We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids. I'm Dr. Jane Gilmour, honorary consultant, clinical psychologist, and child development programme director at UCL. And I'm Umar Toseeb, professor of psychology at the University of York, focusing on children and young people's mental health and special educational needs. In each episode, we select a topic from the research literature and, in conversation with invited authors, sift through the data, dilemmas, and debates to leave you with our takeaways for academics and practitioners. Today, we'll be discussing cannabis use and abuse in the family context and with adolescents. This episode is called "Cannabis-- Context is Everything." Let's talk about weed. And that's what I'm going to call it for the first few bits of this podcast, but I'm sure we'll come to the proper name later. So I have to start by just declaring some implicit biases or explicit biases or just biases I have towards the topic. I think that in the last-- like, in my adult life, I've lived with people or been around people who smoke weed, and I've never really understood the appeal. And I know that this episode is around medical cannabis, not cannabis in general. I don't like it because it smells, and the one time I had it in Canada, where it was legal and you had to buy it from the shop with some stuff, but I didn't see the point. But on some level, I think I still associate cannabis use with risky behaviour. So in adolescents, this is a rebellious behaviour that you're doing or that you're engaging in. And every time I see someone who's smoking weed, I'm a bit like-- in my head, I'm like, what's this person going through that they're trying to deal with by smoking weed? And then when I speak to them, or if I speak to them, they'll just be like, oh, it just helps me relax. I'm not trying to deal with anything by smoking weed. I think you've hit on two to potential mechanisms there. One is risk-taking, and one is the potential effect that it has on an individual and why they might be drawn towards that, because certainly in the UK, we'll come on to some of those exceptions in the paper in a moment. But in the UK, cannabis is illegal and by virtue of taking it, you are engaging in a high-risk behaviour and not just because of the substance itself, because what you're ingesting is not monitored and so anything could be in it, in theory. And who you're connecting with to get hold of it could be a situation that puts you at risk. So there is a lot of risk within it, and I think I'm really interested in the context of risk-taking in adolescence in and of itself, because there will be a draw towards doing something novel, doing something, certainly in the UK, that's illegal by virtue of being post pubertal. And I think that's interesting. And I think the other really interesting thing about this paper is the idea of context, that context is highly influential on risk. We know this from a variety of data sources, looking, for example, at Steinberg's [INAUDIBLE] and the presence of peers and the emotional context and how that might risk the chances of engaging with something illegal, drugs. So I think the idea of context in the moment, but also in the societal, wider context is really important here. And this is something that the paper addresses with a really interesting position, if you like. So I think the risk and the context are two key themes that I want to explore a little bit more carefully. I was just going to say, I was just thinking about risk taking and the idea of generation sensible. So certainly in the UK, and I know a lot of other westernised societies, there's a decrease in the use of substances except where it's legalised. So I read a really interesting systematic review by Wang and his colleagues saying that where cannabis is legalised, the frequency of using it is increasing, but elsewhere it is decreasing, and what's going on there. So again, there's something very interesting about context and risk-taking there. I was going to make a related point, which is the context being important, because I wonder whether it's not the smoking the cannabis or that is the risk-taking behaviour, it's the fact that it's illegal that is the risk-taking behaviour. And that might be what's then associated with the negative outcomes. Because I think-- there's Professor David Nutt. He argued, at the time, that lots of illegal drugs are no more worse for you than alcohol, for example, and he tries to provide an evidence base for that, and he lobbies for decriminalisation of certain drugs. And I think he argues that the reason why cannabis is illegal in the UK is a political choice rather than adverse health outcomes. But I also wonder whether some of this-- I'm not an expert on this-- is about the lack of evidence. So just because there's no evidence that something is bad for you, it doesn't mean that it's not bad for you. But it could be, because it's illegal, so we can't investigate it, or we are more difficult to investigate it or people don't investigate it as much. So I am sure that people who are invested in this line of research have thought of that. But that's my initial reaction, which is like, well, just because we don't have evidence that it's bad for you doesn't mean it's not bad for you. There could be a number of other reasons. And there's lots of-- the political