59

J. Indian Assoc. Child Adolesc. Ment. Health 2006; 2(2): 59-67

Review Article

Cannabis Use and Performance in Adolescents

Anil Malhotra MA, DM&SP, PhD, Parthasarathy Biswas MD

ABSTRACT
Cannabis is a widely used illicit drug among adolescents, many of whom
perceive little risk from cannabis. Cannabis use is associated with poor academic
performance and increased school drop-outs. It is also associated with high-risk
behaviors in adolescents like crime, violence, unprotected sexual encounters, and car
accidents. Many of these adolescents have conduct, disorders, ADHD and learning
disorders. There is some evidence to suggest that cannabis use leads to use of ‘harder’
drugs. It is well documented that it produces acute cognitive effects that last for
several hours after its ingestion. However, it is debatable whether it produces
cognitive dysfunction beyond the period of acute intoxication.
Key words: Adolescents; Cannabis; acute cognitive effects; long-term cognitive
effects
_____________________________________________________________________

INTRODUCTION
Cannabis has been a traditional drug of use in India with moderate
consumption being ritualized in social gatherings.1 Majority of the cannabis users start
using the drug in their adolescence but some leave it after initial experimentation,
while others go on to develop abuse/dependence.
Issues regarding the effects of cannabis on cognitive and psychomotor
performance remain ill understood. These issues attain more importance because of
the fact that an ever greater number of adolescents are abusing cannabis and that too
at earlier ages.2-5 Cannabis use has been associated with poor school performance and
school dropout,6,7 and with reinforcement of conduct symptoms in adolescents,8 which
may further affect academic performance and dropout prior to high school.
Epidemiology
Several researchers have documented cannabis abuse among various sections
of the society including school and college students, non-student youth, psychiatric
patients and in the general population. General population surveys like the National
Household Survey (NHS) in India show that lifetime use of cannabis was 4.1% and
current use was 3.0%.9 Among those who were current abusers of cannabis, 25.7%
fulfilled dependence criteria. Age wise distribution of cannabis use revealed that 3%
of children and adolescents (12-18 years) abused cannabis. Only 4% of the current
abusers contemplated and sought treatment for their problems.10
The Drug Abuse Monitoring System (DAMS) that studied patients attending
the Governmental de-addiction centers under Ministry of Health and Family Welfare
(India) found that 11.6% of patients abused cannabis. Of those abusing cannabis,
3.5% were students. The data from the NGOs (under Ministry of Social Justice and
 60
Empowerment, Government of India) however, revealed that a larger percentage of
subjects were introduced to cannabis at a young age (below 15 years and 16-20
years). The Rapid Assessment Survey (RAS) conducted on street drug abusers (i.e.
not in treatment network) in India showed that although only about 3% of cannabis
abusers were below 18 years, majority of the older population reported initiation of
cannabis use at 15-20 years of age. A significant point of the survey was that cannabis
was the first illicit drug used by most subjects. Some information on drug abuse by
youth is also available from the data obtained from NGOs serving children and
adolescents and Nehru Yuva Kendras (NYKs) who participated in the Category B
component of DAMS. The results from this component of DAMS show that 28.5% of
children and adolescents were abusing cannabis and the age of first use of cannabis
was less than 15 years in 63.6% of cases.10
Similar trends are reported in Western literature, which show that 4.4% of new
users start the use of cannabis at the age of 12 years, 9.3% start its use by 13 years of
age and 15.1% by 15 years of age. For males, the highest proportion of all recent
initiates was at ages 15 and 16 (both at 14.8 percent).11-13
Cannabis: A Gateway Drug
The fear that cannabis use might cause, as opposed to merely precede, the use
of drugs that are more harmful (“harder”) is of great concern. The gateway analogy
evokes two ideas that are often confused. The first, more often referred to as the
"stepping stone" hypothesis, is the idea that progression from cannabis to other drugs
arises from pharmacological properties of cannabis itself. The second is that cannabis
serves as a gateway to the world of illegal drugs in which youths have greater
opportunity and are under greater social pressure to try other illegal drugs. The latter
interpretation is most often used in the scientific literature, and it is supported,
although not proven, by the available data.
There are strikingly regular patterns in the progression of drug use from
adolescence to adulthood. Four stages were identified: 1) beer and wine; 2) cigarettes
and spirits; 3) cannabis; and 4) other illegal drugs.14 It was found that younger age of
onset of abuse and intensity of abuse were the two factors that determined the extent
to which an individual would climb in the drug hierarchy. 15,16 More recent and
methodologically well-conducted studies (including large prospective studies) have
shown that, even after controlling for the effects of other known and suspected
factors, there remains a strong association between cannabis smoking and moving on
