Parental Involvement: A Grounded Theory of the Role of Parents in Adolescent Help Seeking for Mental Health Problems

There is a high prevalence of mental health problems within adolescent populations, but they are unlikely to seek help. Adults, including parents, are important within this help-seeking process. The study, therefore, is aimed to develop a theory of the influence of parents upon adolescent help seeking. Eighteen semistructured interviews were conducted with adolescents, their parents, and clinicians working within child and adolescent mental health services (CAMHS). A grounded theory analysis allowed for the in-depth exploration of participants’ experiences. A model was developed identifying help seeking as a family journey. Parents were highly influential, and parents who were able to be more available to their adolescents tended to be more involved in the help-seeking process. Other adults were utilized within the help-seeking process. Once adolescents were engaged with the help-seeking process, they were often able to then seek further help independently. The findings suggest that consideration should be given to making services accessible to adolescents. CAMH services should explore ways with adolescents to give control over parental involvement, and ways with parents to develop availability. Future research should consider the experiences of older and younger adolescents separately, and the transition into adult services.


Mental Health Needs in the Adolescent Population and Levels of Service Use
Within the adolescent population, there is a high prevalence of mental health problems. One in 10 young people were said to have a diagnosable mental health problem in England in 2014-2015(Mental Health Foundation, 2015Public Health England, 2016). It has also been suggested that half of the people with a long-term mental health problem first experience difficulties by the age of 14 years (Kim-Cohen et al., 2003). Further research has also found that 75% of mental health problems had begun before individuals reached the age of 24 years (Kessler et al., 2005). In addition, mental health problems within adolescence are argued to have a major negative effect upon adult life (Rickwood, Deane, Wilson, & Ciarrochi, 2005). However, despite this high level of need, few adolescents access help from mental health services (Boldero & Fallon, 1995;Pandiani, Banks, Simon, Van Vleck, & Pomeroy, 2005). Studies have reported that one third (Wu et al., 2001) to one half (Porter & Lindberg, 2000) of adolescents with emotional and behavioral difficulties do not receive help for these. In addition, within the United Kingdom, it was found that only 60% of adolescents experiencing a severe mental health problem received support from specialist mental health services (child and adolescent mental health services [CAMHS], 2008).

Models of Help Seeking
Help seeking within a mental health context has been defined as "the process of using informal and professional networks to gain support in coping with mental health problems" (Michelmore & Hindley, 2012, p. 507). Theoretical models of help seeking have largely focused on decisions of adults to seek help for illnesses. These have traditionally focused on 807786S GOXXX10.1177/2158244018807786SAGE OpenHassett et al.

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1 Canterbury Christ Church University, Tunbridge Wells, UK 2 South London and Maudsley NHS Foundation Trust, London, UK characteristics of individuals and demographic and structural factors to predict likeliness to seek help, such as the health care utilization model (Anderson, 1968(Anderson, , 1995. Pescosolido (1992) built upon existing theories with the network episode model (NEM), which focused upon the process of seeking help, and the importance of interpersonal relationships within social networks in making decisions about accessing health care. Costello, Pescosolido, Angold, and Burns (1998) revised the NEM in the network episode model-revised (NEM-R) and considered ways in which this model would need to be adapted to be appropriate for young people. Although Pescosolido (1992) highlighted that help seeking occurs within the context of social networks and relationships, the NEM-R takes account of the difference in independence that young people have in comparison with adults in their decisions about health care (Costello et al., 1998). This model highlights that young people are very unlikely to refer themselves for treatment, and, therefore, are heavily reliant on others to seek help on their behalf. Due to this reliance on others, there is less emphasis on decisions that individuals make about seeking help, and more of a focus upon the need for an adult to notice there is a problem to start the helpseeking process.
In addition, Rickwood et al. (2005) viewed help seeking for young people as a process that shifts from being a personal process to one which heavily involves others. This begins with becoming aware that there is a problem, and feeling that this is a problem that needs professional help. This problem then must be communicated to others. Help must be available and easy to access. Finally, the help seeker (or seekers) must feel able to seek out this help and talk about the problem to the service.
A further model for young people considers the factors that are likely to lead young people to avoid help seeking. Biddle, Donovan, Sharp, and Gunnell (2007) developed the cycle of avoidance, which highlights that young people are likely to view their distress as "normal," and, therefore, not needing an intervention. They argued that this allowed young people to normalize their distress, which was likely to continue even if their problems became more difficult, due to the fear of what it would mean to have a "real" mental health problem. Therefore, the level of severity for a young person to consider needing to seek help for an intervention would continue to shift until the mental health problems became unmanageable.
However, while these models have been developed considering the developmental differences between children and adults, they do not consider the unique developmental differences between children and adolescents. Adolescence is marked by identity development, and a move toward independence (Christe, 2005). This has been argued to be a conflictual stage for young people, who can feel torn between seeking more independence, but also still needing support from their parents or carers in developing autonomy and adjusting to adulthood (Moretti & Peled, 2004). These differences are likely to contribute to differences in help seeking between children and adolescents, and therefore, a model specifically considering adolescent help seeking could be useful.