context is interesting. We're thinking about the wider societal experiences is very pertinent. It reminds me a little bit of the investigations into hallucinogenics and their impact on mental health. And the problems, certainly, in the UK of getting a licence in order to investigate, that means that there's been a variety of different debates about it, just in terms of logistics. But there are data that suggests, to a degree, that cannabis can have a positive effect on some physical illnesses-- chronic pain, nausea, and MS being three examples, I believe, although I don't know this data well. But the reason that I was particularly interested in this paper is that, as you know, I work with lots of young people who have tics. And anecdotally, particularly adolescents will say that they think that this is something they use in order to manage their tics. We need some expert opinions to guide us, I think. Let's bring in our guest. So today, we're joined by Dr. Shelby Steuart, a professor from the University of Maryland; and Victoria Bethel from the University of Georgia. Shelby and Victoria are co-authors of the paper Medical Cannabis and Paediatric Cannabis Exposure-- Evidence from America's Poison Centres, published in the JCPP. Welcome to you both. Thank you so much. Thanks for having us. Yeah. Thanks for having us. We've used a variety of terms so far in the last five or 10 minutes of talking, like "weed," "cannabis," whatever, "marijuana." So what is the difference between those terms, and then what term will you be using as we go forward in this podcast? Yeah, I really like that question. When I was at the University of Georgia, I taught a course exclusively on risky behaviours, and that was something I like to start off the course with, was thinking about the terminology we use and how that contributes to connotation. And so we tend to use the word "cannabis." And that kind of includes a blanket of the herbal plant that we think of as weed or marijuana, but also different formulations, like edibles and tinctures. So a lot of the other terminology is fine-- "weed," "marijuana." Those are just slang connotations. And particularly in the US, the term "marijuana" has a little bit of a stigma to it due to political attempts to connect it to immigrants. And so we tend to use the word "cannabis" just to try to decrease the stigma and also focus on the potential medical effects, but also just try to avoid any kind of political polarisation with it. Thank you. Very helpful. And we're going to be talking about medical cannabis today. But what's the difference between medical cannabis and recreational cannabis? Most of the difference here, and I think in other countries as well, is it's just a legal statute. So in the states in the US, which the majority-- I think it's over 38 now-- have legalised medical cannabis, which means that there is some regulatory system that will work with doctors to determine which patients should have access to cannabis. And then there's state regulatory oversight on the production of cannabis products. Patients have to have a medical card that they usually update every year or every two years, and it's pretty tightly regulated. There's some difference in the formulations available. So especially for children, it tends to be more of the very low THC or no THC, if possible, whereas adults tend to have a little bit more freedom over, if they want, if they feel like a smokable cannabis helps them for their medical condition versus a pill or a tincture. Recreational cannabis, it just is a statute that allows for anyone 21 and up to purchase cannabis, and in most states, it's regulated similarly to alcohol. The same way that you would have to go to a liquor store, you have to be 21 to enter in the US to buy alcohol. You would also you have to show your ID before you walk into a recreational dispensary to show that you're of-age. And then there are purchase limits that are-- I think it's actually a little bit tighter than alcohol because I'm not sure that we have-- most states don't have limits on how much alcohol you can purchase, but there are limits on how much cannabis you can purchase. And I think there is this issue with the recreational market because it incentivizes almost like an arms race for the most potent cannabis in the US. We are just seeing the potency rise so fast, and I personally feel like it's driven by the recreational market because especially younger people, young adults, they want to try the most potent strain and they want to have these psychological effects. But that kind of cannabis has never been studied. Everything that's been used for clinical work has been very low THC, and so I think that's one potential risk, especially if you are seeking to use medically in a recreational environment or a state where that's legal, sometimes your options are kind of driven by the recreational market. And in many states, it's the exact same store you would go to purchase either medical or recreational. It's just there's two different lines that you would go in or two different queues to use. And then as a follow up from that, acronyms like "THC" and "CBD," how does that all fit into this terminology? So cannabis is a poly-pharmaceutical substance, which means that unlike medications you might get from your doctor or over the counter, it doesn't have one or