Poor Sleep From Hidden Breathing Problems Can Look Like ADHD

A child who snores isn’t just making noise, they might be sending a warning about brain development, learning, and long-term health. We sit down together to unpack how airway health and sleep quality can shape cognitive clarity, memory, attention, and emotional regulation in ways families and even clinicians often miss.

We talk through why disrupted sleep is frequently a breathing problem first, and how that disruption can look like “rambunctious” behavior, fidgetiness, morning struggles, and labels like ADD or ADHD. Dr. Mark A. Cruz breaks down the sleep restriction research showing that even one less hour of sleep can reduce prefrontal cortex efficiency and performance on cognitive tests, plus what “snore plus” means when snoring comes with another symptom. We also explore how facial growth and airway development start early, how environmental factors can narrow the airway over time, and why focusing only on tooth crowding or bite misses the real outcomes families care about.

Then we get practical: what we look for in the clinic, how validated pediatric sleep questionnaires help surface patterns parents can’t see at night, and how screening tools like high-resolution pulse oximetry and low-radiation 3D imaging can provide objective data to guide early intervention. The north star stays the same: get kids out of physiologic distress by improving breathing during sleep, so they can rest, grow, and thrive.

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To learn more about Dr. Mark A. Cruz, DDS. visit:
https://www.MarkACruzdds.com
Dr. Mark A. Cruz, DDS. 
32241 Crown Valley Pkwy #200  
Dana Point, CA 92629  
949-661-1006 

Transcript

Welcome And Why Airway Matters

SPEAKER_00 0:03

Welcome to Airway Focused Dentistry with Dr. Mark A. Cruz, the show where better breathing leads to better living. If your nights sound like a lawnmower chorus or your energy stuck on low battery, you're in the right place. Hosted by Dr. Mark A. Cruz, we explore how the airway impacts your sleep, your health, and your smile. So you can breathe, sleep, and be well. Take a deep breath, and let's get started.

Breathing Links To Memory And Focus

SPEAKER_02 0:32

Cognitive clarity, memory, and focus are deeply connected to how well you breathe, often in ways patients never realize. Welcome everyone. I'm Julie Schwenzer, co-host and producer in the studio with Dr. Mark A. Cruz. Dr. Cruz is always great to be with you and learn from you.

SPEAKER_01 0:49

Thank you. Likewise, Julie. Good to see you.

SPEAKER_02 0:52

Thank you. So before we dive in, um, can you tell us the broader picture about how airway health influences cognitive function and what you look out for in your patients when they come in to see if that could be an issue for them?

Sleep Disruption And Misread Behavior

SPEAKER_01 1:08

Yeah, I Julie, this is so important because with an ever focused approach to dentistry, I think this is largely missed in uh most uh individuals that are, you know, quote unquote practicing everything. It's really these morbidities or comorbidities that really should be driving uh the treatment. They should really be justifying the treatment. It's not how wide the palate is or if they're cross-fired. It's how much distress that the kid is, moreover, how it affects their future. And so the studies are very clear coming out of sleep medicine and pediatrics, is that uh uh sleeping uh or perturbed sleeping, which is largely a breathing problem first, has a significant risk factor for uh for the pediatric brain that's growing and affects comorbidities like neurocognitive and uh emotional uh problems. Uh ADD ADHD, largely a misdiagnosis of a separate neurologic condition, actually more related to not getting the right amount of sleep. The grown uh brain really requires that that deep sleep.

One Hour Less Sleep Changes Brains

SPEAKER_01 2:32

In fact, Dr. David Lazal did a study some years ago, and he was, I believe he was um uh director of sleep medicine uh at Louisville, looking at what's called the sleep restriction study, looking at four eight-year-old kids that um had all had uh sleep studies to show that quote unquote they didn't have sleep disorder breathing. Um, and they had neurocognitive tests to test their ability cognitively with a standardized test and uh functional MRI of the brain. And the experimental group was allowed to stay up just one hour beyond what the normal prescribed eight or nine hours of good sleep for a kid is. The control group was the group that went to bed at the proper time. I mean, just one week of one less hour, it showed that those kids that stayed up an extra hour, their brains, the prefrontal cortex, which largely gives executive function, was very inefficient. They scored much poorer in cognitive testing. So it's not like they needed really a tutor or a medication, it's just they needed uh a better sleep. Um, so that's just one example. There have been a number of other studies, uh studies. Um, Karen Bonick out of NYU, multiple studies showing that snoring, for example, just by itself, um, is predictive of behavioral problems. So instead of really going in there and medicating our kids, let's look at

Snoring Signals Facial Growth Problems

SPEAKER_01 4:16

why. And so a lot of those problems have to do with facial development. Okay, so you snore if your face isn't growing properly. That starts from when you're born, as we've talked about. How much you uh you you are able to nurse or bottle feed, the foods that you eat, and all these things that we tend to ignore that the pediatrician tends to not be aware of, um, have a dramatic effect on how the facial skeleton uh grows. And then we treat it later on as a dental problem, like tooth crowding, as if that's really the problem. It's actually started way earlier. It's not a genetic condition, largely, it's more of an environmental condition.

