illicit substances after drug testing was performed in order to investigate the child's treatment-resistant behavioral disturbances.

History. The child was born at term through spontaneous vaginal delivery after a normal pregnancy. The child was small for gestational age (2600 g) but in good health. At delivery, the mother presented with an acute genital infection caused by Herpes simplex virus type 1 (HSV-1), and 9 days after birth the newborn developed a cutaneous and ocular HSV-1–related infection.

At the age of 3 years, the child developed HSV encephalitis, as confirmed by cerebrospinal fluid (CSF) analysis. Three months after the acyclovir treatment was initiated, seizures occurred, and a rapid deterioration of language, along with behavioral changes, was observed. Cerebrospinal fluid analysis led to the diagnosis of NMDAR encephalitis. Treatment with high-dose intravenous immunoglobulins and oral glucocorticosteroids improved the neurologic and behavioral symptoms. However, a prophylactic anticonvulsant therapy with oral carbamazepine was maintained along with acyclovir.

Six months later, during follow-up, the child's language skills were not age appropriate: the child was loquacious but displayed poor articulation, with single-word responses, most commonly “no,” and repeated involuntary use of meaningless syllables. The child exhibited repetitive movements, like putting fingers into the mouth. The child was hetero-aggressive and hyperactive. An attention deficit was also present. Executive functions were poor and restricted to simple commands. The child's neurologic conditions were otherwise stable, and the growth rate was normal (95th, 75th, and 50th percentiles for weight, height, and head circumference, respectively). These behavioral disturbances worsened during the following months when the child started being sleepless. A full outpatient diagnostic work-up was conducted. Blood and CSF tested negative for infections. The evaluation for immunodeficiency was normal. Neuro-electrophysiologic studies excluded epileptic disorders. Small amounts of auto-antibodies against NMDAR and oligoclonal immunoglobulin G bands were detected in both blood and CSF.

A second-line pharmacotherapy with rituximab was considered. A child psychiatrist consultant prescribed a low dosage of risperidone (0.25 mg per day) to manage psychiatric symptoms. Because the clinical response was only partial, mainly not controlling behavioral disturbances, medical investigation was extended to toxicologic analysis.

Toxicologic Work-Up. The child underwent full toxicologic examination with blood, urine, and hair sample testing (Table 1). Cannabinoids were identified in a 6-cm-long hair sample. Concentrations were 0.07 ng/mg, 0.01 ng/mg, and 0.02 ng/mg for tetrahydrocannabinol (THC), cannabidiol (CBD) and cannabinol, respectively. The THC concentration was beyond the cut-off value (0.05 ng/mg) used to enable identification of chronic cannabis use or exposure.¹¹

Table 1.

Patient Toxicology Testing Results

	During the Outpatient Work-Up			Repeated the Following Month
	Blood	Urine	Hair, ng/mg	Blood, ng/mL	Urine, ng/mL	Hair, ng/mg
						0–3 cm	3–6 cm
Drugs of abuse
THC	NT	NT	0.07	NT	NT	0.76	1.29
THC-COOH	NT	NT	NT	0.2	3.2	NT	NT
CBD	NT	NT	0.01	NT	NT	0.64	1.05
CBN	NT	NT	0.02	NT	NT	0.38	0.07
Medicinal drugs, positive or negative
Caffeine*	+	+	+	+	+	+	+
Carbamazepine†	−	−	+	+	+	+	+
Chlorpheniramine†	−	−	+	−	−	−	+
Diazepam*	+	−	NT	−	−	NT	NT
Doxylamine*	+	+	−	−	−	−	−
Lidocaine†	−	−	+	−	−	+	+
Ketamine†	−	−	+	−	−	+	+
Nicotine*	−	−	+	−	−	−	+
Nordazepam*	+	+	NT	−	−	NT	NT
Paracetamol†	−	−	+	−	−	−	+
Risperidone†	+	+	+	+	+	+	+
Temazepam*	+	−	NT	−	−	NT	NT

+, positive; −, negative; CBD, cannabidiol; CBN, cannabinol; NT, not tested; THC, tetrahydrocannabinol; THC-COOH, 11-nor-9-carboxy-THC; NA-

^* Non-prescribed therapy.

^† Prescribedtherapy.

Other active substances were measured in the biologic samples, some of which were part of the prescribed therapy, while others were not. All non-prescribed substances (e.g., various benzodiazepines and doxylamine) were psychoactive drugs. The results of toxicology tests bewildered the parents, who denied any possible child's exposure to second-hand marijuana smoke and/or accidental ingestion of sedatives.

Toxicologic Follow-Up and Child Protection Assessment. Despite the parents' statements, the high number of unexplained drugs and the recent exposure to some of them (benzodiazepines, doxylamine) called for a full toxicologic assessment and for child family evaluation.

