A Systematic Review of Qualitative Research Focusing on Emotional Distress Among Adolescents: Perceived Cause and Help-Seeking

Causal attributions and help-seeking is not well explored among adolescents, despite evidence of perceived causes for difficulties influencing how adults engage with treatment and seek help. This study reviewed extant literature to understand what adolescents at increased risk of developing mental health difficulties and those with clinically significant symptoms perceive to be the cause of emotional distress; to determine the extent to which perceived cause influences help-seeking; and to identify potential differences/commonalities between these groups. A systematic review and qualitative thematic synthesis were conducted. 3,691 articles were identified, 18 were eligible to be included and were synthesized using thematic synthesis. Six main themes related to perceived cause are reported. Three of those themes were shared between the clinical and at-risk groups: (1) challenging social factors and perceived difference, (2) problematic family dynamics, and (3) cause is complex and multifaceted. Three themes were not: (4) unfairness and perceived lack of agency and (5) concern for self and others, were exclusive to the at-risk group, and (6) coping with a mental health difficulty was exclusive to the clinical group. Four main themes related to causal attributions and help-seeking were found, including: (1) cause and implications for self-preservation; (2) the degree of personal and wider knowledge and understanding of cause; (3) perceived extent of control in managing cause; and (4) cause having potential to affect others. The findings of this review demonstrate that perceived cause for emotional distress plays a role in help-seeking among adolescent groups and highlights likely differences in how adolescents at-risk of mental health difficulties and those with clinically significant symptoms attribute cause for their difficulties and subsequently seek help. This has important implications for how to support young people experiencing or at risk of mental health difficulties and presents a strong case for pursuing more research in this area.


Introduction
Perceived cause for difficulties has been found to influence how adults engage with treatment and seek help (e.g., Houle et al., 2013;Stolzenburg et al., 2019); However, causal attributions and related help-seeking is less well explored among adolescents. Adolescence is a time of heightened emotional clinically significant symptoms perceive to be the cause of their emotional distress; explores the ways in which causal perceptions might influence help-seeking; and highlights potential differences between at-risk and clinical adolescent's causal perceptions and subsequent help-seeking behavior.
With half of all lifetime mental health conditions manifesting by age 14 (WHO, 2020), there is considerable interest in preventing onset during adolescence. One of the most significant challenges to early intervention and prevention is poor help-seeking (Rickwood & Thomas, 2012), particularly during this developmental period (Xu et al., 2018). Help-seeking lacks a universally accepted definition (Heerde & Hemphill, 2018). However, in the current study, the World Health Organisation's definition is used (Barker, 2007, p.2), which is as follows: "[a]ny action or activity carried out by an adolescent who perceives [themself] as needing personal, psychological, affective assistance or health and social services, with the purpose of meeting this need in a positive way." Evidence suggests that multiple factors contribute to low uptake of help-seeking in adolescence, including limited mental health knowledge; stigma and embarrassment; trust and confidentiality; logistics (Radez et al., 2021); making sense of difficulties; problem disclosure, and ambivalence to seeking help (Radez et al., 2022). What is clear is that help-seeking is complex.
Adolescents face significant emotional, social, and physical changes (Zhao et al., 2015). While most successfully navigate associated challenges (Arnett, 1999) and emerge with a good general quality of life (Rapee et al., 2019), the overall prevalence of emotional distress increases significantly during this period (Cohen et al., 2018). If not managed successfully, this can increase the risk of mental illness (Gloria & Steinhardt, 2016). Mental health conditions are determined by strict diagnostic criteria, however, anyone can experience emotional distress. Indeed, for young people living with a mental illness, the extent of emotional distress can have implications for experience and management of illness (Cordell & Snowden, 2015). Therefore, it is not only imperative to explore ways to help adolescents manage emotional distress to prevent the onset of illness, but also to help those currently experiencing mental health difficulties.
Informal networks, such as friends, parents, and school staff, are well placed to help young people manage their difficulties as a valuable support system (Hom et al., 2015) and to help them access additional help (Radez at al., 2022). However, emotional distress is often problematically dismissed as "normal" for teenagers (Blakemore, 2018), and such rhetoric can inhibit significant others in the lives of young people from recognising the presence or emergence of mental illness (e.g., see Radez et al., 2022;Stapley et al., 2016). The likelihood that a certain emotional state may signify mental illness in one adolescent yet may be considered "normative" in another, demonstrates that understanding emotional experience during adolescence is imperative (Bailen et al., 2019). Thus, difficulties should not be dismissed as "normal" for teenagers (Blakemore, 2018); rather, steps should be taken to better understand and encourage help-seeking in the context of emotional distress.
Research suggests that perceived cause of difficulties may play a role in the ways in which adults engage with treatment and seek help for their difficulties (e.g., Houle et al., 2013;Stolzenburg et al., 2019). This may also be the case for adolescents. For instance, Midgley and colleagues (2017) suggested that young people diagnosed with depression who view their illness as part of themselves may struggle to believe their difficulties can be ameliorated, and thus be less inclined to seek help. Therefore, it is probable that perceived cause for emotional distress has implications for help-seeking in adolescence. Further work is needed to understand the extent to which this might be the case; particularly as such understanding may prove useful in the development of effective interventions that promote adaptive help-seeking and work to prevent mental illness/ support those currently experiencing clinically significant symptoms.
Much of the work in help-seeking in adolescence focuses on clinical (e.g., Radez et al., 2021;Radez at al., 2022) or general population (e.g. Tharaldsen et al., 2017;Doyle et al., 2017) samples. At-risk groups -with risk being understood as a myriad of factors, including sociocultural and demographic factors (Kirby and Fraser 1997) that may negatively impact health outcomes (Romer, 2003) -have comparatively low research focus. There are likely differences in help-seeking behaviors in the context of perceived cause for emotional distress among clinical and at-risk groups, as research indicates that there may be differences in perceptions of cause of difficulties more generally (e.g., for at risk see O'Neill et al., 2021; for clinical see Midgley et al., 2017). However, to date no study has explored areas of convergence and divergence in relation to perceived cause for emotional distress and help seeking between these groups. Doing so can provide useful insight into how to better support young people based on their level of need, which may be particularly helpful for non-mental health trained professionals. It is imperative that these allied professionals can support young people effectively (Banwell et al., 2021), especially as adolescents may be more comfortable seeking help from informal sources, such as teachers and parents (Rickwood et al., 2005).