to harder drugs.17-19 Cannabis abuse therefore can be considered as an independent
specific factor and in all likelihood a cause of the progression to “hard drugs”.
Acute Cognitive Effects of Cannabis
The immediate and short-term effects of cannabis (minutes to a few hours)
have been the most studied, and have yielded consistent and least controversial
findings. Studies on adolescents have uniformly shown that cannabis often impairs
cognitive and psychomotor functioning that involves impairment in attentional
processes, reaction time, perceptuomotor functions, temporal integration, concept
formation, goal direction, decision making, and immediate and short-term memory,
though recall and recognition for items learnt in drug-free state remain largely
unimpaired.20-23
Research has also demonstrated that adolescent users of cannabis have
impaired performance on some but not all neuropsychological tests.24 The hypothesis
postulated for differential results on subscales of various tests include: (1) lifetime use
was as yet limited, and (2) in adolescents the toxic effects of drug abuse might also be
manifested as a decrease in the rate of cognitive development rather than simply a
general cognitive decline.
 61
Long-Term Residual Cognitive Effects of Cannabis
More recent data have also demonstrated a "drug residue" effect on
attention, psychomotor tasks, and short-term memory during the twelve to twenty-
four hour period immediately after cannabis use.25 The residual effects of heavy
cannabis use on adolescent development are of special concern for a number of
reasons. Firstly, adolescents are minors whose decisions about whether or not to use
drugs are not conventionally regarded as free and informed in the way that adult
choices are.26 Secondly, adolescence is an important period of transition from
childhood to adulthood, in which regular cannabis intoxication may be expected to
interfere with educational achievement, disengagement from dependence upon
parents, the development of peer relationships and making important life choices. 27,28
Thirdly, early initiation of cannabis use predicts an increased risk of escalation to
heavier cannabis use, and to the use of other illicit drugs. It also means a longer period
of heavy use, and hence, an increased risk of experiencing adverse health effects that
chronic cannabis use may have in later adult life.26, 28 Fourth, since adolescence is a
time of risk-taking, the use of any intoxicant, whether alcohol or cannabis while
driving a car, increases the risks of accidental injury, and hence of premature death. 26,
28
The type of evidence that initially shifted the focus about the effects of chronic
cannabis use on adolescents came from clinical case studies in which use of cannabis
in ‘bright adolescents' escalated to daily cannabis use, and the use of other illicit
drugs, leading to declining social and educational performance, as evidenced by high
school drop-out, and immersion in the illicit drug subculture.29-32 In some of these
cases, the syndrome remitted after the adolescent had been abstinent from cannabis
for some months.32
However, the cognitive effects of long-term cannabis use and their
implications are insufficiently understood.33 The major psychological effects of
chronic heavy cannabis use, especially daily use over many years, in adolescents
remain uncertain. This is an area, which is plagued by inconsistent, even directly
conflicting reports and numerous methodological problems, some of which are
inherent to such research.34 There are several issues of interest in residual effects of
cannabis. Firstly, the residual effects must be distinguished from acute effects of
cannabis. As reviewed above, cannabis undoubtedly produces a syndrome of acute
intoxication with characteristic cognitive and perceptual changes lasting or a few
hours after it is consumed. Many chronic users take cannabis regularly, even multiple
times a day, and thus may display acute effects almost perennially. Therefore, the
approach to investigating long lasting effects include clinical assessment of long term
users,35-37 observations of cultures in which long-term daily use of cannabis has been
the cultural norm for decades,38 and in addicts who are given the drug under
controlled laboratory settings after various periods of abstinence.39-41 To study residual
long-term effects in such individuals, it would be mandatory to stop their drug intake
for a certain period, which should outlast the acute effects of cannabis. Ideally, this
abstinence should be supervised. A major flaw in previous studies40-43 assessing long-
term cognitive dysfunction in heavy cannabis users has been that the abstinence
period was only one or two days, when it is well known that cannabinoid metabolites
can be detected in the urine of long-term cannabis users, weeks or even months after
achieving abstinence.44-46 Ideally, residual-effect studies should test their chronic users
after 48 hours of supervised abstinence. Very few studies have fulfilled this condition.
An ideal study to assess the long-term residual effects of cannabis would be one,
which has comparison groups that are as very similar to the drug-using group and
which allow for a prolonged abstinence period.
Secondly, residual effects must not be confused with background
characteristics of heavy cannabis users as compared to non-using control subjects.
 62
Such background attributes like premorbid intellectual, psychological and social