Role of Parents in Help Seeking
As the above theories of help seeking for young people have identified, young people very rarely seek help from formal mental health services without the involvement of others, and are very unlikely to refer themselves for treatment (Costello et al., 1998). Despite the move toward independence, which is a large component of adolescent development (Allen et al., 2003), research suggests that parents continue to play a large role in supporting adolescent development and the move toward autonomy (Moretti & Peled, 2004), in the decision to seek help and in facilitating the help-seeking process (Block & Greeno, 2011;Logan & King, 2001). Trusted relationships have been found to play an important role in the help-seeking behaviors of adolescents, which are often relationships with friends and family (Rickwood et al., 2005). Furthermore, for clinic-based services, the dominant influence for children and adolescents was found to be family and parents, with between 40% and 55% of 15-to 17-year olds reporting that family was the major influence on their help-seeking behavior (Rickwood, Mazzer, & Telford, 2015).
In addition, a recent review of literature regarding parental and family factors relating to adolescent service use found that parental burden, parental problem perception, parent perception of need, and parental availability were significantly related to adolescent mental health service use (Ryan, Jorm, Toumbourou, & Lubman, 2015). Logan and King (2001) aimed to use the available literature at the time to develop a model of how parents facilitate adolescent service use. This proposes that parents are key in adolescents accessing services due to the reluctance of adolescents to seek help, and the difficulties in accessing mental health services. The model outlines multiple steps that parents take in "gaining awareness of an adolescent's distress, recognising the problem as psychological in nature, considering possible courses of action, developing an intention to seek mental health services, making an active attempt to seek services, and obtain services for the adolescent" (Logan & King, 2001, p. 322). The model further identifies enabling and inhibiting factors that either facilitate or hinder these steps in the help-seeking process, such as parents' cognitions and attitudes, availability of services, and the reactions of others.

The Rationale for Current Study
As Logan and King (2001) argued within their model development, it is imperative to consider the unique developmental stage of adolescents within the help-seeking process to build upon the understanding of research that focuses on both children and adolescents. Ryan et al. (2015) also highlighted that future research should focus upon adolescents as a separate group from children within the context of mental health service use. In addition, research acknowledging and exploring the new relationship that both parents and children enter once children reach adolescence has been encouraged (Moretti & Peled, 2004).
The current research highlights the high prevalence of mental health needs within the adolescent population, and also the low numbers of adolescents who receive help for their mental health difficulties. The empirical and theoretical literature emphasizes the importance of social networks, and particularly adults in facilitating the help-seeking process. The current literature base seems unclear as to how parents both facilitate help seeking, and influence the way that adolescents themselves seek help for their mental health. Although a model has been developed based upon previous literature (Logan & King, 2001), further research has not been done to develop a theoretical framework that is grounded in participants' experiences. It also seems particularly pertinent to readdress this topic in the current context of CAMHS within the United Kingdom, given the financial constraints and service limitations currently seen widely across CAMHS. These constraints have resulted in long waiting lists, and limited the ability of many CAMH services to be able to assertively engage adolescents and families, which is likely to make it harder for many adolescents and families to access help.
Much of the current adolescent help-seeking literature has used quantitative designs. Although there has been some qualitative research focusing on the role of adults within the help-seeking process (Lane, 2015), this has not yet focused upon the role of parents. Therefore, it seemed important to use a qualitative approach to develop an understanding of the influence of parents within adolescent help seeking.

Research Questions
This study aimed to develop a theory of the role of parents within adolescent help seeking for a mental health problem, and the influence of parents upon adolescents seeking help for their mental health.
The research questions were as follows: Research Question 1: What do adolescents, parents/carers and practitioners view as the role of parents in adolescent help seeking for a mental health problem? Research Question 2: What parental factors are seen as facilitating or hindering adolescent help seeking from the viewpoint of adolescents, parents/carers, and practitioners?

Research Question 3:
What are the experiences of adolescents, parents/carers, and practitioners of adolescent help seeking within a mental health context?

Design Overview
The study used a qualitative research design, to allow for a greater level of depth of exploration within a research area that has been focused upon using mainly quantitative methodologies. A grounded theory design allows for an approach, which develops a model that is based in the experiences of participants, into an area, which has limited research to date (Urquhart, 2013). Given the lack of theory specifically in relation to adolescent help seeking, this approach seemed to have the potential to allow the development of a theory that would be grounded in the experiences of young people, their parents, and clinicians.