Current Study
Understanding adolescent help-seeking in the context of perceived cause for emotional distress is a valuable but under explored research endeavor. This study aimed to review qualitative and mixed-methods studies to address this gap. The first research question was concerned with what adolescents (at increased risk of developing a mental health difficulty and those with clinically significant symptoms who are undergoing/have undergone clinical treatment) perceive to be the cause of their emotional distress. The second research question addressed the ways in which perceived cause might influence help-seeking. The final research question was concerned with exploring potential differences in the ways in which at-risk and clinical adolescent groups engage with help-seeking in the context of perceived cause for emotional distress. The findings have been organized into two overarching categories, the first of which is "perceived cause of emotional distress in at-risk and clinical groups", and the second being "causal perceptions and their influence on help-seeking: commonalities and differences among at-risk and clinical groups".

Protocol
A meta-synthesis using thematic synthesis was conducted, following an a priori review protocol which was developed in collaboration with co-authors and registered to PROSPERO Centre for Reviews and Dissemination (ID: CRD42019131247). The protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Moher et al., 2009); see Fig. 1. Progress updates were documented periodically.

Eligibility Criteria
Inclusion and exclusion criteria were established to determine if a study was eligible for review (see Table 1).
Initial scoping of the literature on adolescent help-seeking indicated that studies may not focus explicitly on investigating links between perceived cause of emotional distress and help-seeking behavior, as this is still a relatively new and underdeveloped research area (Midgley et al., 2017). Therefore, an inclusion and exclusion criterion was created that allowed for articles that reported both help-seeking and causal beliefs in relation to emotional distress without making explicit links between them in the findings. This broad approach enabled us to explore what extant literature can phrasing can be viewed in the protocol; PROSPERO reference ID: CRD42019131247). Search terms were adapted to suit the requirements of the specific database and studies were limited to publications in English. The population of interest were adolescents aged 10-19 in accordance with the World Health Organisation's (WHO) definition of adolescence (WHO, 2022). In the case where study samples overlapped with the upper or lower limit of this age group, these were excluded, unless it was possible to extract the data within the specified age range. Titles and abstracts were screened to identify studies suitable for inclusion. Those identified as potentially suitable at this stage were then read in full, and those deemed suitable against the inclusion criteria were included in the present study.

Quality Appraisal
While the use of quality appraisal in qualitative research is contested (Mohammed et al., 2016), it is argued that quality needs to be determined for qualitative syntheses to be considered influential, particularly in relation to policy (Scantlebury et al., 2018). Further, transparency in reporting ensures the credibility of the synthesis (Mohammed et al., 2016). The quality assessment used in the current study was based on criteria outlined by Spencer et al., (2004). Inclusion was based on the four guiding principles of Spencer and colleagues (2004): contributory (advances knowledge), defensible in design, rigorous in conduct, and credible in claim. Studies that were found to meet these principles were included. Spencer and colleagues (2004) note the importance of professional judgement when determining the quality of qualitative research; thus, the studies were reviewed by the first and second author, both of whom have qualitative research experience, using the framework. Based on the criteria, each of the final studies were deemed to be a satisfactory level for inclusion on the assumption that they were of sufficient overall quality.

Data Extraction
Initial search results were stored on Endnote; duplicates from the Ovid search were removed during the search and care was taken to ensure additional duplicates were removed once the articles were transferred to Endnote. Titles, abstracts, and key words of all potential studies were screened for inclusion by the first author and those that appeared to match the criteria for inclusion were collated. To establish consistency, 10% were reviewed by the second author, and discrepancies and inconsistencies were reviewed and resolved via discussions. Then the first author read full texts against the inclusion criteria keeping those who fulfilled the criteria. Again, 10% were reviewed by the teach us about this area whilst also providing a foundation for further necessary work. Examples of some of the aims of the included studies are as follows: to capture young people's experience of living with obsessive-compulsive disorder (OCD) (Keyes et al., 2018); explore perceptions of young offender's support-seeking (King et al., 2014); investigate unaccompanied minors views and perceptions of mental health services (Majumder et al., 2015); and, investigate adolescent sexual assault victims' disclosure and helpseeking experiences (Campbell et al., 2015).

Study aim
Studies that aim to illustrate adolescents' lived experience and, in doing so, exploring themes of help-seeking and perceived cause of emotional distress (though this may not be an explicit aim).

Other
Studies in English. Empirical studies. (Boyatzis, 1998 p.4), further supporting the decision to conduct a thematic synthesis.
To begin the analysis, the first author split the included studies into "clinical" or "at-risk" categories based on the sample description; this allocation was discussed with the second author and any discrepancies were discussed and resolved. The first author then transferred the studies to NVivo under either "clinical" or "at-risk" project titles to be analysed independently, allowing for comparison between the two groups. The clinical group comprised studies with a sample of young people reporting clinically significant mental health difficulties/diagnosed with a MHD and engaged with/previously engaged with mental health services for treatment. The at-risk group was defined by studies who included young people exposed to a known risk factor in their sample (e.g., domestic violence, alcoholic parent, sexual assault); see Tables 2 and 3 for specific subgroup information.
With the assistance of the qualitative data analysis software, NVivo, the findings section of each study was analysed verbatim using line-by-line coding to create initial codes, these codes were used to create "descriptive themes". The descriptive themes then acted as a catalyst for the final "analytical codes", this ensured that the final codes were grounded in the data but that they were also able to answer the research questions effectively. The final themes were second author. Rejected studies at this point and reasons for rejecting were recorded.

