Last week, heavy rain fell in Harlan County, Kentucky. Families living in mobile homes were at high risk for flooding. Gina Stewart, homeless youth coordinator for Harlan County High School, saw a young student who stops by her office almost every morning. He was raised by his grandparents, but they both died recently, and he was forced to move in with his parents, from whom he was estranged. Stewart told Rewire, “This same boy who comes by for a clean pair of clothes most mornings came to school with his shoes and clothes covered in mud. His parents’ trailer had flooded, but they stayed in it because they had no place else to go.”

The collapse of the coal mining industry is often cited for the disintegration of the housing economy in eastern Kentucky and the resulting increase in homelessness. But among young adults, the highest risk factors for homelessness are not having a high school diploma and being pregnant or parenting, according to a recent study by Chapin Hall at the University of Chicago.

During the 2015-2016 school year, eastern Kentucky recorded over 27,000 students experiencing homelessness. In a high school of only 1,100, more than 300 students at Harlan County High—where Stewart works providing counseling, support, clean clothing, and other basic needs—are characterized as homeless.

Eastern Kentucky contains the poorest counties in the state, if not the entire country. In 2014, the New York Times called Clay County, Kentucky, “the hardest place in America to live.” A year later, an interactive map created by the Lexington Herald Leader revealed that more than 7 percent of Clay County’s 3,267 students between ages 3 and 18 were homeless. Meanwhile, in neighboring Harlan County, where median household income is barely $3,000 more than the average household income in Clay County, a quarter of the 4,788 students were reported to be homeless.

Without a steady income, families struggle to pay their utility bills, grocery bills, and rent. A housing marketing analysis completed by Kentucky Housing noted that “eastern Kentucky continues to have a high concentration of manufactured housing” including mobile homes, boats, RVs, and vans. These temporary living situations take the place of long-term stable housing for some families. People end up couch surfing with relatives or friends, which can become increasingly difficult with multiple children in tow.

“In families experiencing homelessness, the parents often focus on the younger kids whereas teenagers will split off,” said Barbara Duffield, executive director of Schoolhouse Connection, a nonprofit leading policy reform of the early care and education of children and youth experiencing homelessness. Some high school-age children decide they might be better off if they live on their own and fend for themselves, which can continue the cycle of homelessness.

To confront and combat the relationship between rural youth homelessness and unplanned pregnancy in the Appalachian part of the state, Kentucky’s Department for Public Health instituted the HANDS program, which stands for Health Access Nurturing Development Services. Vanessa Brewer and Jo Comley oversee HANDS, providing voluntary home visitation for families in conjunction with local health departments. Health workers, known as “parent visitors,” help equip parents with aid, which can mean aligning them with a specific health service or simply training a new parent how to properly change a diaper. Aid is based on an assessment families fill out that evaluates ten “risk factors,” including inadequate income, histories of domestic abuse or substance abuse, and access to prenatal care.

Housing, however, is not included in HANDS’ assessment because over the years, Brewer and Comley have discovered that “stable housing” is unique for each individual, and in rural Kentucky, it can mean owning property, living in a mobile home, staying with extended family, or sleeping on friends’ couches. In the last year alone, HANDS’ parent visitors have found that the Kentucky families they support will ask not to meet at home but instead, at a local health clinic, their child’s school, or a restaurant. The parent visitors honor this request. A repeated request, however, raises a red flag that the families could be experiencing homelessness.

“Our main objective,” Brewer says, “is helping families to raise the children in their care. We want them to trust us and to ask us questions, like if they are struggling with housing and need a safe place to stay.”

Stewart says that most students experiencing homelessness come forward and ask for help. But for less forthcoming students, surveys like the Youth Risk Behavior Surveillance System (YRBSS) help high schools try to identify homelessness among their students.

The Centers for Disease Control and Prevention (CDC) requires public high schools to administer the survey every two years and monitors types of health-risk behaviors that contribute to the leading causes of death and disability in children 18 and under. Over the years, the CDC has developed an optional questionnaire, which states can include in full or partially. Some of the questions on the questionnaire directly target youth facing homelessness, including questions about where a young person sleeps at night.

Surveys such as the YRBSS have helped to inform national definitions of homelessness. The U.S. Department of Education’s definition is considered to be the most inclusive, particularly because of its consideration of rural homelessness. It describes homeless youth as “living in a shelter, motel or campground, car, outside, or with another family member due to loss of housing or economic hardship.”

These definitions are important because they influence government policy focused on allowing greater access to services, especially health services, by minors who are experiencing homelessness.

“High school students who are homeless may also be experiencing abuse or severe conflict or have been kicked out by their parents,” said Duffield of Schoolhouse Connection. “They are more aware of the neglect they are experiencing and choose to be homeless to survive.”

The University of Chicago’s study found that homeless youth under 18 are generally not receiving services because they are not able to consent to these services without the signature of a legal guardian. Consent becomes even more tricky when young people experiencing homelessness, who are three times more likely to commit suicide than teenagers who live in stable housing, seek out physical or mental health care. Without the consent of a legal guardian, these services are often out of reach.

Stewart explained that Harlan County High School has responded to mental health issues by having seven counselors available at all times. Five of their counselors deal exclusively with psychological and emotional problems, while two handle the particular academic issues that arise with unstable housing, including truancy and a lack of parental support.

Some parents of the students that Stewart works with are illiterate; it is impossible for them to help with their child’s homework even if they are available. Stewart is helping a family who lost their mobile home in the recent flooding. The parents have three children and the father, who is 40 years old, cannot read or write.

Homeless youth who are able to overcome their circumstances need an escape route that most often starts with a stable environment. Stewart cites a student raised by a father with substance abuse issues. The student made contact with his mother, who lives in Harlan County, when his father overdosed and returned to jail. But the student was pushed out of his mother’s living situation and onto the streets of Harlan. He couch surfed while making strong connections at Harlan County High School, particularly with Stewart.

“He would get good at asking different people at school so he could stay a new place every few days. But then he got kicked out of his friend’s house,” Stewart said. What was meant to be a weekend stay with a local National Guard sergeant whom Stewart had introduced the student to turned into a long-term home. The student, who enlisted, will be living with the sergeant until his basic training begins.

“You can’t just take 18-year-old boys in,” says Stewart. “I’m a single woman, I could never do that. But … [this student] worked something out and now finally has his own bedroom that he knows he can come home to every day, for the first time in his life.”