Epistemological Stance
The research is based within a critical realist epistemological stance, considering that "the way that we perceive facts, particularly in the social realm, depends partly on our beliefs and expectations" (Bunge, 1993, p. 231). Using this stance, the researcher's beliefs and experiences were viewed as having an influence upon the research process, which could give a further interpretation to the analysis process (Oliver, 2012). Although acknowledging this the researchers want to see what the data indicated, rather than fit it into a theory that already exists as this provides more chance of discovering something new, it does not try to impose preconceived ideas on the world (Urquhart & Fernandez, 2006). Therefore, theory development was an interaction between what was emerging from the data and the experiences of the researchers. In this way an ontological stance, which argues that we come to know "external reality indirectly through our constructs, even though an outer reality exists" (Raskin, 2008, p. 8) is taken.

Participants
Inclusion criteria are as follows: • • Young people aged between 13 years and 18 years who were currently attending or had attended appointments within the last year with CAMHS in the selected locations, • • Parents or carers of young people who were currently or had been engaged with mental health services as above, • • Parents and their young people, both, did not have to participate to be eligible for the research study, and • • Clinicians who had been working within child and adolescent mental health settings for at least 6 months.
Exclusion criteria are as follows: • • Young people judged by the team to be at high risk of harm or distress from the project, and • • Young people with a significant learning disability as assessed by formal learning disability measures.

Recruitment
Participants were recruited from two CAMH services within London, one providing outpatient Tier 4 services, and the other providing Tier 3 services. Young people and parents were recruited either by staff teams or, with ethical and R&D approval, directly by the researcher if they had given "consent to be contacted." Clinicians were contacted directly by the researcher.

Sample
Eighteen participants were recruited to the study (see Table 1 for demographic details of the sample in the order they were recruited). Younger adolescents were particularly difficult to recruit, with the main barrier expressed by parents and adolescents being uncertainty in meeting with a stranger to talk about their experiences of their mental health. It seemed perhaps older adolescents had more confidence to do this.

Ethical Considerations
The study was given approval by the University, following which approval was given by the National Research Ethics Service and Health Research Authority. The relevant National Health Service (NHS) trust gave research and development approval. Careful consideration was given to potential risk and safeguarding issues given the vulnerability of the research population, and local risk and safeguarding policies were followed.

Procedure
Young people, parents, and clinicians were interviewed using a semistructured interview schedule with 11 initial questions based upon the research questions. These questions were based around the following areas: Experiences of help seeking and young people's experience of parental influence on their help seeking, and parental factors facilitating or hindering adolescent help seeking. The questions were adapted to suit whether the participant was a young person, parent/ carer, or clinician. The schedule for young people had been approved by young people within the service, while the parent schedule was approved by a service user research service. Two young people were initially interviewed, following which the data were analyzed, and further participants were then recruited based upon this, in accordance with theoretical sampling (Urquhart, 2013). For the full order of recruitment, please see Table 1.

Data Analysis
Data analysis followed the method of Glaserian Grounded Theory using the following steps as described by Urquhart (2013). A constant comparative method was used, developing concepts from the data by coding and analyzing at the same time as collecting data (Kolb, 2012). Interviews were analyzed following every two interviews, with the analysis guiding further recruitment, and amendment of the interview schedule. A process of constant comparison was used to ensure interpretation of emerging themes was grounded in the data of the participants.
1. Interviews recorded for accuracy and then were fully transcribed verbatim and initially analyzed line by line for the first six interviews, creating open codes. 2. Open codes were then refined into focused codes, focusing on those that were relevant to the research question. 3. Following this, selective coding was conducted, during which focused codes began to be organized into initial subcategories and categories. 4. Theoretical coding then considered the relationships between categories, and began developing theoretical ideas about these relationships. Theoretical memos Recruitment ended when theoretical sufficiency (Dey, 1999) seemed to have been reached, when no further new codes relevant to the research question were drawn from the data. One further interview was completed after this point to ensure theoretical sufficiency, resulting in 18 interviews in total.

Quality and Validity
Qualitative research guidelines taken from Yardley (2000) and Mays and Pope (2000) were used to evaluate the research process. The researcher acknowledged that their beliefs and experiences would influence the data analysis. A reflective research journal allowed for the exploration of the researcher's thoughts and impressions throughout the data collection and analysis, which were then discussed with the research supervisor. During each stage of analysis this journal was returned to, with comments about interpretations noted, and reflections made regarding the rationale of decisions such as the grouping of initial codes. The journal also considered the positioning of the investigator, particularly in relation to biases likely to have been bought by the researcher to the process, such as a belief that adolescents are likely to benefit from the involvement of their parents even if they report they do not want this, that parents are often best placed to create change for young people, and that current CAMH services are frequently not designed in a way to offer accessible help to young people. Focused codes were listed in a table, which was then followed by maps made of subcategory and category development to create an audit trail and were discussed with the research supervisor. Multiple drafts of the initial model development were created and were also discussed with the research supervisors until agreement was reached. The developed theory was also presented to a CAMHS team, and to two individuals with little knowledge of the area, and feedback obtained.

