*2.3. Study Population*

Eligible participants were children and adolescents between 5 and 21 years old, with an ASD diagnosis, as per the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), criteria, and as confirmed by the Autism Diagnostic Observation Schedule (ADOS-2), and moderate or greater behavioral problems rating (rating ≥ 4) on the Clinical Global Impression's (CGI) severity scale. The full list of inclusion and exclusion criteria appears in Table S1.

## *2.4. Treatment Scheme*

Participants were randomly allocated for treatment with two out of three oral preparations, each given in a distinct 12-week treatment period. Treatment options were as

SSRIs n (%)

**Mean** ± SD

[median, range]

> **Mean** ± SD

[median, range]

**Total CSHQ score**

**Bedtime Resistance** **21** (14.0%)

**49.9** ± 9.2

**9.4** ± 3.3

[8.0, 6.0–17.0]

[48.5, 34.0–73.5]

follows: (1) BOL-DP-O-01-W (BOL Pharma, Revadim Israel), a whole-plant (full spectrum) cannabis extract, containing CBD and THC at a 20:1 ratio; (2) BOL-DP-O-01 (BOL Pharma, Revadim, Israel), purified CBD and THC at the same ratio; and (3) placebo (BOL Pharma, Revadim, Israel). In each treatment period, starting dose was 1 mg/kg/d CBD (and 0.05 mg/kg/d THC) or an equivalent placebo. The dose was increased by 1 mg/kg/d CBD (and 0.05 mg/kg/d THC) every other day, up to 10 mg/kg body weight per day CBD (and 0.5 mg/kg/d THC), for children weighing 20–40 kg or 7.5 mg/kg/d CBD (and 0.375 mg/kg/d THC) for weight >40 kg (maximum 420 mg CBD and 21 mg THC per day), divided into 3 daily doses. Treatments were given orally (sublingual whenever possible), as an add-on to any ongoing stable medication (Table 1). At the end of the first treatment period, the study treatment was gradually decreased over 2 weeks, followed by 2 weeks of no study treatment to enable full elimination of the cannabinoids given in the first period [30].


**Table 1.** Participants' baseline characteristics.

**6** (12.0%)

**49.7** ± 8.7

**9.7** ± 3.2

[9.0, 6.0–17.0]

[49.0, 34.0–69.2] **8** (16.0%)

**50.1** ± 9.4

**9.4** ± 3.4

[6.0–16.0]

[47.5, 36.0–72.0] **7** (4.0%)

**49.7** ± 9.6

**9.1** ± 3.3

[8.0, 6.0–17.0]

[35.0, 34.0–73.5] **0.84** \*

**0.97** #

**0.63** #


Baseline characteristics of participants stratified to treatment arms. ADOS-2—Autism Diagnostic Observation Schedule, comparison score of 8–10 indicated severe autistic symptoms; BMI—body mass index; CARS—Childhood Autism Rating Scale, scores above 36.5 are indicative of severe ASD; CSHQ—Children's Sleep Habits Questionnaire; SRS—Social Responsiveness Scale, total score ≥ 75 indicates severe autistic symptoms; VABS—Vineland Adaptive Behavior Scale, composite score ≤ 70 indicates low adaptive level. \* Categorical parameters (sex and medications) were compared using Pearson chi-square tests. # Continuous parameters were compared using one-way analysis of variance (ANOVA).

The CBD:THC ratio and daily dose were chosen based on our clinical experience and previous open-label studies on the effect of medical cannabis on ASD core symptoms and comorbidities, including sleep problems [22,24,25]. Further details regarding the cannabinoids' preparations and randomization process appear in the Supplemental Information.

### *2.5. Baseline Evaluations*

Baseline assessments at study onset (day 1) included the following: ADOS-2 [31], a systematic and standardized assessment of communication, social interaction, play, and imaginary use of materials, which was administered by a developmental psychologist (MH), with research reliability; Vineland Adaptive Behavior Scales (VABS) [32], a caregiver interview assessing communication, socialization, and daily living skills, which was administered by the same psychologist; and Childhood Autism Rating Scale, second edition (CARS2-ST) [33]—A quantitative measure of direct behavior observation–which was administered by a trained pediatric neurologist (AA).