two active ingredients, it has hundreds. And so scientists are still mapping all of the different molecules and cannabinoids or active ingredients within the cannabis plant. We know for sure that there are between 80 and 100 cannabinoids or molecules that interact with the endocannabinoid system in our bodies, and we also know that there could be at least 200 different terpenes, some of which can have therapeutic benefit. They're just another type of molecule. Some of them contribute just to the taste or the smell of different cannabis plants. And so it's a really very kind of complicated substance, despite I think we all have some idea from the media or from just interactions we've had in our personal lives, like you mentioned, Umar. But it's pretty complicated. It's still definitely being mapped by scientists. The molecules or cannabinoids that interact with our body that we know the best about is THC and CBD. So THC is delta-9 tetrahydrocannabinol, which is the-- it was just the first active ingredient that we knew about. It's also the most psychoactive, and so when people are talking about feeling a high or psychoactive effect, it's our current understanding is that that's mainly related to THC content. CBD is cannabidiol, and that is another just really well-known chemical or molecule or active ingredient, depending on how you want to think about it. And that one is not psychoactive. It's very popular here in the United States, especially as of 2018. We passed a law kind of legally separating CBD from THC and making CBD more widely available for people to consume, in which case it's typically extracted either from something that has grown to have very little to no THC, which we call "industrial hemp," just to separate from the cannabis plant that people would smoke for a high. And yeah, that one is most closely related to addressing seizures and epilepsy in children, but also chronic pain for adults. And there's some supposed anxiolytic effects, though I'm not sure that that's been proven yet. A lot of it is still kind of developing. So in the UK, it is possible to be prescribed a medical prescription related to cannabis. So is that the CBD that would be prescribed? Because that's, as I understood it, as being the THC. But I don't know this literature at all well, so it would be good-- if you can figure it out for me, then that would be helpful. Yeah. I think it kind of depends. I don't know about the UK context, but I know that in the United States, there's different formulations. So as Shelby was saying, there's going to be some pharmaceutical formulations for kids with epilepsy or perhaps spasticity and tics, although that's less understudied and those are going to be very high CBD formulas, although some of those medications would also contain THC. And I can't think of the name off the top of my head. I would have to look it up, but there is a specific THC drug that was marketed specifically to try and help with appetite, specifically among patients with cancer, I think, initially, and I'm wondering if that's what you're referring to. Marinol? Yes. Marinol? Yeah, that's right. That's what I have read. So thank you, Victoria. It's a THC. It was related to nausea following cancer treatment. So that would make sense. And I always thought that was kind of interesting because, again, I'm not sure how good the evidence is in this space, but I think the suggestion is, again, that with the nausea and with the appetite stimulus, that CBD might be the active ingredient in cannabis that's helping with some of those issues. So if you're in cancer treatment and you don't have an appetite, it might be the CBD that's stimulating your appetite, which is interesting when you think about, well, is Marinol accomplishing the same effect for people? Maybe not, and I think that kind of speaks to, because cannabis is illegal, we do have a limited understanding of what these different chemicals are doing. So certainly it's complex and there's a lack of data because of the complications of the substance itself that there's a lot to be learned and understood. I have a question about the patterns of use, particularly in young people, as we talked about a little bit earlier and I discussed this a little bit at the beginning, were sort of hinting at this-- the idea of the rates in general, certainly in the UK and other westernised countries, of illegal drug use dropping. Although the only exception to that is that vaping, which is obviously not illegal, but that's the only substance in terms use that seems to be increasing in young people. Do you have any comments on these patterns, either in reference to your paper or in terms of the wider literature? Yes. So I think both in the UK and in the US, we're seeing this growing trend of differences of leisure activities. So we see young people spending more time inside, on phones, less time with in-person socialisation. And I think a lot of that was also increased by the COVID pandemic and just decreasing the in-person aspect of socialisation. And so we do see, as many adolescents try substances for the first time in a very social situation as opposed to on their own, that's currently one of the mechanisms that we think that substance use is decreasing. And I do want to mention, though, that at the same time as overall substance use is decreasing, we are seeing