functioning as also comorbid psychiatric disorders (conduct disorder, learning
disorders and delinquent behavior) and use of other psychoactive substances
(especially alcohol) may heavily influence the findings and confound the
interpretations. Some earlier studies have been flawed on such methodological
grounds as well. Of these, the remarkable study by Schwartz et al used a 6-week
abstinence period for ensuring complete wash-off of any residual cannabis effect and
still found significant impairment of short-term memory (auditory/verbal and
visual/spatial memory) in the ten adolescents.37 It was concluded that cannabis-
dependent adolescents have selective short-term memory deficits that continue for at
least 6 weeks after the last use of cannabis.
Several studies provide more direct data on the effects of cannabis use on the
adolescent's cognition. "Heavy" cannabis use (defined as use seven or more times
weekly) was associated with deficits in mathematical skills and verbal expression on
the Iowa Test of Educational Development and with selective impairments in memory
retrieval processes in Buslike's Test.43 Drug abusers achieved lower numbers correct
and made more errors on Benton's Revised Visual Retention Test, which assesses
visuographic functions.47 Pope and Yurgelun-Todd assessed premorbid intelligence
and considered it in their statistics.41 They also ensured a strictly supervised abstinent
period of 19 hours. Also, rather than taking totally non-users as controls, they used
infrequent users (smoking about 1 day in the past 30 days) because the latter may be
expected to differ less from heavy users in some possible confounding variables than
would control subjects who had never used cannabis at all. In this study, heavy users
displayed significantly greater impairment than light users on attentional executive
functions, as evidenced particularly by greater preservations on card sorting and
reduced learning of word lists. These differences remained after controlling for
potential confounding variables such as estimated levels of premorbid cognitive
functioning, and for use of alcohol and other substances in the two groups. Thus, in
studies where residual effect have been reported, the most consistent findings are
impairment of performance on tests of focused attention, short-term memory,
perceptuomotor functions, and ‘executive functions’ (shifting of set). It must,
however, also be noted that the impairment in these areas are mostly modest in
magnitude, often just reaching statistical significance. It is debated to what extent
these subtle cognitive impairments reflect themselves in daily functioning of an
individual vis-à-vis the culturally normative functional demands in his/her relevant
society. Curiously enough, even the heaviest cannabis users of Pope et al41 study did
not exhibit any significant differences on prevalence of other psychiatric disorders
and scores on mental health and functional inventory when compared with the lightest
users.48
Traditional research evidence is as yet insufficient to support or refute the
existence of a prolonged "drug residue" effect and toxic effects on the central nervous
system that persist after drug residues have left the body. Furthermore, chronic
cannabis use does not produce cognitive impairment of comparable severity as
alcohol but there is suggestive evidence that chronic cannabis use may produce subtle
defects in cognitive functioning that may or may not be reversible after abstinence.
Cannabis and academic performance
Researchers have suggested that cannabis use in adolescents may interfere
with the capacity to 1) concentrate 2) organize information and 3) use information.41,
43,49,50
Regular cannabis use has been shown to be associated with cognitive deficits
and poor academic performance/achievements.7,22,51 This is particularly problematic
during teens’ peek learning years. This effect seems to last several weeks after use.
 63
In the study by Pope & Yurgelun-Todd, 57% of students in the sample
reported using cannabis while studying, and over 60% of those who did study after
using cannabis said it impaired academic performance.41 In terms of specific effects of
cannabis on academic performance, majority reported adverse effects of forgetfulness
(75%), impaired attention (66%), day-dreaming (77%), slowing down (75%) and
distractibility (64%). Another study found that children and adolescents with an
average grade of “D” or below were more than four times as likely to have used
cannabis in the past 1 year as those who reported an average grade of “A”.51 Cannabis
use was proportionately higher for students who have learning disabilities.52 Not
surprisingly, cannabis users displayed overall poorer school performance, spent less
time on homework, and had more school absenteeism than non-users.53 However, a
large study in New Zealand that followed up 1265 children for 25 years reported that
though cannabis use in adolescence was linked to poor school performance, there was
no direct connection between the two. The study hypothesized that cannabis use
simply encouraged a way of life that didn't help with schoolwork.54
There are conflicting results on the issue of absenteeism as well. A study
found that students who smoked cannabis within the past 1 year were more than twice
as likely to bunk classes as those who did not smoke.49 Furthermore, this report stated
that health problems related to smoking of cannabis could also keep students from