The child was immediately admitted to the hospital, and the toxicology tests were repeated throughout the following month. Upon further testing, the hair sample was divided into 2 segments (0–3 and 3–6 cm) (Table 1). Cannabinoids were still detectable in all biologic samples. 11-nor-9-carboxy-THC (THC-COOH) was identified both in blood and urine. Hair concentrations of cannabinoids were much higher than during the the previous analysis. These results confirmed that the child had been repeatedly exposed to cannabinoids and that the last exposure was very recent. Nonetheless, the parents kept being uncooperative. Urine samples, although collected in the hospital, continued to be positive to THC-COOH up to the first week. Another hair sample, cut 15 days after the previous, showed a sensible reduction in the concentration of cannabinoids. Parental hair was analyzed as well. According to the full toxicology results listed in Table 2, the test was positive for cannabinoids and nicotine in both samples, while cocaine and ethyl glucuronide were only detected in the father's and mother's hair, respectively).

Table 2.

Toxicology Results of Parent's Hair Analysis

Drugs of Abuse	Mother			Father
	Hair Segment, cm
	0–3	3–6	6–15
THC*	0	0.09	0.24	0.33
CBD*	0	0.02	0	1.05
CBN*	0	0.04	0.11	0.26
Cocaine*	0	0	0	0.25
Ethyl glucuronide†	12	0	0	0
Nicotine	+	+	+	+

+, positive; CBD, cannabidiol; CBN, cannabinol; THC, tetrahydrocannabinol

^* Measured in nanograms per milligram.

^† Measured in picograms per milligram.

Family Disclosure. The parents were questioned about how they might explain the toxicologic results and the progressive reduction in cannabinoids while the young patient was far from home. Finally, the parents disclosed that their child had been given a CBD oily extract at the dosage of 4 drops per day for the last 2 months. They claimed that it was a therapeutic use designed to calm the child down and control hyperactive behavior. They used the same oil in cooking and to enrich foods. The product was purchased online and, according to the parents, it was “legal” because it was labelled as “CBD oil 5%.”

Once the oil flacon was brought to the hospital, it was ascertained that THC was also present, because the package insert specified a THC content below 0.2%.

The father himself admitted to consuming seeds and inflorescences of Carmagnola hemp, the THC content of which was stated to be below 0.6%. According to him, it was a therapeutic use to relax himself and help him quit alcohol and heroin use. He was also on therapy with diazepam for bipolar disorder. He assumed that the child could have accidentally swallowed some of his tablets. Because of his diabetes, the father's hand grip was weak and things occasionally dropped on the floor.

The mother admitted to smoking marijuana to treat her depressed mood, although occasionally. She worked all day long, and the child stayed with the unemployed father most of the day.

As both clinical and historical data were consistent with a diagnosis of child abuse and neglect and chemical abuse and because the family seemed very fragile because of parental psychiatric and substance use disorders, reports were sent to law-enforcement agencies, juvenile court, and local child protective services (CPS). The child was discharged after a 3-week hospitalization with a strict child protective services supervision program according to what the judge had decreed.

Discussion

Self-medication by proxy in children is of great concern worldwide, because its prevalence is extremely high both in developed and developing countries.^12,13 The use of medicines without professional advice may expose children to various risks (drug interactions, drug resistance, and adverse drug reactions). This practice has been reported with psychoactive substances as well, either legal or illegal products, with the purpose of soothing the children or modulating their behavior.

From a cultural perspective, such practice is not new: narcotic and sedative drugs have been part of the European habit of self-medication since the Industrial Revolution, when the working class, exhausted from 18-hour workdays and sleep-deprived because of their infant crying, used to put drugs into soups and pacifiers;¹⁴ likewise, poppyseeds and straw used to prepare a sedative infusion is common in some eastern geographic areas¹⁵ and was exported to western countries because of migration of ethnic communities, who remain attached to their folk remedies.¹⁶

Parental misbehaviors of self-medication with cannabis are expected to increase. Many reasons underlie this phenomenon: 1) the legalization of cannabis in many countries, 2) the wide accessibility to cannabis-derived products, 3) the common belief that treatments derived from natural products are safer or more effective than are conventional medications, and 4) the regular consumption of cannabis products by parents for either recreational or medical purposes.^17,18

This reported case describes a relatively unusual scenario in which the parents deliberately and regularly administered a cannabis-derived product with a curative purpose in a multi-drug–treated child with an autoimmune disease combined with behavioral disturbances, without informing the doctors in charge of treating the child of their choice and actions. These parents, focused on mitigating the problematic behavior of their child, administered CBD oil without knowing whether it was appropriate to their purpose, unaware of the possible interactions with the other prescribed medicines and of the underlying autoimmune encephalitic disorder. Their decision, not scientifically grounded, was simply based on the father's own experience of having benefited from cannabis, which made him feel more “relaxed” and capable of giving up his addictions. Even after the clinical worsening was evident, the parents did not turn to a specialist or tell the assisting physicians about what they were doing. Additionally, we had further concerns that they began coadministering benzodiazepines and doxylamine to the child, because these drugs were detected in the child's blood and urine.