increasing drug mortality, so overdoses among young people. And this is mostly connected to the increasing lethality in the drug supply here in the US. Like, we do drug checks indicating that you can find fentanyl in everything from cocaine to counterfeit pills that look like prescription drugs to things people are trying to buy as heavier opioids. And Victoria and I actually have another paper recently that came out where we found that exposures to opioids really increased during the pandemic among 12 to 17-year-olds, mostly for substance misuse, but also, we think as an artefact of poorer mental health, decreased access to the mental health care system. That was just-- that happened as a result of COVID. So it's an interesting time to be living in, where we do see this wider decrease in the percentage, but we still see an increase in the percentage of mortality as a result of it. To add to that, especially considering the lethality of the drug supply in the United States, this isn't something that I think has been researched, so this is just of speculation. But I do wonder if people are spending less time together, there may be less learning about, oh, this is a safe way to consume a substance, or I'm going to consume this substance in the company of friends. And I think there's a lot of risk that's associated with drug use, but there's even more risk, perhaps, that's associated with drug use alone. So it may be positive if you're not being exposed to drugs by your friends, but it could be negative if you're not using drugs around other people, or if you don't learn from other people how to safely obtain substances, because when you start getting into the idea of contamination, there's young people who aren't going to know the difference between a real and a counterfeit pharmaceutical, whereas someone who was more seasoned may know that difference. Yeah. And I also want to mention that the increased mortality is in the UK as well. It's not just in the US. I think there are a lot of parallels that we see between the cultures, especially with youth and how they spend their time and what they're doing, so just wanted to clarify that we studied it in the US context, but I looked it up, and there's other literature finding that in the UK context as well. Well, I mean, it's really-- and I appreciate you're saying it's speculation, but it's really interesting to think about the social context for teenagers being a break, if you like, for risk-taking, because we also know that it can be a crucible for risk-taking. The rates of doing various illegal activities is much higher when there are a lot of kids around rather than single. But it's really interesting because, of course, there will be a learning and there will be a sense of somebody who cares about you being around to perhaps put the brakes on something or perhaps bring you out of that mental state that pulls you into drug-taking. So that's a really interesting, and I never thought about it that way. So that's a really thought-provoking comment to make, so thank you for that. If we move on to medical cannabis specifically, which is the focus of your paper, let's try and situate this within the general population. So what proportion of children or young people take medical cannabis, and is that different depending on the age of the young person? So it's quite small. Only, as of the most recent counts, less than four million people at all in the US use medical cannabis, and we have a population of over 330 million. So that's about a tenth. Of those, estimated that between 0.4%-- a fraction of a percentage point-- and 1% of them are under 18. So our current best estimates are between 10,000 and 34,000 across the entire country. So it's very small. And the type of cannabis that those children have access to is very different. It's not the same thing that's available to adults. It tends to be low or no THC, and it's also much harder to get medical approval as an under 18-year-old to use medical cannabis. Instead of having one doctor sign off, you have to have two. You have to have documented evidence that it will help your condition, and so there are much fewer conditions that children can get access to cannabis for. And I also just want to highlight that what we're seeing in our article with the unintentional exposures, those are, by and large, not medical cannabis patients. Those are young children who are being exposed to cannabis because it's in their household, because their parents either use recreationally or medically. And so the formulations that we're seeing causing these poisonings are not the same as the formulations that are available for medical consumption for children. That's really interesting. So again, there's a context there in terms of availability and presumably-- we talked about these-- these accidental ingestions. So as I understand it, I mean, because there are these differences in state law across the US, it's one of the most interesting natural experiments, I guess, in terms of the capacity to make observations because there's so many cultural commonalities across the US, but there's differences in state law. So you're in a unique position, so you can talk about the social context of drug use. How would you summarise that? And here's my very unfair question, but what would you do if you were to legislate? What would you do in