Data Synthesis
As noted, research explicitly focusing on the extent to which causal attributions may influence how adolescents seek help is limited. However, it was found that numerous studies reported findings that encapsulated both cause and help seeking without explicit links. To successfully draw these ideas together, an interpretive framework that allowed for a close reading as well as a holistic overview of the research findings was required. Accordingly, the present review was conducted as a thematic synthesis, following the 3 stages outlined by Thomas & Harden (2008): 1) line-by-line coding; 2) developing descriptive themes; and 3) generation of analytical themes. Stages 1 and 2 provided a "close" analysis of the findings section of the included studies, and stage 3 provided an interpretive stage to go beyond the findings of the primary studies to generate the final themes (Thomas & Harden, 2008). Further, while thematic analysis (TA) was the most frequently used method of analysis in the included studies (see Table 1), it was important to be able to successfully analyse data from studies that used an alternative analysis. Thematic analysis has been described as a "process that can be used with most, if not all, qualitative methods"  (5) concern for self and others; and, (6) coping with a mental health difficulty. Of these, challenging social factors and perceived difference, problematic family dynamics, and cause is complex and multifaceted were shared across both the at-risk group (ARG) and clinical group (CG). Several main themes were broad and captured the nuance of the content, some required subthemes for further clarification (see Fig. 2). The themes are presented to emulate the thematic map (see Fig. 2), with shared themes including ARG and CG findings, and divergent themes including findings only from the relevant group. Shared theme 1: challenging social factors and perceived difference. This shared theme illustrates that social pressure related to acceptance and feeling/being made to feel different were factors that young people felt contributed to the onset of distress. This includes pressure to emulate body "ideals" and not being able to live up to perceived beauty standards (Sabiston et al., 2007); family non-acceptance and personal non-acceptance regarding sexual orientation e.g., "[r]ight now, I'm not really, I don't really accept it … it feels like there's a weight on me" (Diamond et al., 2011 P.139); and, judgments and prejudices held by others based on the previous actions of the adolescents (King et al., 2014) or their background, for instance, "it seems that most people is afraid, they must be thinking that I'm a thug or something like that. Then, a robbery happens, and who is to blame? Me, of course. [and I feel] Outraged" (Magalhães et al., 2018(Magalhães et al., , p.1809. Fear related to the judgments of others and the possible repercussions of those judgements, as well as fears for personal safety, worrying about others finding out, parents not being supportive, and being bullied were all noted as contributory factors for sexual minorities (Diamond et al., 2011). Other adolescents found that feeling alone (Majumder et al., 2015), being bullied/experiencing friendlessness as a result of being "different", failing discussed and refined by the first and second authors and sent to the third author for discussion and feedback. An interpretive synthesis proved a useful way to pull together seemingly incongruent concepts from the findings of extant research to demonstrate the possibility of links between perceived cause for emotional difficulties and help-seeking. However, given the dearth of explicit research in this area, this review seeks to highlight the potential links and to lay the foundations for further necessary work in this area.

Study Selection and Characteristics
Through the review process, 18 studies from the 3,691 identified through initial searches were determined to be eligible for inclusion. Figure 1 illustrates the PRISMA flowchart which outlines the retention and exclusion of studies throughout the review process.
Table 2(at-risk) and Table 3(clinical) outline the characteristics of the 18 included studies. Six studies were conducted in the UK (33%), four in the USA (22%), two in Australia (11%), two in Canada (11%), two in Sweden (11%), and one each in Portugal (6%) and New Zealand (6%). Six studies used a clinical sample, and twelve used an at-risk sample. See Tables 2 and 3 for further details.

Category 1: Perceived Cause of Emotional Distress in at Risk and Clinical Groups
Six main themes were identified within this category: (1) challenging social factors and perceived difference; (2) problematic family dynamics; (3) cause is complex and multifaceted; (4) unfairness and perceived lack of agency; Shared theme 3: problematic family dynamics. Young people identified difficult home circumstances as emotionally distressing. This included witnessing parental abuse, "I wanted to kill myself 'cause of shit between my mother and father" (Aymer, 2008, p.661), and fear of being abused in by paternal figures, "[h]e was so mean to us when he drank. I was scared he would hurt me" (Aymer, 2008, p.659 (Aymer, 2008;Tinnfa lt et al., 2011) were also identified. Other adolescents highlighted family conflict (Crouch & Wright, 2004), hostility in the family, parental divorce, separation, and arguments between parents, for instance: "I know there was arguments between (my) parents. Obviously, that does make you sad because you want them both to be happy" Keyes et al., 2018, p.180) as causal. Some young people even felt that if they were not dealing with family problems it would be transformative, for instance, "I think if my parents weren't divorced and if my sister didn't have cancer I would be a very, very different person and I would be smiley, happy" (Porteous et al., 2019, p.121).
At-risk group theme 1: concern for self and others. Some young people identified concern for themselves and those they care about as a source of emotional difficulties. This may include safety concerns due to the possible actions of an alcoholic paternal figure, or fear of gang-related violence: "I was afraid, 'cause gang fights can start up again and, if you are around, you could be killed" (Aymer, 2008, p.660). Personal health related anxiety, feeling forgotten in the wake of a sibling having a terminal illness, as well as to feel "right" (Keyes et al., 2018), and a lack of authenticity from others (Crouch & Wright, 2004) as distressing. This included feeling like some people copied self-harming behavior to get attention, detracting from what they felt were the experiences of "authentic" self-harmers (Crouch & Wright, 2004). Similarly, nasty (Porteous et al., 2019) and derogatory comments, as well as ridicule in relation to racial and cultural identity, were also instances that young people identified as contributing to emotional distress (Edwards et al., 2019).
Shared theme 2: cause is complex and multi-faceted. Across both groups, adolescents identified multiple difficulties which, when combined, were perceived as causal, e.g. simultaneously dealing with factors like an ill loved one, financial/family/school/social-based stressors, and death of someone close (Porteous et al., 2019;McAndrew & Warne, 2014): "[i]t was just all at once: stress from school and stress from people, friends being horrible people, and the family arguing" (McAndrew & Warne 2014, p.573). While their personal circumstances may be different, for instance, being exposed to war and the associated difficulties -including the death of loved ones, extreme violence, seeing dead bodies, and having to leave their homes and families - (Majumder et al., 2015), or sexual minorities who may be dealing with the death of friends and family, rape, financial hardship, feeling unsupported and uncared for, family issues, and ill loved ones (Diamond et al., 2011), there is a recognition that emotional distress is not caused by a single factor. The multifaceted nature of causal attributions is also highlighted by some young people's inability to understand what they are feeling or why they are feeling it (Wilmots et al., 2020), or that, for some, talking about the cause of their difficulties engenders further distress (Majumder et al., 2015). Indeed, coping strategies used to deal with distress may also subsequently become a cause of emotional distress; for instance, Fig. 2 Thematic map of perceived cause of emotional distress for the at-risk and clinical groups thought to myself, 'Oh my god, this is a battle now" (Keyes et al., 2018, p.181). Indeed, living in fear of a "bad" feeling coming was noted as contributing to distress: "I find I am always scared of every day that comes because I am scared I am going to get depressed again. I am scared of that every day" (Woodgate, 2006, p.264).