Results
Help seeking was conceptualized following the analysis in a preliminary model as a journey through which both parents and young people navigate. The model below (see Figure 1) identifies help seeking as a family journey, and depicts the journey of help seeking from the initial perception of the problem, to engaging with help, alongside the parents' role in this process. For clarity, the model is shown with forward movement within the help-seeking journey; however, it is important to note that young people and their parents are likely to move forward and backward along the process at different points.
The model highlights the availability of parents as having an influence upon how ready a young person feels to seek help, and how, and to whom the young person discloses the problem to. For young people, whose parents were able to be highly available to them, it seemed more likely that help seeking would be a collaborative process between the parent and adolescent, or that the parent would be more forceful in facilitating help. It seemed that young people whose parents struggled to be available to them may disclose their problem to another adult, or that for these young people, the problem may be noticed by another adult. However, if this was not possible, it seemed that these young people would be more likely to reach a crisis point, and access help through systems such as accident and emergency units (A&E), used for accessing medical or psychiatric help during a crisis in the United Kingdom. Findings suggested that CAMHS clinicians used expertise in engaging both young people and parents, and supporting parents to be more available to their adolescent, and to support parents in engaging their young people. Once young people were engaged with help, it seemed that they then felt more confident to seek further help independently. On a broader level, the model acknowledges the wider contexts existing around the family help-seeking journey, such as the family context, the current CAMHS context and the wider societal context.
Developed categories and their relevant subcategories can be found in Table 2.

Category 1: Availability of Parents
Availability of parents was described as both physical and emotional availability of parents to their young people. This availability was felt to be likely to have an effect upon whether young people felt they could disclose their problems to their parents, how able parents felt to assist young people in help seeking, and to what extent parents and young people were able to collaborate within the help-seeking process. There were also factors that seemed to have an effect on how available parents were able to be, and therefore, how involved they were able to be within help seeking, such as their own mental health needs, beliefs around help seeking, and other stressors and contextual difficulties.
Emotional availability. Young people found it important that their parents were able to hear their worries and feel that their parents understood the difficulties they were facing to feel confident that their parents would be able to help them.
Cos we've never had that relationship, I just don't think they'd be able to understand or be able to help me. (YP 6) Clinicians identified this as containment, and considered how this could be difficult for many parents, and particularly parents with their own mental health needs.
It's not necessarily that straight forward, because these parents can be struggling on a day to day basis. These parents might not necessarily be in a place to contain their child's difficulties. (Clinician 2) It seemed that for some parents it felt to them that they were able to be emotionally available to their young people,.
He knows he can come and talk to us. I think he knows we are there for him, yeah I think he definitely does know that. (Parent 1) For other parents this was something that was more difficult, and one parent commented on the difficulties she had had in speaking with her young person about the problem; Interviewer: Did she ever speak to you about why she felt like that?
Parent 5: No not really, she tries to be flowery and butter things up, and I'm not like that, you talk straight with me or don't bother.
Parents identified challenges that they faced in trying to be available to their young person, including being unsure as to when a problem needed help, not knowing how to help if they did recognize a problem, and the emotional impact of supporting their young people with complex needs. One challenge for many parents was knowing whether adolescent difficulties were part of "normal teenage behaviour" or whether these were a sign of a mental health problem.
She was quiet and withdrawn, I didn't really think nothing of it, I thought oh maybe she was going through a stage where you know kids go through. (Parent 3) It also seemed that there was a large emotional impact upon parents who were continuing to support their young person facing continued difficulties.  This seemed particularly important for lone parents or those with limited social support.
Parental facilitation. Clinicians noted the role that parents often had in facilitating the formal help-seeking process for young people.
Parental involvement is almost always central to the decision to come and seek help. There are very few children and adolescents who would come off their own back. (Clinician 4) Clinicians also noted the way that parents can model seeking help and engaging with professionals to their young people and be key within interventions.
About the parent just making me as accepted as possible, and you know that's great role modelling by mum really, to show just how much she must trust and to let the young person know, she's alright. It's quite powerful. (Clinician 3) For young people who struggled to talk to adults about their problems, there were times when parents needed to be forceful in their facilitation of them accessing help.
Yeah, then she informed the doctor. Yeah, she forced me to come. (YP 7) Something happened one night and I told my mum on the way to school, and she changed direction from school to hospital and went to CAMHS and said you need to talk about it. (YP 2) Other parents found they had been able to collaborate with their young people in starting to seek formal help.
At that point I said, there's options. We could go and see the doctor and see if we can get referred, and again she was absolutely clear she didn't want the school to know anything. And because there was no apparent physical risk and so on it seemed best to respect that really. (Parent 6) Several young people felt that their parents were key in facilitating their help seeking when they had reached a crisis level.
My mum, she'd be the one who most of the time would be taking me to A&E. (YP 1) Parents also identified the feelings of helplessness they had in feeling unsure of how to help their young person, and trying to get their young person help.
Parental beliefs about help seeking. It seemed that parental beliefs about the help-seeking process had an impact on the way in which they assisted their young person in help seeking. Some parents found that their or other family member's experience of using mental health services made them feel more confident in facilitating the help-seeking process.
I think the main advantage of it was that it enabled us to identify the problem, and also perhaps not be quite so initially horrified by the idea of going to see a psychiatrist. (Parent 4) Clinicians identified that these previous experiences could support the help-seeking process or act as a barrier.
For a parent who has a history themselves of emotional difficulties perhaps might have a better understanding of their child's mental health difficulties. But, for example if someone has had a bad experience, they might not necessarily feel able to guide the process. (Clinician 2) Another important element of parental beliefs around help seeking seemed to be around the feelings of judgment, blame, and guilt that parents often experienced.
And if they're coming from feeling like they're under scrutiny from social services, if they are feeling under threat as a family maybe, maybe they're more likely to perceive CAMHS as another threatening service. (Clinician 1) And of course obviously, you, wonder were there things we did wrong? Should we have picked it up earlier? You know the sort of, we've failed as parents. (Parent 4) Another belief shared by several parents was that they were not skilled enough to help their child, and professionals would be the only ones who would be able to understand the problem.
They are the ones that can diagnose and help you, and put you on the right road to recovery. Because they can work it out. We can't. (Parent 5)