order to protect or invite therapy? There are two opposing forces there. Yeah, I can start answering this, and then, of course, add anything you want to, Shelby. But I think one important finding that we see in our paper is that there's this increase in exposures after medical cannabis is legalised. And in the United States, we see, in each state, it's a step-wise process where you legalise medical cannabis and then you legalise recreational cannabis. To make this clear, this is relative to medical cannabis. So we're still seeing higher rates of exposures than in the pre-cannabis legalisation period, but we do see that there's this decrease relative to the medical cannabis legalisation period and exposures during the recreational cannabis period. And what we think we're seeing is maybe some policy learning in the sense that with recreational policies and the research that we've done-- and I think it would be cool to do this more systematically at some point-- there's more policies about you have to have child-proof packaging. You cannot package this to look like an edible that is candy, which was happening, especially in some of the more grey area states, because there's such heterogeneity between states and how they're adopting these policies. And some states, there's a high amount of regulation, even when medical cannabis is passed. But then in a lot of the earlier states, we see evidence that there's less medicalization. So even in the medical programme, it's more of like a recreational status in states like California and Colorado that are super early on, and then they kind of learn over time. So by the time these recreational policies are passed, there's a protective effect, perhaps, because they're adding in these stipulations that we're not going to market this to look like something that's appetising to kids, and we're going to make it challenging for kids to open. So again, it's still higher than the pre-policy period. I don't want to say recreational cannabis is the solution to poisonings after medical cannabis. That's not what I'm insinuating at all, but I think there is evidence that not making it so appealing, marking it so it looks like a medication, because a lot of the kids that we're seeing are being exposed, or kids who are very young and they're not going to be reading a package, but if it's in a pill bottle versus a package that looks like candy, there's one of those that they're going to be willing to reach for. Yeah, I think those are good points and I echo those. And it's been hard for us to collect data on the ways in which states are learning because sometimes they don't publicise it. You might just hear anecdotally from people who live in a state that, oh, my state just started putting up these billboards of, like, lock up your edibles and things like that. But we do also see the differences in how the legislation itself is written from the very early days of medical cannabis. So in the US, the first state to legalise was California, and they started with this very unregulated programme in the 1990s, where you just would have to carry a piece of paper with you that says, I have a condition that could be treated with cannabis, and it was like a way to defend against being arrested for cannabis possession. But there was no medical registry. There was no list of what conditions there's support for and there wasn't the same regulatory maintenance done. And we've seen of, especially as more politically conservative states are starting to legalise, there are really-- the legislation itself is much more complicated. They are setting out ahead of time to set limits on the potency, on the purchase limits, on the ages, on the conditions, whereas in the earlier more experimentation of these policies, it was much less regulated and monitored. And so we think that that's a large component of what we're seeing as well, is just states are kind of learning from each other, and it's as each next state legalises, they try to close some of the loopholes that they saw a state before them leave open. And we see that more consistently when medical states then go to pass recreational legalisation, they're closing their own loopholes also in the legislation. And so they're trying to make it run smoother, and they're trying to make it so that more patients can access or more individuals can access it. Because we also see a lot of adults use it as an alternative to alcohol. And there are, especially if you're using it in a smaller quantity than you would be consuming alcohol, there are some non-negligible positive health effects that we see because we know alcohol is really damaging to our bodies. So yeah, I think that generally we're seeing this progress where policies are changing, states are changing. There are all these little things being done to try to tighten it so that we can keep the protective and helpful effects while minimising these unintentional negative spillover effects. But there are many spillover effects. We also see increased traffic accidents and emergency department visits. And so, yeah, it is complicated for sure, but I think if I were to have a magic wand, I would do a lot of what Victoria was saying, of just making it not look fun to kids while also kind of keeping it available for both medical and recreational uses. Because we've seen DUIs decreasing in states that