Doxylamine is an antihistamine similar in structure to diphenhydramine, which is reported to be administered to children in order to get them to calm down. In this case, the parents justified themselves, saying that the CBD oil was legal because it was purchased easily and online easily and safe because its content in THC was “low.” Such arguments are intrinsically fallacious. According to Italian law, the use of cannabis derivatives for treatment purposes, especially in the pediatric population, is strictly limited to specific monitored products.

In countries where the sale of cannabis is regulated,¹⁹ non-prescription products are easily obtainable, because a growing number of shopping sites and hemp dispensaries sell them in many forms, from oil to flour and chewable gummies. These products are presented as CBD-only or CBD-dominant, because the THC concentration must not exceed an established percentage, generally 0.2% to 0.3%.

The wide availability of non-prescription cannabis and the listed low content of the most psychoactive cannabinoid could be misunderstood to provide reassurance/proof that there is no health hazard. On the contrary, except for cannabidiol (Epidiolex), the only FDA- and European Medicines Agency–approved purified form of CBD oil, there is no way to be certain of the THC content of a CBD product. Significant inconsistency has been found between the labels of artisanal CBD products and the actual content in THC and CBD.^20,21

In the presented case, the THC concentration in both hair samples indicated product use that was not as low as the parents claimed. Rather, this concentration served as an expression of chronic rising exposure to this cannabinoid in the child. With regard to the possible interference with other prescriptions or disorders, such those reported in our case, scientific research on the efficacy and safety of CBD in children is still underway, and long-term studies to assess neurocognitive development upon CBD use will need to be conducted.²²

To date, most literature reports describe accidental cannabis intoxication in pediatrics,^23–25 especially from resin ingestion in toddlers. Our reported case represents a “red alert” for health professionals working in pediatric care environments to the possibility that parents may intentionally administer cannabis products to children for “treatment purposes.” In the present case, the familial context, characterized by past and ongoing substance abuse and idealization of cannabis product benefits, appeared to elicited such behavior.

The differential diagnosis between accidental and non-accidental cannabis exposure can be challenging, but it is of paramount importance: if not differentiated, the child will be at high risk of repeatedly receiving harmful drugs. Along with a complete physical examination looking for signs of physical abuse or neglect and ones' clinical examination should also include a thorough toxicologic work-up including a detailed family history investigating the safety of the home environment.

Because the risk of child abuse seems to increase when parents are cannabis users or, in general, drug users,²⁶ toxicologic analysis should be repeated during the hospital stay and should also be extended to parents. In the reported case, such a work-up allowed physicians to understand what had happened and to take child-protective measures. As proved by parent hair drug tests, the environment in which the child was living represented a safety hazard. The detection of THC-COOH in the urine samples collected from the child in the hospital elicited great concern that cannabis had been given to the child purposely, as was later confessed.

From a medico-legal perspective, both types of cannabis exposure—intentional and accidental—may substantiate child abuse, defined as “acts or omissions by a caregiver that cause harm or potential harm to the child.”²⁷ However, parental conduct might be widely different, from inadequate parental supervision to malicious poisoning, and questions may arise whether the report is mandatory or not.

Several pediatric neurologic and behavioral disorders are a heavy burden for families and some parents; whenever unsatisfied by the effectiveness of conventional treatments, the parents may turn to cannabis self-treatment of their children, grounding this choice more on anecdotal online reviews in parenting communities than on scientific evidence.²⁸ Whenever parents reveal that they were confused because of both the legality of the product and the information collected on the World Wide Web, clinicians find it hard to evaluate this behavior and to determine whether or not to report the conduct. In our case, the parental misconduct was judged very severely. The parents were extremely reluctant to confide their self-medication practice with cannabis to the doctors and were reticent about the identification of the other substances—benzodiazepines and doxylamine—that were probably intentionally given to the child for their sedative and hypnotic effects. Nevertheless as the child's champion, all clinicians caring for a patient and neglect and/or abuse is suspected, appriopriate consultation with e.g., social services and/or the appropriate authorities should be stongly considered.

In conclusion, the parents seemed to lack any insight into their dangerous behavior.

Given its complexity (high number of non-prescribed substances in a child with a complex clinical condition, multi-problematic family, dangerous family environment), the case was considered to represent child maltreatment, coexisting with chemical abuse and medical neglect. Therefore, the child and the family were reported to the Criminal, Juvenile Court and Child Protective Services. The issues raised by this case deserve to be reported to health care professionals so that they do not overlook covert child abuse and neglect.

ABBREVIATIONS

CBD

cannabidiol

CSF

cerebrospinal fluid

FDA

US Food and Drug Administration

HSV

Herpes simplex virus

NMDAR

N-methyl-D-aspartate receptor

THC

tetrahydrocannabinol

THC-COOH

11-nor-9-carboxy-THC