Prenatal Sleep Health and Risk of Offspring Neurodevelopmental Issues, Including ADHD

The Lancet, Regional Health Americas, October 2023

A new study, led by Columbia researchers, suggests that mothers who experience poor sleep during pregnancy, particularly during the second trimester, are more likely to have children with neurodevelopmental issues, including attention deficit hyperactivity disorder, as well as sleep problems and emotional dysregulation early childhood.

Claudia Lugo-Candelas, PhD, an assistant professor of medical psychology (in psychiatry) at Columbia University Irving Medical Center and principal investigator of the study, said that while prior studies have documented the link between maternal sleep quality during pregnancy and neonate neurodevelopment, correlates and consequences of poor sleep health in pregnancy remain underexamined.

“For the first time we identify a period of pregnancy where sleep may be most important to offspring neurodevelopment, raising the possibility that the second trimester may be most important to interventions aimed at protecting offspring well-being,” said Dr. Lugo-Candelas, who specializes in the perinatal programming of risk and resilience for neurodevelopmental disorders.

Few differences found in male and female children

To conduct their study, the researchers used data from the NIH Environmental Influences on Child Health Outcomes (ECHO) Program, drawing from multiple cohorts of pregnant individuals. The sample was socioeconomically and racially diverse and included 794 mother-child dyads enrolled in the National Institute of Health ECHO study. Pregnant participants self-reported on sleep duration, quality, and disturbances during pregnancy and on children’s ADHD symptoms and sleep problems on the Child Behavior Checklist.

Among the mother-child dyads, shorter maternal sleep duration and poorer sleep quality in the second trimester of pregnancy were associated with ADHD, sleep problems, emotion regulation difficulties in 4-year-old offspring. The association appears consistent across both male and female children—with no significant moderation by offspring sex.

This finding surprised the researchers as many prenatal programming studies—a conceptual framework that proposes certain events occurring during critical points of pregnancy may cause effects on the fetus and the infant long after birth—suggest early brain insults associated with maternal immune and HPA axis (hypothalamic-pituitary-adrenal) activation in response to stressful events, have differential effects depending on offspring sex.

“It is worth highlighting that children in our sample were, on average, 4 years old at the time parents reported symptoms, an age when neurodevelopmental disorders like ADHD begin to arise but have yet to peak. It may be that with increasing offspring age, sex-specific associations could emerge, which would be in line with the pronounced male bias seen in ADHD at older ages,” the authors write.

According to the Centers of Disease Control and Prevention, an estimated number of children aged 3–17 years in the United States ever diagnosed with ADHD, according to a CDC, is 6 million (9.8%), with boys are diagnosed with ADHD more than times as often as girls are. Researchers believe this is likely due to an underdiagnosis of girls rather than ADHD being more prevalent in boys.

 The study adds to the growing body of evidence linking maternal well-being during pregnancy and neonatal neurodevelopment outcomes. “Although research is needed to understand the underlying mechanisms, our study suggests prenatal maternal sleep may be a future modifiable target for interventions aimed at optimizing fetal neurodevelopment,” the authors write.

The study, “Prenatal sleep health and risk of offspring ADHD symptomatology and associated phenotypes: a prospective analysis of timing and sex differences in the ECHO cohort,” was published Oct. 12, 2023, in The Lancet, Regional Health Americas.    

Launched in 2016, the Environmental influences on Child Health Outcomes (ECHO) Program is a research program in the Office of the Director at the NIH with the mission to enhance the health of children for generations to come. ECHO investigators study the effects of a broad range of early environmental influences on child health and development. For more information, visit

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