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Outlining his education platform on May 28, former vice president and 2020 Democratic presidential contender Joe Biden put the spotlight on an often-ignored mental health problem: kids’ access to mental health care.
In a policy paper released at a town hall in Houston, Biden said, "The current school psychologist to student ratio in this country is roughly 1,400 to 1, while experts say it should be at most 700 to 1."
That matters because children’s mental health care issues are often detected in school settings. The school psychologists provide the first line of treatment and often set in motion any necessary referrals to specialists. Their role is complicated by the fact that, beyond school walls, there is a serious shortage of adolescent and child psychiatrists.
It’s a problem, Biden said, given that "too many of our children are not getting the mental health care they need from a trained professional."
This talking point about school psychologist ratios suggests a glaring gap in health care services, and in an area where need is only growing.
With that in mind, we decided to dig in. We reached out to Biden’s press team for comment but never heard back.
A controversial figure
Biden appears to be using a number promoted by the National Association of School Psychologists, a Washington-based trade group. That statistic comes from the organization’s 2015 membership survey, which found a 1,381-to-1 ratio of students to psychologists — which is "roughly 1,400."
But this tally is not ironclad.
Though NASP sent the survey to a nationally representative sample, the requirement that participants send back responses affects the results of such a survey.
"There are always limitations when you have a process of self-reporting. Those limitations are recognized," said Eric Rossen, NASP’s director of professional development and standards. "For now, this is the best data we have. … It’s not perfect, but it’s the best there is."
There are other numbers and sources to consider, too.
The Department of Education sent us its data from the 2015-16 National Teacher and Principal Survey. It found about 49 million kids enrolled in public schools, and, nationally, about 44,210 full-time psychologists employed by schools.
That yields a ratio of roughly 1,115-to-1 — still nowhere near what experts say is appropriate, but slightly less stark than the 1,400 figure. This is at least in part because DOE’s survey does not differentiate between a school psychologist —a specific discipline within the field — and any other kind of psychologist a school might employ. This category could include specialties such as clinical, developmental, cognitive or child psychology, among others.
The DOE tracks the extent to which schools employ guidance counselors, nurses, psychologists, social workers, speech therapists and "other professional staff." (If one counted those, it would yield an even more favorable ratio.)
Do these distinctions matter?
NASP says yes, arguing that school psychologists are trained in a way that gives them specific, distinct advantages in navigating the educational system — for instance, helping teachers adapt their work to better educate kids with learning disorders — and that they better understand school-specific concerns like discipline, violence prevention and helping families adapt to a school culture.
Still, it’s not a settled issue.
"A school psychologist is great. I would even say a counselor, a therapist, a social worker — there are any number of potential therapists that have the skills and can detect these issues and refer," said Dr. Brian Greenfield, a child psychiatrist who directs the emergency psychiatry service at the Montreal Children's Hospital, and who has researched children’s mental health in the United States.
A growing need, but no one solution
That said, whichever number you look at, Biden’s bigger point appears true — children don’t have enough opportunities to get mental health care in schools.
Biden’s 700-1 aspirational ratio also comes from an analysis by NASP, Rossum said. The group looked at previous surveys, finding that school psychologists were best able to care for students when the ratio hovered between at least 500-to-1 and 700-to-1.
Both the 1,115 and 1,400 ratios mask wide national disparities. DOE’s data suggests that more than 13 million students go to school without any psychologist on staff. More than 1 million students go to schools that not only do not have a psychologist on staff, but also no guidance counselor or social worker.
For its part, NASP’s data shows that in some parts of the country, the ratio can be as high as 1 school psychologist per 4,000 students.
And the consequences are significant. Evidence suggests children are experiencing increased rates of mental health problems. For instance, research published in April found that the number of kids reporting suicidal thoughts in the emergency room went up significantly between 2007 and 2015. (Greenfield, the Montreal psychiatrist, co-authored that paper.)
Preventive mental health care could help address this trend. Most students who receive this care get at least their first assessment in schools. And if there isn’t someone on hand to provide it, they probably go without.
That said, Greenfield noted, the school psychologist is only one part of a team. Lots of school employees — teachers, guidance counselors and administrators — could be trained to notice when something is wrong. The next step is likely more crucial, he said: referring the child to a clinic or other specialized setting for mental health care. That brings its own set of challenges, like confronting the shortage of pediatric psychologists nationally.
"Bravo to our politicians that have this in their heads and want to address it, but we can’t expect one school psychologist to be able to do it all, even if you increase the ratio in the school," he said.
Biden’s specific claim about school psychologist-to-student ratios is correct, and it reflects a substantial problem for adolescent and pediatric mental health. But focusing on school psychologists alone doesn't encompass the entire issue.
And given the broader point he is making — that many kids cannot access mental health care in schools — his statement would benefit from more context.
Children may not have a "school psychologist," but may still attend a school where another kind of psychologist or mental health professional is employed. That means they can still get care from a "trained professional," even though the provider doesn’t have the same level of specialty training.
Biden’s claim is accurate but needs additional information. We rate it Mostly True.
Joe Biden, "The Biden Plan for Educators, Students and Our Future", May 28, 2019.
AMA Journal of Ethics, "Promoting Access to School-Based Services for Children’s Mental Health," December 2016.
George Washington University’s Center for Health and Health Care in Schools, "Children’s Mental Health Needs, Disparities and School-Based Services: A Fact Sheet," Feb. 28, 2012.
JAMA Pediatrics, "Suicidal Attempts and Ideation Among Children and Adolescents in US Emergency Departments, 2007-2015," April 8, 2019.
Kaiser Health News, "Scarcity Of Mental Health Care Means Patients — Especially Kids — Land In ER," Oct. 17, 2016.
National Association of School Psychologists, "Results From the NASP 2015 Membership Survey, Part One Demographics and Employment Conditions," June 2018.
National Center for Education Statistics, "National Teacher and Principal Survey," May 30, 2019.
Telephone interview with Eric Rossen, NASP director of professional development and standards, May 29, 2019.
Telephone Interview with Dr. Brian Greenfield, associate professor of clinical psychiatry and pediatrics at McGill University, June 3, 2019.
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