Category 2: Causal Perceptions and Their Influence on Help-seeking: Commonalities and Differences Among At-risk and Clinical Groups
Four themes were identified in this category, with accompanying subthemes. The main themes were as follows: cause and implications for self-preservation; the degree of personal and wider knowledge and understanding of cause; perceived extent of control in managing cause; and, cause having the potential to affect others. Explicit links between perceived cause and help-seeking were not required in the included studies. Rather, if there was information about help-seeking and perceived cause within the same sample, this was considered to be an association. Each main theme is relevant to both groups except cause having the potential to affect others, which applied only to the ARG. The remaining three themes are shared across the ARG and CG; however, there is divergence in the accompanying subthemes, which can be observed in Figs. 3 and 4. It is important to note that while the reporting of themes varies in length, this does not signify importance, but rather the fact that some are more complex and need more extensive explanation; therefore, the themes are only presented by group, in contrast to synthesis 1.
At-risk group theme 1: cause and implications for self-preservation. The possible reactions and consequences of seeking help for the cause of their emotional difficulties may influence the ways in which young people seek help, seeing a loved one in pain, and fearing they might die, may also be contributory (Phillips & Lewis, 2015;Porteous et al., 2019).
At-risk group theme 2: unfairness and perceived lack of agency. Feeling powerless and/or not having control over things happening in their lives, as well as being treated unfairly appeared to be causal factors for some adolescents. This included not being allowed to do what they wanted, leading to anger and subsequent aggression: "this morning I just punched a hole through my friggin [swear word] bedroom door… it helped" (Edwards et al., 2019, p.165), or teachers unfairly criticising young people (Edwards et al., 2019). Not receiving adequate educational support and subsequent concerns about not being able to secure a job, as well as being discriminated against or treated unfairly by the judicial system (Magalhães et al., 2018) also appeared to engender emotional distress. This extends to having other people make decisions about your life against your will, including reporting that you were the victim of an assault (Campbell et al., 2015). Additionally, not being kept informed about the treatment of an ill sibling may also be perceived as distressing: "You go into her room and it was like "what's happening?" and she's only getting x-rays, but I think she's going into operation or something and it just made it difficult and it made me angry that they weren't telling me anything" (Porteous et al., 2019, p.121).
Clinical group theme 1: coping with a mental health difficulty. Aspects of having a mental health difficulty were highlighted by some adolescents as a source of distress. This included stigma and shame around having a mental health difficulty; however, for some receiving a diagnosis was helpful in making them feel that they were not "crazy" (Keyes et al., 2018). The relentlessness of having a mental health difficulty was also raised as a factor in the onset of difficult affect: "[t]hat's what made me cry, because I Fig. 3 Thematic map for the ways in which perceived cause(s) may influence help-seeking, at-risk group especially if they feel it is difficult for the adult to discuss (Phillips & Lewis, 2015;Porteous et al., 2019;Tinnfa¨lt et al., 2011).
At-risk group theme 2: the degree of personal and wider knowledge and understanding of cause. The value of shared experience and understanding of cause was identified as a factor in seeking support, whereas ignorance regarding cause appeared to be problematic. Young people may feel more comfortable reaching out for help and sharing their experiences with someone they feel has personal experience of the cause. In some instances, adolescents perceive their circumstances to be poorly understood by those without personal experience. They may also find themselves having to manage the ways in which they share their difficulties to avoid making others feel uncomfortable: "if panic arises you back off" (Tinnfa¨lt et al., 2011, p. 141). These kinds of reactions can lead to social isolation and avoidance of sharing difficulties to prevent the discomfort of others (Porteous et al., 2019). While shared experience of cause may be of value to the help-seeking process, some adolescents feel comfortable sharing with those without direct experience, provided they react in an understanding way: "I felt good [for sharing her placement in care with a friend], and my friends understood" (Magalhães et al., 2018(Magalhães et al., , p.1810. In order to share their difficulties, young people need to know that their problems will be taken seriously (Tinnfa¨lt et al., 2011). Nonetheless, a lack of broader understanding of the issue may result in those they seek help from dismissing their problems as typical, possibly leading to disengagement with support (McAndrew & Warne, 2014).
Knowledge surrounding the cause of emotional distress might facilitate understanding and, therefore, may enable young people to feel more comfortable seeking help. Adolescents appear to recognise the benefits of extending knowledge relating to cause and would value information or indeed if they seek help at all. For instance, adolescents may be hesitant to reveal the source out of fear that the cause may lead to bullying and ridicule (Porteous et al., 2019;Tinnfa¨lt et al., 2011), or concern that those they share with may betray their trust (King et al., 2014). Some may be hesitant to seek help due to fears that they may not be believed (Campbell et al., 2015;Tinnfa¨lt et al., 2011), or feel pressure to report their circumstances to make the cause more believable to others: "I hated how much pressure I was under to feel like I needed to prove to everyone that I wasn't lying, so like I went and told" (Campbell et al., 2015, p. 835). There may also be concern that adults will be too quick to report disclosures to the authorities, which could result in negative consequences, such as being taken from their homes or upsetting their parents, which may prevent the disclosure of home-related difficulties (Tinnfa¨lt et al., 2011).
Similarly, concerns regarding perceived and possible judgment from others may affect how able young people feel to get help for their circumstances. As an example, adolescents with a sibling with cancer indicated that they would endure their experience in silence, which ranged from just not wanting to talk about it, due to the personal nature of the topic, to a way to manage impressions (Porteous et al., 2019); silence may also be used as a form of protection from bullies who might use the cause of their distress against them (Porteous et al., 2019;Tinnfa¨lt et al., 2011). However, some young people view school as a kind of respite from their problems: "[b]ecause sometimes I don't want other people to know […] School is my break" (Grove et al., 2016, p.3062). Or may avoid discussing cause as a form of self-protection: "I guess my own fears, death really … stops me from talking about it" (Phillips & Lewis, 2015, p.855). Young people may eventually share their concerns with an adult, but may find it difficult to initiate the conversation, . However, adolescents who do consider exploring options for help may perform a risk assessment on adults before disclosing, perhaps to maximise the extent they can remained involved (Tinnfa lt et al., 2011). On the other hand, adolescents may feel they have no choice but to disclose, especially if they feel the cause has to be reported to the authorities and to do so will have to tell their parents (Campbell et al., 2015). Thus, the extent to which perceived cause for emotional distress might influence help seeking may depend on how much control young people feel they have in overcoming the cause.
The degree to which young people feel they can control their reactions to causal factors may also influence help seeking. For instance, young people appear to explore a number of strategies to help mitigate against the cause of emotional distress. Alternative coping strategies to manage how they react might include thinking positively and trying to expect the best outcome, thinking that others have worse problems than they do, as well as crying and angry outbursts (Porteous et al., 2019). Exercise and recreational activities (Aymer, 2008;Porteous et al., 2019) as well as self-harming as a way to manage/relieve stress and to feel pain elsewhere (Tinnfa lt et al., 2011;McAndrew & Warne, 2014). Strategies may be recommended by peers, including self-harming to relieve stress (McAndrew & Warne, 2014). Some young people indicate they have available support systems around them but prefer self-management, and recognize that everyone has their own way of dealing with things (King et al., 2014). However, some young people may not want others to know about their self-management strategies, specifically self-harming due to associated shame; thus, some coping strategies can become a source of distress and shame surrounding this may delay help-seeking (Tinnfa lt et al., 2011).
At-risk group theme 4: Cause having the potential to affect others. Adolescents may be concerned with protecting others and to do so might conceal the contributing factors of their distress and avoid engaging with support. In this way, perceived cause of emotional distress may influence help-seeking if the nature of the cause has the potential to bring distress to loved ones. For instance, not telling a teacher about having an alcoholic parent to avoid affecting their parents (Tinnfa lt et al., 2011), or not wanting to talk to a parent about their mental illness: "I don't want to hurt mum's feelings or something like that if I ask too personal questions" (Grove et al., 2016. p.3062). Other instances include, not wanting to share emotional pain to avoid burdening or taking away from the difficulties of others (Porteous et al., 2019). Conversely, some young people indicated they would seek help to prevent others from suffering in the way they have, e.g. from a sexual assault; however, the reporting of serious incident such as sexual assault may be avoided if family have previously been in trouble with the being made available more broadly (Grove et al., 2016). An increase in knowledge may even facilitate coping strategies: "I can cope better with help when I know what it is and how her illness works" (Grove et al., 2016, p. 3061). Indeed, some may notice a lack of resources, and indicate that this is problematic: " [t]here are posters all around school (for smoking), but then there's nothing for counselling or anything like that" (McAndrew & Warne, 2014, p.575).