Category 2: Young Person Feeling Ready to Seek Help
Feeling ready to seek help seemed to be a key point for young people within the help-seeking journey, as this helped them feel in some control, allowed them to utilize support from parents or other adults and potentially begin to engage with services. Within the interviews, several factors seemed to affect upon young people's perception of feeling ready to seek help, such as perception of the problem, beliefs about help seeking, and their developmental stage.
Perception of the problem. One area that seemed key to young people feeling they needed to seek help was their perception of the problem being serious enough to need help.
For me it was when it was kind of affecting me every day and I couldn't cope with it anymore. I didn't really like to be at home and I didn't really like to be at school. (YP 5) Young people also needed a way of working out if their problems were severe enough to need help.
No I never really spoke to anyone, I just read up about it, you know like google it, or on yahoo answers you can ask questions, or read other questions that others had asked that were similar to me. (YP 6) It seemed that for most young people, their perception of the problem was different to that of adults around them.
The weirdest thing about me ending up in hospital is a large part of the reason of me going was actually, I mean that was probably one of the most tame situations. (YP 2) Beliefs about help seeking. Young people also perceived that it would be easier to share their problems if the person they approached had experience of mental health difficulties.
I think like, if you have someone who's gone through it, if you've got a family member that's gone through it, it's more relatable. They might have even seen, they might pick up on these things. (YP 4) It was also reiterated by young people, the difference between seeking help for a mental health problem versus other kinds of problems. It was also noted that reaching out to others, particularly those from a young person's peer group, could lead to being bullied. Several young people also felt that for them, having no access to an adult in which they felt comfortable to disclose their problems to had led, or would lead to crisis.
Like some people I know I guess can tell their parents like I'm feeling depressed, but I couldn't, so that was my only way of showing things weren't ok. I had to do something drastic to get help. (YP 6) CAMHS clinicians seemed to be able to provide a relationship to some young people in which they felt able to talk about their problems.
Like a counsellor is someone you just see every week, like they're professionals, you have a relationship with them, but it's not a close relationship if you get what I mean. They're not going to say anything. (YP 4) Young people in the study also identified friends as sources of support, and often disclosed a problem first to friends rather than to family, especially if they felt that friends were facing similar difficulties.
I knew some of my friends had been through similar things so I could talk to them. (YP 5) Young people as protectors. One theme that came from all young people interviewed was of their hope to protect others around them from distress. Several young people felt this was a large part of why they had not disclosed their problems to their parents. Parents also felt this might be one reason why young people often found it hard to talk to them about their problems.
Well she told me the reason why she doesn't tell me things is because she knows it will hurt me. (Parent 3)

Category 3: Expertise of CAMHS
CAMHS clinicians had expertise in involving parents within their young person's care. It seemed clinicians were able to help develop parents' availability, facilitate involvement, help parents to engage young people into CAMH services, to engage young people directly, and to provide support for parents.
Developing parental availability and involvement. Several parents commented on the way they had been helped by CAMHS to develop their understanding of their young person's difficulties and needs.
I know more now when she's struggling, I can tell by her attitude, the way she keeps her personal hygiene. . . I thought wow there were all these things in front of me, but I just didn't know, so it helped me know more about it. (Parent 3) It also seemed that clinicians often found this an important part of their work with young people and families.
But for parents, sometimes maybe it's more about well you need to fix the behaviour. . . and I might be thinking well, perhaps about the function of the behaviour with them. (Clinician 1) CAMHS clinicians were also able to facilitate parents being involved with young people's CAMHS interventions in creative ways, particularly when young people did not want their parents involved.
I'm not quite sure how much of it was directly family therapy, but it did provide a communication channel when he was feeling very angry with us. (Parent 4) Clinicians also noted the importance of being available for parents.
I find it important to give the parent or parents the space to vent and tell me, and you know they might have very important stuff to say as well that they don't want to say in front of their child. (Clinician 4) This availability of clinicians for parents was found very helpful by parents.
I can talk to our worker, not just about Amy. . . , and she would advise me, and say well let me come and see Amy, and you at the same time. I think that woman is very great support.

