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.