(Un)met expectations of support appear to contribute to distress. Adolescents indicate that having the opportunity to reflect on and discuss how they feel may decrease their embarrassment and encourage them to talk more openly, which may lead them to be able to resolve their own problems (Daniunaite et al., 2012). However, depending on the circumstances, some adolescents might attempt to communicate the cause of their distress in less obvious ways, and expect a teacher to realise that there is a problem (Tinnfa¨lt et al., 2011). Young people indicate that having individuals take an interest in them and ask questions was helpful for sharing, but not in a way that would overburden them (Phillips & Lewis, 2015;Porteous et al., 2019;Tinnfa¨lt et al., 2011). Being able to recognise the need for help personally in relation to cause may act as a foundation to help seeking; however, having people close to you confirm the need for help may play a factor in propelling towards change (Campbell et al., 2015;Daniunaite et al., 2012), but only if it is recognized by the young person first (Daniunaite et al., 2012).
In some instances, expectations of support may not be met, or adolescents may not feel that their difficulties are worthy of help: "I don't really know why I keep my emotions to myself cos, I probably like, I know there must be people out there that's worse off than me" (King et al., 2014, p.15). Young people may also feel that their teachers do not recognise their issues or feel that teachers know there is a problem but do not try to help (Tinnfa¨lt et al., 2011, p.143). Further, adolescents may feel the kind of support available is not suited to addressing the cause, for instance, not thinking of a GP as someone you can talk to about self-harming (McAndrew & Warne, 2014, p.574).
At-risk group theme 3: perceived extent of control in managing cause. Some young people expressed a desire to be involved in overcoming the factors influencing their difficult emotions. In some of these instances, it appears that adolescents who believe the cause of their emotional distress can be self-treated may avoid seeking help, opting instead for alternative approaches, e.g., attempting to treat body related anxiety by limiting food intake, excessive exercising, and using diet pills and laxatives to lose weight (Sabiston et al., 2007). Some may feel a sense of responsibility to take control over contributing factors, this might include recognising the issues and putting behaviors in place to address them rather than seeking help (Daniunaite personal and wider understanding of cause may lead to normalising and denial, which can subsequently cause delays in seeking support for mental health difficulties and prevent young people from accepting that they need help: "I don't have any (.)uh (.) I mean I'm not um (.) mental problem (.) I go (.) I saw the bad dream I didn't sleep then sometimes" (Majumder et al., 2015, p.131). Whilst a lack of personal understanding of mental health difficulties can prevent adolescents from recognising there is a problem, a wider lack of understanding may also cause delays in help-seeking, including parents viewing their child's mental health difficulties as childhood quirks (Keyes et al., 2018). Adolescents might sense that their difficulties are poorly understood by society, and in a school setting this may manifest into not receiving appropriate support: "No one helped me in school. The school was really bad" (Keyes et al., 2018, p.180). This lack of wider understanding may mean that when they do share their experience, young people feel misunderstood or dismissed (Diamond et al., 2011).
Like the at-risk group, the value of shared experience and feeling understood in relation to the cause of emotional distress may act as a factor in adolescents help-seeking behaviors. A lack of wider understanding of mental illness may lead to young people feeling lonely and misunderstood, which can result in a preference to share their experiences with people who have dealt with similar issues (Keyes et al., 2018). Some might feel that no one can truly understand them unless they have been through it: "I don't think anyone understands except self-harmers themselves" (Crouch & Wright, 2004 p. 193). Yet, some young people may prefer and be open to speaking to a therapist who is sensitive to their difficulties (Diamond et al., 2011). Adolescents also appear to value wider understanding: "I think what would help is for people to realize that it is not just feeling down, it is actually an illness […] I think the most helpful part is knowing that someone out there understands" (Woodgate, 2006, p.266).
Clinical group theme 3: perceived extent of control in managing cause. Like the at-risk group, some adolescents indicated that they felt reactions to cause could be managed, sometimes with appropriate help and support. Staying positive can be a way to manage reactions, in some instances this was achieved by avoiding anything and anyone who might "bring them down" (Woodgate, 2006), as well as avoiding pessimism, jumping to conclusions, overanalysing (Wilmots et al., 2020), and using self-harm as a way to relieve distress (Crouch & Wright, 2004). Some young people, however, did not want others to know they were self-harming and would purposefully hide the signs, this appeared to be associated with their identity as an "authentic" self-harmer and not wanting to be branded as an "attention seeker" (Crouch & Wright, 2004). For some, getting to police (Campbell et al., 2015). Indeed, some young people recognise they could use loved ones as a source of emotional support, but also see them as needing to be protected, which may result in young people going out of their way not to share their difficulties with their loved ones, even if it means involving themselves in criminal activity (King et al., 2014); however, this desire to protect love ones can also work as a deterrent from further crimes: "I don't ever wanna get myself in that trouble again…I never wanna have to upset my parents or family members again" (King et al., 2014, p.14), but this is seeking to adjust behavior rather than exploring options for help (King et al., 2014).
Clinical group theme 1: cause and implications for self-preservation. Perceptions of the acceptability of the cause and the support offered to manage it may factor into decisions to look for help. For instance, shame induced secrecy surrounding having a mental health "disorder" may lead to delays in seeking help, but receiving a diagnosis may provide relief: "I felt crazy at the time […] But for my GP to say, 'right, it's OCD. .' He's actually saying something" (Keyes et al., 2018, p.181). Perceived acceptance appears to help young people share their difficulties with professionals; indeed, feeling validated and listened to may help young people feel worthy of receiving care and support from others (Wilmots et al., 2020). However, for some, having to conceal their identity because they do not feel that they will be accepted can cause stress (Diamond et al., 2011, p.138).
Adolescents indicate that they want to be seen as individuals and not just for their difficulties, and concerns regarding how their difficulties may inadvertently define them may cause delays in help-seeking or treatment refusal. For instance, not wanting to accept help to avoid perceived associations: "I don't want anyone say [A] is crazy. And I was very crazy actually because I try twice kill myself, I try hung myself. I cut myself, I really was crazy" (Majumder et al., 2015, p.131). Young people indicate that they do not want to be treated as a diagnosis, they want health care professionals to get to know them and not just think of them or judge them in relation to their mental illness (Woodgate, 2006 P.267). A lack of perceived understanding and respect may lead to young people wanting to stop their treatment (Woodgate, 2006). The notion of identity in relation to cause impacting help-seeking may also be seen among adolescents who self-harm. For example, young people who self-harm may want to be seen as "genuine" self-harmers and, thus, self-harm in private, not sharing their difficulties because they value secrecy as part of their identity as a "genuine" self-harmer: "I didn't want anyone to know about it, so that makes me angry, especially when I know some people that do do it for attention" (Crouch & Wright, 2004, p.194).
Clinical group theme 2: the degree of personal and wider knowledge and understanding of cause. A lack of concern for self and others were only found for the at-risk group, whereas (6) coping with a mental health difficulty was found to be exclusive to the clinical group. While it makes sense that coping with a mental health difficulty would be causal for the clinical group only, it is perhaps less clear why unfairness and perceived lack of agency was only a theme in the at-risk group, despite perceived extent of control in managing cause influencing help seeking for both. This may be attributable to a lack of evidence in the area or the fact that there were more studies for the at-risk group eligible for inclusion in this review. Nonetheless, differences such as these highlight the need to look at at-risk groups as well as clinical groups when exploring perception of cause for difficulties to identify how to better support young people experiencing emotional distress.
In relation to the ways in which causal attributions for emotional difficulties might impact help-seeking, four main themes were found, including: (1) cause and implications for self-preservation; (2) the degree of personal and wider knowledge and understanding of cause; (3) perceived extent of control in managing cause; and (4) cause having the potential to affect others, which was only found to be a theme within the at-risk group. While both groups shared three main themes, distinct sub-themes were evident, reflecting again that while there are clear similarities, there are also differences that may have implications for help seeking -this will be discussed further in the implications section. For instance, for cause and implications for selfpreservation, it was found that the possible reactions and consequences of sharing the cause with others, as well as concern about judgements they might receive, influenced help-seeking behavior for the at-risk group. However, for the clinical group, maintaining an identity within their diagnosis was important, as too was the degree of acceptance and support they received. This synthesis, therefore, highlights that perception of cause for difficulties is important in the context of help-seeking during adolescence and calls for further research to explore this in greater depth. This is work that the authors of the present review have begun exploring with adolescents considered at-risk of developing a mental health difficulty.