(Parent 3)
Control, collaboration, and engagement. Young people commented on the flexibility of clinicians in the way they had engaged them within CAMHS.
When I first met my worker she was like you know have to talk to me, and that. And like, she just had a normal conversation with me, like for the first couple of sessions, she didn't talk about any of my problems. (YP 5) Having control over the way their parents were involved was felt to be very important for young people within initially seeking help and engaging with this help. Young people found it very difficult when they felt they had little control, particularly around issues of risk.
They could have least said we need to tell your parents, we need to tell them about your risk, but they didn't. I just got a call from my mum. (YP 6) It also seemed very important to CAMHS clinicians to offer a sense of control and collaboration to young people. This understanding seemed to change the way young people sought help; for some young people this meant seeking help earlier when things became difficult for them.
She's got better I suppose at pre-empting, and saying before things escalate. . . And I think she's got better at communicating with other adults about that as well. (Parent 2) Adolescent development. All young people interviewed within the study were older adolescents, and had mostly begun their help seeking as younger adolescents, and therefore, reflected on their earlier experiences. Young people also mostly believed that getting older had meant that they would have more understanding of their problems.
I think as you get older you're going to be learning about more stuff, just as I'm older I probably would recognise that there was an issue now. (YP 3) Well with everything I'm much more thoughtful about everything. . . I've got a clearer mind to sort of, review. (YP 2) Young people identified that adolescence was a challenging time, as they were starting to keep things private from their parents, so it could be hard to know what they should share with them.
You know like some of the things you don't wanna talk to your parents. . . You know like you face issues with relationships, like drugs, even though I didn't do drugs but you know you have friends that get involved in drugs. (YP 7) Reducing reliance on parents. They also felt that growing older had given them more of an understanding of how to seek help independently.
I think like being a bit older you know how to take yourself places and be more independent and you're more aware of how to do things. (YP 6) For some parents they found that they were able to tailor their involvement to meet the needs of their young person and their developmental stage.
I mean at times I think I probably don't do much for her in that respect, less intervening and explaining. I'm trying to step back a bit because well she's got to go and do it for herself as she puts it. (Parent 2) Some young people recognized that their parent had been able to do this, and that this had been helpful to them in being able to move toward seeking help more independently.
I mean my parents have always been, wanting to try and make me more self-reliant. Yeah, I mean they started it all off and then they kept it running for a bit and then let me carry on. (YP 3) Young people and parents also acknowledged that older adolescents were beginning to share problems with others.
He has a very serious girlfriend, so he talks to her a lot. (Parent 1)

Category 5: The Wider Context
It seemed that young people, parents, and clinicians viewed the help-seeking process as existing within multiple wider contexts. Within the research, the wider family, current situations for CAMH services and wider societal awareness about help seeking were contexts, which interacted with each other, and upon adolescent help seeking and parental facilitation.
Family context. It seemed that for many of the young people and parents interviewed, help seeking had been a family journey.
Family beliefs about talking about problems, mental health and recovery appeared to influence the help-seeking process, along with family experiences and beliefs around culture. For some young people and parents, it felt that within their families there was a norm of talking about problems.
We didn't have the relationship with our parents that we've got with our sons. . . it felt really important to talk about what's going on. (Parent 1) We are very close to our children, we do talk about a lot of things. (Parent 6) Whereas for others it seemed that this was something that they were not used to.
We don't talk about things like that, it's not the way it's been. (YP 5) There also seemed to be family beliefs around mental health and recovery, which influenced the way that parents were involved in the help-seeking process.
My mum did go through depression as well, so it's best for my mum to stay home and relax, and not go through anything tough. So my dad came with me. (YP 7) Parents also identified that cultural experiences affected on their beliefs about mental health and help seeking, which seemed likely to have a role in their involvement. I have a partner, but I don't tell him everything, you know because where we come from, mental health ain't nothing like we think, they think like mental health is eating out of a bin. (Parent 3) Yeah some of the group was good, but you've got to remember that I'm a north country lad with really firm views. (Parent 5) Young people also identified this within their parents, and found that this could make it more difficult for them to speak to their parents about the problem.
But, cos, my mum came from Bangladesh, but yeah, so it's a bit different, isn't it? You won't expect that back home. (YP 7) Because I'm not gonna lie, coming from a black culture, things like that are looked down upon. I know it might sound a bit rude, and I don't mean this in any kind of way, but black people and mental health don't mix. (YP 4) Clinicians also seemed very aware of the role of culture in the help-seeking process, and the difficulties that this could present to parents who are concerned about their young people.
If you think about that a lot of parents from ethnic minority groups struggle, a lot of them, with the notion of presenting their child to what is mostly a white service. (Clinician 4) CAMHS context and service constraints. Many of the young people, parents, and clinicians interviewed commented on the current CAMHS context and limitations of services. Parents particularly identified long-waiting lists and a disjointed referral process. I just rang up several times over the summer and, you know, I was told she was 98 th on the waiting list, and you know, I was kind of invited to suggest that it might be more serious because it might bump her up the list. (Parent 2) Young people also seemed aware of the difficulties in accessing formal help for their mental health.
Like you're never helped when things have just started off when they're difficult, you're only helped after it gets to the worst it can possibly be. (YP 6) The current high needs for services and limited resources raised challenges for clinicians working within CAMHS.
The majority of my clients, their parents have diagnosed or undiagnosed mental health problems. . . , it presents the dilemma of, well do I treat the parent, because that's probably where it's going to be most effective, but thinking about limited resources. (Clinician 5) There also seemed to be difficulties for clinicians around the types of problems, which receive support most quickly from CAMH services.
That seems to be the story within CAMHS at the moment, which is quite political, if there's a referral that states concerns about hyperactivity, then they will almost automatically be assessed, whereas children with the same level of needs, say with anxiety might not get into the service. (Clinician 1) Clinicians noted the high level of deprivation in the local context, and the high level of needs of many people living in the area. This is such a stretched borough, it's an indication of the level of needs. (Clinician 1) Interestingly, this was not mentioned by parents or young people, and it may be that this was noticed more by clinicians within the context of service thresholds.
Wider societal context. Young people seemed to find it important that there would be a wider level of awareness about mental health problems to make it easier for them to seek help.
I think education for parents should be more about the illnesses. . . parents need to be fully taught about them. (YP 2) I think they need, you know in schools and that, they need to like talk about it properly in schools, to say if you do have mental health there's nothing to be ashamed of. (YP 4) Clinicians also highlighted the role that education within schools could have in developing young people's awareness of mental health problems within the school and the support that could be offered there. I think young people being able to access, in schools somebody who has a degree of knowledge and interest in mental health. I mean most schools have this, and you really notice it when you come to a school who doesn't prioritise these issues. (Clinician 5)

