Pediatric sleep-disordered breathing (SDB), ranging from mild snoring to obstructive sleep apnea syndrome (OSAS), is common and associated with substantial morbidity. SDB affects 10.5–17.1% of children, and 1–3% experience OSAS, making it one of the most prevalent chronic conditions in childhood. OSAS is linked to cardiometabolic, cognitive, and behavioral complications. Even mild SDB is associated with hypertension, suboptimal asthma control, and impairments in behavior, attention, and executive functioning. Untreated SDB is associated with increased healthcare utilization, including a 215% rise in child healthcare use and 40% more hospital visits. Multiple epidemiologic studies have identified differences in SDB prevalence, severity, and treatment outcomes across population subgroups. For example, several studies report that Black children have higher rates of SDB across severity levels compared with White children. In the Childhood Adenotonsillectomy Trial (CHAT), Black children demonstrated more severe OSAS on polysomnography (p = 0.004), even after accounting for factors such as obesity. CHAT also found lower postoperative improvement rates following adenotonsillectomy (AT) among Black participants. In a prospective study, postoperative respiratory complications occurred in 35% of Black children compared with 24% of other participants (p = .036). Although SDB appears more prevalent in some groups, treatment rates, including receipt of AT for OSAS, do not consistently reflect these patterns. Research to date has not fully delineated whether factors beyond comorbid conditions (e.g., obesity, prematurity, asthma) and family socioeconomic status (SES) explain the observed population-level differences in SDB prevalence, symptom burden, and outcomes following treatment. The goal of this project is to identify additional socio-ecological contributors to these differences, with a particular focus on SDB-related symptoms of sleepiness and neurobehavioral impairment. The project will also examine how provider-related factors, may influence parent perceptions of SDB-related care and variation in referral practices.