Review in the Context of Ongoing Research
In situating the present findings within ongoing research, it is important to highlight commonalities between the present study and already published empirical work that presents a typology of perceived cause for emotional distress among at-risk adolescents (O'Neill et al., 2021). Most notably, concerns for self and others was also found to be a category for perceived cause of emotional distress in the typology developed from qualitative interviews with young know the signs that indicate possible set-back were seen as important in managing distress (Woodgate 2006).
The degree of involvement in recovery was also noted as a possible factor in the extent to which causal perceptions impact help seeking. Some adolescents acknowledged that they struggle to understand why they feel the way they do, and in some instances, feel that they need and would value help from a therapist to recognise what was causing their difficulties; however, some young people may find it painful to explore the reasons for the onset of depression and prefer to look to the future, and may value a therapeutic approach that allows them to do so (Wilmots et al., 2020). Young people noted that talking about the past can cause emotional distress, and, therefore, may be opposed to helpseeking to avoid further distress (Majumder et al., 2015). Some adolescents were able to recognise that they had to seek help themselves or nothing would get better, this kind of self-awareness was paired with the acknowledgment that they could not be coerced into treatment (Woodgate, 2006).

Discussion
Emotional distress is prevalent during adolescence; if not managed effectively, it can lead to further difficulties. Help-seeking is valuable for preventing the manifestation of mental illness as well as managing existing difficulties. While causal perceptions of difficulties have been found to influence how adults engage with and seek help, perceived cause for emotional distress in the context of help-seeking is not well explored among adolescent groups. To guide intervention and prevention efforts, as well as foster a better understanding of how to support adolescents experiencing emotional distress, a comprehensive review of existing literature focusing on at-risk and clinical adolescent groups was necessary. Therefore, this study aimed to conduct a systematic review and qualitative thematic synthesis to determine what adolescents perceive to be the cause of their emotional distress; the ways in which perceived cause might influence help-seeking tendencies; and the possible differences in how at-risk and clinical groups of adolescents engage with help-seeking in the context of perceived cause for emotional distress. The findings indicate that causal beliefs influence help-seeking in clinical and at-risk groups; they further suggest that there are differences in perceptions of cause and related help-seeking between these groups.
Six main themes related to perceived cause were found. Three of those themes were shared between the clinical and at-risk groups: (1) challenging social factors and perceived difference, (2) problematic family dynamics, and (3) cause is complex and multifaceted. Three of the themes were not shared: (4) unfairness and perceived lack of agency and (5) While there is a paucity of research investigating young people's involvement in shared decision making (Thomas et al., 2021), what is available appears to focus on children and young people from clinical groups (e.g. Hayes et al., 2021). This focus is important; however, this review demonstrates that at-risk groups may also desire control over the management of emotional distress and the direction their help-seeking takes. The findings echo those of Martorell-Poveda and colleagues (2015), who found that young people aged 17-21 wanted to maintain autonomy and control when seeking help for their emotional distress; they also found that young people experiencing emotional distress may view their distress as their own responsibility to resolve. The sample in the research by Martorell-Poveda and colleagues (2015) featured participants with either a clinical diagnosis or selfreported emotional distress, indicating a merge of clinical and at-risk groups. This review emphasizes the importance of giving these groups specific research attention to not only support young people with mental health difficulties, but to also improve prevention strategies through adaptive helpseeking. Indeed, while the benefits of active involvement in and development of one's own healthcare is more widely recognized (Ahmad et al., 2014), this is perhaps not yet well explored in relation to interventions for at-risk groups.