have legalised it, which those can be so damaging. We've seen-- Crime decreased. Yeah, we've seen crime decrease. There have been a lot of really positive effects. So one of the things that I think will be really nice for our listeners is to think about the impacts on children and young people, specifically of cannabis. So if I've understood your study correctly, I think what you're finding is that more children are now accessing cannabis since legalisation. And you've talked already about some of the routes through which that's happening. So what do we know about the impacts of cannabis on children and young people's development? What does the research say about this? I just want to highlight-- so we have one limitation of our study-- well, we have a few. But one of the main ones that's relevant here is that in order to show up in that data set that we use, somebody must make a call to an American's poison centre. And so they must call poison control and say, my child has been exposed, what do I do? And the poison help nurse will say, either you need to go to the hospital or I think you're OK to wait at home. But because we know there is such this strong social context and the destigmatization, it is possible that some of the increases we see are just increases in parents feeling comfortable asking because they're not as worried about a police report coming. We do see these same echoes happening with emergent emergency department visits. So I think that there is a real increase, But. I think also I just want to mention that it could be that also that parents are feeling more empowered and feeling like they can get advice without being arrested. Thanks for adding that. I think one thing that's really important when we're considering the effects of cannabis on kids is this point that Shelby touched on, that everything is getting stronger, and that is when we get really concerned about kids, because we know that high-dose THC for young kids, who are the ones that we see are unintentionally consuming these edible products, which often have really high doses of THC. And when it becomes this arm race, sometimes it's ridiculous amounts of THC that even an adult with a high level of tolerance would not be able to handle very well. And it's these high doses of THC in these young kids who have low body weights, where we see cardiac dysrhythmias needing respiratory support. Some of them even require intubation. It's these little kids that get their hands on strong doses of THC that have the worst health effects. So I think that's another important highlight we can say-- and it's true, perhaps, that maybe cannabis is less harmful for adults to use than our alcohol, but in terms of little kids consuming a large amount, there's probably a higher risk, especially if it tastes good, because alcohol does not taste good to a little kid. And so it's this very vulnerable population that have their hands on very, very, very strong stuff that tastes good, who are going to experience the worst side effects. And so again, sometimes cardiac dysrhythmias we don't fully understand because there isn't this-- there's moral ambiguity, one, in giving cannabis to kids to see what's going to happen to them, of course, or to do the comparisons. Is heavy alcohol use versus heavy cannabis use in teens going to affect them more negatively? Obviously, we can't conduct those studies. But when these kids accidentally ingest these high doses of THC, we're seeing really problematic side effects, and a lot of them end up requiring intensive care treatment, which can be traumatic for the whole family. I think that's a great point also, just the point about the fact that it tastes good means that they're not going to do what a grownup is doing and try one dose or half of one dose of an edible. If they see just a jar of what looks like candy, they could eat the whole thing. And that's when we see these really negative health effects. And so it's exposure to adult formulations and also overconsumption because it seems like something that they should be allowed to eat. Increasingly, we do have child safety locks, and so I think that has been a really positive change that I think was also driven by the recreational market as a way to try to make it safer. But some states still need to improve upon that, especially for edibles. I think sometimes they're just in a pop-up package, whereas a pill-type thing might would have a lock on the top. And so I think there's still room to improve the safety of those packages. We periodically go to dispensaries and just try to see what they're selling and what the safety looks like. And even as a month ago, we're still seeing some products are not being-- are not having-- could be opened by a child. And so, yeah, I think when we think about children's safety around cannabis, the problem is just access to adult products. I think that's true for teenagers as well. It's not the paediatric medical market. I mean, it's very reminiscent of when I was a teenager growing up, it was alcopops that were marketed to young teenagers. They looked like sodas or fizzy drinks and were flavoured to be more palatable to a young palate. And also the vapes are now strawberry flavour or whatever. I heard somebody say, if they were olive and anchovy flavour, we wouldn't have the teenage problem that perhaps we have. So that's