Discussion
This article sought to develop a theoretical understanding of the role of parents within adolescent help seeking using a grounded theory approach from a critical realist epistemological stance. Although previous research has developed theory around help seeking in childhood, this has not been specifically in relation to the unique developmental time of adolescence, which seems pertinent given the high prevalence of mental health problems in adolescence (NHS England, 2015), and relatively low numbers of adolescents seeking help for these (Porter & Lindberg, 2000;Wu et al., 2001).
Help seeking was conceptualized within a preliminary model as a journey that both adolescents and their parents navigated, with acknowledgment given to the interplay between parental and adolescent factors within this process. The findings suggested that parents who were able to be consistently available to their young people were more likely to feel confident in the facilitation of the help-seeking process, whether this be through collaboration with the young person or through more forceful facilitation.
It also seemed that for young people with parents who struggled to be available to them due to their own needs or other stressors, it was more likely that these young people would approach another adult for help if they felt able to do so. Young people within the study had found themselves in crisis if they did not feel that their parents were available to them, and did not have another adult to notice the problem or to confide in. CAMHS clinicians were able to engage young people within the help-seeking process once they had accessed mental health services, and were also able to facilitate parental involvement. Similar themes developed from interviews across the three participant groups, suggesting consistency within the findings.

Links to Previous Theory and Research
The study found that young people tended to have a view of their problems that was discrepant to their parents, often perceiving their problems as less concerning than their parents perceived them to be. This is concurrent with previous research suggesting that adolescents rarely agree with their parents regarding the nature and severity of their problems (Klaus, Mobilio, & King, 2009;Williams, Lindsey, & Joe, 2011). In accordance with the findings of Wahlin and Deane (2012), the research also suggested that this discrepancy influenced the help-seeking process, with the study finding that parents and adolescents who had similar perceptions of the problem having a more collaborative help-seeking style.
The findings concur with previous research suggesting the key role of parents within the help-seeking process, and particularly their role in facilitating the access of services (Costello et al., 1998;Logan & King, 2001). The research particularly highlighted help seeking as a journey, with help sought at various points, linking with previous process-based help-seeking models (Murray, 2005;Rickwood et al., 2005). The study also highlighted the importance of support for parents within the help-seeking process, in line with previous research suggesting the link between parental burden and adolescent service use (Ryan et al., 2015). Furthermore, the findings seem to relate to the influence of adolescent development within the role of parents in the help-seeking process. Adolescence has been characterized as being a period of time in which young people begin to separate from their parents, and develop close relationships with both peers and within romantic relationships (Yurgelun-Todd, 2007). However, research also suggests that adolescents are still reliant upon their parents to support them through developmental changes and into adulthood (Moretti & Peled, 2004). The results of this study build upon these findings to suggest that despite adolescents beginning to confide more in friends and other relationships (Rickwood et al., 2015;Wilson & Deane, 2001), parents continue to be important in supporting adolescents in beginning and engaging with the help-seeking process.
Within the study, parental availability appeared to play a large part within the help-seeking process for adolescents. Parental emotional availability has been said within the literature to refer to several dimensions, sensitivity, structuring, non-intrusiveness and nonhostility, and emphasizes the importance of the way that parents signal their emotions to their children, and their understanding of their child's emotional signals (Biringen & Robinson, 1991). The dimensions of sensitivity (physical and emotional responsiveness to children's physical and emotional signals), and structuring (the ability of a parent to support their children without removing their autonomy; Biringen, 2000) seemed of particular relevance to the current study. Parents within the study who were able to show a high level of responsiveness to their young person's emotional needs seemed more able to facilitate the help-seeking process, and were more likely to be able to collaborate with their young person in the process. It also seemed that young people who had parents who could support them while allowing them autonomy felt more confident to begin seeking help independently.