attending school. In a recent study on educational behaviors of adolescents, it was
found that 63% of the current users as against 17% of nonusers skipped school in past
month. The current users of cannabis were 2 times more likely to hate/dislike school
as compared to non-users.55,56
There are several explanations by researchers regarding the association
between cannabis and early school leaving. One theory is that daily cannabis use may
produce an “amotivational syndrome”, which could result in a reduced commitment to
school with predictable results in school performance. Though, research has not
supported the existence of this unique “amotivational syndrome” nonetheless
cannabis may impair motivation and school performance due to the immediate effects
of cannabis intoxication. The second theory is that daily cannabis use produces
changes in thinking processes that may affect school performance. However, there are
no evidences that regular cannabis users have the same severe memory deficits and
cognitive impairment that is found in people who use alcohol heavily. Proponents of
this theory believe that cognitive changes, which occur in adolescents, are the result
of “cannabis intoxication”- an effect on memory and attention, which occurs
immediately after use. The third theory is that cannabis use is associated with
precocious adoption of adult styles by adolescents who are not equipped to handle
them. There is some support to this hypothesis from a number of studies that show
that adolescent cannabis use is associated with early marriage, early pregnancy and
childbirth as well as early school leaving.57
Behavioral consequences of cannabis
Although the causes of the association are uncertain, Robins recently
concluded that it is more likely that conduct disorders generally lead to substance
abuse than the reverse.58-60 Such a trend might, however, depend on the age at which
the conduct disorder is manifested. Many chronic users of cannabis become involved
in the street scene and its related sex trade practices. Its use is associated with sexually
transmitted diseases, unsafe sex practices and other risky behaviors in adolescents.
The illegal marketing of cannabis promotes weapon carrying, violence, minor crime
and vandalism, and sexual exploitation. The marketing of cannabis to adolescents
significantly impacts the juvenile justice system and child welfare resources.55 In a
recent study on cannabis use and associated risk behaviors in adolescents, it was
found that 57% of the current users had unprotected sexual intercourse as against 7%
 64
55
of non-users. Moreover, current users were more than 2 times likely to be involved
in violence as compared to non-users. More than 2/3rd of the current users (as against
9% of non-users) drive vehicle under the influence of cannabis.
Studies show that adolescents between the ages of 12 and 17 who use cannabis
weekly are nearly four times more likely to engage in violence than those who do not,
and are more prone to behaviors that include destruction of property, stealing and
physical violence against others.49 A recent study found that early adolescent cannabis
use correlated with future deviant behavior, including dropping out of school, taking
risks and behaving violently.61
Conclusions
This review summarizes the harmful effects of cannabis on adolescent users.
The harmful effects on individuals were considered from the perspective of cannabis
use and can be divided into acute and chronic effects. For most people the primary
adverse effect of acute marijuana use is diminished psychomotor performance; it is
inadvisable for anyone under the influence of marijuana to operate any equipment that
might put the user or others in danger (such as driving or operating complex
equipment). Whereas acute affects of cannabis on human cognitive and psychomotor
performance are consistent and robust, the long-term sequelae of chronic cannabis use
are much more difficult to ascertain. Inspite of the many methodological obstacles,
research conducted over the last decade suggests that the long-term cognitive deficits
are more subtle, however, they can affect the adolescent’s development by decline in
academic and occupational functioning. In the face of this lack of sound, adolescent-
specific scientific knowledge and given that this is the era of evidence-based
medicine; the acceptance of marijuana as being ‘safe’ in adolescents is unacceptable.
The paper can be best concluded with the editors comments on the Pope and
Yurgelun-Todd41 paper in JAMA: “It will be interesting to see whether reporters
exaggerate the findings of Pope and Yurgelun-Todd. Physicians should not. There is
far more extensive, consistent evidence of cognitive deficits associated with heavy use
of alcohol relative to cannabis. Most of the cognitive impairments observed by Pope
and Yurgelun-Todd are not large relative to normal cognitive variability among
individuals; such impairment would not make heavy cannabis user ‘stand out from the
crowd’. With continued use of cannabis, however, the impairments might increase
over the years.”61

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Dr Anil Malhotra, Professor, Department of Psychiatry, Postgraduate Institute of Medical Education &
Research, Chandigarh, India.
Dr Parthasarathy Biswas MD (Psychiatry), Senior Research Officer, National Drug Dependence
Treatment Centre, All India Institute of Medical Sciences, New Delhi, India.