Understanding the multilevel impact of racism on suicidal thoughts and behaviors among Black children with ADHD: Intersectionality, Risk, and Protective Factors - Project Summary: 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 structural and interpersonal stress. Black children are disproportionately exposed to structural stress (from adverse social determinants of health) and interpersonal stress (e.g., conflict and trauma) which may compound the risk for STB among children with ADHD. However, little evidence exists on if and how both structural and interpersonal stress increase risk for STB and which factors could mitigate risk among school-age Black children with ADHD. Thus, our objective is to understand how structural and interpersonal stress intersect with clinical risk and protective factors 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 stress 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 based on census tract data as a proxy for access to resources and opportunities shaped by structural stress and parent report of child exposure to interpersonal stress. (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 structural and interpersonal stress 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 stress 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 prevention strategies to reduce suicide disparities in school-age children.