not particular to the cannabis consumption. It is a general problem. It's a marketing issue. And you talked about that as being a policy, something that's been learned in terms of policy. But it does seem to be something that should be ubiquitous in terms of adult consumption products shouldn't be attractive to anyone that's not aware of the risks inherent in taking it. Absolutely. I think I'm just mindful of the times. And just before you go now, what about synthetic cannabis? So what's that about? Sure. So what's really interesting to me, at least about synthetic cannabis, is it's actually not cannabis at all. When it was first noticed that people were using it, it seemed to create some effects similar to cannabis so we thought it was cannabis. But it's actually these different chemicals that are made in labs that can just be sprayed on any plant material and consumed. It does have some interaction with our endocannabinoid system, but it is a lot more harmful than natural cannabis. We see it as very available in the US because the sprays are continually changing and our illegalization method is done at the molecule level. So if people go out and create a new molecule, they can legally sell it until-- it's kind of like whack-a-mole, until you can find that one and add it to the list. And then also we see a lot of what's called "delta-8" THC. And it's increasingly thought of as semi-synthetic because the delta-8 products you can purchase are made in labs where a chemical reaction is done on CBD to change one of the bonds in its molecular structure. And that one is also really unsafe. And so one of the things I hope to get out into the world is just that, these synthetic attempts are very unsafe and they're completely unregulated. And so if you need to use cannabis for health reasons, you really need to go of the medical route because you're going to get no positive effects for your health condition and probably negative effects from using these less regulated options. Good advice. It's an interesting time in the US. I won't speak long, but it's just interesting because there is a lot of ambiguity, even though the state-level legalisation has happened. There are some different interpretations of a federal bill that some people interpret it as making delta-9 tetrahydrocannabinol legal federally. So the whole synthetic cannabis and selling cannabis in different ways has become really popular almost across all states in the US at this point, and that's been in the past couple of years, which just makes everything even more complicated. It's where the political, the social, the legal, and the pharmaceutical worlds collide, and it's quite a collision. Yeah. I'll be interested to continue watching how it plays out in the UK because your legal framework is different from ours. Ours just lists molecules, and yours kind of covers anything that can have an effect similar to cannabis. So I think that might be more effective at preventing these things like synthetic cannabis and delta-8, but yeah, I'll be curious to learn more about how that is playing out in your context. OK, let's call it a day there. Thank you so much. Yeah, that's been fantastic. I really enjoyed that conversation. What we would like to do is say, thank you so much, Victoria and Shelby, of what a fantastic, informed conversation that really is very thought provoking on so many levels. And we're so grateful to have your expertise here. We didn't get on to tics. I will just have to read the literature myself and find out some more about that. We are so grateful for your expertise. Thank you for your conversation. Thank you. Thank you. That was really good because it gave me more ideas about what we could do in terms of more episodes on this related topic. And the first one is legal highs. So we haven't really touched upon legal highs, but it is a thing. So maybe we could get someone on who has written a paper or has a research focus on legal highs. And the second one is vaping. And I know that we are speaking to someone later on in the series about vaping and an impact on children and young people. So I'm very much looking forward to that because it will really help us to-- I think it will help us to contextualise some of these things, because it's really difficult to think about, well, what does that mean for children and young people's development on the whole when we're looking at one thing in isolation, but if we look at one thing and then another thing and then another thing, and then try and get to, oh, our listeners can try and get to a position based on the evidence that they hear from multiple people doing research on different substances or different types of substances. Yeah. I mean, the fact that we have so little long-term data on vaping and it's the growth activity for young people is really important. So I'm very excited about the January episode. I enjoyed that conversation, too, because it was so contextually rich. And it really made me think a little bit about managing risk in a contextual way, and I think you'll be very excited about this, Umar, because I know your frustration with putting an intervention focus on the young person. But here, you might consider putting an intervention focus on the system, and so the family, the young person respond to the environmental shift with an improved outcome, rather than the