Implications
Causes of emotional distress are complex, and this review demonstrates that young people from at-risk and clinical groups are aware of this complexity. It also demonstrates that both groups reflect on and recognize cause; thus, it is imperative to explore young people's beliefs relating to contributory factors and focus on tackling them rather than dismissing their experiences as "typical". This review demonstrates key links with help-seeking and mental health-literacy and calls for the introduction of good quality mental health education, particularly during these years when mental health is vulnerable (Rapee et al., 2019). It is likely this will help all young people, particularly as this study indicates that personal and wider knowledge and understanding is key to supporting help-seeking. For instance, for the atrisk group, the degree of personal and wider understanding about the cause of their difficulties (including parental mental illness) was important for help-seeking. Whereas for the clinical group, a lack of wider mental health knowledge was identified as leading to normalising and denial of clinically significant mental health difficulties.
This review also illustrates that young people want to be treated as individuals and that, for the clinical group in particular, being mindful of identity development and not just treating a diagnosis is important to support continued helpseeking. Indeed, one of the key findings from this review people (O'Neill et al., 2021). Given that 60% of studies in the at-risk group focused on young people's potentially difficult experiences in relation to health and safety (including exposure to domestic violence; victims of sexual assault; and family illness such as alcoholism, cancer, and mental illness), it is perhaps unsurprising to see heightened levels of concern coming through. There are also commonalities in unfairness and perceived lack of agency as control and unfairness were noted as types of cause of emotional distress in O'Neill and colleagues' (2021) study. Again, this is perhaps unsurprising given that adolescence is known as a time for establishing independence (Schwartz et al., 2018). While there was overlap in the period of analysis for the present study and the typology, steps were taken to ensure the findings were fully grounded in the data. For example, while the analysis was led by the first author in both instances, the level of involvement from the co-authors was staggered across the studies, enabling a more neutral perspective when discussing the findings; the second author in the present study was not involved in the generation of types in the typology, but was involved in data analysis and theme generation in the present study. To further ensure the credibility and trustworthiness of the findings, illustrative quotes were provided and the process of data analysis was outlined (Nowell et al., 2017).