MRI Evidence Linking Airway To Cognition

SPEAKER_01 5:00

And about three to four months ago, at this point, there was a large multi-step center study that came out of Harvard, John Hopkins, University of Maryland, a couple of other multi-centered institutions that represented several specialties in medicine, odolarcology, pediatrics, psychiatry, surgery, um, et cetera, et cetera, that looked at a cohort, a group of kids, a rather large group of kids, almost 12,000 in this group of kids from what's called the ABC D study. You can look it up, um, looking at uh pediatric uh pediatric population, specifically looking at neurocognitive development through adolescence. And um, what they did is they took uh MRIs of the brain and the airway, and they put these kids through a rigorous battery of cognitive tests. It was five to seven batteries of cognitive tests that were standardized and validated, looking at fluid intelligence, emotional intelligence, looking at uh tasking, attention, uh emotional intelligence, all these neurocognitive functions, if you will. Um and they also looked at uh MRIs of the brain and of the size of the airway. And one of the main conclusions was that the size or volume of airways measured by MRI was directly correlated to um morbidities or problems in brain development, in intellect, um, in cognitive function. And of course, this isn't really new because David Wazall earlier some years ago actually showed that you can have uh in a community in um I I believe again, this might have been in Louisville um large school district that you're gonna actually lose IQ points, as many as 10 to 15 IQ points based on poor quality sleep. And the force performing kids in that school district all had sleep problems, uh many, many of them related to tonsils, uh, but ultimately it was a breathing problem first, right? So fast forward to this study, I you know, at the end of 2025, beginning uh this year, was underscoring what we've known for a long time in a very large clinical

Measuring Outcomes Beyond Tooth Alignment

SPEAKER_01 7:55

study. So for me, when the parents come in, my biggest concern is not the dental crowding and the size of the palate and the crossbite, all those things that we dentists tend to focus on. It's looking at their future, their cognitive function. And that's just one uh other things that we look at. We're also looking at their cardiovascular well-being, their metabolic risk uh well-being, their release of growth hormones, they derived, all these what we call the medical indications. And that's what we measure. Those are the outcomes that are concrete, that are tangible to the family and to the patient. What's not tangible so much is how the teeth come together. And that seems to be what we as dentists look at. And so uh I think this is super important. I believe it's the future in healthcare that dentistry and medicine needs to really be looking at these these things because a pediatrician doesn't. So just looking at what vaccines uh that you need to take and and um, you know, where you are in the growth chart and that you'll grow out of things, as at Lu said, and the orthodontists, it's already too late. They don't want to see the kid. So it's already too late. So, as I said before, the first thousand days of life largely determine these risks. So um, yeah, that's all related to our brain function, and that has to do with feeding it oxygen, really good breathing, open airways, and that fosters good restorative sleep. Make sense.

Helping Parents Spot Sleep Red Flags

SPEAKER_02 9:29

Yeah, and I know you've touched on this before, and sometimes it can be challenging for parents because children don't always communicate what's going on throughout the night or if they didn't sleep well. So, how do you help parents like see that there might be issues with airway health and that's what's affecting them and their attention span or perhaps something else?

SPEAKER_01 9:50

Yeah, of course. And I have found that most parents don't know what's going on with their kids' sleep, uh, you know, past their you know, toddler years, for example. I mean, like a mystery.

SPEAKER_02 10:01

What's going on in that room all night?

SPEAKER_01 10:04

Certainly early on, the first couple of years, yeah, they might have the crib in the bedroom or they'll have like a uh you know, video monitor or whatever, which which is which is prudent. But uh once they get into the big bed, you know, it's kind of like okay, you wake up in the morning, and that's what we actually measure that quantitatively with metrics.

Screening Tools And Early Intervention

SPEAKER_01 10:24

Two things. One, we do a validated pediatric seat questionnaire. There are a series of them that have been validated. The questionnaires that ask the parents questions about, you know, hearing loss, um, bad wetting, um, how difficult is it for the morning? Are they fidgety? The things that manifest clinically. Um again, um, if Dr. Gozal and others have talked about what they call snore plus, meaning that if your kid snores plus, there's at least one other sign, that means there must be um a uh a rigorous evaluation to see what's going on. It's likely there's there's a problem there. And then there are also quantitative measurements. So I personally, what I've been teaching for 15 years, what we're looking at is using high-resolution pulse oximetry. It's an imperfect way, but quantitatively does give us some data. But there are other uh ways of measuring it. The point is that we're actually measuring something quantitatively, meaning it's kind of like we're using uh blood pressure cuff to look at or screen for high hypertension versus what the patient reports. So we need some quantitative metric that correlates with that. And then, of course, as it's indicated, we'll do a three-dimensional radiograph, very little radiation, um, to look at the structure of the airway. Um, and so there are a number of data points that we look at that we put together to understand better what's going on with the kid for early intervention.

Getting Kids Out Of Distress

SPEAKER_01 12:00

And I think I'll just end by saying that the number one goal in any of these interventions is to get the kid out of distress. And what I mean by that, because you may not know that the kid is in distress, but they are, is by addressing their breathing in sleep. And you can measure that through the autonomic nervous system with high-resolution post-plex symmetry, you have behavior, the fidgetiness, and inattention, talking back, what gets labeled as ADD or ADHD or as a personality trait that they're rambunctious. Um, and so um super important.

SPEAKER_02 12:41

Okay, Dr. Cruz, you always break down things so clearly for us, and we always appreciate your insight.

SPEAKER_01 12:46

Yeah, thank you. Thank you. It's an important topic. Thank you.

Key Takeaways And Next Steps

SPEAKER_00 12:53

That's today's breath of fresh insight from airway focused dentistry with Dr. Mark A. Cruz. Remember, small changes in your airway can spark big changes in your life. Breathe, sleep, and be well. For more information, visit marcacruzds.com or call 949-661-1006. If this helped you, share the episode and maybe give your fellow a quieter night. See you next time.