individual having to move in order to have an improved outcome. I think it was very interesting. And again, because our guests were from the US, I think it added an extra level of contextual interest to it because the legal framework and the cultural framework are very important when it comes to risk-taking. And another thing that I enjoyed about that conversation was-- and this is what I was trying to get to at the end when I asked for that so what bit, which is what I didn't get from the guests was them preaching and being like, cannabis is bad for you, don't take any of this, ah, ah, which is what we've been doing as a society for a long time. And I think their position was much more nuanced, which was it's now becoming legal in lots of different contexts and this is what we can learn about what happens when it becomes legal, and then these are some of the risks associated with it becoming legal. And some of it was around the active ingredients, but some of it was around just-- I would see it as if we're thinking about RCTs in schools or whatever, the implementation and process stuff, so it's not the intervention itself or the policy itself, it's just how it's implemented. And I think what we were seeing here is the legalisation process, how is it implemented and how can we fine tune that implementation to reduce the risks to children and young people? And I liked that about the conversation because it wasn't preachy. It wasn't people saying, you shouldn't be taking cannabis because it's bad for you and whatever. It wasn't about that. It was about, what does the science say, but also how can we learn from the implementation so far to reduce the risk for children and young people? Yeah, I agree. And it was really pragmatic, which I think if one is working in the substance field, one needs to be. You need to take a position of neutrality, otherwise, you won't be able to engage with those young people and so on. So I agree it was really useful. It was data-led, not morally bias. The other clinical point that it made me think about was the idea of risk-taking. And of course, when we're talking about the risk-- and I do it too, but risk simply means that the outcome is unknown. But there is an implication sometimes in our language that risk is inherently negative. But what is interesting about risk-taking, particularly in adolescence, is that we know from Natasha Duell's work that the same individuals are likely to take both positive and negative risks. So a positive risk might be, I'm going to take up the guitar. I don't know how good I'll be at it, but I'm going to do it anyway, whereas a negative risk could be something like drug-taking. And we know that the direction of the risk in that young person is dependent on what's at hand, what the environmental and social cues are telling us. So that idea of contextual understanding and harnessing that need for risk-taking, but shifting the environment so the options for taking a risk in the immediate context are positive ones is interesting. The fact that you know that, for example, cannabis is lying around simply means that a young person might be more inclined to pick it up and explore it in a very dangerous way, potentially. So I thought it was really interesting on so many levels, if we're thinking about the individual, the family context, the community context, the wider environment, and the legal framework. It was so interesting to think about how we can shift risk-taking and just nudge it across into positive risk-taking depending on our environmental cues. So should we move on to our takeaways? Yeah. I think, for me, when I ask the question around what are the impacts on children and young people's development, and I think we touched on part of this at the beginning of the episode, and I think I would like to see more on specifically the impacts now that it's becoming legal in lots of different contexts. What are the impacts of specific active ingredients on things like cognition, working memory, mental health, well-being, self-esteem, friendships, relationships, all of those things? Because I think the fact that it's legal means that we can probably investigate it to a different extent and to a different nuance. But also, as with the theme throughout this episode, has been the context, and the social relationships aspect specifically might be different because the context isn't in a deviant behaviour. The context is within a different type of behaviour. So I wonder what that means for social relationships. So I would like to see more work, and maybe it already exists to some extent, but we'd like to hear more about it, about what are the impacts on children and young people's psychological development, because the guests talked about the physical health of extreme use, everyday use, general use on young people's psychological development. I think that's really interesting, the social context shifting our opportunity to explore that. That's a really good point. Well, I guess my takeaway, unsurprisingly, is the focus on adolescents and leveraging young people's pull toward risk-taking by shifting their environment to invite those good risks and maximise their chances of success. Excellent. Thank you. Next week, we'll be speaking to Professor Erin Schoenfelder Gonzalez about mastering meltdowns, managing big feelings in kids. [MUSIC PLAYING]