It also seemed that parents in the study highlighted factors that hindered the help-seeking process that were similar to that reported in Logan and King's (2001) model of parental facilitation of adolescent help seeking. Parents highlighted that feeling unsure of how to talk to young people about their difficulties and feeling unsure if a problem needed help from mental health services acted as a barrier to help seeking. Given Logan and King's (2001) findings about the role of parental facilitation in help seeking, supporting parents to overcome these barriers seems important to foster the initial stages in help seeking. Having confidence in feeling that a problem needs professional help seems particularly pertinent given that the average maximum waiting time for CAMH services in the United Kingdom is reported to be 6 months for a first appointment, and 10 months until the start of treatment (Young Minds, 2016). Young people, parents, and clinicians within the research highlighted these difficulties, focusing on limited resources in relation to CAMH services, high thresholds and long waiting lists, and it seems that being able to access services despite these resource difficulties relies on greater confidence and skills in help seeking from parents and young people.

Clinical Implications
The findings from the study have implications for clinical practice for those working with adolescents and their families. First, the findings reiterate the importance of the role of adults within adolescent help seeking, and the difficulties that adolescents have in seeking help without the influence of others. As both parents and young people reported that a lack of knowledge felt a significant barrier to accessing professional support, it seems likely that trying to increase mental health literacy widely could support parents and young people in gaining awareness of difficulties that are likely to need support from mental health services. It could be that developing ways to make CAMHS more accessible to young people could facilitate more independent help seeking, such as offering information about CAMH services in an accessible way online, and clear information for adolescents in a developmentally appropriate style about how to seek help, particularly for those who feel they do not have an adult to confide in. It could be that the provision of support within schools could be further utilized to support this.
Second, the findings give support to the importance of planning around the role of parents within assessment of adolescent mental health. Although the majority of clinicians give adolescents time on their own within assessment, young people highlighted the importance of feeling in control of this process. It could be that creating a culture of offering young people a space to plan with a clinician how their parents would be involved within the assessment process would give adolescents a feeling of control.
Finally, the findings highlight the importance of CAMHS clinicians supporting parents where this is possible. Offering support to parents around their own mental health needs helped parents develop availability to their young person and develop relationships. The research is based within a context of financial difficulties for CAMH services, with high thresholds and long waiting lists. However, attention should be given to the importance of support for parents, whether this links into adult mental health services or parent workers within CAMHS.

Research Limitations
Although the aim of qualitative research is not to provide results that are generalizable across populations, there are important considerations regarding the sample demographics that may have influenced the findings within the study. First, while both service context and type of participant were triangulated within the study, both CAMH services were recruited within a similar context within South London. There is likely to be specific factors about these locations that may not be applicable to other areas, such as high levels of deprivation.
Second, most of the service user participants recruited were parents and young people who had engaged well within the service, meaning that the experiences of those who struggle to engage with services are likely to be lost. In addition, despite the high levels of ethnic diversity within the area of the study, the majority of participants were White British. This is perhaps a wider reflection of struggling to recruit ethnic minority groups within research, but is an important consideration for both the implications of findings and for further research.

Future Research
More research is needed to develop accessible services for adolescents. Focus groups could begin to incorporate the experiences of adolescents into the future provision of CAMH services. Given the focus on adolescent development within the findings, it could be helpful to utilize a quantitative research design to explore the differences in the role of parents within adolescent help seeking for younger and older adolescents. Furthermore, it would also be beneficial to explore the ways adolescents then move on as young adults within the context of the move from CAMHS to adult mental health services.

Conclusion
This study sought to develop a theoretical framework of the influence of parents upon the way adolescents seek help for their mental health. Parents were found to be highly influential in the help-seeking process, particularly, those parents who were able to be highly available to their young people. For adolescents with parents who struggled to be consistently available to them, other trusted adults could facilitate help seeking. Once adolescents had been engaged with help, they often found it easier to then seek further help independently. The findings have implications for clinical practice; focusing on offering choices and control to young people, providing accessible services, and supporting parents. Future research would benefit from a further focus on the separate experiences of younger and older adolescents, and considering help seeking within the move from CAMHS to adult mental health services.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.