Over the past two decades, suicide rates have been rising among school-age Black children (5-11 years old), despite decreasing rates among white children of the same age. Black school-age children report suicidal thoughts and behavior (STB) more frequently than their white peers and are twice as likely to die from suicide. The strongest psychiatric risk factor for STB and suicide among Black school-age children is attention- deficit/hyperactivity disorder (ADHD). Children with ADHD are predisposed to STB due to impulsivity, emotion dysregulation, school failure, peer problems, family conflict, and demoralization. Black children may face a disproportionate impact from ADHD-related risk for STB due to racism. Both structural racism (unequal systems of opportunity) and interpersonal racism (biased interactions with others) profoundly and negatively influence child health and may compound the risk for STB among children with ADHD. For example, structural racism leads to less educational and treatment resources, and interpersonal racism leads to biased disciplinary and treatment decisions. However, little evidence exists on if and how racism increases risk for STB and which factors could mitigate risk among school-age Black children with ADHD. Thus, our objective is to understand how structural, interpersonal, and clinical risk and protective factors intersect to determine risk for future STB in this population to inform suicide prevention strategies. To achieve our objective, we propose a mixed-methods prospective cohort study of 320 Black children aged 6-11 years with ADHD assessed every 6 months for 2 years, with a primary outcome of STB reported by child or parent. We have 3 aims: (1) quantitatively examine the impact of structural and interpersonal racism on the development of suicidal thoughts and behavior (STB) among school-age Black children with ADHD, statistically controlling for psychiatric comorbidity, using a Random-Intercept Cross-Lagged Panel Analysis (RI-CLPM). We will use the Child Opportunity Index (COI) based on census tract data as a proxy for access to resources and opportunities shaped by structural racism, and the Everyday Discrimination Scale (EDS) as a parent report of youth discrimination experiences. (2) We will quantitatively examine the impact of clinical and contextual protective factors (ADHD medication treatment, school climate, and family relationships) on future STB using RI-CLPM. (3) We will qualitatively identify parent and child-reported perspectives on and experiences with racism and STB via thematic analysis of semi- structured interview data (Columbia-Suicide Severity Rating Scale semi-structured interviews and separate in- depth interviews with parents and children). Our overarching hypothesis is that both structural and interpersonal racism increase risk for development of STB among children with ADHD beyond the risk conferred by clinical severity, and that protective factors related to medication treatment and social context may reduce risk for STB in this population. This work will lead to the development of suicide prevention strategies for a high-risk group of children.

Project Narrative. Black school-age children report suicidal thoughts and behavior (STB) more frequently than their white peers and are twice as likely to die from suicide. The most common psychiatric disorder associated with STB and suicide deaths in school-age Black children is attention-deficit/hyperactivity disorder (ADHD), and Black children may experience a disproportionate impact from ADHD-related risk for STB due to racism. There is a need for research examining how ADHD may intersect with racism to widen the racial disparity in STB and suicide deaths, and which factors could protect against STB, to inform suicide prevention strategies for Black school-age children with ADHD.