Review in Relation to Existing Literature
This review contributes to an understanding of causal attributions and help seeking by being the first systematic qualitative review to be conducted in this area. The findings align with those of numerous studies in adult clinical groups that demonstrate how causal perceptions can have implications for treatment engagement (e.g., Houle et al., 2013;Nieuwsma & Pepper, 2010;Goldstein & Rosselli, 2003;Stolzenburg et al., 2019). However, this review adds that this process can be observed in adolescence in the context of perceived cause for emotional distress and subsequent helpseeking. The present review also highlights a likely gap in research in relation to at-risk adult groups. While there is evidence of perceived cause influencing treatment preference in clinical groups, there is limited information available to support the understanding of how at-risk adults engage with help-seeking in the context of causal attributions. This is important as while there were numerous similarities among these groups in the present study, there were also key differences that will likely have implications for intervention and clinical practice.
Similarly, extant literature demonstrates that adults in clinical groups express a desire to be involved in treatment plans in a health-care setting, and that this involvement is important for their participation (Thomas et al., 2021).

Conclusion
Despite potential implications for intervention and prevention efforts in relation to mental health difficulties, adolescent help-seeking in the context of perceived cause for emotional distress has so far been under explored. A systematic review of qualitative and mixed-methods research was conducted to discover what extent literature could tell us about the extent to which perceived cause for emotional distress plays a role in help-seeking behavior during adolescence. This research demonstrates that understanding perceptions of cause for emotional distress is important for supporting adolescents, particularly as the findings indicate that causal beliefs are likely to influence help-seeking in both clinical and at-risk groups. This influence was observed to manifest through concerns for self-preservation, knowledge and understanding of cause, and perceived extent of control in managing cause for both groups -concerns regarding cause affecting others was only observed in the at-risk group. This supports the need for further research to enhance understanding of the extent to which help-seeking is guided by causal beliefs among adolescents. These findings call for future primary research that explicitly sets out to explore these potential connections in more depth. This review also found that, while there were elements of overlap, there were notable differences in help-seeking in the context of perceived cause for emotional distress among atrisk and clinical adolescent groups included in this review. Conducting further research in this area with at-risk groups and clinical groups respectively may provide further insight into the areas of divergence observed.
Authors' Contributions AON conceived of the study, participated in its design and coordination, conducted the searches, performed the analysis, drafted the manuscript and made revisions based on feedback from contributing authors; NH participated in the conception and design and assisted with interpretation of the data, provided feedback on drafts, and edited the manuscript; ES participated in the design and coordination of the study, provided support during the analysis, and provided feedback on drafts. All authors reviewed and approved the final submission.
Funding This research was supported by funding from The National Lottery Community Fund. The content is solely the responsibility of the authors, and it does not necessarily reflect the views of The National Lottery Community Fund.

Conflict of Interest
The authors report no conflict of interest.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate is adolescents' desire to be involved in and have autonomy over the direction their help-seeking takes, and that these factors may influence help-seeking behavior. For the clinical group, the degree of involvement in their own recovery was important for engaging with support. Including young people in treatment and care decisions in health-care settings has been called for (World Health Organization, 2012), and shared decision making is often promoted as a beneficial approach across a variety of health-care settings (Cheng et al., 2017). This review supports the benefits of this approach with adolescents; however, shared decision making is typically explored in health-care settings. This review highlights that adolescents considered to be at-risk of developing mental health difficulties may also do a risk assessment to see how much control they can maintain if they seek help. This suggests that educational professionals should also engage in shared decision making with young people when they disclose their difficulties.
This review, then, further highlights the need to take young people's wishes into account, and to involve them in decision making around their support, not just in clinical health care settings, but also in their wider contexts. This may be especially important as cause and control was identified as relating to the extent to which contributory factors may influence help seeking for both groups. It is clear from this review that young people want to be involved in overcoming and dealing with what they believe to be creating their distress or involved in decisions regarding treatment for those who have been diagnosed with a mental health disorder. Ultimately, amplifying their voice and acting upon their views may be helpful in promoting help-seeking and ameliorating perceived cause.

Limitations
While this study aimed to explore help seeking in the context of perceived cause for emotional distress, as outlined earlier this was not the explicit aim of the included studies. It is possible that data collected with this explicit aim would have yielded richer findings in relation to these constructs than the data analysed here. However, qualitative synthesis does not aim to simply summarise the findings from the included literature, rather it seeks to reconceptualize findings and create insights beyond the reporting of the individual studies (Campbell et al., 2003). Given that qualitative studies are not well indexed (Mohammed et al., 2016), there is also a possibility that studies relevant to the review were missed. However, to maximise relevant inclusion, a broad range of search terms were used, reference list of relevant studies were checked, and a number of search engines were used, including Scopus and Google Scholar.
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